Cutaneous squamous cell carcinoma in two pediatric lung transplant patients on prolonged voriconazole treatment Wong JY, Kuzel P, Mullen J, Lien D, Mahmood M, Conrad C, Fiorillo L. (2014) Cutaneous squamous cell carcinoma in two pediatric lung transplant patients on prolonged voriconazole treatment. Pediatr Transplant, 00: 1–8. DOI: 10.1111/petr.12320 Abstract: Oral voriconazole is commonly used for treatment and prophylaxis of invasive fungal disease post-LTx. Development of cutaneous SCC has been described in adult LTx recipients, although it is extremely rare in children. We describe two Caucasian children who developed cutaneous SCC beyond three yr post-LTx. Both developed severe photosensitivity, actinic keratosis and required curative surgical excision of the cutaneous SCC lesions. Neither patient developed metastatic lesions nor had allograft dysfunction as a result of the SCC or the change in medical treatments. The effect of voriconazole on the development of malignant skin lesions is discussed and a recommendation on dermatologic surveillance, preventive measures against phototoxicity and early treatment of SCC are provided. Jackson Y. Wong 1 , Paul Kuzel 2 , John Mullen 3 , Dale Lien 4 , Muhammad Mahmood 5 , Carol Conrad 6,7 and Loretta Fiorillo 1 1 Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada, 2 Division of Dermatology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada, 3 Department of Surgery, University of Alberta, Edmonton, Alberta, Canada, 4 Department of Medicine, University of Alberta, Edmonton, Alberta, Canada, 5 Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada, 6 Pediatric Lung and Heart-Lung Transplant Program, Stanford University, Stanford, CA, USA, 7 Department of Pediatrics, Stanford University, Stanford, CA, USA Key words: lung transplantation – squamous cell carcinoma – voriconazole – malignancy – skin cancer – organ transplantation – pediatrics Dr. Jackson Y. Wong, MBBS, DCH, FRCP, FRCPCH, FRCP Edin, FHKAM, FHKCPaed, Department of Pediatrics, Edmonton Clinic Health Academy (ECHA), Rm 4-529, 11405 – 87 Avenue, Edmonton, Alberta, Canada T6G 1C9 Tel.: 780 248 5579 Fax: 1 888 353 1323 E-mail: jywong2@ualberta.ca Accepted for publication 12 June 2014 Invasive fungal infection, especially aspergillosis, post-SOT is associated with significant morbidity (1, 2) and a mortality rate of 22% (3) in the case of invasive aspergillosis. Compared with other SOT recipients, LTx recipients have increased incidence of fungal and invasive mold infections as well as a higher mortality rate (23–82%) in invasive aspergillosis (2, 4, 5). Post-LTx coloni- zation with Aspergillus spp. is directly associated with morbidity and the development of bron- chiolitis obliterans syndrome (6). Invasive fungal disease in children is associated with increased mortality in the first year post-LTx (7); in adults, post-LTx invasive fungal disease is significantly associated with all-cause mortality (8). Prophy- lactic antifungal therapy post-LTx has become a widely accepted practice especially in patients with increased risk factors (2, 9). For this indica- tion as well as for treatment of established fun- gal infection, oral voriconazole is the most common choice due to its increased oral bio- availability and significant antifungal activity against non-Candida albicans, Scedosporium apiospermum, Fusarium species and invasive aspergillosis over other azole antifungal agents Abbreviations: BAL, bronchoalveolar lavage; CF, cystic fibrosis; L-AmB, liposomal amphotericin B; LTx, lung transplant; PET/CT, positron emission tomography/ computerized tomography; SCC, squamous cell carcinoma; SMX, sulfamethoxazole; SOT, solid organ transplantation; TDM, therapeutic drug monitoring; TMP, trimethoprim; UPF, ultraviolet protection factor; SPF, sun protection factor. 1 Pediatr Transplantation 2014 © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Pediatric Transplantation DOI: 10.1111/petr.12320