# Management of Cutaneous Squamous Cell Carcinoma of the Scalp in Kidney Transplant Recipients

## TL;DR

This paper discusses the challenges and treatment of scalp skin cancer in kidney transplant patients, highlighting a specific surgical technique and its effectiveness.

## Contribution

The paper introduces the crane reconstruction technique as a feasible and effective method for managing large scalp carcinomas in transplant recipients.

## Key findings

- The crane technique was successfully used in six out of seven patients for scalp reconstruction.
- Modifying immunosuppressive therapy post-surgery improved outcomes in fragile transplant recipients.
- The O-Z rotation flap was an alternative used in one case.

## Abstract

Organ transplant recipients are at significantly higher risk of developing skin cancer, particularly cutaneous squamous cell carcinoma, compared to the general population. These tumors are commonly found on the scalp. Scalp reconstruction, especially for large excisions, is complex due to the scalp’s thickness, the inelastic aponeurosis of the galea, and the need to preserve the integrity of the hair-bearing scalp. Additionally, organ transplant recipients face increased challenges due to comorbidities and the heightened risk of complications from immunosuppressive therapy. In this report, we present our experience with seven kidney transplant patients who underwent excision of cutaneous squamous cell carcinomas on the scalp with diameters greater than 3 cm. We highlight the advantages of the crane reconstruction technique and discuss the combined management of medical and immunosuppressive therapies. In cases of scalp cutaneous squamous cell carcinoma in transplant recipients, a multidisciplinary approach is essential for optimal outcomes.

Background: Organ transplant recipients are at a significantly higher risk of developing skin cancer compared to the general population, particularly cutaneous squamous cell carcinoma. Approximately 3–8% of these carcinomas are located on the scalp. Scalp reconstruction is particularly challenging, especially for large excisions, due to the thickness of the scalp, the inelastic aponeurosis of the galea, and the integrity of the hair-bearing scalp. Additionally, in organ transplant recipients, the presence of numerous comorbidities and the increased risk of infection due to immunosuppressive therapy make management more complex. Based on our experience and the existing literature, we aim to describe possible reconstruction methods and discuss the combined management of medical and immunosuppressive therapy. Method: We present our experience with seven kidney transplant patients who underwent excision of cutaneous squamous cell carcinoma with a diameter larger than 3 cm. The crane technique involves three key steps. First, the tumor is excised with wide margins of disease-free tissue. Next, a pericranial flap is rotated and positioned to cover the exposed cranial bone. Finally, a bilayer dermal substitute is applied to create a microenvironment that supports skin graft implantation. Results: The crane technique was used for six patients. In one case, an O-Z rotation flap was used. All patients modified their immunosuppressive therapy, with those receiving antiproliferative therapy switching everolimus after surgery. Conclusions: When combined with a post-operative modification of the immunosuppressive regimen, the crane technique could be considered a feasible, safe, and effective approach to managing large cSCC of the scalp in fragile patients.