A 35-year-old renal transplant recipient on tacrolimus + mycophenolate + prednisolone develops a squamous cell carcinoma of the lip 8 years post-transplant. The most appropriate immunosuppression modification is:
- A Discontinue all immunosuppression immediately
- B Reduce mycophenolate dose and maintain tacrolimus
- C Switch from calcineurin inhibitor to mTOR inhibitor (sirolimus/everolimus) ✓
- D Add hydroxychloroquine as anti-cancer adjunct
Correct answer: C. Switch from calcineurin inhibitor to mTOR inhibitor (sirolimus/everolimus)
Explanation
Post-transplant de novo malignancy, particularly cutaneous SCC, is strongly promoted by calcineurin inhibitors (tacrolimus, ciclosporin) which have direct pro-oncogenic effects beyond immunosuppression. Switching to an mTOR inhibitor (sirolimus or everolimus) has documented antiproliferative and anti-angiogenic properties, and studies (including the CONVERT trial) show reduced rates of de novo malignancy and non-melanoma skin cancer progression. Complete discontinuation risks rejection; abrupt changes without graft monitoring are unsafe.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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