Evaluating Quality of Care Indicators for Metastasis Development in Cutaneous Squamous Cell Carcinoma Among Mexican Renal Transplant Recipients

Abstract

Background

Cutaneous squamous cell carcinoma (cSCC) poses a high metastatic risk in immunosuppressed individuals, especially organ transplant recipients (OTRs). Despite international guidelines recognizing these risks, no universal standard exists for assessing quality of care (QoC) in cSCC. QoC indicators, as defined by NICE, ensure evidence-based management, including histopathology, treatment timelines, and follow-up, yet adherence remains challenging, particularly in low- and middle-income countries.

Objectives

To evaluate the occurrence of metastasis in cSCC among Mexican renal transplant recipients (RTRs) and assess how QoC indicators influenced this outcome.

Methods

Analysis of a subgroup of patients with invasive cSCC from a cohort of 1642 RTRs, excluding keratoacanthomas, SCC in situ, and externally treated tumors, leaving 123 cases. QoC indicators included pathology report completeness, diagnosis-to-surgery time, follow-up duration, and surgical team involvement. Comprehensive reports documented tumor size, depth, differentiation, and perivascular/perineural invasion. Statistical analysis included Fisher's exact test, Wilcoxon-Mann-Whitney test, and LASSO logistic regression.

Results

Among the 123 tumors, 4.9% metastasized, 83.3% in men. Notably, 19.4% of tumors had a comprehensive pathology report. The AJCC 7 guidelines in 2015 improved reporting quality, with 30.5% of reports meeting comprehensive criteria post-2015, compared to 9.4% before (p = 0.005). LASSO logistic regression identified predictors of metastasis: tumor differentiation (OR 3.0, 95%CI: 2–4.5), reporting tumor depth (OR 1.4, 95%CI: 1.2–1.7), and reporting perivascular invasion (OR 8.66, 95%CI: 4.8–15.6). This suggests that pathologists may have been more likely to document aggressive-looking tumors. Time to surgery was similar across cases, but multidisciplinary teams were more involved in metastatic cases.

Conclusions

The lack of universally recognized QoC guidelines for cSCC treatment in OTRs presents a significant gap in patient care. Standardized reporting and treatment protocols, similar to melanoma guidelines, could improve outcomes and support research like ours. The study's retrospective nature and missing data require cautious interpretation.