Rapid onset and fatal outcome of two squamous cell carcinomas of the genitalia in a patient treated with etanercept for cutaneous psoriasis.

by chemotherapy with carboplatin and gemcitabine. Three months after regional surgery, metastatic lymph nodes of the same location progressively recurred with invasion of the femoral vein; the patient finally died 16 months after the initial diagnosis. Anti-TNFagents durably inhibit the development of the cytotoxic T-cell response which plays a central role in tumor promotion and progression control and this biological effect might increase the hazard of malignancy or the aggressivity of tumors as a consequence. In this perspective, the report of 7 cutaneous SCCs of rapid onset in 5 rheumatoid arthritis patients receiving etanercept for a limited period of time was initially worrisome regarding a higher risk of cutaneous tumors, but no additional case was reported since then with the noticeable exception of a penile SCC in a patient receiving etanercept for psoriasis [4] . However, previous exposure to high doses of UVA or UVB and/or to other immunosuppressive agents such as ciclosporine for psoriasis probably delineates a special subset of patients at higher risk of developing SCC when compared to other indications such as rheumatoid arthritis, the genital area being perhaps the more significant target as already reported in psoriasis [5] and as illustrated both by our observation and by the report of Fryrear et al. [4] . The hypothesis of a previous but latent infection by oncogenic strains of HPV can be raised as well since the onset of genital HPV lesions occurring in patients receiving anti-TNF agents has recently been reported [6] ; however, no clue for the presence of HPV sequences was present in our patient. The delay between anti-TNFintroduction and the occurrence of genital mucous membrane SCC was longer in both patients than in the report of Smith and Skelton [3] but not inconsistent with the usual process of carcinogenesis. Owing to the pharmacological profile of these molecules, other clinical features might be more frequent in antiTNF-associated cutaneous SCC such as multiple tumors, rapid local growth and perhaps a higher metastatic potential, all characteristics featured by our patient. On the other hand, it is of interest to note that the use of efalizumab, another non-anti-TNFbiological agent currently used in psoriasis, has not been linked to a significant increase in the patients’ risk of developing skin malignancies [7] although the occurrence of multiple dermatofibromas, a cutaneous condition sometimes also related to immunodeficiency, has recently been reported in this therapeutic setting [8] . Although definitive conclusions cannot be drawn on so few cases, a very careful examination of the whole body surface including the genitals must be carried out on a regular basis in psoriasis patients receiving anti-TNFagents. Furthermore, the patient’s background must be carefully checked before considering anti-TNF treatment, and a history of skin carcinoma might