ESSENTIALS OF DIAGNOSIS
Nonhealing ulcer or warty nodule.
Skin damage due to long-term sun exposure.
Common in fair-skinned organ transplant recipients.
Squamous cell carcinoma usually occurs subsequent to prolonged sun exposure on exposed parts in fair-skinned individuals who sunburn easily and tan poorly. It may arise from an actinic keratosis. The lesions appear as small red, conical, hard nodules that occasionally ulcerate (Figure 6–32). In actinically induced squamous cell cancers, rates of metastasis are estimated from retrospective studies to be 3–7%. Squamous cell carcinomas of the ear, temple, lip, oral cavity, tongue, and genitalia have much higher rates of recurrence or metastasis and require special management. Patients with multiple squamous cell carcinomas (especially more than 10) have higher rates of local recurrence and nodal metastases. Nicotinamide, 500 mg orally twice daily, can decrease the rate of development of squamous cell carcinomas by 30% in high-risk groups.
Squamous cell carcinoma: an irregular-shaped pink plaque with overlying hemorrhagic crust in a chronically sun-exposed area. (Used, with permission, from Richard P. Usatine, MD, in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley H. The Color Atlas of Family Medicine, 2nd ed. McGraw-Hill, 2013.)
Squamous cell carcinoma in situ can be treated with imiquimod or 5-fluorouracil (in similar dosing as for superficial basal cell carcinoma) or curettage and electrodessication. The preferred treatment for invasive squamous cell carcinoma is excision or Mohs micrographic surgery. Mohs micrographic surgery is recommended for high-risk lesions (lips, temples, ears, nose), recurrent tumors, aggressive histologic subtypes (perineural or perivascular invasion), large lesions (greater than 1.0 cm on face, greater than 2.0 cm on trunk or extremities), immunosuppressed patients, lesions developing within a scar, and tumors arising in the setting of genetic diseases. Follow-up for squamous cell carcinoma must be more frequent and thorough than for basal cell carcinoma, starting at every 3 months, with careful examination of lymph nodes for 1 year, then twice yearly thereafter.
Transplant patients with squamous cell carcinomas represent a highly specialized patient population. Biologic behavior of skin cancer in organ transplant recipients may be aggressive, and careful management is required. Multiple squamous cell carcinomas are very common on the sun-exposed skin of organ transplant patients. The intensity of immunosuppression, not the use of any particular immunosuppressive agent, is the primary risk factor in determining the development of skin cancer after transplant. The tumors begin to appear after 5 years of immunosuppression. Voriconazole treatment appears to increase the risk of development of squamous cell carcinoma, especially in lung transplant patients. Regular dermatologic evaluation in at-risk organ transplant recipients is recommended. Other forms of immunosuppression, such as allogeneic hematopoietic stem cell transplants, chronic lymphocytic leukemia, HIV/AIDS, and chronic iatrogenic immunosuppression, may also increase skin cancer risk and be associated with more aggressive skin cancer behavior.
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