Continuing with the reprise of this series. This post was originally posted July 19, 2007. I redid the layout slightly, so that I hope it is easier to read.
- Age 50 yrs or older, Male, Fair Skin (burns easily, very or rarely tans)
- Geography–lives closer to the equator (Florida, Australia)
- History of prior non-melanoma skin cancer
- Exposure to UV light--natural or tanning bed or treatment (psoralen plus UVA (PUVA) for psoriasis
- Exposure to chemical carcinogens (arsenic, tar)
- Radiation exposure–treatment for other cancers (lymphomas, etc)
- Chronic immunosuppression–a history of solid-organ transplantation, hematologic malignancy (CLL), HIV infection or long-term use of immunosuppressive medications for an autoimmune condition
- Chronic scarring condition–Marjolin ulcer refers to an SCC that arises from chronically scarred or inflamed skin. Patients may report a change in the skin (induration, ulceration, weeping) at the site of a preexisting scar or ulcer. The latency period is often 20-30 years. Major burn scars. Chronic venous ulcers. Not scars from simple lacerations.
- Genodermatoses -- Human Papilloma Virus (HPV) infections–Virally induced SCC most commonly manifests as a new or enlarging warty growth on the penis, vulva, perianal area, or periungual region. Patients often present with a history of "warts" that have been refractory to various treatment modalities in the past.
Warning signs: (credit -- photo examples)
- A wart-like growth that crusts and occasionally bleeds.
- A persistent, scaly red patch with irregular borders that sometimes crusts or bleeds
- An open sore that bleeds and crusts and persists for weeks.
- An elevated growth with a central depression that occasionally bleeds. A growth of this type may rapidly increase in size.
Treatment Modalities are similar to those of BCC (see yesterday's post).
Most SCCs are readily treated with an expectation of cure. The 3-year disease-specific survival rate has recently been estimated to be 85%; this rate approaches 100% for lesions with no high-risk factors (see below), but it decreases to 70% for patients with at least 1 risk factor.
- Tumor location (ie, lips,ears, scar)--The historical rates of metastases for SCC of the external ear and the lip are approximately 11% and 10-14%, respectively. Marjolin ulcer subtype of SCC behaves aggressively, with a metastatic rate of approximately 18-38%.
- Tumor size greater than 2 cm –These may have a metastatic rate of up to 30.3%.
- Invasion to subcutaneous fat (or deeper) --SCC with a depth of less than 2 mm rarely metastasizes. SCC with a depth of invasion less than 4 mm has a historical recurrence rate of 5.3% and a metastasis rate of 6.7%; these rates increase to 17.2% and 45.7%, respectively, for tumors invading greater than 4 mm.
- Poorly differentiated tumor – are generally accepted to behave more aggressively.
- Recurrent tumor-- has a site-dependent rate of metastasis of 25-45%.
- Perineural involvement --has been estimated to occur in 2.4-14% of persons with cutaneous SCC, most commonly in elderly men with tumors of the head and neck. The prognosis in such cases is extremely poor, with historical rates of local recurrence and metastasis reported to be as high as 47%.
- Organ transplant recipient --SCC in OTRs occurs more frequently, appears at an earlier age, is often multicentric, and may be clinically aggressive. The rate of local recurrence has been reported to be as high as 13.4%, while metastasis occurs in 5-8% of patients. Metastatic SCC in OTRs has a dismal prognosis, with a 3-year disease-specific survival of only 56%.
- Hematologic malignancy (eg, CLL) --in patients with CLL, the recurrence rate of SCC treated with MMS was 7-fold higher at 5 years compared with patients without CLL. In addition, a small case-control study found the 5-year cumulative incidence of SCC metastasis to be 17.7% for patients with CLL.
- Chronic immunosuppressive therapy or disease state: HIV infection or AIDS--In one small case series, 5 of 10 patients with HIV and aggressive SCC died of metastasis within 7 years of the initial diagnosis.