posed by SCC must be balanced with the risks of a new immunosuppressive regimen and rejection. The transplant physician should be advised by the dermatologist or Mohs surgeon of the impact of SCC on the patient’s quality of life and estimates of morbidity and mortality for high-risk tumors conveyed.

17.5.8 Follow-Up for High-Risk SCC Patients

Because patients with nodal disease can be cured up to 73% of the time [104], patients with cutaneous SCC should be closely followed for recurrence; early detection and treatment are crucial. Full skin and lymph node exam by a dermatologist every 3–6 months is advised with 95% of local recurrences and metastases occurring within 5 years [11]. A neurological exam should be performed if indicated. Aggressive management of actinic keratoses and early biopsy of suspicious or persistent lesions are recommended. For more advanced cases, such as with PNI, with multiple recurrences, or in those who are at higher risk of aggressive tumor behavior secondary to immunosuppression, re-imaging of the draining nodal basin can be considered every 6 months.

Summary: Treatment of Field Cancerization

•The treatment of the immunosuppressed patient with diffuse actinic damage and innumerable atypical squamous tumors requires field therapy, applied sequentially. The treatment of “field cancerization” is likely to improve the quality of life of such patients, ideally limiting the development of invasive disease and the time spent in health care facilities.

As stated above, the first step in an immunocompromised patient is to address and improve their immune status when possible. This should be followed by clearing all invasive SCCs. Histologic margins should be examined for all invasive SCCs, and electrodessication and curettage should be avoided. One approach that is acceptable to patients due to its efficiency is the use of disc excision without prior biopsy to clear numerous invasive SCCs on the body. Invasion can often be determined clinically by the presence of dermal induration. Patients can be seen monthly, and multiple tumors can be removed at each visit. Wound care instructions for secondary intention healing are provided. Tumors that are appropriate for Mohs (large lesions and those on the head, below the knees, and hands) may be biopsied and then treated via Mohs excision. This “clean-up” phase to remove invasive tumors may require several months of frequent visits.

Concurrently, hypertrophic actinic keratoses and suspected early SCCIS are curetted to remove hyperkeratotic overlying scale (Fig. 17.6). This is followed immediately by topical 5-fluorouracil (5-FU) twice a day for a month to a given field. Such a regimen can markedly improve field cancerization (Fig. 17.7). Application of petrolatum every 3–6 h to the treated area can reduce theburningsensationandincreasetolerability.Imiquimod is less useful in this setting given the eroded skin surface and large areas of involvement which can lead to increased systemic absorption and severe flu-like side effects. Similarly, cryotherapy has a limited role in the treatment of field cancerization, as it cannot be applied to large surface areas. Curettage of hyperkeratotic AKs and SCCISs followed by 5-FU may be repeated as needed. Patients with severe dermatoheliosis may need re-treatment every 6–12 months to maintain control of their disease. Lesions that fail to clear must be biopsied or treated with disc excision [132].

Another option for the treatment of field cancerization includes cyclic photodynamic therapy (PDT). The

Patients with diffuse actinic damage on the AK/SCCIS spectrum, termed “field cancerization,” who develop multiple SCCs, particularly OTRs, must be approached differently than the typical sun-damaged patient with one or few tumors. These field-damaged patients spend a considerable amount of time in health care facilities, and their tumors may adversely affect their quality of life in addition to their long-term survival.

wrap occlusion followed by PDT with blue light (417 nm) every 2–4 months has been shown to reduce cutaneous SCC formation by 95% when compared to the year preceding the initiation of this method [133].

If patients continue to develop multiple cancers 6–12 months after instituting the above methods for field treatment, the addition of low-dose oral retinoids, dosed as discussed above, should be considered for tumor prophylaxis. Again, patients are likely to require

Summary: Conclusions

•Cutaneous SCC is common and can be aggressive, with high morbidity and mortality particularly in the immunocompromised. A thorough understanding of disease development as well as all available treatment options is critical in optimizing patient care.

Fig. 17.7 (a) Diffuse actinic keratoses and SCCIS. (b) The same patient after a 4-week course of 5% 5-fluorouracil cream twice daily with marked improvement

17.7Conclusions

SCC is the second most common malignancy in white persons, and despite its visibility on the skin, accounts for thousands of deaths annually in the USA. Although

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