Squamous cell carcinoma of the skin medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2], Raviteja Guddeti, M.B.B.S. [3]
Overview
Squamous cell carcinoma is a locally invasive tumor that has the potential to become malignant, and can be treated successfully in up to 95% - 98% cases with a timely management. The available options for medical treatment are as follows;
- Cryotherapy
- Electrosurgery (curettage and electrodessication)
- Topical therapy (5-Flourouracil, photodynamic therapy, and Imiquimod for cutaneous lesions.
While systemic treatment includes;
- Radiation therapy
- Chemotherapy
Medical Therapy
Medical care of squamous cell carcinoma (SCC) includes cryosurgery, electrosurgery, radiation therapy and topical treatment for cutaneous lesions, and chemotherapy for systemic disease.
- Cryotherapy destroys malignant cells by freezing them and then allowing them to thaw. It is useful for small, well-defined, low-risk invasive SCCs, and for Bowen's disease. In cryosurgery, liquid nitrogen is applied to the tumor and a surrounding rim of normal-appearing skin (usually ≥3 mm). The frozen area is then allowed to thaw unaided. In most cases, the tumor is refrozen to complete two freeze-thaw cycles; for Bowen's disease, a single freeze-thaw cycle may be sufficient.[1].Tumor cell death is due to the formation of intracellular and extracellular ice crystals, hypertonicity, disruption of the phospholipid membrane, and vascular stasis. Cryotherapy is a quick procedure and is cost-effective. This therapy is not indicated for large recurrent lesions, deeply invasive lesions, and other high risk SCC.
- Electrosurgery is usually employed if the lesion is small, well defined and located in non-critical areas of the body. It is also cost-effective, gives favorable cosmetic results and has a low complication rate. The procedure is performed by alternatively curetting away tumor and then electrodessicating the ulcer base with inclusion of a rim of normal surrounding skin. Cure rates of nearly 96% can be achieved with this treatment provide the lesion is small and well defined. This treatment should be avoided on the mid-face region. It is contraindicated in recurrent, large, poorly defined, and other high risk SCCs.
- Topical 5-fluorouracil (5-FU) is approved by the Food and Drug Administration (FDA) for the treatment of actinic keratoses. Although topical 5-FU is not approved for the treatment of SCC in situ, it is widely used for this indication when other treatment modalities are impractical and for patients who refuse surgical treatment. It is especially valuable for situations in which postoperative healing is compromised, such as in lesions that involve the lower extremity in elderly patients or those with venous stasis disease. Topical 5-FU is also useful to treat the widespread SCC in situ lesions that may occur in arsenical dermatitis or xeroderma pigmentosum (XP).[2] Topical 5-FU is available in 0.5%, 1% and 5% concentrations. 1% and 0.5% are used for actinic keratosis. 5% cream is used twice daily for 4 - 8 weeks in the treatment of SCC in situ. Cure rates of up to 85% were achieved in one study with this type of treatment. For recurrent disease, courses are repeated. 5-FU gives favorable cosmetic results, but is contraindicated in invasive lesions.
- Photodynamic therapy is another form of medical therapy used for lesions on the face and scalp. The therapy is performed by applying a photosensitizing agent, such as topical 5-aminolevulinic acid (5-ALA) to the growths. The agent is taken up by the abnormal cells, and the medicated areas are subsequently activated by a strong light. This treatment selectively destroys the abnormal cells of the squamous cell carcinoma while causing minimal damage to the surrounding normal tissue. It is especially effective in early, non-invasive lesions, and is not recommended in invasive lesions. It is performed in the physicians’ office and the patients must avoid sunlight for 48 hrs after the photosensitizing agent is applied on the lesions. This form of treatment is yet to be approved by the FDA.
- Imiquimod is a topical immune response modifier approved by the FDA for the treatment of anogenital warts and actinic keratoses and has been used in the treatment of SCC in situ. It works by stimulating local cytokine production, cell-mediated immunity, and possibly promotes apoptosis. It is applied daily for 6 - 16 weeks. In case of failure with monotherapy it can be combined with 5-FU. It is not approved by FDA for treatment of SCC in situ.
- Radiation therapy is an excellent choice for the management of initial small well defined lesions, especially primary SCCs in older individuals and those who are not candidates for surgical procedures. This form of treatment is administered in a fractionated form requiring nearly 30 treatments.[3] For low risk lesions the cure rate approaches nearly 90%. The main advantage of this kind of treatment is sparing of the surrounding normal healthy skin, thus providing superior cosmetic benefits. Radiotherapy is contraindicated in
- Tumors located on the trunk, extremities, ear and nose.
- Patients younger than 40-50 years.
- Recurrent SCCs that have previously been irradiated.
- Cancers with large and poorly defined lesions, and other high risk SCCs.
In nasopharyngeal squamous cell carcinoma, radiotherapy is the mainstay of treatment along with chemotherapy in advanced lesions. Radiotherapy is administered to the tumor volume and also to the adjoining lymph nodes. A multi-institutional study showed that a dose of at least 66 Gy to the gross disease is needed for optimal control of the lesion. This kind of treatment is usually administered along with Cisplatin and 5-FU.
- Systemic chemotherapy is used in advanced metastatic lesions which cannot be treated with radiotherapy and surgery. Cisplatin combination regimens are particularly effective in the treatment of SCC of skin and lip. The combination of cisplatin and bleomycin seems to be very effective.
References
- ↑ Holt PJ (1988). "Cryotherapy for skin cancer: results over a 5-year period using liquid nitrogen spray cryosurgery". Br. J. Dermatol. 119 (2): 231–40. PMID 3166941. Unknown parameter
|month=ignored (help) - ↑ Mackenzie-Wood A, Kossard S, de Launey J, Wilkinson B, Owens ML (2001). "Imiquimod 5% cream in the treatment of Bowen's disease". J. Am. Acad. Dermatol. 44 (3): 462–70. doi:10.1067/mjd.2001.111335. PMID 11209116. Unknown parameter
|month=ignored (help) - ↑ Lovett RD, Perez CA, Shapiro SJ, Garcia DM (1990). "External irradiation of epithelial skin cancer". Int. J. Radiat. Oncol. Biol. Phys. 19 (2): 235–42. PMID 2394605. Unknown parameter
|month=ignored (help)