Aggressive biologic behavior of basal- and squamous-cell cancers in patients with chronic lymphocytic leukemia or chronic lymphocytic lymphoma

Cumulative incidence and timing of subsequent cutaneous squamous cell carcinomas stratified for patients with organ transplantation and hematologic malignancies: A nationwide cohort study

BACKGROUND

There is lack of nationwide data on the cumulative incidence and timing of subsequent cutaneous squamous cell carcinomas (cSCCs) among patients with a first cSCC.

OBJECTIVE

To investigate the cumulative incidence and timing of subsequent cSCCs.

METHODS

Patients with a first cSCC in 2007/2008 from the Netherlands Cancer Registry were linked to the Netherlands Pathology Registry for subsequent cSCCs and the Netherlands Organ Transplant Registry. Cumulative incidence function curves were calculated for subsequent cSCCs and stratified for immune status.

RESULTS

Among the 12,345 patients, second to sixth cSCC occurred in 4325, 2010, 1138, 739, and 501 patients, with median time intervals of 1.4, 1.2, 0.9, 0.6, and 0.5 years after the previous cSCC, respectively. The cumulative incidence of a subsequent cSCC at 5 years increased from 28% to 67% for the second to sixth cSCC. For solid organ transplant recipients, the cumulative incidences increased from 74% to 92% and from 41% to 64% for patients with hematologic malignancy.

LIMITATIONS

Only histopathologically confirmed cSCCs were included.

CONCLUSION

The risk of a subsequent cSCC steeply rises with the number of prior cSCCs and immune status, while the time interval decreases. This can support more informed decisions about follow-up management.

Risk of second primary malignancies in patients with chronic lymphocytic leukemia: a population-based study in the Netherlands, 1989-2019

The longevity of patients with chronic lymphocytic leukemia (CLL) has improved progressively over the past decades, making it essential to understand long-term health outcomes, such as second primary malignancies (SPMs). Therefore, this nationwide, population-based study assessed the risk of SPM development in CLL patients diagnosed during 1989-2019 in the Netherlands compared to the expected number of malignancies in an age-, sex-, and period-matched group from the general Dutch population. In 24,815 CLL patients followed for 162,698.49 person-years, 4369 SPMs were diagnosed with a standardized incidence ratio (SIR) of 1.63 (95% confidence interval [CI] 1.59-1.68). This elevated risk was observed for solid (SIR, 1.67; 95% CI, 1.65-1.75) and hematological SPMs (SIR 1.42; 95% CI, 1.24-1.62). The highest risk for SPMs was noted beyond five years post-diagnosis (SIR, 1.70; 95% CI, 1.62-1.77), for male individuals (SIR, 1.70; 95% CI, 1.64-1.77), and patients aged 18-69 years (SIR, 1.92; 95% CI, 1.79-2.05). The risk of SPMs was higher in CLL patients who received anti-neoplastic therapy (SIR, 2.12; 95% CI, 1.96-2.28), as compared with those who did not (SIR, 1.58; 95% CI, 1.53-1.63). Routine surveillance activities and tailored interventions to counteract the increased morbidity and excess mortality associated with SPMs are essential for improving long-term outcomes in CLL patients.

Cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia: a systematic review of the literature

The continuous improvement of life expectancy of patients with chronic lymphocytic leukemia (CLL) has resulted in increased risk of second primary malignancy that potentially may affect survival and quality of life of CLL patients. We performed a systematic review to assess the risk and the clinical‐pathological features and prognosis of cutaneous squamous cell carcinoma (cSCC) in patients with CLL. We searched PubMed, Embase, and Cochrane Central Register of Control Trials databases for articles published from database inception to December 31, 2019. English‐language studies reporting original data on patients with a specific diagnosis of CLL and cSCC were included. Data were extracted using a standardized extraction form, and any discordance was resolved by consensus. Descriptive data were generated by pooling patients from eligible studies. Of the 4588 non‐duplicate records identified, 55 articles met our inclusion criteria. These studies reported that CLL patients have a 3.2% prevalence of cSCC, with an 11.5% cSCC‐related lethality and an overall risk of metastasis of 5.7% (7.3% for regional lymph node involvement and 3.8% for distant metastasis). The quality of evidence was limited by the high heterogeneity in the design, populations, and objectives of the included studies. This systematic review suggests that cSCC in CLL patients tends to behave less aggressively compared with the solid organ transplant recipients but has a higher morbidity and mortality than in the general population. Future prospective studies are needed to increase the quality of evidence and to determine the best treatment modalities and screening intervals for these patients.

Knowledge, understanding, and use of preventive strategies against nonmelanoma skin cancer in healthy and immunosuppressed individuals undergoing Mohs surgery

BACKGROUND

Despite various national recommendations advising individuals to reduce their exposure to ultraviolet radiation, many people still do not use these skin cancer prevention strategies.

OBJECTIVES

To assess patient sources of medical information, knowledge of sun protection strategies, and barriers to implementing these strategies and to compare the overall rate of use of skin cancer prevention strategies of healthy and immunocompromised patients.

MATERIALS AND METHODS

Survey-based study conducted on 140 individuals undergoing Mohs surgery.

RESULTS

Seventy-three percent of healthy and 74% of immunosuppressed participants identified sunscreen use as a form of protective strategy, whereas 36% and 27%, respectively, used sunscreen daily. Participants cited physicians and the internet as equal sources of medical information. Knowing two or more strategies correlated to a higher self-rating of daily use of any protective strategy.

CONCLUSION

General knowledge regarding sun protection strategies is limited, but awareness of multiple strategies correlated with greater sun protective behavior. Despite having a much higher incidence of skin cancers, the immunosuppressed group did not show more awareness of prevention strategies or higher use than healthy participants.

The importance of early diagnosis and treatment of actinic keratosis

Chronic, long-term sun exposure results in genetic changes in epidermal keratinocytes and the development of various skin lesions ranging from actinic keratosis (AK) to skin cancer. AK lesions may first appear as rough, scaly spots on sun-exposed skin, and, although most individual AK lesions do not become invasive cancers, the majority of invasive squamous cell carcinomas originate from AK. Genetic analysis demonstrates that ultraviolet radiation-induced mutations and changes in gene expression are present in squamous cell carcinoma, AK, and clinically normal-appearing perilesional sun-exposed skin, which supports the progressive nature of keratinocyte transformation. The presence of certain clinical features, such as large size, ulceration, or bleeding, suggests an increased risk of disease progression. The risk is also increased by evidence of extensive solar damage, advanced age, and immunosuppression. Early diagnosis and consideration for treatment are indicated to clear actinically damaged sites and diminish the risk of invasive squamous cell carcinoma.

Risk of non-melanoma skin cancer in autoimmune hepatitis

BACKGROUND

Most patients with autoimmune hepatitis (AIH) require long-term immunosuppressive therapy (IS). While it is well established that solid organ transplant recipients have a high risk of developing non-melanoma skin cancer (NMSC) as a result of immunosuppression, little is known about the risk of NMSC associated with IS in patients with AIH.

OBJECTIVES

The aim of this study is to determine the incidence and risk factors for NMSC in patients on IS for AIH.

METHODS

We reviewed the medical records of all patients with AIH seen at a tertiary care medical center between 1998 and 2008. We compared the incidence of NMSC to an age- and sex-matched control population and analyzed risk factors for NMSC.

RESULTS

A total of forty-five patients with AIH were identified. Twenty NMSC lesions were found in eight patients. Compared to the age and sex-matched general population, the risk of SCC and BCC were increased as quantified by elevated standardized incidence ratios (28.5 and 5.0, respectively). Patients who developed NMSC were on average 24 years older (78.4 vs. 54.2 years old, p < 0.0001) and had AIH diagnosed at a more advanced age (66.0 vs. 45.4 years old, p = 0.0003).

CONCLUSION

The risk of NMSC is significantly increased in patients with AIH on immunosuppression. Independent risk factors include current age and age at diagnosis of AIH.

Treating recurrent cases of squamous cell carcinoma with radiotherapy

Patients with chronic lymphocytic leukemia (cll) are at a significantly increased risk of developing cutaneous squamous cell carcinoma (scc), in part because of their impaired immunosurveillance. Here, we report the cases of 4 patients with cll who had locally aggressive cutaneous scc managed with radiotherapy for local recurrence following surgical excision. All tumours were located in the head-and-neck region. All patients initially achieved complete regression of disease; however, 2 had local recurrence a mean of 8 months after treatment completion. One patient died from progressive scc. Our findings agree with the high rates reported in literature of multiple tumours, local recurrence, metastases, and mortality from scc in patients with cll. Radiotherapy plays an important role in patient management, and it is the recommended treatment modality when complete surgical excision of disease would result in anatomic and functional defects. Radiotherapy is often used in the case of local recurrence after one or more attempts at surgical excision. Dose escalation through intensity-modulated radiotherapy, hyperfractionation, or novel treatment techniques such as high-intensity focused ultrasound may be explored to improve local control of scc lesions. To optimize patient outcomes, cutaneous scc arising in patients with a history of cll should be managed and followed in a multidisciplinary clinic, with regular skin surveillance and prompt treatment.

Second neoplasms in chronic lymphocytic leukemia: incidence and pathogenesis with emphasis on the role of different therapies

Several surveys have defined chronic lymphocytic leukemia (CLL) patients as a high-risk patient population for developing second neoplasms. As possible mechanisms underlying the increased risk of specific second malignancies in CLL patients the immunodeficiency associated with disease is generally proposed. As far as secondary acute leukemia is concerned, greater insight into the molecular pathogenesis of therapy-related acute myeloid leukemia (AML) developing in CLL would allow to avoid treatment regimens that can lead to this complication. Richter's syndrome continues to be a fatal and highly refractory to chemotherapy disease complicating the clinical course of CLL. Therefore, experimental approaches of therapy should be considered in its treatment. Given the prolonged survival of patients with CLL, it is important to recognize early a second cancer especially whether new symptoms or physical findings arise.

Skin lesions in chronic lymphocytic leukemia

Cutaneous lesions occur in up to 25% of patients with chronic lymphocytic leukemia (CLL). These can be caused by either cutaneous seeding by leukemic cells (leukemia cutis, LC) and other malignant diseases or nonmalignant disorders. Skin infiltration with B-lymphocyte CLL manifests as solitary, grouped, or generalized papules, plaques, nodules, or large tumors. Prognosis in CLL patients with LC is rather good and many authors claim that it does not significantly affect patients' survival. However, prognosis is poor in patients in whom LC shows blastic transformation (Richter's syndrome) and when leukemic infiltrations in the skin appear after the diagnosis of CLL. Secondary cutaneous malignancies are also frequent complications in patients with CLL. A higher risk was seen in skin cancer, for which eightfold higher occurrence has been stated. There are some suggestions that alkylating agents and purine analogs may be associated with an increased incidence of secondary malignancies in CLL. Nonspecific, secondary cutaneous lesions are frequently observed in CLL patients. The most common secondary cutaneous changes seen in CLL are those of infectious or hemorrhagic origin. Other secondary lesions present as vasculitis, purpura, generalized pruritus, exfoliative erythroderma, and paraneoplastic pemphigus. An exaggerated reaction to an insect bite and insect bite-like reactions have been also observed.

Risk of nonmelanoma skin cancer with azathioprine use

While often life-saving for many complex diseases, iatrogenic immunosuppression has been associated with life-threatening infections and malignancies. Among these malignancies is skin cancer. Skin cancer is the most common form of cancer in the United States; the nonmelanoma skin cancers have an annual incidence of greater than 1,000,000 people in the US. It is well documented that the risk of nonmelanoma skin cancer (NMSC) is increased in those who are immunosuppressed. While many articles have been published on skin cancer risk in organ transplant recipients, little has been written regarding the incidence of nonmelanoma skin cancer in inflammatory bowel disease. A review of the literature of patients who are immunosuppressed for autoimmune disorders, and specifically, inflammatory bowel diseases, is discussed, as well as clinical presentations and treatment options.

Intrinsic and treatment-related immune alterations in chronic lymphocytic leukaemia and their impact for clinical practice

BACKGROUND

Chronic lymphocytic leukaemia patients harbour important impairments in both their cellular- and humoral-mediated immunity, which accounts for their notorious susceptibility to a multitude of infections and various autoimmune cytopenias. It has also been shown that the rate of second cancers is increased in chronic lymphocytic leukaemia.

OBJECTIVE

The aim of this study was to review the immune alterations in untreated and treated chronic lymphocytic leukaemia and define their impact for clinical practice.

METHODS

The author gives a comprehensive review of the most relevant preclinical and clinical studies pertaining to various immune abnormalities and infectious complications in both untreated and treated chronic lymphocytic leukaemia. Landmark clinical trials involving the contemporary chronic lymphocytic leukaemia chemo- and immunotherapies, alone or in combination, as well as the main epidemiological studies establishing the increased rate of second cancers in chronic lymphocytic leukaemia are also discussed.

RESULTS/CONCLUSIONS

Iatrogenic immunosuppression in chronic lymphocytic leukaemia alters the pattern of opportunistic infections, can cause autoimmune cytopenias and might further increase the rate of second malignancies in patients whose disease already places them at a greater risk. Careful consideration of existing risk factors in chronic lymphocytic leukaemia could establish the optimal screening and follow-up schedule for chronic lymphocytic leukaemia patients as its therapeutics evolves.

Metastatic cutaneous squamous cell carcinoma: an update

BACKGROUND

Squamous cell carcinoma (SCC) is the second most common type of skin cancer in the United States. Cutaneous SCC has the potential to metastasize and cause morbidity and mortality.

OBJECTIVE

Our purpose was to review and summarize the literature on metastatic cutaneous SCC, including risk factors for metastasis, data from clinical studies, and current management.

RESULTS

Multiple studies confirm that even well-differentiated and small tumors (<2 cm) may metastasize. Over the past two decades, additional literature on the risk factors for metastatic cutaneous SCC, including immunosuppression, has been published. In addition, new staging systems have been proposed that may influence management of these tumors. Chemotherapy regimens are numerous, but remain limited in ability to improve overall survival.

CONCLUSION

Although we know more about the risk factors, survival for patients with metastatic cutaneous SCC depends on extent of nodal involvement. Therefore, emphasis should remain on prevention and aggressive treatment of cutaneous SCC and vigilant observation for signs and symptoms of metastasis.

Incidence of second neoplasia in patients with B-cell chronic lymphocytic leukemia treated with chlorambucil maintenance chemotherapy

The aim of this retrospective study was to examine the impact of prolonged chlorambucil (CLB) therapy on the development of second neoplasia (SN) in 389 patients with B-CLL, comparing untreated cases with those receiving CLB as induction plus maintenance therapy. Fifty-nine SN cases were observed (15.1%) at a median follow-up of 79 months. SN occurrence was significantly related to Binet stage. No difference was detected between untreated and CLB treated cases neither in terms of SN incidence (12.2% vs 18.1%) nor in the median follow-up (81 vs 79.1 months). Moreover, SN free survival was not different between these two groups. Four out of 13 CLB treated patients (30.8%) developed s-MDS after a subsequent treatment with fludarabine plus cyclophosphamide (F + C). In conclusion, SN development is dependent on the length of follow-up rather than on therapy duration. F + C should be administered with caution after prolonged CLB therapy.

Sentinel Lymph Node Biopsy in Cutaneous Squamous Cell Carcinoma: A Systematic Review of the English Literature

BACKGROUND

Although most cutaneous squamous cell carcinoma (SCC) is curable by a variety of treatment modalities, a small subset of tumors recur, metastasize, and result in death. Although risk factors for metastasis have been described, there are little data available on appropriate workup and staging of patients with high-risk SCC.

OBJECTIVE

We reviewed reported cases and case series of SCC in which sentinel lymph node biopsy (SLNB) was performed to determine whether further research is warranted in developing SLNB as a staging tool for patients with high-risk SCC.

METHODS

The English medical literature was reviewed for reports of SLNB in patients with cutaneous SCC. Data from anogenital and nonanogenital cases were collected and analyzed separately. The percentage of cases with a positive sentinel lymph node (SLN) was calculated. False negative and nondetection rates were tabulated. Rates of local recurrence, nodal and distant metastasis, and disease-specific death were reported.

RESULTS

A total of 607 patients with anogenital SCC and 85 patients with nonanogenital SCC were included in the analysis. A SLN could not be identified in 3% of anogenital and 4% of nonanogenital cases. SLNB was positive in 24% of anogenital and 21% of nonanogenital patients. False-negative rates as determined by completion lymphadenectomy were 4% (8/213) and 5% (1/20), respectively. Most false-negative results were reported in studies from 2000 or earlier in which the combination of radioisotope and blue dye was not used in the SLN localization process. Complications were reported rarely and were limited to hematoma, seroma, cutaneous lymphatic fistula, wound infection, and dehiscence.

CONCLUSIONS

Owing to the lack of controlled studies, it is premature to draw conclusions regarding the utility of SLNB in SCC. The available data, however, suggest that SLNB accurately diagnoses subclinical lymph node metastasis with few false-negative results and low morbidity. Controlled studies are needed to demonstrate whether early detection of subclinical nodal metastasis will lead to improved disease-free or overall survival for patients with high-risk SCC.

Cutaneous squamous cell carcinoma metastatic to chronic lymphocytic leukaemia: diagnostic potential of fine needle aspiration cytology

OBJECTIVE

The phenomenon of cancer-to-cancer metastasis of cutaneous squamous cell carcinoma (SCC) and chronic lymphocytic leukaemia (CLL)/small lymphocytic lymphoma (SLL) is a rare event and only occasionally documented in the medical literature.

METHODS

Two patients with SCC of the skin that were previously treated for CLL are presented. Both had palpable lymph nodes in the neck and fine needle aspiration cytology (FNAC) was performed to evaluate the pathological process. In addition, the literature on cutaneous SCC metastatic to CLL/SLL with special emphasis on the role of FNAC in this specific clinical situation was reviewed.

RESULTS

On examination of the FNAC smear, cancer-to-cancer metastasis of cutaneous SCC to lymph node replaced by CLL was found. In one of the patients, light microscopy examination of the smear was complemented by immunostaining of atypical cells with cytokeratin antibodies and immunophenotyping of lymphoid cells by flow cytometry. In addition to our two patients, nine cases of cutaneous SCC metastatic to CLL/SLL have been reported in the literature, and in only one was the diagnosis made by FNAC.

CONCLUSION

FNAC supported by ancillary immunocytological techniques could also be used in diagnosis of specific clinical situations such as cancer-to-cancer metastasis of the tandem of SCC-CLL/SLL.

Basal Cell Carcinoma Progression Correlates With Host Immune Response and Stromal Alterations: A Histologic Analysis

Neoplastic progression is characterized in part by escape from immune surveillance and formation of growth-permissive stroma. Basal cell carcinoma (BCC) can be subclassified into low- and high-risk types for local recurrence. To determine whether these types of BCC correlate with alterations in local host immune response and stroma and whether these changes follow stepwise histologic progression from low- to high-risk subtypes, we assessed the clinicopathologic features in 175 consecutive primary (nonrecurrent) BCC excision specimens. BCCs exhibited a significantly higher frequency of mixed rather than homogeneous growth patterns (76% vs. 24%, P=0.0001). Nodular (84%) was the most common pattern identified followed by superficial (77%), infiltrative (27%), morpheic (5%) and micronodular patterns (4%). Only superficial (12% of all BCC) and nodular (12%) patterns were identified in BCC with a homogeneous histologic phenotype. Micronodular and infiltrative-morpheic patterns were not identified together in mixed patterned BCCs, and these high-risk types were contiguous with nodular BCC. Superficial predominant BCC (major growth pattern) was significantly associated with trunk and extremity location (76%) and skin without solar elastosis (82%), whereas BCC harboring a nodular growth pattern component was significantly associated with a head and neck location (63%) and the presence of adjacent solar elastosis (all P< or =0.03). Significant correlations were identified for BCC subtypes with inflammatory and stromal alterations: superficial BCC with old regression and moderate to dense peritumoral lymphocytic infiltrates; high-risk types correlated with active regression; infiltrative and morpheic BCC with fibrosing tumor stroma; and micronodular BCC with loss of both host inflammatory and stromal tumor responses. Evaluating the theoretical histologic stepwise model of BCC progression (superficial-to-nodular-to-micronodular, or superficial-to-nodular-to-infiltrative-to-morpheic BCC types) revealed significant linear correlations with host response and alterations of tumor stroma (r=0.54, P=0.0001). BCC exhibit distinct epithelial-stromal-inflammatory patterns that correlate with BCC subtype and tumor progression. This ostensible pathway of diminishing host response and gain of permissive tissue environment highlights neoplastic evolution from low to high risk for local recurrence of BCC and implicates a histologic continuum reflecting dynamic host-BCC interactions.

Parotid metastasis--an independent prognostic factor for head and neck cutaneous squamous cell carcinoma

BACKGROUND

Metastatic parotid cutaneous squamous cell carcinoma (SCC) is the most common parotid gland malignancy in New Zealand and Australia. The current AJCC TNM staging system does not account for the extent of nodal metastasis. A staging system that separates parotid (P stage) from neck disease (N stage) has been proposed recently.

AIM

To review the outcome of patients with metastatic head and neck cutaneous SCC treated at our multidisciplinary Head and Neck Service using the proposed staging system.

METHOD

Consecutive patients were culled from our Head and Neck/Skull Base Database, 1990-2004. These patients were restaged according to the proposed staging system: P stage: P0 = no disease in the parotid (i.e., neck disease only); P1 = metastatic node < or = 3 cm; P2=metastatic node > 3 cm and < or =6 cm, or multiple nodes; and P3 = metastatic node > 6 cm, or disease involving the facial nerve or skull base. N stage: N0=no disease in the neck (i.e., parotid disease only); N1 = single ipsilateral metastatic node < or = 3 cm; and N2 = multiple metastatic nodes, or any node > 3 cm, or contralateral neck involvement. Loco-regional recurrence and disease-specific survival were calculated using the Kaplan-Meier method and comparison of graphs made with the log-rank test. Multivariate analysis using the Cox regression model was carried out to assess the impact of various parameters.

RESULTS

Sixty-seven patients with metastatic head and neck cutaneous SCC were identified. Thirty-seven patients had parotid metastasis (of whom 13 also had neck disease) while 21 had neck metastasis alone. Nine patients had dermal or soft tissue metastasis. These nine patients were excluded from this series, and data analysis was carried out on the remaining 58 (46 men, 12 women, mean age 71 years) patients. Sixty-seven percent of the patients underwent post-operative adjuvant radiotherapy. The five-year disease-specific survival rate was 54%. Among 56 patients followed up to disease recurrence or for a minimum period of 18 months, the loco-regional recurrence rate was 52%. The presence of parotid disease was an independent prognostic factor on survival (p < 0.01), and P3 fared significantly worse than P1 and P2. Those patients who had both parotid and neck disease fared worse than those who had parotid or neck disease alone (p = 0.01). N2 had a significantly poorer outcome compared with N1 (p < 0.01). Immunosuppression (p = 0.01) and a positive surgical margin (p < 0.01) were significant adverse prognostic factors for survival. Adjuvant radiotherapy, extracapsular spread, and perineural and vascular invasion did not influence survival. Our study demonstrates that the extent of parotid disease is an independent prognostic factor for metastatic head and neck cutaneous SCC.

Increased metastasis and mortality from cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia

In patients with chronic lymphocytic leukemia, squamous cell carcinoma behaves aggressively. Our purpose was to compare squamous cell carcinoma metastasis and mortality between patients with chronic lymphocytic leukemia and control subjects. Medical records were assessed retrospectively for 28 patients with chronic lymphocytic leukemia who underwent surgical excision of cutaneous squamous cell carcinoma and for 56 matched control subjects. The rate of metastasis and mortality from cutaneous squamous cell carcinoma were determined on a per-patient basis. Three of 28 patients with chronic lymphocytic leukemia had metastasis and died of metastatic disease. No metastases or deaths occurred among the 56 control subjects. Compared with control subjects, chronic lymphocytic leukemia patients with cutaneous squamous cell carcinoma were more likely to have metastasis (P = .0031) and die of metastasis (P = .0033). No significant association was detected between metastasis and history of chemotherapy administration for chronic lymphocytic leukemia. Among patients with chronic lymphocytic leukemia, surveillance for skin cancer and a decreased threshold for biopsy of suspect lesions are warranted.

Cutaneous squamous cell carcinoma in patients with chronic lymphocytic leukemia

Patients with chronic lymphocytic leukemia are at heightened risk for the development of cutaneous malignancies, especially squamous cell carcinoma. These tumors portend a worse prognosis than is typically seen in immunocompetent patients. Patients with chronic lymphocytic leukemia who develop squamous cell carcinoma are more likely to develop multiple tumors, recurrences after treatment, and regional or distant spread of their tumor. Evaluation of the literature substantiates the ominous nature of squamous cell carcinoma in patients with underlying lymphocytic malignancies.

High recurrence rates of squamous cell carcinoma after Mohs' surgery in patients with chronic lymphocytic leukemia

BACKGROUND

Cutaneous cancers exhibit a much higher incidence in patients with chronic lymphocytic leukemia than in nonleukemic patients. Squamous and basal cell carcinomas also exhibit greater subclinical tumor extension in patients with chronic lymphocytic leukemia.

OBJECTIVE

The purpose of this study was to estimate and compare the recurrence rates of squamous cell carcinoma after Mohs' surgery in patients with chronic lymphocytic leukemia compared with those in controls and to evaluate differences among squamous cell carcinoma size and histologic grade.

METHODS

We retrospectively assessed the clinical histories, postoperative notes, and surgical photographs of patients with chronic lymphocytic leukemia and controls matched (2:1) for age, sex, and surgical year. Both patients and controls underwent Mohs' surgery for squamous cell carcinoma of the head and neck at the Mayo Clinic between March 1988 and April 1999.

RESULTS

Twenty-eight patients who underwent Mohs' surgery for 57 squamous cell carcinomas had 7 recurrences. The cumulative incidence of recurrence on a per-tumor basis was 4.3% at 1 year, 14.8% at 3 years, and 19.0% at 5 years. Squamous cell carcinoma was seven times more likely to recur in patients with chronic lymphocytic leukemia than in controls (p = .003). The distribution of tumor histologic grade was not significantly different between patients and controls (p = .39). Maximum preoperative tumor diameters were clinically similar between patients and controls (median 15 mm vs 14 mm; p = .04).

CONCLUSION

The recurrence rates of squamous cell carcinoma were significantly higher in patients with chronic lymphocytic leukemia. Squamous cell carcinomas in patients with chronic lymphocytic leukemia did not exhibit a significant difference in histologic grade or clinical difference in preoperative tumor size. Close surveillance for squamous cell carcinoma recurrence is warranted in patients with chronic lymphocytic leukemia.

Second neoplasms in patients with chronic lymphocytic leukemia

Second malignancies occur with increased frequency in patients with chronic lymphocytic leukemia (CLL) regardless of treatment, but they may be more frequent and more aggressive after nucleoside analog therapy of CLL. In as many as 33% of patients with CLL who develop a second malignancy, a spontaneous remission of CLL precedes the diagnosis of the second malignancy by months or years. Richter's syndrome, whether manifested by anaplastic large cell lymphoma or Hodgkin's disease, is not truly a second malignancy because the CLL clone appears to be involved. However, all other malignancies developing in patients with CLL appear to be derived from a different clone. CLL and the second malignancy may have a common viral etiology. Second malignancies in patients with CLL should be treated as they would be in patients without CLL.

A diagnosis of chronic lymphocytic leukemia prompted by cutaneous lymphocytic infiltrates present in mohs micrographic surgery frozen sections

BACKGROUND

Chronic lymphocytic leukemia (CLL) is the most common form of leukemia in the United States. Patients with CLL are at an increased risk for the development of second malignant neoplasms, the most common of which is cuta-neous squamous cell carcinoma (SCC). Cutaneous infiltrates of CLL have been reported in association with primary cutaneous neoplasms, including SCC, basal cell carcinoma, and actinic keratosis. The finding of a dense lymphocytic infiltrate surrounding a cutaneous neoplasm should prompt consideration of possible underlying CLL.

OBJECTIVE

To review the relationship of CLL to cutaneous SCC and to raise awareness of the possible coexistence of these two neoplasms.

METHODS

The case report describes a patient with a SCC of the left cheek treated with Mohs micrographic surgery. A dense lymphocytic infiltrate was noted on the frozen sections, and a complete blood count was obtained.

RESULTS

A lymphocytosis was detected, leading to the diagnosis of CLL, stage 0.

CONCLUSION

Patients with CLL are at an increased risk for the development of cutaneous neoplasms. An infiltrate of leukemic cells in documented CLL patients can be associated with cutaneous neoplasms such as SCC. We present a patient with no known hematologic malignancy who demonstrated a dense lymphocytic infiltrate on Mohs sections. The diagnosis of CLL was considered based on the appearance of this infiltrate. Subsequently, a new case of CLL was confirmed with appropriate testing. The finding of a dense subcutaneous infiltrate of lymphocytes on Mohs frozen sections should raise the possibility of CLL and lead to appropriate screening tests.

Multiprofessional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma

These guidelines for management of primary cutaneous squamous cell carcinoma present evidence based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation. To reflect the collaborative process for the UK, this article is subject to dual publication in the British Journal of Dermatology and the British Journal of Plastic Surgery.

Lymphocytic infiltrates and subclinical epithelial tumor extension in patients with chronic leukemia and solid-organ transplantation

BACKGROUND

Dense infiltrates in association with squamous cell carcinoma (SCC) or basal cell carcinoma (BCC) in patients with underlying chronic lymphocytic leukemia (CLL) may complicate pathologic interpretation of histologic margins.

OBJECTIVE

The study was conducted to determine the frequency of identifying dense inflammatory infiltrates in frozen histologic sections during Mohs operation for BCC or SCC in patients with CLL and organ-transplant recipients, to characterize the infiltrate (reactive versus leukemic) in CLL, and to estimate the subclinical tumor extension in patients with CLL, transplant recipients, and control subjects undergoing Mohs procedure.

METHODS

Frozen sections of head and neck BCC and SCC obtained during Mohs procedures in patients with CLL, organ transplant recipients, and a control group were reviewed retrospectively. Biopsy specimens of CLL with dense infiltrates were assessed with immunohistochemical stains. Subclinical tumor extension (postoperative defect size minus preoperative tumor size) was evaluated in each group.

RESULTS

Dense infiltrates were found in tumors of 20 of 55 patients with CLL (36%), 1 of 8 transplant recipients (13%), and 1 of 105 controls (1%). In patients with CLL, 75% of the dense infiltrates were B-cell leukemic. Compared with controls, the mean subclinical tumor extension was larger in patients with CLL (P=0.029) and in transplant recipients (P=0.55).

CONCLUSION

Dense leukemic infiltrates associated with BCC or SCC in CLL may complicate pathologic interpretation of Mohs surgical histologic margins and may be associated with larger postoperative defects relative to preoperative clinical tumor appearance. In patients with CLL, as in transplant recipients, SCC seems more likely to develop than BCC.

Multiprofessional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma

These guidelines for management of primary cutaneous squamous cell carcinoma present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.

Effect of perilesional injections of PEG-interleukin-2 on basal cell carcinoma

BACKGROUND

Multiple modalities are available for the treatment of basal cell carcinoma (BCC). The most commonly used modalities include simple excision, Mohs micrographic surgery, curettage and electrodessication, cryosurgery, and irradiation therapy. Interleukin-2 (IL-2) is a cytokine produced chiefly by activated T lymphocytes and has effects on various components of the immune system. Until now the primary clinical use of IL-2 has been in advanced stages of metastatic melanoma and renal cell carcinoma. Systemic administration of IL-2 is known to cause significant toxicity.

OBJECTIVE

The objective of this study was to evaluate the therapeutic efficacy and safety of perilesional PEG-IL-2 injections in patients with BCC in an open label, uncontrolled pilot study.

METHODS

Patients with histologically confirmed primary BCC over 18 years of age were included in the study. Lesions were treated by injecting a total volume of 0.5 cc of IL-2 in a radial fashion in the subcutaneous tissue. Injection dosages ranged from 3000 to 1,200, 000 IU in one to four weekly dosages. A total of 12 tumors were treated in eight patients.

RESULTS

Overall response rates were as follows: complete response in 8 of 12 treated tumors (66.6% cure rate), partial response in 3 of 12 injected tumors (25% partial response rate), stable disease with no improvement in 1 treatment site (8.4%). Side effects included local pain, swelling, and erythema, and in one patient flulike symptoms. There were no significant changes of blood tests as compared to baseline levels.

CONCLUSIONS

The therapeutic response induced by perilesional PEG-IL-2 injections was found to be an encouraging, safe, and well-tolerated treatment of BCC. Further studies including a larger patient population and long-term follow-up are necessary in order to substantiate these findings.

Epidemiology of actinic keratoses and squamous cell carcinoma

OBJECTIVE

The purpose of this article was to review the frequency, distribution, and determinants of actinic keratoses (AKs) and squamous cell carcinoma (SCC).

METHODS

A review of the literature was done.

RESULTS

AKs are extremely common lesions on the sun-exposed skin of Caucasian persons. The most important risk factors are a combination of genetic propensity ("fair skin phenotype") and cumulative sun exposure. Their prevalence increases with advancing age. The epidemiology of SCC is virtually the same, but the lesions occur most often on the head rather than on the upper extremities where most AKs are located. AKs are the most important risk factor identifying those most predisposed to the development of an SCC.

CONCLUSION

AKs are a reliable marker for those people most predisposed to development of an invasive SCC. In addition, AKs are probably an early stage in a biologic continuum that culminates in SCC. However, there are many more AKs than SCCs, and it is difficult to predict exactly which lesions will progress to invasive cancer.

Clinical measurement of dimensions of basal cell carcinoma: effect of waiting for elective surgery

Fifty well-defined basal cell carcinomas (BCCs) on the face, outside the central T, were studied to establish change in size between initial assessment and surgery. The major and minor diameters were measured at presentation and when the patients attended for elective excision 21-155 days later (mean 70). The median change in major diameter was an increase of 0.5 mm (range - 3 to + 4, P < 0.05). The median change in area was 4.71 mm2 (range - 54 to + 64, P < 0.05). Although there is a statistically significant increase in major diameter and area, it was small in clinical terms. The major axis increased by > 1 mm in 8% of cases. In no case was treatment or completeness of excision compromised by waiting. A mean delay of 10 weeks between review and surgery does not appear to compromise the outcome of treatment of BCC in patients with well-defined BCCs of the face outside the central T.

Guidelines for the management of basal cell carcinoma. British Association of Dermatologists

These guidelines on the management of basal cell carcinoma have been prepared for dermatologists on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.

Squamous cell cancer: a practical approach

Cutaneous squamous cell carcinoma (SCC) is the second most common form of skin cancer and is treated frequently by dermatologists. For many years, the level of knowledge regarding treatment of SCC has taken a backseat to the treatment of basal cell carcinoma and malignant melanoma. As dermatologists become more surgically proficient and assume a leading role in the surgical care for cutaneous carcinoma, a thorough knowledge of the appropriate management of SCC is of paramount importance. In particular, it is essential to recognize that, unlike basal cell carcinoma, certain SCC have a significant metastatic potential and require more comprehensive care. This review targets the etiology, pathogenesis, clinical presentation, histopathology, and treatment of SCC. Particular attention is focused on providing appropriate care for SCC and recognizing and arranging appropriate management for high risk SCC.

Squamous cell carcinoma in a patient with chronic lymphocytic leukemia. An intraoperative diagnostic challenge for the Mohs surgeon

BACKGROUND

Chronic lymphocytic leukemia (CLL) is the most common form of chronic leukemia in the US. CLL patients have an increased risk of developing other malignant neoplasms, especially skin cancer. Lymphoma-associated squamous cell carcinomas (SCCs) tend to behave more aggressively and therefore are often treated with Mohs micrographic surgery (MMS).

OBJECTIVE

To elucidate the potential difficulty of distinguishing perineural infiltrates as leukemic infiltrates versus inflammatory infiltrates associated with SCC on frozen tissue sections during MMS.

METHODS

This is a case report illustrating a patient with CLL who develops a SCC on the posterior ear. MMS was employed to treat the patient. Special immunohistochemical stains were performed to help distinguish the type of perineural infiltrate present.

RESULTS

The perineural infiltrate was shown by immunohistochemistry to be leukemic in origin. Special stains for keratin revealed no residual SCC hidden in the infiltrate.

CONCLUSION

CLL is a malignancy that primarily effects the elderly population and markedly increases their risk of developing skin cancers, especially SCC. An intense infiltrate may be present surrounding the tumor. This case report demonstrates one of the potential challenges the Mohs surgeon may face in interpreting histologic frozen section. Immunohistochemistry may be helpful in providing a more definitive answer to this problem.

Cellular proliferation characteristics do not account for the behaviour of horrifying basal cell carcinoma. A comparison of the growth fraction of horrifying and non horrifying tumours

This study compared the clinical features, histological subtype, growth fraction (by Ki67 immunohistochemistry) and proliferation pattern of 22 clinically defined horrifying basal cell carcinoma compared to 81 non horrifying lesions. Late presentation was associated with half of the horrifying tumours. The other half developed horrifying tumours despite early intervention. The horrifying tumours exhibited a variety of histological growth patterns. A total of 50% were infiltrative, 23% nodular and 18% micronodular. There was no difference in the growth fraction or proliferation pattern between horrifying and non horrifying tumours of similar growth pattern (P = ns), although infiltrative tumours in either group exhibited a significantly higher growth fraction than nodular tumours (P < 0.01). This suggests that there is no intrinsic biological difference between horrifying and non horrifying tumours to account for their behaviour. We conclude that late presentation, failed or inadequate early management especially of infiltrative tumours (and other subtypes) determines the development of horrifying tumours.

Aggressive cutaneous squamous cell carcinoma of the head and neck in patients with chronic lymphocytic leukaemia

We describe multiple cutaneous squamous cell carcinomas of the head and neck in five patients with chronic lymphocytic leukaemia (CLL). When associated with CLL, cutaneous squamous cell carcinomata behave in a much more aggressive manner than otherwise expected. Four patients developed local recurrence after primary treatment. All five patients developed lymph node metastases containing squamous cell carcinoma. Three of five patients (60 per cent) had multiple primary lesions. Whereas the increased incidence of second cancers in CLL and notably of skin cancers is documented, little has been written to describe the aggressive behaviour of these tumours. It is important, when treating these patients, to be aware of the high tendency towards local recurrence and lymph node metastasis and to consider an aggressive management plan and careful follow-up.