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Actinic Keratoses (Pre-Cancerous Growths) and Squamous Cell Carcinoma

1.    What are actinic keratoses, disseminated superficial actinic porokeratosis and squamous cell carcinoma?

Actinic keratoses and disseminated superficial actinic porokeratoses (DSAP) or pre-cancerous skin growths, are small, pinkish or skin-colored rough spots most commonly found on sun-exposed skin.  These lesions have the potential of becoming squamous cell carcinomas, and if not treated, these cancers can become dangerously invasive and spread to nearby lymph nodes and/or throughout the body.  Approximately 5% of actinic keratoses may evolve into squamous cell carcinoma.

2.    What do actinic keratoses, disseminated superficial actinic porokeratosis and squamous cell carcinoma look like?

Actinic keratoses appear as “sandpapery” rough pink or skin-colored growths that do not seem to heal.  They may thicken, and become “horn-like.”  Alternatively, actinic keratoses may become eroded or develop a central crust or “scab.”   A skin growth that persists as an open wound for over a month should be evaluated immediately, as it may be a squamous cell skin carcinoma.  Actinic keratoses occur mainly on the face, scalp, tips of the ears, nose, lips, backs of the hands, forearms, and DSAP also occurs most often on sun exposed skin, frequently on arms or legs, and more often in women.  If left untreated, squamous cell skin cancers may develop into large masses, and although rare, may metastasize into surrounding tissue and lead to significant disfigurement upon excision.

3.    Who gets actinic keratoses, disseminated superficial actinic porokeratosis and squamous cell carcinoma?

Actinic keratoses are relatively common, especially in middle-aged, fair-skinned adults, and rarer in African-American, Asian, or other darker skin types.  In Australia or southwestern United States, where there is more sun exposure, fair-skinned adults may develop actinic keratoses at younger ages, such as the later 20s or 30s.  Actinic keratoses occur more frequently among outdoor workers, sportspersons, and lifelong tanners.  These groups also have a higher risk of developing squamous cell skin cancers.  

4.    What causes actinic keratoses, disseminated superficial actinic porokeratosis and squamous cell carcinoma?

Actinic Keratoses are caused by exposure to ultraviolet radiation from the sun.  DNA of the skin cells is damaged and, if this damage is not repaired by the body’s innate DNA-repair system, these cells may transform into cancer.  Sun exposure / UV radiation also reduces the body’s immune system, making the skin more susceptible to damage and cancerous transformation.

5.    What triggers actinic keratoses, disseminated superficial actinic porokeratosis and squamous cell carcinoma?

There are many factors that may trigger or enable actinic keratoses and squamous cell cancers to form.  These include repeated sun or other UV exposure (such as tanning beds), chronic ulcers or burn scars, working with industrial carcinogens such as fuel oils, pitch, or tar, infection with HPV (wart) virus types 16, 18, or 31, or a compromised immune system.  The resulting actinic keratoses and squamous cell skin cancers in these individuals may be much more aggressive.

6.    How can my actinic keratoses, disseminated superficial actinic porokeratosis and squamous cell carcinoma be treated?

How can my actinic keratoses and squamous cell carcinoma be treated?
Squamous cell carcinomas on the body or face can be treated by simple excision in the dermatologist office. However, lesions near the eye, scalp, nose, lips and ears, or on areas where there is minimal excessive normal skin, can be treated with either Mohs micrographic surgery or by a non-surgical, approach called electronic brachytherapy (Ebx, see below), both offered in our offices. For more information on squamous cell carcinoma treatments or to schedule a skin check, please call and speak with a representative at the Berman Skin Institute.

ELECTRONIC BRACHYTHERAPY (EBX) may be the treatment of choice when:

Looking for a painless, nonsurgical therapy?

Scarring needs to be minimal as the tumor is in a visible area (face or nose)

The tumor is in an uncomfortable position (shin)

Surgery is not advised due to a health condition or medication (blood thinners)

It is vital to preserve the structure and use of the area being treated (hand or ear)

The margins are positive after initial surgical excision

Radiation Treatment Options for NMSC:
OLDER, MORE TRADITIONAL External Beam Radiotherapy (EBRT) uses low-dose x-rays or electrons accurately directed to the area of the tumor within a specialized treatment facility. It is used for the vast majority of cancer types and is delivered daily over several weeks. Also, the older HDR Brachytherapy works via a precise, radioactive seed that delivers high dose radiation within specialized catheters to a targeted area within a shielded room. It is also commonly used for breast, lung, prostate and gynecologic cancers.

NEWER, INNOVATIVE Electronic Brachytherapy (Ebx) is a highly focused therapy that uses low-energy x-rays without using a radioactive isotope. The treatment thus maximally spares healthy tissues and can be delivered safely and conveniently in an unshielded room.

The Ebx Procedure: The simple outpatient treatment takes place twice a week for approximately 4 weeks. The number of sessions required will vary based on the tumor size, depth, and location. An individualized treatment plan with custom shielding is developed for each patient. During treatment, a small surface applicator is applied to the skin thru which radiation is delivered for just a few minutes. The therapy is non-invasive and painless.

The patients are able to drive themselves home and immediately return to normal activities. As a superficial skin treatment localized to the skin cancer, there is no radiation exposure to other areas of your body or to anyone else.

A radiation therapist and physicist work under the direct supervision of a radiation oncologist who specializes in radiation treatment of skin cancer.

Proven effective: Cure rates are similar to surgery and EBRT; most people receiving brachytherapy remain cancer-free.

Painless Procedure: Pain-free, knife-free and needle-free, no anesthesia or sedation is needed.
Minimal or no scarring: Outstanding appearance of treatment site.
Minimal loss of use:
Little or no healthy tissue affected so loss of use is minimal compared to surgery.
Minimal side effects: Accurate delivery of radiation directly to tumor reduces the risk of side effects.
Convenience of short treatment: Brachytherapy is often given over a few days compared to weeks of EBRT and unlike surgery, no recovery time is needed.

State-of-the-art therapy: 
Established therapy; continued technological advances providing even more effective treatment. Advances in treatment planning and applicator design facilitate even greater precision in dose delivery and minimizes harmful radiation to surrounding healthy tissues. Excellent efficacy, cosmetic and functional outcomes, combined with reduced risk of side effects, short outpatient treatment times and improved quality of life indicate that brachytherapy is a patient-centered treatment choice. The shorter treatment duration of surface brachytherapy also lowers the total treatment costs.

Actinic keratoses may require multiple treatments, but generally disappear after one or two treatments with liquid nitrogen cryotherapy. After freezing, a blister may form over the lesion, which may crust (scab) while healing. Rarely, a slight difference in pigmentation, either darker or lighter, may be seen after the treatment. Other treatments for these lesions include Photodynamic Therapy, in which photosensitizing medication is applied and the skin is treated under blue light or intense pulsed light laser, topical chemotherapy with prescription creams, and Laser Skin Resurfacing, in which a laser removes the outer layers of the skin.

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