Treatment Of Premalignant Lesions



What is a Premalignant lesion?

  • A premalignant or precancerous lesion is an abnormality in a tissue area which is just a step away form cancer.
  • Not all premalignant lesions change to cancer, but most have greater potential for doing so than normal tissues.
  • There are many varieties of premalignant lesions, but the most important one, especially for the Indian populace, is leukoplakia. (Discussed in the previous section)

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What are the other Premalignant lesions besides leukoplakia?

Other premalignant lesions, although important in their own way, are not so dominating as leukoplakia. Some of the precancerous lesions are:

  • Actinic or solar keratosis - these are common asymptotic lesions seen mostly on sun exposed areas of light skinned people. They are especially seen in those who 'burn' easily or tan poorly. Commonly seen on the back of the hands, the face, upper chest, upper back and lower lip.
  • Chemical and other keratoses - skin lesions caused by exposure to arsenic, tar, polycyclic hydrocarbons, infrared  radiation for a prolonged period at the work place (thermal keratosis) and scar keratosis, when a long standing scar develops a malignant potential.
  • Large cell acanthoma - usually single, but maybe multiple as well, usually on sun exposed skin in fair people. Rare.
  • Chondrodermatitis nodular helicis - usually seen in elderly people; they are tender, inflamed, scaly, reddish, slightly  raised lesions.
  • Cutaneous horn - a hard, raised nodule with a reddish base, usually seen in sun exposed areas in pale persons.
  • Radiation dermatitis - skin damage due to exposure to X-rays or other sources of radiation, either occupational or accidental or due to treatment by radiotherapy. The skin is dry, scaly, reddish, thin and discolored.
  • Bowen's disease - this is actually a cancer located totally within the top layer of the skin called the epidermis, and favors the sun exposed areas of the face, neck and extremities.
  • Sebaceous nevi - they are present at birth or appear soon afterward, usually on the scalp.
  • Porokeratosis - describes a wide variety of skin disorders.
  • Fibroepithelioma of Pinkus - appear as flesh colored skin tags hanging from the back.
  • Keratoacanthoma - a rapidly growing, red, raised lesion on the sun exposed areas of middle aged and elderly people.
  • Condylomata Acuminatum - a virus induced lesion in the genitals, which appears as sharp pointed red, small finger like     projections, either stuck at the base or suspended by a stalk.
  • Buschke - Lowenstein's tumor - a giant variety of condylomata acuminatum.
  • Erythroplasia of Queyrat - a dark red, velvety, flat or slightly raised hard patch on the glans penis (the bulbous tip of  the penis) or on the inner side of the prepuce (the retractile top skin of the penis). It may at times produce a discharge and become painful.

 

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How are Premalignant lesions treated?

Treatment of Actinic or solar keratosis

  • Existing lesions are treated by:
    • Curettage (scraping out).
    • Electrodessication (an electric current is used to desiccate or dry up the lesion).
    • Cryotherapy involves the use of a liquid nitrogen spray or a very cold probe to freeze and kill abnormal cells. This technique is sometimes used to treat precancerous conditions such as those affecting the cervix and the leukoplakia . Cryosurgery is also being tried as a treatment of some cancers like prostate cancers. Usually cryosurgery involves little or no pain.
  • For multiple lesions, one of the following options can be entertained:
    • 5 fluorouracil cream, (5FU is a chemotherapeutic agent) for 3 weeks.
    • Dermabrasion (rubbing away the top layers of the skin).
    • Protection from excessive sunlight.

Treatment of Chemical and other keratoses:

  • Surgical excision

Treatment of Large cell acanthoma:

  • Similar to actinic keratosis.

Treatment of Chondrodermatitis nodular helicis:

  • Applied steroid cream, or steroid directly injected into the lesion.
  • Surgical excision.

Treatment of Cutaneous horn:

  • Determined by the final pathology report of the specimen.

Treatment of Radiation dermatitis:

  • Removal of any overlying lesion in the skin for histopathological diagnosis.
  • Continuous skin care.

Treatment of Bowen's disease.

  • Excision biopsy of the most indurated or hard area.
  • Cryotherapy.
  • CO2 laser vaporization.
  • Photodynamic therapy (a photosensitizer drug is given, a time period is allowed to elapse for the drug to be preferentially absorbed by   the lesion, and then the lesion is exposed to light in order to activate the drug).
  • Surgical excision of entire lesion provides the highest rate of cure.

Treatment of Sebaceous nevi:

  • Excise before puberty, before true malignant potential develops.

Treatment of Porokeratosis:

  • Surgical excision.
  • CO2 laser.
  • Cryotherapy.
  • Oral retinoids are basically derivatives of Vitamin A, derived synthetically or semisynthetically and naturally. They act as antioxidants, that is, they prevent damage due to toxic free radicals which cause oxidative injury.
  • Dermabrasion.
  • Topical 5 FU cream application.

Treatment of Fibroepithelioma of Pinkus.

  • Surgical excision.

Treatment of Keratoacanthoma:

  • Electrodessication
  • Cryosurgery
  • Curettage
  • Surgical excision
  • Shave excision, in which the tumor is just shaved flush off the underlying skin.
  • Mohs micrographic surgery, a special pattern of surgery, when on table assessment of the specimen microscopically is carried out.
  • Radiotherapy
  • Topical and intralesional 5 FU
  • Intralesional:
    • Methotrexate (a chemotherapy drug).
    • Bleomycin ( a chemotherapy drug).
    • Alpha interferon ( biological therapy).
    • Topical podophyllin (a chemotherapy drug).

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