The incidence of all skin cancer is increasing dramatically. Prompt diagnosis and management of any skin cancer decreases morbidity and mortality. All skin cancer, specifically squamous cell carcinoma (SCC), is epidemic in the elderly, though this trend has been poorly documented. SCC incidence increases in a linear fashion with age, proving the elderly are at particular risk for this disease. This cancer can rapidly grow to prodigious size in the very elderly necessitating prompt intervention. Diagnosis and management are often delayed due to various factors, including: difficulty with transportation, poor eyesight by the affected patient and or spouse, a decreased willingness by elderly patients, their families, and physicians to treat any skin tumor under the erroneous impression that treatment morbidity might be worse than the disease in the very elderly. Outpatient surgery under local anesthesia is well tolerated in the elderly, and even large procedures are performed safely in clinicians’ offices everyday. The dermatologic surgeon is particularly adept at managing skin cancer in an outpatient setting utilizing only local anesthesia.
Case Report
A 108-year-old white female was referred for Mohs surgery for a rapidly growing over 10 cm multinodular necrotic fungating tumor of the right calf that proved to be invasive squamous cell carcinoma upon biopsy. The centenarian had 3-4+ pitting edema to the knee and severe stasis dermatitis affecting the right leg. The tumor was ulcerated and secondarily infected, though this responded well to oral antibiotic therapy. The family reported that it had started as a small lesion six months previously but only sought medical advice when it rapidly increased in size over six to eight weeks before seeing her local dermatologist. The patient had no adenopathy or intra-abdominal masses by palpation. No further metastatic workup was performed at the family’s request because no intervention would be pursued even if the advanced disease was due to the patient’s age.
The patient suffered from significant dementia, used a wheelchair, and underwent treatment for mild congestive heart failure. A detailed discussion of the risks of wide resection and split-thickness skin grafting for this patient, with her underlying stasis and edema, was had with the patient’s surviving daughter, who was over 70 years of age.
It was decided that providing palliative treatment was in the patient's best interest, as the the potential complications from surgical resection would have possibly ended her life or — at the very least — would have required a prolonged recovery with the risk of a non-healing ulcer occurring post-operatively. Intralesional methotrexate was used to suppress the tumor, in addition to daily topical imiquimod cream combined with Unna boots to improve her underlying stasis and edema.
The patient responded well to weekly and bi-weekly injections of 12.5-25 mg of methotrexate into the tumor, combined with topical imiquimod daily. The tumor regressed by 50% in one month and 95% in three months. Her stasis and edema responded nearly completely to Unna boot compressive therapy. Her course was complicated by a developing pressure sore of the right heel, which healed with Unna boots and heel pressure devices utilized while she was supine. Her WBC and hematocrit remained stable throughout the treatment. She received intermittent injections of methotrexate over the next 18 months to suppress the tumor, which never completely regressed but remained a minimal concern until her demise nearly two years after presentation from unrelated causes, which included worsening dementia, renal and heart failure.
Discussion
This case was chosen because of the patient’s extreme age. Though she had a reasonable outcome with palliative therapy alone, neglected or mismanaged cutaneous SCC can result in metastatic disease with a poor prognosis. The risk of metastasis varies most importantly with the depth of invasion thus the early intervention is critical to avoid local uncontrolled disease or metastasis. The authors have collectively managed many cases that have resulted in extensive surgery and even death from aggressive SCC, which in nearly every instance might have been avoided had the primary tumor been treated earlier. Prompt presentation of this case would have resulted in a minor out-patient procedure. Excision with local anesthesia of early cutaneous SCC results in very high cure rates with minimal morbidity.
Skin cancer screening of high-risk individuals is very effective in detecting cancers early despite their advanced age; this should include elderly Caucasian patients with a history of previous skin cancer, actinic keratoses, and/or a background of actinic damage. Preventative measures should likely include supplemental Vitamin D as deficiency has been linked to an increased risk of SCC, in addition to a number of other malignancies. The elderly often have little ultraviolet exposure but still have a markedly increased risk of SCC, likely due to decreased immune surveillance and other unknown factors. It is possible that Vitamin D deficiency may be playing a role in the current epidemic of cutaneous SCC in the elderly. Supplementation and monitoring of Vitamin D levels is a fairly simple and non-toxic preventative strategy that may have some bearing on this issue in addition to wider health concerns.
Research has demonstrated an over 20% reduction in the number of skin cancers and actinic or solar keratoses by simply taking 500mg BID of nicotinamide (or niacinamide, the amide version of Vitamin B3 or nicotinic acid). This low-cost supplement may be well worth recommending to such patients as it is non-toxic. However, it can sometimes be problematic to find in local pharmacies which stock niacin or nicotinic acid not the amide.
Prompt surgical intervention for cutaneous malignancy is essential in the elderly to avoid excess morbidity and even mortality from cutaneous malignancies.
Dr. Geisse and Mr. Goleno have no conflicts of interest to report.
Illustration by April Brust
