Presented by: D.J. Elpern, Williamstown, Massachusetts, USA
History This 62 yo man had a 15 year history of a plaque on his left index finger. He had been told it was a wart in the past.
Exam
2.0 cm in diameter verrucous plaque.
Clinical Photos
Lab and Path Because of long history a biopsy was done to r/o SCC. The path showed in situ squamous cell carcinoma.
Therapy: We discussed micrographic surgery vs. topical chemotherapy and he elected the latter. After two weeks of nightly imiquimod there was no reaction. I then added 5% 5FU cream as described in a recent article. Within two weeks the area was ulcerated and painful. The treatment was stopped and he will have a repeat biopsy to test for cure in 2 - 3 months.
Questions and Teaching Points The combination of 5FU and imiquimod is interesting and will be a therapeutic advance, but like imiquimod, it will take some time to master the "Art." I was surprised at the intensity of this reaction. I suspect he may have done better if I used the 5FU three times a week. Your comments are welcome
References
J Am Acad Dermatol. 2006 Dec;55(6):1092-4.
Topical combination therapy for cutaneous squamous cell carcinoma in situ with5-fluorouracil cream and imiquimod cream in patients who have failed topical monotherapy.
Ondo AL, Mings SM, Pestak RM, Shanler SD.
Topical therapeutic options for cutaneous squamous cell carcinoma in situ include 5-fluorouracil cream and imiquimod cream. Such treatment may be preferable to surgical or destructive modalities in certain anatomic locations and in instances where patients are unwilling or poor surgical candidates. We present 4 such patients with cutaneous squamous cell carcinoma in situ involving a digit. Each patient failed treatment with imiquimod cream as monotherapy. In addition, two patients failed treatment with 5-fluorouracil cream as monotherapy. All 4 responded completely to 5-fluorouracil and imiquimod cream as combination therapy. In patients who have failed monotherapy with a topical agent for cutaneous squamous cell carcinoma in situ, combination treatment using both topical 5-fluorouracil cream and imiquimod cream may be considered as an alternative therapeutic strategy.
It looks like Bowen. I've not read the paper you mentioned yet, but in my limited experice with Imiquimod, it works better when you elicit some sort of inflammation on the lesions; in this case, it seems that 5-FU does this job great! Thanks for sharing this case. Cheers. Omid
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