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Field cancerisation

Actinic keratoses (AKs) may sometimes appear as isolated lesions but can often also present across an entire area.1,2 The affected skin area is called field cancerisation or field change. There, clinically visible and (as yet) invisible precancerous lesions may be in close proximity.3,4

The concept of field cancerisation was first described in epithelial tissue in the vicinity of oropharyngeal carcinomas by Slaughter et al. in 1953.3 At the cellular level, field cancerization is thought to result from the growth of a mutant clone that creates a field of cells predisposed to subsequent tumor growth.4

The skin is susceptible to field cancerisation due to chronic UV exposure, especially in sun-exposed areas (Figure 1). These affected skin areas have a high burden of clinical and subclinical actinic damage and are therefore at high risk for the development of multiple cutaneous squamous cell carcinomas.5 In light of potential clinical recurrence or tumor progression in the surrounding area, subclinical AK lesions must also be treated.6

Figure 1: Development of field cancerization. Initially, a mutant cell of the stratum basale forms a "patch", a clonal unit of altered daughter cells. Another critical step in the development of field cancerization is the conversion of a patch into an expanding field. Additional mutations are necessary for this. The proliferating field can now displace the healthy cells due to the growth advantage. The presence of a relatively large number of mutant cells increases the likelihood of tumor progression to invasive squamous cell carcinoma. Modified after Braakhuis et al.4

Therapy

The primary treatment goal is complete clearance of all visible and subclinical AK lesions in the patient.7 Various field-directed therapy options are available for this purpose1,6:

Other available but exclusively lesion-directed therapeutic options, such as cryosurgery and other surgical procedures, are less suitable for the treatment of field cancerisation. The advantage of field-directed therapy options is that they are used to treat subclinical lesions in addition to those that have been clinically diagnosed.6
According to a 2014 network meta-analysis, PDT with narrow-spectrum red light is currently considered the most effective treatment modality for mild to moderate AKs on the face and scalp.8

References

  1. De Berker et al. British Journal of Dermatology 2017;176: 20–43
  2. Vatve M, Ortonne JP, Birch-Machin MA et al. Management of field change in actinic keratosis. Br J Dermatol 2007;157(Suppl. 2):21–4
  3. Slaughter DP et al. Cancer 1953;6:963-8.
  4. Braakhuis BJ et al. Cancer Res 2003;63:1727-1730
  5. Willenbrink TJ et al. J Am Acad Dermatol 2020;83:709-717.
  6. Werner RN et al. J Eur Acad Dermatol Venereol 2015;29:2069-2079.
  7. Reinhold U. Future Oncol 2017;13:2413-2428.
  8. Vegter S, Tolley K. PLoS One 2014;9:e96829.

UKBF-2022-006k-V01, Date of preparation: June 2022