Dr. Whitney High reviews some highlights from his lecture " Challenging Non-Melanoma Skin Cancer Management" on Thursday, November 7, 2024, at the 5th Annual Elevate-Derm West Conference at the Westin Kierland Resort in Scottsdale, Arizona.

In this video

Dr. High, professor of dermatology and dermatopathology and director of dermatopathology at the University of Colorado School of Medicine, walks through atypical fibroxanthoma and pleomorphic dermal sarcoma—two related malignancies on sun-damaged skin, one superficial and less worrisome, the other deeper and more aggressive. Neither is a spindle cell squamous cell carcinoma nor a spindle cell melanoma; they are "their own type of malignancy." He notes that pleomorphic dermal sarcoma can behave more aggressively in CLL patients, and shares a case of metastatic disease in that setting, alongside a co-presenter's case of squamous cell carcinoma that behaved more aggressively in CLL.

He frames CLL patients as part of a larger cadre of immunocompromised patients—whether from medications, disease, or transplant—who lack the same immunosurveillance and need to be followed more closely, often with dedicated transplant skin-check clinics every three to four months and thorough lymph node exams. On prevention, he describes a tiered approach: nicotinamide as low-burden chemoprevention for almost anyone, low-dose retinoids for patients with frequent squames, and, in select high-burden cases, PD-1 agents. Richardson underscores the flipped ratio in immunocompromised patients—roughly four squamous cells for every basal cell—and the need to keep "your antlers up" for early detection.

  • Atypical fibroxanthoma and pleomorphic dermal sarcoma are related but distinct malignancies of sun-damaged skin—not spindle cell SCC or melanoma—with the deeper pleomorphic dermal sarcoma being more aggressive.
  • In CLL and other immunocompromised patients, non-melanoma skin cancers—including pleomorphic dermal sarcoma and squamous cell carcinoma—can behave more aggressively and warrant closer follow-up.
  • Immunocompromised populations lack normal immunosurveillance; metastatic squamous cell carcinoma remains a leading cancer-related death in solid organ transplant patients.
  • The BCC-to-SCC ratio flips in the immunocompromised: roughly one BCC per four SCCs immunocompetent versus four SCCs per one BCC immunocompromised.
  • Chemoprevention is tiered: nicotinamide as low-risk first line, low-dose retinoids for frequent squames, and PD-1 agents reserved for select high-burden cases.