BOWEN'S DISEASE - prognosis and treatment

.Aim of the Bowen's Disease: After reviewing this chapter the reader should be more familiar with Bowen's Disease and its relationship to squamous cell carcinoma proper as well as various types of skin cancer surgery and other therapies currently in use to treat Bowen's Disease. Treatments including liquid nitrogen, Mohs Surgery, plastic surgery, reconstructive surgery and laser surgery are discussed.

... ..Bowen's Disease is also known as Bowen's among dermatologists. Bowen's, most often, looks like a bright-red or pink scaly patch, located on previously or presently sun-exposed skin.

Many doctors and authorities regard Bowen's as a form of squamous cell carcinoma; though some regard it as a precancer. The author prefers to regard Bowen's disease as a squamous cell carcinoma of the intraepithelial (occurring in the epidermis) type. A portion of the cells in Bowen's are often extremely unusual or atypical under the microscope and in many cases look worse under the microscope than the cells of many outright and invading squamous-cell carcinomas. The degree of atypia (strangeness, unusualness) seen under the microscope best tells how cells may behave should they invade another portion of the body. See Predicting Skin Cancer Behavior.

Indeed, if cells of Bowen's invade below the epidermis and the basement membrane that separates the epidermis, the consequences may be grave. The authors Lever, Graham and Helwig have noted that metastatic (spreading internally to other parts of the body) Bowen's can be lethal. On the other side of the coin, metastatic Bowen's is uncommon and there are a few doctors who do not even wish to consider the possibility of internal invasion because it is uncommon. Most reputable university based dermatologists and dermatologic surgeons would disagree with these few doctors and not consider Bowen's just a precancer. These doctors believe the improbability of metastatic Bowen's being discovered is a good reason for disregarding these metastatic lethal cases in determining whether Bowen's is a cancer or precancer. They merely "throw these cases out" because they are so rare.

However, the Web-site author believes that the loss of one life, let alone several or many patients is too much and that the best medicine is still practiced by considering every reasonable possibility and anticipating potential problems. The website author states: "under most circumstances the best doctors are pessimists (looking to counter every chance of disease) and not optimists (taking risks being aware or pursuing the chance that a disease exists).

The author is concerned that Bowen's cells like to grow down hair pores. This tendency for "poral invasion" may give the extremely atypical/unusual cells of Bowen's (intraepithelial squamous-cell carcinoma) access to the bloodstream, should they break through the basement membrane. The author believes that the possibility of invasion may be increased by time, trauma and previously failed treatments.

However, if Bowen's has not spread, it is much preferable to a moderately differentiated squamous cell. See Squamous cell Carcinoma. The diagnosis (knowing what a disease is) of Bowen's portends (predicts) a good prognosis if the Bowen's is localized and treated properly, remembering that cells of the process like to "hide" in pores.

The most respected dermatology texts, such as Rook's, state that the best treatment for Bowen's is EXcision that generates a specimen for a dermatopathologist to read under the microscope. The need for a specimen is due to the fact that Bowen's cells may (occasionally and almost commonly) grow far and wide beyond what the doctor or the patient sees as the borders of the usually red or pink Bowen's lesion. The most accurate and tissue-sparing form of excision is Mohs Surgery, rather than the vertical sections of standard surgical excision. (See Mohs Surgery.) However, you may need to consult your insurance carrier or state Medicare department to see if it will cover using Mohs Surgery for a Bowen's located where yours is located. If the lesion is on the eyelid, lip, ear or nose, it is hoped that Mohs Surgery of the lesions will be covered.

The difficulties with treatments such as liquid nitrogen, 5-FU (Efudex, fluoroplex) and scraping and burning (C&D) when used on a Bowen's lesion are twofold. First, Bowen's may hide deep in the pores. Second, Bowen's cells may extend, invisibly to the naked eye, but visibly to the microscope, beyond what both the doctor and the patient can see. As long as the patient is willing to accept the failure rate, then these non-excisional treatments mentioned in this paragraph may be used. However, the Web-site author agrees with the EXcisional surgery (Mohs EXcisional variety rather than standard vertical section EXcision) approach suggested by the respected texts.

Paul J. Weber, M.D., P.A.
5353 North Federal Highway, Suite 400
Fort Lauderdale, FL 33308
Tel: 954-489-9800 | Fax: 954-489-0401