The first line treatment of invasive SCC is radical surgical excision of the tumor with histopathologic examination of the surgical margins. Topical immune modulatory agents such as imiquimod can be used as another choice of treatment. Imiquimod enhances the innate immune response and the adaptive immune response via interaction with toll like receptor 7 on the various immune cells. It also induces apoptosis of tumor cells via binding of the Fas receptor to the Fas ligand. Imiquimod has shown efficacy against many skin cancers such as superficial SCC, basal cell carcinoma, Bowen dis­ease, cervical intraepithelial neoplasia, and keratoa- canthoma. Imiquimod has been reported to be effective in several cases of invasive SCC. In the reported cases, the frequency of imiquimod appli­cation varied from three times a week to once per day, the mean duration of treatment was 9.4 weeks and the longest recurrence-free follow up was 4 years. The regime of imiquimod therapy for our case was similar with the previous reports. However six months was the longest duration of treatment of all the cases, and this could have been enough time for the cancer to metastasize. We did not intend six months treatment time, but it took time to persuade the patient to have surgery.

Treatment with topical imiquimod has several weak points in comparison with surgical excision. The topical imiquimod can cause local skin irri­tation, which may decrease treatment compliance. Patients apply the imiquimod at home by themselves, so treatment compliance is an extremely important factor for cure. Our patient also experienced mild local skin irritation. We encouraged her to continue the topical application by saying that mild skin irritation is commonly experienced. Encouragement or temporary reduction of the application frequency are good ways to address the weak points of imiquimod.
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And in contrast with surgical excision, the topical imiquimod needs a longer treatment duration time. Invasive SCC can metastasize easily and spread via the lymphatic system. An increased treatment period will therefore increase the chance of tumor cells metastasizing and spreading. The prognosis of SCC on the lower lip is not good because of the high risk of metastasis about 16%, with about 50% mortality in metastatic cases. Considering this, our patient should have been treated promptly but she refused surgery at first. Hence, we had no choice but to apply imiquimod to the lesion during this time. The alternative treatment, topical imiquimod therapy, was very successful and greatly reduced the tumor size, plus there was no evidence of metastasis. We think that she experienced a fortunate outcome, but six months is not recommended for the duration of neoadjuvant therapy. Although disease eradica­tion was not achieved, tumor size reduction was extremely beneficial to the patient. The operation method depends on the mass size, and the chance of complication and morbidity decreases with the simplicity of the operation. Small defects up to 33% of the lower lip can be repaired via direct appro­ximation and primary closure. Cosmetic and functio­nal disturbances after primary repair are acceptable. However, large defects over 33% of the lower lip should be repaired by a flap technique such as a Karapandzic flap or Abbe flap. The problem with these flaps are the significant microstomia and vermilion deficiency which can result, At first, we planned treatment by radical tumor excision then lip reconstruction with orbicularis oris flaps. How­ever, after topical imiquimod therapy, the tumor could be totally removed leaving a small defect which could be repaired without using flaps. She suffered from no cosmetic or functional disturbances after the treatment for invasive SCC.

Additional treatment given before the main treatment is called neoadjuvant therapy. Various therapies can be used as neoadjuvant therapy besides topical imiquimod therapy. Topical imiquimod is not usually effective in immunocompromised patients with low CD4 counts. In contrast to this, cryo­therapy is effective in patients with low CD4 counts. However, cryotherapy destroys tissue and this makes histological examination difficult. Photodynamic therapy is also a useful method to treat skin cancer, although it is less efficacious in hyperpigmented and hyperkeratotic lesions. canadian discount pharmacy

Topical imiquimod therapy has many weak points and limitations for it to be a main treatment of invasive SCC, however it is a good optional choice that makes the following surgery conservative. We recommend that this neoadjuvant immunotherapy can be an alternative for the treatment of cos- metically-critical SCC.