text:
Plasma Donation: Sell Your Blood for Cash
Dominic is an electrical engineer who enjoys spending his spare time finding ways for people to generate additional sources of income.
Make Money With Plasma Donation
Fewer plasma donations are happening now that the economy is getting better. But if you need to make a little extra cash, donating plasma is still a great way to do it.
I think donating plasma is an amazingly great thing to do. It's a safe and easy way for people to help others while making some extra cash. I've known poor college students that might have been homeless college students without this option. One time at the plasma center, I met a single dad who told me he'd been giving plasma so he could put gifts for his daughter under the Christmas tree.
Without plasma donors, hemophiliacs, burn victims, people with immunodeficiencies and autoimmune diseases, those undergoing transplants or other major surgeries, and countless other people in need could die waiting for essential transfusions. This is a great example of a win-win situation, but I'm sure you have questions about the process before you roll up your sleeve and let a phlebotomist take your precious plasma away.
Let's take some time to talk about how to make money selling plasma!
Question: Are there any rules about who can donate plasma?
Answer: Donors must be 18 years old and weigh at least 110 pounds (50kg). All individuals must first pass a medical examination, a medical history screening, and tests for transmissible viruses.
What Is Plasma?
Plasma makes up about 55% of your total blood volume. It is a yellowish liquid composed mostly of water (about 90%) that carries things such as vitamins and hormones through your body. Platelets, red blood cells, and white blood cells circulate through your body while suspended in plasma.
Question: Does my blood type affect my ability to donate plasma?
Answer: People with all blood types (A, B, AB, and O) can donate plasma. Since these are blood types and not plasma types, they don't affect who can give or receive plasma.
Is Donating Plasma Safe?
Absolutely. Most complications from plasma donation are very minor. One common complication is the development of a hematoma (which is just fancy doctor-speak for "bruise") at the needle entry site. I personally had a vein infiltrated once which is when the needle goes through the vein twice. That left a real big bruise, but it didn't hurt very much at all, and there's no medical danger to it.
Are Plasma Donation Centers Clean?
Some people have images of druggies lined up out the door looking to sell plasma in dingy clinics. This couldn't be further from the truth. I've donated plasma at three different locations, and each was impeccably clean. Remember that there's nobody forcing you to donate, and you can always walk out if you feel uncomfortable.
Is It Ethical to Make Money Selling Plasma?
I can only speak for my own conscience here, and this is how I think of it: Plasma treatments save lives. The payment system was adopted because a very large amount of plasma is needed for treatments. In order to encourage the maximum number of donations, the system was incentivized. For those who are on the fence morally about this, I suggest you ask your physician what they think. My doctor said the vital need for plasma far outweighs any of his moral concerns.
Does the Procedure Hurt?
The technical term for the process is plasmapheresis, and if you don't like needles, plasma donation probably isn't for you. A relatively large needle is used. After the stick, the most you should feel is a slight discomfort in your arm. I typically don't feel anything after the needle is inserted.
How Long Does It Take?
The process itself takes about 45 minutes to an hour. You aren't allowed to sleep or eat, but I usually take my laptop and either watch a movie or do homework.
Question: Are there risks involved in donating too often?
Answer: Long-term plasma donation can lead to habitual dehydration, lowered levels of antibodies, and deficient levels of iron or hemoglobin. You need your plasma, too. This is why there are limits placed on the frequency of donations.
How Often Can I Donate Plasma?
Two times every seven days. Don't try to work the system and go to multiple donation centers. On top of being stupid (you need to keep enough plasma in your system so your blood doesn't turn to sludge), there is a national database that all centers check.
How Much Money Can I Make Selling Plasma?
Every center has its own compensation plan. Generally, you are paid $20 to $25 for the first visit and $30 to $45 for the second. I go to BioLife Services and they pay $20 plus $45, for a total of $65 a week (and $260 a month). On top of this, many centers have additional cash prizes or gift certificate programs to keep things fun and interesting.
Question: Can I make more money if I have a rare blood type?
Answer: Although AB donors have a blood type compatible with only 3% of the population, this doesn't mean they make any more money. Rare and common blood types make the same amount.
How Do I Get Paid for My Plasma?
Some places pay in cold, hard cash. BioLife gives you a debit card that they deposit money into every time you donate.
The video below is one a donor shot while he was giving plasma. This is a must-watch if you're nervous about what the procedure actually looks like.
Before You Donate Plasma, Follow These Tips
- Drink lots of water. This can speed up the process by pumping up your veins.
- Avoid greasy and fatty food, which can give plasma a milky appearance and disqualify you for donation.
- No coffee or booze. These drinks dehydrate you.
- Eat something healthy. Protein and complex carbohydrates like bread, cereal, and fruit are best.
- Don't smoke. Smoking increases the likelihood you'll feel lightheaded after donating. Not a fun way to drive home.
First-Time Plasma Donors
It's a little bit different for the uninitiated. If it's your first time, bring a valid form of government-issued identification (passport, driver's license, or state ID), proof of residence (utility bill, car insurance, etc.), and your social security card. You will undergo a more exhaustive medical history and physical examination your first time: Including the plasma donation itself, this visit should take about 2 to 2.5 hours. You'll also be asked to stick around for 15 minutes so they can make sure you're not the type that gets lightheaded after this sort of thing.
Step 1: Pre-Screening
- Check-in at the front desk
- Answer screening questions (at BioLife, these are done on a touchscreen computer)
- Wait for your turn
Step 2: Screening
- Your name will be called to begin the screening
- Get your weight checked (you must weigh at least 110 pounds to donate)
- Blood pressure check
- Pulse check
- Temperature check
- Finger prick (a small sample of blood from your finger is checked to measure protein and hematocrit)
Step 3: Plasmapheresis (the Actual Plasma Donation Part)
- You will be directed to lie down and get comfortable.
- They'll do an iodine cleansing at the needle entry site (you choose which arm).
- The needle is placed in your vein.
- Sit back and relax for 45 minutes to an hour. You can watch your plasma bag slowly fill up as blood is taken out, plasma removed, and the rest is pumped back in. The amount taken is dependent on your weight and how quickly the bag fills depends in part on how hydrated you are.
- Once full, the plasma bag is removed.
- Saline is pumped into your system. This water and salt solution fills in for the loss of blood volume and makes your body feel cold for a few minutes (since it's room temperature and your body should be around 98.6 degrees). This is why many donors bring blankets.
- The needle is removed and you're bandaged up.
Step 4: Getting Paid
- Some places pay cash. BioLife deposits money onto the debit card they give you.
Step 5: Schedule Your Next Appointment
Finding Plasma Donation Centers
There are many plasma donation sites you can visit to donate. The Plasma Protein Therapeutics Association search engine lists many of the donation centers in the United States, and I go to BioLife Plasma Services. Contact one in your area to set up your screening appointment (where you will also make your first donation if you pass the screening). If you can't find a center here, try Googling plasma donation in your area, looking in the yellow pages, or asking at a local hospital.
Other Resources on Plasma Donation
- Plasma Donation
BioLife Plasma Donation Services
- Donating Plasma
This article is accurate and true to the best of the author's knowledge. Content is for informational or entertainment purposes only and does not substitute for personal counsel or professional advice in business, financial, legal, or technical matters.
Oksi on February 13, 2015:
How cash depends on type of blood?
fapsavaby on February 05, 2015:
Prompt service on writing essays
fapsavaby on February 04, 2015:
Prompt service on writing essays
mary on February 03, 2015:
Is there a age limit on donating?
Johne542 on January 10, 2015:
Hey are using WordPress for your blog platform? I'm new to the blog world but I'm trying to get started and set up my own. Do you require any coding knowledge to make your own blog? Any help would be really appreciated! bdgaekcdekcc
moreinformed on February 27, 2011:
Thanks so much for putting this whole site together. I was hesitant about the process and now I see the real value to society and appreciate the return price I hopefully will receive. The videos about the processes and concerns were a great explanation of all of the aspects of the event.
Karen on October 26, 2010:
Unfortunately, there don't appear to be any plasma donation centers in the NYC tri-state area.
jules on September 30, 2010:
I am wondering what kind of Id or info do you need to be able to donate. Is a Driver's Licease enough?
sean on September 29, 2010:
how old you have to be to give it
Money on September 21, 2010:
1. Your getting compensated for your time there, not the donation itself. 2. The machines are called Auto-Cs or PCS-2s. 3. It is imperitive that you eat and drink healthy the day before and the day of donation. I am currently working at a donation center and have also worked at the lab where all testing is done, going on 9 years. If anyone has a moral dilema as to whether or not this is right then go ask a person that has hemophilia if we should stop. Talk to a burn victim and see if there is another solution. I am not aswering anymore questions just stumbled across.
Red on September 20, 2010:
I'm going in to donate for my second time tomorrow but thought I'd look up some more info after what happened last time. My appointment was set for 9 but I didn't get in till almost 12 and by then it had been too long since I last ate. I almost threw up as they were taking the blood on my second draw and had to stop the procedure early because I was so dizzy and sick. Turns out this was a good idea. I laid there for a half an hour til I felt better then walked across the room and sat down. Next thing I knew my vision went. I woke up as they were taking me to a bed to lay down. I was impressed with the care I got. They made sure I was alright, checked my vitals several times, got me some food and juice, and made sure I had someone to drive me home before they let me go.
Turns out I just needed some food, but a scary time anyways! But even with all that I was impressed with the clinic and the employees. The people that were there to donate were nice too. A girl gave me the tip to eat a peanut butter sandwich right before I enter the building and bring another for after so I'll be doing that tomorrow.
Wish me luck!
Kris on September 20, 2010:
I went to biolife today and did my fist donation. They only pay 20 & 20 now so $40 a week. It's better than nothing. But I have a bruise and can't go back till it has started to fade. Is there anything you can do to prevent bruising? Or at least help it go away faster so you can actually donate twice a week? I really need the extra cash right now so would like to be able to donate again before the week is out.
Caligurl on September 15, 2010:
Very Informative thank you very much
gc on August 27, 2010:
How can you say donation when you are getting paid????
andrea cain on August 23, 2010:
I tried a couple of years ago my mom thought I was nuts but she stopped paying for car insurance. I went they wouldnt let me. I didnt eat protine before i went and they said that they had a emt come in and take care of a paticent. What is that called when you dont eat protine before a blood draw.
Kim on August 20, 2010:
This was very informative! I recently started donating at a Biolife center in my area! The facilities are clean, the staff is excellent and I never have to wait long to donate. I am a smoker and coffee drinker, though I limit myself to one cup of coffee on donation days, eat a good breakfast and stay hydrated and I have never had a problem! Also, my biggest fear is needles but after the initial sting of it being inserted there really is little to no discomfort. Its a little different from donating blood because you have to pump constantly between each return, but I have time to get homework done or catch up on some reading!
Rusty on August 03, 2010:
Can you find a paid plasma donation center near Syracuse, NY? If you can, please email me at email@example.com.
Dominic Joseph (author) from New York on July 31, 2010:
Hi John,
I believe that the machine used is simply called a plasmapheresis machine (as that's what the procedure is known as). Hope that helps!
John on July 31, 2010:
Please tell me if you know the name of the machine that separates the plasma from the blood? Thanks
Arjun Mainali on July 23, 2010:
Please donate blood at least once a year volunteerly.
Vegabond on July 19, 2010:
Plasma donation isn't scary. Where I go the worst part is waiting in line to get screened if the place is packed (Sometimes I've waited over an hour, other times I get screened almost as soon as I walk into the door. First come, first serve, here.) They then take you into a room, get your blood pressure, heart rate, and temperature, prick you with one of those little needles diabetics use to test their blood (it rarely hurts, and when it does it ain't much), collect a tiny vial of your blood, and toss it into a centrifuge. Next they ask you the same questions that they ask every time ("In the past six months have you gotten any tattoos or body piercings? In the past eight weeks have you had sex with or been in close contact with someone who has hepatitis?" That sort of thing. Then they check the blood they took for your protein counts and something else, and if everything checks out you're good to go.
Once the usual BS is done with you wait for them to call your name (takes next to no time), and then they bring you to this curvy bed thing where you're sitting back with your legs up, but you are sitting up. Rather comfy. After confirming your information one last time (name, date of birth, last four of your social) they swab the hell out of the inside of your elbow with iodine, and then they stab you. Yes, it usually does hurt, but if you get the right person to stab you it might not. I don't like it so I always close my eyes and look away.
My plasma donation place has TVs all over the place playing movies (PG13 or lower only), except during football season when they'll have the game on Sundays. Thing is, I hate their movies so I always bring my trusty laptop to tear up their open WiFi. After about an hour to an hour and a half (I donate a full bottle as I am 200 pounds) the machine will transfer all your blood back, flush out the machine, and the techs will unhook you by pulling out the needle (doesn't hurt a bit) and taping on a bandage to your puncture site. Then they give you a paper with a pin code, which you take to an ATM nearby to get paid. Total average time for me in and out: About 2 hours.
Personally, I don't like doing it but it does give me a bit of extra cash to survive on until I _finally_ find a real job. And truth be told, it ain't that bad. The worst part is being jabbed with a needle and that's a relatively minor pain which lasts all of 2 seconds.
Saving lives? Eff that, I wanna eat! XD
Ashleigh on July 05, 2010:
Excellent article. My fiancee and I have been thinking about doing this and with this article and watching BioLife's insider look at a first time donation, I can't wait to make my appointment. I used to give blood but haven't in a while so it'll feel good to spend a couple hours a week giving to someone in need. Not a big fan of needles, but I think this would be absolutely worth it.
jesse on June 11, 2010:
i am actually part of the access clinical program mentioned earlier in this thread, and yes, they pay well. ofcourse i spent alot of time in the hospital to qualify. the company i do my donations with is cangene, and they are a great bunch to work with, while yes i hate needles, they make it as pleasant as possible and the center is immaculately clean. even the public bathrooms are spotless. if i didnt live an hour away i would probably continue after the program with access clinical ends. for other people they pay 25 per donation onto a prepaid debit card
esllr from Charlotte on June 03, 2010:
Informative and interesting Hub.Blood drives give snacks. Giving Feels Good.
Being able to have the Option of getting paid is also a privilege when your in need. Thanks
mike on May 27, 2010:
I started donations in Wisconsin at $20 and $30 for $50 total per week but just recently the cost went down to $20 and $20 per week for only $40. Plus service seems to have gotten worse; less workers means longer wait times and rushed assistance...
I wonder how come plasma donation prices have decreased? I have heard that the mark-up these plasma centers are making on our plasma is HUGE!
ew on May 17, 2010:
I also tried to donate and they told me my veins were to small, I asked if there is anything I can do. They told me no. I am gonna drink lots of water and try the other place in town here. It just sucks.
Brenda Jennings on May 12, 2010:
I just donated my first plasma yesterday and go back tomorrow to donate the second. I'm on SSI (disability) and live in Texas, so I'm wondering if I have to claim this money as " earned income" on my taxes? Being on SSI, I dont file taxes because its not "earned" money. So will this income make me have to file taxes?
I do know they took my social security number, so I dont know if they report the money I get for donation. Thanks!
kaliprincess22 on May 10, 2010:
cjscott on May 09, 2010:
I tried to donate and was told my veins were too small, so to drink lots of water and come back in 6mos. I haven't found anything on web to say this is so, and that is worthwhile to go back. What do you think?
slickgirl2006 on May 04, 2010:
I just signed up last week to start donating, but on the that day was not able to donate because i didn't eat enough. My question is how much should you eat before you donate. I go in the morning and don't have an appitite, i need to make sure i eat just enough to not get sick. I also have a problem with a high pulse rate, is any suggestions to try to lower it on my day of donating
Kris A. on April 22, 2010:
I donated for 2 yrs solid twice a week, then got an on call job and it was more complicated to do. I took 2 years off from donating and I recently started going back. It is quick simple and you meet alot of cool other regulars. I do look like I have track marks, you can't avoid it. Getting stuck that many times, and that often. email@example.com
Sarah R Wertz on April 13, 2010:
I've scheduled my first plasma donation for this Thursday. The question I have is: I tend to get scared or nervous when I get my blood taken or so on. Will I pass out if I get too scared or nervous? Does the blood get taken out and put back in at the same time?
jay on February 27, 2010:
Been selling my plasma for a few weeks now, money helps as I have lost my 70k job and now exist on 1300 a month plus plasma cash.....the economy is especially cruel to those over 55. The plus side, no more pestering phone calls from the dispatcher who un-beknown to him, has ruined lot's of family gatherings and pleasant chats around the fire ring...my pockets are thin, life is much richer as it turns out , day by day.
Anne de Clamence on February 27, 2010:
Do you get paid more on your first time there because you have to have the physical?
timtom on February 26, 2010:
Why in the world do the "powers that be" feel it is perfectly fine to sell their plasma for money, yet when it comes to organs, selling them is out of the question. Thousands of infants, children and adults die every day from a lack of available organs. There is a critical shortage of available organs that qualify for donation practically continuously. Yes, it is more complicated regarding organs, and there are moral questions, but it is food for thought. I am always dumfounded at why in the world so many people refuse to donate their organs if they die, and take their organs to their graves (or flames in cremations) to simply rot or burn into useless dust and ash. So many lives could be saved if more people would donate organs. So fill out those organ donation cards PLEASE! I worked in hospitals for 15 years, and it is so sad to see people die who could have had a 2nd chance at life if others would simply fill out organ donor cards!
Peter Dickinson from South East Asia on February 20, 2010:
I have donated blood many times and plasma once. I have also sold my blood a couple of times. In principle I am all for giving and helping those less fortunate than myself BUT if they are paying for it I am not going to complain. Any cash is helpful to me.
Interesting and well informed article. Thank you.
William on February 12, 2010:
Is there a donation center near me in Newark NJ?
kellarlln on February 05, 2010:
What are compensation rates in Central Washington(state) per visit?
kellarlln on February 05, 2010:
Anyone experience dramatic weight loss while donating?
I went from 130/40 and a few months later was
moviedownloads on January 23, 2010:
How often can you donate Plasma without it being hazardous?
wsp2469 from Alta Loma, Ca on January 09, 2010:
I donated plasma twice a week while going to college in the 80s. I was paid 50 bucks a week and since there was no place to do this near my home I could only do it while school was in session. Still, it paid for beer, smoke, comics and porn.
Betty Reid from Texas on January 04, 2010:
I tried plasma donation for a while, and it was not bad. Like you said, the needle hurts, but not for long. Eventually I became too poor to eat well, and they started rejecting me for low blood protein. Then I had to find a full-time job.
TnFlash from Tampa, Florida on December 29, 2009:
Great Hub! I have donated to pick up extra cash. The rates are a little lower here in Florida. $20 & $25
Zarathushtra from United States on December 23, 2009:
This article has been very informative, thank you for writing it!
supermom_in_ny from NY on November 30, 2009:
Rated your article up! Great content and presentation. It's also a blessing to save a life. The money is an added plus.
Deana on November 22, 2009:
Hi! Do you know of other places that pay? There's no BioLife in my state! firstname.lastname@example.com
Deana on November 22, 2009:
Hi! Do you know of other places that pay? There's no BioLife in my state! firstname.lastname@example.com
teddysalad on November 16, 2009:
do you all realize how much hospitals pay for plasma? IT'S A LOT. A heck of a lot more than is being paid to the donor. Some of you are very naive and childish.
Miss Marsh from USA on November 11, 2009:
Excellent, excellent hub! Very informative and the pictures are amazing! I'm really into donating blood to help others, but I've never donated plasma. Thanks for sharing this awesome hub!
thaninja from America on November 05, 2009:
Oh man, just looking at this hub made me a little queezy. I am sure that I could do it, and I probably should give blood / plasma, but I am not a fan of hospitals or needles!
Dominic Joseph (author) from New York on November 04, 2009:
Artemus - I don't think there is any reason at all to be nervous. It does not "surely weaken your immune system." I appreciate the comment, but you should be careful when making statements like that with absolutely no scientific backing. There is no evidence that plasma donation has ANY negative consequences on the donors body.
Artemus Gordon on November 04, 2009:
This really makes me nervous. I know a teen who is doing this for gas money and he is always sick. It surely weakens your immune system and with the flu going around that cannot be good.
Alicia8657 from Georgia on August 27, 2009:
Great hub! Too bad Georgia dosent have a bio center here :(
Aslanspal on August 14, 2009:
I did fine my first try...but some of the people were snotty and some gave you information...my 1st try was fine but they readjusted the needle twice and it bruised me on my 2nd visit that disqualified that arm...then no one told me to drink the water the day before not the day of ..or have coffee that morning or have some salty food so my blood pressure was 102 then they gave me 15 minutes but I know it was less and this snotty girl said it was to high again...I asked how much ..I could swears she looked at the old reading , because she told me 102...she was no help another lady who looked at my bruise was...I am older these young workers really are not patient with us the girl just dismissed me with little or no respect and just said donate some other time , and then just walked away...how do you complained at these places. A nice fellow at the front said
I could give the next day as long as it was 100 or below and he was nice enough to give me a password and login, but I traveled 28 miles for nothing!! btw this was at biolife in Fayetteville, Arkansas ...what is a good way to avoid "Sugar" that was her name the next time???
Chris1|Chris2 from Los Angeles on July 30, 2009:
Really informative hub. I will definitely be checking out donation centers in my area!
skippy on July 27, 2009:
I see no problem with getting for this. I think you shoud be paid for your blood as well. After the place you donate to is going to charge the person who receives it. Then they will get charge a secound time by the hospital that gives it to them. Laws that prevent you from getting a fee are just protecting the company and hospitals from having to pay up for me taking a risk of infection and other complications, I don't care how small the chances are. I was told that there was a small 2% chance that may back surgery would cause more pain. Well I was in that 2%.
plasmaking on July 22, 2009:
There are also other companies that pay much more for plasma, the only thing is you have to be sick. This company looks for people who have auto immune disorders or viral infections and pay as much as 500 each time you donate. Check out this site accessclinical.com
myfirst50000 from New Brunswick on July 11, 2009:
Very courageous article! I just couldn't watch the pics for very long... We should all donate plasma and blood like you do.
Eaglekiwi from New Zealand on July 08, 2009:
Interesting information.
Enjoyed learning something new. Thankyou.
PaulD on July 07, 2009:
Hi all, I was considering donating and wondering about blood pressure requirements. I know mine can go from normal to high, anywhere from 110 - 140. What range do you have to be in to donate ?
BundleBoy from Atlanta, GA on June 30, 2009:
Nice! very informative hub.
metaphysician on June 29, 2009:
Here at my place nobody pay for donation especially plasma. Anyway if that's donation, money doesn't matter. Thanks for the info.
discostu from Australia on June 28, 2009:
I had to do plasmapheresis for health reasons. Let me tell you it was no fun!
I would say though to all of you, give blood / plasma, you could save a life like mine was saved 15 years ago.
JPSO138 from Cebu, Philippines, International on June 27, 2009:
Wow, that is great. Here in our country when you donate blood or plasma there is not payment. But of course, you can sell your blood. I have heard of some people selling their blood from time to time.
carpesomediem on June 27, 2009:
I donated plasma during college, and it is amazing what hospitals and other facilites can do with what you give them from your body. This is something that many people should seriously consider, because it does help save lives and if it can help your wallet, too, what's so bad about donating?
tomerr from Far Far Away... on June 26, 2009:
Great hub!
Mac Mission from bangalore on June 26, 2009:
good job ..... keep it up .. but not for money pls
MITB on June 26, 2009:
Saves lives and get paid...not bad, not bad at all!
Alice Paul from Texas on June 25, 2009:
I know someone who ended up with track marks b/c he donated so much...is there a way to avoid that?
BrianC on June 24, 2009:
Very informative--I'm just now getting back into donating plasma because I'm going to be laid off in a few days. I'm kind of bummed, my local Biolife dropped their amounts $10 a week from when I used to go.
mwaky on June 22, 2009:
Garrett McLee from Florida on June 22, 2009:
I always just donate for free. Great hub!
Simao from Porugal on June 21, 2009:
very usefull thanks for this great hub
Lady Rogue from Cleveland Heights, Ohio on June 20, 2009:
Great info, madhubber! Very cool!
Dominic Joseph (author) from New York on June 19, 2009:
@annvans: Yeah, I would never do a place that only had walk in service. One of the benefits of BioLife is that you can schedule online. I'm usually hooked up and donating my plasma within 10 minutes of walking in.
@ rosierific: You should try calling a local donation center. They should be able to tell you if your medical problems preclude you from being a donor.
rosierific from Florida on June 19, 2009:
very interesting subject! I've always wondered about this... I have some medical problems myself and don't know if I'd personally be able to do it (though I'd love to!)
annvans on June 19, 2009:
Good thing to see that someone is having good luck with donating plasma. I tried to donate plasma where I lived and I could never find a parking place and it was only on a walk in basis where you spend 3 hours or more waiting to get in. I found a parking place about a mile away, but figured if I walk a mile in 100 degree weather, I would not be giving plasma by the time I got there, lol. I guess some people liked to do it since the place was so busy all the time. Great hub!
David Lim from Singapore on June 19, 2009:
This is interesting but unfortunately, where I come from, they don't pay you for your plasma. Would have been a real nice source of spare change. :)
Dominic Joseph (author) from New York on June 18, 2009:
Hi LondonGirl, That's true. This Hub is specifically for people here in the States.
LondonGirl from London on June 18, 2009:
In the UK, I don't think anyone is ever paid to donate. It's against the law to be paid to donate organs, bone marrow, sperm, or eggs, and the National Blood Service recruits volunteers.
Dominic Joseph (author) from New York on June 17, 2009:
Hi Whikat, Good point. At one point when I was donating I was also a smoker and coffee drinker. It's good to point out that it doesn't preclude you from donating. I never noticed much of a difference either, but most donation centers seem to recommend you stay away from them the morning you plan to give. Thanks for helping me clarify!
Whikat on June 17, 2009:
Hi Madhubber, Nice to meet a fellow plasma donor. I liked your hub, it is very informative. I did want to comment that I am a smoker, a coffee drinker, and a regular donor and the coffee and cigarettes have never had an effect on me during or after donating. I think it is good that you advise caution, but I wanted to let people also know that they do not have to change their lifestyle and habbits just to be able to donate. Thanks for the article it was a good read. :-)
Dominic Joseph (author) from New York on June 11, 2009:
Hi raquel: I've never come across any donation center that pays different amounts based on blood type.
I'm guessing you're thinking about how O negative blood is in such high demand from the Red Cross. For whole blood donation, O neg is particularly important because they are "universal donors" (anybody can be transfused with their blood).
Some plasma donation centers do pay more for people who weigh more since they're able to donate a larger volume of plasma.
I hope that answers your question! Let me know if I can help any more.
raquel on June 11, 2009:
i lrft you my e mail so please try to answer me this question there... does it matter what blood type you are as far as the pay goes?


text:
Tierra de Reorx v 1.0
Map taken from the imagination of the creator
It's a map of size 4x, with a mountainous terrain, many slopes in the land, and lots of vegetation between lands.
The fields are of medium size and large size, with a total of 65 normal and 5 fields of grass.
The fields do not need to buy them, they are unlocked by default.
Map brings crops by default, wheat, barley, rapeseed, corn, potatoes and beetroot, and added him oat, maiz, sunflower and soybean.
Also added you pig farm, the watermod in cows, sheep and chickens, and the Wool palette collector for the wool of sheep.
Also has the mod multisprayer herbicide, so you have to watch out for weeds that grow in the fields.
Milk from the cows must sell them manually, although at 00.00 sold single.
Added a store to sell manure and liquidmanure.
Authors: Juanathan (BBM), Javier007 (BBM), Giants, Triple farming, 1113
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A Physical Count allows for counts to be scanned into a Physical Inventory freeze.
- To begin a Physical Count you'll need to Freeze the inventory you'd like to count in Inform. See Run physical inventory.
- From your scanners Main menu, select Physical Count and then press the Enter key.
- To begin counting, scan the bin location you'd like to count.
- Scan any product in the bin, or type in the Product Number in the Prod field.
- To change the products unit of measure press the F6 (Uom) key. Select from a list of available units of measure and press the Enter key to change.
- Enter the total quantity in the bin and press the Enter key.
- Repeat the last step for all products in the bin.
Note: If a product is scanned and is not systemically in the bin, a message will appear, Product Not in Count. Add Product? Press the Y key to add the product to the bin and count in the quantity, or press the N key to go back.
- Once all products in a specific bin have been counted, press the F9 (Save) key.
Note:If you attempt to escape without pressing the F9 (Save) key a message will appear, Exit without Saving? . Press the Y key to exit without saving or press the N key to go back.
- Repeat steps 3-5 for all bin locations you'd like to count
- Once all bins have been counted, update your count from Physical Inventory.


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I searched for days trying to find an example at least of a 2D Style racing game #MADEWITHFUSION to no avail. I did find a ton for the old KLIK and PLAY maker. Just none for MMF2.5DEV.
If anyone knows of a link to an example, an .mfa or anything. Please post it below.
Regardless, I will be trying to create my own as I love this type of top down racing.
I did see the Fusion made RC car one, but honestly it didn't look like it had any physics to it. Looked more like cars on a path that couldn't be moved or wrecked out.
Thanks for any help!


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Tag: sandwich
After a week of only eating plants, I would say that the hardest part in switching our diet is not that we can not have meat. But rather it is the fact that we had to make a conscious effort discerning what type of food we eat. Are we getting enough proteins? Are we eating […]


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Shop here for all naturally grown, non-GMO herb plants to grow in your garden. Find your tried-and-true favorites! Look at the options available, and call us. Bigger plants may vary in price!
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Predators' point streak ends with loss to Canucks
VANCOUVER, British Columbia — In each of the first three games of the Predators' five-game road trip, they trailed first but still won, a testament to the never-say-die attitude that powered their franchise-record point streak.
But the Predators were unable to overcome another uninspired start Saturday, losing 4-2 to the Canucks to end their 14-game run without a regulation loss. It was also Nashville's first regulation road loss since Jan. 12, halting their franchise-record road point streak at 13 games.
"Today was just bad," Predators defenseman Roman Josi said of the team's start. "We didn't work hard in the first period. There's no effort, and that just can't happen. It was one of the worst periods in a long time for us. Just didn't battle."
Predators' Colton Sissons scores in front of hometown contingent
Against the Flames on Wednesday, the Predators also fell behind 2-0 in the first period but salvaged a point by forcing overtime. That didn't happen Saturday, with Nashville slogging through a lackluster first period, getting outshot 13-4 and trailing 2-0 again.
The final 40 minutes were an entirely different story as the Predators decidedly controlled play, taking 33 shots to the Canucks' 15. Nashville, however, wasn't able to get closer than one goal, stymied by Canucks goaltender Ryan Miller.
"We managed to squeak out a point out of that game (against Calgary), but we just fell a little bit short tonight," said Predators forward Colton Sissons, who scored one of Nashville's two second-period goals. "As you saw in the second and third, when we were on top of our game, we're a pretty dangerous team to play against. We had a lot of chances, and we just couldn't find a way."
5 takeaways from Predators' 4-2 loss to Canucks
Consistently collecting points over the past month has turned the Predators from a fringe playoff team into one that has a legitimate chance to qualify. Nashville is in a much better position because of its point streak, but it isn't satisfied with its standing.
"It's a tight playoff race, and you need all the points you can get," Josi said. "It got us some separation from the teams below us, but it's still a tight race. We're nowhere near the playoffs yet, so we've got to keep going and get points along the way here."
Reach Adam Vingan on Twitter @AdamVingan.
PREDATORS at OILERS
When: 8 p.m. Monday
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Research by Andrew Crawshaw, opinions by Tony Attwood
The FA have for years been trying to break away from the EU imposed rule of allowing EU players from all nationalities to play for clubs without restriction.
UEFA introduced the rule at the start of the 2006/07 football season requiring that all teams entering European club competitions had to name eight 'home grown' players in their 25 man squad. As part of the argument UEFA argued that since the 1995 Bosman ruling in the European Court of Justice, European competitions were becoming less competitive and clubs were not training up local players.
The Football Association however went much further, claiming without any evidence at all that allowing foreign players to play in the English league has negative consequences for the English national team. And indeed this was not just without any evidence but contrary to such evidence as could be found.
The fairly simple research that established that the contrary of the FA's position was true was first published in Untold in 2010 and has since been republished (without acknowledgement) in the Daily Telegraph in August 2013.
In 2011 the European Commission reviewed whether the home grown rule breached Article 45 of the European Treaty. This and other research showed that improvements in competitiveness have been very small and there is likely very little evidence to show that the rule has improved the quality of youth development in football.
But despite a total lack of evidence that the current situation does restrict the ability of England to compete in international competitions or has any effect on youth opportunities, the desire to change by the FA continues and they are repeatedly suggesting they will use Brexit to enforce the views.
Which makes the situation concerning Cohen Bramall really weird.
Cohen was an Arsenal player – he has just been released by the club and is now looking for another club. He is also English – he was born in England and qualifies like all British born people, to live in England.
But the chaotic and crazy homegrown rules of the FA require a player to be registered with a club affiliated with either the English or Welsh FAs for a period of three years prior to their 21st birthday.
Cohen came to football late having concentrated on athletics as a youth and it seems that not all of the non-league teams he played for were properly affiliated to the FA or maybe they just failed to complete the required paperwork. Nothing wrong with that – clubs don't have to be affiliated. They can be, but they don't have to.
Whilst his recent clubs, Arsenal and Hedensford Town will have had him properly registered, this has happened after his 18th birthday so he can't count as homegrown. It is a quirk of the system but getting the FA to admit their system has a fault is unlikely to happen. It doesn't fit their agenda.
From Arsenal's point of view it doesn't matter since he has left the club. He will probably make a living playing in one of the lower leagues but if not he has at least lived his dream for a couple of years rather than working in a car factory, albeit making Bentleys!
All this fuss over getting more English players to play in England, which appears from all the evidence to make no difference at all, and yet here is a bit of the rule that stops an English player from being registered as home grown.
The FA let us not forget were the organising body in control of football in England when the increasing number of sex abuse cases evolved – they were the controlling body that had no idea anything was amiss. They still don't want to admit anything has been going on. The people who appointed Sam Allerdyce and then quickly had to unappoint him after one game because he didn't behave like a gent.
The organisation that spent millions and millions of pounds of public money on a lunatic bid to host the world cup a second time, and were shocked to find the vote at Fifa was rigged and that England got only two votes.
Yes that FA, and here they are at it again, screwing up the one rule that they claim is their way to winning the world cup. Ah well.
Recent Posts
- Beyond any doubt Infantino is getting his way. Next: Fifa will leave Zurich
- World Cup chaos: the bits you may have missed
- Fifa establish their unchallengable right to change football rules as they go
- Extraordinary report claims Arsenals' FA Cup win was not a major trophy!
- 2022/23 Women's Champions League Juventus v Arsenal – match preview


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Matthew, Mark, Luke & John: Session 11
February 15, 2010
|Click Here To Download This MP3 Podcast
Being Judgmental VS Being Discerning
|Jesus Heals Another Multitude From All Over Judaea and Jerusalem.
|Luke 6:17-19
The Beginning Of Jesus' Famous Sermon On The Mount.
In This Session, We're Only Going To Look At Luke's Record Of The Sermon.
We Will Synchronize Luke's Record With Matthew's More Extensive Record In The Next 3 Sessions.
(a) Matthew's Record VS Luke's Record Of The Sermon
(b) The Kingdom Of God vs The Kingdom Of Heaven
(c) Blessed Are The Poor?
|Luke 6:20
|Matthew 5:1-3
|Blessed Are Those Who Now Hunger And Cry.
|Luke 6:21
|Blessed Are Those Who Are Persecuted For My Sake.
|Luke 6:22-23
|Matthew 5:11-12
|Those WIth Woes Instead Of Blessing.
|Luke 6:24-26
|Loving Your Enemies & Praying For Those Who Persecute You.
|Luke 6:27-28
|Matthew 5:43-45
|Loving Your Enemies & Turning The Other Cheek.
|Luke 6:29
|Matthew 5:38-40
|Giving To Those In Need.
|Luke 6:30
|Matthew 5:42
|What Has Become Known As "The Golden Rule".
|Luke 6:31
|Matthew 7:12
|What Makes You Different If You Only Love Those Who Love You?
|Luke 6:32-35
|Matthew 5:46-47
|"Be Perfect, Just As Your Father Is Perfect & Be Merciful, Just As Your Father Is Merciful."
|Luke 6:36
|Matthew 5:48
|Judging Others VS Judging Fruit: What It REALLY Means To "Judge Not".
|Luke 6:37-38
|Matthew 7:1-2
|The Blind Leading The Blind.
|Luke 6:39-40
|Criticizing The Speck In Your Brother's Eye While A Beam Of Timber Remains In Yours.
|Luke 6:41-42
|Matthew 7:3-5
|Judging (Or Discerning) Trees By Their Fruit.
|Luke 6:43-45
|Matthew 7:16-20
|If You Don't Do What I Say, Can You Really Call Me Your Lord?
|Luke 6:46
|Matthew 7:21
|Building Your House Upon The Rock.
|Luke 6:47-49
|Matthew 7:24-27


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Actinic Keratosis and Cutaneous Squamous Cell Carcinoma
Treatment options
; ; ; ; ;
Background: Cutaneous squamous cell carcinoma (cSCC) and its precursors, actinic keratoses (AK), are common. Physicians of multiple specialties are confronted with their treatment.
Methods: This review is based on publications retrieved by a selective search in PubMed, as well as on the German guidelines on AK and cSCC, skin cancer prevention, and surgery with histologic guidance.
Results: Local treatments for AK include lesional cryotherapy, curettage, and laser ablation as well as field-directed treatments with topical agents, e.g., diclofenac plus hyaluronic acid, imiquimod, 5-fluorouracil, ingenol mebutate, and photodynamic therapy. These treatments can be administered in various sequences or combinations, depending on individual factors and the stage of the disease. The gold standard of treatment for cSCC is histologically confirmed complete resection; radiotherapy is an alternative. Locally uncontrollable or metastatic disease is treated with systemic drugs. The use of various chemotherapeutic agents, EGFR-directed therapies, and the PD-I inhibitor cemiplimab, either singly or in combination, has been described in uncontrolled trials and case series. Cemiplimab has a reported response rate of 47% and was recently approved for the treatment of advanced cSCC.
Conclusion: There are many options for the treatment of AK and cSCC that must be considered in the interdisciplinary care of these entities.
Actinic keratosis (AK) consists of the intradermal proliferation of histologically atypical keratinocytes in an area of skin that has been chronically damaged by exposure to ultraviolet light (UV). AK presents as reddish or brownish spots or plaques with increased keratosis on areas of the skin that have been exposed to the sun. If the entire thickness of the skin contains atypical keratinocytes, but the basal membrane is preserved, this is called carcinoma in situ, or Bowen's disease (1). Multiple lesions in a contiguous area of skin with visible UV-induced skin damage (e.g., on the scalp, forehead, or dorsa of the hand) are called field cancerization (Figure 1a) (1). In cutaneous squamous cell carcinoma (cSCC), the atypical keratinocytes break through the basal membrane; this can manifest itself with nodular growth (Figure 1b) (1). cSCC can arise de novo or on the basis of preexisting AK. The probability and speed of the transition from AK to cSCC is individual, highly variable, and unpredictable. In a systematic review, the progression rate of a single AK to cSCC was variably estimated at 0% to 0.075% per lesion per year. A higher progression rate of 0.53% per lesion per year was estimated if the patient already had cSCC elsewhere. At the same time, however, single AK were found to have high regression rates ranging from 15% to 53% per year, as well as long-term recurrence rates above 50% (2). In the review article, this dynamic was attributed in part to methodological weaknesses in the published studies (e.g., missing data on treatments received and on sun-screening methods, as well as high dropout rates). Yet the literature and clinical experience do, in fact, show that AK and light-induced skin damage are a dynamic rather than static pathological process (2).
The age-standardized incidence rate of cSCC in Germany in the period 2010 to 2014 was 26.90 per 100 000 persons per year, which was 30% higher than the corresponding figure for 2005 to 2009 (1). After a diagnosis of cSCC, 50% of patients go on to develop further epithelial skin tumors, most often within 1 year of the initial diagnosis (1).
Cumulative UV exposure is the main risk factor for AK and cSCC (Box 1). If a patient has six or more AK, a cSCC, or field cancerization over an area of at least 4 cm2 on a region of skin that is exposed to UV light because of the patient's work, the possible presence of an occupational disease should be assessed (no. 5103 in the German classification of occupational diseases). Immune compromise, e.g., in transplant recipients and patients with hematologic cancers such as chronic lymphocytic leukemia, is also associated with a higher incidence and a more aggressive course of cSCC (3).
The risk of recurrence and metastasis of cSCC is low with appropriate therapy. Clinical and histological risk factors have been determined (Box 2). In a series of 114 patients with metastatic cSCC, 46 (40%) had locoregional metastasis in the skin and lymph nodes (Figure 1c), 35 (31%) had distant metastases (usually to the lungs and pleura), and 33 (29%) had simultaneous locoregional and distant metastases (e63). Curative treatment is considered no longer possible in patients with distant metastases or a regional metastasis or local recurrence that cannot be completely controlled with surgery or radiotherapy (e63).
Learning objectives
This article is intended to enable the reader to:
- Gain an up-to-date understanding of the clinical features and prognosis of actinic keratosis and cutaneous squamous cell carcinoma
- Become familiar with the essential procedures for treatment of these lesions
- Assess the advantages and limitations of the various treatment options
This review is based on pertinent publications retrieved by a systematic review of the Medline database, as well as on the German guidelines on AK and cSCC, skin cancer prevention, and histologically guided surgery. The evidence levels are taken from the assessments contained in the German clinical practice guidelines on AK and cSCC, which employ the system of the Oxford Center for Evidence-Based Medicine in its version of 2011 (1). Evidence levels are given on a scale from 1 to 5, with 1 being the highest and 5 the lowest.
Actinic keratosis
It cannot yet be reliably determined on clinical and histological grounds which AK lesions will undergo transformation into invasive cSCC and which will not. Important indicators of the individual risk of developing cSCC include immune suppression, a prior history of epithelial skin cancer, high cumulative UV exposure, and the number of lesions present. In view of this and the fact that AK is perceived as a chronic, progressive disease, adequate treatment for all cases of AK is recommended after critical evaluation of the patient's life expectancy, comorbidities, and individual preferences.
There are many treatments for AK (Table 1, Figure 2). Lesion-directed treatments include procedures with the scalpel (e.g., shave excision), liquid nitrogen (cryosurgery), or laser (e.g., erbium/YAG; CO2). These are provided directly by the physician to the patient and are appropriate for isolated, well-demarcated lesions. An advantage of the surgical approach is that it provides for histopathological control of the clinical diagnosis and the complete removal of the lesion; its disadvantages include the need for local anesthesia, bleeding, and possible scar formation. Cryosurgery and laser therapy can be performed very rapidly in experienced hands but can cause pain, blisters, and superficial wounds. Moreover, hyper- or hypopigmentation can arise during and immediately after these treatments and may be permanent. A major advantage of field-directed techniques is that they can be used to treat multiple contiguous lesions, including subclinical ones, i.e., sites of AK that cannot yet be seen or palpated. Such techniques include the topical application of agents in solution or in the form of a gel or cream, as well as photodynamic therapy (PDT). The common features of field-directed treatments are healing without scar and predominantly no more than transient local side effects such as pain, erythema, swelling, sterile pustules, erosions, and scabbing. Ten different preparations are now approved for field-directed treatment in Germany, differing in their mechanisms of action, galenic formulation, maximal area of application, duration of application, and side-effect profiles (Table 1). A hierarchical ranking of the available treatments is difficult, as direct comparison studies are generally lacking. Four field-directed treatments were recently compared directly with one another in an independently financed trial published in a high-ranking journal: 5-fluorouracil was found to yield the highest rate of healing at 12 months in patients with at least five lesions on the scalp (4).
The choice of a suitable treatment depends on patient-, lesion-, and treatment-specific factors (Table 2). Lesion-directed techniques can generally be carried out rapidly, but they are only effective over a small area. Field-directed techniques take a few days to months to apply and thus require high patient compliance. Some of them are not covered by health insurance in Germany (e.g., red-light PDT). Alongside the parameters listed in Table 2, the physician's experience, the patient's prior history, and the availability of treatments are further important factors that need to be considered in the choice of therapy.
Combinations of treatment approaches are reasonable and are being applied more and more frequently, e.g., field-directed treatment after lesion-directed treatment. For example, laser ablation can be carried out before PDT to remove especially thick hyperkeratotic lesions, thereby making the skin surface more permeable for cream application. Other studies have shown that the combination of imiquimod and PDT leads to significantly higher healing rates than monotherapy (5–7).
Cutaneous squamous cell carcinoma
The treatment options for cSCC include surgery, radiotherapy, and medication (Table 3, Figure 2).
Surgical treatment
Complete excision under histopathological guidance is the standard treatment of cSCC. There is no commonly accepted definition of an R0 resection; the desired distance from the edge of the tumor to the border of the resection varies in the literature from 0 to 6 mm (8). After resection and until the time of definitive histopathological confirmation, the wound should only be closed if the borders of the resection will remain clearly identifiable. For tumors less than 1 cm in size, shave-excision is an alternative to resection. In this situation, the diameter of the excised tissue should be no less than 5 mm to enable reliable histopathological examination (1). If the clinical diagnosis is unambiguously clear, excision can be carried out without prior biopsy. The risk factors for local recurrence and metastasis (Box 2) are also relevant to surgical planning, as one may want to consider wider safety margins or elective lymph node surgery (e.g., biopsy of a sentinel node) in patients at higher risk.
The technique of histopathological examination is what distinguishes conventional surgery from micrographically controlled surgery (MCS), also known as Mohs surgery (9). The latter generally involves 3D histology, i.e., once the tumor has been excised, the outer sides of the resection specimen are separately analyzed histologically to enable complete inspection of the three-dimensional edges of the resection (9). MCS allows the detection of outward extensions of the tumor with high sensitivity; consequently, the safety margin for excision can be kept relatively low. Although frozen sections are quicker to prepare, paraffin sections are superior for the detection of subclinical tumor extensions (9). MCS is to be distinguished from excision with a wide safety margin and lamellar sectioning of the specimen (the loaf-of-bread technique), in which the entire extent of the tumor is histologically examined (9). The safety margin for resection is not definitively laid down in the literature (1–4 mm, up to 50 mm under certain circumstances), but the risk of subtotal resection increases with the size of the specimen and in inverse relation to the safety margin (8). The local recurrence rate after MCS ranges from 0 to 33%, with rates of 2% to 8% reported in most studies. The local recurrence rate after resection with the loaf-of-bread technique ranges from 0% to 53%, with numbers of 2% to 13% most commonly reported (8). No method has yet been shown to be clearly superior to any other.
The identification and excision of one or more sentinel lymph nodes (sentinel lymph node biopsy, SLNB) is an option for minimally invasive lymph node diagnosis in order to detect occult metastasis while avoiding excessive lymphadenectomy. SLNB can be considered in patients with high-risk cSCC, particularly in the head and neck region, with its variable lymphatic flow. Despite high sensitivity (79%) and specificity (100%) and a negative predictive value of 96% (10), SLNB of one or more nodes has not been shown to result in significantly longer disease-specific overall or metastasis-free survival (11, 12), and it therefore cannot be generally recommended (1). Prophylactic lymphadenectomy should not be performed (1, 13). In the case of clinically or histologically apparent lymph node metastasis, therapeutic lymph node dissection should be performed, as this improves locoregional tumor control (8, 13). The extent of the therapeutic lymph node removal has not been precisely defined; if possible, selective functional resection should be carried out (1).
Resection is also the standard treatment for locoregional recurrence, as long as the conditions for local and general operability are met.
Although there have not been any prospective, randomized trials comparing primary radiotherapy with other local treatments, retrospective studies have shown a local tumor control rate of 94.0% at 5 years with radiotherapy alone (14). A prospective phase III trial compared radiation alone with radiochemotherapy for cSCC in the head and neck region. The additional administration of carboplatin was found not to have any additional effect; the rate of locoregional tumor control at 5 years was 83% after radiotherapy and 87% after radiochemotherapy, and the rates of 5-year overall survival were 76% and 79% (15).
Postoperative radiotherapy is indicated only in the presence of risk factors. These include R1 or R2 resection, a narrow resection margin (<2 mm), recurrent tumor, large tumor (>2 cm), deep tumor penetration (>4 mm), infiltration of adipose tissue, perineural sheath infiltration, and extensive lymphatic involvement (>1 lymph node, extension beyond capsule) (16–19). Postoperative radiotherapy should be performed after R1 or R2 resection or when the resection margin is <2 mm (1, 8, 17, 18, 20). The same holds for perineural sheath infiltration by tumor, although the extent of the infiltration is relevant here. If the infiltration is microscopic, the local control rate after surgery alone is 78% to 87%; if it is macroscopic, the local control rate after surgery is 50% to 55%, compared to 100% after postoperative radiotherapy in selected patients (19). Postoperative radiotherapy should also be performed in the case of extensive involvement of the cervical lymph nodes (> 1 lymph node, lymph node metastasis > 3 cm, extension beyond capsule, intraparotid lymph node involvement) (18, 21, 22). In a retrospective study, the local recurrence rate, 5-year disease-free survival rate, and overall survival rate after surgery alone were 55%, 34%, and 27%, respectively, while the corresponding rates after surgery and postoperative radiotherapy were 23%, 74%, and 66% (22). The procedure to be followed in the case of lymph node metastasis in the axillary or inguinal regions is analogous to the indication for postoperative radiotherapy in the head and neck region. Depending on the risk constellation, radiation doses ranging from 50 Gy (R1 resection, resection margin <2 mm) to 66 Gy (R2 resection) are recommended (18). For local or locoregional recurrences, the same criteria as in the primary situation apply with respect to the indication for postoperative radiotherapy (1).
Systemic drug treatment
Systemic drugs are given when local measures no longer suffice, e.g., in the case of a locally advanced lesion (usually after prior surgery and radiotherapy) or distant metastasis. In a systematic review of the literature from the years 1970 to 2011, Behshad et al. identified 28 studies (all with low-level evidence) including 119 patients with locally advanced cSCC who were treated with systemic drugs. In a large majority of cases, various chemotherapeutic agents were used either singly, in combination, or together with radiotherapy (23). The observed overall response rate was 72%, and the median response duration was 10.5 months.
In addition to chemotherapy, many publications have described the use of targeted therapies against the epidermal growth factor receptor (EGFR) to treat cSCC, but there have been only a few, uncontrolled prospective trials (24). In a trial of cetuximab on 36 patients, the response rate was 28%, and the median response duration was 6.8 months (25); in a trial of panitumumab on 16 patients, the response rate was 31%, and the median response duration was 6 months (26). In principle, EGFR blockers such as cetuximab can also be combined with chemotherapeutic drugs such as paclitaxel (27) or platinum derivatives (28), in a manner analogous to the treatment of mucosal squamous cell carcinoma.
Squamous cell carcinomas often express PD-L1 and contain tumor-infiltrating lymphocytes (29); thus, immune therapy targeted on PD-1 is another worthwhile approach. A single-armed trial of the anti-PD-1 antibody cemiplimab in 59 patients with metastatic squamous cell carcinoma yielded a response rate of 47%, and, at the time of assessment, most of these remissions had persisted longer than 6 months (30). The European Medicines Agency (EMA) has approved cemiplimab for the treatment of inoperably advanced or metastatic cSCC. Patients with inoperable cSCC are currently being recruited for a trial of cetuximab combined with the PD-L1 antibody avelumab. The PD-1 antibodies cemiplimab and pembrolizumab are being tested in placebo-controlled studies for the adjuvant treatment of patients after resection and radiotherapy of high-risk cSCC. It is particularly important that the treatment strategy for patients with cSCC should be designed on an individual basis in consideration of the patient's age, comorbidities, and personal preferences.
Special considerations for immune-suppressed patients
Patients being treated with immune-suppressant drugs, particularly organ transplant recipients, have a markedly higher risk of developing AK and of progression of AK into invasive cSCC; these cSCC also show more aggressive growth than in the usual situation, with greatly elevated morbidity and mortality (31, 32). Organ transplant recipients have a 20- to 50-fold elevation of the risk of developing a non-melanocytic skin cancer compared to immune-competent persons (32). The same holds for patients who are immunocompromised because of an underlying illness, particularly chronic lymphocytic leukemia. Such patients should be informed early of the elevated risk and taught how to examine themselves; they should undergo dermatological surveillance examinations at intervals depending on the risk, and any suspect lesions should be diagnosed and treated as early as possible.
Data are available from randomized, controlled trials on the treatment of AK in organ transplant recipients with PDT combined with methyl aminolevulinic acid (MAL-PDT), ablative fractionated laser therapy (AFXL), diclofenac sodium 3% gel, imiquimod 5% cream, and 5-fluorouracil 5% cream: healing rates were highest with MAL-PDT and lowest with AFXL (33) (Table 1). Early diagnosis and surgical resection are determinative for the successful treatment of squamous cell carcinoma (34). Radiotherapy can be used to treat advanced lesions or those with a high risk of recurrence. The drug treatments listed here must be carefully considered because of their side effects. Immune therapy, in particular, can exacerbate an existing autoimmune disease or cause transplant rejection (35, 36).
As for iatrogenic immune suppression, multiple prospective, randomized trials carried out in kidney transplant recipients have unanimously shown that switching the immune-suppressant drug from a calcineurin inhibitor to an mTOR inhibitor in high-risk patients who have had epithelial skin tumors resected significantly lowers the risk of further skin tumors (37). This effect is greatest in patients who have had only one tumor resected, rather than two or more.
Prophylactic measures
In two prospective, randomized, placebo-controlled trials on patients in whom epithelial skin tumors had been resected, the development of new cSCC was shown to be significantly less common after prophylactic treatment: one study concerned topical treatment with 5% 5-fluorouracil on the face for 2 to 4 weeks (38), and the other concerned the daily taking of 1000 mg nicotinic acid amide/vitamin B3 (39). In both trials, however, the effect was lost once the treatment was terminated. It follows that permanent nicotinic acid amide treatment can be considered for high-risk patients. Topical treatment with 5% 5-fluorouracil can be repeated depending on the clinical course and the development of new lesions. In organ transplant recipients, switching the immune-suppressant drug to an mTOR inhibitor can be considered.
The definition of actinic keratosis
Actinic keratosis (AK) consists of the intradermal proliferation of histologically atypical keratinocytes in an area of skin that has been chronically damaged by exposure to ultraviolet light.
The origin of cutaneous squamous cell carcinoma (cSCC)
In cSCC, the atypical keratinocytes break through the basal membrane; this can manifest itself with nodular growth. cSCC can arise de novo or on the basis of preexisting AK. The probability and speed of the transition from AK to cSCC is individual, highly variable, and unpredictable.
Rising incidence
The age-standardized incidence rate of cSCC in Germany in 2010 to 2014 was 26.90 per 100 000 persons per year, 30% higher than the corresponding figure for 2005 to 2009.
Risk factors
Cumulative ultraviolet exposure is the main risk factor for AK and cSCC.
Treatment options for actinic keratosis
Actinic keratosis can be treated with lesion-directed and field-directed methods.
The choice of treatment
The choice of treatment depends on patient-, lesion-, and treatment-specific factors.
The gold standard
Complete excision is the gold standard treatment for cSCC.
Safety margins
The complete excision of cSCC should be histologically confirmed.
Radiotherapy should be performed if a tumor cannot be completely excised locally or is inoperable for medical reasons.
Postoperative radiotherapy
Postoperative radiotherapy is indicated if there are risk factors for local or locoregional recurrence.
Drug therapy
The available types of drug therapy are chemotherapy, anti-EGFR therapy, and immune therapy targeted on PD-1.
Criteria for the choice of treatment
The treatment strategy for patients with cSCC should be designed on an individual basis in consideration of the patient's age, comorbidities, and personal preferences.
Caveat: immunosuppression
The incidence and aggressiveness of AK and cSCC are higher in immune-suppressed patients.
The special case of the organ transplant recipient
In organ transplant recipients with AK or cSCC, switching the immune-suppressant drug to an mTOR inhibitor can be considered.
In organ transplant recipients, switching the immune suppressant drug to an mTOR inhibitor can be considered.
Conflict of interest statement
Prof. Gutzmer has served as a paid consultant for Roche, Bristol-Myers Squibb, Almirall Hermal, Amgen, Pierre Fabre, Merck Serono, Takeda, SUN, ASC, Incyte, Pfizer, Sanofi, and Novartis. He has received lecture honoraria from Roche, Bristol-Myers Squibb, MSD, Novartis, Amgen, Pierre Fabre, Merck-Serono, Almirall, AstraZeneca, Sanofi, and SUN. He has received reimbursement of congress participation fees and travel expenses from Merck-Serono, Pierre Fabre, BMS, Roche, and SUN. He has received funding from Novartis, Amgen, Merck-Serono, Pfizer, and Johnson & Johnson for a research project that he initiated.
Prof. Wiegand has served as a paid consultant for Bristol-Myers Squibb and MSD. She has received lecture honoraria from Astra Zeneca, MSD, Merck-Serono, and Bristol-Myers Squibb. She has received reimbursement of travel and accommodation expenses from Astra Zeneca, MSD, and Bristol-Myers Squibb.
PD Wermker has served as a paid member of an Advisory Board for Bristol-Myers Squibb.
Dr. Heppt has served as a paid consultant for Sanofi-Aventis.
Prof. Berking has served as a paid consultant for Almirall Hermal, Galderma, Leo Pharma, MSD, and Sanofi-Aventis. She has received lecture honoraria from Leo Pharma and Galderma. She has received funding from Leo Pharma for a research project that she initiated and third-party research funding from Biofrontera.
Prof. Kölbl states that he has no conflict of interest.
Manuscript submitted on 29 March 2019, revised version accepted on
4 July 2019
Translated from the original German by Ethan Taub, M.D.
Corresponding author
Prof. Dr. med. Ralf Gutzmer
Hauttumorzentrum Hannover
Klinik für Dermatologie, Allergologie und Venerologie
Medizinische Hochschule Hannover (MHH)
Carl Neuberg Str. 1
30625 Hannover, Germany
Cite this as:
Gutzmer R, Wiegand S, Kölbl O, Wermker K, Heppt M, Berking C:
Actinic keratosis and cutaneous squamous carcinoma—treatment options.
Dtsch Arztebl Int 2019; 116: 616–26; DOI: 10.3238/arztebl.2019.0616
►Supplementary material
For eReferences please refer to:
Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Leipzig:
Prof. Dr. med.
Susanne Wiegand
Department of Radiotherapy, University Hospital Regensburg: Prof. Dr. med. Oliver Kölbl
Department of Oromaxillofacial, Plastic and Esthetic Surgery, Osnabrück Hospital GmbH, Osnabrück: PD Dr. med. Dr. med. dent. Kai Wermker
Department of Dermatology and Allergology, University Hospital (LMU), Munich: Dr. med. Markus Heppt, Prof. Dr. med. Carola Berking
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