What are the other Names for this Condition? (Also known as/Synonyms)

• Heat-Induced Squamous-Cell Skin Carcinoma due to Kangri

What is Kangri Cancer? (Definition/Background Information)

• Kangri Cancer is a rare type of heat-induced squamous cell carcinoma (SCC) of skin that is only described among the Kashmiris. Kashmir is the northernmost state of India, bordering the Himalayas
• The ‘Kangri’ is a traditional baked clay pot, about 15 cm or less in size, covered with wicker. The pots are used to store burnt wood embers and act as a heat source. They are held close to the body, sometimes under traditional garments, during the wintry months
• Kangri Cancer may appear as slow-growing skin lesions, commonly on the abdomen region. The lesions may ulcerate and cause scarring of skin. In case of progression of the skin condition, it may metastasize to the lymph nodes
• The treatment of choice is a surgical excision with clear margins followed by radiation therapy or chemotherapy, as decided by the healthcare provider. In majority of the cases, the prognosis is excellent with appropriate treatment
• In general, the number of cases of Kangri Cancer is decreasing with increased awareness and education. However, some cases are still being reported from parts of Kashmir

Who gets Kangri Cancer? (Age and Sex Distribution)

• Kangri Cancer generally affects elderly or older adults, though individuals of any age may be affected
• No gender predominance is observed and both males and females are affected
• This form of squamous-cell skin cancer is only observed among the Kashmiri Indians, who use Kangri clay pots as a heat source, to keep themselves warm during the cold seasons

What are the Risk Factors for Kangri Cancer? (Predisposing Factors)

• Long-term use of Kangri, an earthen clay pot that holds burning wood embers, is the primary risk factor for Kangri Cancer

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Kangri Cancer? (Etiology)

Kangri Cancer is described as a heat-induced skin cancer that develops within a skin condition called erythema ab igne (EAI). EAI is a skin reaction that occurs on exposure of the skin to infra-red (heat) radiation for long durations.

• Kangri Cancer is a form of squamous cell carcinoma of skin, which is caused when skin cells are burnt or damaged from prolonged (and frequently severe) exposure to heat, over many decades
• Some studies have reported specific genetic mutations that make individuals susceptible to the cancer; such mutations are currently being well-characterised

What are the Signs and Symptoms of Kangri Cancer?

The signs and symptoms of Kangri Cancer may include:

• In majority of the cases, skin squamous cell carcinomas are asymptomatic and do not present any signs or symptoms (during the initial period)
• The appearance of a slow-growing lesion may be noted
• The skin lesions may be noticed on the abdomen (usually), or on the pelvic region or upper thigh
• The skin lesions may appear as crusted ulcer, plaques, and nodules
• It may ulcerate and bleed
• Occasionally, after the ulcer heals, it may become ulcerated again
• In some cases, the affected skin may appear more/less pigmented than the surrounding skin

How is Kangri Cancer Diagnosed?

A diagnosis of Kangri Cancer is made via the following tests and exams:

• Complete physical examination with detailed medical history evaluation; a history of long duration heat exposure may be established
• Examination by a dermatologist using a dermoscopy, a special device to examine the skin
• Wood’s lamp examination: In this procedure, the healthcare provider examines the skin using ultraviolet light. It is performed to examine the change in skin pigmentation

Although the above modalities can be used to make an initial diagnosis, a tissue biopsy of the tumor is necessary to make a definitive diagnosis to begin treatment.

Tissue/skin biopsy:

• A tissue biopsy of the tumor is performed and sent to a laboratory for a pathological examination. A pathologist examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed) and with microscope findings, the pathologist arrives at a definitive diagnosis. Examination of the biopsy under a microscope by a pathologist is considered to be gold standard in arriving at a conclusive diagnosis
• Biopsy specimens are studied initially using Hematoxylin and Eosin staining. The pathologist then decides on additional studies depending on the clinical situation
• Sometimes, the pathologist may perform special studies, which may include immunohistochemical stains, molecular testing, and very rarely, electron microscopic studies to assist in the diagnosis

In case of metastatic tumors, the following diagnostic procedures can be used to procure the tissue sample:

• Fine needle aspiration (FNA) biopsy of the tumor: A FNA biopsy may not be helpful, because one may not be able to visualize the different morphological areas of the tumor. Hence, a FNA biopsy as a diagnostic tool has certain limitations, and an open surgical biopsy is preferred
• Core biopsy or open biopsy of the tumor; although, generally, these methods are not suited or preferred for this condition

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Kangri Cancer?

The possible complications due to Kangri Cancer include:

• Discomfort, irritability of the affected skin
• Large lesions may ulcerate and bleed resulting in superimposed bacterial or fungal infections
• Permanent scarring might occur and cosmetic surgery may be required to restore the affected skin areas
• They are frequently observed to metastasize to the lymph nodes
• Treatment complications and medication side effects

How is Kangri Cancer Treated?

Early diagnosis and treatment of Kangri Cancer is important to avoid complications such as metastasis to other regions. The treatment measures may include:

• In most cases, a wide surgical excision and removal of the entire tumor is the preferred treatment option. This may be followed by radiation therapy and/or chemotherapy
• If the tumor has metastasized, then a combination of chemotherapy, radiation therapy, and invasive procedures may be used to treat the tumor
• Targeted therapy medications are generally used for locally-infiltrated or metastatic squamous cell carcinomas. This therapy destroys the tumor cells by acting against certain proteins that are responsible for tumor growth
• Use of photodynamic light or laser therapy: Light destroys the damaged cells after they are treated with a special medication application
• Scraping and dermabrasion: Removal of skin lesions by scraping them, or using abrasion techniques (rapid brushing)
• Cryotherapy: It involves the controlled use of liquid nitrogen to kill tumor cells. There is a biological preferential killing of the greater fluid-filled tumor cells compared to the relatively acellular collagen/elastin/glycosaminoglycan substrate of the uninvolved surrounding dermis
• Stepwise removal of the entire tumor, with meticulous pathologic examinations of the margins of the specimen, until a tumor-free defect is created. This is termed  Moh's micrographic surgery
• Large tumors after complete skin excision may need skin grafting
• Post-operative care is important until the surgical wound heals

Follow-up care with regular screening and check-ups are recommended and important.

How can Kangri Cancer be Prevented?

• Kangri Cancer may be prevented by avoiding the use of Kangri baskets/pots close to the body skin. Individuals may instead using adequate thermal protective clothing and other heat sources appropriately
• Education and awareness of this particular cancer type among the local Kashmiri community can help reduce the incidence rates. Nevertheless, it is important to note that the incidence of this cancer is on the decline

Regular medical screening at periodic intervals with blood tests, scans, and physical examinations are mandatory, due to its high metastasizing potential and possibility of recurrence. Often several years of active vigilance are necessary.

What is the Prognosis of Kangri Cancer? (Outcomes/Resolutions)

• In general, the prognosis of Kangri Cancer is good, if it is detected and treated early. However, if it metastasizes to other regions, such as to the local lymph nodes, the prognosis may be guarded
• The prognosis of squamous cell skin carcinomas, in general, depends upon a set of several factors that include:
  • Stage of tumor: With lower-stage tumors, when the tumor is confined to site of origin, the prognosis is usually excellent with appropriate therapy. In higher-stage tumors, such as tumors with metastasis, the prognosis is poor
  • The size of the tumor: Individuals with small-sized tumors fare better than those with large-sized tumors
  • Overall health of the individual: Individuals with overall excellent health have better prognosis compared with those with poor health
  • Age of the individual: Older individuals generally have poorer prognosis than younger individuals
  • Involvement of the lymph node can adversely affect the prognosis
  • Involvement of vital organs may complicate the condition
  • The surgical resectability of the tumor (meaning if the tumor can be removed completely)
  • Whether the tumor is occurring for the first time, or is a recurrent tumor. Recurring tumors have worse prognosis compared to tumors that do not recur 
  • Response to treatment: Tumors that respond to treatment have better prognosis compared to tumors that do not respond to treatment
  • Progression of the condition makes the outcome worse

Additional and Relevant Useful Information for Kangri Cancer:

• Do not pick or pop the blisters, for doing so can affect the healing process and may result in secondary infections
• Cleaning the skin too hard with strong chemicals or soaps may aggravate the skin condition. Care must be taken avoid strong soaps and chemicals that could potentially worsen the condition
• The presence of dirt on the body is not a causative factor for the condition. However, it helps to be clean and hygienic, which may help the condition from getting worse