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Tumors of the Skin: Benign and Malignant Dr. Robert Norman, DO, MPH, MBA Dr. Robert Norman & Associates Tampa, Florida PCOMS 2015 Disclosure: I have no financial relationship in regard to the content of this presentation Learning Objectives 1. 2. 3. Gain an understanding of benign and malignant tumors of the skin as it relates to: Differentiating between benign and malignant tumors Appreciating a basic understanding of the tumors discussed in the lecture Knowledge of the basic statistics and diagnostic tools related to malignant melanoma Benign Tumors of the Skin Seborrheic keratosis Cherry angioma Spider angioma Melanocytic nevus Halo nevus Seborrheic Keratosis Most common benign epithelial tumor Hereditary Start at around age 30 Can be few or multiple Vary in morphology and color depending on location of body Seborrheic Keratoses: many faces Cherry Angioma Very common, bright red to violaceous domed papules Can thrombose and appear black Most commonly on the trunk Develop around age 30 Can be multiple Only a cosmetic nuisance Spider Angioma Focal telangiectatic network of dilated capillaries radiating from a central arteriole Most common on face May be assoc with hyperestrogenic states, ie. Pregnancy, OC use Common in children Acquired Melanocytic Nevus One of the most common lesions in Caucasians Most adults have 20 Appear in early childhood Gradually involute around 60 Halo Nevus Nevus surrounded by a halo of leukoderma or depigmentation Immunologic phenomenon via action of cytotoxic lymphocytes Nevus will usually disappear in months-years Skin repigments in months-years May occur on one or multiple nevi Possible precursor to vitiligo Halo Nevi Halo Nevus? Malignant Tumors of the Skin Basal cell carcinoma Squamous cell carcinoma Malignant melanoma Basal Cell Carcinoma Most common type of skin cancer Slow growing Locally invasive and destructive but not metastatic Usually in sun-exposed areas in fair-skinned people Basal Cell Carcinoma Typically looks like a ‘pearly’ shiny papule with overlying telangiectasia and rolled borders Center may be ulcerative Several variants: superficial, sclerosing, pigmented Superficial BCC Think superficial BCC when You think you are looking at Eczema but it does not clear with Steroids. Good Rule Of Thumb in Dermatology If something does not look or respond like you think it should, ie. “it looks like eczema but doesn’t respond to steroids”…you should always consider a biopsy as your next move Destructive skin cancers Actinic Keratosis Aka. solar keratosis Seen in sun exposed areas: face, scalp, ears, hands, arms Erythematous, scaly papule; tender Can possibly evolve into SCC if not treated Squamous Cell Carcinoma 2nd most common type of skin cancer Sun exposed areas in fair-skinned people Erythematous, keratotic nodule, may ulcerate SCC Can metastasize (3-4%) Most common skin cancer in black patients Can occur in burn scarsMarjolin’s ulcer- met rate is 20% SCC Secondary to HPV Infection HIV + History of condyloma Giant condyloma of Buschke and Lowenstein HPV types 16,18,31,33, 35 and 45 are liked to carcinoma SCC 52 year old woman with growth on the breast Biopsy showed SCC Pt. lost to follow up SCC 8 year old boy with history of Xeroderma Pigmentosum with multiple SCC’s on the face and severe actinic damage SCC 7 year old with Xeroderma Pigmentosum Multiple actinic keratoses and SCC’s Malignant Melanoma Most deadly form of skin cancer 2% of all cancer deaths are from Melanoma Melanoma One person dies of melanoma every hour One in 55 people will be diagnosed with melanoma during their lifetime Melanoma is the most common form of cancer for young adults 25-29 years old and the second most common form of cancer for young people 15-29 years old. There were 123,590 new case of melanoma in the U.S. in 2011 Melanoma is the 6th most common cancer in the U.S. for females and the 5th for males Oh, by the way….. DON’T LET THIS ONE WALK OUT YOUR DOOR…. THIS ONE DOESN’T BOTHER ME Lentigo Maligna Malignant Melanoma The most common occurring cancer death in women between 25 and 29 Usually triggered by the sun, but also has a strong genetic component Melanoma In the U.S. your chance of getting melanoma in 1940 was 1 in 1500. By 2004, it was 1 in 67. Now it’s 1/55 If caught in the earliest stages, melanoma is entirely treatable with a survival rate of nearly 100%. If untreated and allowed to spread, there is no known treatment or cure. Early identification is key…. Does this lesion fit the A,B,C’s of melanoma? Another good rule of thumb If your patient tells you that a mole is changing and you cannot be 100% certain that it is benign, you need to biopsy it or document that you have sent that patient somewhere to have it biopsied. Even if a patient isn’t saying that a mole has changed but that it ‘worries” them, you need to biopsy it. Mohs Micrographic Surgery 1. 2. 3. Developed in 1930’s by Frederick Mohs Greater than 99% cure rate for many skin cancers Recommended for: Cancers on the face Large cancers Recurrent cancers, esp. of face Tanning Beds=A VERY BAD Idea! Since the introduction of indoor tanning in the 1970’s the incidence of skin cancer has rocketed Dose of UVA in a tanning bed is 10-100 times greater than what you get outside There is no such thing as a safe tan, unless it comes from a bottle or spray Tanning more than 12 times per year increases the risk of melanoma by 40-75% 30 million people tan indoors every year, 2.3 million are teens Indoor tanning industry has yearly revenues of 5 billion dollars UV Camera Reveals Damage In a 4 year old A 17 year old And a 64 year old Don’t assume that you don’t have any Damage…it starts a a very young age! Cutaneous Lesions – SCC & BCC Skin Cancer is 2.5 X Greater than all other cancers combined. 4M lesions will have been treated in 2013. 50% Increase by 2020 / 6M 1 in 2 over the age of 60 will have skin cancer, according to MD Anderson. 1/3 of the US Population will have skin cancer by 2025. SRT in Dermatology: Back to the Future Need for SRT in Dermatology: Dramatic increase in NMSC Comorbidities, anticoagulation in aging population Increased larger tumors in difficult areas such as tibial and scalp Perceived overutilization and decreased reimbursement of Moh’s Need to make sure that Dermatology has access to all modalities SRT offers high cure rate low morbidity and scaring Tumor Margin, Energy, Fractionation Guidelines Treatment margins, energy, and fractionation schemes are selected based upon certain parameters to insure optimal dosage is delivered across the tumor and marginal volume. Factors influencing prognosis of NMSC: Tumor size (increasing size confers higher risk of recurrence) Tumor site (location of lesions on the central face, especially around the eyes, nose, lips and ears, are at higher risk of recurrence) Tumor thickness Definition of clinical margins (poorly defined lesions are at higher risk of recurrence) Histological subtype (certain subtypes confer higher risk of recurrence) Histological features of aggression (perineural and ⁄ or perivascular involvement confers higher risk of recurrence) Failure of previous treatment (recurrent lesions are at higher risk of further recurrence) Immunosuppression (possibly confers increased risk of recurrence) 1.Nonmelanoma skin cancer Current Treatment Options in Oncology 2002, Volume 3, Issue 3, pp 193-203Tri H. Nguyen MD, Diana Quynh-Dao Ho MD Fractionation Fractionation is a method of treating cancer, with ionizing radiation therapy, where the total dose is divided into several smaller doses over a period of time. An optimal fractionation scheme will maximize the effects of radiation on cancer and minimize the negative side effects. Fractionation Dose / Fraction TDF Table Time Dose Fractionation Factors for Three Fractions per Week TDF # Between 90 and 110 for NSMC Skin Lesions - NUMBER OF FRACTIONS (cGy) 4 5 6 8 20 40 60 80 100 110 120 130 140 150 160 170 180 190 200 210 220 230 240 250 260 270 280 290 300 320 340 360 380 400 420 440 460 480 500 520 540 560 580 600 700 800 900 1000 0 0 1 1 1 1 1 1 1 2 2 2 2 2 2 2 3 3 3 3 3 4 1 1 2 2 3 3 4 4 4 5 5 6 6 6 7 7 8 8 9 9 9 10 2 2 3 4 5 6 7 7 8 9 10 10 11 12 12 13 14 15 16 17 17 19 3 4 4 6 7 9 10 11 12 13 15 16 18 19 19 21 22 24 25 26 27 30 4 5 6 8 10 13 15 16 17 19 21 23 25 26 27 29 31 33 36 37 38 42 5 6 7 10 12 15 17 18 19 22 24 27 29 30 32 34 36 39 41 42 44 48 6 7 8 11 14 17 19 21 22 25 28 30 33 35 36 39 42 44 47 48 50 55 6 8 9 13 16 19 22 24 25 28 31 34 38 39 41 44 47 50 53 55 56 63 7 9 11 14 18 21 25 26 28 32 35 39 42 44 46 49 53 56 60 61 63 70 8 10 12 16 20 23 27 29 31 35 39 43 47 49 51 55 59 62 66 68 70 78 9 11 13 17 22 26 30 32 35 39 43 47 52 54 56 60 65 69 73 75 78 86 9 12 14 19 24 28 33 36 38 43 47 52 57 59 62 66 71 76 80 83 85 95 10 13 16 21 26 31 36 39 41 47 52 57 62 65 67 72 78 83 88 90 93 103 11 14 17 22 28 34 39 42 45 51 56 62 67 70 73 79 84 90 96 98 101 112 12 15 18 24 30 36 43 46 49 55 61 67 73 76 79 85 91 97 103 106 109 122 13 16 20 26 33 39 46 49 52 59 66 72 79 82 85 92 98 105 111 115 118 131 14 18 21 28 35 42 49 53 56 63 70 77 84 88 92 99 106 113 120 123 127 141 15 19 23 30 38 45 53 57 60 68 75 83 90 94 98 106 113 121 128 132 136 151 16 20 24 32 40 48 56 60 64 72 80 89 97 101 105 113 121 129 137 141 145 161 17 21 26 34 43 51 60 64 69 77 86 94 103 107 111 120 129 137 146 150 154 18 23 27 36 46 55 64 68 73 82 91 100 109 114 118 127 137 146 155 19 24 29 39 48 58 68 72 77 87 96 106 116 121 125 135 145 154 20 25 31 41 51 61 71 76 82 92 102 112 122 127 133 143 153 22 27 32 43 54 65 75 81 86 97 108 118 129 135 140 151 23 28 34 45 57 68 79 85 91 102 113 125 136 142 147 159 25 31 38 50 63 75 88 94 100 113 125 138 150 157 163 27 34 41 55 69 82 96 103 110 124 137 151 30 38 45 60 75 90 105 113 120 135 150 165 33 41 49 65 82 98 114 122 131 147 163 35 44 53 71 88 106 124 132 141 159 38 48 57 76 95 114 133 143 152 41 51 61 82 102 123 143 153 44 55 66 88 109 131 153 47 58 70 93 117 140 164 50 62 75 100 124 149 174 53 66 79 106 132 159 56 70 84 112 140 168 59 74 89 118 148 178 63 78 94 125 156 82 99 132 165 66 83 104 125 167 103 128 154 123 154 145 181 10 12 14 15 16 18 20 22 24 25 26 28 30 32 34 35 36 40 Versatile Solution Treatment Applicators/RADCheck • 8 Standard sizes – 1.0,1.5, 2.0, 2.5, 3.0, 4.0, 5.0 and 10cm – Safety X-Ray Port Block – Ease of use – Turn & Lock – Size display – Console • Replaceable safety contact shields – Treated area visibility – Margin clearance – Clinical safety • Dual collimated design – Precise X-ray delivery • RAD Check – same design for pretreatment verification Applicator Port Ring and Sensors Position Locking Knob • 180 degree Horizontal & Vertical Articulation 180 180 Versatile X-Ray Port • Turn & Lock • Electromagnetic Applicator Sensor Auto Filter Magazine Control • Auto Filter Assembly • Interchangeable Applicators • Elevator Controlled • Precise Arm Locking in Position Field Proven Mobile Platform Under-Seat Inverter Lift Sliding Side Door Lift Actuator Patient Treatment Bench Electrical Panel in Upper Bulkhead Wall Extracting Laptop Table SRT-100™ Operator Console 36” x 24” Bench with Storage Access Patient Treatment Area Overhead Cabinet Storage 120v/30A Inlet 2 Under-Floor Batteries A/C and Vent Unit Lead-Lined Shielded Area