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Skin cancers
Outline
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Basal cell carcinoma
Squamous cell carcinoma
Cutaneous T-cell Lymphoma
Paget’s & Extramammary Paget’s
Cutaneous metastases
Melanoma
Basal Cell Carcinoma
Basal Cell Carcinoma
• Most common skin malignancy
– Metastasis extremely rare – 0.0028-0.55%
– locally invasive & destructive
• Demographics
– older persons
– increasing in those <40
• Often on sun-exposed areas
– 85% on head/neck, esp nose
– Can occur on sun-protected areas
Basal Cell CA
• Clinical subtypes:
– Nodular – most common
– Pigmented
– Sclerosing or Morpheaform
– Superficial
Nodular BCC
• Most common
• Pearly, white or pink, telangiectases, rolled
borders, center can ulcerate
Pigmented BCC
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Brown, blue, or black
Dark-complexioned persons – Hispanics, Asians
Borders still pearly with telangiectases
DDx: Melanoma
Sclerosing/Morpheaform BCC
• Pale yellow/white, waxy, firm, depressed and
scar-like, indistinct borders
• History of prior cryotherapy
• Need Mohs or wide excision
Superficial BCC
• Least aggressive, but can be difficult to diagnose
• Mimic eczema or psoriasis
• Alcohol swab reveal pearly border + telangiectases
Treatment Modalities
• Imiquimod (Aldara):
– FDA-approved for superficial BCC
– little or no scarring, spares tissue
– variable or unpredictable response
• Electrodessication & Curettage (ED&C):
– Best for nodular and small superficial forms
– Leaves a noticeable scar
– Best for low risk sites – trunk, extremities
Treatment Modalities
• Excision:
– Offers standard margin check
– Large long scar
• Mohs micrographic surgery
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Tissue sparing procedure
Gold standard with 100% margin check
Expensive, labor intensive
Reserved for:
• High risk sites
– Head & neck, shins, hands, tight areas
• High risk subtypes
– Recurrent disease
– Aggressive histology
» Sclerosing, infiltrating, micronodular, basosquamous
Squamous Cell Carcinoma
What is the precursor lesion for
squamous cell carcinoma?
• Actinic keratosis
Actinic Keratosis
• Partial thickness epidermal atypia
• Sun exposure, immunosuppressed
• Erythematous scaly papules, not indurated
– Smaller lesions often easier felt than seen
– Can be hypertrophic or even tall (cutaneous horn)
AK Management
• Sun protection
• Cryotherapy – best for isolated lesions
• Multiple or extensive lesions:
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5-fluorouracil (5-FU/Efudex)
Imiquimod (Aldara)
Solaraze/Diclofenac – milder reaction than Efudex
Chemical peels – pain; wound care
Photodynamic therapy (PDT) – pain, minimal wound
care, expensive
Why we treat AKs…
• 1-5% risk of SCC transformation per year
– More likely in hypertrophic AK
– Suspicious for transformation:
• Induration
• Oozing, easy bleeding
• Recurrent after cryosurgery
Squamous Cell Carcinoma
• 2nd most common skin cancer
• High association
– UV exposure
• located mostly on sun-exposed sites
– scalp, forehead, dorsal nose, superior ears, dorsal hands
– Prior radiation
– Marjolin’s ulcer
• SCC arising on sites of burns, chronic wound/inflammation
– Immunosuppression (SCC >> BCC)
• Transplant patients
Squamous Cell Carcinoma
• Scaly papules or plaques with induration,
erosion, bleeding
– May be tender
– Recurrent after cryosurgery
Squamous Cell Carcinoma
• Local spread can be extensive
– Follows path of least resistance
• Subcutaneous & fascial planes, perineural,
perichondrium/periosteum, perivascular
• Treatment similar to BCC except:
– 4-6 mm margins for standard excision
– Electrodessication & curettage
• for small, thin SCC’s in low risk areas
SCC
• Metastasis rate: up to 5.2%
• Lymphatics & hematogenous
• Higher risk lesions:
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Size > 2 cm
Depth > 4 mm
Aggressive histology
Lip or ear location
Immunosuppressed
Prior XRT
Burns or chronic inflammation
Bowen’s Disease
• Squamous cell carcinoma in-situ
– full thickness atypia
• Well-demarcated, erythematous, scaly, thin
papules/plaques
– Most common on legs of women & scalp/ears of men
– Mimic psoriasis or eczema
Bowen’s Disease
• Grows slowly, can become invasive SCC
• Treatment
– Small lesions – ED&C, 5-FU, Aldara
– Large lesions – Excision, 5-FU, Aldara
Erythroplasia of Queyrat
• SCC in-situ of penis or vulva
• Moist glistening, red, thin
plaque (under foreskin)
• Grows slowly, can become
invasive
• Treatment
– Aldara or 5-fluorouracil (5-FU)
– Mohs if around or into urethra
Keratoacanthoma
• Smooth dome-shaped nodule with keratinfilled crater
• Rapid growth/expansion  regresses with
scarring
Keratoacanthoma
• Considered as a well-differentiated form of SCC
• Treatment
– ED&C, blunt dissection, or excision
– Intralesional injections
• 5-FU, Bleomycin, MTX
Verrucous Carcinoma
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Exophytic, slow-growing, low-grade SCC
Rarely metastasize
Often mistaken for warts
Treatment:
– Excision
– Avoid XRT, risk of aggressive transformation
Verrucous Carcinoma
• 3 subtypes:
– Buschke-Lowenstein
• Genital form
• HPV 6, 11
– Oral florid papillomatosis
• tobacco chewing
• poor oral hygiene
– Epithelioma cuniculatum
• Plantar feet
• Older men
Arsenical Keratoses
• Discrete round keratoses
• Appear 20 yrs after chronic arsenic
exposure
• Most common on palms and soles
• Not fatal, but may persist indefinitely
• Pain, bleeding, fissuring, and
ulceration
• Rare in US
• More common in 3rd world
• Risk of SCC degeneration
Cutaneous T-cell Lymphoma
Cutaneous T-Cell Lymphoma
• Malignant T-cells with cutaneous lymphoid
antigen (CLA) localize to skin
• Most common form of CTCL is mycosis
fungoides
– 4 stages
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Pre-MF
Patch
Plaque
Tumor
– Prognosis good for first 2 stages then worsens
Cutaneous T-Cell Lymphoma
• Erythroderma can occur in any stage
• Lesions like persistent eczema/tinea, often sunprotected areas
• Difficult to diagnose in early stages
– Average of 6 biopsies before diagnosis made
– Clinical & histology difficult to distinguish from other
inflammatory disorders
– Monoclonality on T-cell gene rearrangement study is
helpful
Mycosis Fungoides
• Pre-MF: diagnosis suspected but not proven
– Nonspecific pruritis and/or eruption
– Persists or recurs over months to years
– Can mimic eczema
Mycosis Fungoides
• “Patch” stage: diagnosis possible with histo
– Similar morphology pre-MF
– Poikiloderma vasculare atrophicans: variant of MF
Mycosis Fungoides
• Plaque stage:
– thickening of epidermis
– Dusky red-brown plaques
with variety of shapes
– Pruritis can be intense
– Can remain stable, regress,
or progress
Mycosis Fungoides
• Tumor stage
– may progress from patch or plaque stage
lesions or arise de novo
– Necrosis/ulceration possible
Mycosis Fungoides
• Sezary syndrome
– leukemic form MF
– Triad:
• Erythroderma
• Lymphadenopathy
• Sezary cells
– lymphocytes with
cerebriform nuclei
MF Treatment
• Patch stage:
– Group I topical steroids, topical nitrogen mustard,
Bexarotene (RXR retinoid)
• Generalized lesions
– PUVA/UVB
– Electron beam radiation
• patch/plaque/tumor
• most reliable for generalized; high relapse, side-effects
• Extracorporeal photophoresis
– Sezary syndrome & erythrodermic MF
– PUVA of extracted lymphocytes then reinfused into
patient
Paget’s Disease
Paget’s Disease of the Breast
• Invasion of skin from underlying breast cancer
• Unilateral nipple erythema with serous drainage
• Appears eczematous, but fixed & indurated with
sharp margins
Paget’s Disease of the Breast
• Often confused with eczema of the breast
• Good diagnostic test:
– Trial of potent steroid (Lidex or Clobetasol) x 2 weeks
– If improved or resolved  most likely eczema
– If not  need to biopsy to exclude malignancy
• Treatment:
– Excision
Extramammary Paget’s Disease
• Usually genital or perianal area
• Associated with underlying malignancy
– Location related to internal CA
• Perianal – GI malignancy
• Genital – GU malignancy
Extramammary Paget’s Disease
• White-to-red scaling or macerated plaque
– Often persistent itching or burning
• Treatment
– Excision, XRT
Cutaneous Metastases
Cutaneous Metastases
• Usually present as asymptomatic, firm, deep
nodules
• Metastases to skin in 2-10%
– Most common primaries:
• Women:
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Breast (69%)
Colon (9%)
Melanoma (5%)
Ovarian (4%)
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Lung (24%)
Colon (19%)
Melanoma (13%)
SCC oral cavity (12%)
Cutaneous Metastases
• Primary tumors that metastasize to scalp
– Thyroid carcinoma (especially papillary
carcinoma)
– Renal cell carcinoma
– Nodules with alopecia
Cutaneous Metastases
• Metastasis to the umbilicus
– Sister Mary Joseph’s nodule
• solitary, firm, fissured nodules
• represents advanced disease and carries a very
poor prognosis
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Adenocarcinoma of the stomach
Adenocarcinoma of the large bowel
Ovary
Pancreas
Endometrium
Breast
Cutaneous Metastases
• Breast metastasis to skin has variable appearance
– Resemble cellulitis
– Carcinoma en cuirasse
• hard infiltrated plaque with leathery appearance
Melanoma
Melanoma
• Malignancy of melanocytes
– skin >>> eyes, GI tract, and oral/genital
mucosa
• May metastasize to any organ
• Incidence of melanoma has tripled for
Caucasians in the last 40 years
• Highest incidence in Australia and New
Zealand
Melanoma
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Accounts for 75% of skin cancer deaths in US
Median age at = 53 years
Most common cancer in women aged 25 to 29
Risk factors
– Family history/genetics
– People who do not tan or sunburn easily
– Increased UV exposures and sunburns
• intermittent UV exposures may be at highest risk
ABCDE of Melanoma
• Goal of this effort is to recognize more
melanomas at an early stage
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Asymmetry
Border irregularity
Color variation
Diameter enlargement
• Evolution over time
ABCDE of Melanoma
• Other factors that should provoke a
biopsy:
– Erosion or ulceration
– Scaling
– Bleeding
– Loss of normal skin lines
– Sudden development of pruritus, tenderness,
or pain
– Patient report that “it just feels different”
Melanoma Types
• Based upon clinical and histological
appearance
– Superficial Spreading
– Lentigo Maligna
– Nodular
– Acral Lentiginous
Superficial Spreading Melanoma
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Most common type
4th to 5th decade
May develop anywhere on the body
Early radial growth  Late vertical growth
Location:
– Trunk in men and women
– Extremities (legs) in women
• Characterized by variation in color and shape
Superficial Spreading Melanoma
Superficial spreading melanoma
Superficial Spreading Melanoma
Superficial Spreading Melanoma
Superficial Spreading Melanoma
Nodular Melanoma
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5th and 6th decade of life
15-20% of melanomas
Males > females
May be found anywhere, but more often on the
trunk and legs
• Most commonly dark brown, red-brown, redblack or flesh colored
• Dome shaped, polypoid or pedunculated
• Often rapidly growing, friable, ulcerated, and
oozing blood
Nodular Melanoma
Nodular Melanoma
Nodular Melanoma
Lentigo Maligna Melanoma
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6th or 7th decade of life
4-15 % of melanomas
Most common on the face
Extended radial growth phase
– long period of melanoma-in-situ
• Vertical growth usually begins in the
central portion of the lesion
Lentigo Maligna Melanoma
Lentigo Maligna Melanoma
Lentigo Maligna Melanoma
Acral Lentiginous Melanoma
• Palms, soles, terminal phalanges, mucous
membranes
• 2-8% of melanomas in whites
• 30-75% of melanomas in more darkly
pigmented patients
• Sudden appearance of a pigmented nail
band is suspicious for melanoma
Acral Lentiginous Melanoma
Acral Lentiginous Melanoma
Acral Lentiginous Melanoma
• Hutchinson’s sign
– spread of pigment to the lateral or proximal
nail fold in association with nail plate
pigmentation
What do you do with this patient?
• Atypical Mole
Syndrome and
Familial
Melanoma
Atypical Mole Syndrome and
Familial Melanoma
• Family members with large numbers of
atypical moles and tendency to develop
thin, superficial spreading melanomas
• 32,000 patients in the US
• 5.5% of all melanomas
Atypical Mole Syndrome and
Familial Melanoma
• Definition
– Melanoma in one or more 1st degree relatives
– More than 50 nevi, with many having atypical
appearance
– Nevi with characteristic histological features
• 100% lifetime risk of melanoma
• Remember:
– Most atypical nevi occur sporadically in people
without personal or family history of melanoma
Atypical Mole Syndrome and
Familial Melanoma
• Management
– Refer to dermatology
• Total body photography
• Low threshold for biopsy
– Extensive patient education on:
• Sun protection
• Self skin examination
– Suggest screening of relatives
Melanoma Evaluation
• Refer all suspicious lesions to dermatology
• Biopsy should include evaluation of deep
dermis – we try to avoid shave biopsies
– Excisional
– Incisional
– Punch
Melanoma Evaluation
• The most important prognostic factors
– Breslow Depth
• Depth of invasion
• Measured from granular layer to the deepest
invasive component and expressed in millimeter
– Presence of ulceration upstages the tumor
Melanoma Evaluation
• Sentinel lymph node biopsy
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indicated for thicker melanoma > 1 mm
helpful in staging
provides prognostic information
identifying those who may benefit from further surgery
or adjuvant therapy
• Other evaluation
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LFTs
Chemistry
CBC
Imaging studies
• PET scan and yearly CXR
Melanoma Management
• Wide local excision is the primary
treatment for melanoma
• Adjuvant high-dose interferon alpha-2b
may be indicated in certain patients
• Rarely, radiation therapy may be used,
especially in LMM
• Vaccine trials are ongoing
Melanoma Management
• Close follow up with history and physical
at regular intervals is essential
• Recurrence may develop up to 10 years
after the primary diagnosis
• Patients with diagnosis of melanoma and
non-melanoma skin cancer in the past
have increased risk for future melanoma
Quiz
Basal cell carcinoma
Keratoacanthoma
Lentigo maligna
Basal cell carcinoma
Superficial spreading melanoma
Sister Mary Joseph’s Nodule
Cutaneous horn
Nodular melanoma
Be kind to your skin!