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Skin cancers Outline • • • • • • 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 • • • • 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 – – – – 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: – – – – – 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: – – – – – – – 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 • • • • 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 • • • • 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: – – – – Breast (69%) Colon (9%) Melanoma (5%) Ovarian (4%) • Men: – – – – 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 – – – – – – 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 • • • • 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 • • • • 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 • • • • • 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 • • • • 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 • • • • 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 – – – – 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 – – – – 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!