CUTANEOUS MALIGNANCIES and

SIMPLE PROCEDURESJASON M. CHEYNEY, MPAS, PA-CSkin Care Physicians of Georgia

Macon, GA 31217

• Basal Cell Carcinoma• Squamous Cell Carcinoma• Melanoma• Rare Skin Cancers• Benign “look alikes”• Skin Cancer Prevention

Anatomy

Basal Cell Carcinoma

• Originates in the basal layer of the epidermis• Most common skin cancer

• 1 in 7 individuals will develop in a lifetime• 1/3 of all cancer diagnoses

• Develops most commonly in sun exposed skin• Non life-threatening• Approximately 800,000 new cases diagnosed yearly• Can be cosmetically and locally destructive that is the

reason it is considered malignant• Three common types

• Superficial• Nodular• Infiltrative

BCC Treatment

• Based on Type• Topical • Imiquimod• 5-fluorouracil

• Curretage and dessication• Surgery• Mohs Surgery• Radiation• Vismodegib

Squamous Cell Carcinoma

• Develops in upper layers of epidermis• Derived from epithelial cells• Can be seen in other areas to include lips, mouth,

esophagus, lungs, vagina, bladder and cervix• Despite name these present differently and with quite

different prognosis and therapies• 2nd most common skin cancer• Most prevelant in light skinned individuals• Direct relationship with sun exposed and sunburned

skin• Most common in the 5th decade of life and beyond

SCC Prognosis

• Higher metastasis than BCC• Much greater risks on lips, scars, mucosa and

immunosuppression• Approximately 1/3 of lingual and mucosal lesions

metastasize before diagnosis• Metastasis typically occur after 10 years of

appearance• Quicker in areas mentioned above

• Rarely seen but can be seen on the penis of uncircumcised males• ? Associated with HPV

SCC Treatment

• Chemotherapy• Curettage and Desiccation• Surgery• Excision• Mohs Micrographic

• Radiation

Melanoma

• Develops in skin as well as other organs• Mouth, intestines and eyes

• Most lethal of all skin cancers• 1 in 75 will develop in a lifetime• Incidence is on the rise• 25% develop in existing moles

• Prophylactic mole removal not recommended• Survival rate 98% with local disease, 17% with

metastatic• Genetics and UV radiation play integral role

Melanoma Treatment

• Surgery – Gold standard• Prognosis based on Depth of invasion at diagnosis

• In-situ• Superficial <1 mm• Intermediate >1 mm-4 mm• Deep >4 mm

• Sentinel lymph node biopsy if intermediate or above• Ulceration and mitotic rate also prognostic indicators• Alternative therapies showing promise in metastatic

disease• Immunotherapy• Chemotherapy• Radiation

Melanoma Evaluation

• Recommend every 3 months for the first year, then every 6 months for year two then eval risk and can consider yearly exams if no new occurences in low-grade disease• ABCD’s of melanoma• A – Asymmetry• B – Border• C – Color• D – Diameter

•

Skin Cancer Prevention

• Sun avoidance• Sun Screen/Block• Avoid tanning beds THESE ARE NO SAFER THAN

THE SUN!!!!!!!!

Cryo Procedureby Jason Cheyney, PA-C

Treatment Expectation

• Advise patient the treatment is uncomfortable and may be for 30 minutes after treatment.

• A blister will typically form within a few hours; blister will either be clear or red or purple because of bleeding (this is harmless).

• Within a few days a scab will form and the blister gradually dries up.

Post-Treatment Wound Care• No special attention is needed during the healing

phase.• Once scab has formed, apply vaseline and advise

patient not to pick off scab.• Once scab has formed, apply vaseline and advise

patient not to pick off scab.• Advise patient of the potential for dyspigmentation or

scarring of the treated area.

Cryotherapy:Potential Complications

• Post-inflammatory hyper- or hypopigmentation• Scarring• Nail Deformity: caution over nail matrix• With a hard freeze over a finger (for example) may

cause damage to the sensory nerve causing a temporary numbness for a few weeks or months.

Considerations Prior to Biopsy

• Patient Medication Allergies?• Is Patient Anti-coagulated?• Does Patient have a Defibrillator?• Previous Vaso-vagal reactions?• Informed Patient Consent Signed?• Discuss Potential Complications

BIOPSY SHAVE & PUNCH

Preparation for Biopsy

• Mark Site with Surgical Marker• Take Photos to Document Site of Biopsy• Document Location on Map• Cleanse Area:

• Alcohol• Chlorhexidine

Biopsy Techniques

• Varies by Location• Types of Biopsies:

• Shave• Punch• Excisional• Saucerization

Safety with Epinepherine

• Nose and Penis OK - very vascular

• Digits are controversial• Pitfalls: patients with severe peripheral vascular disease,

diabetic angiopathy and Raynaud’s phenomenon may be exceptions to the rule.• Ask patient if they smoke

Hemostasis Considerations

• Aluminum Chloride• Monsel’s Solution• Cautery: Heat vs Electric

Aluminum Chloride• Most commonly used form of hemostasis for shave

biopsies and superficial skin procedures.• Tends to burn if not properly anesthesized.• Caustic to eye. Use caution around eyes. Could cause

corneal ulcer. If it gets in eye immediately flush with saline and refer to opthalmologist.• Flammable: Caution with Electrocautery

Monsel’s Solution• Used often and works best with stretching the skin

to slow blood flow for 5-19 sec. • Greater Hemostatic Activity vs Aluminum Chloride• May leave pigment changes that can obscure

subsequent pathology readings.• Avoid sun exposure.

Shave Biopsy

• Necessary supplies• Blade (small scapel blade; curved razor blade, or a broken

piece of “safety” razor)• Light electrocautery; monsel’s solutions or aluminum

chloride for hemostasis

• Technique:• Shave remove a superficial portion of lesion

Shave Biopsy Technique• Stretch the Skin Tight – Very Important!• Shave Horizontally• Use Short Sawing Motion• Bend of the blade determines the depth• More bend = deeper biopsy

Saucerization

• Deep shave excision for pigmented lesions, such as potential dysplastic nevi or melanomas.• The potential for scarring is greater.• More economic for surgeon. Decrease costs of sutures

and surgical supplies.• Can bill as an excision healing by secondary intention.• Similar supplies and technique as a shave biopsy.

Punch Biopsy

• Necessary Supplies• Round shaped knife ranging in size from 1mm to 8mm• Most common sized used is a 4mm• Preferred size for scalp biopsies-6mm

• Technique• Ideally, the punch biopsy includes the full thickness skin and

subcutaneous fat in the diagnosis of skin disease.

Excisional Biopsy• Same as an incisional biopsy, except the entire lesion

or tumor is included.• Many providers prefer to use this method for

suspicious melanomas, but may prefer to do a punch biopsy instead.

Electrodessication• Useful for cauterization• Biopsies (Shave or Scallop)• Dermatosis Papulosa Nigra• Cherry Angiomas• Sebaceous Hyperplasia• Sebaceous Hyperplasia• Skin Tags

Intralesional Triamcinolone