Review of Cutaneous Malignancies - capanet.org · – Cure rates for nodular BCC range from 53-75%,...

CAPA 2015 Annual Conference

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Review of CutaneousMalignancies

Tanya Nino, MDDepartment of Dermatology

Did You Know?• More than 3.5 million skin cancers are

diagnosed in the US annually• Melanoma incidence rates have been

increasing for at least 30 years• 1 in 5 Americans will develop some form of

skin cancer during their lifetime

Rogers, HW, Weinstock, MA, Harris, AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 2010; 146(3):283-287.

American Cancer Society. Cancer Facts and Figures 2014. http://www.cancer. org/research/cancerfactsstatistics/cancerfactsfigures2014/index

Why is this important?• In 2015, it is estimated that 137,310 new melanomas

will be diagnosed in the US and that 9,940 deaths willoccur from melanoma…

• Nearly every hour, an American dies from Melanoma.• US melanoma incidence has increased approximately

15 fold in the past 50 years.• This represents a substantial public health problem

American Cancer Society. Cancer Facts and Figures 2014. http://www.cancer. org/research/cancerfactsstatistics/cancerfactsfigures2014/index

Bolognia JL, Jorizzo JL, Rapini RP, eds. Mosby: St. Louis, Dermatology, 2nd edition


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Melanoma affects all of us…

• While people with darkerskin are less likely to getmelanoma, they are still atrisk, and it may often beadvanced, partly becauseof late detection.

• We all have loved ones andfriends at risk.

• Melanoma is curable ifcaught early and treatedquickly.

• Many melanoma deathsmight have beenprevented by educationalone.

… Beautiful California

• Of all states, California will have the greatest number of newMelanoma cases

• Of all counties in California, Orange County has the thirdhighest annual count of melanoma (surpassed by Los Angelesand nearly tied with San Diego)

National Cancer Institute, State Cancer Profiles. http://statecancerprofiles.cancer.gov

Sunburn = Serious Sun Damage

• Having a blistering sunburnincreases the lifetime risk ofdeveloping melanoma

• The chances of developing asunburn are greatestbetween 10am and 2pm,when the sun’s rays arestrongest.


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Sun DamageWrinkles

• While wrinkles can occur naturally with age, they canappear earlier and be more severe because of sunexposure we get when we’re young.

• We get a great percentage of our lifetime sunexposure before we are 18 years old.

Anatomy of the skin

Actinic Keratoses


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Actinic Keratoses

• Pre-cancerous

• 1 AK will become SCC 10% of the time over 10 years

• Increased Risk: Elderly patients, fair skin, history ofchronic sun exposure, head and neck location

• Rough erythematous papule with white to yellow scale

• Look for background solar damage: dyspigmentation,telangiectasias and wrinkling

• Marker for increased risk of non-melanoma skin cancer

Actinic Keratoses


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AK Types

• Hyperkeratotic

• Lichenoid

• Atrophic

• Pigmented

• Acantholytic

• Bowenoid

• Actinic Cheilitis


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Actinic Keratosis - Treatment

• Cryotherapy

– Quick and Easy

– Great for AKs

– Disadvantages

• Not as precise for larger, patch-like AKs

• Hypertrophic scarring

• Post-inflammatory hyper-or hypo-pigmentation

• Recurrent carcinoma can become extensive because ofconcealment by the fibrous scar tissue

Actinic Keratosis - Treatment

• Topical 5-fluorouracil

• Topical Imiquimod

• Topical diclofenac (NSAID)

• Topical ingenol mebutate

• Photodynamic Therapy – topical 5-aminolevulinic acid

Am Fam Physician. 2010 May 15;81(10):1186-1188.


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Basal Cell Carcinoma


• Most common type ofskin cancer

• Slow-growing, rarelyfatal, but can bedisfiguring

• Caused by a largeamount of totalaccumulated lifetimesun exposure

Photographs courtesy of Gary Cole, MD


• Most common skin cancer

• Many variants: >26 types

• Nodular most common

• Metastasis very rare, usually in setting ofimmunosuppression and aggressive subtype:Morpheaform, Infiltrating, Metatypical,Basosquamous

• Higher risk with intermittent intense episodes ofsunburn


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Nodular BCC

• 60% of all BCC• Raised, Translucent

papule/nodule withTelangiectasias

• Extend Locally

Superficial BCC

• Erythematous macule or thinplaque

• More common on trunk andextremities

• Younger age (57)• Growth pattern is horizontal,

can have extensive lateralspread

Morpheaform BCC

• Flat, atrophic lesion or ill-defined plaque

• Scar-like lesion• Indurated• Frequently much more

extensive tumor that clinicallyvisualized


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Micronodular Basal Cell Carcinoma

• Macules, papules orelevated plaques

• Very Destructive• High Recurrence Rate• Subclinical Spread

Squamous Cell Caricinoma


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Squamous Cell Carcinoma

• Second most common type of skin cancer

• If treated early, 100% curable

• If untreated, can metastasize: higher risk on lip, ear, genital mucosa

• Caused by large amount of total accumulated lifetime sun exposure

SCC in situ (aka Bowen’s Disease)

Squamous Cell Carcinoma


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Keratoacanthoma• Variant of SCC

• Rapidly enlarging papule that evolves into a crateriformnodule with a keratotic core

• May spontaneously resolve with atrophic scarring

• Sun-Exposed Areas

NMSC- Treatment

- Curettage and electrodesiccation for small andsuperficial lesions – cure rates as high as 97-98%have been reported for carefully selected lesions

- Standard excision with 4-6 mm margins for lowrisk lesions

- Standard excision with > 6 mm margins for highrisk lesions

- Mohs micrographic surgery

- Radiation therapy for non-surgical candidates


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Wide Local Excision With Margins

Pathology Specimen Processing:Bread Loafing Technique

Mohs surgery is indicated when:

• The edges of the cancer (clinical margins) cannot be clearly defined• Prior treatment has failed, i.e. recurrent tumor• The cancer is located in a cosmetically sensitive or functionally

critical area of the body (such as eyelids, nose, ears, lips, fingers,toes, and genitals)

• The histologic pattern of the cancer is aggressive (e.g.,morpheaform, infiltrative, metatypical BCC, anaplastic SCC)

• The patient is immunosuppressed• The cancer is > 2cm on the trunk or extremities• The patient has a genetic syndrome with high risk for skin cancer

(i.e. XP, BCC nevus syndrome)• Cancer arising in: prior radiated skin, traumatic scar, osteomyelitis,

area of chronic inflammation/ulceration


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Pathology Specimen Processing:Mohs Technique


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NMSC - Treatment

• Radiation– Use if surgery is contraindicated

– Advantages: avoidance of invasive procedure

– Disadvantages:• Lack of margin control

• Poor cosmesis in some patients (scars worsen withtime, unlike surgery)

• Prolonged course of therapy

• Increased risk for future skin cancers

• Higher recurrence rates


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NMSC – Medical management

• Topical 5-fluorouracil for AKs, superficial BCCs,and selected SCCs in situ

• Topical imiquimod – induces interferon-alphaand other cytokines, promotes Th1-typeimmunity

– Cure rates for nodular BCC range from 53-75%,higher cure rates for superficial BCC

NMSC - Medical Management

• Intralesional interferon-α-2b

– 3x weekly for 3 weeks

• Intralesional fluorouracil or methotrexate

– Used for KA rather than for BCC or other forms ofinvasive SCC

• Oral retinoid prophylaxis

– Usually for multiple KAs

Risk Factors for Non-Melanoma SkinCancer

• Fair skin, freckling, red hair, always burns/never tans• Environmental exposures: Sun exposure, tanning

beds, ionizing radiation, chemicals (arsenic), humanpapillomavirus, cigarette smoking

• Chronic, non-healing wounds, DLE, LP, LSA• Organ transplantation


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Melanoma

Melanoma

• Malignant tumor arising from melanocytes

• Majority are brown-black due to melanindeposition, but some are skin-colored to pink-red (i.e. amelanotic)

Photographs courtesy of Kenneth Linden, MD, PhD

Melanoma


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Melanoma

The ABCDE’s of Melanoma

ASSYMETRY:-If you were to fold it in half, the two sides

wouldn’t match up.

BORDER IRREGULARITY:-Jagged or blurred edges rather than smooth,

continuous line.

COLOR VARIATION:-Two or more different colors are present.

DIAMETER:-Any sudden or continuing growth

-Any mole larger than 6mm (pencil-top eraser)

EVOLUTION:-Change over time

Melanoma


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Melanoma

Superficial Spreading Melanoma

• Most common type• Age 30-50• Trunk of men, legs of women• 50% arise de novo and 50% arise in a

pre-existing nevus• Can be < 5mm


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Nodular Melanoma

• Arises as a de novo vertical growthphase tumor without the pre-existinghorizontal growth phase

• Diagnosed at a thicker, moreadvanced stage

• Poorer prognosis

Lentigo Maligna Melanoma

• Chronically sun damaged skin• Mostly on the face• Slow growing• In situ precursor to invasive lentigo

maligna melanoma

Acral Lentiginous Melanoma

• Palms, soles, around nails


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Pigmented nail streaks

• Possibility of melanomashould be considered for allpigmented nail bands in fair-skinned individuals,especially if darklypigmented, irregularlypigmented, or width > 3mm

• Hutchinson sign:Pigmentation of theperiungual tissues andvaluable clue to diagnosis ofsubungual melanoma

If melanoma is suspected:

• Excisional biopsy with 1-2mm margins is best

– Prevents sampling error

– Enables pathologist to assess overall architecture ofthe lesion

• Saucerization biopsy – thick disc of tissue removed witha curved blade

• Incisional biopsy if:

– Impractical to perform a full excision (i.e. tumor istoo large to be excised, sensitive location)

• Urgent Derm Referral if uncomfortable doing biopsy


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Surgical Excision – How big do themargins need to be?

Who gets a Sentinel Lymph Node Biopsy?

• Primary melanomas > 0.75mm Breslow Depth

• Reasons to proceed with SLN biopsy

– Obtain most complete and accurate diagnostic andstaging information

– Institute early therapeutic complete lymph nodedissection

• Impacts disease-free survival but not overall survival

– Institute adjuvant therapy

– Gain entry into clinical trial for new adjuvanttherapies

• Disadvantage of SLN biopsy

– Morbidity from completion lymphadenectomy chronic lymphedema

Treatments for metastatic melanoma

• Chemotherapy– i.e. interferon, dacarbazine

• Immunotherapy– IL-2

– CTLA-4 blockade

– PD-1 inhibition

• Molecularly targeted therapy – targeting the cellsignaling pathways involved in melanomaprogression– BRAF/MEK inhibitors


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Prognosis• Patients with Stage IA melanoma have 10 year survival

expectancy of > 95%

• Median survival time for stage IV patients is 9 months

Other Types of Skin Cancer

• Atypical fibroxanthoma

• Microcystic adnexal carcinoma

• Merkel cell carcinoma

• Dermatofibromasarcoma protuberans

• Undifferentiated pleomorphic sarcoma

• Sebaceous carcinoma

• And many more…..

Encourage self skin exams…

(Images and text from the AmericanAcademy of Dermatology)


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Encourage self skin exams…

(Images and text from the AmericanAcademy of Dermatology)

Sunlight consists of two types of harmful ultraviolet (UV) rays that reach the earth –ultraviolet A (UVA) rays and ultraviolet B (UVB) rays. Exposure to either can lead toskin cancer. In addition to causing skin cancer:

UVA rays can prematurely age your skin, causing wrinkles and age spots and canpass through window glass.

UVB rays are the primary cause of sunburn and are blocked by window glass.

Ultraviolet Radiation

Ultraviolet Radiation

The sun emits harmful UV rays year round. Even on cloudy days, UV rays canpenetrate the skin.

The United States Department of Health & Human Services and theInternational Agency of Research on Cancer have declared ultraviolet (UV)radiation from the sun and artificial sources, such as tanning beds and sunlamps, as a known carcinogen (cancer causing substance).

There is no safe way to tan. Every time you tan, you damage your skin. As thisdamage builds, you speed up the aging of your skin and increase your risk for alltypes of skin cancer.


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What is SPF?

DETERMINATION OF THE SUN PROTECTION FACTOR:

• 20 human subjects

• Skin type I or II

• Instrumentation: light source which mimics solarspectrum

• Procedure: determine minimal erythema dose (MED)in protected and unprotected skin

• SPF = MED (protected)

MED (unprotected)

Is SPF 100 better than SPF 30?

How to Select A Sunscreen

• The best sunscreen is the one that you will actuallyuse again and again!

• Creams are best for dry skin and face

• Sticks are good to use around the eyes

• Combination products: cosmetics and moisturizers

• Avoid combination sunscreens/insect repellants

• Sprays… current FDA regulations on testing andstandardization do not pertain to spray sunscreens


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Sunscreen Recommendations

• The American Academy of Dermatologyrecommends everyone use sunscreen thatoffers the following:– Broad-spectrum protection (protects against

UVA and UVB rays).– Sun Protection Factor (SPF) 30 or greater.– Water resistance.

• Sunscreen helps to protect your skin fromsunburn, early skin aging, and skin cancer.

• Seek shade when your shadow is shorterthan you are

• Wear sleeves, pants, a wide-brimmed hat,and sunglasses whenever possible.


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When should patients use sunscreen?

• Every day. The sun emits harmful ultraviolet (UV)rays year round.

• Even on cloudy days, harmful UV rays canpenetrate your skin.– On a cloudy day, up to 80 percent of the sun’s UV rays

can pass through the clouds.

• Snow and sand increase the need for sunscreen.– Snow reflects 80 percent of the sun’s rays, and sand

reflects 25 percent of the sun’s rays.

How much suncreen should be used?

• Use enough sunscreen to generously coat all skin that will be not becovered by clothing. Ask yourself, “Will my face, ears, arms, orhands be covered by clothing?” If not, apply sunscreen.

• To be sure you use enough, follow this guideline:– One ounce, enough to fill a shot glass, is considered the amount

needed to cover the exposed areas of the body. Adjust the amount ofsunscreen applied depending on your body size.

– Most people only apply 25-50 percent of the recommended amount ofsunscreen.

• Apply the sunscreen to dry skin 15 minutes BEFORE going outdoors.• To protect your lips, apply a lip balm or lipstick that contains

sunscreen with an SPF of 30 or higher.• Re-apply sunscreen approximately every two hours or after

swimming or sweating heavily


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New FDA Sunscreen Regulations

• On the label, you’ll see whether the sunscreen:– Protects against UVB and/or UVA rays.– Reduces the risk of skin cancer and early skin aging in addition

to helping prevent sunburn, or just protects against sunburnalone.

– Is water-resistant up to 40 or 80 minutes.• Sunscreen manufacturers will no longer claim that a sunscreen is

“waterproof” or “sweat proof.” This is not possible because allsunscreen eventually washes off.

• In order to reduce the risk of skin cancer and early skin aging, thesunscreen must offer two things: broad-spectrum protection(protects against UVA and UVB rays) and an SPF of 30 or higher.Without both, the sunscreen only helps prevent sunburn.

Will using sunscreen limit levels of Vitamin D?

• Using sunscreen may decrease skin’s production of vitamin D.

• Vitamin D in sunscreen users vs. non-users

• Vitamin D in dark-skinned individuals, women, and people innorthern climates in winter

• Controversy about Vitamin D – optimum levels, healthbenefits

• Tanning salon industry

• Nevertheless: Adequate vitamin D should be obtained fromdiet and supplements, NOT UV radiation

More on Vitamin D

• Many people can get the vitaminD they need from foods and/orvitamin supplements. Thisapproach gives you the vitamin Dyou need without increasing yourrisk for skin cancer.


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Foods rich in Vitamin D

• Fish oils (salmon, mackerel, tuna)

• Fortified milk/yogurt

• Egg yolks

• Cheese

• Beef or calf liver

• Mushrooms exposed to UV light

Conclusion

• Exposure to UV light is the most preventablerisk factor for skin cancer

• Many skin cancers are curable if diagnosedand treated early

• Remember the ABCDEs of Melanoma

• Encourage patients to use sunscreen/sunprotective clothing regularly

• Incorporate a skin exam in your routine whenpossible

Review of Cutaneous Malignancies - capanet.org · – Cure rates for nodular BCC range from 53-75%,...

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