SKIN CANCERAmy Stinson

ENT Resident

Affinity Medical Center

SKIN CANCER

Most common human malignancy US: >1,300,000 cases annually 2,000 deaths annually (non-melanoma) Most common location – sun exposed areas

of head and neck Basal Cell accounts for 90% (baileys) Squamous cell next most common, then

melanoma Pearls: What is the reported ratio of BCC to

SCC in the US? 4:1

SKIN CANCER RISK FACTORS Age > 60 UV light exposure

Pearls: specifically UV B (280-320nm) Specific Traits: fair complexion, blue/green eyes,

light hair, inability to tan, celctic ancestry Hx of multiple or severe sunburns Tanning bed use

Mainly UV A – UV A synergistically augments UV B response

Arsenic exposure Chronic radiodermatits (pearls) Immunosuppression (pearls) Trauma: burns, ulcers or scars

Pearls: Marjolin Ulcer

RISK FACTORS

RISK FACTORS

Genetic disorders (Pearls) Basal Cell-Nevoid Syndrome (Grolin’s)

Aut Dom, multiple BCC, odontogenic keratocysts, rib abnormailties, palmar/plantar pits, calcification of falx cerebri

Xeroderma pigmentosa Albinism Epidermisdysplastic verruciformis Epidermolysis bullosa dystrophica Dyskeratosis congenital

NORMAL SKIN

NORMAL SKIN

5 layers of epidermis from superficial to deep (Pearls) Stratum Corneum Stratum Lucidum Stratum Granulosum Stratum Spinosum Stratum Basale

Pneumonic: Come, Let’s Get Sun

Burned

BASAL CELL Slowly growing malignancy

of the epidermis Extends peripherally

without vertical invasion Rarely metastasizes Cells appear histologically

similar to basal cells of epidermis (small dark blue cells with little cytoplasm)

BCC – clefting, lack of intracellular bridges, nuclear pallisading, peritumoral lucunae

Basal Cell

Growth pattern (pearls) Follows the path of least resistance Typically along embryonic fusion planes Susceptible areas:

Inner canthus Philtrum Mid - Lower chin Nasolabial groove Periauricular area Retroauricular sulcus

BASAL CELL Clinical subtypes (pearls)

Nodular – Most Common Pearly, telangiectatic papule, central ulceration, rolled

border Superficial

Rare in H & N, scaly, waxy, indurated, irregular More common on extremeties and trunk

Pigmented/Cystic Similar to nodular type, more pigmented resembling

melanoma or benign nevus Morpheaform

Common on face, flat or depressed, indurated, aggressive with high rate of recurrence, worst prognosis, can resemble scar

Keratotic aggressive

BASAL CELL

NodularSuperficial

Pigmented

BASAL CELL

MorpheaformPost - excision

BASAL CELL

Management Avoid excess sun – sunblock Careful follow-up for recurrence

Pearls: After having one (BCC or SCC) what are the chances of developing another within 5 yrs?

50% Curettage with Electrodisiccation Cryosurgery Scalpel excision – need 5 mm margins Radiation therapy – poor operative candidates Mohs – for high risk areas, morpheaform 1/3 of incompletely excised BCC will recur

SQUAMOUS CELL

More aggressive Higher recurrence rates Vertical extension 1-4% metastatic potential

Scar/chronic inflam > de novo > from AK Signs:

Erythematous, hyperkeratotic, opaque nodule, ulcerative, granular base, bleeds easily

SCC that arise in sun exposed areas have better prognosis than those arising de novo

SQUAMOUS CELL

Histopath Keratin pearls Broder Classification

1 – well differentiated 4 – poorly differentiated

Types: Adenoid Bowenoid Verrucus – mc in oral mucosa Spindle-pleomorphic – least common Generic – from actinic change

SQUAMOUS CELL

Premalignant Lesions Actinic Keratosis

Most common Sun exposed skin Less than 1 cm Chance of progression – 20% Erythematous patch with scale Can have cutaneous horn

Pearls: Most common premalignant lesion of H & N? AK

TYPICAL AK

CUTANEOUS HORN

SQUAMOUS CELL

Premalignant Lesions Bowen Disease

Pearls: Squamous cell carcinoma in situ of the skin Full thickness dysplasia of epidermis Well circumscribed Common with hx of arsenic exposure

Keratoacanthoma (pearls) Benign, usually self limited Common in older males 2-6 mo hx of rapid growth – usually on nose Central area of ulceration – volcano-like Spontaneous involution

KERATOACANTHOMA

SQUAMOUS CELL The following are features of high-risk SCC:

Size Width greater than 2 cm Depth greater than 4 mm

Location Ear Lip

Histologic features Perineural invasion Lymphovascular invasion Poorly differentiated grade

Recurrence Immunosuppression

MANAGEMENT

Initial evaluation involves Assessment of location Punch or excisional biopsy Staging

AJCC CLASSIFICATION TNM staging system for NMSC Primary tumor (T)

TX - Primary tumor cannot be assessed. T0 - No evidence of primary tumor Tis - Carcinoma in situ T1 - Tumor 2 cm or less T2 - Tumor larger than 2 cm but smaller than 5 cm T3 - Tumor larger than 5 cm T4 - Tumor invades deep extradermal structures (bone, muscle,

cartilage). Regional lymph nodes (N)

NX - Regional lymph nodes cannot be assessed. N0 - No regional lymph node metastasis N1 - Regional lymph node metastases

Distant metastasis (M) MX - Distant metastasis cannot be assessed. M0 - No distant metastasis M1 - Distant metastasis

MANAGEMENT - CRYOSURGERY

Cryogen such as liquid Nitrogen to kill tumor cells

Typical temperature of -50°C . Tissue-sparing, but leave open wound Hypopigmentation and scarring may result Limited to favorable small lesions with well-

defined borders

MANAGEMENT – RADIATION THERAPY

Used extensively in the past, now sparingly High cure rate (95%) Does not allow surgical staging Protracted treatment course, and expensive Radiodermatitis, delayed carcinogenesis Currently reserved for poor operative

candidates, adjuvant in high risk malignancy

PHOTODYNAMIC THERAPY Photosensitizing drug (porphyrin, 5-ALA)

applied topically, orally or parenterally and localizes into tumor cells

Drug is activated by exposure to light (laser) Efficacy is low (45%) Side effects include local edema, erythema,

blistering, ulceration Used as palliation

MANAGEMENT - EXCISIONAL SURGERY Most often used by surgeons, esp for larger

lesions Can be with cold steel or laser Can allow reconstruction in the same sitting Frozen sections decrease recurrence rate Can be time consuming and inconvenient If more than 1/3 of a cosmetic facial unit is

excised, better cosmesis with removal of entire unit

Success rate 93-95%

MANAGEMENT – EXCISIONAL SURGERY

MOHS SURGERY - INDICATIONS Recurrent skin cancer Skin cancer in “high risk anatomic areas” and

cosmetically important areas Histologically aggressive skin cancer Large skin cancers Skin cancer with ill-defined clinical margins Irradiated skin Dermatofibrosarcoma Protuberans Selected mucosal squamous cell cancers

LYMPHATIC DISSECTION No hard and fast rules

governing lymphatic dissection in N0 Necks

Elective Parotidectomy for deeply invasive tumors of the periauricular region

Large SCCA (>2cm), recurrent SCCA, Marjolin’s ulcer, perineural invasion may require regional lymphadenectomy

Prophylactic neck when SCC >4 cm with deep invasion arising on cheek, neck, scalp

RARE CUTANEOUS MALIGNANCIES

Merkel’s Cell Carcinoma Tumor arising from pluripotential

basal cells within or around hair cells (pearls)

Poorly differentiated histology High rate of recurrence and

lymph node metastasis requires excisional surgery with adjuvant radiation and treatment of lymphatic drainage in most cases

NO neck should be treated Solitary erythematous to deep

purple plaque or nodule of up to several centimeters in size

RARE CUTANEOUS MALIGNANCIES

Dermatofibrosarcoma Protuberans Arises in dermis, spreads deeply Large indurated plaque with firm irregular flesh

colored nodules Mohs is treatment of choice

Pilomatrix Carcinoma Arises from Pilomatricoma, a benign tumor of

hair matrix origin Aggressive wide local excision is treatment

THE END

Questions?