Skin Cancer

1. Skin Cancer Amy Stinson ENT Resident Affinity Medical Center

2. 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

3. 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

4. Risk Factors

5. 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

6. Normal Skin

7. 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

8. 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

9. 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

10. 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

11. Basal Cell Superficial Nodular Pigmented

12. Basal Cell Morpheaform Post - excision

13. 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

14. 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

15. 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

16. 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

17. Typical AK

18. Cutaneous Horn

19. 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

20. Keratoacanthoma

21. 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

22. Management • Initial evaluation involves • Assessment of location • Punch or excisional biopsy • Staging

23. 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

24. 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

25. 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

26. 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

27. 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%

28. Management – Excisional Surgery

29. 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

30. 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

31. 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

32. 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

33. THE END Questions?