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CC Wong PYNEH

CC Wong PYNEH. Skin cancer. Non-melanoma Basal cell carcinoma Squamous cell carcinoma Dermatofibrosarcoma Merkel cell carcinoma Kaposi sarcoma Angiosarcoma Melanoma. Non-melanoma skin cancer. Non-melanoma skin cancer. Most common cancer in the USA

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CC Wong PYNEH

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  1. CC Wong PYNEH

  2. Skin cancer • Non-melanoma • Basal cell carcinoma • Squamous cell carcinoma • Dermatofibrosarcoma • Merkel cell carcinoma • Kaposi sarcoma • Angiosarcoma • Melanoma

  3. Non-melanoma skin cancer

  4. Non-melanoma skin cancer • Most common cancer in the USA • Over 1,000,000 new cases in the USA per year • Fair skinned population

  5. Risk factors • Environmental factors • Sunlight exposure (Ultraviolet radiation) • Ionizing radiation • Chemical exposure eg. arsenic agent • Patient factors • Genetics disease • Precursor lesion • HIV and HPV infection

  6. UV radiation

  7. More carcinogenic 95%

  8. Basal cell carcinoma

  9. Basal cell carcinoma 75% of non-melanoma skin cancer Male : female = 3:2 Sunlight exposure Head & neck Slow growing Rarely metastasizes

  10. Basal cell carcinoma • Nodular • most common, pearly appearing papule • Pigmented • more frequent in darker-skinned population • Cystic • bluish or gray cystic nodule • Superficial • scaly patch-like lesion • pink to red to brown

  11. Basal cell carcinoma • Micronodular • aggressive variant • Morpheaform (infiltrating) • aggressive variant • scar-like appearance with ill-defined border

  12. Squamous cell carcinoma

  13. Squamous cell carcinoma Second most common skin cancer Male : female = 2-3:1 Sunlight exposure Old scar, chronic inflammation and ulcer Area of pre-exiting skin damage Faster growing

  14. Squamous cell carcinoma • Actinic keratosis: precursor • Bowen's disease: SCC in-situ • Unhealed ulcer with "heaped up" edge • Enlarging lesion irregular border • Cranial nerve dysfunction • perineural invasion

  15. Diagnosis Clinical diagnosis Incisional / excisional biopsy Imaging

  16. Treatment

  17. Surgical excision N.R. Telfer et al. British J of Dermatology. 2008 Murad Alam et al. N Engl J Med. 2001 • Major treatment method • High clearance rate • ~95% in both SCC and BCC • Low recurrence rate (in 5 year) • 5.8% in SCC, <2% in BCC

  18. How much margin should we take?

  19. BCC Lesion • Low risk • Trunk & extremities <2cm • Head &neck <1cm • Around eyes, ears, nose, mouth, hand and feet <6mm • High risk • Recurrent tumor • Immunocompromised • Previous radiation site • Perineural invasion • Micronodular, sclerosing, morpheaform Margin (mm) 4-5 10

  20. SCC Lesion • Low risk • Trunk & extremities <2cm • Head &neck <1cm • Around eyes, ears, nose, mouth, hand and feet <6mm • High risk • Recurrent tumor • Immunocompromised • Previous radiation site • Perineural invasion • Poorly differentiated • Adenoid, adenosquamous, desmoplastic Margin (mm) 4-5 10

  21. Facial H area

  22. Mohs' micrographic surgery Frederic E. Mohs in 1938 Complete circumferential peripheral and deep margin assessment Performed in stages / single day 5 year local control rate Murad Alam et al. N Engl J Med. 2001 Nicole W.J. et al. The Lancet 2004

  23. Mohs' micrographic surgery Preserve healthy skin tissue Time consuming High cost

  24. Mohs' micrographic surgery • Important site: • eyelids, ear, nose, lips, nasolabila fold, forehead, scalp or embryonic fusion plane • Recurrence • Size >2cm • Perineural involvement • Poorly defined margins in high-risk area Nicole W.J. et al. The Lancet 2004

  25. Radiation therapy • Primary vs adjuvant • 5-year local control rate ~90% • Multiple visits • No histological result • Side effect: dermatitis, telangiectasia • Contraindication: • Genetic condition eg. xeroderma pigmentosa • Connective tissue disease I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010

  26. Electrodesiccation and Curettage I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010 N.R. Telfer et al. British J of Dermatology. 2008 • Indication: • Small lesion <1cm • Superficial • Well-defined • 5-year local control rate: 95% in low risk BCC • Multiple attempts • No histopathology

  27. Cryotherapy I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010 N.R. Telfer et al. British J of Dermatology. 2008 Liquid nitrogen Frozen the skin -> tissue necrosis Multiple cycles 5-year recurrence rate: 8% in low risk BCC No histopathology Good cosmetic result

  28. Cryotherapy I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010 N.R. Telfer et al. British J of Dermatology. 2008 • Indication: Low risk BCC • Size <1cm • Superficial, nodular • Well-defined margin

  29. Topical immunotherapy • Imiquimod • Toll-like receptor 7 agonist • Modify the immune response -> antitumor activity -> tumor cell apoptosis • 5 application a week for 6 week • Indication: Small superficial BCC • Initial response rate 89.6% • Lack of long term data • Excellent cosmetic result I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010

  30. Photodynamic therapy Photosensitizing agent followed by illumination of visible light Produced activated oxygen molecule -> destroy target cell Usually 2 cycles 5-year recurrence rate: 14% Excellent cosmetic effect I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010

  31. Photodynamic therapy • Limited penetration • Indication: • Superficial lesion • Depth <2mm I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010

  32. 5-Fluorouracil • Topic chemotherapeutic agent • Blocking DNA synthesis • Apply twice a day for minimum 6 week • Cure rate: 93% • Indications: • Superficial BCC • Small ~1cm • Local inflammatory response I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010

  33. Interferon • Intralesional injection • Induce apoptosis • 3 injections per week for 3 week • Complete response rate: 50-80% • Indications: • Surgery could be disfiguring • Not a surgical candidate • Influenza-like symptom I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010

  34. Conclusion Non-melanoma skin cancer • Common • Rate of cure is high with proper treatment in local disease • Surgical excision is associated with lowest recurrence rate • Other non-surgical treatment • Early superficial disease • Non-surgical candidates

  35. Thank you

  36. SLN • No definite guideline • Lack of large scale study on non-melanoma skin cancer • Renzi et al.: 22 patients • Reschly et al.: 9 patients • Useful in high risk SCC

  37. Involved margin ~30-41% do not recur Re-excision of margin Mohs micrographic surgery Radiotherapy

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