A Primer on Skin Cancers Cathryn Zhang, MD University of Arizona 3/8/14.

A Primer on Skin A Primer on Skin CancersCancers

Cathryn Zhang, MDUniversity of Arizona3/8/14

ObjectivesObjectives1. Review the major types of skin

cancers (basal cell carcinoma, squamous cell carcinoma, melanoma)

2. Describe the treatment options for skin cancers

3. Recognize the risk of skin cancers arising in chronic wounds (specifically SCCs, termed Marjolin's ulcer)

Skin Cancer Disease Skin Cancer Disease BurdenBurden

Very common, especially in individuals with fair complexion

Estimated annual cases: 3.5 million

1 in 5 Americans will develop skin cancer in their lifetime

Amount of annual UV radiation correlates with incidence

National Cancer Institute National Cancer Institute statsstats

More than 3.5 million nonmelanoma skin cancers are diagnosed annually.

Types of skin cancersTypes of skin cancersBCC: 2.8 million cases annuallySCC: 700,000 cases annually Melanoma: 76,690 cases in 2013Other types comprise < 1% of skin

cancers: cutaneous lymphomas (CTCL, CBCL and all their variants), leukemia cutis, Merkel cell carcinoma, DFSP, AFX, Kaposi’s sarcoma, angiosarcoma, liposarcoma, Paget’s disease, EMPD, MAC, clear cell sarcoma, pilomatrix carcinoma, sebaceous carcinoma, adenoid cystic carcinoma, eccrine porocarcinoma, mucinous carcinoma, hidradenocarcinoma, eccrine ductal carcinoma, apocrine carcinoma, superficial malignant fibrous histiocytoma, epithelioid sarcoma, malignant peripheral nerve sheath tumor, leiomyosarcoma, cutaneous metastases, etc.

BASAL CELL CARCINOMABASAL CELL CARCINOMA

Basal cell carcinomaBasal cell carcinomaBasaloid cells which appear similar to

cells in the basal layer of the epidermisThought to arise from pluripotent stem

cells within hair folliclesTypes:

◦ Nodular: up to 80% ◦ Superficial◦ Morpheaform◦ Fibroepithelial

Arises in sun-damaged skin Can ulcerateOccasionally can be pigmented

Nodular BCCNodular BCC• Most common subtype• Primary lesion• Shiny, pearly papule or nodule• Smooth surface• Arborizing telangiectasias

• Ulcerate with enlargement ,“rodent ulcer”• Face (cheeks, melolabial folds,

forehead, eyelids), any hair-bearing area of skin

Superficial BCCSuperficial BCC

Well-circumscribed, erythematous macule/patch or thin papule/plaque

Few mm to several cmFocal scale and/or crustThin rolled borderSpontaneous regression in larger

lesionsFavors trunk and extremities

Morpheaform BCCMorpheaform BCCLess common aggressive subtypePrimary lesion

◦Slightly elevated or depressed indurated light pink to white patch/plaque

◦Ill-defined borders◦Resembles scar ◦Smooth +/- crusts, erosions, ulcerations◦+/- telangiectasia◦Absence of rolled border

Fibroepithelial BCC Fibroepithelial BCC (Fibroepithelioma of Pinkus)(Fibroepithelioma of Pinkus)

Skin-colored or pink pedunculated papulonodule with smooth surface

Can resemble acrochordon or an intradermal nevus

Favors trunk (lower back)

PrognosisPrognosisUsually slow growing with local

extensionMetastases extremely rare:

0.0028-0.55%◦Lymph node most common ◦Lung, bone, distant skin, liver, pleura

Rare cause for mortality: 0.12/100,000 (0.00012%)

TreatmentsTreatmentsMohs micrographic surgeryExcisionED&C (electrodessication and

curettage) CryotherapyTopical (superficial subtype only)

◦ Imiquimod◦Fluorouracil

XRT Photodynamic therapyVismodegib: smoothened inhibitor

Excision vs MohsExcision vs Mohs

ED&CED&C

SQUAMOUS CELL SQUAMOUS CELL CARCINOMACARCINOMA

Actinic keratosis (AK)Actinic keratosis (AK)Syn: solar keratosis, senile keratosisSyn: solar keratosis, senile keratosis

Pre-cancerousAtypical keratinocytes in the

basal layer of the epidermis (not full-thickness)

No risk of metastasisEvolution to SCC: 0.075-0.096%

per lesion per year estimated 5% chance of developing SCC over 5-10 years.

Actinic KeratosisActinic Keratosis

Clinical features• Present on sun-damaged skin• Head, neck, upper trunk and extensor

extremities• Cluster in areas of highest sun exposure• Superior helices of ears• Upper forehead• Supraorbital ridge• Nasal bridge• Malar eminences• Dorsal hands• Extensor forearms• Bald scalp

Actinic KeratosisActinic KeratosisClinical features• Primary lesion• Rough erythematous papule with white

to yellow scale• +/- tenderness• Few mm to confluent patches several cm• Early sign: slight erythema with

imperceptible scale• Clues: background photodamage

(dyspigmentation, telangiectasia, wrinkling)• Advanced lesion: thicker, better defined

Actinic Keratosis VariantsActinic Keratosis VariantsHyperkeratotic/hypertrophic

◦Papules, plaques with scale or scale-crust on an erythematous base

◦Base extends beyond overlying hyperkeratosis

Pigmented AK ◦Usually lacks erythema◦Hyperpigmented/reticulated

appearance

Actinic Keratosis VariantsActinic Keratosis Variants

Lichenoid AK◦Dx histopathologically by dense, band-

like inflammatory infiltrate◦More erythema than traditional AK

Atrophic◦Minimal surface change◦Pink/red slightly scaly macule or patch

Actinic cheilitis◦Lower vermilion lip◦Classic vs diffuse◦+/- leukoplakia

TreatmentsTreatmentsCryotherapy: >99%Topical therapies:

◦Fluorouracil: 50% have 100% clearance◦Imiquimod: 50% have 100% clearance ◦Diclofenac: 40% clearance◦Ingenol mebutate: 34-47% clearance rate◦Retinoids: mixed results

Photodynamic therapy: 50-70% clearance

Surgical: Shave removal or curettage

AKsAKsConsider removal:

◦pearly or glassy appearance◦palpable dermal component◦> 6mm◦persistence after multiple treatments

A Primer on Skin Cancers Cathryn Zhang, MD University of Arizona 3/8/14.

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Transcript of A Primer on Skin Cancers Cathryn Zhang, MD University of Arizona 3/8/14.