Cutaneous Oncology- What

you need to know

Joshua Kentosh, DO, FAAD

Dermatologist/Mohs Surgeon, Soderstrom Skin Institute

Assistant Clinical Professor of Dermatology, UICOMP

I have no relevant financial conflicts of

interest

Objectives:

• Identify the three most common forms of

skin cancer

• Become familiar with the appropriate and

effective treatment options for common

cutaneous malignancies

• Understand the importance of staging of

malignant melanoma and be able to

identify the clinical components required

for appropriate staging of the tumor

Skin Cancer Incidence

• 1 in 5 Americans will develop skin cancer

• >4.5 million non-melanoma skin cancers diagnosed annually in the USA

• Estimated that 96,480 invasive melanomas and 95,830 in-situ melanomas will be diagnosed this year, with 7,230 deaths predicted (decrease of 22%)

• Non-melanoma skin cancer (BCC/SCC) is highly curable if caught and treated appropriately

• Regular daily use of an SPF 15 or higher sunscreen reduces the risk of developing squamous cell carcinoma by about 40 percent

https://www.skincancer.org/skin-cancer-information/skin-cancer-

facts

Why the rapid increase?

Causes of Skin Cancer

• Ultraviolet radiation

– UVB (290nm - 320nm) most important

– UVA (320nm - 400nm) more penetrating

• Ionizing radiation (X-rays)

• Chemicals (arsenic, coal tars)

• “Marjolin’s ulcers”

• Immunosuppression

– Organ transplant patients

– 10%-45% of transplant patients develop skin cancers

– 2 to 3 times more SCCs than BCCs

• Human papillomavirus - beta HPVs (type 5 SCC)

• Inherited diseases - XP, BCNS, albinism

Basal Cell Carcinoma

• Most common cancer in America (>4.5 million cases each year)

• Usually seen in the middle-aged and elderly

• Usually due to solar radiation

• Common locations

• Frequently develop another within 5 years

• Subtypes

N Engl J Med 2005; 353:2262-2269

DOI:10.1056/NEJMra044151

Basal Cell Carcinoma

• Course

– Slow progressive

growth

– Bleeding, ulceration

– Enlarges over months

to years

– Is capable of extensive

tissue destruction

(invading into muscle,

cartilage, and bone)

Squamous Cell Carcinoma

• >1 million diagnosed yearly with 15,000 deaths annually

• Arise primarily on sun damaged skin– Actinic Keratosis

• Immunocompromised patients (100x increased risk)

• Patients with skin of color

• PUVA treatment patients

• Many subtypes

Immunotherapy and squamous cell carcinoma

Timothy Allen Nepton Sheikh-Khoni Naveed Basha Court

DOI: 10.15761/CRR.1000109

Squamous Cell Carcinoma

• Metastasis more likely in

– Recurrent tumors

– Those with diameter > 2 cm

– Those with depth > 4 mm

– Mucosal sites, periauricular skin

– Those arising from chronic wounds (Marjolin’s)

– Perineural invasion

– Immunocompromised patients

Treatment of Nonmelanoma

Skin Cancer

Treatment- Cryotherapy

Treatment- Electrodessication

and Curretage

Treatment- Radiation

Treatment of BCCs and

SCCs

• Lasers

– Carbon dioxide

– Erbium: YAG

– Photodynamic

therapy

Treatment- Surgical excision

Treatment- Mohs Micrographic

Surgery• Mohs Micrographic Surgery– Highest cure rate (97% - 99%)

– Spares healthy tissue

– Evaluates the entire surgical margin microscopically

• 100% of peripheral & deep margin

examined

– Traditional vertical sections examine

less than 1%

• Conserves tissue in cosmetically sensitive

areas

• Standard of care when:

• tumor is in critical location (cosmetic or functional)

• tumor is recurrent

• tumor has ill-defined margins

• tumor is large (> 2 cm) or aggressive histology

Mohs Surgery Advantages-

Highest cure rates

97% - 99% for primary tumors

94% for recurrent tumors

Entire margin evaluated microscopically

Cure rates of other methods

Standard excision 89.9 %

Destruction 81% - 96%

Radiation 91 %

Paoli J, Daryoni S, Wennberg AM, Mölne L, Gillstedt M, Miocic M, et al. 5-year recurrence rates of Mohs

micrographic surgery for aggressive and recurrent facial basal cell carcinoma. Acta Derm Venereol.

2011;91:689–93. [PubMed]

Leibovitch I, Huilgol SC, Selva D, Hill D, Richards S, Paver R. Cutaneous squamous cell carcinoma treated with

Mohs micrographic surgery in Australia I.Experience over 10 years. J Am Acad Dermatol. 2005;53:253–60.

[PubMed]

Pugliano-Mauro M, Goldman G. Mohs surgery is effective for high-risk cutaneous squamous cell carcinoma.

Dermatol Surg. 2010;36:1544–53. [PubMed]

Margin Control

Standard “breadloafing” section

Mohs surgery frozen section

Mohs Micrographic Surgery• Other Cutaneous

Tumors– Melanoma in-situ, Lentigo

maligna

– Thin melanomas (Breslow depth 1.0mm)

– Dermatofibrosarcoma protuberans (DFSP)

– Atypical fibroxanthoma (AFX)

– Sebaceous carcinoma

– Merkel cell carcinoma

– Microcystic adnexal carcinoma

– Verrucous carcinoma

– Angiosarcoma

Why do we utilize Mohs Micrographic

Surgery for Non-Melanoma Skin Cancer?

Sometimes what is seen at the surface is only the tip of the iceberg

Non-Melanoma Skin Cancer

Sometimes what is seen at the surface

is only the tip of the iceberg

Mohs Surgery ProcedureTumor identified and +/- debulked

with curette

Mohs Surgery ProcedureBeveled incision with minimal (1 mm - 2 mm)

border

Mohs Surgery ProcedureHatch mark(s) made on skin for orientation

Mohs Surgery ProcedureTissue removed just under beveled edge

Mohs Surgery ProcedureTissue grossed and mapped

Mohs Surgery Procedure

Sections color coded for orientation

Mohs Surgery ProcedureSections embedded for horizontal sectioning

Mohs Surgery ProcedureFrozen sections taken and mounted on slide

Mohs Surgery ProcedureSections stained and read by Mohs surgeon

Mohs Surgery ProcedurePathology read by surgeon and mapped

Mohs Surgery ProcedureOnly small area with tumor re-excised

Mohs Surgery ProcedureProcess continued until no tumor at margins

Melanoma

What is the number one cause of

dermatology associated litigation?

A. Cosmetic surgery complications

B. Misdiagnosed melanoma

C. Accutane complications

D. Phototherapy induced injury

E. Not making someone really, really good-

looking enough…

Why the fuss over

pigmented lesions?

- Estimated that 96,480 invasive melanomas

and 95,830 in-situ melanomas will be

diagnosed this year

-7,230 deaths predicted (decrease of 22%)

- 5th most common malignancy in US

- median age of diagnosis is 64 yo

- fastest increasing incidence of any invasive

cancer (2% lifetime risk in the United States)

American Cancer Society & National Cancer Institute

Which one of these celebrities has

NOT had melanoma?

A. Bob Marley

B. John McCain

C. Troy Aikmen

D. Caitlyn Jenner

"I was diagnosed with a form of melanoma

called basal cell carcinoma and have

undergone Mohs surgery to remove it,"

Malignant Melanoma: ABCDE

A symmetry

B order irregularities

C olor variegation

D iameter usually > 6 mm

E volving, enlarging

Risk factors for melanoma

• Prior melanoma

• Numerous (especially if atypical) nevi

• Family h/o MM or atypical nevi

• Fair skin (burn easily, red hair, freckles)

• H/o intermittent intense sun exposure

• Immunosuppression

Cutaneous Melanoma-BRAF

mutations

• 40-60% of melanomas have somatic

BRAF mutations

• Up to 90% of the BRAF mutations lead to

V600E

• V600E leads to 10-12% basal kinase

activity

• No classical UV radiation-induced

mutations

New systemic therapies for

Melanoma:

• Kinase inhibitors:

-small molecules

-oral, taken daily

-specific mutations

-rapid tumor response

-high response rate

-RESISTANCE

-Vemurafanib,

Trametinib

• Immunostimulators:

-monoclonal

antibodies

-IV, q2-4 weeks

-no specific mutations

-slower tumor

response

-lower response rate,

but long-lasting

-Ipilimumab,

checkpoint inhibitors

If you suspect

melanoma…

• Best to evaluate entire

specimen to avoid sampling error

• Consider narrow excisional biopsy because

you can always take wider margin if malignant

• If you are uncomfortable excising it yourself, ask for

help (call your dermatologist)

Breslow level and prognosis

• Prognosis for all subtypes depends on the

histologic thickness (Breslow level) of the

tumor

– If < 1mm thick without ulceration, 95% 5 year

survival

– If > 4mm thick and ulcerated, 45% 5 year

survival

– If it’s spread to the lymph nodes, ~25% 5 year

survival and if distant met’s, then ~10% 5 year

survival

Melanoma• Usually asymptomatic, pigmented lesion that

may ulcerate or bleed

– Patch, papule, nodule, ulcer

• ~1/3 develop within existing nevi;

the rest develop de novo

• 1 in 75 Americans will develop melanoma

Melanoma in situ (MIS)

• Confined to the epidermis

• Excellent prognosis with excision

Lentigo Maligna

Lentigo maligna is

one type of MIS

Lentigo Maligna

• Large brown patch

• Irregular shape & pigmentation

• Sun-damaged skin

• Slow, insidious growth over

many years

• Treatment: excision

Once the lentigo maligna invades

the dermis, then it becomes a invasive

melanoma

Superficial Spreading Melanoma

• No sun-damage preference

• Upper back, legs

• Better defined than LMM

Nodular Melanoma

• 15% of all MM

• Men > women

• Sun-exposed areas

Acral Lentiginous

Melanoma

• Most common type

in darker skin types and

Asian populations

• Metastases are common

Mucosal pigmented lesions(oral, genital)

Labial melanotic macule.

Benign.

Intraoral melanoma.

Malignant.

Pigment diffusion a bad sign

Melanoma can occur wherever there

are melanocytes…

Amelanotic

Melanoma

• Differs only in lack of pigment

• Mimics BCC or vascular lesions,

e.g. pyogenic granuloma

• Often diagnosed late, therefore

poor prognosis

Points to remember:

• Skin cancer is highly prevalent and there are many different types (1 in 5 Americans will suffer from skin cancer)

• Many treatment options, and treatment is tailored to type, risk of spread, location, and many other factors.

• Mohs surgery is a very effective treatment modality for many of the most common skin cancers.

• Appropriate use criteria should be followed, however there are exceptions.

• 0.8mm Breslow depth, or any melanoma with ulceration should prompt referral for WLE and SLNBx

References:

• Most photos are from my personal

collection

• SEER database

• NCCN guidelines 2018

• References are stated with relevant slides