SKIN CANCER - internal.nfp.com · Stage IIIa – T1-4a, N1a or N2a. MELANOMA TNM/STAGING Stage I...
Transcript of SKIN CANCER - internal.nfp.com · Stage IIIa – T1-4a, N1a or N2a. MELANOMA TNM/STAGING Stage I...
SKIN CANCER• Most common cancer diagnosis – 40% of all cancers
OBJECTIVES
� Review common and uncommon cancers of the skin. Special emphasis on melanoma and dysplastic nevus
� Review pathology/TNM/staging, which is critical in underwriting
� Review survival/mortality studies, although some are limited
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GENERAL POINTS
� Careful reading of pathology report� Grade & stage – critical for solid tumors� Margins of resection, mitoses, necrosis, vascular
invasion� Beware of under-staging. Clin. vs. path.
Is treatment optimal?
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� Is treatment optimal?� Clinical, laboratory, pathology evidence of recurrence� If pathology report is inadequate or unavailable, try
doctor records
PRIMARY TYPES
•80%(800,000/yr)Basal Cell
Carcinoma
•16%Squamous Cell
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•16%Squamous Cell
Carcinoma
•4%Malignant Melanoma (Largely related to sun exposure)
SKIN CANCER
� Non-melanoma – most common cancer world-wide, incidence increasing
� Biggest risk factors – SUN, genetics, tobacco use in that order
� Recent increase in those < 40, esp. basal cell cancer in young females
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young females� Christenson. JAMA 2005; 294:681-690
BASAL CELL CARCINOMA
� “Low metastatic potential” (met. rate <0.1%)� Mortality rate – 0.05% (deep invasion >10 cm.). Rarely fatal. Cure
highly probable. Face, head� Basosquamous cell carcinoma – greater risk. Treat as squamous cell
cancer. � Tx – Moh’s surgery, radiation, cryosurgery, topical (5FU), electrosurgery
-90 % cure
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-90 % cure� Second BCC common (40% in 5 yrs)
SQUAMOUS CELL CARCINOMA
� Most remain localized & curable� Precursor – actinic, solar, senile keratosis
� Lifetime SCC risk: 6-10% if multiple lesions
� Seborrheic keratosis – not a precursor
� Assoc. w/ sun, smoking, tx w/ PUVA or immune
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� Assoc. w/ sun, smoking, tx w/ PUVA or immune suppression
� If one SCC – high chance of 2nd SCC (or BCC or melanoma) within 5 yrs
SQUAMOUS CELL CARCINOMA
� Bowen’s Disease – SCC in situ� Up to 2 cm tumors- few recur or metast.� Recurrence rate – 8-16% - depends on size, depth, facial
areas, differentiation, tx� Mets w/ SCC – 1-5% (85% of those in LN). > risk if face,
scalp, ears, scars, burns, if d/t radiation/immune
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scalp, ears, scars, burns, if d/t radiation/immune suppression, older men
TMN FOR SCC OF SKIN
� Tis – Carcinoma in situ (non-invasive)� T1 - < 2 cm diam. < 2 high risk features� T2 - >2 cm or any T w/ > 2 high risks� T3 & T4 – (much deeper invasion) – maxilla, mandible,
orbit, etc.
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SCC HIGH RISK FEATURES
� Depth > 2 mm or Clark level IV or perineural invasion� Location – ear or hair-bearing lip� Poorly differentiated or undifferentiated (does not look like
normal skin)
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SKIN SCC STAGE
Stage 0 Stage I Stage II Stage Stage
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Stage 0 – Tis
N0 M0
Stage I – T1
N0 M0
Stage II – T2
N0 M0
Stage III - T3 N0 M0
Stage III T1 N1 M0
SCC TREATMENT
•97% cureMoh’s micrographic
surgery
•92% cureOther surgery
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Other tx less effective: radiation, cryotherapy, 5FU
•77% cureSurgery for recurrence
Need close follow-up after treatment
SCC MORTALITY
� Overall mortality – 1% (1000/yr)� Pos lymph nodes – 25-35% 5 yr. survival & < 20% 10 yr.
survival� Distant mets - < 10% 5 yr. survival� 5 year cure rate > 90%
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MALIGNANT MELANOMA
� 75% of T1 melanomas are T1a w/ 95% five yr survival & 93% ten yr survival
� Thickness proportional to how long it has been there & to risk
� Thickness & ulceration: best predictors of survivalMore common if freckles, moles (esp. atypical), non-
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� More common if freckles, moles (esp. atypical), non-melanoma skin ca and sporadic sun exposure
MALIGNANT MELANOMA
� 50% of melanoma - no preexisting lesion� 10% - familial
� If family history, 8-12 fold increased incidence
� If family history, need exam Q 6 months� 2/3 secondary to sunlight (UVA & UVB)
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� 2/3 secondary to sunlight (UVA & UVB)� -Intense sunburn in childhood 4- 5 x
� Sporadic sun exposure (cf. SCC, when sun more constant exposure)
MALIGNANT MELANOMA
� Life time risk 1 in 37 or 50 (1/600 in 1965)� Rare until age 10� Recent increases ages 10-20 & up� Mortality ratio stable or mild increase except men > 65 (up
150%)
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� With early dx, overall survival 90%
ABCDE –MELANOMA DX
� A – asymmetry� B – border irregularity� C – color variegation� D – diameter >6 mm. (pencil
eraser)� E – evolving (change, itching,
Rigel. CA 2010;60:301-316
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� E – evolving (change, itching, bleeding)
MELANOMA TYPES
� Superficial spreading – radial growth- 70%� Nodular –vertical invasion- 15-30%� Acral – dark skin, soles, palms, nails- 5%� Lentigo –elderly, in situ for years- 5%
� Abbasi. JAMA 2004;292:2771-2776
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MALIGNANT MELANOMA
� Early radial (horizontal) growth, thin & confined to epidermis� In situ or microinvasion almost all curable
� But risk of another melanoma
� Vertical growth phase into dermis – metastatic potential
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MELANOMA – PATH REPORT
� In situ or invasive� Breslow thickness & Clark level� Ulceration + or –� Mitoses – many or very few� Growth - radial or vertical
Regression
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� Regression� Margins of resection� Satellites or vascular invasion
MM – 10 YEAR SURVIVAL
� Extremity <0.76 mm, women <60: 99%� Extremity <0.76 mm, men < 60: 98%� Axis <0.76 mm, women < 60: 97%� Axis < 0.76mm, men < 60: 94%� Extremity < 0.76 mm, women >60: 98%
Extremity < 0.76 mm, men >60: 96%
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� Extremity < 0.76 mm, men >60: 96%
� * Axis: trunk, head, neck, volar, subungual
MM – 10 YEAR SURVIVAL
� Axis <0.76 mm, women >60: 92%� Axis <0.76 mm, men > 60: 84%� Extremity 0.76-1.69mm, women <60: 96%� Extremity 0.76-1.69mm, men <60: 93%� Axis 0.76-1.69mm, women <60: 86%
Axis 0.76-1.69mm, men <60: 75%
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� Axis 0.76-1.69mm, men <60: 75%� Extremity 0.76-1.69mm, women >60: 90%� Extremity 0.76-1.69mm, men > 60: 81%
MM-10 YEAR SURVIVAL
� Axis 0.76-1.69mm, women >60: 67%� Axis 0.76-1.69mm, men >60: 50%� Extremity 1.7-3.6mm, women <60: 89%� Extremity 1.7-3.6mm, men <60: 80%
Axis 1.7-3.6mm, women <60: 65%
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� Axis 1.7-3.6mm, women <60: 65%� Axis 1.7-3.6mm, men<60: 48%� Extremity 1.7-3.6mm, women >60: 73%� Extremity 1.7-3.6mm, men >60: 57%
� Ann Int Med 1996;125:369
MELANOMA2002 AJCC STAGING
� Tis – melanoma in situ � T1a- < or = 1.0 mm. w/o ulceration, level II,III� T1b -< or =1.0 mm. w/ ulceration or level IV, V� T2a – 1.01-2.0 mm. w/o ulceration
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� T2a – 1.01-2.0 mm. w/o ulceration� T2b – 1.01-2.0 mm. w/ ulceration� T3a – 2.01-4.0 mm. w/o ulceration� T3b – 2.01-4/0 mm. w/ ulceration
� H/O Melanoma, risk of 2nd is 10-25 x.
� Recent study: 8% risk of 2nd melanoma w/in 2 yrs.
TNM & STAGING
� Stage 0 – Tis (jn situ)� Stage IA – T1a (N0 M0 for all I & II)� Stage IB – T1b or T2a� Stage IIA – T2b or T3a� Stage IIB – T3b or T4a
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� Stage IIB – T3b or T4a� Stage II C – T4b� Stage IIIa – T1-4a, N1a or N2a
MELANOMA TNM/STAGING
� Stage I – low risk for metastases and melanoma mortality� Stage II – intermediate risk for metastases & melanoma
mortality� Balch. CA 2004; 54:131-149
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MM – STAGE/ 5 YR SURVIVAL
� IA (T1a nonulcerated) - 95%� IB (T1b ulcerated) – 91%� IB (T2a nonulcerated) – 89%� IIA (T3a nonulcerated) – 79%� IIA (T2b ulcerated) – 77%
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� IIA (T2b ulcerated) – 77%� IIB (T4a nonulcerated) – 67%� IIB (T3b ulcerated) – 63%
� Balch. CA 2004; 54:131-149
MM - STAGE/10 YR SURVIVAL
� IA (T1a nonulcerated) – 93%� IB (T1b ulcerated) – 82%� IB (T2a nonulcerated) – 80%� IIA (T2b ulcerated) – 68%� IIA (T3a nonulcerated) – 68%
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� IIA (T3a nonulcerated) – 68%� IIB (T3b ulcerated) – 53%� IIB (T4a nonulcerated) – 55%
MM STAGE/ MORTALITY RATIO
� Stage IA – Slightly > 100% MR� Stage IB – 250% MR� Stage IIA – 400% MR� Stage IIB – 600% MR� Stage IIC – 900% MR
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� Stage IIC – 900% MR� Stage IIIA – 1200% MR
� REMEMBER LONG MORTALITY TAIL IN - long risk for underwriting
HISTORY OF MELANOMA
� 100 fold increase risk if previous melanoma in patient� 200 fold increase risk if 2 family members with melanoma� 1200 fold increase risk if both personal and family history of
melanoma� Naeyaert. NEJM 2003;349:2233-2240
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T1 & T2 MELANOMAS
� T1a - < 1.0 mm, no ulceration, only level II and level III (Clark)
� T1b - < 1.0 mm but level IV or V or ulceration regardless of level
� Clark level important only –thin melanoma� Ulceration raises lesion to next stage (IB is either T1b or
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� Ulceration raises lesion to next stage (IB is either T1b or T2a)
� Stage I & II – no evidence of mets
MALIGNANT MELANOMA
� Path stage (pT) – more information than clinical stage (cT)� Caution: amelanotic melanoma (colorless) – usually
nodular; often overlooked� Melanoma in situ. No invasion, 100% survival, but still risk
of additional melanomas
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MELANOMA TREATMENT
� Complete excision w/ adequate margins of surrounding tissue for cure (all directions)
� AVOID shave biopsies. Need subq for depth. May transect melanoma
� Sentinel node bx in melanomas 1.2mm to 3.5 mm. (T2-3) –survival higher cf no bx
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survival higher cf no bx� Morton. NEJM 2006;355:1307-1317
� If sentinel node +, then complete node dissection w/ adjuvant tx for hope of cure
MELANOMA METS
� If + lymph node on bx, then have better survival than only clinical dx (by 20-29%)
� Satellite mets in skin by primary MM has equally poor prognosis as + lymph nodes (N2 & stage III)Stage III ten yr survival – 9-63%
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� Stage III ten yr survival – 9-63%
MALIGNANT MELANOMA
� Ulceration, bleeding, regression, satellites, high mitotic rate: all worse prognosis.
� Pos. lymph nodes worst prognosis� Dermoscopy (surface microscopy) now allows
differentiation of benign and malignant pigmented lesionsP.S. – can also have melanoma in eye or GI tract (increase
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� P.S. – can also have melanoma in eye or GI tract (increase risk if dysplastic nevus)
MELANOMA - FUTURE
� Identification of gene alterations will be basis of future classification of melanoma & provide rationale for drug treatment & effective targeted therapy
� Advance/Laboratory, Feb. 2011, p. 26
� For other new techniques being investigated –
-Rigel CA 2010; 60:301-316
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� -Rigel CA 2010; 60:301-316
DYSPLASTIC NEVI� AKA atypical mole, BK mole, Clark’s nevi� Path & clin. between nevus and melanoma� No consensus on formal definition� Precursor or marker for melanoma� Appears at puberty. Prevalent < 30-40 y/o
Often 50 - >100 nevi on body
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� Often 50 - >100 nevi on body� Autosomal dominant inheritance but not always family
history
DYSPLASTIC NEVUS
� Occurs in 2-18% of white adults (20% of all have at least one atypical mole)
� Median age 33� Occurs in 17-59% of melanoma patients� Most common on trunk, esp back
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� Dysplastic nevus syndrome: >100 moles, with one > 8mm and one atypical mole
� May evolve from nevus or de novo
DYSPLASTIC NEVUS
� Relationship of familial melanoma & dysplastic nevus is FAMMM – familial atypical multiple mole- melanoma syndrome. AKA dysplastic mole syn.
� >15 x relative risk of melanoma if multiple� Intense f/u q 6-12 months w/ photos
Also increased incidence others cancers
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� Also increased incidence others cancers� Naeyaert. NEJM 2003;349:2233-2240
KINDREDS & DYSPLASTIC NEVUS SYNDROME
� A: sporadic atyp mole – 1 in family � B familial atyp mole – 2 or more in family� C sporadic atyp mole & melanoma – 1 in family w/ both
conditions� D1 familial atyp mole & melanoma – 2 or more w/ atyp
mole; 1 in family w/ both
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mole; 1 in family w/ both� D2 – familial atyp mole & MM – 2 or more with both atyp
mole & MM
DYSPLASTIC NEVUS TREATMENT
� Most do not evolve into melanoma� Most are therefore not excised unless changes occur� Stress again need for close follow-up, including photos, for
both dysplastic nevus and melanoma patients
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LESS COMMON SKIN TUMORS
� Keratoacanthoma – looks like SCC but rapid growth. Most regress to scar. A few may be or become malignant w/ mets
� Sebaceous carcinoma. Malignant, 10 to 30 % mortality in 5 years. Face & head, esp. eyelids. Assoc. w/ 2nd cancer
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LESS COMMON SKIN TUMORS
� Merkel cell carcinoma. Rare, aggressive, esp. older males or immunocompromised. Tend to recur or metastasize. Rapid growth, esp. face. Assoc. w/ 2nd cancers.
� Dermatofibrosarcoma protruberans. Locally invasive, similar to basal cell ca.
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similar to basal cell ca.
CUTANEOUS LYMPHOMA
� 90% T cell lymphoma. � Majority are mycosis fungoides
� Next, anaplastic large T cell lymphoma
� 10% B cell lymphoma� 20-25% are stage IA, w/ good survival
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� 20-25% are stage IA, w/ good survival� 2% of all lymphomas are cutaneous
CUTANEOUS LYMPHOMA
� Diagnosis by biopsy only� No consensus: dx of mycosis fungoides� For all – immunophenotyping to diagnose abnormal
lymphocyte clones� Can ultimately involve lymph nodes, blood and visceral
organs
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organs� More aggressive leukemic variant - Sezary
TNM – CUTANEOUS LYMPHOMAS
� T0 – suspicious lesions� T1 – limited lesions < 10% skin surface� T2 – generalized lesions, > 10% skin� T3 – skin tumors
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TNM STAGE MYCOSIS FUNGOIDES
� Stage IA – T1 N0 (<10%): 20-25% have� Stage IB – T2 N0 (>10%): 30-40% have� Stage IIA – T1-2, N1
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SURVIVAL –MYCOSIS FUNGOIDES
� Stage IA – studies show excellent prognosis and long-term survival
� Stage IB & IIA – 20% die of MF. Median overall survival > 11 years.
� Higher stages (IIB, III and up) – very short survival
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PRIMARY CUTANEOUS ANAPLASTC LARGE T CELL
� 8-18% of primary cutaneous lymphomas� Radiation therapy for most� Some regress spontaneously� Some studies – good survival
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SUMMARY
Many common skin tumors have excellent survival if adequate treatment
Melanoma may have excellent survival if diagnosed early and if treated adequately
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Rarer skin tumors require caution
T1, esp. T1a, and Stage I cancers have the best prognoses, best UW risks
All skin tumors require close follow-up
Thank you for the privilege ofpresenting this topic
Jack Swanson, M. D.