Download - Clinical characteristics Skin Cancer

Skin Caner

Fernando Vega, M.D. 1

Skin Cancer

Fernando Vega, MDSeattle Healing Arts

Precancerous lesions

Clinical characteristics

Precancerous lesionsCommon skin cancers

Precancerous skin lesionsActinic keratosesActinic keratoses

Dysplastic melanocytic nevi

ACTINIC KERATOSISCommon sun-induced premalignant neoplasm of the epidermis that occurs primarily on exposed skin

Consequence of cumulative qlong-term sun exposure

Prevalence ↑with ↑age

Men > women

Also genetic factors - ↑in fair skin and in genetic syndromes eg xeroderma pigmentosum

NATURAL HISTORY

Some lesions (10%) spontaneously regress

Some (majority) remain unchangedSome (majority) remain unchanged

Others (1-10%) progress and develop into SCC – risk increased with continued sun exposure or concurrent immunosuppression

CLINICAL FEATURESEarliest evidence is a tiny red telangiectatic spot

Then dry, rough and adherent scale

Ski l d/ d/ ll / bSkin coloured/ red/ yellow/ brown

Usually multiple

Lesions on hands and forearms tend to be thicker

Actinic change on lips=actinic chelitis

Associated with other signs of sun damage – solar elastosis, wrinkled skin, solar lentigines

Skin Caner


Actinic keratoses Actinic keratoses

Actinic keratoses and SCC Actinic keratoses and SCC

Actinic keratoses and BCC Actinic keratoses

10% risk of malignant transformation

Skin Caner


Hypertrophic AK’s Actinic cheilitis

Liquid nitrogen cryotherapy

Topical therapies

Treatment of AK’s

5-FU (Efudex)

Imiquimod (Aldara)

Curettage for hypertrophic lesions

Residual hypopigmentation

Liquid nitrogenCryotherapy

Blister formation

Topical therapiesEfudex or Aldara

* 3-5 times per week* 6-8 weeks

Dysplastic nevi

•Precursors for melanoma•When to biopsy

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Biologic Events and Molecular Changes in the Progression of Melanoma

Miller A and Mihm M. N Engl J Med 2006;355:51-65

Clinical Images of Pigmented Lesions

Tsao H et al. N Engl J Med 2004;351:998-1012

Non-melanoma skin cancers

Basal cell carcinoma

Squamous cell carcinomaSquamous cell carcinoma

Keratoacanthoma

Risk factors for development of BCC and SCC

Fair skin (Fitzpatrick’s types I-III)Blue eyesRed hair

Family historyy yGenetic syndromes

Chronic sun exposure

Old age

Arsenic, tar

Basal cell carcinoma

BCC- clinical types

Nodular

SuperficialSuperficial

Morpheaform

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Nodular BCCChronic lesion

Easy bleeding

Pearly border

Surface telangiectasias

Head and neck, trunk, and extremities

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Superficial BCCErythematous scaly plaque

Slow growth

Asymptomatic

Trunk, extremities, face

Superficial BCC Morpheaform BCC

Resembles scar

Asymptomatic and slow growinggrowing

Ill-defined margins

Marked subclinical extension

BCC is the most frequent skin cancer (80%)

BCC is 4x more frequent than SCC

Metastases are rare (<1% of cases)

Local destruction of tissue

Treatment of BCCCurettage electrodessication (ED/C)

Surgical excisionTraditional

95% Cure Rate

Mohs surgery

Radiation therapy

Topical therapyimiquimod

50-75% Cure Rate

Skin Caner


Squamous cell carcinoma

SCC types

In-situBowen’s disease

f QErythroplasia of QueyratInvasive SCCKeratoacanthoma

Bowen’s disease

In-situ SCC

Arsenic HPV 16Arsenic, HPV 16, radiation

Invasive SCC

Erythematous nodule

Indurated lesion

Sun-exposed skinMen > women

Slow growth

Invasive SCC Keratoacanthoma Low grade SCC

Rapid growth over weeks

Trauma, sun exposure, HPV 11 and 16

May progress to invasive SCC

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SCC is locally invasive and destructive

Metastases in 1-3% of casescases

To lymph nodes50-73% survival

Distant sites (lungs)Incurable

Malignant Melanoma

Risk factorsFair skin, red hair, and blue eyes

Intermittent sun exposureSunburnsTanning beds

Freckles and melanocytic nevi

Family history of melanoma

Clinical types- MM

Superficial spreading melanomaSuperficial spreading melanoma

Lentigo maligna melanoma

Acral lentiginous melanomaNodular melanoma

ABCD of Melanoma

Asymmetry

Border irregularityBorder irregularity

Color variegation

Diameter >6mm

Clinical Images of Pigmented Lesions

Tsao H et al. N Engl J Med 2004;351:998-1012

Skin Caner


Biologic Events and Molecular Changes in the Progression of Melanoma

Miller A and Mihm M. N Engl J Med 2006;355:51-65

Benign Melanocytic Neoplasms




Congenital nevus

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Malignant Melanoma Malignant MelanomaWith Regression

Malignant MelanomaSupeerficial Spreading

Malignant Melanoma

Malignant MelanomaCiliary Body

Malignant Melanoma

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Malignant Melanoma Malignant Melanoma



Skin Caner




Malignant Melanoma LENTIGO MALIGNA

An in situ pattern of malignant melanomaOften reaches a large size before the diagnosis is madeLentigo → lentigo maligna →lentigo maligna melanoma

Skin Caner


CLINICAL FEATURESBegins as a flat pigmented lesion

Usually on sun-yexposed skin of head and neck

With time the colour and border become more irregular

MANAGEMENT Surgery – excision with a 2-5mm margin

Radiotherapy

Cryotherapy (deviation from rule)

Prognostic features- MMGood prognosis

Breslow < 1mm

Intermediate prognosisBreslow 1-4mm

Bad prognosisBreslow >4mm