Skin Cancer of the Nose: Common and Uncommon

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1 Skin Cancer of the Nose: Common and Uncommon Mark Russell, M.D. Associate Professor of Dermatology, Otolaryngology, and Pathology University of Virginia

2 Objectives Review clinical presentations of select nasal skin cancers Display common nasal defects after tumor extirpation

3 Skin Cancers of the Head and Neck Common Actinic keratosis (AK) Squamous cell carcinoma (SCC) Basal cell carcinoma (BCC) Melanoma (MM) Uncommon Atypical fibroxanthoma (AFX) Merkel cell carcinoma (MCC) Sebaceous carcinoma (SebCa) Angiosarcoma (AS)

4 Best Diagnosis: A. SCC B. AK C. BCC D. SebCa E. Angiosarcoma 0% 0% 0% 0% 0% SCC AK BCC MAC Angiosarcoma

5 Actinic Keratosis

6 Actinic Keratoses

7 Actinic Keratosis

8

9 Best Diagnosis: A. SCC B. AK C. AFX D. SebCa E. Angiosarcoma 0% 0% 0% 0% 0% SCC AK AFX MAC Angiosarcoma

10 SCC in situ

11 SCC, well differentiated

12 SCC, mod differentiated

13 SCC

14 SCC, poorly differentiated

15 SCC, poorly differentiated

16 Squamous Cell Carcinoma

17 Diagnosis: A. SCC B. Angiosarcoma C. SebCA D. MCC E. Keratoacanthoma 0% 0% 0% 0% 0% DFSP MAC SebCA MCC BCC

18 Keratoacanthoma Rapid growth (weeks) Usually males >50 Spontaneous regression over several months Differentiation from SCC often difficult

19

20

21 Diagnosis: A. Angiosarcoma B. MAC C. SebCA D. MCC E. BCC 0% 0% 0% 0% 0% DFSP MAC SebCA MCC BCC

22 Hugh Jackman Treated for Skin Cancer November 2013 Please don't be foolish like me. Get yourself checked. And USE sunscreen!!! Jackman urged his fans, while sharing an Instagram photo of his bandaged nose.

23 Hugh Jackman's Skin Cancer Returns; Actor Receives Treatment For Basal Cell Carcinoma Huffington Post 5/8/2014 "Another Basel Cell Carcinoma. All out now. Thanks Dr. Albom and Dr. Arian," Jackman wrote on Instagram. "PLEASE! PLEASE! WEAR SUNSCREEN!

24 Hugh Jackman Treated for Skin Cancer on His Nose for the Fourth Time 2/8/16 "An example of what happens when you don't wear sunscreen. Basal Cell. The mildest form of cancer but serious, nonetheless. PLEASE USE SUNSCREEN and get regular check-ups."

25 Hugh Jackman reveals another skin cancer treatment. CNN 2/14/17 "Another basal cell carcinoma. Thanks to frequent body checks and amazing doctors, all is well. Looks worse with the dressing on than off. I swear! #wearsunscreen"

26 Figure 1. Google Trends graph from May 6, 2012, to May 6, 2017 showing the search pattern for basal cell carcinoma. The dates of Hugh Jackman s announcements of his surgeries are highlighted in red. Dermatologic Surgery. 44(7): , JUL 2018

27 BCC Histologic Subtypes Indolent Superficial Nodular Aggressive Micronodular Infiltrative Morpheaform Squamous diff Dermatol Pract Concept Jul; 2(3).

28 BCC, superficial

29 Basal Cell Carcinoma, nodular

30 BCC, infiltrative

31 BCC, micronodular

32 BCC, morpheaform

33 BCC, Pigmented

34

35

36

37

38

39

40

41 Suggested excisional margins for cutaneous malignant lesions based on Mohs micrographic surgery. Schell AE, Russell MA, Park SS. JAMA Facial Plast Surg Sep-Oct;15(5):

42 Assessing BCC Size The basics Proper exposure Clean skin (e.g. 70% isopropyl alcohol) Bright light Magnification

43

44

45

46

47 Normal pilosebaceous Absent pilosebaceous Normal pilosebaceous

48 BCC engulfing a hair follicle

49 Conclusions Efficient surgical treatment of BCC relies on accurate assessment of tumor extent. Loss of vellus hair follicles may help delineate BCC, which may reduce positive margins.

50 How Fast Do BCC s Grow?

51 BCC 47 years old 62 years old 69 years old Surgery 2001;130:90-2.

52 BCC 74 years old Surgery 2001;130:90-2.

53 Diagnosis A. AFX B. Angiosarcoma C. Melanoma D. SebCa E. MCC 0% 0% 0% 0% 0% AFX MCC elanoma MAC DFSP

54 Melanoma 0.5% of cutaneous melanomas occur on the nose

55 Lentigo Maligna

56 Melanoma May arise from pre-existing nevus or lentigo Predominantly occur in the elderly Malignancy of melanocytes

57 Melanoma

58 Melanoma

59

60 Melanoma, Amelanotic

61 Diagnosis: A. SebCA B. AFX C. BCC D. Angiosarcoma E. MCC 0% 0% 0% 0% 0% SebCA AFX MAC Angiosarcoma MCC

62 Anatomic distribution of 140 cases of atypical fibroxanthoma. Cancer 1973;31:

63 AFX

64 AFX

65 Diagnosis: A. MCC B. BCC C. Angiosarcoma D. Seb Ca E. SCC 0% 0% 0% 0% 0% MCC BCC Angiosarcoma MAC DFSP

66

67 Merkel Cell Carcinoma Primary neuroendocrine skin tumor Derived from Merkel cells, which are neurotactile cells of epithelial origin with neuroendocrine features

68 Why is MCC important? More lethal than melanoma 46% mortality (~15% for melanoma) Reported incidence increasing Quadrupled from ~ 2,000 new cases/yr in USA A polyomavirus is associated with MCC Treatment options SLNB Excision XRT Immunotherapy avelumab or pembrolizumab

69 Merkel Cell Carcinoma

70

71 Merkel Cell Carcinoma

72

73 Diagnosis: A. SCC B. MCC C. SebCA D. Angiosarcoma E. BCC MAC 0% 0% 0% 0% 0% JAMA Otolaryngol Head Neck Surg. 2014;140(3): MCC SebCA iosarcoma Chalazion

74 Seb Ca Acta Derm Venereol May;91(3):367-8

75 Sebaceous Carcinoma Hoffmann M, Braun-Falco M. Rhinophyma-like sebaceous carcinoma. J Eur Acad Dermatol Venereol Oct;23(10):

76 Diagnosis: A. Melanoma B. rhinophyma C. BCC D. Angiosarcoma E. AFX 0% 0% 0% 0% 0% Melanoma DFSP MAC Angiosarcoma AFX

77

78

79 Angiosarcoma

80 Angiosarcoma J Am Acad Dermatol May;54(5):883-5

81 Angiosarcoma mimicking rhinophyma. Dermatol Res Pract. 2010;2010:

82 Angiosarcoma mimicking hemangioma J Cutan Pathol May 15. doi: /cup

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