Clinical characteristics

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1 Skin Cancer Fernando Vega, MD Seattle Healing Arts Clinical characteristics Precancerous lesions Common skin cancers ACTINIC KERATOSIS Precancerous skin lesions Actinic keratoses Dysplastic melanocytic nevi Common sun-induced premalignant neoplasm of the epidermis that occurs primarily on exposed skin Consequence of cumulative long-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 unchanged Others (1-10%) progress and develop into SCC risk increased with continued sun exposure or concurrent immunosuppression CLINICAL FEATURES Earliest evidence is a tiny red telangiectatic spot Then dry, rough and adherent scale Skin 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 Fernando Vega, M.D. 1

2 Actinic keratoses Actinic keratoses Actinic keratoses and SCC Actinic keratoses and SCC Actinic keratoses and BCC Actinic keratoses 10% risk of malignant transformation Fernando Vega, M.D. 2

3 Hypertrophic AK s Actinic cheilitis Treatment of AK s Liquid nitrogen cryotherapy Liquid nitrogen Cryotherapy Residual hypopigmentation Topical therapies 5-FU (Efudex) Imiquimod (Aldara) Curettage for hypertrophic lesions Blister formation Topical therapies Efudex or Aldara Dysplastic nevi * 3-5 times per week * 6-8 weeks Precursors for melanoma When to biopsy Fernando Vega, M.D. 3

4 Biologic Events and Molecular Changes in the Progression of Melanoma Clinical Images of Pigmented Lesions Miller A and M ihm M. N Engl J Med 2006;355:51-65 Tsao H et al. N Engl J Med 2004;351: Non-melanoma skin cancers Basal cell carcinoma Squamous cell carcinoma Keratoacanthoma Risk factors for development of BCC and SCC Fair skin (Fitzpatrick s types I-III) Blue eyes Red hair Family history Genetic syndromes Chronic sun exposure Old age Arsenic, tar BCC- clinical types Basal cell carcinoma Nodular Superficial Morpheaform Fernando Vega, M.D. 4

5 Nodular BCC Chronic lesion Easy bleeding Pearly border Surface telangiectasias Head and neck, trunk, and extremities Fernando Vega, M.D. 5

6 Superficial BCC Erythematous scaly plaque Slow growth Asymptomatic Trunk, extremities, face Superficial BCC Morpheaform BCC Resembles scar Asymptomatic and slow growing Ill-defined margins Marked subclinical extension BCC is the most frequent skin cancer (80%) Treatment of BCC Curettage electrodessication (ED/C) BCC is 4x more frequent than SCC Metastases are rare (<1% of cases) Local destruction of tissue Surgical excision Traditional Mohs surgery Radiation therapy Topical therapy imiquimod 95% Cure Rate 50-75% Cure Rate Fernando Vega, M.D. 6

7 SCC types Squamous cell carcinoma In-situ Bowen s disease Erythroplasia of Queyrat Invasive SCC Keratoacanthoma Bowen s disease Invasive SCC In-situ SCC Erythematous nodule Arsenic, HPV 16, radiation Indurated lesion Sun-exposed skin Men > 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 Fernando Vega, M.D. 7

8 SCC is locally invasive and destructive Metastases in 1-3% of cases To lymph nodes 50-73% survival Distant sites (lungs) Incurable Risk factors Clinical types- MM Fair skin, red hair, and blue eyes Intermittent sun exposure Sunburns Tanning beds Freckles and melanocytic nevi Superficial spreading melanoma Lentigo maligna melanoma Family history of melanoma Acral lentiginous melanoma Nodular melanoma ABCD of Melanoma Clinical Images of Pigmented Lesions Asymmetry Border irregularity Color variegation Diameter >6mm Tsao H et al. N Engl J Med 2004;351: Fernando Vega, M.D. 8

9 Biologic Events and Molecular Changes in the Progression of Melanoma Miller A and M ihm M. N Engl J Med 2006;355:51-65 Benign Melanocytic Neoplasms Benign Melanocytic Neoplasms Benign Melanocytic Neoplasms Benign Melanocytic Neoplasms Congenital nevus Fernando Vega, M.D. 9

10 With Regression Supeerficial Spreading Ciliary Body Fernando Vega, M.D. 10

11 Fernando Vega, M.D. 11

12 LENTIGO MALIGNA An in situ pattern of malignant melanoma Often reaches a large size before the diagnosis is made Lentigo lentigo maligna lentigo maligna melanoma Fernando Vega, M.D. 12

13 CLINICAL FEATURES Begins as a flat pigmented lesion Usually on sunexposed skin of head and neck MANAGEMENT Surgery excision with a wide margin Radiotherapy Cryotherapy (deviation from rule) With time the colour and border become more irregular Immiquimod (by report) Prognostic features- MM Good prognosis Breslow < 1mm Intermediate prognosis Breslow 1-4mm Bad prognosis Breslow >4mm Fernando Vega, M.D. 13

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