Skin Cancer 101: Diagnosis and Management of the Most Common Cancer

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1 Skin Cancer 101: Diagnosis and Management of the Most Common Cancer Sarah Patton, PA-C, MSHS Skin Surgery Center Seattle/Bellevue, WA

2 Skin cancer Skin cancer is by far the most common type of malignant tumors in humans Each year there are more new cases of skin cancer than the combined incidence of cancers of the breast, prostate, lung and colon1 1 in 50 men and women will be diagnosed with melanoma of the skin during their lifetime2 1 American Cancer Society. Cancer Facts a& Figures

3 Risk Factors At least 90% of skin cancers are caused by UV radiation UVR (ultraviolet radiation) is a PROVEN HUMAN CARCINOGEN SPF, hats, clothing

4 TANNING BEDS TANNING BEDS SIGNIFICANTLY INCREASE YOUR RISK FOR ALL TYPES OF SKIN CANCER

5 Tanning Beds People who tan indoors are: 74 percent more likely to develop melanoma times more likely to develop squamous cell carcinoma 1.5 times more likely to develop basal cell carcinoma 4 3 Lazovich D, Vogel RI, Berwick M, Weinstock MA, Anderson KE, Warshaw EM. Indoor tanning and risk of melanoma: a casecontrol study in a highly exposed population. Cancer Epidem Biopmar Prev 2010 June: 19 (6): Karagas MR, Stannard VA, Mott LA, Slattery MJ, Spencer SK, and Weinstock MA. Use of tanning devices and risk of basal cell. and squamous cell skin cancers. J Natl Cancer Inst 2002; 94 (3):

6

7 Skin Cancer Risk Factors HPV Radiation Smoking Genes (XP, BCNS) Chronic Ulcers/Inflammation Burns Arsenic, coal tar Weakened immune system

8 Examples of SUN Damage

9 Patient Risk Factors Blonde/red hair Light (blue/green eyes) Easily burns/hx of sunburns Fam hx of skin CA Personal hx of Skin CA/Pre-cancers Hx of excessive UV exposure

10

11 Basal Cell Carcinoma Arises from basal cells of the epidermis 4 MILLION cases diagnosed annually in the US Presentations include: pink pearly papule pink scaling patches non-healing lesions pimple that doesn t heal pigmented macules or papules white-scar like Slow growing Tips: nose, ears, medial canthus, shoulders, chest, vermillion border

12 Basal Cell Cancer

13

14

15 Nodular Basal Cell Carcinoma Hair bearing skin More than half of BCCs are nodular Clinically they are typically slow growing, pearly nodules with rolled borders, telangiectasias

16 Pigmented BCC Brown eyed individuals and others Difficult to differentiate from melanomas at times

17

18 Superficial Basal Cell Carcinoma

19 Morpheaform Basal Cell Carcioma Clinically appears as a scar Most aggressive of BCC s Accounts for 5% of all BCC s Can invade into muscle and fat

20 Morpheaform BCC

21 Morpheaform Basal Cell Carcinoma RARELY may metastasize

22 Squamous Cell Carcinoma Arises from keratinocytes in the epidermis 1 million diagnosed each year in the US Types include SCCIS, invasive, KAs Potential to metastasize (not in SCC in Situ) Etiology UV light (predominant) X-Ray Chemicals, i.e. arsenic Burns(fire) Chronic ulcers or other sites of chronic inflammation

23 Squamous Cell Carcinoma in Situ Clinically Sharply marginated erythematous scaling/crusting Does not metastasize*

24 Risk Factors for SCC to metastasize Location lower lip, ear, temple Formation in scar Large size Immunosuppressed patients

25 Squamous Cell Carcinoma

26 SCC Invading Bone

27 Squamous Cell Carcinoma (Keratoacanthoma Type) Symmetric, red nodule with ulceration centrally Low grade SCC Often painful Rapid growth Increased incidence in transplant patients Low metastatic rate

28

29

30 Treatment options for Basal Cell and Squamous Cell Carcinoma

31 Treatment of BCC/SCC Cryotherapy Electrodessication and Curettage Radiation Topical Chemotherapy Photodynamic Therapy Traditional Surgical Excision Mohs Micrographic Surgery

32 CRYOTHERAPY Simple, rapid, inexpensive tissue destruction LN2 for seconds, typically two cycles 90%+ effective Hypopigmentation, hypertrophic scarring, alopecia, milia, tissue distortion

33 Topical Creams EFUDEX AKA 5-FLUOROURACIL IMIQUIMOD AKA ALDARA Superficial BCC, some SCCIS Superficial BCC, some nodular BCC, some SCCIS 85+% EFFICACY Up to 94% EFFICACY BID UNDER OCCLUSION 6-8 wks QD/BID 6-12 weeks (-): recurrence, patient administered (-): recurrence, patient administered, systemic like sxs, hypopigmentation

34 Electrodessication and Currettage

35 Electrodessication and Currettage Sup BCCs, small SCCIS Torso, extremities Will leave a scar not appropriate for cosmetically sensitive regions or patients Takes at least two weeks to heal Effective (93-99% cure rate)

36 Mohs Micrographic Surgery Described by Dr. Fredrick E. Mohs Tissue sparing skin cancer surgery most often reserved for the face Tissue specimen stained and mapped Micro - microscopic examination used to evaluate tumor margins graphic - tissue oriented and tumor is mapped Frozen section obtained 100% of tumor margin examined Surgeon is the pathologist

37 o Other locations include: hands, pretibial region, genitalia, feet, nail units, nipples/areola o Clinically larger skin cancers ( >1.5 cm) o Recurrent skin cancers o Aggressive pathologies

38 Several Ways of Checking Surgical Margins Traditional Vertical Sections Mohs en fas Sections Adapted from Rapini, JAAD 1990

39 Mohs Micrographic Surgery Tangential excision is used to remove the tissue specimen (saucerization) Tissue specimen stained and mapped Frozen section obtained 100% of tumor margin examined Surgeon is the pathologist

40 Five year Recurrence Rate for BCC Retrospective study Literature review since 1947 Method of treatment Primary Recurrent Cryotherapy C & E Excision Radiation All non-mohs modalities Mohs surgery 7.5% 7.7% 10.1% 8.7% 8.7% 1% 13% 40% 17.4% 9.8% 19.9% 5.6% Adapted from Rowe et al., J Dermatol Surg Oncol 1989

41 A FEW CLINICAL EXAMPLES (Permission from Dr. Annalisa K. Gorman) Reconstruction after Mohs Surgery

42 Full Thickness Skin Graft (Left) 5 wks post-op (Right)

43 Second Intention healing after Mohs

44 Second Intention 1 month post-op

45 Mohs Surgery reconstructed with CLC

46 Mohs Defect and 1 month post-op

47 Mohs Surgery reconstructed with CLC

48 1 month post-op

49 1 in 50 Americans Melanoma According to the American Cancer Society, cases estimated for 2017 : 87,110 new melanomas will be diagnosed 9,730 people are expected to die of melanoma Rate of melanoma diagnoses in WA state is 35% higher than national average from ; 5 th highest rate of melanoma in US (7) (7)

50 Melanoma and dysplastic Nevi Melanoma tumor of the pigment producing cells (melanocytes) A Asymmetry B Borders Irregular C Color DARK BLACK in color, multicolored, red and pigmented, change in color D Diameter least sensitive, > 5 mm E Evolving

51 Melanoma

52 Melanoma (Lentigo Maligna)

53 People under 45 account for 25% of all melanoma cases (5) Melanoma is the leading cause of cancer death in women ages and the second leading cause of cancer death in women ages (6) (5) (6) 5FactSheetUpdated pdf

54 MALIGNANT MELANOMA Family history, UV exposure (including tanning beds), blistering sunburns Redheads, freckles, blue eyes Depth at presentation indicates prognosis Melanoma In Situ: % 10 year survival rate < 1mm depth, no ulceration, no mitoses (IA)= 95% 10 year survival rate <1mm depth +/- ulceration, +/- mitoses (IB)=86% 10 year survival rate VS Stage 2 (depths 1.01mm-4 mm depth) 40-67%

55 Melanoma WLE Melanoma in situ 5 mm margins <1mm depth -1.0 cm margins Staged excisions Sentinel LN bx >1mm depth Consider >0.75 mm depth with ulceration or mitoses, young age

56 Dysplastic Nevi

57 THANK YOU

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