Skin Malignancies Non - Melanoma & Melanoma Marilyn Ng, MD Dept. of Surgery M&M Conference Downstate Medical Center July 19, 2012

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1 Skin Malignancies Non - Melanoma & Melanoma Marilyn Ng, MD Dept. of Surgery M&M Conference Downstate Medical Center July 19, 2012

2 Case Presentation 57 yo man with 3 month hx of a nonhealing < 1 cm right arm erythematous plaque Punch biopsy path: superficial squamous cell carcinoma

3 Case Presentation PMHx: asthma, GERD, childhood sun exposure, s/p colonoscopy SHx: s/p biopsy (6/12) left flank basal cell carcinoma, superficial type FamHx: melanoma (mother) SocHx: 20+ pack-yr hx

4 On Physical Exam Vitals: normal Skin: s/p punch bx site 8 cm inferior to right deltoid muscle Chest: Clear bilateral Abd: no palpable masses Lymph node: No LAD

5 Re Excision 1 cm margins 3 : 1 ratio IOFS before closure

6 Skin Cancer Non Melanoma Skin Cancer (NMSC) Basal Cell Carcinoma (BCC) Squamous Cell Carcinoma (SCC) Cutaneous Melanoma Conclusion

7 Basal Cell Carcinoma 2 million cases NMSC per year BCC 5 times more common than SCC Onset: 40 years Males > females Etiology: UVB spectrum

8 NMSC Clinical Risk Factors Fair skinned patients Cumulative sun exposure Immunosuppression status Genetic syndromes Albinism, xeroderma pigmentosum

9 BCC Distribution 90% occur in the face Isolated single lesion Danger sites: Canthi Nasolabial fold Behind ears

10 BCC Clinical Types Nodular: well defined pearly firm papule or nodule with telangiectasia Ulcerating: crusted ulcer with rolled border (rodent ulcer) Pigmented: brown, blue or black, smooth, hard lesion

11 BCC Clinical Types Sclerosing: infiltrating type; small patch of morphea or superficial scar Superficial multicentric: thin plaques; fine threadlike border & telangiecstasia; considerable scaling

13 BCC Prognosis Rarely metastatic, but causes substantial local destruction 50% local recurrences in first 2 yrs Local control 95% for primary cases & 83% for recurrent low-risk cases Mohs cure rate 98% for primary & 98% for recurrences for high-risk cases

14 SQUAMOUS CELL CANCER

15 Bowen Disease Caused by UVR or HPV infection Precursor lesions: Actinic keratoses HPV induced squamous lesions (SIL) Untreated lesions invasive SCC Metastasize to lymph nodes

16 Bowen Disease

18 Invasive SCC Onset: > 55 yrs in the U.S. Age yrs if living in Sunbelt, Australia, New Zealand Incidence: 7-12 : 100,000 Sex: males > females

19 SCC Appearance Invasive SCC rapidly evolve and often tender Keratinous crust over an erythematous thick base

20 SCC Types Highly differentiated Hyperkeratosis Firm or hard upon palpation Poorly differentiated Fleshy, granulomatous & soft to palpation Bleeds easily

21 SCC Etiology Exposure: sunlight, phototherapy, PUVA, ionizing radiation Outdoor occupations Human papillomavirus Oncogenic HPV type-33, -35,- 39, -40, -51, -60

22 SCC Etiology Immunosuppression Chronic inflammation Industrial carcinogens Inorganic arsenic Historic treatment of psoriasis

23 SCC in Immunosuppression 40-50x increased incidence of SCC Tumors grow rapidly & aggressively AIDS pts have only 4 fold SCC risk Skin type Risk Factors Cumulative sun exposure Age at transplantation Male sex HPV infections Degree & length of immunosuppression Immunosuppressant type

24 SCC Metastatic Rate Percentage, % Occurrence

27 Surgical Margins

28 NMSC Management Therapy Indication Response Electrodissection & Curettage Low-risk lesion < 1 cm Superficial 95% local control Cryotherapy Lesion < 1 cm 8-13% recurrence Chemotherapy (5-FU, imiquimod) Radiation Therapy Low-risk BCC in pts refusing or not fit for surgery BCC and SCC Adjuvant for high-risk lesions Lymph node metastasis 80% cure, superficial BCC 66% cure, nodular BCC 91-93% local control for primary lesions 86-91% local control for recurrent lesions

29 Mohs Microscopic Surgery

30 Surgical Excision Excise oncologic specimen before planning closure Incision down to deep fascia Intra-operative frozen section V-Y closure, rotation flap, transposition flap, or advancement flap

31 NMSC Follow - Up Exam at least every 3 to 6 months for first 2 years Every 6 to 12 months for the 3 rd year Annually thereafter Encourage sunscreen and protection

32 CUTANEOUS MELANOMA

33 Melanoma Epidemiology Melanocytes 68,130 new cases; 8,700 deaths (U.S., 2010) Accounts for 5% of all cancers and 80% of deaths from skin cancer Median age at presentation: yrs

34 20x

36 Melanoma Distribution

37 Melanoma Risk Factors Fair complexion, severe sunburns, intermittent doses of radiation Xeroderma pigmentosum, family history of melanoma and/or NMSC, dysplastic nevi syndrome Aging and carcinogen exposure

39 Management History & skin exam Punch or excisional biopsy Full thickness biopsy with margin of normal skin

40 Breslow Classification

45 Sentinel Lymph Node Biopsy First described by Dr. Morton 5-year survival rate was 72% SLN(+) and 90% SLN (-) Complication rate 10% Lymphedema 1%

47 Poor prognostic factors Thick tumors, ulceration, mitotic level, macrometastasis, positive LN, LDH

48 Melanoma Follow - Up

49 Recurrence Local & Regional (5 cm radius) Resection with clear histological margins Intralesional injection BCG or interferon Isolated hyperthermic limb perfusion (IHLP) Nodal: FNA, metastatic w/u, if + CLND Interferon α2b for resected Stage IIB - III

50 Survival Median survival (stage IV) 7 to 8 mos, 5% 5-yr survival MC distant metastasis to lung, brain, liver, bone and GI tract Radiation therapy

53 The Skinny BCC is the most common malignancy in the United States Low metastatic potential in SCC High incidence of SCC in transplant patients Melanoma accounts for 80% of skin cancer deaths

54 Which of the following statements about basal cell carcinoma is TRUE? A. Can cause local tissue destruction if left untreated B. No role for radiation therapy C. Metastasis common D. Superficial the most common type E. 1.0 cm margin optimal

Treatment is surgical excision with 1 cm margin C.

55 Which of the following statements about squamous cell carcinoma is TRUE? A. More common than basal cell B. Treatment is surgical excision with 1 cm margin C. Impaired cell mediated immunity a cause D. No role for radiation therapy E. Lower mortality rate than basal cell

56 Which of the following is the most significant prognostic factor for patients with node-positive (stage III) melanoma? A. Nodal size B. Number of involved lymph nodes C. Tumor thickness D. Tumor ulceration E. Patient gender

57 References Cameron et al. Current Surgical Therapy, 10 th Ed, pp Grotz TE, et al. May0 Clinic Consensus Recommendations for the Depth of Excision in Primary Cutaneous Melanoma. Mayo Clin Proc. 2011;86(6): Morton DL etal. Sentinel-Node Biopsy or Nodal Observation in Melanoma. N Engl J Med 2006;355: A Snapshot of Melanoma. National Health Institute. NCCN Clinical Practice Guidelines in Oncology. Basal Cell and Squamous Cell Skin Cancers. Version NCCN Clinical Practice Guidelines in Oncology. Melanoma. Version Wolff K, Johnson, RA: Fitzpatrick s Color Atlas and Synopsis of Clinical Dermatology, 6 th Edition.

Clinical characteristics

Skin Cancer Fernando Vega, MD Seattle Healing Arts Clinical characteristics Precancerous lesions Common skin cancers ACTINIC KERATOSIS Precancerous skin lesions Actinic keratoses Dysplastic melanocytic