Skin Cancer. 5 Warning Signs. American Osteopathic College of Occupational and Preventive Medicine OMED 2012, San Diego, Monday, October 8, 2012 C-1

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1 Skin Cancer AMERICAN OSTEOPATHIC COLLEGE OF OCCUPATIONAL & PREVENTIVE MEDICINE OMED 2012 October 8, 2012 E. Robert Wanat II, D.O., M.P.H. Learning Objectives: Identify the 3 Basic Types of Skin Cancer Understand the Risk Factors for Skin Cancer Describe Common Treatments for Skin Cancer Describe Common Prevention Strategies for Skin Cancer 3 Basic Types of Skin Cancer Occupational Exposure to UV o Basal Cell Carcinoma o Squamous Cell Carcinoma o Malignant Melanoma Basal Cell Carcinoma [BCC] Most common skin cancer Most common form of any cancer > 1 of every 3 new cancers are skin cancer ~2.8 million cases BCC/year in U.S. Usually caused by Cumulative UV exposure & Occasional Intense UV exposure Highly disfiguring if untreated Almost Never Spreads 5 Warning Signs Open Sores Red Patches Pink Growths Shiny Bumps Scars C-1

2 Basal Cell Open Sore Basal Cell Red Patch Basal Cell Pink Growth Basal Cell Shiny Bump/Nodule Basal Cell Scar Like Area Treatment Easily Treated in Early Stages Late Stages Significant Destruction and Disfigurement Skin Graft or Flap may be required C-2

Squamous Cell Carcinoma [SCC] Squamous Cell Carcinoma 2 nd Most Common Skin Cancer Cumulative UV exposure over lifetime Deadly if undiagnosed and untreated ~ 700,000 cases annually ~ 2,500 deaths

3 Squamous Cell Carcinoma [SCC] Squamous Cell Carcinoma 2 nd Most Common Skin Cancer Cumulative UV exposure over lifetime Deadly if undiagnosed and untreated ~ 700,000 cases annually ~ 2,500 deaths annually May occur on any area of the body Most common on sun exposed areas More common in people with: Fair skin & light hair and eye color Occupations requiring long hours outdoors Sun Worshipers Prior Basal Cell Carcinoma Inherited Disorders with increased UV sensitivity [e.g. xeroderma pigmentosum] Squamous Cell Carcinoma Causes 2X higher in men Rare < 50 years old Usually seen 70 s or older Most common Skin Cancer in African Americans # 1. Chronic sun/tanning bed exposure Skin Injuries Chronic Skin Infection & Inflammation Immunodeficency Precancers Actinic Keratoses Actinic Cheilitis Leukoplakia Bowen s Disease Warning Signs - Appearance Squamous Cell Red Scaly Patch Red Scaly Patch Elevated and Crusted Persistent Open Bleeding Sore Wart like appearance C-3

Squamous Cell Raised & Crusted Squamous Cell Open & Bleeds Squamous Cell Wart Like Treatment Early Diagnosis & Treatment almost always curable Late Diagnosis &

Excisional Biopsy [~92% cure 1 o & 77% cure recurrent] Mohs Micrographic Surgery [94 99% cure rate] Curettage & Electrodesiccation (Electrosurgery) Cryosurgery [95%

: 5 FU & Imiquimod [being tested] Most Dangerous/Fatal Skin Cancer UV damages DNA in melanocytes [pigment making cells] Damaged cells rapidly reproduce and spread

4 Squamous Cell Raised & Crusted Squamous Cell Open & Bleeds Squamous Cell Wart Like Treatment Early Diagnosis & Treatment almost always curable Late Diagnosis & Treatment disfiguring & 2 10% fatal Treatment choice is based on: Type, Size, Location & Depth of tumor Age General Health Types of Treatment Malignant Melanoma Excisional Biopsy [~92% cure 1 o & 77% cure recurrent] Mohs Micrographic Surgery [94 99% cure rate] Curettage & Electrodesiccation (Electrosurgery) Cryosurgery [95% + 5 year cure rate] Radiation [85 95% cure rate] Photodynamic Therapy [not yet FDA approved for SCC] Laser Surgery [not yet FDA approved for SCC] Topical Meds.: 5 FU & Imiquimod [being tested] Most Dangerous/Fatal Skin Cancer UV damages DNA in melanocytes [pigment making cells] Damaged cells rapidly reproduce and spread Early diagnosis curable Late diagnosis often fatal [~8,790 deaths annually] ~ 120,000 new cases/yr. & ~68,130 cases were invasive 38,870 cases in males & 29,260 cases in females C-4

5 Melanoma Risk Factors: Know Your ABCDE s Sun &/or Tanning Bed Exposure Asymmetry Moles Border irregular Skin Type Color varies in lesion Personal History/Heredity Diameter usually > pencil eraser [1/4 or 6 mm] Weakened Immune System Evolving Any Change points to danger Asymmetry Border Color Diameter C-5

Evolving Four Basic Types of Melanoma 3 Types start in situ localized to the skin s top layers

lentiginous melanoma under nails, palms & soles 4th Type usually starts out as invasive Nodular

Lintiginous [oral & genital] New Staging System in 2010 Desmoplastic Incorporates new findings

6 Evolving Four Basic Types of Melanoma 3 Types start in situ localized to the skin s top layers Superficial Spreading most common [~70%] in young Lentigo meligna most common in elderly Acral lentiginous melanoma under nails, palms & soles 4th Type usually starts out as invasive Nodular melanoma recognized when nodule appears Unusual Types of Melanoma Melanoma Staging Mucosal Lintiginous [oral & genital] New Staging System in 2010 Desmoplastic Incorporates new findings about melanoma and will: Provide a more accurate diagnosis & Verucous Determination of prognosis C-6

7 Am. Joint Committee on Cancer AJCC Staging Information for Melanoma Clark Classification [Level of Invasion] Level I: involves only epidermis [in situ melanoma] Level II: invades papillary dermis but not papillary-reticular dermal interface Malignant Melanoma Staging by TMN Classification Level III: expands papillary dermis but does not penetrate reticular dermis Primary Tumor [T] Level IV: invades reticular dermis but not into subcutaneous tissue Distant Metastasis [M] Regional Lymph Nodes [N] Level V: invades through the reticular dermis into subcutaneous tissue Breslow Classification [Thickness] Primary Tumor [T] Regional Lymph Nodes [N] TX 1o cannot be assessed T0 No evidence of 1o tumor NX nodes cannot be assessed Tis Melanoma in situ No regional metastasis T1-1mm thickness N1-3 based on # nodes & presence/absence of intralymphatic metastasis T1a w/o ulcer & mitosis < 1/mm2 N1 1 metastatic node: a micrometastsis b macro T1b w/ ulcer or mitosis 1/mm2 T mm thickness: N2 2 3 nodes: a micrometastisis b macrometastasis a w/o ulcer, b w/ ulcer T mm thickness: N3-4 nodes or matted nodes or in transit met(s)/ satellite(s) with metastatic node(s) a w/o ulcer, b w/ ulcer T4 - > 4 mm thickness: a w/o ulcer, b w/ ulcer Distant Metastasis (M) Melanoma Clinical Staging Stage 0 Tis Stage IA T1a Stage IB T1b T2a T2b T3a T3b T4a Stage IIC T4b Stage III Any T N1 Stage IV Any t Any N M1 none detected Stage IIA M1a skin, subcutaneous, or distant lymph nodes M1b lung Stage IIB M1c any other visceral site or any site combined with increased LDH C-7

8 Stage 0 Stage III Tis,, excision w/ minimal but microscopically free margins Any T; N1, N2, N3; Stage I Standard Treatment Options T1a, T1b, T2a;, radial excision with 1 cm margins Wide local excision 1 3 cm margins Stage II High dose pegylated interferon high risk for relapse T2b, T3a, T3b, T4a, T4b;, Thickness 2 4 mm Ipilimumab for unresectable disease Surgical margins 2 cm Vemurafenib for unresectable dz & + BRAFV600 mutation Adjuvant treatment post resection not shown to improve survival Stage IV and Recurrent Melanoma Any T, any N, M1 Resected Stage III Adjuvant Treatment Options Standard Treatment Options High-dose interferon Immunotherapy Pegylated Interferon Ipilimumab Unresectable Stage III Adjuvant Treatment Options Interleukin-2 [IL-2] Ipilimumab Signal transduction inhibitors Vermurafenib Vemurafenib [+ for BRAF600 mutation] Local Tx for extremity melanoma [Stage IIIC] Chemotherapy Treatment Options Under Clinical Evaluation Response rates 10 20% Usually short lived [3-6 months] Skin Cancer Prevention Overview for Stage IV and Recurrent Melanoma Always Easier, Cheaper and Better than Treatment Palliative Local Therapy Keep newborns/infants out of sun Metastasis to distant lymph node-bearing areas Stay in the Shade [10 AM 4 PM] Regional lymphadenectomy may be palliative Don t Burn Isolated Metastasis to lung, GI, bone, brain Resection may be palliative Avoid Tanning Booths/Salons Occasional long-term survival Cover UP Palliative Radiation Use UVA/UVB Sunscreen SPF A relatively radiation resistant tumor Monthly self-exam & Annual Skin Exam May achieve symptom relief and some tumor shrinkage C-8

9 Resources Skin Cancer Foundation: Robert M. Adams, M.D.; Occupational Skin Disease Questions? National Cancer Institute: [PDQ ]. Bethesda, MD: National Cancer Institute. Date last modified <05/11/2012> Available at: HealthProfessional. Accessed <09/26/2012 C-9

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