Cutaneous Malignancies: A Primer COPYRIGHT. Marissa Heller, M.D.
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1 Cutaneous Malignancies: A Primer Marissa Heller, M.D. Associate Director of Dermatologic Surgery Department of Dermatology Beth Israel Deaconess Medical Center December 10, 2016
2 Skin Cancer Non-melanoma skin cancer (NMSC) Basal cell carcinoma (BCC) Cutaneous squamous cell carcinoma (SCC) Malignant Melanoma skin cancer (MM) Rarer cutaneous malignancies Merkel Cell Carcinoma Dermatofibrosarcoma Protuberans Porocarcinoma Atypical Fibroxanthoma
3 NMSC: Diagnosis Most common forms of skin cancer (BCC>SCC) >2 million each year Sun-exposed areas face, ears, scalp, neck May appear anywhere vulvar, peri-anal Unlikely to metastasize Disfigurement from local destruction Definitive diagnosis with biopsy pathology
4 NMSC: Diagnosis Basal Cell Carcinoma (BCC) Most common form of skin cancer Basal layer of the epidermis and appendages <1% metastasize Types: Superficial, Nodular, Infiltrative
5 NMSC: Superficial BCC Erythematous scaly patch (mimics eczema)
6 NMSC: Superficial BCC
7 NMSC: Nodular BCC Shiny pearly papule, telangiectasias, ulceration
8 NMSC: Nodular BCC
9 NMSC: Nodular BCC
10 NMSC: Nodular BCC
11 NMSC: Nodular BCC
12 NMSC: Infiltrative BCC (Morpheaform, Micronodular) Scar like thickening
13 NMSC: Diagnosis Cutaneous squamous cell carcinoma (SCC) Second most common form of skin cancer Malignant proliferation of epidermal keratinocytes 1-5% may metastasize Actinic keratosis (AK) can be precursor Sun damage Rough gritty feel
14 Actinic Keratosis: Diagnosis
15 SCC: High risk SCC NMSC: Diagnosis Scalp, ears, nose, lips, genitalia In scars, ulcers, burns, sinus tracts Large neglected tumors Recurrent tumors Ionizing radiation, PUVA (psoralen and ultraviolet A light therapy), arsenic ingestion Immunosuppressed patients Older age, male sex
16 NMSC: Diagnosis SCC: Low risk SCC Small Do not invade From actinic keratoses or sun
17 NMSC: Diagnosis SCC Appearance is highly variable Erythematous scaly patch Eroded nodule Ulcerated plaque
18 NMSC: SCCIS
19 NMSC: SCCIS
20 NMSC: SCC
21 NMSC: SCC
22 NMSC: SCC
23 NMSC: SCC
24 NMSC: SCC
25 NMSC: SCC
26 NMSC: SCC
27 NMSC: Treatment Factors that affect treatment Size, location, pathology (aggressiveness) Tolerability, cost, patient preference If these rarely metastasize, why treat them?
28 NMSC: Treatment
29 NMSC: Treatment Types Electrodessication and curettage (ED&C) Surgical excision Mohs Micrographic Surgery Topical therapy Radiation therapy Newer therapy - vismodegib
30 NMSC: ED&C Site: trunk and extremities Cure rate: ~85% Pros: easy, fast, low cost, little down time Cons: scar, no pathologic cure
31 NMSC: Excision Site: trunk, extremities, small lesions on head/neck Cure rate: ~95% Pros: quick, pathologic surgical margins Cons: need to remove margin of normal tissue, two weeks of down time
32 NMSC: Mohs Micrographic Surgery Site: head & neck (cosmetically sensitive), high-risk of tumors on trunk and extremities Cure rate: ~99% Pros: tumor removal with minimal resection of normal tissue, analysis of 100% of margin Cons: time consuming, costly
33 NMSC: Mohs surgery
34 NMSC: Mohs Surgery
35 NMSC: Mohs Surgery
36 NMSC: Mohs Surgery
37 NMSC: Mohs Surgery Pics of Mohs
38 NMSC: Mohs Surgery
39 NMSC: Mohs Surgery
40 NMSC: Mohs Surgery
41 NMSC: Topical Therapy Imiquimod: 5% cream daily x 6-12 wks Toll-like receptor-7 agonist Enhances immune inflammatory response Site: superficial BCCs on trunk, extremities Patient: not a surgical candidate, f/u is assured
42 NMSC: Topical therapy 5-Flurouracil (5-FU): 5% cream bid x 3-6 wks Pyrimidine analog which interferes with DNA synthesis by inhibiting thymidylate synthetase Rapidly proliferating cells sensitive to cytotoxic effect Site: superficial BCCs on trunk, extremities Patient: not a surgical candidate, f/u is assured
43 NMSC: Topical therapy Pros: minimal scarring, for poor surgical candidates Cons: lower cure rate, only treats superficial lesions well
44 NMSC: Other therapies Radiation Adjuvant therapy for aggressive lesions Primary therapy for poor surgical candidates Erivedge (vismodegib) Metastatic BCC or locally advanced BCC, in patients who are not surgical candidates Daily pill that inhibits the Hedgehog pathway which is active in BCC
45 NMSC: Follow-up Excellent prognosis ~20% new primary within 1 yr ~40% new primary within 5 yrs Q6 month total body skin exam (TBSE) Q1 month self examination
46 NMSC: Take Home Points Variable appearance Treatment usually surgical Early detection
47 MM: Diagnosis Most serious form of skin cancer Potentially fatal Poor treatment for advanced disease Early detection is key
48 MM: Diagnosis ABCDE A = Asymmetry B = Border irregularity C = Color variability D = Diameter >6mm
49 E = Evolution MM: Diagnosis ABCDE Ref: Abbasi NR, et al. JAMA 292:2771, 2004
50 MM: Diagnosis Ugly duckling sign Dermoscopy Polarized light in 10x lens
51 MM: Diagnosis Subtypes Superficial spreading: ~70% Nodular melanoma: ~15% Lentigo maligna: ~10% Acral lentiginous melanoma: ~5%
52 MM: Superficial Spreading
53 MM: Superficial Spreading
54 MM: Superficial Spreading
55 MM: Nodular Bolognia
56 MM: Lentigo Maligna
57 MM: Acral Lentiginous Bolognia
58 MM: Acral Lentiginous
59 MM: Acral Lentiginous
60 MM: Diagnosis
61 MM: Diagnosis
62 MM: Diagnosis
63 MM: Diagnosis
64 MM: Diagnosis
65 MM: Diagnosis C P O G I R Y T H
66 MM: Treatment Stage 0: MMIS, epidermis only Stage I: low risk 1a: <1mm, no ulceration, no mitoses 1b: <1mm, ulceration or at least 1 mitosis/mm2 Stage II: higher risk, >1mm Stage III: involvement of LN pathologically, unknown primary Stage IV: distant metastases
67 MM: Treatment Surgical excision Margins depend on stage Baseline CXR, CBC, LDH Risk of recurrence and death is closely related to the stage at presentation
68 MM: Treatment Stage 0: MMIS on trunk/extremities Surgical excision with 5mm margins Stage 0: MMIS (lentigo maligna) on head/neck Staged excision ( slow Mohs ) Evaluation of margins by dermatopathologist
69 MMIS: Staged Excision
70 MM: Treatment Stage 1B and higher Referral to Cutaneous Oncology Program Potential adjuvant therapies include: Sentinel lymph node biopsy Radiation therapy Chemotherapy Interferon alpha Zelboraf (vemurafenib)» For metastatic or unresectable tumors that express gene mutation BRAF V600E (approx ½ patients)» BRAF inhibitor blocks the function of mutated protein» Companion diagnostic test cobas 4800 BRAF V600
71 MM: Follow-up Risk of recurrence of primary melanoma Increased risk of second primary melanoma Initial TBSE every 3-4 months Pigmented Lesion Clinic Patients: history of MM or many moles (atypical) Digital total body photography as an objective baseline to track atypical lesions over time Cutaneous Oncology Program
72 MM: Take Home Points ABCDE Treatment is surgical Early detection can save a life
73 Skin Cancer Prevention: Education Broad spectrum sunscreen (UVA & UVB) Avoid midday sun No sun burns, no tanning beds
74 Skin Cancer Prevention: Education Sun glasses Sun protective clothing Broad brimmed hat
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