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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