Cutaneous Malignancies: A Primer Marissa Heller, M.D. Associate Director of Dermatologic Surgery Department of Dermatology Beth Israel Deaconess Medical Center December 10, 2016
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
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
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
NMSC: Superficial BCC Erythematous scaly patch (mimics eczema)
NMSC: Superficial BCC
NMSC: Nodular BCC Shiny pearly papule, telangiectasias, ulceration
NMSC: Nodular BCC
NMSC: Nodular BCC
NMSC: Nodular BCC
NMSC: Nodular BCC
NMSC: Infiltrative BCC (Morpheaform, Micronodular) Scar like thickening
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
Actinic Keratosis: Diagnosis
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
NMSC: Diagnosis SCC: Low risk SCC Small Do not invade From actinic keratoses or sun
NMSC: Diagnosis SCC Appearance is highly variable Erythematous scaly patch Eroded nodule Ulcerated plaque
NMSC: SCCIS
NMSC: SCCIS
NMSC: SCC
NMSC: SCC
NMSC: SCC
NMSC: SCC
NMSC: SCC
NMSC: SCC
NMSC: SCC
NMSC: Treatment Factors that affect treatment Size, location, pathology (aggressiveness) Tolerability, cost, patient preference If these rarely metastasize, why treat them?
NMSC: Treatment
NMSC: Treatment Types Electrodessication and curettage (ED&C) Surgical excision Mohs Micrographic Surgery Topical therapy Radiation therapy Newer therapy - vismodegib
NMSC: ED&C Site: trunk and extremities Cure rate: ~85% Pros: easy, fast, low cost, little down time Cons: scar, no pathologic cure
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
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
NMSC: Mohs surgery
NMSC: Mohs Surgery
NMSC: Mohs Surgery 4 1 3 2
NMSC: Mohs Surgery 4 1 3 2
NMSC: Mohs Surgery Pics of Mohs
NMSC: Mohs Surgery
NMSC: Mohs Surgery
NMSC: Mohs Surgery
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
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
NMSC: Topical therapy Pros: minimal scarring, for poor surgical candidates Cons: lower cure rate, only treats superficial lesions well
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
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
NMSC: Take Home Points Variable appearance Treatment usually surgical Early detection
MM: Diagnosis Most serious form of skin cancer Potentially fatal Poor treatment for advanced disease Early detection is key
MM: Diagnosis ABCDE A = Asymmetry B = Border irregularity C = Color variability D = Diameter >6mm
E = Evolution MM: Diagnosis ABCDE Ref: Abbasi NR, et al. JAMA 292:2771, 2004
MM: Diagnosis Ugly duckling sign Dermoscopy Polarized light in 10x lens
MM: Diagnosis Subtypes Superficial spreading: ~70% Nodular melanoma: ~15% Lentigo maligna: ~10% Acral lentiginous melanoma: ~5%
MM: Superficial Spreading
MM: Superficial Spreading
MM: Superficial Spreading
MM: Nodular Bolognia
MM: Lentigo Maligna
MM: Acral Lentiginous Bolognia
MM: Acral Lentiginous
MM: Acral Lentiginous
MM: Diagnosis
MM: Diagnosis
MM: Diagnosis
MM: Diagnosis
MM: Diagnosis
MM: Diagnosis C P O G I R Y T H
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
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
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
MMIS: Staged Excision
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
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
MM: Take Home Points ABCDE Treatment is surgical Early detection can save a life
Skin Cancer Prevention: Education Broad spectrum sunscreen (UVA & UVB) Avoid midday sun No sun burns, no tanning beds
Skin Cancer Prevention: Education Sun glasses Sun protective clothing Broad brimmed hat