Skin Cancer of the Nose: Common and Uncommon Mark Russell, M.D. Associate Professor of Dermatology, Otolaryngology, and Pathology University of Virginia
Objectives Review clinical presentations of select nasal skin cancers Display common nasal defects after tumor extirpation
Skin Cancers of the Head and Neck Common Actinic keratosis (AK) Squamous cell carcinoma (SCC) Basal cell carcinoma (BCC) Melanoma (MM) Uncommon Atypical fibroxanthoma (AFX) Merkel cell carcinoma (MCC) Sebaceous carcinoma (SebCa) Angiosarcoma (AS)
Best Diagnosis: A. SCC B. AK C. BCC D. SebCa E. Angiosarcoma 0% 0% 0% 0% 0% SCC AK BCC MAC Angiosarcoma
Actinic Keratosis
Actinic Keratoses
Actinic Keratosis
Best Diagnosis: A. SCC B. AK C. AFX D. SebCa E. Angiosarcoma 0% 0% 0% 0% 0% SCC AK AFX MAC Angiosarcoma
SCC in situ
SCC, well differentiated
SCC, mod differentiated
SCC
SCC, poorly differentiated
SCC, poorly differentiated
Squamous Cell Carcinoma
Diagnosis: A. SCC B. Angiosarcoma C. SebCA D. MCC E. Keratoacanthoma 0% 0% 0% 0% 0% DFSP MAC SebCA MCC BCC
Keratoacanthoma Rapid growth (weeks) Usually males >50 Spontaneous regression over several months Differentiation from SCC often difficult
Diagnosis: A. Angiosarcoma B. MAC C. SebCA D. MCC E. BCC 0% 0% 0% 0% 0% DFSP MAC SebCA MCC BCC
Hugh Jackman Treated for Skin Cancer November 2013 Please don't be foolish like me. Get yourself checked. And USE sunscreen!!! Jackman urged his fans, while sharing an Instagram photo of his bandaged nose.
Hugh Jackman's Skin Cancer Returns; Actor Receives Treatment For Basal Cell Carcinoma Huffington Post 5/8/2014 "Another Basel Cell Carcinoma. All out now. Thanks Dr. Albom and Dr. Arian," Jackman wrote on Instagram. "PLEASE! PLEASE! WEAR SUNSCREEN!
Hugh Jackman Treated for Skin Cancer on His Nose for the Fourth Time 2/8/16 "An example of what happens when you don't wear sunscreen. Basal Cell. The mildest form of cancer but serious, nonetheless. PLEASE USE SUNSCREEN and get regular check-ups."
Hugh Jackman reveals another skin cancer treatment. CNN 2/14/17 "Another basal cell carcinoma. Thanks to frequent body checks and amazing doctors, all is well. Looks worse with the dressing on than off. I swear! #wearsunscreen"
Figure 1. Google Trends graph from May 6, 2012, to May 6, 2017 showing the search pattern for basal cell carcinoma. The dates of Hugh Jackman s announcements of his surgeries are highlighted in red. Dermatologic Surgery. 44(7):1039 1040, JUL 2018
BCC Histologic Subtypes Indolent Superficial Nodular Aggressive Micronodular Infiltrative Morpheaform Squamous diff Dermatol Pract Concept. 2012 Jul; 2(3).
BCC, superficial
Basal Cell Carcinoma, nodular
BCC, infiltrative
BCC, micronodular
BCC, morpheaform
BCC, Pigmented
Suggested excisional margins for cutaneous malignant lesions based on Mohs micrographic surgery. Schell AE, Russell MA, Park SS. JAMA Facial Plast Surg. 2013 Sep-Oct;15(5):337-43.
Assessing BCC Size The basics Proper exposure Clean skin (e.g. 70% isopropyl alcohol) Bright light Magnification
Normal pilosebaceous Absent pilosebaceous Normal pilosebaceous
BCC engulfing a hair follicle
Conclusions Efficient surgical treatment of BCC relies on accurate assessment of tumor extent. Loss of vellus hair follicles may help delineate BCC, which may reduce positive margins.
How Fast Do BCC s Grow?
BCC 47 years old 62 years old 69 years old Surgery 2001;130:90-2.
BCC 74 years old Surgery 2001;130:90-2.
Diagnosis A. AFX B. Angiosarcoma C. Melanoma D. SebCa E. MCC 0% 0% 0% 0% 0% AFX MCC elanoma MAC DFSP
Melanoma 0.5% of cutaneous melanomas occur on the nose
Lentigo Maligna
Melanoma May arise from pre-existing nevus or lentigo Predominantly occur in the elderly Malignancy of melanocytes
Melanoma
Melanoma
Melanoma, Amelanotic
Diagnosis: A. SebCA B. AFX C. BCC D. Angiosarcoma E. MCC 0% 0% 0% 0% 0% SebCA AFX MAC Angiosarcoma MCC
Anatomic distribution of 140 cases of atypical fibroxanthoma. Cancer 1973;31:1541 52.
AFX
AFX
Diagnosis: A. MCC B. BCC C. Angiosarcoma D. Seb Ca E. SCC 0% 0% 0% 0% 0% MCC BCC Angiosarcoma MAC DFSP
Merkel Cell Carcinoma Primary neuroendocrine skin tumor Derived from Merkel cells, which are neurotactile cells of epithelial origin with neuroendocrine features
Why is MCC important? More lethal than melanoma 46% mortality (~15% for melanoma) Reported incidence increasing Quadrupled from 1986-2013 ~ 2,000 new cases/yr in USA A polyomavirus is associated with MCC Treatment options SLNB Excision XRT Immunotherapy avelumab or pembrolizumab
Merkel Cell Carcinoma
Merkel Cell Carcinoma
Diagnosis: A. SCC B. MCC C. SebCA D. Angiosarcoma E. BCC MAC 0% 0% 0% 0% 0% JAMA Otolaryngol Head Neck Surg. 2014;140(3):267-268. MCC SebCA iosarcoma Chalazion
Seb Ca Acta Derm Venereol. 2011 May;91(3):367-8
Sebaceous Carcinoma Hoffmann M, Braun-Falco M. Rhinophyma-like sebaceous carcinoma. J Eur Acad Dermatol Venereol. 2009 Oct;23(10):1216-8.
Diagnosis: A. Melanoma B. rhinophyma C. BCC D. Angiosarcoma E. AFX 0% 0% 0% 0% 0% Melanoma DFSP MAC Angiosarcoma AFX
Angiosarcoma
Angiosarcoma J Am Acad Dermatol. 2006 May;54(5):883-5
Angiosarcoma mimicking rhinophyma. Dermatol Res Pract. 2010;2010:365173.
Angiosarcoma mimicking hemangioma J Cutan Pathol. 2018 May 15. doi: 10.1111/cup.13275.