Skin Cancer 101: Diagnosis and Management of the Most Common Cancer

Skin Cancer 101: Diagnosis and Management of the Most Common Cancer Sarah Patton, PA-C, MSHS Skin Surgery Center www.skinsurgerycenter.com Seattle/Bellevue, WA

Skin cancer Skin cancer is by far the most common type of malignant tumors in humans Each year there are more new cases of skin cancer than the combined incidence of cancers of the breast, prostate, lung and colon1 1 in 50 men and women will be diagnosed with melanoma of the skin during their lifetime2 1 American Cancer Society. Cancer Facts a& Figures 2012 http://www.cancer.org/acs/groups/content/@epdemiologysurveilance/documents-0319.2012 2 http://seer.cancer.gov/statfacts/html/melan.html

Risk Factors At least 90% of skin cancers are caused by UV radiation UVR (ultraviolet radiation) is a PROVEN HUMAN CARCINOGEN SPF, hats, clothing

TANNING BEDS TANNING BEDS SIGNIFICANTLY INCREASE YOUR RISK FOR ALL TYPES OF SKIN CANCER

Tanning Beds People who tan indoors are: 74 percent more likely to develop melanoma 3 2.5 times more likely to develop squamous cell carcinoma 1.5 times more likely to develop basal cell carcinoma 4 3 Lazovich D, Vogel RI, Berwick M, Weinstock MA, Anderson KE, Warshaw EM. Indoor tanning and risk of melanoma: a casecontrol study in a highly exposed population. Cancer Epidem Biopmar Prev 2010 June: 19 (6): 1557-1568. 4 Karagas MR, Stannard VA, Mott LA, Slattery MJ, Spencer SK, and Weinstock MA. Use of tanning devices and risk of basal cell. and squamous cell skin cancers. J Natl Cancer Inst 2002; 94 (3): 224-226.

Skin Cancer Risk Factors HPV Radiation Smoking Genes (XP, BCNS) Chronic Ulcers/Inflammation Burns Arsenic, coal tar Weakened immune system

Examples of SUN Damage

Patient Risk Factors Blonde/red hair Light (blue/green eyes) Easily burns/hx of sunburns Fam hx of skin CA Personal hx of Skin CA/Pre-cancers Hx of excessive UV exposure

Basal Cell Carcinoma Arises from basal cells of the epidermis 4 MILLION cases diagnosed annually in the US Presentations include: pink pearly papule pink scaling patches non-healing lesions pimple that doesn t heal pigmented macules or papules white-scar like Slow growing Tips: nose, ears, medial canthus, shoulders, chest, vermillion border

Basal Cell Cancer

Nodular Basal Cell Carcinoma Hair bearing skin More than half of BCCs are nodular Clinically they are typically slow growing, pearly nodules with rolled borders, telangiectasias

Pigmented BCC Brown eyed individuals and others Difficult to differentiate from melanomas at times

Superficial Basal Cell Carcinoma

Morpheaform Basal Cell Carcioma Clinically appears as a scar Most aggressive of BCC s Accounts for 5% of all BCC s Can invade into muscle and fat

Morpheaform BCC

Morpheaform Basal Cell Carcinoma RARELY may metastasize

Squamous Cell Carcinoma Arises from keratinocytes in the epidermis 1 million diagnosed each year in the US Types include SCCIS, invasive, KAs Potential to metastasize (not in SCC in Situ) Etiology UV light (predominant) X-Ray Chemicals, i.e. arsenic Burns(fire) Chronic ulcers or other sites of chronic inflammation

Squamous Cell Carcinoma in Situ Clinically Sharply marginated erythematous scaling/crusting Does not metastasize*

Risk Factors for SCC to metastasize Location lower lip, ear, temple Formation in scar Large size Immunosuppressed patients

Squamous Cell Carcinoma

SCC Invading Bone

Squamous Cell Carcinoma (Keratoacanthoma Type) Symmetric, red nodule with ulceration centrally Low grade SCC Often painful Rapid growth Increased incidence in transplant patients Low metastatic rate

Treatment options for Basal Cell and Squamous Cell Carcinoma

Treatment of BCC/SCC Cryotherapy Electrodessication and Curettage Radiation Topical Chemotherapy Photodynamic Therapy Traditional Surgical Excision Mohs Micrographic Surgery

CRYOTHERAPY Simple, rapid, inexpensive tissue destruction LN2 for 40-60 seconds, typically two cycles 90%+ effective Hypopigmentation, hypertrophic scarring, alopecia, milia, tissue distortion

Topical Creams EFUDEX AKA 5-FLUOROURACIL IMIQUIMOD AKA ALDARA Superficial BCC, some SCCIS Superficial BCC, some nodular BCC, some SCCIS 85+% EFFICACY Up to 94% EFFICACY BID UNDER OCCLUSION 6-8 wks QD/BID 6-12 weeks (-): recurrence, patient administered (-): recurrence, patient administered, systemic like sxs, hypopigmentation

Electrodessication and Currettage

Electrodessication and Currettage Sup BCCs, small SCCIS Torso, extremities Will leave a scar not appropriate for cosmetically sensitive regions or patients Takes at least two weeks to heal Effective (93-99% cure rate)

Mohs Micrographic Surgery Described by Dr. Fredrick E. Mohs Tissue sparing skin cancer surgery most often reserved for the face Tissue specimen stained and mapped Micro - microscopic examination used to evaluate tumor margins graphic - tissue oriented and tumor is mapped Frozen section obtained 100% of tumor margin examined Surgeon is the pathologist

o Other locations include: hands, pretibial region, genitalia, feet, nail units, nipples/areola o Clinically larger skin cancers ( >1.5 cm) o Recurrent skin cancers o Aggressive pathologies

Several Ways of Checking Surgical Margins Traditional Vertical Sections Mohs en fas Sections Adapted from Rapini, JAAD 1990

Mohs Micrographic Surgery Tangential excision is used to remove the tissue specimen (saucerization) Tissue specimen stained and mapped Frozen section obtained 100% of tumor margin examined Surgeon is the pathologist

Five year Recurrence Rate for BCC Retrospective study Literature review since 1947 Method of treatment Primary Recurrent Cryotherapy C & E Excision Radiation All non-mohs modalities Mohs surgery 7.5% 7.7% 10.1% 8.7% 8.7% 1% 13% 40% 17.4% 9.8% 19.9% 5.6% Adapted from Rowe et al., J Dermatol Surg Oncol 1989

A FEW CLINICAL EXAMPLES (Permission from Dr. Annalisa K. Gorman) Reconstruction after Mohs Surgery

Full Thickness Skin Graft (Left) 5 wks post-op (Right)

Second Intention healing after Mohs

Second Intention 1 month post-op

Mohs Surgery reconstructed with CLC

Mohs Defect and 1 month post-op

Mohs Surgery reconstructed with CLC

1 month post-op

1 in 50 Americans Melanoma According to the American Cancer Society, cases estimated for 2017 : 87,110 new melanomas will be diagnosed 9,730 people are expected to die of melanoma Rate of melanoma diagnoses in WA state is 35% higher than national average from 2001-2006; 5 th highest rate of melanoma in US (7) (7) https://www.epa.gov/sites/production/files/documents/wa_facts_web.pdf

Melanoma and dysplastic Nevi Melanoma tumor of the pigment producing cells (melanocytes) A Asymmetry B Borders Irregular C Color DARK BLACK in color, multicolored, red and pigmented, change in color D Diameter least sensitive, > 5 mm E Evolving

Melanoma

Melanoma (Lentigo Maligna)

People under 45 account for 25% of all melanoma cases (5) Melanoma is the leading cause of cancer death in women ages 25-30 and the second leading cause of cancer death in women ages 30-35. (6) (5) http://www.aimatmelanoma.org/en/aim-foranswers/about-melanoma-and-other-lesions.html (6) https://www.melanoma.org/sites/default/files/u13882/201 5FactSheetUpdated3-16-15.pdf

MALIGNANT MELANOMA Family history, UV exposure (including tanning beds), blistering sunburns Redheads, freckles, blue eyes Depth at presentation indicates prognosis Melanoma In Situ: 99-100% 10 year survival rate < 1mm depth, no ulceration, no mitoses (IA)= 95% 10 year survival rate <1mm depth +/- ulceration, +/- mitoses (IB)=86% 10 year survival rate VS Stage 2 (depths 1.01mm-4 mm depth) 40-67%

Melanoma WLE Melanoma in situ 5 mm margins <1mm depth -1.0 cm margins Staged excisions Sentinel LN bx >1mm depth Consider >0.75 mm depth with ulceration or mitoses, young age

Dysplastic Nevi

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