SKIN CANCERSKIN CANCER
KARINA PARR, MDKARINA PARR, MDRONALD GRIMWOOD, MDRONALD GRIMWOOD, MD
KARA KENNEYKARA KENNEY
SKIN CANCERSKIN CANCER
More new cases last year than breast, colon, More new cases last year than breast, colon, lung, and prostate cancer combinedlung, and prostate cancer combined
Over 3.5 million cases per yearOver 3.5 million cases per year
BCC – 80%, SCC – 16%, Melanoma – 4%BCC – 80%, SCC – 16%, Melanoma – 4%
Expected deaths from skin cancer this yearExpected deaths from skin cancer this year
Melanoma: > 9700, Non-Melanoma: >4,000Melanoma: > 9700, Non-Melanoma: >4,000
Non-Melanoma Skin CancerNon-Melanoma Skin Cancer
> 3.5 million cases in > 2 million people per > 3.5 million cases in > 2 million people per yearyearBCC > 2.8 millionBCC > 2.8 millionSCC > 700,000SCC > 700,000Lifetime risk is 1 in 5 overallLifetime risk is 1 in 5 overallFair skin, fair colored hair, light eye colorFair skin, fair colored hair, light eye colorChronic sun exposure/tanning bed useChronic sun exposure/tanning bed useExpected deaths - 2200Expected deaths - 2200
Basal Cell CarcinomaBasal Cell Carcinoma
Most common skin carcinoma in USMost common skin carcinoma in US
Almost exclusively in hair-bearing skin, Almost exclusively in hair-bearing skin, especially faceespecially face
40% dx w/ BCC will have another w/in 10 40% dx w/ BCC will have another w/in 10 yearsyears
Metastasis rate 0.0028%Metastasis rate 0.0028%
Basal Cell CarcinomaBasal Cell Carcinoma
NodularNodular
PigmentedPigmented
CysticCystic
MorpheaformMorpheaform
SuperficialSuperficial
Squamous Cell Carcinoma PrecursorsSquamous Cell Carcinoma Precursors
Actinic KeratosisActinic Keratosis
Bowen’s DiseaseBowen’s Disease
Arsenical KeratosisArsenical Keratosis
Treatment of Actinic KeratosisTreatment of Actinic Keratosis
Cryotherapy with Liquid NitrogenCryotherapy with Liquid Nitrogen5 – fluorouracil cream (Efudex or Carac)5 – fluorouracil cream (Efudex or Carac)Chemical Peels Chemical Peels Photodynamic therapyPhotodynamic therapyDermabrasionDermabrasionCurettageCurettageImmune response therapy – AldaraImmune response therapy – AldaraDiclofenac Sodium 3% gel – SolarazeDiclofenac Sodium 3% gel – SolarazeTopical RetinoidsTopical RetinoidsLasersLasers
Bowen’s DiseaseBowen’s Disease
SCC in situSCC in situ
Can become invasive Can become invasive
Mucous membranes can be involvedMucous membranes can be involved
Treatment of Bowen’s DiseaseTreatment of Bowen’s Disease
ExcisionExcision
Topical 5-fluorouracilTopical 5-fluorouracil
Mohs surgery (depends on the site and Mohs surgery (depends on the site and size)size)
Squamous Cell CarcinomaSquamous Cell Carcinoma
May occur anywhere on skin including May occur anywhere on skin including mucous membranesmucous membranesMost commonly arises on sun damaged Most commonly arises on sun damaged skinskinOverall, rate of metastasis is 2-3%Overall, rate of metastasis is 2-3%SCC lower lip approx 11% metastasisSCC lower lip approx 11% metastasis SCCs in areas of chronic inflammation SCCs in areas of chronic inflammation (burns, radiation tx, osteomyelitis) also (burns, radiation tx, osteomyelitis) also have higher rate of metastasishave higher rate of metastasis
SCC Factors Associated w/Local SCC Factors Associated w/Local Recurrence & MetastasisRecurrence & Metastasis
Size > 2.0 cmSize > 2.0 cm
Depth > 0.4 cm (into deep dermis or fat)Depth > 0.4 cm (into deep dermis or fat)
Histology – poorly differentiatedHistology – poorly differentiated
Perineural involvmentPerineural involvment
SCC Factors Associated w/Local SCC Factors Associated w/Local Recurrence & Metastasis Recurrence & Metastasis
Sites – ear, lip (lower), scar, non-sun Sites – ear, lip (lower), scar, non-sun exposed skinexposed skin
Recurrent tumorRecurrent tumor
Immunosuppression – transplant patientsImmunosuppression – transplant patients
Treatment for Non-Melanoma Treatment for Non-Melanoma Skin CancerSkin Cancer
CryotherapyCryotherapy
Electrodessication & Curettage (ED & C) Electrodessication & Curettage (ED & C)
Radiation therapyRadiation therapy
Surgical ExcisionSurgical Excision
Mohs Micrographic SurgeryMohs Micrographic Surgery
Indications for MohsIndications for Mohs
Clinically ill-defined marginsClinically ill-defined margins
Aggressive histological growth patternsAggressive histological growth patterns
Tumor size Tumor size
Perineural involvementPerineural involvement
Uncommon tumors that are locally Uncommon tumors that are locally aggressive w/high recurrence rate (MAC, aggressive w/high recurrence rate (MAC, DFSP, Atypical fibroxanthoma, malignant DFSP, Atypical fibroxanthoma, malignant fibrous histiocytomafibrous histiocytoma
Indications for MohsIndications for Mohs
High risk anatomic locations (medial High risk anatomic locations (medial canthus, nasal ala, nasal tip, external canthus, nasal ala, nasal tip, external auditory canal, temple, eyelids, lower lip)auditory canal, temple, eyelids, lower lip)
Young patients – often have aggressive Young patients – often have aggressive histology, in areas of high recurrence rate, histology, in areas of high recurrence rate, cosmetic concernscosmetic concerns
Skin Cancer Update 2014 for MelanomaSkin Cancer Update 2014 for Melanoma
Number of new invasive cases – 76,100Number of new invasive cases – 76,100
Men - 43,890, Women - 32,210Men - 43,890, Women - 32,210
Deaths – 9710Deaths – 9710
Highest mortality rate in white, older menHighest mortality rate in white, older men
Lifetime risk of developing melanomaLifetime risk of developing melanoma
Invasive = 1 in 62Invasive = 1 in 62
Invasive + in-situ = 1 in 34Invasive + in-situ = 1 in 34
Risk Factors for Developing Malignant Risk Factors for Developing Malignant MelanomaMelanoma
Lentigo MalignaLentigo Maligna
Red or blond hairRed or blond hair
Actinic KeratosisActinic Keratosis
Marked frecklingMarked freckling
> 3 blistering sunburns as a teenager> 3 blistering sunburns as a teenager
> 3 yrs with outdoor summer job as a > 3 yrs with outdoor summer job as a teenagerteenager
Risk Factors for Developing Malignant Risk Factors for Developing Malignant MelanomaMelanoma
Type I & II skin typesType I & II skin types
Excessive sun exposureExcessive sun exposure
ImmunosuppressionImmunosuppression
Family hx of melanomaFamily hx of melanoma
Personal hx of melanomaPersonal hx of melanoma
Dysplastic neviDysplastic nevi
Melanoma TypesMelanoma Types
Superficial spreading 65 - 70%Superficial spreading 65 - 70%
Nodular 15 - 30%Nodular 15 - 30%
Lentigo Maligna Melanoma 4 - 10%Lentigo Maligna Melanoma 4 - 10%
Acral Lentiginous 2 - 8%Acral Lentiginous 2 - 8%
Appropriate Management of Pts w/ Early Appropriate Management of Pts w/ Early Melanoma (<1mm depth)Melanoma (<1mm depth)
Ask about personal or family history of MMAsk about personal or family history of MM
Total body skin examTotal body skin exam
Palpation of regional lymph nodesPalpation of regional lymph nodes
Surgical excision w/ 1.0 cm marginsSurgical excision w/ 1.0 cm margins
SLN biopsy if >0.75 mmSLN biopsy if >0.75 mm
Melanoma 10 yr Survival RateMelanoma 10 yr Survival Rate
Tumor thickness Tumor thickness (mm)(mm)
No UlcerationNo Ulceration With UlcerationWith Ulceration
T1 0.01-1.00T1 0.01-1.00 95%95% 86%%
T2 1.01-2.00T2 1.01-2.00 67%% 57%%
T3 2.01-4.00T3 2.01-4.00 68%68% 43%%
T4 > 4.00T4 > 4.00 10-15%15% 10-15%15%
How to protect your skin
Seek shade
Wear protective clothing
Generously apply a broad-spectrum sunscreen with a Sun Protective Factor (SPF) of at least 30 to all exposed skin
Use extra caution near water, snow, and sand
AVOID TANNING BEDS
Consult your physician for any new or changing skin lesions
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Further reading
• "Skin Cancer Facts." SkinCancer.Org. The Skin Cancer Foundation, 4 June 2014. Web. 27 Aug. 2014.
• Skin Cancer section from the American Academy of Dermatology website www.aad.org