Clinical characteristics Skin Cancerfaculty.washington.edu/fvega/HIHIM2010/Class Notes... · n...

Skin Caner

Fernando Vega, M.D. 1

Skin Cancer

Fernando Vega, MDSeattle Healing Arts

nPrecancerous lesionsnCommon skin cancers

Clinical characteristics

Precancerous skin lesionsnActinic keratoses

nDysplastic melanocytic nevi

ACTINIC KERATOSISn Common sun-induced

premalignant neoplasm of the epidermis that occurs primarily on exposed skin

n Consequence of cumulative long-term sun exposure

n Prevalence ↑with ↑age

n Men > women

n Also genetic factors - ↑in fair skin and in genetic syndromes eg xeroderma pigmentosum

NATURAL HISTORY

n Some lesions (10%) spontaneously regress

n Some (majority) remain unchanged

n Others (1-10%) progress and develop into SCC – risk increased with continued sun exposure or concurrent immunosuppression

CLINICAL FEATURESn Earliest evidence is a tiny red

telangiectatic spot

n Then dry, rough and adherent scale

n Skin coloured/ red/ yellow/ brown

n Usually multiple

n Lesions on hands and forearms tend to be thicker

n Actinic change on lips=actinic chelitis

n Associated with other signs of sun damage – solar elastosis, wrinkled skin, solar lentigines

Skin Caner

Fernando Vega, M.D. 2

Actinic keratoses Actinic keratoses

Actinic keratoses and SCC Actinic keratoses and SCC

Actinic keratoses and BCC Actinic keratoses

10% risk of malignant transformation

Skin Caner

Fernando Vega, M.D. 3

Hypertrophic AK’s Actinic cheilitis

n Liquid nitrogen cryotherapy

n Topical therapies

n 5-FU (Efudex)

n Imiquimod (Aldara)

n Curettage for hypertrophic lesions

Treatment of AK’sResidual hypopigmentation

Blister formation

Liquid nitrogenCryotherapy

Topical therapiesEfudex or Aldara

* 3-5 times per week* 6-8 weeks

Dysplastic nevi

•Precursors for melanoma•When to biopsy

Skin Caner

Fernando Vega, M.D. 4

Miller A and M ihm M. N Engl J Med 2006;355:51-65

Biologic Events and Molecular Changes in the Progression of Melanoma

Tsao H et al. N Engl J Med 2004;351:998-1012

Clinical Images of Pigmented Lesions

Non-melanoma skin cancers

nBasal cell carcinoma

nSquamous cell carcinoma

nKeratoacanthoma

Risk factors for development of BCC and SCC

n Fair skin (Fitzpatrick’s types I-III)n Blue eyesn Red hair

n Family historyn Genetic syndromes

n Chronic sun exposure

n Old age

n Arsenic, tar

Basal cell carcinoma

BCC- clinical types

n Nodular

n Superficial

n Morpheaform

Skin Caner

Fernando Vega, M.D. 5

Nodular BCCn Chronic lesion

n Easy bleeding

n Pearly border

n Surface telangiectasias

n Head and neck, trunk, and extremities

Skin Caner

Fernando Vega, M.D. 6

Superficial BCCn Erythematous scaly

plaque

n Slow growth

n Asymptomatic

n Trunk, extremities, face

Superficial BCC Morpheaform BCC

n Resembles scar

n Asymptomatic and slow growing

n Ill-defined margins

n Marked subclinical extension

n BCC is the most frequent skin cancer (80%)

n BCC is 4x more frequent than SCC

n Metastases are rare (<1% of cases)

n Local destruction of tissue

Treatment of BCCn Curettage electrodessication (ED/C)

n Surgical excisionn TraditionalnMohs surgery

n Radiation therapy

n Topical therapyn imiquimod

95% Cure Rate

50-75% Cure Rate

Skin Caner

Fernando Vega, M.D. 7

Squamous cell carcinoma

SCC types

n In-situnBowen’s diseasenErythroplasia of Queyrat

n Invasive SCCn Keratoacanthoma

Bowen’s disease

n In-situ SCC

n Arsenic, HPV 16, radiation

Invasive SCC

n Erythematous nodule

n Indurated lesion

n Sun-exposed skinn Men > women

n Slow growth

Invasive SCC Keratoacanthoma n Low grade SCC

n Rapid growth over weeks

n Trauma, sun exposure, HPV 11 and 16

n May progress to invasive SCC

Skin Caner

Fernando Vega, M.D. 8

n SCC is locally invasive and destructive

n Metastases in 1-3% of cases

n To lymph nodesn 50-73% survival

n Distant sites (lungs)n Incurable

Malignant Melanoma

Risk factorsn Fair skin, red hair, and blue eyes

n Intermittent sun exposuren Sunburnsn Tanning beds

n Freckles and melanocytic nevi

n Family history of melanoma

Clinical types- MM

Superficial spreading melanomaLentigo maligna melanoma

Acral lentiginous melanomaNodular melanoma

ABCD of Melanoma

n Asymmetry

n Border irregularity

n Color variegation

n Diameter >6mmTsao H et al. N Engl J Med 2004;351:998-1012

Clinical Images of Pigmented Lesions

Skin Caner

Fernando Vega, M.D. 9

Miller A and M ihm M. N Engl J Med 2006;355:51-65

Biologic Events and Molecular Changes in the Progression of Melanoma

Benign Melanocytic Neoplasms

Benign Melanocytic Neoplasms

Benign Melanocytic Neoplasms

Benign Melanocytic Neoplasms

Congenital nevus

Skin Caner

Fernando Vega, M.D. 10

Malignant Melanoma Malignant MelanomaWith Regression

Malignant MelanomaSupeerficial Spreading

Malignant Melanoma

Malignant MelanomaCiliary Body

Malignant Melanoma

Skin Caner

Fernando Vega, M.D. 11

Malignant Melanoma Malignant Melanoma

Malignant Melanoma Malignant Melanoma

Malignant Melanoma Malignant Melanoma

Skin Caner

Fernando Vega, M.D. 12

Malignant Melanoma Malignant Melanoma

Malignant Melanoma Malignant Melanoma

Malignant Melanoma LENTIGO MALIGNA

n An in situ pattern of malignant melanoma

n Often reaches a large size before the diagnosis is made

n Lentigo → lentigo maligna →lentigo maligna melanoma

Skin Caner

Fernando Vega, M.D. 13

CLINICAL FEATURESn Begins as a flat

pigmented lesion

n Usually on sun-exposed skin of head and neck

n With time the colour and border become more irregular

MANAGEMENT n Surgery – excision with a wide margin

n Radiotherapy

n Cryotherapy (deviation from rule)

n Immiquimod (by report)

Prognostic features- MMn Good prognosis

n Breslow < 1mm

n Intermediate prognosisn Breslow 1-4mm

n Bad prognosisn Breslow >4mm