2Module InstructionsThe following module contains a number of underlined terms which are hyperlinked to the dermatology glossary, an illustrated guide to clinical dermatology and dermatopathology.We encourage the learner to read all the hyperlinked information.
3Goals and ObjectivesThe purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with suspicious lesions.By completing this module, the learner will be able to:Identify and describe the morphology of basal cell carcinomaFormulate a differential diagnosis based on the patient’s history and physical findingsRefer patients with skin lesions suspicious for non- melanoma skin cancer to dermatology
4Clinical Case HistoryMr. Carter is a 62-year-old man who presents to your office with a growth by his right ear. He first noticed the growth about six months ago. He states that it has increased in size, but it otherwise does not bother him.
5You learn more about Mr. Carter’s history… Past Medical History:Extensive history of sun exposure, especially in childhoodFair skin, usually burns, rarely tansNo history of skin cancerNo history of arsenic exposure or radiationHypertension, dyslipidemia, diabetesMedications: Aspirin, Insulin, Lisinopril, SimvastatinFamily history: No history of skin cancerSocial history: Married with 3 children.Health-related behaviors: 10-pack year smoking history; quit 10 years ago. No alcohol or drug use.
8What is your differential diagnosis? After you have considered the differential diagnosis, go to the next slide for a list of possible diagnoses.
9What is your differential diagnosis? Basal cell carcinomaIntradermal nevusSebaceous hyperplasiaSeborrheic keratosisSquamous cell carcinoma
10Evaluation What is your next step in evaluating this patient? Liquid nitrogen cryotherapyReassurance with close follow-upShave biopsySurgical removalTopical antibiotics
11EvaluationAnswer: cWhat is your next step in evaluating this patient?Liquid nitrogen cryotherapy (cyrotherapy will not help diagnose the lesion)Reassurance with close follow-up (this is a suspicious lesion and should be biopsied)Shave biopsySurgical removal (best to biopsy the growth in order to obtain histologic confirmation prior to surgical removal)Topical antibiotics (the lesion does not appear to have a bacterial etiology)
13Ordering PathologyNote that the pathologist did not comment on the marginsThis is because we ordered a biopsy (for diagnosis) and not an excision (to confirm it is all out)Click here to watch a video on pathology requests
14Shave Biopsy Click here to watch a video on local anesthesia Click here to watch a video on how to perform a shave biopsy
15What is the diagnosis? Basal cell carcinoma Intradermal nevus Sebaceous hyperplasiaSeborrheic keratosisSquamous cell carcinoma
16What is the diagnosis? Answer: a Basal cell carcinoma Intradermal nevus (Pigmented or skin colored, appears early in life, and would not be expected to develop in this age group. Histologically, melanocytic nevi show nests of nevo-melanocytic cells in the dermis, without palisading or clefting)Sebaceous hyperplasia (Can have telangiectasias but tend to be yellowish or pink. Histologically, they show groups of normal looking sebaceous glands)Seborrheic keratosis (Verrucous (irregular surfaced) and NOT smooth. Also, they are not pearly and do not have surface telangiectasias. Histologically, they show thickend and verrucous epidermis with keratin cysts)Squamous cell carcinoma (Red nodule with keratin. Histologically, there are atypical keratinocytes in the epidermis and invading the dermis)
17Management What is your next step in management? Shave biopsy Liquid nitrogen cryotherapyReassurance with close follow-upSurgical removalTopical antibiotics
18Management Answer: d What is your next step in management? Shave biopsy (You already have a diagnosis and there is no need for another biopsy)Liquid nitrogen cryotherapy (Liquid nitrogen cryotherapy is the treatment of choice for several benign and pre- cancerous skin lesions (e.g. actinic keratoses). It is not 1st-line treatment for BCC)Reassurance with close follow-up (Basal cell carcinomas are malignant and produce significant local tissue destruction. They must be treated early)Surgical removal (The treatment of choice for basal cell carcinoma is surgical excision. Alternatively, electrodesiccation and curettage or radiation therapy can be used)Topical antibiotics (Basal cell carcinoma is a tumor not an infection)
19Biopsy vs. ExcisionHow come we did not excise the whole lesion to begin with?It is best to biopsy the growth in order to obtain histologic confirmation prior to surgical removal, as biopsy may have revealed:A benign growth, in which case excision would have been unnecessaryA tumor different from BCC that may have required a different management approach
20At the follow-up visit 6 months later… Mr. Carter healed well following surgical removal. There is no evidence of tumor recurrence or new primary tumors.You counsel Mr. Carter on the importance of continued sun protection and regular self-skin exams, and you schedule him for routine full-skin exams every 6 months to a year in order to monitor for skin cancers.Now, let’s review Basal Cell Carcinoma
21Basal cell carcinoma (BCC) Most common skin cancer>1 million new cases per year in the USNeoplasm arises from nonkeratinizing keratinocytes that originate in the basal layer of the epidermisEtiologyUltraviolet radiation induces DNA damagePTCH (tumor suppressor gene) mutationSpontaneous/acquired mutations from UV-induced DNA damage
22Basal cell carcinoma (BCC) Risk factorsSkin types I, II (fairer skin types)*History of intense or prolonged ultraviolet light exposureHistory of ionizing radiation exposure or arsenic ingestionImmune suppression (transplant patients, systemic immunosuppressive medications)Genetic conditions that increase skin cancer risk* BCC is still commonly seen in darker skin types
23Classifying Skin Types The Fitzpatrick Skin Phototype Classification is used to classify skin based on the ability to burn and tan when challenged with UV radiationWhite skin, always burns, never tansWhite skin, always burns, minimal tanWhite skin, burns minimally, tans moderately and graduallyLight brown skin, burns minimally, tans wellBrown skin, rarely burns, tans deeplyDark brown/black skin, never burns, tans deeplyNote: sunscreen is recommended for all skin types, including the darkest of skin
25Nodular BCC Most common subtype Presents as a pearly papule or nodule with rolled border and telangiectasiasAlthough any part of the body may be involved, the lesions are most frequently found on the head and neck
26Superficial BCCPresents with features suggestive of BCC including a pink or translucent color, telangiectasia, and a slightly rolled borderMorphology is a patch or a thin plaque, which may be scalyDifferential diagnosis may include squamous cell carcinoma in situ or actinic keratosis
27Ulcerated BCCPresents with features suggestive of BCC including a translucent color, telangiectasia, and a rolled borderIn addition, the growth is grossly or microscopically ulcerated, which often results in crusting over the growth
28Pigmented BCCPresents with features typical of a BCC along with globules of dark pigmentThe differential diagnosis may include malignant melanoma
29Morpheaform BCCPresents with features suggestive of BCC including a translucent color, telangiectasia, and a rolled borderIn addition, the plaque appears white and bound down or scar-like in areas
30BCC: TreatmentThere are several surgical and non-surgical treatment options.The best option is selected after consideration of clinical and histologic features.To select the optimum therapy, refer to a dermatologist
31BCC: Treatment Surgical Treatment Options: Curette and DesiccationCryosurgeryExcision with standard 3-4mm marginsMohs micrographic surgery – permits real time evaluation of tumor margins and consequent tissue conservation to minimize defect sizeNon-Surgical Treatment Options:Imiquimod cream – FDA approved for superficial BCC5% fluorouracil cream for superficial BCCPhotodynamic therapy for superficial BCCRadiation
32Mohs Micrographic Surgery (MMS) MMS offers superior histologic analysis of tumor margins while permitting maximal conservation of tissue compared with standard surgical excisionRecurrence rates tend to be lower with MMS compared to other modalities, including standard excision, curettage and desiccation, radiation, and cryotherapyIndications include:Location: nose, ears, eyes, lips, scalp, handsAggressive histologic subtypes: infiltrative, sclerosing, morpheaform, or micronodularLarge tumors or tumors with indistinct clinical bordersRecurrent tumors
33Mohs Micrographic Surgery Step 1: The roots of a skin cancer may extend beyond the visible portion of the tumor. If these roots are not removed, the cancer will recur.Step 2: The visible tumor is surgically removed.Step 3: A layer of skin is removed and divided into sections. The surgeon then color codes each of these sections with dyes and makes reference marks on the skin to show the source of these sections. A map of the surgical site is then drawn.
34Mohs Micrographic Surgery Step 4: The undersurface and edges of each section are microscopically examined for evidence of remaining cancer.Step 5: If cancer cells are found under the microscope, the surgeon marks their location onto the "map" and returns to the patient to remove another layer of skin - but only from precisely where the cancer cells remain.Step 6: The removal process stops when there is no longer any evidence of cancer remaining in the surgical site.
35BCC: Course & Prognosis BCC is locally invasiveMetastasis is rarePatients with BCC are at risk for developing other non-melanoma and melanoma skin cancersThey should have follow-up at regular intervals (e.g. every 6 months to 1 year)
36Patient EducationThere are multiple resources to help educate patients about sun safety and skin cancer prevention, including:American Academy of Dermatology: Skin Cancer PreventionAmerican Cancer Society: Skin Cancer Prevention and Early DetectionThe following slides are adapted from the AAD Be Sun Smart® program
37Patient Education: Be Sun Smart® Generously apply a broad-spectrum, water-resistant sunscreen with a Sun Protection Factor (SPF) of 30 or more to all exposed skin.“Broad-spectrum” provides protection from both UVA and UVB rays.Reapply approximately every two hours, even on cloudy days, and after swimming or sweating.Wear protective clothing, such as a long-sleeved shirt, pants, a wide-brimmed hat, and sunglasses.Seek shade.Remember that the sun's rays are strongest between 10 AM – 4PM.If your shadow appears to be shorter than you are, seek shade.
38Patient Education: Be Sun Smart® Use extra caution near water, snow, and sand because they reflect and intensify the damaging rays of the sun, which can increase your chances of a sunburn.Get vitamin D safely through a healthy diet that may include vitamin supplements. Don't seek the sun.Avoid tanning beds. Ultraviolet light from the sun and tanning beds can cause skin cancer and wrinkling. If you want to look tan, consider using a self-tanning product, but continue to use sunscreen with it.Check your birthday suit on your birthday. If you notice anything changing, growing, or bleeding on your skin, see a dermatologist.
39How to perform a skin self-examination Examine your body front and back in the mirror, then look at the right and left sides with your arms raised.Look at the backs of your legs and feet, the spaces between your toes, and the soles of your feet.Examine the back of your neck and scalp with a hand mirror. Part hair for a closer look.Bend elbows and look carefully at forearms, upper underarms, and palms.
40Take Home Points BCC is the most common skin cancer It is most common in the head and neckBCC is locally destructive but metastases are extremely rareDiagnosis is established by biopsyTreatment depends on clinical and histological features but is usually surgicalEducate patients about skin cancer prevention
41AcknowledgementsThis module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup fromPrimary authors: Amit Garg, MD, FAAD; Lisa Nguyen, MD; Meera Mahalingam, MD.Contributor: Sarah D. Cipriano, MD, MPH.Peer reviewers: Timothy G. Berger, MD, FAAD; Patrick McCleskey, MD, FAAD; Carlos Garcia, MD; Isaac M. Neuhaus, MD, FAAD.Revisions: Sarah D. Cipriano, MD, MPH. Last revised September, 2011.Thank you to the American College of Mohs Surgery for providing images of the Mohs surgery process
42ReferencesCarucci John A, Leffell David J, "Chapter 115. Basal Cell Carcinoma" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e:Chartier TK. Treatment and prognosis of basal cell carcinoma. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011.James WD, Berger TG, Elston DM, “Chapter 29. Epidermal Nevi, Neoplasms, and Cysts” (chapter). Andrews’ Diseases of the Skin Clinical Dermatology. 11th ed. Philadelphia, Pa: Saunders Elsevier; 2011:McGovern TW and Leffell DJ. Actinic Keratoses and Non-Melanoma Skin Cancer, Clinical Dermatologic Curriculum for Medical Students,Neville JA, et al. Management of nonmelanoma skin cancer in 2007, Nat Clin Pract Oncol, 2007;4(8):462-9.Wolff K, Johnson RA, "Section 11. Precancerous Lesions and Cutaneous Carcinomas" (Chapter). Wolff K, Johnson RA: Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology, 6e:
43Additional ResourcesBerger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; Available from:Nguyen L, Mahalingam M, Garg A. Dermatology Clinical Case Modules: 62- Year-Old Man With a Facial Growth. MedEdPORTAL. 2010; Available from: d=7751Nguyen L, Mahalingam M, Garg A. Dermatology Clinical Case Modules: 70- Year-Old Man with a Red Crusty Bump on his Right Arm. MedEdPORTAL; Available from: d=8055Nguyen L, Mahalingam M, Garg A. Dermatology Clinical Case Modules: 40- year-old Woman with a Dark Mole. MedEdPORTAL; Available from: d=8067