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Detection and Treatment of Non- Melanoma Skin Cancers Toby Maurer, MD University of California, San Francisco.

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Presentation on theme: "Detection and Treatment of Non- Melanoma Skin Cancers Toby Maurer, MD University of California, San Francisco."— Presentation transcript:

1 Detection and Treatment of Non- Melanoma Skin Cancers Toby Maurer, MD University of California, San Francisco

2 Basics of Skin Cancer Large majority caused by sun exposure Often sun exposure before age 20 Persons who burn easily and tan poorly are at greatest risk

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5 Sunscreen Dont forget sun-protective clothing Physical sunscreen –zinc oxide and titanium dioxide –thick and more waterproof –fewer allergic reactions Chemical sunscreens –burns if gets into eyes –more comedonegenic

6 Sunscreen Apply 1/2 hr. before going out May need to reapply every 2-3 hours –especially if going in water Be liberal with amount UVA protection probably added benefit

7 Non-Melanoma Skin Cancers Basal cell carcinoma (BCC) Actinic keratosis (AK) Squamous cell carcinoma (SCC)

8 Basal Cell Carcinoma (BCC) Who is at Risk? –Age 20+ –Fair-skinned persons –Sun-exposed sites over 50% on face

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15 Clinical Features of BCC Pearly papule with telangiectasia (face, ears forehead, neck) Scaly red patch (back, chest, legs of women) Sclerotic (scarlike) lesion Pigmented in pigmented races (blacks, etc.) May erode or ulcerate

16 Diagnosis of BCC: Shave or Punch Biopsy

17 Differential Diagnosis of BCC Intradermal Nevus Sebaceous hypersplasia Fibrous Papule (angiofibroma) Eczema Melanoma

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28 Recommended Treatment of BCC Surgical excision (head and neck) Curettage and desiccation (trunk) Radiation therapy (debilitated pt) Microscopically controlled surgery (Mohs) –Recurrent/sclerotic BCCs –BCCs on eyelid and nasal tip

29 Aldara (Imiquimod) Topical therapy designed for wart treatment Upregulates interferon and down regulates tumor necrosis factor Seems to have efficacy in superficial BCCs Do Not use in BCCs that are nodular or invasive

30 Topical Treatment of Skin Cancer Imiquimod 5% cream can effectively treat superficial BCCs and SCC in situ Treatment regimen is 5X per week for 6-10 weeks depending on the host reaction Efficacy is relatively high (75%-85%) Scarring may be reduced compared to surgery Other possible uses: Extramammary Pagets, lentigo maligna (trials needed)

31 Topical Treatment of Skin Cancer Patient selection is the key Biopsy to confirm diagnosis before TX

32 Treatments NOT Recommended Cryotherapy Topical chemotherapy - 5 Fleurourical (Efudex) Radiation therapy (age < 65)

33 When to Refer It depends on your surgical skills > 1 cm Sclerotic BCC Recurrent BCC Eyelid BCC

34 Actinic Keratosis (AK) Who is at risk? –Over age –Fair-skinned persons –Sun-exposed sites Face, forearms, hands, upper trunk –History of chronic sun exposure

35 Clinical Features of AK Red, adherent, scaly lesions, usually < 5mm Sandpapery, rough texture Tender when touched or shaved Thick, warty character (cutaneous horn)

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40 Diagnosis of AK Diagnosis –Clinical features –Shave or punch biopsy Differential Diagnosis –BCC/SCC –Seborrheic keratosis –Wart

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43 Treatment of AK Cryotherapy Topical chemotherapy/chemical peel –Efudex (5FU crème) 2xs/day x 6 wks or Imiquimod- 3Xs /wk and 3 mos. When to refer? –Too extensive for local treatment –Consider biopsy or referral with any lesion that doesnt resolve with cryotherapy

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45 Make sure you know what you are treating Be very careful with pigmented lesions

46 Rule of thumb for cryotherapy: –make sure lesion resolves after one month –if not, refer or biopsy to rule out malignancy

47 Squamous Cell Carcinoma (SCC) Who is at risk? –Age 50+ –Chronic sun exposure Head, neck, lower lip, ears, dorsal hands, trunk –Special circumstances Immunosuppression (organ transplant) Radiation therapy

48 Clinical Features of SCC Papule, nodule or tumor Non-healing erosion or ulcer Cutaneous horn (wart-like lesion) Fixed, red, scaling patch/plaque (Bowens- SCC-in-situ)

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54 Differential Diagnosis of SCC Actinic keratosis Wart Seborrheic keratosis BCC Eczema or psoriasis

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61 How to Diagnose Punch or excisional/incisional biopsy Shave biopsy for flat, non-elevated lesion

62 Treatment of SCC Recommended treatment –Excision –Radiation therapy ( debilitated pt) Treatments NOT recommended –Curettage and desiccation –Topical chemotherapy

63 When to Refer SCCs may metastasize Low threshold for biopsy and referral Regularly check draining lymph nodes High risk SCCs

64 High-risk SCCs Lip Temple Immunocompromised host (i.e. organ transplant) Area of previous radiation therapy

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