SKIN CANCER KARINA PARR, MD RONALD GRIMWOOD, MD KARA KENNEY

Over 3.5 million cases per year BCC – 80%, SCC – 16%, Melanoma – 4% SKIN CANCER More new cases last year than breast, colon, lung, and prostate cancer combined Over 3.5 million cases per year BCC – 80%, SCC – 16%, Melanoma – 4% Expected deaths from skin cancer this year Melanoma: > 9700, Non-Melanoma: >4,000 http://www.skincancer.org/skin-cancer-information/skin-cancer-facts

Non-Melanoma Skin Cancer > 3.5 million cases in > 2 million people per year BCC > 2.8 million SCC > 700,000 Lifetime risk is 1 in 5 overall Fair skin, fair colored hair, light eye color Chronic sun exposure/tanning bed use Expected deaths - 2200 http://www.skincancer.org/skin-cancer-information/skin-cancer-facts

Basal Cell Carcinoma Most common skin carcinoma in US Almost exclusively in hair-bearing skin, especially face 40% dx w/ BCC will have another w/in 10 years Metastasis rate 0.0028%

Basal Cell Carcinoma Nodular Pigmented Cystic Morpheaform Superficial

Squamous Cell Carcinoma Precursors Actinic Keratosis Bowen’s Disease Arsenical Keratosis

Treatment of Actinic Keratosis Cryotherapy with Liquid Nitrogen 5 – fluorouracil cream (Efudex or Carac) Chemical Peels Photodynamic therapy Dermabrasion Curettage Immune response therapy – Aldara Diclofenac Sodium 3% gel – Solaraze Topical Retinoids Lasers

Mucous membranes can be involved Bowen’s Disease SCC in situ Can become invasive Mucous membranes can be involved

Treatment of Bowen’s Disease Excision Topical 5-fluorouracil Mohs surgery (depends on the site and size)

Squamous Cell Carcinoma May occur anywhere on skin including mucous membranes Most commonly arises on sun damaged skin Overall, rate of metastasis is 2-3% SCC lower lip approx 11% metastasis SCCs in areas of chronic inflammation (burns, radiation tx, osteomyelitis) also have higher rate of metastasis

SCC Factors Associated w/Local Recurrence & Metastasis Size > 2.0 cm Depth > 0.4 cm (into deep dermis or fat) Histology – poorly differentiated Perineural involvment

SCC Factors Associated w/Local Recurrence & Metastasis Sites – ear, lip (lower), scar, non-sun exposed skin Recurrent tumor Immunosuppression – transplant patients

Treatment for Non-Melanoma Skin Cancer Cryotherapy Electrodessication & Curettage (ED & C) Radiation therapy Surgical Excision Mohs Micrographic Surgery

Clinically ill-defined margins Aggressive histological growth patterns Indications for Mohs Clinically ill-defined margins Aggressive histological growth patterns Tumor size Perineural involvement Uncommon tumors that are locally aggressive w/high recurrence rate (MAC, DFSP, Atypical fibroxanthoma, malignant fibrous histiocytoma

Indications for Mohs High risk anatomic locations (medial canthus, nasal ala, nasal tip, external auditory canal, temple, eyelids, lower lip) Young patients – often have aggressive histology, in areas of high recurrence rate, cosmetic concerns

Skin Cancer Update 2014 for Melanoma Number of new invasive cases – 76,100 Men - 43,890, Women - 32,210 Deaths – 9710 Highest mortality rate in white, older men Lifetime risk of developing melanoma Invasive = 1 in 62 Invasive + in-situ = 1 in 34 http://www.skincancer.org/skin-cancer-information/skin-cancer-facts

Risk Factors for Developing Malignant Melanoma Lentigo Maligna Red or blond hair Actinic Keratosis Marked freckling > 3 blistering sunburns as a teenager > 3 yrs with outdoor summer job as a teenager

Risk Factors for Developing Malignant Melanoma Type I & II skin types Excessive sun exposure Immunosuppression Family hx of melanoma Personal hx of melanoma Dysplastic nevi

Superficial spreading 65 - 70% Nodular 15 - 30% Melanoma Types Superficial spreading 65 - 70% Nodular 15 - 30% Lentigo Maligna Melanoma 4 - 10% Acral Lentiginous 2 - 8% Still seems accurate based on: http://www.skincancer.org/skin-cancer-information/melanoma/types-of-melanoma

Appropriate Management of Pts w/ Early Melanoma (<1mm depth) Ask about personal or family history of MM Total body skin exam Palpation of regional lymph nodes Surgical excision w/ 1.0 cm margins SLN biopsy if >0.75 mm

Melanoma 10 yr Survival Rate Tumor thickness (mm) No Ulceration With Ulceration T1 0.01-1.00 95% 86% T2 1.01-2.00 67% 57% T3 2.01-4.00 68% 43% T4 > 4.00 10-15% http://www.cancer.org/cancer/skincancer-melanoma/detailedguide/melanoma-skin-cancer-survival-rates

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

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 23