1. Precancers and Skin Cancers
Adam O. Goldstein, MD, MPH
Associate Professor
Family Medicine
University of North Carolina at Chapel Hill

2. Actinic Keratoses
premalignant skin lesions = “keratinocytic intraepidermal neoplasia”
chronic sun, radiation or polycyclic aromatic hydrocarbons
Skin Type I-II
organ transplant

3. Actinic Keratosis

4. Actinic Keratoses Distribution: Sunexposed, esp. dorsa hands/forearms
Description: papules,plaques with scale and erythema, occasional crust or cutaneous horn
Sandpapery feel

5. Actinic Keratoses
epidermal atypia
abnormal maturation

6. Actinic Keratoses 60% predisposed >40 have at least 1 AK
6-10% lifetime >> invasive SCC
>10 AK - 14% an SCC w/n 5 yrs
60-97% of SCC from AK
~ 40% of met SCC>> AK
^ aggressive immsupp

7. Actinic Keratoses lip lesions: actinic cheilitis/leukoplakia
white plaques-mucosa
persistent scaling lesions on the lip
^ aggressive behavior
tobacco/sun

8. Differential Diagnosis
squamous cell carcinoma: more indurated, thicker, recurrence of AK after treatment

9. Differential Diagnosis
seborrheic keratosis: hyperpigmented,more stuck on appearing

10. Differential Diagnosis
nummular eczema: coin-shaped scaling lesions; responds to emollients/topical corticosteroids

11. AK Treatment PREVENTION Screen for skin cancers Broad-brimmed hats
sun protective clothing
sunscreens
avoidance of sunlight
ed s/sx skin cancer
avoidance of tobacco
low fat diet?

12. AK Treatment 5-fluorouracil cream or solution Diclofenac Sodium-3% gel
Cryosurgery(liquid nitrogen)
5-fluorouracil cream or solution
Diclofenac Sodium-3% gel
Imiquimod 2 x week/ 16 weeks

13. AK Treatment
Excision
Electrocautery
Curettage
Carbon dioxide laser

14. AK Treatment Photodynamic therapy Retinoids-topical/oral
Chemical peels
Photodynamic therapy
Retinoids-topical/oral
Investigational-dimericine

15. TREATMENT Liquid Nitrogen-Advantages cure rates of 98.8% common
minimal patient ed
multiple/thicker lesions
quick recovery

16. TREATMENT Liquid Nitrogen-Disadvantages storage pain
pigment alteration
training

17. 5-Fluorouracil
Cure 50-80%
Blocks methylation reaction of deoxyuridylic acid to thymidilic acid
DNA (and RNA) synthesis

18. Diclonfenac Sodium 3% Topical Gel
mechanism of action unknown
NSAID
inhibition of cyclo-oxygenase >>>PGE-2
90 days BID--overall 33-47% clearance vs 10-19% vehicle
avoid ASA triad
hypersensitivity

19. Photodynamic therapy
(Pariser DM - J Am Acad Dermatol -2003)

20. Salasche SJ et al Am Acad Dermatol 2002;47:571-7.
Cycle therapy of actinic keratoses of the face and scalp with 5% topical imiquimod cream: An open-label trial.
Significant irritation
Rest periods required
Evolving protocols
Expensive
Effective
Salasche SJ et al Am Acad Dermatol 2002;47:571-7.

21. Skin Cancer Statistics
>1 million cases/yr
>50% of all new cancers
1 in 5 Americans will develop skin cancer

22. Types of Skin Cancers Basal Cell Carcinoma - 80%
Squamous Cell Carcinoma - 16%
Melanoma - 4%

23. BCC /SCC Most common skin cancers Most important risk factors
sun exposure
family history
skin type
Incidence of these cancers increase with age, probably related to cumulative sun exposure

24. Basal Cell Carcinoma the most common skin cancer
90% appear on face, ears, head

25. Main Types Basal Cell Carcinomas
Nodular BCCs - most common type
Sclerosing BCCs (morpheaform)
Superficial BCCs

26. Pattern of Nodular BCC
raised pearly white, smooth translucent surface with telangiectasias

27. Pattern of Nodular BCCs
may ulcerate leaving a small bloody crust
may be pigmented

28. Pattern of Sclerosing BCCs
ivory or colorless
flat or atrophic
indurated
may resemble scars
are easily overlooked

29. Pattern of Sclerosing BCCs
ivory or colorless
flat or atrophic
indurated
may resemble scars
are easily overlooked

30. Pattern of Superficial BCCs and SCC in situ
red or pink scaling plaques
occasionally with shallow erosions or crusts
differentiation between these two similar lesions usually requires a biopsy

31. Pigmented BCCs may look like melanoma increased brown or black pigment
seen more commonly in dark-skinned individuals

32. Differential Diagnosis of Nodular BCC
Intradermal nevus
Sebaceous hyperplasia
Fibrous papule of the face
trichoepithelioma

33. Differentiating Intradermal Nevus from Nodular BCC
Stable size
Soft
No crusting or ulceration
May have telangiectasias

34. Differentiating Intradermal Nevus from Nodular BCC
Stable size
Soft
No crusting or ulceration
May have telangiectasias

35. Sebaceous Hyperplasia from Nodular BCC
yellow coloration
stable size
umbilication without ulceration
is hard to see after injecting anesthesia

36. Diagnosis of Basal Cell Carcinomas
Shave biopsy
nodular
thick superficial types
Punch biopsy
morpheaform
flat superficial types

37. Treatment options for Basal Cell Carcinomas
C + D after a shave biopsy
Cryotherapy with thermocouple if you have experience
Excision with 3- 5 mm margins
Superficial trunk/ext: imiquimod qd x 12 wks
Mohs for recurrent BCC and areas of cosmetic importance

38. Mohs micrographic surgery
removal of tumor by scalpel in sequential horizontal layers.
each tissue sample is frozen, stained, and microscopically examined
repeated until all the margins are clear
treatment of choice for BCCs with poorly defined margins
especially those on the nose or eyelids

39. Recurrence rates after Tx of BCCs
C + D 10%
Cryotherapy 10%
Excision 2 - 5%
Imiquimod ???
Mohs <1%

40. Factors that increase recurrence rates
sclerosing vs others
larger size of BCC
margins
experience of the surgeon

41. Sclerosing BCC is most dangerous
tend to be deeply invasive
often not diagnosed until they have caused extensive damage
invade muscle, nerve, and bone
nodular BCC can also invade deeply

42. Bowen’s disease - features
SCC in situ
Mainly sun exposed areas
Slightly elevated red scaly plaque with well-demarcated borders

43. Bowen’s disease - features
May resemble psoriasis, superficial BCC, chronic eczema, SK
Curable using C & D, cryo, 5-FU, imiquimod, excision

44. Keratoacanthoma Appear suddenly, grow rapidly
Central crater with keratin plug
May grow to 2cm in size
May resolve spontaneously
May look like SCC

45. Keratoacanthoma C and D elliptical excision 5-FU topically tid
5-FU intralesional injection

46. Location of SCCs Same distribution as bccs.
Especially on the lips, ears, and scalp
Initially grow by direct extension
Metastasize to local lymph nodes and then to distant sites

47. SCCs with an increased risk of metastasis
larger, advanced lesions
SCC on mucous membranes (in the oral cavity, on the lips)
BCCs rarely metastasize

48. SCC more aggressive (local & mets)
Size >2 cm
SCC in a scar
Patient is immunosuppressed
Poorly differentiated
There is perineural invasion

49. Importance of early diagnosis of BCC and SCC
especially in facial cancers
the nose is the single most frequent site of BCC
reconstruction is difficult
extension into underlying bone and cartilage may occur

50. The differential diagnosis of superficial BCC and SCC in situ
Actinic keratosis, nummular eczema
Nummular eczema can usually be distinguished by its coin-like shape, transient nature, and itchiness
Biopsy any thickened and crusting actinic keratosis to rule out BCC or SCC

51. Treatment options for SCC
C + D after a shave biopsy
cryotherapy with thermocouple if you have experience
excision with 5 mm margin
Mohs for recurrent SCC and areas of cosmetic importance

52. Erythroplasia of Queyrat
SCC in situ on the penis
Usually under the foreskin of the uncircumcised penis
May occur on the vulva
5-FU, imiquimod or mohs

53. Indications for Referral for Mohs Surgery

54. Indications for Referral for Mohs Surgery
Recurrent tumors, sclerosing BCC
Primary tumors in locations with high tumor-recurrence rates
Nasolabial fold,temple, periauricular area, periocular area, scalp, nasal alae, center face
Preservation of normal tissue is vital (for cosmetic and functional reasons)
Nose, eyelids, lips, fingers, ears, penis

55. When to consider referral
Aggressive and recurrent skin cancers
A large skin cancer lesion
A lesion located in a sensitive area (cosmetic or functional)
When treatment or diagnosis of the lesion is beyond the scope of one’s skills
If mohs surgery is the treatment of choice

56. Melanoma Risk Factors Family history Personal history Atypical Nevi
Blistering Sunburns
Type 1 skin

57. History of a changing lesion

58. Melanoma Statistics Fastest rising incidence rates
Most common cancer in 25-9 y/o
2nd only to breast CA in 30-4 y/o women

59. Melanoma Facts 87,900 new cancers 7400 deaths in 2003 due to melanoma
34,300 in situ
53,600 invasive
4% increase from 2001
7400 deaths in 2003 due to melanoma

60. Melanoma

61. Melanoma-Early detection
Total treatment costs by stage
Stage I 5.5%
Stage II 5.5%
Stage III 34%
Stage IV 55%

62. MNEMONIC FOR MALIGNANT MELANOMA RECOGNITION
A- ASYMMETRY
B- BORDER IRREGULARITY
C- VARIATION IN COLOR
D- DIAMETER> .6CM
E- ELEVATION ABOVE SKIN SURFACE

63. Melanoma with regression

64. Melanoma

65. Acral lentiginous Melanoma

66. Lentigo Maligna Melanoma

67. Venous Lake

68. Blue Nevus

69. Seborrheic Keratosis

70. Pyogenic Granuloma

71. Look everywhere

72. Melanoma Management Excisional “biopsy” 1-2 mm margins
Dermatopathologist consultation

73. Breslow’s Measurement
Depth of granular cell layer to deepest malignant cell
Strongest correlation with prognosis

74. Melanoma Managment Sentinel lymph node biopsy
1mm or greater depth, regression, >Level III or IV
Interferon
Vaccine clinical trials

75. Melanoma Management Full skin exam Family screening Follow up
Education

76. Take home points Prevent skin cancers by risk factor reduction
Early detection of pre-cancers and skin cancers can prevent morbidity and mortality
Use the appropriate biopsy technique for diagnosing skin cancers
Treat or refer based on your skills

77. Online References
Derm Online Atlas is at
Derm Image Bank is at medstat.med.utah.edu/kw/derm/
Basal Cell Carcinoma is at emedicine.com/derm/topic47.htm