1. Principles and Practice of Radiation Therapy
Chapter 40 Skin Cancers and Melanoma
Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

2. Integumentary System Overview Hypodermis Dermis Epidermis
Accessory structures
Effects of aging

3. Overview Largest organ Functions 22 square feet 10 to 12 pounds
Protection
Temperature control
Waste removal
Sensory
Vitamin D production

4. Hypodermis Subcutaneous tissue or superficial fascia
Acts as the foundation
Composition
Adipose tissue
Function
Padding
Insulation
Shape

5. Dermis
Reticular layer
Tension lines
Papillary layer

6. Epidermis Cellular composition Desquamation Keratinization
Keratinocytes
Melanocytes
Langerhans cells
Desquamation
Keratinization

7. Epidermis Stratum corneum Stratum lucidum Stratum granulosum
Stratum spinosum
Stratum basale

8. Accessory Structures Hair Muscles Types Structure Arrector pili Lanugo
Vellus
Terminal
Structure
Shaft
Root
Muscles
Arrector pili

9. Accessory Structures
Glands
Sebaceous
Sweat
Ceruminous

10. Accessory Structures Nails Purpose Structure Protection Manipulation
Scratching
Structure
Root
Body
Matrix

11. Effects of Aging Reduced blood flow Thinner skin Loosened structure
Decreased activity of glands
Decrease in melanin

12. Skin Cancer Epidemiology Etiology Clinical presentation
Detection and diagnosis
Disease classification
Pattern of spread
Treatment
Side effect management

13. Skin Cancer Types Melanoma Nonmelanoma Benign skin conditions
Basal cell carcinoma
Squamous cell carcinoma
Merkel cell carcinoma
Benign skin conditions
Actinic keratosis
Squamous cell carcinoma in situ

14. Nonmelanoma Epidemiology
Incidence
13 million new cases each year
80% basal cell carcinoma (BCC)
20% squamous cell carcinoma (SCC)
Deaths
1000 to 2000 deaths

15. Nonmelanoma Etiology Sun exposure Genetics Radiation Chemical agents
Ultraviolet B (UVB)
Artificially produced ultraviolet A (UVA)
Genetics
Hair color
Complexion
Xeroderma pigmentosum
Radiation
Chemical agents
Viruses
Human papillomavirus (HPV)
Chronic irritations

16. Nonmelanoma Clinical Presentation
Asymmetry
Border
Color
Diameter
Elevation

17. Nonmelanoma Detection and Diagnosis
Screening
Clinical examination
Self-examination
Inspect face
Check hands including nails
Women should examine under breasts
Use two mirrors to inspect back
Check legs and feet

18. Nonmelanoma Disease Classification
Staging
BCC often not staged
Pathologic staging
Tumor Node Metastasis (TNM)
Clinical staging

19. Nonmelanoma Pattern of Spread
Slow growing
Direct extension
Embryologic fusion planes
Perineural space
Nodes and metastases

20. Nonmelanoma Treatment
Surgery
Curettage and electrodesiccation
Scraping and burning
Mohs’ microscopic surgery
Cryosurgery
Temperature −50° Celsius
Recommended for bleeding or oozing skin cancers

21. Nonmelanoma Treatment
Laser surgery
Typically performed by a dermatologist
Chemotherapy
Topical
5-fluorouracil (5-FU)
Systemic
Salvage
Investigative methods
Immunotherapy
Photodynamic therapy

22. Nonmelanoma Treatment
Radiation therapy treatment
Treatment volume localization
Visualization
Palpation
Treatment margins

23. Nonmelanoma Treatment
Radiation therapy treatment
Simulation
Patient positioning
Immobilization devices
Treatment parameters
Blocking
Beam arrangement
Special considerations

24. Nonmelanoma Treatment
Radiation therapy treatment
Treatment delivery
Beam energy
Superficial
Electrons
Photons
Brachytherapy

25. Nonmelanoma Treatment
Radiation therapy treatment
Treatment delivery
Dose schedule
BCC
Smaller than 2 cm – 4500 cGy
2 to 5 cm – 5000 cGy
Larger than 5 cm – 6000 cGy
SCC
Smaller than 2 cm – 5000 cGy
2 to 5 cm – 5500 cGy
Larger than 5 cm – 6500 cGy
Lesions larger than 8 cm or with bone invasion – 6500 to 7500 cGy

26. Nonmelanoma Side Effect Management
Acute
Types of injuries
Management
Avoid trauma
Cleansing
Ointments
Chronic
Telangiectasis
Hyperpigmentation
Hair loss
Necrosis

27. Melanoma Epidemiology
Incidence is on the rise
54,200 new cases in 2003
62,190 new cases in 2006
Only 3% of all skin cancers
Most deadly skin cancer

28. Melanoma Etiology Sun exposure Moles Genetics Family history
UVB
Artificially produced UVA
Moles
Genetics
Hair color
Complexion
Family history
Immune suppression
Age
Gender
Xeroderma pigmentosum
History of melanomas

29. Melanoma Clinical Presentation
Types
Superficial spreading melanoma
Lentigo maligna
Acral lentiginous melanoma
Nodular melanoma

30. Melanoma Detection and Diagnosis
Screening
Physical examination
Imaging studies

31. Melanoma Pattern of Spread
Rapid vertical growth typical
Risk of nodal or metastatic involvement increases with increased tumor depth

32. Melanoma Disease Classification
American Joint Committee on Cancer (AJCC) − TNM
Clark’s
Breslow measurement

33. Melanoma Treatment Surgery Chemotherapy Radiation therapy
Simple excision
Reexcision
Mohs’ surgery
Amputation
Chemotherapy
Radiation therapy
Dose schedule
Hypofractionation

34. Melanoma Survival Survival by stage Stage 0 Stage I Stage II Stage III
Stage IV