1. Skin cancers

2. Outline Basal cell carcinoma Squamous cell carcinoma
Cutaneous T-cell Lymphoma
Paget’s & Extramammary Paget’s
Cutaneous metastases
Melanoma

3. Basal Cell Carcinoma

4. Basal Cell Carcinoma Most common skin malignancy Demographics
Metastasis extremely rare – %
locally invasive & destructive
Demographics
older persons
increasing in those <40
Often on sun-exposed areas
85% on head/neck, esp nose
Can occur on sun-protected areas

5. Basal Cell CA Clinical subtypes: Nodular – most common Pigmented
Sclerosing or Morpheaform
Superficial

6. Nodular BCC Most common
Pearly, white or pink, telangiectases, rolled borders, center can ulcerate

7. Pigmented BCC Brown, blue, or black
Dark-complexioned persons – Hispanics, Asians
Borders still pearly with telangiectases
DDx: Melanoma

8. Sclerosing/Morpheaform BCC
Pale yellow/white, waxy, firm, depressed and scar-like, indistinct borders
History of prior cryotherapy
Need Mohs or wide excision

9. Superficial BCC Least aggressive, but can be difficult to diagnose
Mimic eczema or psoriasis
Alcohol swab reveal pearly border + telangiectases

10. Treatment Modalities Imiquimod (Aldara):
FDA-approved for superficial BCC
little or no scarring, spares tissue
variable or unpredictable response
Electrodessication & Curettage (ED&C):
Best for nodular and small superficial forms
Leaves a noticeable scar
Best for low risk sites – trunk, extremities

11. Treatment Modalities Excision: Mohs micrographic surgery
Offers standard margin check
Large long scar
Mohs micrographic surgery
Tissue sparing procedure
Gold standard with 100% margin check
Expensive, labor intensive
Reserved for:
High risk sites
Head & neck, shins, hands, tight areas
High risk subtypes
Recurrent disease
Aggressive histology
Sclerosing, infiltrating, micronodular, basosquamous

13. Squamous Cell Carcinoma

14. What is the precursor lesion for squamous cell carcinoma?
Actinic keratosis

15. Actinic Keratosis Partial thickness epidermal atypia
Sun exposure, immunosuppressed
Erythematous scaly papules, not indurated
Smaller lesions often easier felt than seen
Can be hypertrophic or even tall (cutaneous horn)

16. AK Management Sun protection Cryotherapy – best for isolated lesions
Multiple or extensive lesions:
5-fluorouracil (5-FU/Efudex)
Imiquimod (Aldara)
Solaraze/Diclofenac – milder reaction than Efudex
Chemical peels – pain; wound care
Photodynamic therapy (PDT) – pain, minimal wound care, expensive

17. Why we treat AKs… 1-5% risk of SCC transformation per year
More likely in hypertrophic AK
Suspicious for transformation:
Induration
Oozing, easy bleeding
Recurrent after cryosurgery

18. Squamous Cell Carcinoma
2nd most common skin cancer
High association
UV exposure
located mostly on sun-exposed sites
scalp, forehead, dorsal nose, superior ears, dorsal hands
Prior radiation
Marjolin’s ulcer
SCC arising on sites of burns, chronic wound/inflammation
Immunosuppression (SCC >> BCC)
Transplant patients

19. Squamous Cell Carcinoma
Scaly papules or plaques with induration, erosion, bleeding
May be tender
Recurrent after cryosurgery

20. Squamous Cell Carcinoma
Local spread can be extensive
Follows path of least resistance
Subcutaneous & fascial planes, perineural, perichondrium/periosteum, perivascular
Treatment similar to BCC except:
4-6 mm margins for standard excision
Electrodessication & curettage
for small, thin SCC’s in low risk areas

21. SCC Metastasis rate: up to 5.2% Lymphatics & hematogenous
Higher risk lesions:
Size > 2 cm
Depth > 4 mm
Aggressive histology
Lip or ear location
Immunosuppressed
Prior XRT
Burns or chronic inflammation

22. Bowen’s Disease Squamous cell carcinoma in-situ
full thickness atypia
Well-demarcated, erythematous, scaly, thin papules/plaques
Most common on legs of women & scalp/ears of men
Mimic psoriasis or eczema

23. Bowen’s Disease Grows slowly, can become invasive SCC Treatment
Small lesions – ED&C, 5-FU, Aldara
Large lesions – Excision, 5-FU, Aldara

24. Erythroplasia of Queyrat
SCC in-situ of penis or vulva
Moist glistening, red, thin plaque (under foreskin)
Grows slowly, can become invasive
Treatment
Aldara or 5-fluorouracil (5-FU)
Mohs if around or into urethra

25. Keratoacanthoma Smooth dome-shaped nodule with keratin-filled crater
Rapid growth/expansion  regresses with scarring

26. Keratoacanthoma Considered as a well-differentiated form of SCC
Treatment
ED&C, blunt dissection, or excision
Intralesional injections
5-FU, Bleomycin, MTX

27. Verrucous Carcinoma Exophytic, slow-growing, low-grade SCC
Rarely metastasize
Often mistaken for warts
Treatment:
Excision
Avoid XRT, risk of aggressive transformation

28. Verrucous Carcinoma 3 subtypes: Buschke-Lowenstein
Genital form
HPV 6, 11
Oral florid papillomatosis
tobacco chewing
poor oral hygiene
Epithelioma cuniculatum
Plantar feet
Older men

29. Arsenical Keratoses Discrete round keratoses
Appear 20 yrs after chronic arsenic exposure
Most common on palms and soles
Not fatal, but may persist indefinitely
Pain, bleeding, fissuring, and ulceration
Rare in US
More common in 3rd world
Risk of SCC degeneration

30. Cutaneous T-cell Lymphoma

31. Cutaneous T-Cell Lymphoma
Malignant T-cells with cutaneous lymphoid antigen (CLA) localize to skin
Most common form of CTCL is mycosis fungoides
4 stages
Pre-MF
Patch
Plaque
Tumor
Prognosis good for first 2 stages then worsens

32. Cutaneous T-Cell Lymphoma
Erythroderma can occur in any stage
Lesions like persistent eczema/tinea, often sun-protected areas
Difficult to diagnose in early stages
Average of 6 biopsies before diagnosis made
Clinical & histology difficult to distinguish from other inflammatory disorders
Monoclonality on T-cell gene rearrangement study is helpful

33. Mycosis Fungoides Pre-MF: diagnosis suspected but not proven
Nonspecific pruritis and/or eruption
Persists or recurs over months to years
Can mimic eczema

34. Mycosis Fungoides “Patch” stage: diagnosis possible with histo
Similar morphology pre-MF
Poikiloderma vasculare atrophicans: variant of MF

35. Mycosis Fungoides Plaque stage: thickening of epidermis
Dusky red-brown plaques with variety of shapes
Pruritis can be intense
Can remain stable, regress, or progress

36. Mycosis Fungoides Tumor stage
may progress from patch or plaque stage lesions or arise de novo
Necrosis/ulceration possible

37. Mycosis Fungoides Sezary syndrome leukemic form MF Triad: Erythroderma
Lymphadenopathy
Sezary cells
lymphocytes with cerebriform nuclei

38. MF Treatment Patch stage: Generalized lesions
Group I topical steroids, topical nitrogen mustard, Bexarotene (RXR retinoid)
Generalized lesions
PUVA/UVB
Electron beam radiation
patch/plaque/tumor
most reliable for generalized; high relapse, side-effects
Extracorporeal photophoresis
Sezary syndrome & erythrodermic MF
PUVA of extracted lymphocytes then reinfused into patient

39. Paget’s Disease

40. Paget’s Disease of the Breast
Invasion of skin from underlying breast cancer
Unilateral nipple erythema with serous drainage
Appears eczematous, but fixed & indurated with sharp margins

41. Paget’s Disease of the Breast
Often confused with eczema of the breast
Good diagnostic test:
Trial of potent steroid (Lidex or Clobetasol) x 2 weeks
If improved or resolved  most likely eczema
If not  need to biopsy to exclude malignancy
Treatment:
Excision

42. Extramammary Paget’s Disease
Usually genital or perianal area
Associated with underlying malignancy
Location related to internal CA
Perianal – GI malignancy
Genital – GU malignancy

43. Extramammary Paget’s Disease
White-to-red scaling or macerated plaque
Often persistent itching or burning
Treatment
Excision, XRT

44. Cutaneous Metastases

45. Cutaneous Metastases
Usually present as asymptomatic, firm, deep nodules
Metastases to skin in 2-10%
Most common primaries:
Women:
Breast (69%)
Colon (9%)
Melanoma (5%)
Ovarian (4%)
Men:
Lung (24%)
Colon (19%)
Melanoma (13%)
SCC oral cavity (12%)

46. Cutaneous Metastases Primary tumors that metastasize to scalp
Thyroid carcinoma (especially papillary carcinoma)
Renal cell carcinoma
Nodules with alopecia

47. Cutaneous Metastases Metastasis to the umbilicus
Sister Mary Joseph’s nodule
solitary, firm, fissured nodules
represents advanced disease and carries a very poor prognosis
Adenocarcinoma of the stomach
Adenocarcinoma of the large bowel
Ovary
Pancreas
Endometrium
Breast

48. Cutaneous Metastases Breast metastasis to skin has variable appearance
Resemble cellulitis
Carcinoma en cuirasse
hard infiltrated plaque with leathery appearance

50. Melanoma

51. Melanoma Malignancy of melanocytes May metastasize to any organ
skin >>> eyes, GI tract, and oral/genital mucosa
May metastasize to any organ
Incidence of melanoma has tripled for Caucasians in the last 40 years
Highest incidence in Australia and New Zealand

52. Melanoma Accounts for 75% of skin cancer deaths in US
Median age at = 53 years
Most common cancer in women aged 25 to 29
Risk factors
Family history/genetics
People who do not tan or sunburn easily
Increased UV exposures and sunburns
intermittent UV exposures may be at highest risk

53. ABCDE of Melanoma Evolution over time Asymmetry Border irregularity
Goal of this effort is to recognize more melanomas at an early stage
Asymmetry
Border irregularity
Color variation
Diameter enlargement
Evolution over time

54. ABCDE of Melanoma Other factors that should provoke a biopsy:
Erosion or ulceration
Scaling
Bleeding
Loss of normal skin lines
Sudden development of pruritus, tenderness, or pain
Patient report that “it just feels different”

55. Melanoma Types Based upon clinical and histological appearance
Superficial Spreading
Lentigo Maligna
Nodular
Acral Lentiginous

56. Superficial Spreading Melanoma
Most common type
4th to 5th decade
May develop anywhere on the body
Early radial growth  Late vertical growth
Location:
Trunk in men and women
Extremities (legs) in women
Characterized by variation in color and shape

57. Superficial Spreading Melanoma

58. Superficial spreading melanoma

59. Superficial Spreading Melanoma

60. Superficial Spreading Melanoma

61. Superficial Spreading Melanoma

62. Nodular Melanoma 5th and 6th decade of life 15-20% of melanomas
Males > females
May be found anywhere, but more often on the trunk and legs
Most commonly dark brown, red-brown, red-black or flesh colored
Dome shaped, polypoid or pedunculated
Often rapidly growing, friable, ulcerated, and oozing blood

63. Nodular Melanoma

64. Nodular Melanoma

65. Nodular Melanoma

66. Lentigo Maligna Melanoma
6th or 7th decade of life
4-15 % of melanomas
Most common on the face
Extended radial growth phase
long period of melanoma-in-situ
Vertical growth usually begins in the central portion of the lesion

67. Lentigo Maligna Melanoma

68. Lentigo Maligna Melanoma

69. Lentigo Maligna Melanoma

70. Acral Lentiginous Melanoma
Palms, soles, terminal phalanges, mucous membranes
2-8% of melanomas in whites
30-75% of melanomas in more darkly pigmented patients
Sudden appearance of a pigmented nail band is suspicious for melanoma

71. Acral Lentiginous Melanoma

72. Acral Lentiginous Melanoma

73. Acral Lentiginous Melanoma
Hutchinson’s sign
spread of pigment to the lateral or proximal nail fold in association with nail plate pigmentation

74. What do you do with this patient?
Atypical Mole Syndrome and Familial Melanoma

75. Atypical Mole Syndrome and Familial Melanoma
Family members with large numbers of atypical moles and tendency to develop thin, superficial spreading melanomas
32,000 patients in the US
5.5% of all melanomas

76. Atypical Mole Syndrome and Familial Melanoma
Definition
Melanoma in one or more 1st degree relatives
More than 50 nevi, with many having atypical appearance
Nevi with characteristic histological features
100% lifetime risk of melanoma
Remember:
Most atypical nevi occur sporadically in people without personal or family history of melanoma

77. Atypical Mole Syndrome and Familial Melanoma
Management
Refer to dermatology
Total body photography
Low threshold for biopsy
Extensive patient education on:
Sun protection
Self skin examination
Suggest screening of relatives

78. Melanoma Evaluation Refer all suspicious lesions to dermatology
Biopsy should include evaluation of deep dermis – we try to avoid shave biopsies
Excisional
Incisional
Punch

79. Melanoma Evaluation The most important prognostic factors
Breslow Depth
Depth of invasion
Measured from granular layer to the deepest invasive component and expressed in millimeter
Presence of ulceration upstages the tumor

80. Melanoma Evaluation Sentinel lymph node biopsy Other evaluation
indicated for thicker melanoma > 1 mm
helpful in staging
provides prognostic information
identifying those who may benefit from further surgery or adjuvant therapy
Other evaluation
LFTs
Chemistry
CBC
Imaging studies
PET scan and yearly CXR

81. Melanoma Management
Wide local excision is the primary treatment for melanoma
Adjuvant high-dose interferon alpha-2b may be indicated in certain patients
Rarely, radiation therapy may be used, especially in LMM
Vaccine trials are ongoing

82. Melanoma Management
Close follow up with history and physical at regular intervals is essential
Recurrence may develop up to 10 years after the primary diagnosis
Patients with diagnosis of melanoma and non-melanoma skin cancer in the past have increased risk for future melanoma

83. Quiz

84. Basal cell carcinoma

85. Keratoacanthoma

86. Lentigo maligna

87. Basal cell carcinoma

88. Superficial spreading melanoma

89. Sister Mary Joseph’s Nodule

90. Cutaneous horn

91. Nodular melanoma

92. Be kind to your skin!