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Skin Cancer Update 2012

Skin Cancer Update 2012. Peter Ehrnstrom, MD, FAAD, FASDS alaska center for dermatology, p.c. May 11, 2012. Types of Skin Cancer. Basal cell carcinoma (BCC) Squamous cell carcinoma (SCC) Melanoma DFSP AFX Mets (breast, colon, renal, lung, melanoma…) Unusual tumors

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Skin Cancer Update 2012

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  1. Skin Cancer Update 2012 Peter Ehrnstrom, MD, FAAD, FASDS alaska center for dermatology, p.c. May 11, 2012

  2. Types of Skin Cancer • Basal cell carcinoma (BCC) • Squamous cell carcinoma (SCC) • Melanoma • DFSP • AFX • Mets (breast, colon, renal, lung, melanoma…) • Unusual tumors • Leiomyosarcoma, 1oadenoca, malig neural sheath tumor, sebaceous carcinoma, Merkel cell ca, angiosarcoma, microcysticadnexal carcinoma

  3. Skin Cancer • Who gets skin cancer? • Genetics • Melanoma especially • Personal history • Primary relative • UV exposure • Sun, tanning beds • Early and intermittent exposure • Rare causes • Viruses • Genetic disorders • Xeroderma pigmentosa • Basal Cell Nevus Syndrome

  4. Basal Cell Carcinoma

  5. Basal Cell Carcinoma

  6. Basal Cell Carcinoma

  7. Basal Cell Carcinoma

  8. Squamous Cell Carcinoma

  9. Squamous Cell Carcinoma

  10. Mohs Surgery • Developed in 1930s by Frederic Mohs at University of Wisconsin • Highest cure rates for contiguously growing tumors while being tissue sparing as well • Labor- and time-intensive

  11. Classic breadloafing

  12. False negative in breadloafing

  13. Mohs slide preparation

  14. Mohs slide preparation

  15. Mohs for SCC

  16. Mohs for SCC

  17. Mohs for SCC

  18. Mohs for BCC

  19. Mohs for BCC

  20. Mohs for BCC

  21. Indications for Mohs • Head and neck • >2 cm elsewhere • Aggressive growth tumors • Recurrent tumors • Ill-defined margins

  22. Sonic Hedgehog and BCC • SHH signaling crucial for embryo development • Left-right and up-down • SHH signaling in adult necessary for normal stem cell growth • Abnormal signaling likely turns adult stem cells into cancer stem cells—especially in skin (leading to BCC) but also in brain, lung, breast and prostate

  23. Difficult BCCs

  24. Vismodegib (Erivedge®) • Therapy for metastatic BCC, intractable or inoperable/otherwise untreatable BCC • Competitive antagonist of one of the receptors in the SHH-signaling pathway • Prevents expression of genes leading to tumor growth from abnormal SHH-signaling • Possible uses in many other tumors • Drugs causing opposite effect might be helpful post-MI or post-stroke

  25. Melanoma

  26. Melanoma

  27. Melanoma treatment • In situ • 0.5-cm margins • > in situ but <1.0 mm with no “bad signs” • 1.0-cm margins • 1.0-4.0 mm with no bad signs • At least 1.0-cm margins + SLN bx • >4.0 mm • Add possible interferon • Any depth with mets • Interferon and/or immunotherapy and/or GMCSF • Possibly vemurafenib • Bad signs • Ulceration, high mitotic rate, and possibly regression

  28. Vemurafenib (Zelboraf®) • ~60% of melanomas have mutation at  V600E BRAF gene (glutamic acid instead of valine) • Vemurafenib inhibits one of the steps in the B-Raf pathway thereby leading to programmed cell death • May actually promote tumor growth in melanomas without this mutation • Very helpful but resistance develops

  29. Protection From DNA Damage That Leads to Cancer • Behavior modification • Clothing and hats • Sunscreen • Bottom line: Don’t change the color of your skin through radiation exposure!

  30. Myths • Indoor tanning is safe • I need 15 minutes of sun exposure per day to keep my vitamin D levels up • Pre-tanning will make my vacation exposure safer

  31. Skin Cancer Update 2012 Peter Ehrnstrom, MD, FAAD, FASDS alaska center for dermatology, p.c. May 11, 2012

  32. Peter Ehrnstrom, MDPeggy O’Reilly, MDRobert Moreland, MDKim Kinnebrew, PA-CCarmen T’Joens, PA-C (907) 646-8500

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