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Skin cancers

Skin cancers. Outline. Basal cell carcinoma Squamous cell carcinoma Cutaneous T-cell Lymphoma Paget’s & Extramammary Paget’s Cutaneous metastases Melanoma. Basal Cell Carcinoma. Basal Cell Carcinoma. Most common skin malignancy Metastasis extremely rare – 0.0028-0.55%

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Skin cancers

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  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 • Metastasis extremely rare – 0.0028-0.55% • 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: • 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

  12. Squamous Cell Carcinoma

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

  14. 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)

  15. 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

  16. 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

  17. 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

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

  19. 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

  20. 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

  21. 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

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

  23. 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

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

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

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

  27. 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

  28. 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

  29. Cutaneous T-cell Lymphoma

  30. 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

  31. 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

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

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

  34. 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

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

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

  37. MF Treatment • Patch stage: • 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

  38. Paget’s Disease

  39. 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

  40. 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

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

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

  43. Cutaneous Metastases

  44. 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%)

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

  46. 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

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

  48. Melanoma

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