Skin Caner

Fernando Vega, M.D. 1

Skin Cancer

Fernando Vega, MDSeattle Healing Arts

Precancerous lesions

Clinical characteristics

Precancerous lesionsCommon skin cancers

Precancerous skin lesionsActinic keratosesActinic keratoses

Dysplastic melanocytic nevi

ACTINIC KERATOSISCommon sun-induced premalignant neoplasm of the epidermis that occurs primarily on exposed skin

Consequence of cumulative qlong-term sun exposure

Prevalence ↑with ↑age

Men > women

Also genetic factors - ↑in fair skin and in genetic syndromes eg xeroderma pigmentosum

NATURAL HISTORY

Some lesions (10%) spontaneously regress

Some (majority) remain unchangedSome (majority) remain unchanged

Others (1-10%) progress and develop into SCC – risk increased with continued sun exposure or concurrent immunosuppression

CLINICAL FEATURESEarliest evidence is a tiny red telangiectatic spot

Then dry, rough and adherent scale

Ski l d/ d/ ll / bSkin coloured/ red/ yellow/ brown

Usually multiple

Lesions on hands and forearms tend to be thicker

Actinic change on lips=actinic chelitis

Associated with other signs of sun damage – solar elastosis, wrinkled skin, solar lentigines

Skin Caner

Fernando Vega, M.D. 2

Actinic keratoses Actinic keratoses

Actinic keratoses and SCC Actinic keratoses and SCC

Actinic keratoses and BCC Actinic keratoses

10% risk of malignant transformation

Skin Caner

Fernando Vega, M.D. 3

Hypertrophic AK’s Actinic cheilitis

Liquid nitrogen cryotherapy

Topical therapies

Treatment of AK’s

5-FU (Efudex)

Imiquimod (Aldara)

Curettage for hypertrophic lesions

Residual hypopigmentation

Liquid nitrogenCryotherapy

Blister formation

Topical therapiesEfudex or Aldara

* 3-5 times per week* 6-8 weeks

Dysplastic nevi

•Precursors for melanoma•When to biopsy

Skin Caner

Fernando Vega, M.D. 4

Biologic Events and Molecular Changes in the Progression of Melanoma

Miller A and Mihm M. N Engl J Med 2006;355:51-65

Clinical Images of Pigmented Lesions

Tsao H et al. N Engl J Med 2004;351:998-1012

Non-melanoma skin cancers

Basal cell carcinoma

Squamous cell carcinomaSquamous cell carcinoma

Keratoacanthoma

Risk factors for development of BCC and SCC

Fair skin (Fitzpatrick’s types I-III)Blue eyesRed hair

Family historyy yGenetic syndromes

Chronic sun exposure

Old age

Arsenic, tar

Basal cell carcinoma

BCC- clinical types

Nodular

SuperficialSuperficial

Morpheaform

Skin Caner

Fernando Vega, M.D. 5

Nodular BCCChronic lesion

Easy bleeding

Pearly border

Surface telangiectasias

Head and neck, trunk, and extremities

Skin Caner

Fernando Vega, M.D. 6

Superficial BCCErythematous scaly plaque

Slow growth

Asymptomatic

Trunk, extremities, face

Superficial BCC Morpheaform BCC

Resembles scar

Asymptomatic and slow growinggrowing

Ill-defined margins

Marked subclinical extension

BCC is the most frequent skin cancer (80%)

BCC is 4x more frequent than SCC

Metastases are rare (<1% of cases)

Local destruction of tissue

Treatment of BCCCurettage electrodessication (ED/C)

Surgical excisionTraditional

95% Cure Rate

Mohs surgery

Radiation therapy

Topical therapyimiquimod

50-75% Cure Rate

Skin Caner

Fernando Vega, M.D. 7

Squamous cell carcinoma

SCC types

In-situBowen’s disease

f QErythroplasia of QueyratInvasive SCCKeratoacanthoma

Bowen’s disease

In-situ SCC

Arsenic HPV 16Arsenic, HPV 16, radiation

Invasive SCC

Erythematous nodule

Indurated lesion

Sun-exposed skinMen > women

Slow growth

Invasive SCC Keratoacanthoma Low grade SCC

Rapid growth over weeks

Trauma, sun exposure, HPV 11 and 16

May progress to invasive SCC

Skin Caner

Fernando Vega, M.D. 8

SCC is locally invasive and destructive

Metastases in 1-3% of casescases

To lymph nodes50-73% survival

Distant sites (lungs)Incurable

Malignant Melanoma

Risk factorsFair skin, red hair, and blue eyes

Intermittent sun exposureSunburnsTanning beds

Freckles and melanocytic nevi

Family history of melanoma

Clinical types- MM

Superficial spreading melanomaSuperficial spreading melanoma

Lentigo maligna melanoma

Acral lentiginous melanomaNodular melanoma

ABCD of Melanoma

Asymmetry

Border irregularityBorder irregularity

Color variegation

Diameter >6mm

Clinical Images of Pigmented Lesions

Tsao H et al. N Engl J Med 2004;351:998-1012

Skin Caner

Fernando Vega, M.D. 9

Biologic Events and Molecular Changes in the Progression of Melanoma

Miller A and Mihm M. N Engl J Med 2006;355:51-65

Benign Melanocytic Neoplasms

Benign Melanocytic Neoplasms

Benign Melanocytic Neoplasms

Benign Melanocytic Neoplasms

Congenital nevus

Skin Caner

Fernando Vega, M.D. 10

Malignant Melanoma Malignant MelanomaWith Regression

Malignant MelanomaSupeerficial Spreading

Malignant Melanoma

Malignant MelanomaCiliary Body

Malignant Melanoma

Skin Caner

Fernando Vega, M.D. 11

Malignant Melanoma Malignant Melanoma

Malignant Melanoma Malignant Melanoma

Malignant Melanoma Malignant Melanoma

Skin Caner

Fernando Vega, M.D. 12

Malignant Melanoma Malignant Melanoma

Malignant Melanoma Malignant Melanoma

Malignant Melanoma LENTIGO MALIGNA

An in situ pattern of malignant melanomaOften reaches a large size before the diagnosis is madeLentigo → lentigo maligna →lentigo maligna melanoma

Skin Caner

Fernando Vega, M.D. 13

CLINICAL FEATURESBegins as a flat pigmented lesion

Usually on sun-yexposed skin of head and neck

With time the colour and border become more irregular

MANAGEMENT Surgery – excision with a wide margin

Radiotherapy

Cryotherapy (deviation from rule)

Immiquimod (by report)

Prognostic features- MMGood prognosis

Breslow < 1mm

Intermediate prognosisBreslow 1-4mm

Bad prognosisBreslow >4mm