Post on 11-Jan-2016
description
Precancers and Skin CancersPrecancers and Skin Cancers
Adam O. Goldstein, MD, MPHAdam O. Goldstein, MD, MPHAssociate ProfessorAssociate Professor
Family MedicineFamily Medicine
University of North Carolina at Chapel HillUniversity of North Carolina at Chapel Hill
aog@med.unc.eduaog@med.unc.edu
Actinic KeratosesActinic Keratoses
premalignant skin lesions = premalignant skin lesions = “keratinocytic “keratinocytic intraepidermal neoplasia”intraepidermal neoplasia”
chronic sun, radiation or chronic sun, radiation or polycyclic aromatic polycyclic aromatic hydrocarbonshydrocarbons
Skin Type I-II Skin Type I-II organ transplantorgan transplant
Actinic KeratosisActinic Keratosis
Actinic KeratosesActinic Keratoses Distribution: Sunexposed, esp. dorsa Distribution: Sunexposed, esp. dorsa
hands/forearmshands/forearms Description: papules,plaques with scale and Description: papules,plaques with scale and
erythema, occasional crust or cutaneous hornerythema, occasional crust or cutaneous horn Sandpapery feelSandpapery feel
Actinic KeratosesActinic Keratoses
epidermal atypiaepidermal atypia abnormal maturationabnormal maturation
Actinic KeratosesActinic Keratoses
60% predisposed >40 have at least 1 AK60% predisposed >40 have at least 1 AK 6-10% lifetime >> invasive SCC6-10% lifetime >> invasive SCC >10 AK - 14% an SCC w/n 5 yrs>10 AK - 14% an SCC w/n 5 yrs 60-97% of SCC from AK60-97% of SCC from AK ~ 40% of met SCC>> AK~ 40% of met SCC>> AK ^ aggressive immsupp^ aggressive immsupp
Actinic KeratosesActinic Keratoses
lip lesions: actinic cheilitis/leukoplakialip lesions: actinic cheilitis/leukoplakia white plaques-mucosa white plaques-mucosa persistent scaling lesions on the lippersistent scaling lesions on the lip ^ aggressive behavior^ aggressive behavior tobacco/suntobacco/sun
Differential DiagnosisDifferential Diagnosis
squamous cell carcinoma: more indurated, squamous cell carcinoma: more indurated, thicker, recurrence of AK after treatmentthicker, recurrence of AK after treatment
Differential Diagnosis Differential Diagnosis
seborrheic keratosis: hyperpigmented,more seborrheic keratosis: hyperpigmented,more stuck on appearingstuck on appearing
Differential DiagnosisDifferential Diagnosis
nummular eczema: coin-shaped scaling lesions; nummular eczema: coin-shaped scaling lesions; responds to emollients/topical corticosteroidsresponds to emollients/topical corticosteroids
AK TreatmentAK Treatment
PREVENTIONPREVENTION Screen for skin cancersScreen for skin cancers Broad-brimmed hatsBroad-brimmed hats sun protective clothingsun protective clothing sunscreenssunscreens avoidance of sunlightavoidance of sunlight ed s/sx skin cancered s/sx skin cancer avoidance of tobaccoavoidance of tobacco low fat diet?low fat diet?
AK TreatmentAK Treatment
CCryosurgery(liquid nitrogen)ryosurgery(liquid nitrogen) 5-fluorouracil cream or solution5-fluorouracil cream or solution Diclofenac Sodium-3% gelDiclofenac Sodium-3% gel Imiquimod 2 x week/ 16 weeksImiquimod 2 x week/ 16 weeks
AK TreatmentAK Treatment
Excision Excision ElectrocauteryElectrocautery CurettageCurettage Carbon dioxide laserCarbon dioxide laser
AK TreatmentAK Treatment
Chemical peelsChemical peels Photodynamic therapy Photodynamic therapy Retinoids-topical/oralRetinoids-topical/oral Investigational-dimericineInvestigational-dimericine
TREATMENTTREATMENT
Liquid Nitrogen-AdvantagesLiquid Nitrogen-Advantages cure rates of 98.8% cure rates of 98.8% commoncommon minimal patient edminimal patient ed multiple/thicker lesionsmultiple/thicker lesions quick recoveryquick recovery
TREATMENTTREATMENT
Liquid Nitrogen-DisadvantagesLiquid Nitrogen-Disadvantages storagestorage painpain pigment alterationpigment alteration trainingtraining
5-Fluorouracil5-Fluorouracil
Cure 50-80%Cure 50-80% Blocks methylation Blocks methylation
reaction of reaction of deoxyuridylic acid to deoxyuridylic acid to thymidilic acidthymidilic acid
DNA (and RNA) DNA (and RNA) synthesissynthesis
Diclonfenac Sodium 3% Topical GelDiclonfenac Sodium 3% Topical Gel
mechanism of action mechanism of action unknownunknown
NSAIDNSAID inhibition of cyclo-inhibition of cyclo-
oxygenase >>>PGE-oxygenase >>>PGE-22 90 days BID--overall 90 days BID--overall
33-47% clearance vs 33-47% clearance vs 10-19% vehicle10-19% vehicle
avoid ASA triadavoid ASA triad hypersensitivityhypersensitivity
Photodynamic therapyPhotodynamic therapy
(Pariser DM - J Am Acad Dermatol -2003)
Cycle therapy of actinic keratoses of the face and scalp Cycle therapy of actinic keratoses of the face and scalp with 5% topical imiquimod cream: An open-label trial.with 5% topical imiquimod cream: An open-label trial.
Salasche SJ et al Am Acad Dermatol 2002;47:571-7.
Significant irritation
Rest periods required
Evolving protocols
Expensive
Effective
Skin Cancer StatisticsSkin Cancer Statistics
>1 million cases/yr>1 million cases/yr
>50% of all new cancers >50% of all new cancers
1 in 5 Americans will develop skin cancer1 in 5 Americans will develop skin cancer
Types of Skin CancersTypes of Skin Cancers
Basal Cell Carcinoma - 80%Basal Cell Carcinoma - 80% Squamous Cell Carcinoma - 16%Squamous Cell Carcinoma - 16% Melanoma - 4%Melanoma - 4%
BCC /SCCBCC /SCC
Most common skin cancers Most common skin cancers Most important risk factors Most important risk factors
sun exposure sun exposure family history family history skin typeskin type
Incidence of these cancers increase with Incidence of these cancers increase with age, probably related to cumulative sun age, probably related to cumulative sun exposure exposure
Basal Cell CarcinomaBasal Cell Carcinoma
the most common skin cancer the most common skin cancer 90% appear on face, ears, head90% appear on face, ears, head
Main Types Basal Cell Main Types Basal Cell Carcinomas Carcinomas
Nodular BCCs - most common typeNodular BCCs - most common type Sclerosing BCCs (morpheaform)Sclerosing BCCs (morpheaform) Superficial BCCsSuperficial BCCs
Pattern of Nodular BCC Pattern of Nodular BCC
raised pearly white, raised pearly white, smooth translucent smooth translucent surface with surface with telangiectasias telangiectasias
Pattern of Nodular BCCs Pattern of Nodular BCCs
may ulcerate leaving may ulcerate leaving a small bloody crusta small bloody crust
may be pigmentedmay be pigmented
Pattern of Sclerosing BCCs Pattern of Sclerosing BCCs
ivory or colorlessivory or colorless flat or atrophicflat or atrophic induratedindurated may resemble scarsmay resemble scars are easily overlookedare easily overlooked
Pattern of Sclerosing BCCs Pattern of Sclerosing BCCs
ivory or colorlessivory or colorless flat or atrophicflat or atrophic induratedindurated may resemble may resemble
scarsscars are easily are easily
overlookedoverlooked
Pattern of Superficial BCCs and SCC in Pattern of Superficial BCCs and SCC in
situsitu red or pink scaling red or pink scaling
plaquesplaques occasionally with occasionally with
shallow erosions or shallow erosions or crustscrusts
differentiation differentiation between these two between these two similar lesions usually similar lesions usually requires a biopsyrequires a biopsy
Pigmented BCCsPigmented BCCs
may look like may look like melanomamelanoma
increased brown or increased brown or black pigmentblack pigment
seen more commonly seen more commonly in dark-skinned in dark-skinned individualsindividuals
Differential Diagnosis of Nodular BCCDifferential Diagnosis of Nodular BCC
Intradermal nevusIntradermal nevus Sebaceous hyperplasiaSebaceous hyperplasia Fibrous papule of the faceFibrous papule of the face trichoepitheliomatrichoepithelioma
Differentiating Intradermal Nevus from Differentiating Intradermal Nevus from Nodular BCCNodular BCC
Intradermal nevusIntradermal nevus Stable sizeStable size SoftSoft No crusting or No crusting or
ulcerationulceration May have May have
telangiectasiastelangiectasias
Differentiating Intradermal Nevus from Nodular Differentiating Intradermal Nevus from Nodular BCCBCC
Intradermal nevusIntradermal nevus Stable sizeStable size SoftSoft No crusting or No crusting or
ulcerationulceration May have May have
telangiectasiastelangiectasias
Sebaceous Hyperplasia from Nodular Sebaceous Hyperplasia from Nodular
BCCBCC Sebaceous Sebaceous
hyperplasiahyperplasia yellow colorationyellow coloration stable sizestable size umbilication without umbilication without
ulcerationulceration is hard to see after is hard to see after
injecting anesthesiainjecting anesthesia
Diagnosis of Basal Cell Diagnosis of Basal Cell CarcinomasCarcinomas
Shave biopsyShave biopsy nodularnodular thick superficial typesthick superficial types
Punch biopsyPunch biopsy morpheaformmorpheaform flat superficial typesflat superficial types
Treatment options for Basal Cell Treatment options for Basal Cell CarcinomasCarcinomas
C + D after a shave biopsyC + D after a shave biopsy Cryotherapy with thermocouple if you have Cryotherapy with thermocouple if you have
experienceexperience Excision with 3- 5 mm marginsExcision with 3- 5 mm margins Superficial trunk/ext: imiquimod qd x 12 Superficial trunk/ext: imiquimod qd x 12
wkswks Mohs for recurrent BCC and areas of Mohs for recurrent BCC and areas of
cosmetic importancecosmetic importance
Mohs micrographic surgeryMohs micrographic surgery
removal of tumor by scalpel in sequential removal of tumor by scalpel in sequential horizontal layers. horizontal layers.
each tissue sample is frozen, stained, and each tissue sample is frozen, stained, and microscopically examinedmicroscopically examined
repeated until all the margins are clearrepeated until all the margins are clear treatment of choice for BCCs with poorly treatment of choice for BCCs with poorly
defined marginsdefined margins especially those on the nose or eyelidsespecially those on the nose or eyelids
Recurrence rates after Tx of Recurrence rates after Tx of BCCsBCCs
C + D 10%C + D 10% Cryotherapy 10%Cryotherapy 10% Excision 2 - 5%Excision 2 - 5% Imiquimod ???Imiquimod ??? Mohs <1%Mohs <1%
Factors that increase Factors that increase recurrence ratesrecurrence rates
sclerosing vs otherssclerosing vs others larger size of BCClarger size of BCC marginsmargins experience of the surgeonexperience of the surgeon
Sclerosing BCC is most Sclerosing BCC is most dangerousdangerous
tend to be deeply invasivetend to be deeply invasive often not diagnosed until they have often not diagnosed until they have
caused extensive damagecaused extensive damage invade muscle, nerve, and boneinvade muscle, nerve, and bone nodular BCC can also invade deeply nodular BCC can also invade deeply
Bowen’s disease - featuresBowen’s disease - features
SCC in situSCC in situ Mainly sun Mainly sun
exposed areasexposed areas Slightly elevated Slightly elevated
red scaly plaque red scaly plaque with well-with well-demarcated demarcated bordersborders
Bowen’s disease - featuresBowen’s disease - features
May resemble psoriasis, superficial BCC, May resemble psoriasis, superficial BCC, chronic eczema, SKchronic eczema, SK
Curable using C & D, cryo, 5-FU, Curable using C & D, cryo, 5-FU, imiquimod, excisionimiquimod, excision
KeratoacanthomaKeratoacanthoma
Appear suddenly, grow rapidlyAppear suddenly, grow rapidly Central crater with keratin plugCentral crater with keratin plug May grow to 2cm in sizeMay grow to 2cm in size May resolve spontaneouslyMay resolve spontaneously May look like SCCMay look like SCC
KeratoacanthomaKeratoacanthoma
C and DC and D elliptical excisionelliptical excision 5-FU topically tid5-FU topically tid 5-FU intralesional injection5-FU intralesional injection
Location of SCCs Location of SCCs
Same distribution as Same distribution as bccs. bccs.
Especially on the lips, Especially on the lips, ears, and scalp ears, and scalp
Initially grow by direct Initially grow by direct extension extension
Metastasize to local Metastasize to local lymph nodes and then lymph nodes and then to distant sitesto distant sites
SCCs with an increased risk of SCCs with an increased risk of metastasis metastasis
larger, advanced lesionslarger, advanced lesions SCC on mucous membranes (in the oral SCC on mucous membranes (in the oral
cavity, on the lips) cavity, on the lips) BCCs rarely metastasizeBCCs rarely metastasize
SCC more aggressive (local & SCC more aggressive (local & mets)mets)
Size >2 cmSize >2 cm SCC in a scarSCC in a scar Patient is immunosuppressedPatient is immunosuppressed Poorly differentiated Poorly differentiated There is perineural invasionThere is perineural invasion
Importance of early diagnosis of Importance of early diagnosis of BCC and SCCBCC and SCC
especially in facial cancers especially in facial cancers the nose is the single most frequent site the nose is the single most frequent site
of BCCof BCC reconstruction is difficultreconstruction is difficult extension into underlying bone and cartilage extension into underlying bone and cartilage
may occurmay occur
The differential diagnosis of superficial BCC The differential diagnosis of superficial BCC
and SCC in situand SCC in situ Actinic keratosis, nummular Actinic keratosis, nummular
eczemaeczema Nummular eczema can usually Nummular eczema can usually
be distinguished by its coin-like be distinguished by its coin-like shape, transient nature, and shape, transient nature, and itchinessitchiness
Biopsy any thickened and Biopsy any thickened and crusting actinic keratosis to crusting actinic keratosis to rule out BCC or SCCrule out BCC or SCC
Treatment options for SCCTreatment options for SCC
C + D after a shave biopsyC + D after a shave biopsy cryotherapy with thermocouple if you cryotherapy with thermocouple if you
have experiencehave experience excision with 5 mm marginexcision with 5 mm margin Mohs for recurrent SCC and areas of Mohs for recurrent SCC and areas of
cosmetic importancecosmetic importance
Erythroplasia of QueyratErythroplasia of Queyrat
SCC in situ on the SCC in situ on the penispenis
Usually under the Usually under the foreskin of the foreskin of the uncircumcised penisuncircumcised penis
May occur on the May occur on the vulvavulva
5-FU, imiquimod or 5-FU, imiquimod or mohsmohs
Indications for Referral for Mohs SurgeryIndications for Referral for Mohs Surgery
Indications for Referral for Mohs Indications for Referral for Mohs SurgerySurgery
Recurrent tumors, sclerosing BCCRecurrent tumors, sclerosing BCC Primary tumors in locations with high Primary tumors in locations with high
tumor-recurrence ratestumor-recurrence rates Nasolabial fold,temple, periauricular area, Nasolabial fold,temple, periauricular area,
periocular area, scalp, nasal alae, center faceperiocular area, scalp, nasal alae, center face Preservation of normal tissue is vital (for Preservation of normal tissue is vital (for
cosmetic and functional reasons)cosmetic and functional reasons) Nose, eyelids, lips, fingers, ears, penisNose, eyelids, lips, fingers, ears, penis
When to consider referralWhen to consider referral
Aggressive and recurrent skin cancersAggressive and recurrent skin cancers A large skin cancer lesionA large skin cancer lesion A lesion located in a sensitive area A lesion located in a sensitive area
(cosmetic or functional)(cosmetic or functional) When treatment or diagnosis of the lesion When treatment or diagnosis of the lesion
is beyond the scope of one’s skillsis beyond the scope of one’s skills If mohs surgery is the treatment of choiceIf mohs surgery is the treatment of choice
Melanoma Risk FactorsMelanoma Risk Factors
Family historyFamily history Personal historyPersonal history Atypical NeviAtypical Nevi Blistering SunburnsBlistering Sunburns Type 1 skinType 1 skin
History of a changing lesionHistory of a changing lesion
Melanoma StatisticsMelanoma Statistics
Fastest rising incidence ratesFastest rising incidence rates
Most common cancer in 25-9 y/oMost common cancer in 25-9 y/o
2nd only to breast CA in 30-4 y/o women2nd only to breast CA in 30-4 y/o women
Melanoma FactsMelanoma Facts
87,900 new cancers87,900 new cancers 34,300 in situ34,300 in situ 53,600 invasive53,600 invasive 4% increase from 20014% increase from 2001
7400 deaths in 2003 due to melanoma7400 deaths in 2003 due to melanoma
MelanomaMelanoma
Melanoma-Early detectionMelanoma-Early detection
Total treatment costs by stageTotal treatment costs by stage Stage I 5.5%Stage I 5.5% Stage II 5.5%Stage II 5.5% Stage III 34%Stage III 34% Stage IV 55%Stage IV 55%
MNEMONIC FOR MALIGNANT MNEMONIC FOR MALIGNANT MELANOMA RECOGNITIONMELANOMA RECOGNITION
A- ASYMMETRY A- ASYMMETRY B- BORDER IRREGULARITYB- BORDER IRREGULARITY C- VARIATION IN COLORC- VARIATION IN COLOR D- DIAMETER> .6CMD- DIAMETER> .6CM E- ELEVATION ABOVE SKIN SURFACEE- ELEVATION ABOVE SKIN SURFACE
Melanoma with regressionMelanoma with regression
MelanomaMelanoma
Acral lentiginous MelanomaAcral lentiginous Melanoma
Lentigo Maligna MelanomaLentigo Maligna Melanoma
Venous LakeVenous Lake
Blue NevusBlue Nevus
Seborrheic KeratosisSeborrheic Keratosis
Pyogenic GranulomaPyogenic Granuloma
Look everywhereLook everywhere
Melanoma ManagementMelanoma Management
Excisional “biopsy”Excisional “biopsy” 1-2 mm margins1-2 mm margins Dermatopathologist consultationDermatopathologist consultation
Breslow’s MeasurementBreslow’s Measurement
Depth of granular cell layer to deepest Depth of granular cell layer to deepest malignant cellmalignant cell
Strongest correlation with prognosisStrongest correlation with prognosis
Melanoma ManagmentMelanoma Managment
Sentinel lymph node biopsySentinel lymph node biopsy 1mm or greater depth, regression, 1mm or greater depth, regression,
>Level III or IV>Level III or IV InterferonInterferon Vaccine clinical trialsVaccine clinical trials
Melanoma ManagementMelanoma Management
Full skin examFull skin exam Family screeningFamily screening Follow upFollow up EducationEducation
Take home pointsTake home points
Prevent skin cancers by risk factor Prevent skin cancers by risk factor reductionreduction
Early detection of pre-cancers and skin Early detection of pre-cancers and skin cancers can prevent morbidity and cancers can prevent morbidity and mortalitymortality
Use the appropriate biopsy technique for Use the appropriate biopsy technique for diagnosing skin cancersdiagnosing skin cancers
Treat or refer based on your skills Treat or refer based on your skills
Online ReferencesOnline References
Derm Online Atlas is at Derm Online Atlas is at www.dermis.net/www.dermis.net/bilddbbilddb/index_e./index_e.htmhtm
Derm Image Bank is at Derm Image Bank is at medstat.med.utah.edu/kw/derm/medstat.med.utah.edu/kw/derm/
Basal Cell Carcinoma is at Basal Cell Carcinoma is at emedicine.com/derm/topic47.htmemedicine.com/derm/topic47.htm