detection and treatment of non- melanoma skin cancers toby maurer, md university of california, san...

Detection and Treatment of Non-Detection and Treatment of Non-Melanoma Skin CancersMelanoma Skin Cancers

Toby Maurer, MDUniversity of California, San Francisco

Basics of Skin CancerBasics of Skin Cancer

• Large majority caused by sun exposure

• Often sun exposure before age 20

• Persons who burn easily and tan poorly are at greatest risk

SunscreenSunscreen

• Don’t forget sun-protective clothing• Physical sunscreen

– zinc oxide and titanium dioxide– thick and more waterproof– fewer allergic reactions

• Chemical sunscreens– burns if gets into eyes– more comedonegenic

SunscreenSunscreen

• Apply 1/2 hr. before going out

• May need to reapply every 2-3 hours– especially if going in water

• Be liberal with amount

• UVA protection probably added benefit

Non-Melanoma Skin CancersNon-Melanoma Skin Cancers

• Basal cell carcinoma (BCC)

• Actinic keratosis (AK)

• Squamous cell carcinoma (SCC)

Basal Cell Carcinoma (BCC)Basal Cell Carcinoma (BCC)

• Who is at Risk?– Age 20+– Fair-skinned persons– Sun-exposed sites

• over 50% on face

Clinical Features of BCCClinical Features of BCC

• Pearly papule with telangiectasia (face, ears forehead, neck)

• Scaly red patch (back, chest, legs of women)

• Sclerotic (scarlike) lesion

• Pigmented in pigmented races (blacks, etc.)

• May erode or ulcerate

Diagnosis of BCC: Shave or Punch Biopsy

Differential Diagnosis of BCC

• Intradermal Nevus

• Sebaceous hypersplasia

• Fibrous Papule (angiofibroma)

• Eczema

• Melanoma

Recommended Treatment of BCCRecommended Treatment of BCC

• Surgical excision (head and neck)

• Curettage and desiccation (trunk)

• Radiation therapy (debilitated pt)

• Microscopically controlled surgery (Mohs)– Recurrent/sclerotic BCC’s– BCC’s on eyelid and nasal tip

Aldara (Imiquimod)

• Topical therapy designed for wart treatment

• Upregulates interferon and down regulates tumor necrosis factor

• Seems to have efficacy in superficial BCC’s

• Do Not use in BCC’s that are nodular or invasive

Topical Treatment of Skin Cancer

• Imiquimod 5% cream can effectively treat superficial BCC’s and SCC in situ

• Treatment regimen is 5X per week for 6-10 weeks depending on the host reaction

• Efficacy is relatively high (75%-85%)• Scarring may be reduced compared to surgery• Other possible uses: Extramammary Paget’s, lentigo

maligna (trials needed)

Topical Treatment of Skin Cancer

• Patient selection is the key

• Biopsy to confirm diagnosis before TX

Treatments Treatments NOTNOT Recommended Recommended

• Cryotherapy

• Topical chemotherapy

- 5 Fleurourical (Efudex)

• Radiation therapy (age < 65)

When to ReferWhen to Refer

• It depends on your surgical skills

• > 1 cm

• Sclerotic BCC

• Recurrent BCC

• Eyelid BCC

Actinic Keratosis (AK)Actinic Keratosis (AK)

• Who is at risk?– Over age 35-40– Fair-skinned persons– Sun-exposed sites

• Face, forearms, hands, upper trunk

– History of chronic sun exposure

Clinical Features of AKClinical Features of AK

• Red, adherent, scaly lesions, usually < 5mm

• Sandpapery, rough texture

• Tender when touched or shaved

• Thick, warty character (cutaneous horn)

Diagnosis of AKDiagnosis of AK

• Diagnosis– Clinical features– Shave or punch biopsy

• Differential Diagnosis– BCC/SCC– Seborrheic keratosis– Wart

Treatment of AKTreatment of AK

• Cryotherapy• Topical chemotherapy/chemical peel

– Efudex (5FU crème) 2x’s/day x 6 wks or Imiquimod-3X’s /wk and 3 mos.

• When to refer?– Too extensive for local treatment– Consider biopsy or referral with any lesion that doesn’t

resolve with cryotherapy

• Make sure you know what you are treating

• Be very careful with pigmented lesions

• Rule of thumb for cryotherapy:– make sure lesion resolves after one month– if not, refer or biopsy to rule out malignancy

Squamous Cell Carcinoma (SCC)Squamous Cell Carcinoma (SCC)

• Who is at risk?– Age 50+– Chronic sun exposure

• Head, neck, lower lip, ears, dorsal hands, trunk

– Special circumstances• Immunosuppression (organ transplant)

• Radiation therapy

Clinical Features of SCCClinical Features of SCC

• Papule, nodule or tumor

• Non-healing erosion or ulcer

• Cutaneous horn (wart-like lesion)

• Fixed, red, scaling patch/plaque (Bowen’s-SCC-in-situ)

Differential Diagnosis of SCCDifferential Diagnosis of SCC

• Actinic keratosis

• Wart

• Seborrheic keratosis

• BCC

• Eczema or psoriasis

How to DiagnoseHow to Diagnose

• Punch or excisional/incisional biopsy

• Shave biopsy for flat, non-elevated lesion

Treatment of SCCTreatment of SCC

• Recommended treatment– Excision– Radiation therapy ( debilitated pt)

• Treatments NOT recommended– Curettage and desiccation– Topical chemotherapy

When to ReferWhen to Refer

• SCC’s may metastasize

• Low threshold for biopsy and referral

• Regularly check draining lymph nodes

• High risk SCC’s

High-risk SCC’sHigh-risk SCC’s

• Lip

• Temple

• Immunocompromised host (i.e. organ transplant)

• Area of previous radiation therapy