SKIN CANCERSKIN CANCER

KARINA PARR, MDKARINA PARR, MDRONALD GRIMWOOD, MDRONALD GRIMWOOD, MD

KARA KENNEYKARA KENNEY

SKIN CANCERSKIN CANCER

More new cases last year than breast, colon, More new cases last year than breast, colon, lung, and prostate cancer combinedlung, and prostate cancer combined

Over 3.5 million cases per yearOver 3.5 million cases per year

BCC – 80%, SCC – 16%, Melanoma – 4%BCC – 80%, SCC – 16%, Melanoma – 4%

Expected deaths from skin cancer this yearExpected deaths from skin cancer this year

Melanoma: > 9700, Non-Melanoma: >4,000Melanoma: > 9700, Non-Melanoma: >4,000

Non-Melanoma Skin CancerNon-Melanoma Skin Cancer

> 3.5 million cases in > 2 million people per > 3.5 million cases in > 2 million people per yearyearBCC > 2.8 millionBCC > 2.8 millionSCC > 700,000SCC > 700,000Lifetime risk is 1 in 5 overallLifetime risk is 1 in 5 overallFair skin, fair colored hair, light eye colorFair skin, fair colored hair, light eye colorChronic sun exposure/tanning bed useChronic sun exposure/tanning bed useExpected deaths - 2200Expected deaths - 2200

Basal Cell CarcinomaBasal Cell Carcinoma

Most common skin carcinoma in USMost common skin carcinoma in US

Almost exclusively in hair-bearing skin, Almost exclusively in hair-bearing skin, especially faceespecially face

40% dx w/ BCC will have another w/in 10 40% dx w/ BCC will have another w/in 10 yearsyears

Metastasis rate 0.0028%Metastasis rate 0.0028%

Basal Cell CarcinomaBasal Cell Carcinoma

NodularNodular

PigmentedPigmented

CysticCystic

MorpheaformMorpheaform

SuperficialSuperficial

Squamous Cell Carcinoma PrecursorsSquamous Cell Carcinoma Precursors

Actinic KeratosisActinic Keratosis

Bowen’s DiseaseBowen’s Disease

Arsenical KeratosisArsenical Keratosis

Treatment of Actinic KeratosisTreatment of Actinic Keratosis

Cryotherapy with Liquid NitrogenCryotherapy with Liquid Nitrogen5 – fluorouracil cream (Efudex or Carac)5 – fluorouracil cream (Efudex or Carac)Chemical Peels Chemical Peels Photodynamic therapyPhotodynamic therapyDermabrasionDermabrasionCurettageCurettageImmune response therapy – AldaraImmune response therapy – AldaraDiclofenac Sodium 3% gel – SolarazeDiclofenac Sodium 3% gel – SolarazeTopical RetinoidsTopical RetinoidsLasersLasers

Bowen’s DiseaseBowen’s Disease

SCC in situSCC in situ

Can become invasive Can become invasive

Mucous membranes can be involvedMucous membranes can be involved

Treatment of Bowen’s DiseaseTreatment of Bowen’s Disease

ExcisionExcision

Topical 5-fluorouracilTopical 5-fluorouracil

Mohs surgery (depends on the site and Mohs surgery (depends on the site and size)size)

Squamous Cell CarcinomaSquamous Cell Carcinoma

May occur anywhere on skin including May occur anywhere on skin including mucous membranesmucous membranesMost commonly arises on sun damaged Most commonly arises on sun damaged skinskinOverall, rate of metastasis is 2-3%Overall, rate of metastasis is 2-3%SCC lower lip approx 11% metastasisSCC lower lip approx 11% metastasis SCCs in areas of chronic inflammation SCCs in areas of chronic inflammation (burns, radiation tx, osteomyelitis) also (burns, radiation tx, osteomyelitis) also have higher rate of metastasishave higher rate of metastasis

SCC Factors Associated w/Local SCC Factors Associated w/Local Recurrence & MetastasisRecurrence & Metastasis

Size > 2.0 cmSize > 2.0 cm

Depth > 0.4 cm (into deep dermis or fat)Depth > 0.4 cm (into deep dermis or fat)

Histology – poorly differentiatedHistology – poorly differentiated

Perineural involvmentPerineural involvment

SCC Factors Associated w/Local SCC Factors Associated w/Local Recurrence & Metastasis Recurrence & Metastasis

Sites – ear, lip (lower), scar, non-sun Sites – ear, lip (lower), scar, non-sun exposed skinexposed skin

Recurrent tumorRecurrent tumor

Immunosuppression – transplant patientsImmunosuppression – transplant patients

Treatment for Non-Melanoma Treatment for Non-Melanoma Skin CancerSkin Cancer

CryotherapyCryotherapy

Electrodessication & Curettage (ED & C) Electrodessication & Curettage (ED & C)

Radiation therapyRadiation therapy

Surgical ExcisionSurgical Excision

Mohs Micrographic SurgeryMohs Micrographic Surgery

Indications for MohsIndications for Mohs

Clinically ill-defined marginsClinically ill-defined margins

Aggressive histological growth patternsAggressive histological growth patterns

Tumor size Tumor size

Perineural involvementPerineural involvement

Uncommon tumors that are locally Uncommon tumors that are locally aggressive w/high recurrence rate (MAC, aggressive w/high recurrence rate (MAC, DFSP, Atypical fibroxanthoma, malignant DFSP, Atypical fibroxanthoma, malignant fibrous histiocytomafibrous histiocytoma

Indications for MohsIndications for Mohs

High risk anatomic locations (medial High risk anatomic locations (medial canthus, nasal ala, nasal tip, external canthus, nasal ala, nasal tip, external auditory canal, temple, eyelids, lower lip)auditory canal, temple, eyelids, lower lip)

Young patients – often have aggressive Young patients – often have aggressive histology, in areas of high recurrence rate, histology, in areas of high recurrence rate, cosmetic concernscosmetic concerns

Skin Cancer Update 2014 for MelanomaSkin Cancer Update 2014 for Melanoma

Number of new invasive cases – 76,100Number of new invasive cases – 76,100

Men - 43,890, Women - 32,210Men - 43,890, Women - 32,210

Deaths – 9710Deaths – 9710

Highest mortality rate in white, older menHighest mortality rate in white, older men

Lifetime risk of developing melanomaLifetime risk of developing melanoma

Invasive = 1 in 62Invasive = 1 in 62

Invasive + in-situ = 1 in 34Invasive + in-situ = 1 in 34

Risk Factors for Developing Malignant Risk Factors for Developing Malignant MelanomaMelanoma

Lentigo MalignaLentigo Maligna

Red or blond hairRed or blond hair

Actinic KeratosisActinic Keratosis

Marked frecklingMarked freckling

> 3 blistering sunburns as a teenager> 3 blistering sunburns as a teenager

> 3 yrs with outdoor summer job as a > 3 yrs with outdoor summer job as a teenagerteenager

Risk Factors for Developing Malignant Risk Factors for Developing Malignant MelanomaMelanoma

Type I & II skin typesType I & II skin types

Excessive sun exposureExcessive sun exposure

ImmunosuppressionImmunosuppression

Family hx of melanomaFamily hx of melanoma

Personal hx of melanomaPersonal hx of melanoma

Dysplastic neviDysplastic nevi

Melanoma TypesMelanoma Types

Superficial spreading 65 - 70%Superficial spreading 65 - 70%

Nodular 15 - 30%Nodular 15 - 30%

Lentigo Maligna Melanoma 4 - 10%Lentigo Maligna Melanoma 4 - 10%

Acral Lentiginous 2 - 8%Acral Lentiginous 2 - 8%

Appropriate Management of Pts w/ Early Appropriate Management of Pts w/ Early Melanoma (<1mm depth)Melanoma (<1mm depth)

Ask about personal or family history of MMAsk about personal or family history of MM

Total body skin examTotal body skin exam

Palpation of regional lymph nodesPalpation of regional lymph nodes

Surgical excision w/ 1.0 cm marginsSurgical excision w/ 1.0 cm margins

SLN biopsy if >0.75 mmSLN biopsy if >0.75 mm

Melanoma 10 yr Survival RateMelanoma 10 yr Survival Rate

Tumor thickness Tumor thickness (mm)(mm)

No UlcerationNo Ulceration With UlcerationWith Ulceration

T1 0.01-1.00T1 0.01-1.00 95%95% 86%%

T2 1.01-2.00T2 1.01-2.00 67%% 57%%

T3 2.01-4.00T3 2.01-4.00 68%68% 43%%

T4 > 4.00T4 > 4.00 10-15%15% 10-15%15%

How to protect your skin

Seek shade

Wear protective clothing

Generously apply a broad-spectrum sunscreen with a Sun Protective Factor (SPF) of at least 30 to all exposed skin

Use extra caution near water, snow, and sand

AVOID TANNING BEDS

Consult your physician for any new or changing skin lesions

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Further reading

• "Skin Cancer Facts." SkinCancer.Org. The Skin Cancer Foundation, 4 June 2014. Web. 27 Aug. 2014.

• Skin Cancer section from the American Academy of Dermatology website www.aad.org