Precancers and Skin Cancers

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Precancers and Skin Cancers

• Adam O. Goldstein, MD, MPH
• Associate Professor
• Family Medicine
• University of North Carolina at Chapel Hill
• aog_at_med.unc.edu

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Actinic Keratoses

• premalignant skin lesions keratinocytic
  intraepidermal neoplasia
• chronic sun, radiation or polycyclic aromatic
  hydrocarbons
• Skin Type I-II
• organ transplant

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Actinic Keratosis
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Actinic Keratoses

• Distribution Sunexposed, esp. dorsa
  hands/forearms
• Description papules,plaques with scale and
  erythema, occasional crust or cutaneous horn
• Sandpapery feel

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Actinic Keratoses

• epidermal atypia
• abnormal maturation

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Actinic Keratoses

• 60 predisposed gt40 have at least 1 AK
• 6-10 lifetime gtgt invasive SCC
• gt10 AK - 14 an SCC w/n 5 yrs
• 60-97 of SCC from AK
• 40 of met SCCgtgt AK
• aggressive immsupp

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Actinic Keratoses

• lip lesions actinic cheilitis/leukoplakia
• white plaques-mucosa
• persistent scaling lesions on the lip
• aggressive behavior
• tobacco/sun

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Differential Diagnosis

• squamous cell carcinoma more indurated, thicker,
  recurrence of AK after treatment

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Differential Diagnosis

• seborrheic keratosis hyperpigmented,more stuck
  on appearing

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Differential Diagnosis

• nummular eczema coin-shaped scaling lesions
  responds to emollients/topical corticosteroids

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AK Treatment

• PREVENTION
• Screen for skin cancers
• Broad-brimmed hats
• sun protective clothing
• sunscreens
• avoidance of sunlight
• ed s/sx skin cancer
• avoidance of tobacco
• low fat diet?

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AK Treatment

• Cryosurgery(liquid nitrogen)
• 5-fluorouracil cream or solution
• Diclofenac Sodium-3 gel
• Imiquimod 2 x week/ 16 weeks

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AK Treatment

• Excision
• Electrocautery
• Curettage
• Carbon dioxide laser

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AK Treatment

• Chemical peels
• Photodynamic therapy
• Retinoids-topical/oral
• Investigational-dimericine

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TREATMENT

• Liquid Nitrogen-Advantages
• cure rates of 98.8
• common
• minimal patient ed
• multiple/thicker lesions
• quick recovery

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TREATMENT

• Liquid Nitrogen-Disadvantages
• storage
• pain
• pigment alteration
• training

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5-Fluorouracil

• Cure 50-80
• Blocks methylation reaction of deoxyuridylic acid
  to thymidilic acid
• DNA (and RNA) synthesis

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Diclonfenac Sodium 3 Topical Gel

• mechanism of action unknown
• NSAID
• inhibition of cyclo-oxygenase gtgtgtPGE-2
• 90 days BID--overall 33-47 clearance vs 10-19
  vehicle
• avoid ASA triad
• hypersensitivity

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Photodynamic therapy
(Pariser DM - J Am Acad Dermatol -2003)
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Cycle therapy of actinic keratoses of the face
and scalp with 5 topical imiquimod cream An
open-label trial.
Significant irritation Rest periods
required Evolving protocols Expensive Effective
Salasche SJ et al Am Acad Dermatol 200247571-7.
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Skin Cancer Statistics

• gt1 million cases/yr
• gt50 of all new cancers
• 1 in 5 Americans will develop skin cancer

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Types of Skin Cancers

• Basal Cell Carcinoma - 80
• Squamous Cell Carcinoma - 16
• Melanoma - 4

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BCC /SCC

• Most common skin cancers
• Most important risk factors
• sun exposure
• family history
• skin type
• Incidence of these cancers increase with age,
  probably related to cumulative sun exposure

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Basal Cell Carcinoma

• the most common skin cancer
• 90 appear on face, ears, head

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Main Types Basal Cell Carcinomas

• Nodular BCCs - most common type
• Sclerosing BCCs (morpheaform)
• Superficial BCCs

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Pattern of Nodular BCC

• raised pearly white, smooth translucent surface
  with telangiectasias

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Pattern of Nodular BCCs

• may ulcerate leaving a small bloody crust
• may be pigmented

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Pattern of Sclerosing BCCs

• ivory or colorless
• flat or atrophic
• indurated
• may resemble scars
• are easily overlooked

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Pattern of Sclerosing BCCs

• ivory or colorless
• flat or atrophic
• indurated
• may resemble scars
• are easily overlooked

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Pattern of Superficial BCCs and SCC in situ

• red or pink scaling plaques
• occasionally with shallow erosions or crusts
• differentiation between these two similar lesions
  usually requires a biopsy

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Pigmented BCCs

• may look like melanoma
• increased brown or black pigment
• seen more commonly in dark-skinned individuals

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Differential Diagnosis of Nodular BCC

• Intradermal nevus
• Sebaceous hyperplasia
• Fibrous papule of the face
• trichoepithelioma

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Differentiating Intradermal Nevus from Nodular BCC

• Intradermal nevus
• Stable size
• Soft
• No crusting or ulceration
• May have telangiectasias

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Differentiating Intradermal Nevus from Nodular BCC

• Intradermal nevus
• Stable size
• Soft
• No crusting or ulceration
• May have telangiectasias

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Sebaceous Hyperplasia from Nodular BCC

• Sebaceous hyperplasia
• yellow coloration
• stable size
• umbilication without ulceration
• is hard to see after injecting anesthesia

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Diagnosis of Basal Cell Carcinomas

• Shave biopsy
• nodular
• thick superficial types
• Punch biopsy
• morpheaform
• flat superficial types

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Treatment options for Basal Cell Carcinomas

• C D after a shave biopsy
• Cryotherapy with thermocouple if you have
  experience
• Excision with 3- 5 mm margins
• Superficial trunk/ext imiquimod qd x 12 wks
• Mohs for recurrent BCC and areas of cosmetic
  importance

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Mohs micrographic surgery

• removal of tumor by scalpel in sequential
  horizontal layers.
• each tissue sample is frozen, stained, and
  microscopically examined
• repeated until all the margins are clear
• treatment of choice for BCCs with poorly defined
  margins
• especially those on the nose or eyelids

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Recurrence rates after Tx of BCCs

• C D 10
• Cryotherapy 10
• Excision 2 - 5
• Imiquimod ???
• Mohs lt1

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Factors that increase recurrence rates

• sclerosing vs others
• larger size of BCC
• margins
• experience of the surgeon

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Sclerosing BCC is most dangerous

• tend to be deeply invasive
• often not diagnosed until they have caused
  extensive damage
• invade muscle, nerve, and bone
• nodular BCC can also invade deeply

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Bowens disease - features

• SCC in situ
• Mainly sun exposed areas
• Slightly elevated red scaly plaque with
  well-demarcated borders

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Bowens disease - features

• May resemble psoriasis, superficial BCC, chronic
  eczema, SK
• Curable using C D, cryo, 5-FU, imiquimod,
  excision

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Keratoacanthoma

• Appear suddenly, grow rapidly
• Central crater with keratin plug
• May grow to 2cm in size
• May resolve spontaneously
• May look like SCC

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Keratoacanthoma

• C and D
• elliptical excision
• 5-FU topically tid
• 5-FU intralesional injection

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Location of SCCs

• Same distribution as bccs.
• Especially on the lips, ears, and scalp
• Initially grow by direct extension
• Metastasize to local lymph nodes and then to
  distant sites

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SCCs with an increased risk of metastasis

• larger, advanced lesions
• SCC on mucous membranes (in the oral cavity, on
  the lips)
• BCCs rarely metastasize

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SCC more aggressive (local mets)

• Size gt2 cm
• SCC in a scar
• Patient is immunosuppressed
• Poorly differentiated
• There is perineural invasion

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Importance of early diagnosis of BCC and SCC

• especially in facial cancers
• the nose is the single most frequent site of BCC
• reconstruction is difficult
• extension into underlying bone and cartilage may
  occur

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The differential diagnosis of superficial BCC and
SCC in situ

• Actinic keratosis, nummular eczema
• Nummular eczema can usually be distinguished by
  its coin-like shape, transient nature, and
  itchiness
• Biopsy any thickened and crusting actinic
  keratosis to rule out BCC or SCC

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Treatment options for SCC

• C D after a shave biopsy
• cryotherapy with thermocouple if you have
  experience
• excision with 5 mm margin
• Mohs for recurrent SCC and areas of cosmetic
  importance

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Erythroplasia of Queyrat

• SCC in situ on the penis
• Usually under the foreskin of the uncircumcised
  penis
• May occur on the vulva
• 5-FU, imiquimod or mohs

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Indications for Referral for Mohs Surgery
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Indications for Referral for Mohs Surgery

• Recurrent tumors, sclerosing BCC
• Primary tumors in locations with high
  tumor-recurrence rates
• Nasolabial fold,temple, periauricular area,
  periocular area, scalp, nasal alae, center face
• Preservation of normal tissue is vital (for
  cosmetic and functional reasons)
• Nose, eyelids, lips, fingers, ears, penis

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When to consider referral

• Aggressive and recurrent skin cancers
• A large skin cancer lesion
• A lesion located in a sensitive area (cosmetic or
  functional)
• When treatment or diagnosis of the lesion is
  beyond the scope of ones skills
• If mohs surgery is the treatment of choice

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Melanoma Risk Factors

• Family history
• Personal history
• Atypical Nevi
• Blistering Sunburns
• Type 1 skin

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History of a changing lesion
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Melanoma Statistics

• Fastest rising incidence rates
• Most common cancer in 25-9 y/o
• 2nd only to breast CA in 30-4 y/o women

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Melanoma Facts

• 87,900 new cancers
• 34,300 in situ
• 53,600 invasive
• 4 increase from 2001
• 7400 deaths in 2003 due to melanoma

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Melanoma
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Melanoma-Early detection

• Total treatment costs by stage
• Stage I 5.5
• Stage II 5.5
• Stage III 34
• Stage IV 55

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MNEMONIC FOR MALIGNANT MELANOMA RECOGNITION

• A- ASYMMETRY
• B- BORDER IRREGULARITY
• C- VARIATION IN COLOR
• D- DIAMETERgt .6CM
• E- ELEVATION ABOVE SKIN SURFACE

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Melanoma with regression
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Melanoma
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Acral lentiginous Melanoma
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Lentigo Maligna Melanoma
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Venous Lake
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Blue Nevus
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Seborrheic Keratosis
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Pyogenic Granuloma
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Look everywhere
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Melanoma Management

• Excisional biopsy
• 1-2 mm margins
• Dermatopathologist consultation

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Breslows Measurement

• Depth of granular cell layer to deepest malignant
  cell
• Strongest correlation with prognosis

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Melanoma Managment

• Sentinel lymph node biopsy
• 1mm or greater depth, regression, gtLevel III or
  IV
• Interferon
• Vaccine clinical trials

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Melanoma Management

• Full skin exam
• Family screening
• Follow up
• Education

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Take home points

• Prevent skin cancers by risk factor reduction
• Early detection of pre-cancers and skin cancers
  can prevent morbidity and mortality
• Use the appropriate biopsy technique for
  diagnosing skin cancers
• Treat or refer based on your skills

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Online References

• Derm Online Atlas is at www.dermis.net/bilddb/inde
  x_e.htm
• Derm Image Bank is at medstat.med.utah.edu/kw/derm
  /
• Basal Cell Carcinoma is at emedicine.com/derm/topi
  c47.htm