basal cell carcinoma incidence: the most common malignant skin tumor 75% predisposing factors:...

Basal Cell CarcinomaBasal Cell CarcinomaIncidence:Incidence:

The most common malignant skin tumor The most common malignant skin tumor 75%75%

Predisposing Factors:Predisposing Factors:

Exposure to the sun (ultraviolet rays for Exposure to the sun (ultraviolet rays for long time 10-15 years) so more in maleslong time 10-15 years) so more in males

White or fair hair complexion peoples are White or fair hair complexion peoples are more affected (dark skin gave protection) more affected (dark skin gave protection)

Clinical PictureClinical Picture

Usually male above 40yearsUsually male above 40years

95% occur in the middle of the face,the 95% occur in the middle of the face,the angles of the triangle areangles of the triangle are

Tragus of the earTragus of the ear

Inner canthusInner canthus

Angle of the mouthAngle of the mouth

Clinical typesClinical types

1.1. Ulcerative typeUlcerative type

2.2. Nodular and cystic typeNodular and cystic type

3.3. Papillary typePapillary type

4.4. CicatrizingCicatrizing

5.5. SclerosingSclerosing

6.6. FissuringFissuring

7.7. PigmentedPigmented

8.8. Morphy tyeMorphy tye

ComplicationsComplications

1.1. Spread:Spread:a)a) Only by direct spread erode the surrounding Only by direct spread erode the surrounding

eye ball,cartilage,sinus,…..eye ball,cartilage,sinus,…..

b)b) Lymphatic and blood very rareLymphatic and blood very rare

2.2. Infection Infection that may cause cavernous that may cause cavernous sinus thrombosissinus thrombosis

3.3. HaemorrageHaemorrage erode large vessel may erode large vessel may cause fatal hgecause fatal hge

4.4. Epitheliomatous transformationEpitheliomatous transformation

BCC with palpable LNs!!!!BCC with palpable LNs!!!!

I.I. Secondary infection (tender and firm)Secondary infection (tender and firm)

II.II. Epitheliomatous transformation Epitheliomatous transformation (hard and not tender)(hard and not tender)

Causes of death in BCCCauses of death in BCC

I.I. Erosion of a large vessel lead to sever Erosion of a large vessel lead to sever uncontrollable hemorrhageuncontrollable hemorrhage

II.II. Direct intracranial extensionDirect intracranial extension

III.III. Inhalation pneumoniaInhalation pneumonia

Differential DiagnosisDifferential DiagnosisI.I. Infections Infections

– Non specific Non specific Chronic infectionChronic infectionInfected sebaceousInfected sebaceousMolluscum sebaceum simulate scc but Molluscum sebaceum simulate scc but disappear spontaneous within 2 months disappear spontaneous within 2 months

– Specific Specific TB TB Syphilis Syphilis ActinomycosisActinomycosisLeishmaniasisLeishmaniasisAnthraxAnthrax

Differential DiagnosisDifferential Diagnosis

Traumatic ulcerTraumatic ulcer

Tumors ulceratedTumors ulcerated– Rodent ulcer (commonest)Rodent ulcer (commonest)– Epithelioma Epithelioma – MelanomaMelanoma– Deep tumor invade the skin Deep tumor invade the skin – Metastatic tumor Metastatic tumor

Locally Malignant Tumors

A d am an tim om a

A

B asa l ce ll ca rc in om a

B

C aro tid b od y tu m ors C arc in o id C ran yop h aryn g iom a

C

D esm oid

D

G ian t ce ll(os teoc las tom a)

G

localy M alignant tum ors

TreatmentTreatmentSurgerySurgery

Indications Indications – Diagnosis Diagnosis

small lesions excisional biopsysmall lesions excisional biopsylarge lesions incisional biopsylarge lesions incisional biopsy

– Treatment of small and advanced casesTreatment of small and advanced casessmall in dangerous areas as eyelidsmall in dangerous areas as eyelidadvanced involving bones advanced involving bones (sequestration)(sequestration)recurrence after irradiationrecurrence after irradiation

TreatmentTreatmentOperation Operation

Radical local excisionRadical local excision with safety with safety margin margin – 1 cm (in the face) all around and in depth. 1 cm (in the face) all around and in depth. – In areas like eye lid (6-8mm can be In areas like eye lid (6-8mm can be

accepted)accepted)– In areas other than the face (2cm) In areas other than the face (2cm)

Reconstruction after excisionReconstruction after excision – Grafts Less cosmeticsGrafts Less cosmetics– Flaps more cosmeticFlaps more cosmetic

TreatmentTreatmentRadiotherapyRadiotherapy

IndicationsIndications– Recurrence after surgeryRecurrence after surgery– Contraindication to surgery (unfit ,old Contraindication to surgery (unfit ,old

age)age)ContraindicationsContraindications– Small lesions near sensitive organsSmall lesions near sensitive organs– Advanced lesions invading bonesAdvanced lesions invading bones– Radio-resistant types Radio-resistant types

(pigmented,nodular,cystic(pigmented,nodular,cystic))

Squamous Cell CarcinomaSquamous Cell Carcinoma

The second common skin cancer occur in The second common skin cancer occur in about 15 %about 15 %

Occur in areas with pre-malignant lesionsOccur in areas with pre-malignant lesions– Actinic keratosisActinic keratosis– RadiodermatitsRadiodermatits– Paget’s diseasePaget’s disease– Bowen’s diseaseBowen’s disease– Lupus vulgarisLupus vulgaris– Xeroderma pigmentosaXeroderma pigmentosa

Squamous Cell CarcinomaSquamous Cell Carcinoma

It arise from the prickle cell layer of the It arise from the prickle cell layer of the dermisdermis

It is more in maleIt is more in male

Above 50 yearAbove 50 year

SitesSites– Face and head (away from sites of BCC)Face and head (away from sites of BCC)– MM of the mouth, anus, vagina and MM of the mouth, anus, vagina and

esophagusesophagus– Areas with sq metaplasia as lung , UBAreas with sq metaplasia as lung , UB

Squamous Cell CarcinomaSquamous Cell Carcinoma

Start as nodule or ulcer grow rapidly in Start as nodule or ulcer grow rapidly in size and bleed on touch with LNsize and bleed on touch with LN

Clinical typesClinical types– UlcerativeUlcerative– NodularNodular– PapillaryPapillary– EczematousEczematous– FissuringFissuring– keratinizingkeratinizing

Marjolin UlcerMarjolin Ulcer

It is a squamous cell carcinoma It is a squamous cell carcinoma developing on top of old scardeveloping on top of old scar– VenousVenous– IschemicIschemic– NaturopathicNaturopathic– Post burnPost burn– Infective TB or $Infective TB or $– Sinus of ostomyelitisSinus of ostomyelitis

Marjolin UlcerMarjolin Ulcer

Characterized by different morphologyCharacterized by different morphology– The scar is devoid of nerves , vessels and The scar is devoid of nerves , vessels and

lymphaticlymphatic– No nerves no sensationNo nerves no sensation– No vessels so grow very slowly without No vessels so grow very slowly without

metastasesmetastases

Treatment is surgical excision with Treatment is surgical excision with safety margin taken from the scar tissue safety margin taken from the scar tissue not the ulcernot the ulcer

Squamous Cell CarcinomaSquamous Cell Carcinoma

Confirm diagnosis by biopsy either Confirm diagnosis by biopsy either Excisional or incisionalExcisional or incisional

Radiotherapy for massive unresectable Radiotherapy for massive unresectable lesions or post operative after excision as lesions or post operative after excision as adjuvant therapyadjuvant therapy

Squamous Cell CarcinomaSquamous Cell Carcinoma

Radical excision with safety marginRadical excision with safety margin– 1 inch in all direction followed by reconstruction1 inch in all direction followed by reconstruction– 5 mm could be enough in H&N5 mm could be enough in H&N

LNLN– If not palpable wait and seeIf not palpable wait and see– If palpableIf palpable

Mobile RNDMobile RNDFixed radiotherapyFixed radiotherapy

Radiotherapy for Radiotherapy for – massive unrespectable lesions massive unrespectable lesions – post operative after excision as adjuvant therapypost operative after excision as adjuvant therapy

Malignant Malignant MelanomaMelanoma

MelanomaMelanoma

Almost 30% of all melanomas arise in the Almost 30% of all melanomas arise in the head and neckhead and neck

Widespread use of sunscreen has not Widespread use of sunscreen has not lowered the incidence.lowered the incidence.

Incidence is increasing almost 5% per Incidence is increasing almost 5% per yearyear

Approximately 47,000 new cases in 2001Approximately 47,000 new cases in 2001

Predisposing FactorsPredisposing Factors

Sun ExposureSun Exposure– Age, frequency, severity of exposure may play a roleAge, frequency, severity of exposure may play a role– Sunscreen use may not be protectiveSunscreen use may not be protective

Familial Melanoma / DNSFamilial Melanoma / DNS– Family members have almost 50% chance of Family members have almost 50% chance of

developing melanomadeveloping melanoma– Lesions may be multiple and in sun shielded areasLesions may be multiple and in sun shielded areas

Xeroderma PigmentosaXeroderma Pigmentosa– Predisposes to several types of skin cancerPredisposes to several types of skin cancer– Skin malignancies often appear by age 10Skin malignancies often appear by age 10

SunlightSunlight

UVB UVB (280-320nm)(280-320nm) – Causes direct DNA damageCauses direct DNA damage– Originally thought to be primary factorOriginally thought to be primary factor– Blocked by current sunscreensBlocked by current sunscreens

UVA UVA (320-400nm)(320-400nm) – Causes indirect DNA damage via free radicalsCauses indirect DNA damage via free radicals– Some now consider as more important than Some now consider as more important than

UVBUVB– Sunscreen has little UVA protectionSunscreen has little UVA protection

Types of MelanomaTypes of Melanoma

Superficial SpreadingSuperficial Spreading– Most commonMost common– Cells atypical but uniform in appearanceCells atypical but uniform in appearance

NodularNodular– Early invasion due to vertical growthEarly invasion due to vertical growth

Acral LentiginousAcral Lentiginous– Appears on palms and solesAppears on palms and soles– Histology shows heavily pigmented dendritic Histology shows heavily pigmented dendritic

processes in the basal layer processes in the basal layer

Types of MelanomaTypes of Melanoma

Lentigo Maligna MelanomaLentigo Maligna Melanoma– May remain in-situ for decadesMay remain in-situ for decades– Can spread along hair folliclesCan spread along hair follicles

DesmoplasticDesmoplastic– May lack pigmentMay lack pigment– Peri-neural invasion is classicPeri-neural invasion is classic– Histologic exam may show “school of fish” appearanceHistologic exam may show “school of fish” appearance

MucosalMucosal– Often lack melaninOften lack melanin– Conventional staging system does not applyConventional staging system does not apply– Site of lesion corresponds to prognosisSite of lesion corresponds to prognosis

Nasal cavity best prognosis, 31% at 5-yrsNasal cavity best prognosis, 31% at 5-yrsParanasal sinuses worst prognosis, 0% at 5-yrsParanasal sinuses worst prognosis, 0% at 5-yrs

DiagnosisDiagnosis

HistoryHistory– Family HistoryFamily History– Sun exposureSun exposure– Bleeding, painBleeding, pain

PhysicalPhysical– ABCDABCD

HistologyHistology– H&EH&E– S-100, HMB-45S-100, HMB-45

BiopsyBiopsy

ExcisionalExcisional– Recommended for small lesionsRecommended for small lesions– Margins of 2mmMargins of 2mm

IncisionalIncisional– For larger lesionsFor larger lesions– Does not alter draining lymphaticsDoes not alter draining lymphatics

PunchPunch– Same as incisionalSame as incisional

ShaveShave– ContraindicatedContraindicated

NeedleNeedle– ContraindicatedContraindicated

Clark stagingClark staging

Based upon histological level of invasionBased upon histological level of invasion

Level I – Level I – Epidermis only (in situ)Epidermis only (in situ)

Level II – Level II – Invades the papillary dermis, but not Invades the papillary dermis, but not to the papillary-reticular interfaceto the papillary-reticular interface

Level III – Level III – Invades to the papillary-reticular Invades to the papillary-reticular interface, but not into the reticular dermisinterface, but not into the reticular dermis

Level IV – Level IV – Into the reticular dermisInto the reticular dermis

Level V – Level V – Into subcutaneous tissueInto subcutaneous tissue

Breslow stagingBreslow staging

Based upon absolute depth of invasionBased upon absolute depth of invasion

Stage I – < 0.75 mmStage I – < 0.75 mm

Stage II – 0.76 – 1.5 mmStage II – 0.76 – 1.5 mm

Stage III – 1.51 – 4.0 mmStage III – 1.51 – 4.0 mm

Stage IV - > 4.0 mmStage IV - > 4.0 mm

AJCC stagingAJCC staging

AJCC stagingAJCC staging

AJCC stagingAJCC staging

Prognosis by AJCC stagePrognosis by AJCC stage

Stage IStage I– < 0.75 – 96 %< 0.75 – 96 %– 0.75 – 1.5 – 87 %0.75 – 1.5 – 87 %

Stage II Stage II – 1.5 – 2.49 – 75 %1.5 – 2.49 – 75 %– 2.5 – 3.99 – 66 %2.5 – 3.99 – 66 %– > 4.0 – 47 %> 4.0 – 47 %

Stage IIIStage III– One node 45 %One node 45 %– Two nodes < 20 %Two nodes < 20 %

Stage IVStage IV– 8 – 10 %8 – 10 %

Percentages are five year survival except stage IV lesions which Percentages are five year survival except stage IV lesions which represent one year survivalrepresent one year survival

Treatment - Stage ITreatment - Stage I

LabsLabs– LDHLDH

RadiologyRadiology– CXRCXR

ExcisionExcision– 1 cm margins1 cm margins

Adjunctive TherapyAdjunctive Therapy– NoneNone

Treatment - Stage IITreatment - Stage II

LabsLabs– LDHLDH

RadiologyRadiology– CXRCXR– Possible CT for metastasisPossible CT for metastasis– Possible LymphoscintigraphyPossible Lymphoscintigraphy

ExcisionExcision– 2 cm margins2 cm margins

Adjunctive TherapyAdjunctive Therapy– Possible elective neck dissectionPossible elective neck dissection– Possible sentinel lymph node biopsyPossible sentinel lymph node biopsy– Possible elective radiationPossible elective radiation

Treatment - Stage IIITreatment - Stage III

LabsLabs– LDHLDH

RadiologyRadiology– CXRCXR– CT neckCT neck– Possible CT abdomen, MRI brainPossible CT abdomen, MRI brain

ExcisionExcision– 2 cm margins2 cm margins– Remove in-transit lymphatic basinsRemove in-transit lymphatic basins– Neck dissection directed by siteNeck dissection directed by site

Posterolateral vs. Lateral vs. SupraomohyoidPosterolateral vs. Lateral vs. Supraomohyoid

Adjunctive TherapyAdjunctive Therapy– Probable radiotherapyProbable radiotherapy– Possible chemotherapyPossible chemotherapy

Treatment - Stage IVTreatment - Stage IV

LabsLabs– CBC, LFT’s, LDHCBC, LFT’s, LDH

RadiologyRadiology– CT Chest, Abdomen, PelvisCT Chest, Abdomen, Pelvis– MRI brainMRI brain

ExcisionExcision– 2 cm margins2 cm margins– Remove in-transit lymphatic basinsRemove in-transit lymphatic basins– Neck dissection directed by siteNeck dissection directed by site

Posterolateral vs. Lateral vs. SupraomohyoidPosterolateral vs. Lateral vs. Supraomohyoid

Adjunctive TherapyAdjunctive Therapy– Radiation therapyRadiation therapy– Consider chemotherapy as part of a clinical trialConsider chemotherapy as part of a clinical trial

Sentinel Lymph Node BiopsySentinel Lymph Node Biopsy

Used to determine nodal status in low-risk Used to determine nodal status in low-risk tumorstumors

Allows for limited surgical morbidity.Allows for limited surgical morbidity.

Has prognostic value for patient outcomeHas prognostic value for patient outcome

Sentinel Lymph Node BiopsySentinel Lymph Node Biopsy

ProcedureProcedure– Preoperative lymph basin mapping using Preoperative lymph basin mapping using

lymphscintigraphy with Tc99lymphscintigraphy with Tc99– Preoperative injection of radiotracer allows for Preoperative injection of radiotracer allows for

intraoperative gamma counter localizationintraoperative gamma counter localization– Intraoperative injection of iosulfan blue allows Intraoperative injection of iosulfan blue allows

for visual detection of involved nodes.for visual detection of involved nodes.– Allows for detection of sentinel nodes in 88-Allows for detection of sentinel nodes in 88-

99% of patients depending on the study cited.99% of patients depending on the study cited.

RadiationRadiation

Indications include stage III or IV lesionsIndications include stage III or IV lesions

Patients with positive SLNB should be Patients with positive SLNB should be consideredconsidered

Decreases local recurrence rates to 85-Decreases local recurrence rates to 85-88%88%

Does not affect overall survivalDoes not affect overall survival

May be contraindicated for lesions near May be contraindicated for lesions near the eye or for midline lesionsthe eye or for midline lesions

ChemotherapyChemotherapy

Numerous therapy modalities existNumerous therapy modalities exist

No significant benefit has been found for No significant benefit has been found for any therapy to dateany therapy to date

Administration of chemotherapy should be Administration of chemotherapy should be done as part of an ongoing clinical trial.done as part of an ongoing clinical trial.