clinical characteristics skin cancerfaculty.washington.edu/fvega/hihim2010/class notes... · n...
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Skin Caner
Fernando Vega, M.D. 1
Skin Cancer
Fernando Vega, MDSeattle Healing Arts
nPrecancerous lesionsnCommon skin cancers
Clinical characteristics
Precancerous skin lesionsnActinic keratoses
nDysplastic melanocytic nevi
ACTINIC KERATOSISn Common sun-induced
premalignant neoplasm of the epidermis that occurs primarily on exposed skin
n Consequence of cumulative long-term sun exposure
n Prevalence ↑with ↑age
n Men > women
n Also genetic factors - ↑in fair skin and in genetic syndromes eg xeroderma pigmentosum
NATURAL HISTORY
n Some lesions (10%) spontaneously regress
n Some (majority) remain unchanged
n Others (1-10%) progress and develop into SCC – risk increased with continued sun exposure or concurrent immunosuppression
CLINICAL FEATURESn Earliest evidence is a tiny red
telangiectatic spot
n Then dry, rough and adherent scale
n Skin coloured/ red/ yellow/ brown
n Usually multiple
n Lesions on hands and forearms tend to be thicker
n Actinic change on lips=actinic chelitis
n Associated with other signs of sun damage – solar elastosis, wrinkled skin, solar lentigines
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Skin Caner
Fernando Vega, M.D. 2
Actinic keratoses Actinic keratoses
Actinic keratoses and SCC Actinic keratoses and SCC
Actinic keratoses and BCC Actinic keratoses
10% risk of malignant transformation
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Skin Caner
Fernando Vega, M.D. 3
Hypertrophic AK’s Actinic cheilitis
n Liquid nitrogen cryotherapy
n Topical therapies
n 5-FU (Efudex)
n Imiquimod (Aldara)
n Curettage for hypertrophic lesions
Treatment of AK’sResidual hypopigmentation
Blister formation
Liquid nitrogenCryotherapy
Topical therapiesEfudex or Aldara
* 3-5 times per week* 6-8 weeks
Dysplastic nevi
•Precursors for melanoma•When to biopsy
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Skin Caner
Fernando Vega, M.D. 4
Miller A and M ihm M. N Engl J Med 2006;355:51-65
Biologic Events and Molecular Changes in the Progression of Melanoma
Tsao H et al. N Engl J Med 2004;351:998-1012
Clinical Images of Pigmented Lesions
Non-melanoma skin cancers
nBasal cell carcinoma
nSquamous cell carcinoma
nKeratoacanthoma
Risk factors for development of BCC and SCC
n Fair skin (Fitzpatrick’s types I-III)n Blue eyesn Red hair
n Family historyn Genetic syndromes
n Chronic sun exposure
n Old age
n Arsenic, tar
Basal cell carcinoma
BCC- clinical types
n Nodular
n Superficial
n Morpheaform
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Skin Caner
Fernando Vega, M.D. 5
Nodular BCCn Chronic lesion
n Easy bleeding
n Pearly border
n Surface telangiectasias
n Head and neck, trunk, and extremities
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Skin Caner
Fernando Vega, M.D. 6
Superficial BCCn Erythematous scaly
plaque
n Slow growth
n Asymptomatic
n Trunk, extremities, face
Superficial BCC Morpheaform BCC
n Resembles scar
n Asymptomatic and slow growing
n Ill-defined margins
n Marked subclinical extension
n BCC is the most frequent skin cancer (80%)
n BCC is 4x more frequent than SCC
n Metastases are rare (<1% of cases)
n Local destruction of tissue
Treatment of BCCn Curettage electrodessication (ED/C)
n Surgical excisionn TraditionalnMohs surgery
n Radiation therapy
n Topical therapyn imiquimod
95% Cure Rate
50-75% Cure Rate
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Skin Caner
Fernando Vega, M.D. 7
Squamous cell carcinoma
SCC types
n In-situnBowen’s diseasenErythroplasia of Queyrat
n Invasive SCCn Keratoacanthoma
Bowen’s disease
n In-situ SCC
n Arsenic, HPV 16, radiation
Invasive SCC
n Erythematous nodule
n Indurated lesion
n Sun-exposed skinn Men > women
n Slow growth
Invasive SCC Keratoacanthoma n Low grade SCC
n Rapid growth over weeks
n Trauma, sun exposure, HPV 11 and 16
n May progress to invasive SCC
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Skin Caner
Fernando Vega, M.D. 8
n SCC is locally invasive and destructive
n Metastases in 1-3% of cases
n To lymph nodesn 50-73% survival
n Distant sites (lungs)n Incurable
Malignant Melanoma
Risk factorsn Fair skin, red hair, and blue eyes
n Intermittent sun exposuren Sunburnsn Tanning beds
n Freckles and melanocytic nevi
n Family history of melanoma
Clinical types- MM
Superficial spreading melanomaLentigo maligna melanoma
Acral lentiginous melanomaNodular melanoma
ABCD of Melanoma
n Asymmetry
n Border irregularity
n Color variegation
n Diameter >6mmTsao H et al. N Engl J Med 2004;351:998-1012
Clinical Images of Pigmented Lesions
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Skin Caner
Fernando Vega, M.D. 9
Miller A and M ihm M. N Engl J Med 2006;355:51-65
Biologic Events and Molecular Changes in the Progression of Melanoma
Benign Melanocytic Neoplasms
Benign Melanocytic Neoplasms
Benign Melanocytic Neoplasms
Benign Melanocytic Neoplasms
Congenital nevus
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Skin Caner
Fernando Vega, M.D. 10
Malignant Melanoma Malignant MelanomaWith Regression
Malignant MelanomaSupeerficial Spreading
Malignant Melanoma
Malignant MelanomaCiliary Body
Malignant Melanoma
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Skin Caner
Fernando Vega, M.D. 11
Malignant Melanoma Malignant Melanoma
Malignant Melanoma Malignant Melanoma
Malignant Melanoma Malignant Melanoma
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Skin Caner
Fernando Vega, M.D. 12
Malignant Melanoma Malignant Melanoma
Malignant Melanoma Malignant Melanoma
Malignant Melanoma LENTIGO MALIGNA
n An in situ pattern of malignant melanoma
n Often reaches a large size before the diagnosis is made
n Lentigo → lentigo maligna →lentigo maligna melanoma
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Skin Caner
Fernando Vega, M.D. 13
CLINICAL FEATURESn Begins as a flat
pigmented lesion
n Usually on sun-exposed skin of head and neck
n With time the colour and border become more irregular
MANAGEMENT n Surgery – excision with a wide margin
n Radiotherapy
n Cryotherapy (deviation from rule)
n Immiquimod (by report)
Prognostic features- MMn Good prognosis
n Breslow < 1mm
n Intermediate prognosisn Breslow 1-4mm
n Bad prognosisn Breslow >4mm