skin cancer crash course - mghcme
TRANSCRIPT
![Page 1: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/1.jpg)
Skin Cancer Crash Course:
Recognition and Management of Nonmelanoma Skin Cancer
Victor Neel, MD, PhDDirector, Dermatologic Surgery, MGH
![Page 2: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/2.jpg)
Disclosures
Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest
to disclose.
![Page 3: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/3.jpg)
![Page 4: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/4.jpg)
sebaceous carcinoma
sebaceous adenoma
sebaceoma
Microcystic adnexal ca
Mucinous eccrine carcinoma
Eccrine spriradenoma
Cylindroma
Poroma
Porocarcinoma
Nodular hidradenoma
Syringoma
Chondroid syringoma
Digital papillary adenocarcinoma
Extramammarary Paget’s
Basal cell carcinoma
Trichoepithelioma
Pilar sheath acanthoma
Tricholemmoma
Trichofolliculoma
Pilomatricoma
Trichoblastoma
Fibrofolliculoma
Desmoplastic trichoepithelioma
Pyogenic granuloma glomus tumor
Kaposi’s sarcoma Angiosacoma
Epitheliod hemangioendothelioma Masson tumor
Targetoid hemosiderotic hemangioma Angiokeratoma
Glomangioma AV hemangioma
Lipoma
angiolipoma
Spindle cell lipoma
liposarcoma
pleomorphic lipoma
Neurofibroma
Neurothekeoma
Schwannoma
Palisaded encapsulated neuroma
Merkel cell carcinoma
Atypical fibroxanthoma
Malignant fibrous histiocytoma
actinic keratosissquamous cell carcinomakeratoacanthomaseborrheic keratosis porokeratosis
sebaceous
eccrine
Blood Vesselsneural
fibroblastsfollicular
fat
epithelial
smooth muscle
Leiomyoma
Leiomyosarcoma
angioleiomyoma
immune cell
Lymphoma
Mast cell disease
histiocytosis
metastatic
![Page 5: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/5.jpg)
Goals of This Talk
• Discuss the most common NMSC tumors you will see and possibly diagnose & treat
• Convince you to consider performing skin biopsies in your practice
![Page 6: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/6.jpg)
Primary Care & Dermatology
• Too many patients, too many tumors
• Delayed diagnosis, delayed treatment
• Many skin cancers can be diagnosed and treated in primary care setting
• PCPs must definitively diagnosis and have treatment algorithms in place
![Page 7: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/7.jpg)
![Page 8: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/8.jpg)
US Skin Cancer Incidence
• >5 million new cases of NMSC each year
• BCC about 80%, SCC about 20%
• About 15,000 deaths per year from SCC, more than twice as many than melanoma
![Page 9: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/9.jpg)
Causes of Nonmelanoma Skin Cancer
• Chronic UV exposure –> genetic mutations
• Immunosuppression– Organ transplant patients and CLL patients– 80% of transplant patients develop skin cancers– 200-fold increased risk of SCC
• Human papillomavirus - HPV 6,16 (vaccine may affect)
• Inherited diseases - XP, BCNS, albinism
![Page 10: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/10.jpg)
Basal Cell CarcinomaStats
• most common cancer in humans
• 3 million new cases a year, increasing 5% per year
• 1/3 of all Caucasians will develop at leastone lesion
• billions of healthcare $$ spent
![Page 11: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/11.jpg)
Basal Cell CarcinomaBiology
• very indolent growth – perhaps decades until clinically apparent
• rarely metastatic (<0.01%) but very lethal –usually in neglected or multiply-recurrent tumors – locally destructive (cosmetically devastating)
• >75% most sporadic tumors have defects in Sonic hedgehog signaling pathway (oral drug, vismodegib, topicals in develpoment)
![Page 12: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/12.jpg)
Which Is BCC?
![Page 13: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/13.jpg)
Basal Cell Carcinoma
• Subtypes– Nodulo-ulcerative (most common)
– Morpheaform (sclerosing, infiltrative)
– Micronodular
– Metatypical (basosquamous)
– Superficial (“multicentric”)
![Page 14: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/14.jpg)
Basal Cell Carcinoma
• Subtypes
– Nodulo-ulcerative (most common)
![Page 15: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/15.jpg)
Basal Cell Carcinoma
• Pigmented BCC • Can mimic MM
![Page 16: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/16.jpg)
Basal Cell Carcinoma
• Subtypes– Morpheaform BCC
– Can look like scar
![Page 17: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/17.jpg)
![Page 18: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/18.jpg)
Basal Cell Carcinoma
• Subtypes
– Superficial “multicentric”
– Can be misdiagnosed as psoriasis, tinea or eczema
– Most common type on trunk and extremities
![Page 19: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/19.jpg)
BCC or Tinea?
![Page 20: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/20.jpg)
BCCTinea
itchy & scalyoften multiple
antifungals
crusts/bleedsusually singlesun-exposed
![Page 21: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/21.jpg)
BCCs?
![Page 22: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/22.jpg)
Basal Cell Carcinoma
• Course
– Slow, progressive growth
– Bleeding, ulceration, superinfection
– Enlarges over months to years
– Is capable of extensive tissue destruction (invading
into muscle, cartilage, and bone)
![Page 23: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/23.jpg)
![Page 24: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/24.jpg)
Suspected lesion Differential
diagnosis
?biopsy
?refer
Treatment
options
Actinic keratosis SK, wart, porokeratosis,
trichilemmoma
NO
NO
5-FU, imiquimod,
cryotherapy, PDT-ALA
Squamous cell
carcinoma, in situ
AK, discoid lupus, tinea
psoriasis, SK
YES
YES
5-FU, imiquimod, PDT-ALA,
cryotherapy, curettage
surgery
Squamous cell
carcinoma, invasive
SK, AK, BCC, pyoderma
gangrenosum
YES
YES
surgery, Mohs surgery,
radiation (rarely)
BCC, superficial
(body)
tinea, SCC in situ, discoid lupus,
porokeratosis, SCC in situ
?
?
5-FU, imiquimod,
cryotherapy, curettage,
surgery
BCC, nodular
(body)
nevus (melanocytic), molluscum YES
YES
cryo, curettage, surgery
BCC, infiltrative or
recurrent (body)
scar YES
YES
BCC, any type
(head & neck)
nevus, rosacea, angiofibroma,
syringoma, sebaceous
hyperplasia, tinea, discoid lupus,
SCC, trichoepithelioma,
telangiectasia, scar
YES
YES
Mohs surgery
![Page 25: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/25.jpg)
Squamous Cell Carcinoma
• Second most common skin cancer in the general population
• Most common skin cancer in transplant recipients
• Appears on sun-exposed skin
• Red, scaly, firm, may ulcerate
• 1-15% metastasize (lip & ear)
![Page 26: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/26.jpg)
Squamous Cell Carcinoma
• Arises primarily on sun-damaged skin– Precursor is actinic keratosis (AK) on sun-exposed sites
– 90% of AKs spontaneously resolve
• May occur anywhere on skin• Face
• Lips (usually lower)
• Ears
• Dorsal hands
• Chest
![Page 27: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/27.jpg)
Diffuse AKs? 5-FU!!
![Page 28: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/28.jpg)
Two Weeks of Topical 5-FU
![Page 29: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/29.jpg)
Squamous Cell Carcinoma
• Metastasis more likely in:
– Recurrent tumors
– Those with diameter > 2 cm
– Those with depth > 6 mm
– Mucosal sites, periauricular skin (lip & ear)
– SCC arising from chronic wounds (Marjolin’s ulcer)
– Perineural invasion of larger nerve fibers
– Immunocompromised patients
![Page 30: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/30.jpg)
Squamous Cell Carcinoma
• Subtypes– Keratoacanthoma
• Rapid initial growth
• May be painful (unlike most NMSCs)
• Exophytic nodule with central keratin-filled crater
• Remains stable for a few months
• May spontaneously resolve – new research!!
• Dermpath reports as well-differentiated SCC
![Page 31: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/31.jpg)
![Page 32: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/32.jpg)
Time to get the derm surgeonon the phone
![Page 33: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/33.jpg)
Squamous Cell Carcinoma
• Subtypes
– Bowen’s Disease• Squamous cell carcinoma in situ
• Thin, erythematous, scaling plaques
• Can progress into, and/or coincide with invasive SCC
• Can be misdiagnosed as psoriasis, tinea, eczema or BCC
![Page 34: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/34.jpg)
• Squamous cell carcinoma
• Basal cell carcinoma
• Melanoma
100-fold increase
10-fold increase
3.4-fold increase
Incidence Ratios of Skin Cancer in Transplant Recipients
![Page 35: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/35.jpg)
Mortality from Metastatic Skin Cancerin Transplant Patients
Country Organ Cancer type
Mortality Rate
Australia
New Zealand
Kidney SCC 5% of all patients with SCC
Australia Heart All 27% total deaths occurring after the 4th yr post transplant
USA All SCC 3 yr cause specific survival 54%, n = 71
USA All Melanoma 30% (compared to 15% in general population)
![Page 36: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/36.jpg)
A Lethal Tumor in a Transplant Patient
Please have your transplantpatients see a dermatologist for baseline evaluation
![Page 37: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/37.jpg)
Surgical Emergencies in Dermatology
• SCC in immunosuppressed population
– Iatrogenic (organ transplant, anti-inflammatory states)
– CLL or other leukemias/marrow failures
AML – 80% blast, 0%PMNs
![Page 38: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/38.jpg)
Suspected lesion Differential
diagnosis
?biopsy
?refer
Treatment
options
Actinic keratosis SK, wart, porokeratosis,
trichilemmoma
NO
NO
5-FU, imiquimod,
cryotherapy, PDT-ALA
Squamous cell
carcinoma, in situ
AK, discoid lupus, tinea
psoriasis, SK
YES
YES
5-FU, imiquimod, PDT-
ALA, cryotherapy,
curettage
surgery
Squamous cell
carcinoma, invasive
SK, AK, BCC, pyoderma
gangrenosum
YES
YES
surgery, Mohs surgery,
radiation (rarely)
BCC, superficial
(body)
tinea, SCC in situ, discoid lupus,
porokeratosis,
?
?
5-FU, cryotherapy.
curettage, surgery
BCC, nodular
(body)
nevus (melanocytic),
molluscum
YES
YES
cryo, curettage, surgery
BCC, infiltrative or
recurrent (body)
scar YES
YES
BCC, any type
(head & neck)
nevus, rosacea, angiofibroma,
syringoma, sebaceous
hyperplasia, tinea, discoid
lupus, SCC, trichoepithelioma,
telangiectasia, scar
YES
YES
Mohs surgery
![Page 39: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/39.jpg)
Less Common Tumors
![Page 40: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/40.jpg)
DFSP
![Page 41: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/41.jpg)
Dermatofibroma
![Page 42: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/42.jpg)
![Page 43: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/43.jpg)
Extramammary Paget’s
![Page 44: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/44.jpg)
Extramammary Paget’s
![Page 45: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/45.jpg)
A Challenge to Primary Care:
DO YOUR OWN BIOPSIES!
![Page 46: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/46.jpg)
Primary Care & DermatologyDelay in Diagnosis & Treatment
• Community dermatology shortage: 2-6 months
• Community surgical dermatology shortage (Mohs surgery): 1-3 months
Typical delay from Primary care to definitive treatment: 3-9 months!!!
![Page 47: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/47.jpg)
Do a “real” skin exam
Document lesions and take a pre-biopsy photo & measurement
Do not be afraid to biopsy early – low-risk of complications
If the biopsy is inadequate or doesn’t fit the clinical picture, re-biopsy!
Essentials for Serious PCPs
![Page 48: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/48.jpg)
• Don’t worry if your biopsies come back with benign diagnoses – steep learning curve
• If you treat a lesion, see the patient back to confirm improvement. If not improving biopsy or refer, DON’T KEEP TREATING!!
Essentials for Serious PCPs
![Page 49: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/49.jpg)
This Is Not an Actinic Keratosis!
![Page 50: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/50.jpg)
sterile #15 bladeclean gauze & Q-tips3cc lido/epibottle Drysol in roomvaseline & plaster
obtain signed consent
In-Office BiopsyCost: $1.50
Time: 5-10 minutes. CLEAN not STERILE prep
Reimbursement: $60-100 (CPT 11102)
![Page 51: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/51.jpg)
Biopsy Video
![Page 52: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/52.jpg)
Please refer biopsy-proven skin cancersto dermatologic surgery, not plastics
![Page 53: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/53.jpg)
![Page 54: Skin Cancer Crash Course - mghcme](https://reader031.vdocument.in/reader031/viewer/2022013001/61ca4cb9d5176158a3704ff4/html5/thumbnails/54.jpg)
Nicotinamide for Prevention
• Nicotinamide (vitamin B3) 500mg BID
• ~25% reduction of SCC/BCC in high risk skin cancer patients at 1 yr
• low side effect profile
• (NOT NIACIN)