skin cancer crash course - mghcme

Skin Cancer Crash Course:

Recognition and Management of Nonmelanoma Skin Cancer

Victor Neel, MD, PhDDirector, Dermatologic Surgery, MGH

Disclosures

Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest

to disclose.

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

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

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

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

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

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

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)

Which Is BCC?

Basal Cell Carcinoma

• Subtypes– Nodulo-ulcerative (most common)

– Morpheaform (sclerosing, infiltrative)

– Micronodular

– Metatypical (basosquamous)

– Superficial (“multicentric”)


• Subtypes

– Nodulo-ulcerative (most common)


• Pigmented BCC • Can mimic MM


• Subtypes– Morpheaform BCC

– Can look like scar


• Subtypes

– Superficial “multicentric”

– Can be misdiagnosed as psoriasis, tinea or eczema

– Most common type on trunk and extremities

BCC or Tinea?

BCCTinea

itchy & scalyoften multiple

antifungals

crusts/bleedsusually singlesun-exposed


• Course

– Slow, progressive growth

– Bleeding, ulceration, superinfection

– Enlarges over months to years

– Is capable of extensive tissue destruction (invading

into muscle, cartilage, and bone)

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

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)


• 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

Diffuse AKs? 5-FU!!

Two Weeks of Topical 5-FU


• 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


• 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

Time to get the derm surgeonon the phone


• 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

• 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

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)

A Lethal Tumor in a Transplant Patient

Please have your transplantpatients see a dermatologist for baseline evaluation

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

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

Less Common Tumors

Dermatofibroma

Extramammary Paget’s

A Challenge to Primary Care:

DO YOUR OWN BIOPSIES!

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!!!

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

• 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

This Is Not an Actinic Keratosis!

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)

Biopsy Video

Please refer biopsy-proven skin cancersto dermatologic surgery, not plastics

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)

The dermatologist will see you!

[email protected]

skin cancer crash course - mghcme

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