Skin Cancer


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A presentation on identifying and treating skin cancer prepared for my Surgery Rotation

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  • Skin Cancer

    1. 1. Treatment of Common Skin Cancers Jon Paul Nielsen MD/MPH Candidate 2010 New York Medical College
    2. 2. <ul><li>Benign skin lesion </li></ul><ul><li>Premalignant Lesions </li></ul><ul><li>Basal cell carcinoma– most common </li></ul><ul><li>Squamous cell carcinoma </li></ul><ul><li>Melanoma - present the greatest risk to life </li></ul>Types of Skin Lesions
    3. 3. <ul><li>Seborrheic Keratoses </li></ul><ul><li>Acanthosis Nigricans </li></ul><ul><li>Fibroepithelial Polyp, aka squamous papilloma, skin tag </li></ul><ul><li>Adnexal (appendage) tumors eg cylindroma </li></ul>Benign Skin Lesions Observe, no treatment necessary
    4. 4. Seborrheic Keratoses
    5. 5. Acanthosis Nigricans
    6. 6. Fibroepithelial Polyp, aka squamous papilloma, skin tag
    7. 7. Adnexal (appendage) tumors eg cylindroma
    8. 8. <ul><li>Precursors to squamous cell carcinoma </li></ul><ul><ul><li>Actinic keratoses </li></ul></ul><ul><ul><li>Bowen’s disease </li></ul></ul><ul><ul><li>Red scaly macules on sun-exposed area </li></ul></ul>Precancerous Lesions Dysplastic Nevi = Melanoma precursor
    9. 9. Actinic Keratosis
    10. 10. <ul><li>(picture of Actinic keratosis) </li></ul>
    11. 11. Bowen’s Disease
    12. 12. <ul><li>(pictures of 2 Dysplastic Nevi) </li></ul>
    13. 13. Malignant Skin Cancer Prevalence
    14. 14. <ul><li>Malignant Melanoma ~ 20% </li></ul><ul><li>Squamous Cell 2% Carcinoma </li></ul><ul><li>Basal Cell Carcinoma < 1% </li></ul>Malignant Skin Cancer Mortality Rates
    15. 15. Skin Cancer Incidence and Mortality Source: Cancer Statistics 2000, American Cancer Society Nonmelanoma: (basal and squamous cell) Melanoma: 1,300,000 New Cases Deaths 47,700 7,700 Deaths New Cases Deaths 1,900
    16. 16. <ul><li>Usually slow growing </li></ul><ul><li>Rarely metastasizes </li></ul><ul><li>May cause functional or cosmetic impairment </li></ul>Basal Cell Carcinoma Clinical Course
    17. 17. <ul><li>Pink, pearly, translucent papules with prominent telangiectasia </li></ul><ul><li>May ulcerate in center </li></ul><ul><li>Uncommon subtypes </li></ul><ul><li>- Scar-like appearance </li></ul><ul><li>- Red macules </li></ul>Clinical Appearance of Basal Cell Carcinoma
    18. 18. <ul><li>(pictures of Basal Cell Carcinoma) </li></ul>
    19. 19. <ul><li>Faster growing </li></ul><ul><li>May metastasize (3 - 30%) </li></ul><ul><li>May cause functional or cosmetic impairment </li></ul>Clinical Course of Squamous Cell Carcinoma
    20. 20. <ul><li>Red nodule </li></ul><ul><li>With or without ulceration </li></ul><ul><li>On sun-exposed skin </li></ul><ul><li>On traumatized skin </li></ul>Clinical Appearance of Squamous Cell Carcinoma
    21. 21. <ul><li>(pictures of squamous cell cancer) </li></ul>
    22. 22. <ul><li>Biopsy to confirm diagnosis </li></ul><ul><li>Medical Management- topical chemo </li></ul><ul><li>Curettage and electrodessication </li></ul><ul><li>Moh’s micrographic surgery </li></ul><ul><li>Cryosurgery </li></ul><ul><li>Excision </li></ul><ul><li>Radiation therapy </li></ul><ul><li>Photodynamic therapy </li></ul>Management of Nonmelanoma Skin Cancer
    23. 23. <ul><li>(picture of biopsy of lesion on nose) </li></ul>
    24. 24. Medical Management <ul><li>For in-situ lesions or as adjuvant therapy </li></ul><ul><li>Generally 5-FU for SCC, BCC, AK, Bowen’s </li></ul><ul><li>BCC: imiquimod 5% cream, 5-FU </li></ul>
    25. 25. Curettage and electrodessication <ul><li>Cut out tumor with curette </li></ul><ul><li>Bovey the edges to control bleeding and zap remaining cancer cells </li></ul>
    26. 26. Mohs Microsurgery <ul><li>Surgical removal of tissue </li></ul><ul><li>Mapping the piece of tissue, freezing and cutting the tissue between 5 and 10 micrometres using a cryostat, and staining with (H&E) or other stains </li></ul><ul><li>Interpretation of microscope slides </li></ul><ul><li>Reconstruction of the surgical defect </li></ul><ul><li>After each removal of tissue, the specimen is cut and placed on slides, stained with H&E and examined. If cancer is found, its location is marked on the map and the surgeon removes the indicated cancerous tissue. This procedure is repeated until no further cancer is found. </li></ul>
    27. 27. <ul><li>50% within 5 years </li></ul><ul><li>Greatest risk within the 1st year (20%) </li></ul><ul><li>Source: Marghoob, et al. 1993 </li></ul>Risk of Developing Second Nonmelanoma Skin Cancer
    28. 28. Melanoma Projected 2000 1996 1992 1985 1980 1960 1935 Adapted from: Rigel, et al. J. Am. Derm. 34: 839-47, 1996. Lifetime Risk of Malignant Melanoma Rate / 100,000 1:1500 1:600 1:250 1:150 1:105 1:87 1:75
    29. 29. <ul><li>Prior history of skin cancer </li></ul><ul><li>Fair skin </li></ul><ul><li>Family history </li></ul><ul><li>Sun exposure </li></ul><ul><li>Immunosuppression </li></ul><ul><li>Age </li></ul><ul><li>Precursor lesions </li></ul>Risk Factors for Malignant Melanoma
    30. 30. <ul><li>History of Skin Cancer Relative Risk </li></ul><ul><li>Previous melanoma 9 </li></ul><ul><li>Previous nonmelanoma 4 </li></ul><ul><li>skin cancer or precancer </li></ul><ul><li>Source: Balch, et al, 1992; Rhodes, 1987. </li></ul>Previous Skin Cancers as a Risk Factor for Melanoma
    31. 31. <ul><li>Precursor Lesions Relative Risk </li></ul><ul><li>Changing mole >400 </li></ul><ul><li>Dysplastic mole/ 148 familial melanoma </li></ul><ul><li>Dysplastic mole/ 27 no familial melanoma </li></ul><ul><li>Congenital mole 21 </li></ul><ul><li>Lentigo maligna 10 </li></ul><ul><li>Source: Balch, et al., 1992; Rhodes, 1987. </li></ul>Precursor Lesions as a Risk Factor for Melanoma
    32. 32. <ul><li>A – Asymmetry </li></ul><ul><li>B – Border </li></ul><ul><li>C – Color </li></ul><ul><li>D – Diameter </li></ul>
    33. 33. <ul><li>(pictures of the following) </li></ul><ul><li>Superficial Spreading Melanoma </li></ul><ul><li>Lentigo Maligna Melanoma </li></ul><ul><li>Nodular Melanoma </li></ul><ul><li>Acral Lentiginous Melanoma </li></ul>
    34. 34. <ul><li>Thickness/depth of tumor, greater than 1.7 mm = deep enough to metastasize </li></ul><ul><li>Location of tumor </li></ul><ul><li>Ulceration </li></ul><ul><li>Clark Level IV/V </li></ul>Establishing Prognosis in Melanoma
    35. 35. Clark Levels 1 2 3 4 5
    36. 36. Melanoma Staging
    37. 37. <ul><li>Stage TNM Classification 5 Year Survival Rate (%) </li></ul><ul><li>IA T1a N0 M0 >95 </li></ul><ul><li>IB T1b N0 M0 80-95 </li></ul><ul><li>T2a N0 M0 </li></ul><ul><li>IIA T2b N0 M0 70-80 T3a N0 M0 </li></ul><ul><li>IIB T3b N0 M0 50-70 </li></ul><ul><li>T4a N0 M0 </li></ul><ul><li>IIC T4b N0 M0 30-50 </li></ul><ul><li>IIIA T1-4a N1a M0 60-70 </li></ul><ul><li>T1-4a N2a M0 50-60 </li></ul>Malignant Melanoma: Relative Survival According to Stage
    38. 38. <ul><li>Stage TNM Classification 5 Year Survival Rate (%) </li></ul><ul><li>IIIB T1-4a N1b M0 40-50 </li></ul><ul><li>T1-4a N2b M0 20-40 </li></ul><ul><li>T1-4a/b N2c M0 30-50 T1-4b N1a/N2a M0 30-45 </li></ul><ul><li>IIIC T1-4b N2a M0 20-30 </li></ul><ul><li>T1-4b N2b M0 10-30 </li></ul><ul><li>Any T N3 M0 10-30 </li></ul><ul><li>IV Any T any N M1 5-10 </li></ul><ul><li>Any T any N M2 <5 </li></ul><ul><li>Any T any N M3 <5 </li></ul>Malignant Melanoma: Relative Survival According to Stage Swetter, Susan M., MD. “Malignant Melanoma.” eMedicine Journal 2.5 (2001). 12 Jun. 2001 <http://www. emedicine .com/ derm /topic257. htm > .
    39. 39. <ul><li>If treated early: 100% cure rate </li></ul><ul><li>If untreated: 100% mortality </li></ul>Clinical Course of Melanoma
    40. 40. <ul><li>Tissue Biopsy + SLNB </li></ul><ul><li>Surgical excision with lymph node dissection if SN+ </li></ul><ul><li>Medical Adjuvant therapy controversial </li></ul>Treatment for Malignant Melanoma
    41. 41. <ul><li>Incisional </li></ul><ul><li>Narrow Excisional </li></ul><ul><li>Avoid shave biopsies </li></ul>Biopsy for Malignant Melanoma
    42. 42. <ul><li>Standard of care </li></ul><ul><li>Recommended for Breslow depth melanoma > 1mm or any Breslow depth melanoma which exhibits ulceration or is a Clark Level IV/V </li></ul><ul><li>Identifies nodal involvement without radical lymph node dissection </li></ul><ul><li>Powerful prognostic indicator </li></ul>Sentinel Node Biopsy
    43. 43. <ul><li>Surgical margins are based on depth </li></ul><ul><li>Lesion Margin </li></ul><ul><li>In situ 0.5 cm </li></ul><ul><li>< 1mm 1.0 cm </li></ul><ul><li>> 1mm 2.0 cm </li></ul><ul><li>Source: Balch, et al, 1992 </li></ul>Surgical Excision for Malignant Melanoma
    44. 44. Medical adjuvant therapy for melanoma <ul><li>the use of adjuvant IFN-{alpha} in high-risk melanoma remains controversial </li></ul><ul><li>Melanoma vaccines </li></ul><ul><li>Based on melanoma cell expression of certain HLA- and tumor-associated antigens. No proven benefits; however, multiple studies are in progress </li></ul>
    45. 45. <ul><ul><li>A 65 year old West Texas farmer of Swedish ancestry has an indolent, raised, waxy, 1.2 cm skin mass over the bridge of the nose that has been slowly growing over the past three years. There are no enlarged lymph nodes in the head and neck. </li></ul></ul>What is it? – Basal cell carcinoma. How is it diagnosed? - Full thickness biopsy at the edge of the lesion (punch or knife). Treatment: Surgical excision with clear margins, but conservative width.
    46. 46. A blond, blue eyed, 69 year old sailor has a non-healing, indolent 1.5 cm. ulcer n the lower lip, that has been present, and slowly enlarging for the past 8 months. He is a pipe smoker, and he has no other lesions or physical findings. What is it? - Squamous cell carcinoma. How is the diagnosis made? - Biopsy, as described before. Treatment: he will need surgical resection with wider (about 1 cm.) clear margins . Local radiation therapy is another option.
    47. 47. A red headed 23 year old lady who worships the sun, and who happens to be full of freckles, consults you for a skin lesion on her shoulder that concerns her. She has a pigmented lesion that is asymetrical, with irregular borders, of different colors within the lesion, and measuring 1.8 cms. What is it? – The classical ABCD that alerts you to melanoma or a forerunner (dysplastic nevus). Management: full thickness biopsy at the edge of the lesion, .5 cm local excision if superficial melanoma (Clarks’ levels one or two, or under 0.75 mm), wide local excision with 2 or 3 cm. margin if deep melanoma.