Skin Cancer September 17 th  2008 Cormac Joyce
Basal Cell Carcinoma
BCC <ul><li>Most common cutaneous malignancy </li></ul><ul><li>Almost NEVER metastasizes </li></ul><ul><li>Often leads to ...
Epidemiology <ul><li>Most common in fair skin </li></ul><ul><li>Fitzpatrick types : I and II </li></ul><ul><li>Males > Fem...
Fitzpatrick Skin Types <ul><li>Type 1 </li></ul><ul><li>Pale skin </li></ul><ul><li>Blond, red hair </li></ul><ul><li>Neve...
Fitzpatrick Skin Types <ul><li>Type 2 </li></ul><ul><li>Fair skin, blue eyes </li></ul><ul><li>Burns easily </li></ul><ul>...
Fitzpatrick Skin Types <ul><li>Type 3 </li></ul><ul><li>Darker white skin </li></ul><ul><li>Tans after burning first </li>...
Fitzpatrick Skin Types <ul><li>Type 4 </li></ul><ul><li>Light brown skin </li></ul><ul><li>Burns minimally </li></ul><ul><...
Fitzpatrick Skin Types <ul><li>Type 5 </li></ul><ul><li>Brown skin </li></ul><ul><li>Tans easily </li></ul><ul><li>Rarely ...
Fitzpatrick Skin Types <ul><li>Type 6 </li></ul><ul><li>Black skin </li></ul><ul><li>Never burns </li></ul>
Aetiology <ul><li>Sunlight: mainly UVB </li></ul><ul><li>Artificial UVB: Tanning salons </li></ul><ul><li>Ionizing radiati...
Aetiology <ul><li>Xeroderma Pigmentosa </li></ul><ul><li>Autosomal recessive: inability to repair UV damaged DNA, increase...
Aetiology <ul><li>Bazex Syndrome </li></ul><ul><li>Features: </li></ul><ul><li>-follicular atrophoderma : “ice pick hands”...
Types of BCC <ul><li>Nodular-Ulcerative </li></ul><ul><li>Cystic </li></ul><ul><li>Pigmented </li></ul><ul><li>Sclerosing ...
Types of BCC <ul><li>Nodular-ulcerative </li></ul><ul><li>Most common type </li></ul><ul><li>Raised, round pearly lesion <...
Nodular BCC
Types of BCC <ul><li>Cystic </li></ul><ul><li>Uncommon variant of nodular </li></ul><ul><li>Polypoid appearance </li></ul>...
Types of BCC <ul><li>Pigmented </li></ul><ul><li>Brown - black macules in some areas </li></ul><ul><li>Difficult to distin...
Types of BCC <ul><li>Sclerosing </li></ul><ul><li>White-yellow, waxy sclerotic plaque </li></ul><ul><li>Increased collagen...
Types of BCC <ul><li>Superficial </li></ul><ul><li>Erythematous patch or plaque </li></ul><ul><li>Multicentric </li></ul><...
Investigations <ul><li>Biopsy </li></ul><ul><li>Punch </li></ul><ul><li>Shave </li></ul><ul><li>Incisional </li></ul><ul><...
Investigations <ul><li>Imaging </li></ul><ul><li>Not required as very little risk of metastasis < 0.01% </li></ul>
Treatment <ul><li>Medical </li></ul><ul><li>5-FU cream (Efudex) </li></ul><ul><li>-T bd x 2/52 </li></ul><ul><li>-cure in ...
Treatment <ul><li>Surgery </li></ul><ul><li>Excision </li></ul><ul><li>-direct closure </li></ul><ul><li>-local flap </li>...
Mohs Surgery <ul><li>Tumour excised and 1mm of surrounding tissue is examined under microscope </li></ul><ul><li>Additiona...
Recurrence <ul><li>Risk factors: </li></ul><ul><li>BCC in NL fold </li></ul><ul><li>Recurrent tumours </li></ul><ul><li>La...
Squamous Cell Carcinoma
Squamous Cell Carcinoma <ul><li>2nd most common skin Ca </li></ul><ul><li>Malignant tumour of epidermal keratinocytes </li...
Epidemiology <ul><li>Age > 50 </li></ul><ul><li>Fitzpatrick I and II </li></ul><ul><li>Males </li></ul><ul><li>Closer to e...
Aetiology <ul><li>Sunlight: UVB </li></ul><ul><li>Sunbeds </li></ul><ul><li>Ionizing Radiation </li></ul><ul><li>Arsenic <...
SCC
Bowens Disease <ul><li>Intra-epidermal form of SCC </li></ul><ul><li>SCC in situ:  BM not invaded </li></ul><ul><li>Well d...
Bowens Disease
SCC Types <ul><li>Typical: most common </li></ul><ul><li>Periungual </li></ul><ul><li>Perioral </li></ul><ul><li>Marjolins...
Typical SCC <ul><li>A raised, firm, pink-to-flesh – coloured keratotic papule or plaque arising on sun-exposed skin </li><...
SCC Pathophysiology <ul><li>malignant tumour of epidermal keratinocytes </li></ul><ul><li>De novo or from actinic keratose...
Investigations <ul><li>Biopsy </li></ul><ul><li>Incisional  </li></ul><ul><li>Excisional </li></ul><ul><li>Punch </li></ul...
Investigations <ul><li>If a patient has lymphadenopathy: </li></ul><ul><li>Imaging studies: CT </li></ul><ul><li>LN biopsy...
Staging: AJCC <ul><li>Use TNM guidelines </li></ul><ul><li>Most SCC are not metastatic at time of presentation </li></ul>
Staging: AJCC <ul><li>Classification of primary tumour: </li></ul><ul><li>T0: no evidence of primary </li></ul><ul><li>Tis...
Medical Care <ul><li>Topical therapy </li></ul><ul><li>For premalignant and in-situ lesions </li></ul><ul><li>Efudex (5 FU...
Medical Care <ul><li>Radiotherapy </li></ul><ul><li>Indications: </li></ul><ul><li>-patients refusing/not fit for surgery ...
Medical Care <ul><li>Radiotherapy problems: </li></ul><ul><li>Expensive and time consuming </li></ul><ul><li>Irritation at...
Surgery <ul><li>Cryotherapy </li></ul><ul><li>Liquid nitrogen </li></ul><ul><li>For selective SCCs: AKs or Cis </li></ul><...
Surgery <ul><li>Electrodessication and Curettage </li></ul><ul><li>Indications; AK and Cis </li></ul><ul><li>Tumour margin...
Surgery <ul><li>Excision with conventional margins </li></ul><ul><li>4mm margin for low risk lesions: </li></ul><ul><li><2...
Surgery <ul><li>Mohs Micrographic Surgery  </li></ul><ul><li>Excellent option if tissue preservation is required </li></ul...
Surgery <ul><li>Mohs Micrographic Surgery </li></ul><ul><li>Best cure rates for SCC (94-99%) </li></ul><ul><li>Local recur...
Chemotherapy <ul><li>Useful for metastatic disease </li></ul><ul><li>Capecitabine (Xeloda) and IFN α </li></ul>
Prognosis <ul><li>Variable: </li></ul><ul><li>Tumor- and patient-related risk factors associated with higher rates of recu...
Prognosis <ul><li>Tumor-related factors in high-risk SCC: </li></ul><ul><li>Location: lips, ears, scar </li></ul><ul><li>T...
Prognosis <ul><li>Patient-related factors in high-risk SCC </li></ul><ul><li>Organ transplant recipient </li></ul><ul><li>...
Prognosis: Overall <ul><li>The 3-year disease-specific survival rate is 85% </li></ul><ul><li>Almost 100% if none of previ...
The Future? <ul><li>NSAIDS: </li></ul><ul><li>May protect against SCC development </li></ul><ul><li>COX 2 often overexpres...
Malignant Melanoma
MM <ul><li>A malignancy of pigment producing melanocytes </li></ul><ul><li>Predominantly skin </li></ul><ul><li>Also: eyes...
MM <ul><li>Accounts for 4% of skin cancers </li></ul><ul><li>Responsible for 74% of all skin cancer deaths </li></ul>
Frequency <ul><li>6 th  most common cancer in U.S. </li></ul><ul><li>1 in 60 lifetime risk of developing melanoma in Cauca...
Epidemiology <ul><li>Primarily disease of whites </li></ul><ul><li>Whites: African-Americans  = 20:1 </li></ul><ul><li>MR ...
Aetiology/Risk factors <ul><li>Changing mole </li></ul><ul><li>Atypical naevus </li></ul><ul><li>Large numbers of common n...
Pathophysiology <ul><li>Tumour progression: 5 stages </li></ul><ul><li>Benign melanocytic naevus </li></ul><ul><li>Dysplas...
Classification <ul><li>Superficial Spreading Melanoma </li></ul><ul><li>Nodular Melanoma </li></ul><ul><li>Lentigo Maligna...
Superficial Spreading Melanoma <ul><li>Most common, accounts for 70% </li></ul><ul><li>Usually > 6mm in diameter </li></ul...
Superficial Spreading Melanoma <ul><li>Irregular, asymmetric borders are characteristic </li></ul><ul><li>Histologically, ...
Superficial Spreading Melanoma
Nodular Melanoma <ul><li>Second most common : 25% </li></ul><ul><li>Legs and trunk are most common sites </li></ul><ul><li...
Nodular Melanoma
Nodular Melanoma
Lentigo Maligna Melanoma <ul><li>Accounts for 4-10% </li></ul><ul><li>Most common on head, neck and arms </li></ul><ul><li...
Lentigo Maligna Melanoma <ul><li>In Australia: on the face.. </li></ul><ul><li>More common in men on RHS </li></ul><ul><li...
Lentigo Maligna Melanoma
Acral Lentiginous Melanoma <ul><li>Accounts for 2-4% </li></ul><ul><li>Accounts for 55% in dark skinned individuals </li><...
Acral Lentiginous Melanoma <ul><li>Characteristic features: </li></ul><ul><li>Irregular pigmentation </li></ul><ul><li>Lar...
Acral Lentiginous Melanoma
Amelanotic Melanoma <ul><li>Non pigmented </li></ul><ul><li>Pink or flesh coloured – often mimicking BCC or SCC </li></ul>
Rare Sub-Types <ul><li>Desmoplastic Melanoma </li></ul><ul><li>Mucosal Melanoma </li></ul><ul><li>Malignant Blue Naevus </...
Assessment <ul><li>History </li></ul><ul><li>Exam </li></ul><ul><li>Inspection alone can diagnose 65% </li></ul><ul><li>No...
Assessment <ul><li>MacKies 7 point checklist </li></ul><ul><li>Major (2 points each) </li></ul><ul><li>Change in size </li...
Assessment <ul><li>MacKies 7 point checklist </li></ul><ul><li>Minor (1 point each) </li></ul><ul><li>Inflammation </li></...
Assessment <ul><li>MacKies 7 point checklist </li></ul><ul><li>Needs further evaluation in presence of one major or if sco...
Assessment <ul><li>American ABCDE </li></ul><ul><li>A: asymmetry </li></ul><ul><li>B: border is irregular </li></ul><ul><l...
ABCDE
Biopsy <ul><li>Incisional </li></ul><ul><li>Excisional </li></ul><ul><li>Punch </li></ul><ul><li>NB not shave </li></ul>
Biopsy <ul><li>Information gained from biopsy: </li></ul><ul><li>Tumour depth </li></ul><ul><li>Anatomical level </li></ul...
Biopsy <ul><li>Information gained from biopsy: ctd </li></ul><ul><li>Regression </li></ul><ul><li>Immunohistochemical stai...
Biopsy <ul><li>Excisional biopsy </li></ul><ul><li>1-3mm of normal skin should be removed with the lesion as more than thi...
Clarkes Level <ul><li>Classifies level of invasion </li></ul><ul><li>Level 1: only epidermis involved </li></ul><ul><li>Le...
Breslows Thickness <ul><li>Most important histological determinant of prognosis </li></ul><ul><li>Measured vertically in m...
Breslows Thickness <ul><li>5yr survival </li></ul><ul><li>1.  </= 0.75mm  90% </li></ul><ul><li>2.  0.76mm – 1.5mm  80% </...
Breslows Thickness <ul><li>Gives better indication of prognosis </li></ul><ul><li>As depth (Clarkes) of papillary and reti...
Staging <ul><li>AJCC </li></ul><ul><li>Incorporates TNM with Clarkes and Breslow </li></ul>
Spread <ul><li>Locally, in LN basins or distally: </li></ul><ul><li>Remote skin </li></ul><ul><li>Remote nodes </li></ul><...
Surgery <ul><li>Excision margins; </li></ul><ul><li>0.5 cm for melanoma in situ </li></ul><ul><li>1cm with Breslow thickne...
Surgery <ul><li>Melanomas near vital structures may require a reduced margin </li></ul><ul><li>Aggressive histological fea...
Sentinel Node Mapping <ul><li>Growing in popularity </li></ul><ul><li>Isosulfan blue dye and lymphoscintigraphy </li></ul>...
Sentinel Node Mapping <ul><li>Advantages </li></ul><ul><li>If node –ve, no need for nodal clearance </li></ul><ul><li>More...
Sentinel Node Mapping <ul><li>Disadvantages </li></ul><ul><li>Poor mapping in head and neck tumours </li></ul><ul><li>Tumo...
Sentinel Node Mapping <ul><li>Indications: controversial </li></ul><ul><li>Patients in whom the estimated risk of LN metas...
Elective LN Dissection <ul><li>Lymphadenectomy when nodes are clinically negative </li></ul><ul><li>Rationale is that MM s...
Nodal Dissection <ul><li>Patients with palpable, clinically +ve nodes should undergo complete nodal dissection </li></ul>
Adjuvant Therapy <ul><li>Interferon  α  2b </li></ul><ul><li>For high risk resected MM: </li></ul><ul><li>>4mm depth </li>...
Chemotherapy <ul><li>For unresectable regional mets or distant mets </li></ul><ul><li>Dacarbazine is the most active chemo...
Biological Therapy <ul><li>Interleukin 2 </li></ul><ul><li>Useful for metastatic melanoma </li></ul><ul><li>In one study, ...
Biological Therapy <ul><li>Monoclonal antibody therapy </li></ul><ul><li>Experimental but very promising </li></ul><ul><li...
Perfusion Chemo <ul><li>Isolated Limb Perfusion (ILP) </li></ul><ul><li>Tourniquet applied </li></ul><ul><li>Artery and ve...
Radiotherapy <ul><li>For palliation </li></ul><ul><li>Specific indications: </li></ul><ul><li>Brain metastases </li></ul><...
Prevention <ul><li>Public education </li></ul><ul><li>Australia: “slip, slop, slap” campaign </li></ul><ul><li>Adequate cl...
Thank You Will be on Blackboard tomorrow!!
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Fwd: Skin Cancer (Cormac Joyce)

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---------- Forwarded message ----------
From: UCD Graduate '09 None <ucdgrad09@gmail.com&gt;
Date: 2009/2/25
Subject: Skin Cancer (Cormac Joyce)
To: ucdgrad09@gmail.com

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Fwd: Skin Cancer (Cormac Joyce)

  1. 1. Skin Cancer September 17 th 2008 Cormac Joyce
  2. 2. Basal Cell Carcinoma
  3. 3. BCC <ul><li>Most common cutaneous malignancy </li></ul><ul><li>Almost NEVER metastasizes </li></ul><ul><li>Often leads to local destruction </li></ul><ul><li>Usually arise from epidermis or outer root sheath of hair follicle </li></ul>
  4. 4. Epidemiology <ul><li>Most common in fair skin </li></ul><ul><li>Fitzpatrick types : I and II </li></ul><ul><li>Males > Females </li></ul><ul><li>Rarely found before age 40 </li></ul>
  5. 5. Fitzpatrick Skin Types <ul><li>Type 1 </li></ul><ul><li>Pale skin </li></ul><ul><li>Blond, red hair </li></ul><ul><li>Never tans </li></ul>
  6. 6. Fitzpatrick Skin Types <ul><li>Type 2 </li></ul><ul><li>Fair skin, blue eyes </li></ul><ul><li>Burns easily </li></ul><ul><li>Tans poorly </li></ul>. .
  7. 7. Fitzpatrick Skin Types <ul><li>Type 3 </li></ul><ul><li>Darker white skin </li></ul><ul><li>Tans after burning first </li></ul>
  8. 8. Fitzpatrick Skin Types <ul><li>Type 4 </li></ul><ul><li>Light brown skin </li></ul><ul><li>Burns minimally </li></ul><ul><li>Tans easily </li></ul>
  9. 9. Fitzpatrick Skin Types <ul><li>Type 5 </li></ul><ul><li>Brown skin </li></ul><ul><li>Tans easily </li></ul><ul><li>Rarely burns </li></ul>
  10. 10. Fitzpatrick Skin Types <ul><li>Type 6 </li></ul><ul><li>Black skin </li></ul><ul><li>Never burns </li></ul>
  11. 11. Aetiology <ul><li>Sunlight: mainly UVB </li></ul><ul><li>Artificial UVB: Tanning salons </li></ul><ul><li>Ionizing radiation </li></ul><ul><li>For acne treatment </li></ul><ul><li>Immunosuppression </li></ul><ul><li>Renal transplants etc </li></ul>
  12. 12. Aetiology <ul><li>Xeroderma Pigmentosa </li></ul><ul><li>Autosomal recessive: inability to repair UV damaged DNA, increased risk of all skin Ca . </li></ul><ul><li>Other features: corneal deposits, blindness </li></ul><ul><li>Gorlin syndrome </li></ul><ul><li>Autosomal Dominant </li></ul><ul><li>Odontogenic keratocysts, palmoplantar pitting, intracranial calcs, rib anomalies </li></ul>
  13. 13. Aetiology <ul><li>Bazex Syndrome </li></ul><ul><li>Features: </li></ul><ul><li>-follicular atrophoderma : “ice pick hands” </li></ul><ul><li>-local anhydrosis </li></ul><ul><li>-multiple BCCs </li></ul><ul><li>Hx of previous non-melanoma skin Ca </li></ul>
  14. 14. Types of BCC <ul><li>Nodular-Ulcerative </li></ul><ul><li>Cystic </li></ul><ul><li>Pigmented </li></ul><ul><li>Sclerosing </li></ul><ul><li>Superficial </li></ul>
  15. 15. Types of BCC <ul><li>Nodular-ulcerative </li></ul><ul><li>Most common type </li></ul><ul><li>Raised, round pearly lesion </li></ul><ul><li>As it enlarges : telangiectasia and central ulceration </li></ul><ul><li>Mainly on face </li></ul>
  16. 16. Nodular BCC
  17. 17. Types of BCC <ul><li>Cystic </li></ul><ul><li>Uncommon variant of nodular </li></ul><ul><li>Polypoid appearance </li></ul><ul><li>Typically blue-grey cyst </li></ul>
  18. 18. Types of BCC <ul><li>Pigmented </li></ul><ul><li>Brown - black macules in some areas </li></ul><ul><li>Difficult to distinguish from MM </li></ul>
  19. 19. Types of BCC <ul><li>Sclerosing </li></ul><ul><li>White-yellow, waxy sclerotic plaque </li></ul><ul><li>Increased collagen deposit from fibroblasts- thus resembling a scar </li></ul><ul><li>Margins are difficult to see </li></ul>
  20. 20. Types of BCC <ul><li>Superficial </li></ul><ul><li>Erythematous patch or plaque </li></ul><ul><li>Multicentric </li></ul><ul><li>-normal skin interspersed with malignant patches </li></ul>
  21. 21. Investigations <ul><li>Biopsy </li></ul><ul><li>Punch </li></ul><ul><li>Shave </li></ul><ul><li>Incisional </li></ul><ul><li>Excisional </li></ul><ul><li>Deep-wedge </li></ul>
  22. 22. Investigations <ul><li>Imaging </li></ul><ul><li>Not required as very little risk of metastasis < 0.01% </li></ul>
  23. 23. Treatment <ul><li>Medical </li></ul><ul><li>5-FU cream (Efudex) </li></ul><ul><li>-T bd x 2/52 </li></ul><ul><li>-cure in 93% in some trials </li></ul><ul><li>-surgery is preferred </li></ul>
  24. 24. Treatment <ul><li>Surgery </li></ul><ul><li>Excision </li></ul><ul><li>-direct closure </li></ul><ul><li>-local flap </li></ul><ul><li>-FTSG ie PAWG (Wolf) </li></ul><ul><li>Mohs Micrographically controlled surgery </li></ul>
  25. 25. Mohs Surgery <ul><li>Tumour excised and 1mm of surrounding tissue is examined under microscope </li></ul><ul><li>Additional pieces of tumour are removed in the persisting area </li></ul><ul><li>Highest cure rate: 99% </li></ul><ul><li>Time consuming, LA top ups required </li></ul>
  26. 26. Recurrence <ul><li>Risk factors: </li></ul><ul><li>BCC in NL fold </li></ul><ul><li>Recurrent tumours </li></ul><ul><li>Large tumours >2cm </li></ul><ul><li>Deeply infiltrating tumours </li></ul><ul><li>Young females </li></ul>
  27. 27. Squamous Cell Carcinoma
  28. 28. Squamous Cell Carcinoma <ul><li>2nd most common skin Ca </li></ul><ul><li>Malignant tumour of epidermal keratinocytes </li></ul><ul><li>Can Metastasize </li></ul><ul><li>Strongly related to sun exposure </li></ul><ul><li>70% occur on head and neck </li></ul>
  29. 29. Epidemiology <ul><li>Age > 50 </li></ul><ul><li>Fitzpatrick I and II </li></ul><ul><li>Males </li></ul><ul><li>Closer to equator </li></ul>
  30. 30. Aetiology <ul><li>Sunlight: UVB </li></ul><ul><li>Sunbeds </li></ul><ul><li>Ionizing Radiation </li></ul><ul><li>Arsenic </li></ul><ul><li>Xeroderma Pigmentosa </li></ul><ul><li>Transplants: greatest in heart </li></ul><ul><li>HPV: 5,6,8,11,16 </li></ul><ul><li>Chronic Ulcers: Marjolins </li></ul><ul><li>Burns </li></ul><ul><li>Necrobiotic Lipoidica </li></ul><ul><li>Hidradenitis </li></ul><ul><li>Actinic Keratosis </li></ul>
  31. 31. SCC
  32. 32. Bowens Disease <ul><li>Intra-epidermal form of SCC </li></ul><ul><li>SCC in situ: BM not invaded </li></ul><ul><li>Well demarcated erythematous plaque </li></ul><ul><li>Irregular border </li></ul><ul><li>Surface crusting or scaling </li></ul><ul><li>Rx: Photodynamic therapy, Cryotherapy or topical 5-FU. </li></ul>
  33. 33. Bowens Disease
  34. 34. SCC Types <ul><li>Typical: most common </li></ul><ul><li>Periungual </li></ul><ul><li>Perioral </li></ul><ul><li>Marjolins </li></ul><ul><li>Anogenital </li></ul><ul><li>Verrucous </li></ul>
  35. 35. Typical SCC <ul><li>A raised, firm, pink-to-flesh – coloured keratotic papule or plaque arising on sun-exposed skin </li></ul><ul><li>70% occur on head and neck </li></ul><ul><li>Surface changes may include: </li></ul><ul><li>Scaling </li></ul><ul><li>Ulceration </li></ul><ul><li>Crusting </li></ul>
  36. 36. SCC Pathophysiology <ul><li>malignant tumour of epidermal keratinocytes </li></ul><ul><li>De novo or from actinic keratoses </li></ul><ul><li>Capable of: </li></ul><ul><li>Local infiltration </li></ul><ul><li>Spread to regional nodes </li></ul><ul><li>Distant mets </li></ul>
  37. 37. Investigations <ul><li>Biopsy </li></ul><ul><li>Incisional </li></ul><ul><li>Excisional </li></ul><ul><li>Punch </li></ul><ul><li>Must reach level of mid dermis to see if invasion has occurred </li></ul>
  38. 38. Investigations <ul><li>If a patient has lymphadenopathy: </li></ul><ul><li>Imaging studies: CT </li></ul><ul><li>LN biopsy or FNA </li></ul><ul><li>May require lympadenectomy of the draining basin </li></ul>
  39. 39. Staging: AJCC <ul><li>Use TNM guidelines </li></ul><ul><li>Most SCC are not metastatic at time of presentation </li></ul>
  40. 40. Staging: AJCC <ul><li>Classification of primary tumour: </li></ul><ul><li>T0: no evidence of primary </li></ul><ul><li>Tis: Ca in situ </li></ul><ul><li>T1: <2cm in greatest diameter </li></ul><ul><li>T2: 2-5cm in greatest diameter </li></ul><ul><li>T3: >5cm in greatest diameter </li></ul><ul><li>T4: deep invasion; bone,cartilage, muscle </li></ul>
  41. 41. Medical Care <ul><li>Topical therapy </li></ul><ul><li>For premalignant and in-situ lesions </li></ul><ul><li>Efudex (5 FU) </li></ul><ul><li>Topical immune response modifier </li></ul><ul><li>enhances cell-mediated immune responses via the induction of proinflammatory cytokines </li></ul><ul><li>e.g. imidazoquinoline (Imiquimod) </li></ul>
  42. 42. Medical Care <ul><li>Radiotherapy </li></ul><ul><li>Indications: </li></ul><ul><li>-patients refusing/not fit for surgery </li></ul><ul><li>-metastatic disease </li></ul>
  43. 43. Medical Care <ul><li>Radiotherapy problems: </li></ul><ul><li>Expensive and time consuming </li></ul><ul><li>Irritation at site: erythema, erosions </li></ul><ul><li>Pain: requiring narcotic analgesia </li></ul><ul><li>Poor long term cosmesis: cutaneous atrophy, dyspigmentation, telangiectasia </li></ul><ul><li>Increased risk of further cutaneous malignancy </li></ul>
  44. 44. Surgery <ul><li>Cryotherapy </li></ul><ul><li>Liquid nitrogen </li></ul><ul><li>For selective SCCs: AKs or Cis </li></ul><ul><li>Complications: </li></ul><ul><li>-transient pain </li></ul><ul><li>-oedema </li></ul><ul><li>-blistering </li></ul>
  45. 45. Surgery <ul><li>Electrodessication and Curettage </li></ul><ul><li>Indications; AK and Cis </li></ul><ul><li>Tumour margins are delineated with a curette and scraped out: tumour is far more friable than normal tissue </li></ul><ul><li>Main disadvantage is loss of margin </li></ul><ul><li>Cure rates of 96-99% have been quoted </li></ul>
  46. 46. Surgery <ul><li>Excision with conventional margins </li></ul><ul><li>4mm margin for low risk lesions: </li></ul><ul><li><2cm, well differentiated, without fat invasion </li></ul><ul><li>6mm margin for higher risk lesions: </li></ul><ul><li>>2cm, fat invasion, high risk areas- central face, ears, genitalia </li></ul>
  47. 47. Surgery <ul><li>Mohs Micrographic Surgery </li></ul><ul><li>Excellent option if tissue preservation is required </li></ul><ul><li>Almost 100% of histologic margin is examined (compared to 1% in conventional excision) </li></ul>
  48. 48. Surgery <ul><li>Mohs Micrographic Surgery </li></ul><ul><li>Best cure rates for SCC (94-99%) </li></ul><ul><li>Local recurrences are fewer </li></ul>
  49. 49. Chemotherapy <ul><li>Useful for metastatic disease </li></ul><ul><li>Capecitabine (Xeloda) and IFN α </li></ul>
  50. 50. Prognosis <ul><li>Variable: </li></ul><ul><li>Tumor- and patient-related risk factors associated with higher rates of recurrence and metastasis are as follows: </li></ul>
  51. 51. Prognosis <ul><li>Tumor-related factors in high-risk SCC: </li></ul><ul><li>Location: lips, ears, scar </li></ul><ul><li>Tumour size > 2cm </li></ul><ul><li>Poorly diff tumour </li></ul><ul><li>Recurrent tumour </li></ul><ul><li>Perineural involvement </li></ul>
  52. 52. Prognosis <ul><li>Patient-related factors in high-risk SCC </li></ul><ul><li>Organ transplant recipient </li></ul><ul><li>Haematological malignancy ie CLL </li></ul><ul><li>Chronic immunosuppression </li></ul><ul><li>HIV infection </li></ul>
  53. 53. Prognosis: Overall <ul><li>The 3-year disease-specific survival rate is 85% </li></ul><ul><li>Almost 100% if none of previous risk factors </li></ul><ul><li>70% if 1 risk factor present </li></ul>
  54. 54. The Future? <ul><li>NSAIDS: </li></ul><ul><li>May protect against SCC development </li></ul><ul><li>COX 2 often overexpressed in SCC </li></ul><ul><li>Studies are ongoing </li></ul>
  55. 55. Malignant Melanoma
  56. 56. MM <ul><li>A malignancy of pigment producing melanocytes </li></ul><ul><li>Predominantly skin </li></ul><ul><li>Also: eyes, ears, GI tract, and oral and genital mucous membranes </li></ul>
  57. 57. MM <ul><li>Accounts for 4% of skin cancers </li></ul><ul><li>Responsible for 74% of all skin cancer deaths </li></ul>
  58. 58. Frequency <ul><li>6 th most common cancer in U.S. </li></ul><ul><li>1 in 60 lifetime risk of developing melanoma in Caucasians </li></ul><ul><li>Highest incidence in Australia and NZ </li></ul><ul><li>Incidence increasing worldwide. </li></ul>
  59. 59. Epidemiology <ul><li>Primarily disease of whites </li></ul><ul><li>Whites: African-Americans = 20:1 </li></ul><ul><li>MR far higher in darker skin types </li></ul><ul><li>Incidence greatest in females </li></ul><ul><li>Mortality highest in males </li></ul><ul><li>Median age at Dx = 53 </li></ul>
  60. 60. Aetiology/Risk factors <ul><li>Changing mole </li></ul><ul><li>Atypical naevus </li></ul><ul><li>Large numbers of common naevi >100 </li></ul><ul><li>Naevus >20cm </li></ul><ul><li>Previous melanoma </li></ul><ul><li>Sun exposure </li></ul><ul><li>1 st degree relative </li></ul><ul><li>BCC/SCC </li></ul><ul><li>Male </li></ul><ul><li>>50 </li></ul><ul><li>XP </li></ul><ul><li>Fitzpatrick I and II </li></ul><ul><li>Immunosuppression </li></ul>
  61. 61. Pathophysiology <ul><li>Tumour progression: 5 stages </li></ul><ul><li>Benign melanocytic naevus </li></ul><ul><li>Dysplastic naevus: cytolological atypia </li></ul><ul><li>Primary MM: radial growth phase </li></ul><ul><li>Primary MM: vertical growth phase </li></ul><ul><li>Metastatic MM </li></ul>
  62. 62. Classification <ul><li>Superficial Spreading Melanoma </li></ul><ul><li>Nodular Melanoma </li></ul><ul><li>Lentigo Maligna Melanoma </li></ul><ul><li>Acral Lentiginous Melanoma </li></ul><ul><li>Amelanocytic Melanoma </li></ul><ul><li>Rare sub-types </li></ul>
  63. 63. Superficial Spreading Melanoma <ul><li>Most common, accounts for 70% </li></ul><ul><li>Usually > 6mm in diameter </li></ul><ul><li>Occurs most commonly: </li></ul><ul><li>On trunk in men </li></ul><ul><li>On legs in women </li></ul>
  64. 64. Superficial Spreading Melanoma <ul><li>Irregular, asymmetric borders are characteristic </li></ul><ul><li>Histologically, characterized by “buckshot scatter “(pagetoid) of atypical melanocytes within the epidermis </li></ul>
  65. 65. Superficial Spreading Melanoma
  66. 66. Nodular Melanoma <ul><li>Second most common : 25% </li></ul><ul><li>Legs and trunk are most common sites </li></ul><ul><li>Raised dark brown-black papule or nodule </li></ul><ul><li>Usually lacks the ABCDE warning signs </li></ul><ul><li>Lacks radial growth phase </li></ul>
  67. 67. Nodular Melanoma
  68. 68. Nodular Melanoma
  69. 69. Lentigo Maligna Melanoma <ul><li>Accounts for 4-10% </li></ul><ul><li>Most common on head, neck and arms </li></ul><ul><li>Precursor lesion = lentigo maligna </li></ul><ul><li>Usually present for 10-15yrs </li></ul><ul><li>Dark brown macule or patch </li></ul><ul><li>Dermal invasion characterized by raised blue-black lesions within precursor </li></ul>
  70. 70. Lentigo Maligna Melanoma <ul><li>In Australia: on the face.. </li></ul><ul><li>More common in men on RHS </li></ul><ul><li>More common in women on LHS </li></ul>
  71. 71. Lentigo Maligna Melanoma
  72. 72. Acral Lentiginous Melanoma <ul><li>Accounts for 2-4% </li></ul><ul><li>Accounts for 55% in dark skinned individuals </li></ul><ul><li>Usually occurs in glabrous skin or beneath the nail plate (subungual variant) </li></ul><ul><li>Pigment spread to the proximal or lateral nail folds is termed the “Hutchinson sign” </li></ul>
  73. 73. Acral Lentiginous Melanoma <ul><li>Characteristic features: </li></ul><ul><li>Irregular pigmentation </li></ul><ul><li>Large size > 3cm </li></ul><ul><li>Plantar location </li></ul>
  74. 74. Acral Lentiginous Melanoma
  75. 75. Amelanotic Melanoma <ul><li>Non pigmented </li></ul><ul><li>Pink or flesh coloured – often mimicking BCC or SCC </li></ul>
  76. 76. Rare Sub-Types <ul><li>Desmoplastic Melanoma </li></ul><ul><li>Mucosal Melanoma </li></ul><ul><li>Malignant Blue Naevus </li></ul><ul><li>Melanoma of Soft Parts (clear cell sarcoma) </li></ul>
  77. 77. Assessment <ul><li>History </li></ul><ul><li>Exam </li></ul><ul><li>Inspection alone can diagnose 65% </li></ul><ul><li>Nodes: axillary, cervical and groin </li></ul>
  78. 78. Assessment <ul><li>MacKies 7 point checklist </li></ul><ul><li>Major (2 points each) </li></ul><ul><li>Change in size </li></ul><ul><li>Irregular pigmentation </li></ul><ul><li>Irregular outline </li></ul><ul><li>Diameter > 6mm </li></ul>
  79. 79. Assessment <ul><li>MacKies 7 point checklist </li></ul><ul><li>Minor (1 point each) </li></ul><ul><li>Inflammation </li></ul><ul><li>Oozing </li></ul><ul><li>Itch or altered sensation </li></ul>
  80. 80. Assessment <ul><li>MacKies 7 point checklist </li></ul><ul><li>Needs further evaluation in presence of one major or if score = 3 </li></ul>
  81. 81. Assessment <ul><li>American ABCDE </li></ul><ul><li>A: asymmetry </li></ul><ul><li>B: border is irregular </li></ul><ul><li>C: colour variation </li></ul><ul><li>D: diameter >6mm </li></ul><ul><li>E: examine other lesions </li></ul>
  82. 82. ABCDE
  83. 83. Biopsy <ul><li>Incisional </li></ul><ul><li>Excisional </li></ul><ul><li>Punch </li></ul><ul><li>NB not shave </li></ul>
  84. 84. Biopsy <ul><li>Information gained from biopsy: </li></ul><ul><li>Tumour depth </li></ul><ul><li>Anatomical level </li></ul><ul><li>Ulceration </li></ul><ul><li>Presence of mitoses </li></ul><ul><li>LVI </li></ul><ul><li>Host response (tumour infiltrating lymphocytes) </li></ul>
  85. 85. Biopsy <ul><li>Information gained from biopsy: ctd </li></ul><ul><li>Regression </li></ul><ul><li>Immunohistochemical staining for lineage: (S-100) or for proliferation markers (Ki67) </li></ul>
  86. 86. Biopsy <ul><li>Excisional biopsy </li></ul><ul><li>1-3mm of normal skin should be removed with the lesion as more than this could disrupt lymphatic drainage and compromise subsequent LN mapping </li></ul>
  87. 87. Clarkes Level <ul><li>Classifies level of invasion </li></ul><ul><li>Level 1: only epidermis involved </li></ul><ul><li>Level 2: invades part of papillary dermis </li></ul><ul><li>Level 3: invasion fills papillary dermis </li></ul><ul><li>Level 4: invades reticular dermis </li></ul><ul><li>Level 5: invades subcutaneous tissue </li></ul>
  88. 88. Breslows Thickness <ul><li>Most important histological determinant of prognosis </li></ul><ul><li>Measured vertically in mm </li></ul><ul><li>From top of granular layer (base of superficial ulceration) </li></ul><ul><li>To deepest point of tumour invasion </li></ul>
  89. 89. Breslows Thickness <ul><li>5yr survival </li></ul><ul><li>1. </= 0.75mm 90% </li></ul><ul><li>2. 0.76mm – 1.5mm 80% </li></ul><ul><li>3. 1.5mm – 4mm 65% </li></ul><ul><li>4. >/= 4mm 35% </li></ul>
  90. 90. Breslows Thickness <ul><li>Gives better indication of prognosis </li></ul><ul><li>As depth (Clarkes) of papillary and reticular dermis vary throughout the body </li></ul>
  91. 91. Staging <ul><li>AJCC </li></ul><ul><li>Incorporates TNM with Clarkes and Breslow </li></ul>
  92. 92. Spread <ul><li>Locally, in LN basins or distally: </li></ul><ul><li>Remote skin </li></ul><ul><li>Remote nodes </li></ul><ul><li>Viscera </li></ul><ul><li>Skeleton </li></ul><ul><li>CNS </li></ul>
  93. 93. Surgery <ul><li>Excision margins; </li></ul><ul><li>0.5 cm for melanoma in situ </li></ul><ul><li>1cm with Breslow thickness <2mm </li></ul><ul><li>2cm with Breslow thickness >/= 2mm </li></ul>
  94. 94. Surgery <ul><li>Melanomas near vital structures may require a reduced margin </li></ul><ul><li>Aggressive histological features may necessitate a wider margin </li></ul><ul><li>Mohs surgery may have certain &quot;niche&quot; indications- MM of face, neck or hands </li></ul>
  95. 95. Sentinel Node Mapping <ul><li>Growing in popularity </li></ul><ul><li>Isosulfan blue dye and lymphoscintigraphy </li></ul><ul><li>Is it as useful as mapping in breast Ca? </li></ul>
  96. 96. Sentinel Node Mapping <ul><li>Advantages </li></ul><ul><li>If node –ve, no need for nodal clearance </li></ul><ul><li>More thorough pathological assessment of nodes </li></ul><ul><li>Psychological relief to patient if node negative </li></ul>
  97. 97. Sentinel Node Mapping <ul><li>Disadvantages </li></ul><ul><li>Poor mapping in head and neck tumours </li></ul><ul><li>Tumour may skip SN </li></ul>
  98. 98. Sentinel Node Mapping <ul><li>Indications: controversial </li></ul><ul><li>Patients in whom the estimated risk of LN metastasis is at least 10% </li></ul><ul><li>Clinically node –ve patients with tumours >/= 1mm </li></ul><ul><li>Not indicated in tumours <0.75mm </li></ul><ul><li>0.76-0.9mm: nebulous area </li></ul>
  99. 99. Elective LN Dissection <ul><li>Lymphadenectomy when nodes are clinically negative </li></ul><ul><li>Rationale is that MM spreads to nodal basin first – so clearing the LNs reduces risk of spread </li></ul><ul><li>Controversial: studies have conflicting results </li></ul>
  100. 100. Nodal Dissection <ul><li>Patients with palpable, clinically +ve nodes should undergo complete nodal dissection </li></ul>
  101. 101. Adjuvant Therapy <ul><li>Interferon α 2b </li></ul><ul><li>For high risk resected MM: </li></ul><ul><li>>4mm depth </li></ul><ul><li>Regional nodal metastases </li></ul><ul><li>Diminishes occurrence of mets </li></ul><ul><li>Prolongs disease free survival </li></ul>
  102. 102. Chemotherapy <ul><li>For unresectable regional mets or distant mets </li></ul><ul><li>Dacarbazine is the most active chemotherapeutic agent </li></ul>
  103. 103. Biological Therapy <ul><li>Interleukin 2 </li></ul><ul><li>Useful for metastatic melanoma </li></ul><ul><li>In one study, 7% had complete response with patients remaining disease free for up to 8yrs </li></ul>
  104. 104. Biological Therapy <ul><li>Monoclonal antibody therapy </li></ul><ul><li>Experimental but very promising </li></ul><ul><li>Vaccines </li></ul><ul><li>Undergoing trials currently </li></ul>
  105. 105. Perfusion Chemo <ul><li>Isolated Limb Perfusion (ILP) </li></ul><ul><li>Tourniquet applied </li></ul><ul><li>Artery and vein cannulated </li></ul><ul><li>Agent infused and removed from circulation </li></ul><ul><li>Most effective method of Rx for local recurrence or in-transit metastases </li></ul><ul><li>Agents used: TNF α , melphalan </li></ul>
  106. 106. Radiotherapy <ul><li>For palliation </li></ul><ul><li>Specific indications: </li></ul><ul><li>Brain metastases </li></ul><ul><li>Pain with bony mets </li></ul><ul><li>Superficial subcutaneous mets </li></ul>
  107. 107. Prevention <ul><li>Public education </li></ul><ul><li>Australia: “slip, slop, slap” campaign </li></ul><ul><li>Adequate clothing </li></ul><ul><li>Avoid UV rays </li></ul><ul><li>Systemic carotenoids : retinol </li></ul><ul><li>Useful in preventing malignant transformation </li></ul>
  108. 108. Thank You Will be on Blackboard tomorrow!!

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