Non-melanoma skin cancers like basal cell carcinoma and squamous cell carcinoma primarily affect elderly individuals. They are usually treated with surgical excision, with Mohs micrographic surgery used for difficult locations. Early-stage cancers may also be treated with topical therapies or cryotherapy. Advanced cancers require wider excision and sometimes adjuvant radiation. Immunotherapy drugs have shown promise for locally advanced or recurrent cases. Screening and sun protection can help prevent non-melanoma skin cancers.

1. NON MELANOMA SKIN CANCERS
DR. S. GOKUL KUMARAN
FIRST YEAR RESIDENT,
SURGICAL ONCOLOGY, GRH
Prof. S. Subbiah et al

2. INTRODUCTION:
• Cutaneous head and neck malignancies - primarily
diseases of the geriatric population.
• The primary treatment remains surgical.
• Adjuvant treatments - Radiation, Chemotherapy,
Monoclonal antibodies and Immunotherapy
Prof. S. Subbiah et al

3. Head and neck skin cancers
Melanoma Non melanoma
Basal cell carcinoma Squamous cell carcinoma Merkel cell carcinoma Other rare
Sarcoma Skin appendage carcinomas
(e.g. sebaceous carcinoma)
Fibrous tissue
(malignant fibrous
histiocytoma,
dermatofibrosarcoma)
Vascular tissue
(angiosarcoma,
Kaposi’s sarcoma,
hemangiopericytoma)
Prof. S. Subbiah et al

4. NON MELANOMA SKIN CANCER
Prof. S. Subbiah et al

5. BASAL CELL CARCINOMA
• Most common malignancy
• Men > Women
• Typically occur in the head and
neck region
• Regional and distant metastasis -
very rare < 0.1%
• Five histological subtypes
– Nodular
– Superficial
– Basosquamous
– Pigmented
– Morpheic
Prof. S. Subbiah et al

6. • Risk factors
– Solar UV radiation
– Ionizing radiation
– Arsenic exposure
– Chronic immunosuppression
– Organ transplantation
• BCC - 10 fold increased risk
– HIV/AIDS
– Autoimmune disorders
– Hematologic malignancies
Prof. S. Subbiah et al

7. • UVRays - induce skin carcinogenesis via
(1) DNA damage
(2) Immunosuppression
• UV-A : 320-400 nm; UV-B : 290-320 nm.
• Primary prevention is protection against UVR.
• Sun protection behaviors
– Protective clothing
– Hats
– Sunblock with SPF exceeding 30
– Avoidance of direct sun exposure during peak hours (10 AM to 4 PM).
• BCC - highest rate of mutations per megabase
Prof. S. Subbiah et al

8. • Risks factors for aggressive BCCs
–Diameter > 2 cm
–Location - H region of the face
–Incomplete prior excision
–Long-standing presence
–Perineural invasion
–Aggressive histologic subtype (morpheaform and
basosquamous)
Prof. S. Subbiah et al

9. Nodular BCC
• Most common subtype
• Small pearly dome-shaped
nodule
• Surface telangiectasia
• Raised rolled edge
• Locally invasive - rodent ulcer
Prof. S. Subbiah et al

10. Superficial BCC
• Least aggressive subtype
• Scaly, dry, erythematous
plaques
• Round or oval in shape
• Typically occur on the
limbs and trunk
Prof. S. Subbiah et al

11. Basosquamous BCC
• More aggressive tumour
• Often ulcerated
• Histologic features of SCC
and BCC
• Definite metastatic
potential
Prof. S. Subbiah et al

12. Pigmented BCC
• Dark skinned individuals
• The pigment is due to
melanin
• Easily confused with
melanoma
Prof. S. Subbiah et al

13. Morphoeic BCC
• Indurated pale plaque with
indistinct borders
• Locally aggressive
tumours
• Margin control is difficult
• High propensity for local
recurrence
• Intraoperative frozen
section is recommended
Prof. S. Subbiah et al

14. SQUAMOUS CELL CARCINOMA
• Elderly males
• Sun-exposed sites
• Precursor lesions - actinic keratosis
(solar keratosis)
• Transformation rate - 5-20 % over
10-25 years
• Topical 5-fluorouracil eliminate
actinic keratoses reduce the
risk of SCC
• Erythematous nodule or scaly
plaque Ulceration and crusting
Invasion of deep structures
Prof. S. Subbiah et al

15. • Risk factors
– Solar UV radiation
– Ionizing radiation
– Tobacco
– HPV 2, 3, 4, 5
– Polycyclic aromatic hydrocarbons
– Arsenic exposure
– Chronic ulcers/sinus tracts/scars
– Non healing wound / Marjolin ulcers
– Organ transplantation
• SCC - 30 fold increased risk
Prof. S. Subbiah et al

16. Features of high risk SCC
• Size > 2 cm
• Invasion into subcutaneous fat (depth >4–5 mm)
• Poorly differentiated
• Perineural invasion
• Lymphovascular invasion
• Site: ear or lip
• Incomplete excision
• Local recurrence
• Immunosuppression
Prof. S. Subbiah et al

17. • Regional metastases - 5% (overall)
• High risk SCCs metastasize 20%
• Parotid nodes - regional mets for head and neck SCC
• 25 - 50 % patients with parotid node metastases have concurrent
cervical nodal disease
Prof. S. Subbiah et al

18. • Histopathological features that confer increased risk of
recurrence
–High-risk features of primary cutaneous squamous cell
carcinoma
–Diameter >/= 2 cm
–Poorly differentiated
–Depth beyond subcutaneous fat
–Perineural invasion
–Ear, temple region
Prof. S. Subbiah et al

19. MERKEL CELL CARCINOMA
• High grade neuroendocrine malignancy of skin
• Highest case fatality rate among skin cancer
• Arise from mechanoreceptor (Merkel) cells
• Head and neck region - 50%
• Annual Incidence - 0.23 per 100 000
• Elderly males
Prof. S. Subbiah et al

20. • Risk factors
– Ultraviolet radiation exposure
– Environmental agents - arsenic, methoxysalen
– UVA treatment for psoriasis
– Merkel cell polyomavirus
Prof. S. Subbiah et al

21. • Solitary cutaneous papule
or nodule
• Purplish or pink in colour
• Multiple nodules or
satellitosis
• High metastatic potential
• Distant mets - liver, bone,
lung, brain and skin
MERKEL CELL CARCINOMA
Prof. S. Subbiah et al

22. CLINICAL ASSESSMENT OF NON MELANOMA
SKIN CANCER
• Areas that are prone to suboptimal surgical therapy includes:
i. Periorbital region
ii. Periauricular region
iii. Nose
iv. Lip commissure
• Lack of preoperative planning may result in inadequate tissue
margins
Prof. S. Subbiah et al

23. • Cranial nerve examination - to
assess for perineural invasion
– Motor nerves at risk - Facial
nerve
– Cutaneous nerves at risk
• Trigeminal nerve in the
face
• Branches of the cervical
plexus in the neck, scalp
and ear
Facial paresis from facial nerve (perineural) invasion from
metastatic squamous cell carcinoma to the parotid gland.
Prof. S. Subbiah et al

24. • Nodes that draining
cutaneous malignancy of
Head & neck include:
– Parotid gland (preauricular
lymph nodes),
– Postauricular nodes,
– External jugular lymph node
– Suboccipital lymph nodes. Metastatic squamous cell carcinoma to the
external jugular lymph node from temple primary
Prof. S. Subbiah et al

25. BIOPSY
• For small tumours - Excision biopsy with 3–4mm margins
• Incisional biopsy - when diagnosis is uncertain and
excision is likely to be morbid
• FNAC - for enlarged or suspicious lymph nodes
• BCC - low incidence of metastatic spread, including
regional lymph nodes, so SLNB or lymph node
dissections are not routinely performed.
Prof. S. Subbiah et al

26. IMAGING
• Imaging is not routinely indicated
for early stage disease
• Mandatory in advanced lesions and
selected recurrent tumours
• CONTRAST CT:
– Assessment of the tumour and
surrounding soft tissue
structures.
– Bone windows - to determine
cranial or mandibular invasion.
– Examines the parotid and neck
nodes
CT of basal cell carcinoma invading anterior
mandible
Prof. S. Subbiah et al

27. • MRI:
– Neurotropic cancers
– Tumours with intracranial, orbital or
parapharyngeal extension
• USG:
- Highly specific and sensitive for cervical
node disease
- Limited role in structural definition of
primary malignancies.
• PETCT:
– Assessment of regional and distant
metastatic disease
• MRI showing orbital invasion by recurrent
basal cell carcinoma
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28. Staging for NMSC
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31. TREATMENT OF EARLY STAGE NON MELANOMA
SKIN CANCER
• Surgery remains the mainstay of treatment
• The recommended margins for SCC
– 4mm for lesions under 2 cm
– 6mm for lesions greater than 2 cm.
• BCC - minimum 3mm margin.
• Moh’s micrographic surgery - in difficult areas where wide excision is
impractical.
Prof. S. Subbiah et al

32. • Topical drug therapy:
– 5 fluorouracil cream - SCC/BCC in situ
– Imiquimod 5 % - SCC in situ and superficial BCCs
• Cryotherapy:
– Superficial, Nonpigmented lesions (SCC/BCC in situ, superficial BCCs,
actinic keratoses).
• For BCC: Hedgehog pathway inhibitors -
– vismodegib and sonidegib
• Thin superficial and nodular BCCs - Photodynamic therapy
Prof. S. Subbiah et al

33. TREATMENT FOR ADVANCED STAGE NON
MELANOMA SKIN CANCER
• En-bloc resection of tumour incorporating invaded
structures (fat, muscle, bone, orbit)
• Requires adjuvant postoperative radiotherapy
• Definitive radiotherapy with or without concurrent
chemotherapy - where the morbidity of surgery is
excessive
• SCC - Regional nodal disease - Parotidectomy, Neck
dissection
Prof. S. Subbiah et al

34. • Adjuvant radiation increases DFS by more than 1 year
• Primary radiation can be considered for lesions not amenable to surgery -
where surgery produce significant cosmetic and functional sequelae
– Cure rates - 60 to 90 % for both SCC and BCC
• Early toxicity:
- Erythema
- Desquamation
- Pain
- Crusting
• Resolves within 4 weeks.
• Late radiation sequelae:
- Pigmentation or Depigmentation
- Tissue fibrosis
- Contracture and Atrophy
• Develop over years
• Irreversible
Prof. S. Subbiah et al

35. • Reconstructive options
– Skin graft (full thickness or split-skin)
– Local and Regional flaps
– Free flap
• Nodes at risk:
– Anterior tumours of the face - the parotid, external jugular nodes and
levels I, II, III and IV.
– Posterior tumours of the scalp - retroauricular, external jugular, occipital
nodes and levels II, III, IV and V
Prof. S. Subbiah et al

36. RECURRENT SCC - WLE + SUPERFICIAL PAROTIDECTOMY +
CERVICOTHORACIC FLAP RECONSTRUCTION
Prof. S. Subbiah et al

37. • Indications for postoperative radiotherapy
– close or positive margins,
– perineural invasion,
– two or more positive nodes,
– extracapsular spread
– nodes > 3 cm
• Radiation dose:
– 50–60 Gy in 25–30 #,
– 2 Gy / #,
– 5 # / week
Prof. S. Subbiah et al

38. • Chemotherapy remains experimental
• Cisplatin and Fluorouracil in conjunction with radiotherapy
• BCCs with close or positive margins - repeat surgery
where feasible
• Regional therapy is not indicated in BCC unless there is
documented nodal disease
Prof. S. Subbiah et al

39. • For locally advanced cutaneous SCC:
Programmed death (PD)-1 inhibiting antibodies
– Cemiplimab - response rate - 47%
– Pembrolizumab - response rate - 42%
• For locally advanced BCC:
- cemiplimab
Prof. S. Subbiah et al

40. Treatment for Merkel cell carcinoma
• stage I :
– Wide excision+ SNB
– Radiotherapy to primary and neck if SNB positive.
• stage II :
– Wide excision + SNB (N0) or neck dissection (N1)
– Radiotherapy to primary and neck.
Prof. S. Subbiah et al

41. • stage III :
– Wide excision + neck dissection
– Radiotherapy to primary and neck.
– Concurrent chemotherapy in patients with good performance status
– For locally advanced Merkel cell cancer:
- avelumab
- pembrolizumab
• stage IV :
– Palliative
– Consider radiotherapy to primary and neck
– Concurrent/adjuvant chemotherapy
– Consider clinical trial
Prof. S. Subbiah et al

42. THANK YOU
Prof. S. Subbiah et al