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Non melanoma skin cancers

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Non melanoma skin cancers

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Non melanoma skin cancers

  1. 1. Non-melanoma Skin Cancers Ihab Samy Lecturer of surgical oncology NCI – Cairo University
  2. 2. Squamous Cell Cancer
  3. 3. Epidemiology • The second most common skin cancer, ranking behind basal cell carcinoma (4:1). • 20% of cutaneous malignancies. • Generally occurs in mid to late life (usually after age 40). • Most commonly affects areas of sun exposure. • Men are affected more often than women.
  4. 4. • A number of variables must be considered when evaluating a squamous cell carcinoma. • They relate to the lesion’s ability to recur locally and to metastasize: 1. Location. 2. Size. 3. Depth of invasion. 4. Histologic grade.
  5. 5. Location • The central zone of the face is considered a high risk area for subclinical extension because of its anatomy; lesions located in this area are therefore at high risk for local recurrence. • Lesions of the temple, dorsum of the hand, lips, scalp, and penis are associated with a high risk of metastatic disease. Patients with lesions in these areas must be carefully examined for evidence of regional lymphadenopathy.
  6. 6. Size • The larger the lesion, the greater the chance for local recurrence. As a consequence, excision margins are selected according to tumor size. • A 4- to 5-mm margin for lesions <2cm in diameter and a 6- to 9-mm margin for lesions >2cm in diameter have been recommended.
  7. 7. Depth of invasion and histologic grade • Invasion into the deep dermis or subcutaneous tissue and a Broder’s grade 2 or higher are associated with higher recurrence rates. • Squamous cell cancers demonstrate a propensity to invade along perineural planes. • The immunosuppressed or immunocompromised patient has an increased risk for local recurrence or metastasis (typically to regional lymph nodes).
  8. 8. Verrucous squamous cell cancer • An exophytic wart-like appearance. • Often arises on the foot or glans penis and anal canal (giant condyloma of Buschke- Lowenstein). • Histologically, there is no invasion of the dermis.
  9. 9. • Squamous cell carcinomas are generally divided into spindle cell and acantholytic types. • Spindle cell tumors may appear similar to malignant melanoma or superficial malignant fibrocytomas. • Immunohistologic staining can help make this differentiation. Squamous cell cancers are positive for cytokeratin and negative for S-100; melanomas are S- 100-positive and cytokeratin-negative. • Acantholytic-type squamous cell cancers usually arise from acantholytic solar keratoses.
  10. 10. Risk Factors • Cumulative lifetime exposure to sunlight  Ultraviolet B radiation (290–320mm). • Whites more than Blacks. • Scrotal tumors in chimney sweeps (soot is the causative agent). • Chronic arsenic exposure. • Exposure to radiation. • Compromised immunity.
  11. 11. • Human papilloma virus (HPV) exposure (16 and 18). • Thermal injury. • Chronic ulceration. • Sinus tracts. • Hidradenitis suppurativa. • Chronic cutaneous lupus erythematosus. • Genetic predisposition (xeroderma pigmentosum, epidermal dysplasia, and recessive dystrophic epidermolysis bullosa and oculocutaneous albinism). • Alcohol and tobacco use.
  12. 12. Treatment • Excisional therapies • Superficial ablative therapies. • Radiation therapy.
  13. 13. Excision • Wide excision: 4–5 mm margins for lesions <2cm in diameter and 6–9mm for larger lesions. • Tumors at high risk for local recurrence and metastases are those >1–2cm in diameter that have invaded the mid-dermis or deeper. • Those involving cartilage and bone are extremely high risk. • Squamous cell carcinoma of the lip, ear, temple, and genitalia and lesions associated with the preexisting conditions previously discussed are also high risk. • For these high risk lesions, excision with a frozen section margin check should be used to assess the adequacy of excision.
  14. 14. Superficial ablative techniques • Squamous cell carcinoma in situ (Bowen’s disease). • Lesions that invade no deeper than the superficial dermis. N.B. Tumors that are indurated and have undermined the skin laterally and those with associated local pain may be deeply invasive and should be treated by excision.
  15. 15. 1-Curettage and electrodesiccation • Superficial squamous cell cancers. • Should not be used for lesions with aggressive histology, large size, or high risk anatomic location (central face). • First, curettage is performed by paring down the lesion to normal tissue. • Then electrodesiccation is used to destroy potential tumor nests at the base.
  16. 16. 2-Cryotherapy • Freezes tissue to -195.5°C with liquid nitrogen. • Can be used for small lesions (<2cm) on the eyelid, ear, chest, back, or tip of the nose. • Also used for recurrent tumors with definable margins. • Should not be used for eyelid free margins, the vermilion border of the lip, ala nasi, scalp, and tumors >3cm.
  17. 17. Radiation therapy • Cure rates approach 92%. • Of particular value in the central face, ear, and forehead, where excisional therapy is potentially deforming. • Has the advantage of treating a wide region around the tumor with excellent local control and good cosmetic outcome. • Prior to initiating therapy, a biopsy should be obtained for both histologic confirmation and evaluation of tumor thickness.
  18. 18. • Most tumors are treated with a dose of 4000–6000 cGy to the superficial skin. • The dose is usually divided over 3–4 weeks to prevent complications. • Short term, the most troublesome sequelae after irradiation is “burn” to the area. • Long-term sequelae include destruction of hair follicles and sweat glands, radiation dermatitis leading to changes in skin pigmentation (hyper- or hypopigmentation), and the development of radiation- induced precancerous lesions.
  19. 19. BASAL CELL CANCER
  20. 20. • A malignancy of basaloid epithelial cells and is the most common cancer, outnumbering cutaneous squamous cell cancer 4 : 1. • Most often affects light-skinned people, and rarely affects those with dark skin. • Develops mainly on sun-exposed areas, the incidence varying directly with increasing accumulated sun exposure and inversely with increasing skin pigmentation.
  21. 21. Histology • Several distinctive clinical subtypes that correlate with histology and biologic potential. • In addition, these subtypes affect treatment choices. • Histologic subtypes include: 1. Nodular basal cell cancer (most common) 2. Morpheaform. 3. Superficial. 4. Fibroepitheliomatous. 5. Infundibulocystic.
  22. 22. Nodular basal cell cancer • An elevated papule with overlying telangiectasia. • It can become ulcerated as it enlarges, giving the appearance of having been nibbled at, leading to its name “rodent ulcer.” • Pigmented basal cell cancer is a variant of nodular basal cell cancer that, because of its dark pigment, must be differentiated from melanoma. • This type often occurs in dark-skinned individuals.
  23. 23. Morpheaform or sclerosing basal cell cancers • Also known as fibrosing or desmoplastic. • A flat, scar-like appearance. • Some demonstrate endophytic growth leading to a true tumor margin that is larger than the visible margin (should be palpated carefully to assess the true extent of tissue induration). • This biologic feature leads to a higher recurrence rate and makes it considered aggressive.
  24. 24. Superficial basal cell cancers • Tend to appear on the trunk and extremities. • They appear as erythematous patches, some have an overlying patchy scale-like or pigmented appearance. • They are the most common type of basal cell cancer, seen with chronic arsenism and in radiation fields.
  25. 25. Treatment • Wide excision (Mohs’ microsurgical therapy). • Curettage and electrodesiccation • Cryotherapy. • Radiation therapy.
  26. 26. Surgical excision • The margin of excision for basal cell cancers <1cm in diameter should be 4–5mm wide. • The margin should be increased up to 9 mm for aggressive growth pattern basal cell cancer and those >1cm in diameter. • Margin checks at the time of excision are mandatory for optimizing results.
  27. 27. Mohs’ micrographic surgery (MMS) • Described in 1941 by Frederick Mohs. • Its main advantages are high cure rates and minimal tissue loss. • Its ability to optimize tissue preservation is important in areas where maintaining function and cosmetic appearance is difficult, such as the nose, eyelids, lips, ears, digits, and genitalia.
  28. 28. Irradiation • Cure rates of 96% and a favorable cosmetic outcome for small lesions of the central face including the eyelids, nose, and lips. • Radiation dose varies between 100 and 300kV per day and is given according to several fractionation schedules. • Typically, 15–17 fractions are given for tumors <2cm in diameter, increased to 20–22 fractions for tumors >2cm in diameter, and increased to 30–33 fractions for larger lesions involving cartilage.
  29. 29. Cases
  30. 30. 1st Case
  31. 31. 2nd Case
  32. 32. 3rd Case
  33. 33. Thank you

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