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Cheratosi Attinica: lesioni cliniche e campo di cancerizzazione

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Definizione e classificazione della Cheratosi Attinica, presentazione del modello di progressione in Carcinoma Squamocellulare e spiegazione del concetto di campo di cancerizzazione

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Cheratosi Attinica: lesioni cliniche e campo di cancerizzazione

  1. 1. Cheratosi Attinica lesioni cliniche e campo di cancerizzazione Alessandro MARTELLA
  2. 2. neoplasia cutanea in stadio iniziale, considerata un carcinoma squamocellulare in fase precoce Werner RN, Sammain A, Erdmann R et al. The Natuarl History of Actnic Keratosis: A Systematic Review. Br J Dermatol. 2013 May 6 Heaphy MR, Ackerman AB. The nature of solar keratosis: a critical review in historical perspective. J Am Acad Dermal 2000;43:138-50 Anadolu-Brasie R, Patel A.R. Patel S.S. et al. Squamous cell carcinoma of the skin. In: Keyvan N, editor. Skin cancer, McGraw-Hill 2008 Cheratosi Attinica
  3. 3. Cheratosi Attinica A Seconda diagnosi dermatologica US National Ambulatory Medical Centre Survey I prevalenza stimata intorno all’1,4% della popolazione sopra i 45 anni di età A prevalenza 40-60% Prevalenza globale 11-25% nella popolazione generale Oltre 2 milioni di individui nel mondo Frost Ca, Green AC. William GM - Br J Dermatol 1998;139:1033-9 Frost Ca, Green AC. - Br J Dermatol 1994;Vol 131, Is 4, 455–464 Berman B. - Cutis. 2012;89:241-250
  4. 4. Fotoesposizione cumulativa Fattori di Rischio Fototipo chiaro Fattori genetici Immunosoppressione cronica Cheratosi Attinica
  5. 5. © Alessandro Martella
  6. 6. © Alessandro Martella
  7. 7. © Alessandro Martella
  8. 8. l ABOUT OUR COMPANY ! Little subtitle here like lorem ipsum dolor
  9. 9. epidermide normale Mutazione p53 resistenza all’apoptosi e incapacità a riparare il DNA danneggiato Clone pre-maligno Cheratosi Attinica Carcinoma Squamocellulare invasivo mutazioni addizionali le mutazioni favoriscono la proliferazione incontrollata delle cellule mutazioni addizionali le cellule diventano invasive 90% dei SCC invasivi presentano mutazione p53 Butani A, Arbesfeld D, Schwartz R. Clin Plast Surg 2005;32(2):223-235
  10. 10. © Alessandro Martella
  11. 11. Grado I macchie/chiazze rosa leggermente ruvide su cute fotodanneggiata Cheratosi Attinica Classificazione CLINICA Grado II papule rosa-rosse con superficie rugosa ed ipercheratosica su cute fotodanneggiata Grado III placche rosse dure ed esfolianti, a volte pigmentate su cute fotodanneggiata atipia localizzata di cheratinociti del terzo inferiore dell’epidermide atipia localizzata ai cheratinociti di almeno i due terzi dell’epidermide: ipercheratosi localizzata proliferazione diffusa di cheratinociti atipici che coinvolge tutto lo spessore dell’epidermide. Alcune atipie possono coinvolgere le strutture annessiali (gh. sebacee, sudoripare, follicoli) sistema di classificazione proposto da Cockerell
  12. 12. © Alessandro Martella
  13. 13. © Alessandro Martella
  14. 14. © Alessandro Martella
  15. 15. © Alessandro Martella © Alessandro Martella
  16. 16. © Alessandro Martella
  17. 17. Cheratosi Attinica Classificazione DERMATOSCOPICA pattern a fragola (follicoli cheratinizzati) aree giallo-biancastre, aree prive di strutture GRADO I GRADO II GRADO III Grado I Pseudorete rossa Grado II GRADO III Pattern a fragola (follicoli cheratinizzati) Aree giallo-biancastre, aree prive di struttura
  18. 18. © Alessandro Martella
  19. 19. © Alessandro Martella
  20. 20. © Alessandro Martella
  21. 21. © Alessandro Martella
  22. 22. © Alessandro Martella
  23. 23. © Alessandro Martella
  24. 24. © Alessandro Martella © Alessandro Martella
  25. 25. © Alessandro Martella
  26. 26. epidermide normale Mutazione p53 resistenza all’apoptosi e incapacità a riparare il DNA danneggiato Clone pre-maligno Cheratosi Attinica Carcinoma Squamocellulare invasivo mutazioni addizionali le mutazioni favoriscono la proliferazione incontrollata delle cellule mutazioni addizionali le cellule diventano invasive 90% dei SCC invasivi presentano mutazione p53 Butani A, Arbesfeld D, Schwartz R. Clin Plast Surg 2005;32(2):223-235
  27. 27. Cheratosi Attinica 92 % 20% progredisce in Carcinoma Squamocellulare 65-80% degli Squamocellulari originano dalle Cheratosi Attiniche 65-97% concomitante o attigua a Carcinoma Squamocellulare 36% dei Basaliomi diagnosticati nell’arco di 6 anni erano Cheratosi Attiniche Criscione VD. Weinstock MA, Naylor MF et al Actinic keratoses: natural history and risk of malignant trasformation in the Veterans Afafirs topical Tretinoin Chemoprevention Trial. Cancer 2009;115(11):2523-2530 Hurwitz RM, Monger LE. Solar keratosis: an evolving squamous cell carcinoma. Benign or malignant? Dermatol Surg 1995:21(2):184 Salasche S.J. Epidemiology of actnic keratoses and squamous cell carcinoma. J Am Acad Dermal 2000 Jan 42 (1Pt2):4-7 Quaedvlieg Pjl, Tirsi E, Thissen MR, Krekels GA. Actinic keratosis: how to differentiate the good from the bad ones? Eur J Dermal 2006 Jul-Aug 16(4) 335-9 Lurid HZ. How often does squamous cell carcinoma of the skin metastasize? Arch Dermal 1985;92:636-637 Breuninger H Bootz F, Hauschild A, Kortmann RD, Wolff, Stockfleth E, et al Short German guidlines: squamous cell carcinoma. J Dtsch Dermatol Ges 2008 May:6 Suppl 1:S5-S8 2-6% metastasi di Carcinoma Squamocellulare con SV5 del 25-50%
  28. 28. l ABOUT OUR COMPANY ! Little subtitle here like lorem ipsum dolor
  29. 29. © Alessandro Martella © Alessandro Martella
  30. 30. Cheratosi attinica: la progressione IDRBEU induration and inflammation, diameter of greater than 1 cm, rapid enlargement, bleeding, erythema and ulceration Neo angiogenesi Fattori di rischio - età - area geografica (elevata altitudine, bassa latitudine) - attività lavorative/ricreazionali - aumenta con il numero di cheratosi attiniche Zalaudek I. et al.J Am Acad Dermatol. 2012 Apr;66(4):589-97 ?progressione… E’ impossibile predire né quale lesione progredirà verso un Carcinoma Squamocellulare invasivo né in quali tempi
  31. 31. © Alessandro Martella © Alessandro Martella
  32. 32. Slauther (1953) per spiegare lo sviluppo di neoplasie primitive multiple in un’area di cellule geneticamente alterate sia l’elevato tasso di recidive locali dopo terapia. Descritto in diversi distretti come le regioni testa/collo, i polmoni, la vulva, l’esofago, la cervice uterina, le mammelle, il colon, la vescica. Campo di CANCERIZZAZIONE Si stima che per ogni lesione clinica visibile sono presenti almeno 10 lesioni subcliniche Vasta area di lesioni caratterizzata da cellule geneticamente alterate ma istologicamente senza atipie che precedono lo sviluppo di una neoplasia e si affiancano a cellule maligne già presenti Il trattamento esteso a tutto il CAMPO di CANCERIZZAZIONE nel quale si sono sviluppate le lesioni per prevenire l’invasione della membrana basale, le metastasi e abbattere la mortalità Lesioni cliniche Lesioni subcliniche
  33. 33. Algoritmo diagnostico della Cheratosi Attinica Diagnosi clinica di Cheratosi Attinica in paziente immunocompetente Non certa e rischio di progressione della Cheratosi Attinica in Carcinoma Squamocellulare invasivo Dermatoscopia Non diagnostica Persiste rischio di progressione della Cheratosi Attinica in Carcinoma Squamocellulare Specialmente se in presenza di: -corno cutaneo -cheratosi Attinica grado II -lesione labbra/orecchio/palpebra -pregressa terapia potenzialmente cancerogena -esposizione a radiazioni ionizzanti o arsenico -alterazioni genetiche dei sistemi di riparazione del DNA -difetti genetici della pigmentazione Biopsia/asportazione diagnostica Diagnosi clinica certa di Cheratosi Attinica in paziente immunocompromesso Eventuale trattamento non chirurgico Attento monitoraggio clinico della progressione della Cheratosi Attinica
  34. 34. www.myskin.it

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