diagnosing and treating skin cancers with radiation

2. Standard photograph for grading severe solar damage on the shoulders. Standard photographs for grading freckling of the back: (B) mild (C) moderate (D) extensive People with a lot of sun damage are more prone to skin cancers Journal of Clinical Oncology , Vol 24, No 22 (August 1), 2006: pp. 3590-3596

3. Basal Cell Carcinoma Basal cell carcinoma (BCC): About 80% of all skin cancers are BCC, a cancer that develops in the basal cells - skin cells located in the lowest layer of the epidermis. BCC can take several forms. It can appear as a shiny translucent or pearly nodule, a sore that continuously heals and then re-opens, a pink slightly elevated growth, reddish irritated patches of skin, or a waxy scar. Most BCCs appear on skin with a history of exposure to the sun, such as the face, ears, scalp, and upper trunk. These tumors tend to grow slowly and can take years to reach ½ inch in size. While these tumors very rarely metastasize

4. Typical basal cell on the nose

5. Typical basal cell below lower lip

6. Typical basal cell on the ear

7. Ulcer type of basal cell superficial type of basal cell

8. Classic presentation of basal cell

9. Classic superficial basal cell

10. Squamous Cell Carcinoma Squamous cell carcinoma (SCC): About 16% of diagnosed skin cancers are SCC. This cancer begins in the squamous cells, which are found in the upper layer of the epidermis. SCC tends to develop in fair-skinned middle-aged and elderly people who have had long-term sun exposure. It most often appears as a crusted or scaly area of skin with a red inflamed base that resembles a growing tumor, non-healing ulcer, or crusted-over patch of skin. While most commonly found on sun-exposed areas of the body, it can develop anywhere, including the inside of the mouth and the genitalia. SCC requires early treatment to prevent metastasis (spreading).

11. Typical squamous cell cancer on the ear

12. Typical squamous cell cancer on the face and scalp

13. Squamous Cancer of the Lower Lip

14. Typical squamous cell cancer on the hand

15. More advanced squamous cell cancer on the finger

16. Typical squamous cell cancer on the leg

17. Typical appearance of a well differentiated squamous cancer on the shin called keratoacanthoma

18. Malignant Melanoma Melanoma: Accounting for about 4% of all diagnosed skin cancers, melanoma begins in the melanocytes, cells within the epidermis that give skin its color. With early detection and proper treatment, the cure rate for melanoma is about 95%. Once its spreads, the prognosis is poor. Melanoma most often develops in a pre-existing mole or looks like a new mole, which is why it is important for people to know what their moles look like and be able to detect changes to existing moles and spot new moles.

19. Distribution of superficial spreading melanoma of the skin in men and women.

20. Superficial spreading melanomas in all stages of development. The small early lesions have irregular borders, irregular pigmentation, and small white areas indicating regression. The largest tumors show an accentuation of all of these features.

21. Superficial Spreading Melanoma

22. Nodular Melanoma

23. Lentigo Maligna Melanoma

24. Variety of Melanoma Skin Lesions

25. Twenty images of skin lesions. Images 1-6, 7-13, and 14-20 show atypical, benign, and malignant lesions, respectively.

31. Literature Review (untreated basal cell) Technique Number of Cases Local Control surgical excision 2,606 90% radiation therapy 4,695 91% curettage and electr. 3,573 92% cryotherapy 269 93% Mohs' microsurgery 7,670 99%

32. Literature Review (recurrent basal cell) Technique Number of Cases Local Control surgical excision 522 83% radiation therapy 234 87% curettage and electr. 115 60% Mohs' microsurgery 3,009 94%

33. Control Rate with Radiation, 3 Large Series Control Rates with Radiation Basal Cell 98% 95% 96% Squamous Cell 92% 87% 88% Type Untreated Relapsed Basal Cell 95% 82% Squamous Cell 87% 65%

34. Control by Tumor Size Skin Damage with Radiation Size Control Rate < 2 cm 99% 2 - 5 cm 92% > 5 cm 60% Size Skin Damage < 1cm 0.9% 1 - 5 cm 6.5%

35. Radiation for Skin Cancer Electron beam for large areas. Daily (Mon-Fri) for 3 – 6 weeks

36. With electron beam then skin will get moderately sun-burned by the last day, but usually heals up in 2 to 3 weeks

38. Radiation for Skin Cancer HDR skin applicators – three times a week for 6 treatments over a two week period

39. Results with HDR for skin

40. Results with HDR for skin

41. Results with HDR Skin applicator for small basal cell cancers on the face

42. Small squamous cancer of the chin, appearance 3.5 weeks after radiation (HDR)

43. Results with Radiation

44. Results with HDR for skin on shin

45. Results with HDR for skin on shin

46. Radiation can be used for large areas of small recurrent basal cell cancers Area treated with electrons Appearance of skin two weeks after completion

47. Even large or neglected skin cancers usually heal well with radiation

48. Appearance at 2 months

49. Appearance at 3 months

50. Radiation for areas difficult to operate, squamous cancer of the finger before and 19 days after electron beam

51. Squamous Cancer of the Ear Helix The radiation healed the cancer and prevented further destruction of the ear

52. Side Effects of Skin Radiation The treated skin will get red, itchy and sunburned. There are a number of good creams than can be used including Aloe, Aquaphor, Sween, Biafine. The skin reaction may show up in a delayed manner (worse at 1-2 weeks) and may develop slight, superficial ulceration or crusting, but heals quickly (1-2 weeks) except the shin which heals more slowly

53. Side Effects of Skin Radiation most people get mild sun burn effect , but some get blistering or crusting (scab formation) but they heal quickly Prior to radiation 1 week after radiation

54. Side Effects of Skin Radiation Prior to radiation last day of radiation

55. Typical delayed reaction where the lesion forms a scab at 1 – 2 weeks after completion, the scab usually falls off in another week or two

56. Radiation side effects may show up in delayed manner after HDR Basal cell Last day Three weeks later Three months later

58. Delayed Skin Reaction with HDR

59. Skin reaction is often delayed with HDR and can take several weeks to return completely back to normal

61. Typical Time pattern for skin healing with HDR

63. Lesions on shin may heal more slowly

64. Typical delayed reaction with superficial ulceration but quick healing, the small ‘hole’ at the biopsy site may take 2-3 months to disappear

65. Skin healing over the shin in an elderly woman

66. Skin cancers on the shin in an elderly patient may take several months to heal

67. Radiation prescription for # Diagnosis: # Number of Treatments: #

68. Radiation prescription for # Diagnosis: # Number of Treatments: #