Lecture #2 Common Skin Lesions and Skin Malignancies

Benign Lesions

Seborrheic Keratosis Seborrheic Keratosis

Histopathology of seborrheic keratosis: expansion of epidermis by benign, uniform small keratinocytes. Note horn cysts/pseudocysts, which correspond to small comedo-like openings clinically.

Clinical variant - stucco keratoses Stucco Keratosis

Dermatosis Papulosa Nigra Clinical variant - dermatosis papulosa nigra Dermatosis Papulosa Nigra

Skin Tags (Acrochordon, Fibroepithelial Polyp) Skin tags (fibroepithelial polyps) Skin Tags (Acrochordon, Fibroepithelial Polyp)

Skin Tags and Acanthosis nigricans Can be accompanied by acanthosis nigracans; indicator of insulin resistance and risk for diabetes Skin Tags and Acanthosis nigricans

Hemangiomas (Cherry Angiomas) missinglink.ucsf.edu Hemangiomas (Cherry Angiomas)

Pyogenic granuloma Pyogenic Granuloma

Pre-malignant and malignant lesions

Skin cancer incidence >1 million new cancers per year 1 in 5 lifetime risk in America BCC>SCC>melanoma in incidence 1 million BCC/year 250,000 SCC 70,000 melanoma (invasive) http://www.skincancer.org/Skin-Cancer-Facts/

Skin cancer deaths, 2009 Projected skin cancer deaths - 2009 Source: American Cancer Society http://www.cancer.org

Actinic keratoses and Photodamage Actinic Keratosis and photodamage on face of elderly man Actinic keratoses and Photodamage

Actinic keratoses on the ear and cheek

Actinic Keratoses Epidemiology Prevalence in Australia: 40-50% of >40yo 80% by age 70 Incidence increases with fair skin, male gender, age Salasche, JAAD 42(1) S2-7

Actinic Keratoses: precursor lesion to SCC ~60% SCC arise from AK Risk of progression to SCC 0.9% at 1 year 4% at 5 years >50% spontaneously regress Marks et al, Arch Dermatol 1988 1224:1039 Criscione et al, Cancer 2009 115:2523

AK/SCC: mutations leading to cancer progression Oncogenes Ras Tumor suppressors p53: UV “signature” mutations p16INK/CDKN2A Increased expression of oncogenes Decreased expression of tumor suppressors Spencer et al, Arch Dermatol 1995 131:796 Pacifico, Br J Dermatol 2008 158:291

AK and NMSC - prevention Sunscreen Caffeine PO or topical NSAIDs PO or topical Nicotinamide 500mg PO bid *patients with fewer Aks were more likely to have used NSAIDs; ongoing trials

Basal Cell Carcinoma (Nodular x2) Nodular BCC Basal Cell Carcinoma (Nodular x2)

Basal Cell Carcinoma commons.wikimedia.org/wiki/File:Skinlayers.png Thought to arise from the basal cell layer commons.wikimedia.org/wiki/File:Skinlayers.png

Basal Cell Carcinoma (Rodent ulcer) “rodent ulcer” BCC Basal Cell Carcinoma (Rodent ulcer)

Basal Cell Carcinoma (Superficial) Superficial BCC; note resemblance to dermatitis Basal Cell Carcinoma (Superficial)

Basal Cell Carcinoma (Morpheaform) Morpheaform BCC Basal Cell Carcinoma (Morpheaform)

Squamous Cell Carcinoma SCC Squamous Cell Carcinoma

Squamous Cell Carcinoma in situ (Bowen’s disease) Bowen’s disease/squamous cell carcinoma in situ Squamous Cell Carcinoma in situ (Bowen’s disease)

Squamous Cell Carcinoma Squamous cell carcinoma on lower lip in a smoker Squamous Cell Carcinoma

Squamous Cell Carcinoma (Keratoacanthoma type) One month later SCC, Keratoacanthoma type Squamous Cell Carcinoma (Keratoacanthoma type)

melanoma Melanoma

Melanoma lifetime risk was 1/600 in 1960, what was it in 2010? B. 1/100 C. 1/50 D. 1/10

Melanoma lifetime risk was 1/600 in 1960, what was it in 2010? B. 1/100 C. 1/50 D. 1/10

Melanoma statistics Increasing incidence #1 cancer in 25-59yo 1/67 people born in 2003 will have invasive melanoma 1 death per hour from melanoma http://www.aad.org/media/background/factsheets/fact_skincancer.html

Melanoma incidence by state Cases per 100,000 people; 2005 data Source: Journal of the American Academy of Dermatology 2011; 65:S6-S16 (DOI:10.1016/j.jaad.2011.04.037 )

Melanoma risk factors Risk factor Relative risk Blue eyes Red hair Prior melanoma >100 common nevi FHx (1st degree relative) Relative risk 1.4 4.1 3.1 - 5.0 7.6 8.0 Melanoma risk factors

Melanoma risk factors UVR – natural and artificial, is carcinogenic to humans Melanoma risk factors – IARC monograph, Group 1 = carcinogenic to humans. Includes alpha & beta particles, X-ray, gamma radiation El Ghissassi F, et al., Lancet Oncol 10:751, 2009 38

ABCDEs of melanoma A Asymmetry B Border Irregularity C Color variegated D Diameter > 6mm E Evolution ABDC’s of malignant melanoma

A Asymmetry B Border Irregularity C Color variegated D Diameter > 6mm E Evolution

Malignant melanoma with asymmetry

A Asymmetry B Border Irregularity C Color variegated D Diameter > 6mm E Evolution

Melanoma with border irregularity

A Asymmetry B Border Irregularity C Color variegated D Diameter > 6mm E Evolution

Melanoma with color variegation

A Asymmetry B Border Irregularity C Color variegated D Diameter > 6mm E Evolution

Melanoma >6mm

Lentigo Maligna Melanoma (Melanoma of sun damaged skin) Melanoma subtype: lentigo maligna melanoma - note telengiectasia, mottled pigmentation in surrounding skin indicating sun damaged skin Lentigo Maligna Melanoma (Melanoma of sun damaged skin)

Acral Lentiginous Melanoma Melanoma subtype - Acral lentiginous melanoma Acral Lentiginous Melanoma

Approach to the pigmented lesion

Where would you biopsy?

Where would you biopsy?

Where would you biopsy?

Approach to the pigmented lesion Biopsy if changing (growing, bleeding, etc) Perform excisional biopsy whenever possible Avoid partial biopsy Avoid shallow shave biopsy Biopsy read by dermatopathologist Consider referral to dermatologist

Melanoma prognosis: Depth Why is proper biopsy important?