Basal Cell Carcinoma Incidence: The most common malignant skin tumor 75% Predisposing Factors: Exposure to the sun (ultraviolet rays for long time years) so more in males White or fair hair complexion peoples are more affected (dark skin gave protection)

Clinical Picture Usually male above 40years 95% occur in the middle of the face,the angles of the triangle are Tragus of the ear Inner canthus Angle of the mouth

Clinical types 1. Ulcerative type 2. Nodular and cystic type 3. Papillary type 4. Cicatrizing 5. Sclerosing 6. Fissuring 7. Pigmented 8. Morphy tye

Complications 1. Spread: a) Only by direct spread erode the surrounding eye ball,cartilage,sinus,….. b) Lymphatic and blood very rare 2. Infection that may cause cavernous sinus thrombosis 3. Haemorrage erode large vessel may cause fatal hge 4. Epitheliomatous transformation

BCC with palpable LNs!!!! I. Secondary infection (tender and firm) II. Epitheliomatous transformation (hard and not tender)

Causes of death in BCC I. Erosion of a large vessel lead to sever uncontrollable hemorrhage II. Direct intracranial extension III. Inhalation pneumonia

Differential Diagnosis I. Infections –Non specific Chronic infection Infected sebaceous Molluscum sebaceum simulate scc but disappear spontaneous within 2 months –Specific TBSyphilisActinomycosisLeishmaniasisAnthrax

Differential Diagnosis Traumatic ulcer Tumors ulcerated –Rodent ulcer (commonest) –Epithelioma –Melanoma –Deep tumor invade the skin –Metastatic tumor

Locally Malignant Tumors

Treatment SurgeryIndications – Diagnosis small lesions excisional biopsy large lesions incisional biopsy – Treatment of small and advanced cases small in dangerous areas as eyelid advanced involving bones (sequestration) recurrence after irradiation

Treatment Operation Radical local excision with safety margin Radical local excision with safety margin –1 cm (in the face) all around and in depth. –In areas like eye lid (6-8mm can be accepted) –In areas other than the face (2cm) Reconstruction after excision –Grafts Less cosmetics –Flaps more cosmetic

TreatmentRadiotherapyIndications –Recurrence after surgery –Contraindication to surgery (unfit,old age) Contraindications –Small lesions near sensitive organs –Advanced lesions invading bones –Radio-resistant types (pigmented,nodular,cystic )

Squamous Cell Carcinoma The second common skin cancer occur in about 15 % Occur in areas with pre-malignant lesions –Actinic keratosis –Radiodermatits –Paget’s disease –Bowen’s disease –Lupus vulgaris –Xeroderma pigmentosa

Squamous Cell Carcinoma It arise from the prickle cell layer of the dermis It is more in male Above 50 year Sites –Face and head (away from sites of BCC) –MM of the mouth, anus, vagina and esophagus –Areas with sq metaplasia as lung, UB

Squamous Cell Carcinoma Start as nodule or ulcer grow rapidly in size and bleed on touch with LN Clinical types –Ulcerative –Nodular –Papillary –Eczematous –Fissuring –keratinizing

Marjolin Ulcer It is a squamous cell carcinoma developing on top of old scar –Venous –Ischemic –Naturopathic –Post burn –Infective TB or $ –Sinus of ostomyelitis

Marjolin Ulcer Characterized by different morphology –The scar is devoid of nerves, vessels and lymphatic –No nerves no sensation –No vessels so grow very slowly without metastases Treatment is surgical excision with safety margin taken from the scar tissue not the ulcer

Squamous Cell Carcinoma Confirm diagnosis by biopsy either Excisional or incisional Radiotherapy for massive unresectable lesions or post operative after excision as adjuvant therapy

Squamous Cell Carcinoma Radical excision with safety margin –1 inch in all direction followed by reconstruction –5 mm could be enough in H&N LN –If not palpable wait and see –If palpable Mobile RND Fixed radiotherapy Radiotherapy for –massive unrespectable lesions –post operative after excision as adjuvant therapy

Malignant Melanoma Malignant Melanoma

Melanoma Almost 30% of all melanomas arise in the head and neck Widespread use of sunscreen has not lowered the incidence. Incidence is increasing almost 5% per year Approximately 47,000 new cases in 2001

Predisposing Factors Sun Exposure –Age, frequency, severity of exposure may play a role –Sunscreen use may not be protective Familial Melanoma / DNS –Family members have almost 50% chance of developing melanoma –Lesions may be multiple and in sun shielded areas Xeroderma Pigmentosa –Predisposes to several types of skin cancer –Skin malignancies often appear by age 10

Sunlight UVB ( nm) –Causes direct DNA damage –Originally thought to be primary factor –Blocked by current sunscreens UVA ( nm) –Causes indirect DNA damage via free radicals –Some now consider as more important than UVB –Sunscreen has little UVA protection

Types of Melanoma Superficial Spreading –Most common –Cells atypical but uniform in appearance Nodular –Early invasion due to vertical growth Acral Lentiginous –Appears on palms and soles –Histology shows heavily pigmented dendritic processes in the basal layer

Types of Melanoma Lentigo Maligna Melanoma –May remain in-situ for decades –Can spread along hair follicles Desmoplastic –May lack pigment –Peri-neural invasion is classic –Histologic exam may show “school of fish” appearance Mucosal –Often lack melanin –Conventional staging system does not apply –Site of lesion corresponds to prognosis Nasal cavity best prognosis, 31% at 5-yrs Paranasal sinuses worst prognosis, 0% at 5-yrs

Diagnosis History –Family History –Sun exposure –Bleeding, pain Physical –ABCD Histology –H&E –S-100, HMB-45

Biopsy Excisional –Recommended for small lesions –Margins of 2mm Incisional –For larger lesions –Does not alter draining lymphatics Punch –Same as incisional Shave –Contraindicated Needle

Clark staging Based upon histological level of invasion Level I – Epidermis only (in situ) Level II – Invades the papillary dermis, but not to the papillary-reticular interface Level III – Invades to the papillary-reticular interface, but not into the reticular dermis Level IV – Into the reticular dermis Level V – Into subcutaneous tissue

Breslow staging Based upon absolute depth of invasion Stage I – < 0.75 mm Stage II – 0.76 – 1.5 mm Stage III – 1.51 – 4.0 mm Stage IV - > 4.0 mm

AJCC staging

Prognosis by AJCC stage Stage I –< 0.75 – 96 % –0.75 – 1.5 – 87 % Stage II –1.5 – 2.49 – 75 % –2.5 – 3.99 – 66 % –> 4.0 – 47 % Stage III –One node 45 % –Two nodes < 20 % Stage IV –8 – 10 % Percentages are five year survival except stage IV lesions which represent one year survival

Treatment - Stage I Labs –LDH Radiology –CXR Excision – 1 cm margins Adjunctive Therapy –None

Treatment - Stage II Labs –LDH Radiology –CXR –Possible CT for metastasis –Possible Lymphoscintigraphy Excision – 2 cm margins Adjunctive Therapy –Possible elective neck dissection –Possible sentinel lymph node biopsy –Possible elective radiation

Treatment - Stage III Labs –LDH Radiology –CXR –CT neck –Possible CT abdomen, MRI brain Excision –2 cm margins –Remove in-transit lymphatic basins –Neck dissection directed by site Posterolateral vs. Lateral vs. Supraomohyoid Adjunctive Therapy –Probable radiotherapy –Possible chemotherapy

Treatment - Stage IV Labs –CBC, LFT’s, LDH Radiology –CT Chest, Abdomen, Pelvis –MRI brain Excision –2 cm margins –Remove in-transit lymphatic basins –Neck dissection directed by site Posterolateral vs. Lateral vs. Supraomohyoid Adjunctive Therapy –Radiation therapy –Consider chemotherapy as part of a clinical trial

Sentinel Lymph Node Biopsy Used to determine nodal status in low-risk tumors Allows for limited surgical morbidity. Has prognostic value for patient outcome

Sentinel Lymph Node Biopsy Procedure –Preoperative lymph basin mapping using lymphscintigraphy with Tc99 –Preoperative injection of radiotracer allows for intraoperative gamma counter localization –Intraoperative injection of iosulfan blue allows for visual detection of involved nodes. –Allows for detection of sentinel nodes in % of patients depending on the study cited.

Radiation Indications include stage III or IV lesions Patients with positive SLNB should be considered Decreases local recurrence rates to % Does not affect overall survival May be contraindicated for lesions near the eye or for midline lesions

Chemotherapy Numerous therapy modalities exist No significant benefit has been found for any therapy to date Administration of chemotherapy should be done as part of an ongoing clinical trial.