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Principles and Practice of Radiation Therapy
Chapter 40 Skin Cancers and Melanoma Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.
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Integumentary System Overview Hypodermis Dermis Epidermis
Accessory structures Effects of aging
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Overview Largest organ Functions 22 square feet 10 to 12 pounds
Protection Temperature control Waste removal Sensory Vitamin D production
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Hypodermis Subcutaneous tissue or superficial fascia
Acts as the foundation Composition Adipose tissue Function Padding Insulation Shape
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Dermis Reticular layer Tension lines Papillary layer
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Epidermis Cellular composition Desquamation Keratinization
Keratinocytes Melanocytes Langerhans cells Desquamation Keratinization
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Epidermis Stratum corneum Stratum lucidum Stratum granulosum
Stratum spinosum Stratum basale
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Accessory Structures Hair Muscles Types Structure Arrector pili Lanugo
Vellus Terminal Structure Shaft Root Muscles Arrector pili
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Accessory Structures Glands Sebaceous Sweat Ceruminous
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Accessory Structures Nails Purpose Structure Protection Manipulation
Scratching Structure Root Body Matrix
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Effects of Aging Reduced blood flow Thinner skin Loosened structure
Decreased activity of glands Decrease in melanin
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Skin Cancer Epidemiology Etiology Clinical presentation
Detection and diagnosis Disease classification Pattern of spread Treatment Side effect management
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Skin Cancer Types Melanoma Nonmelanoma Benign skin conditions
Basal cell carcinoma Squamous cell carcinoma Merkel cell carcinoma Benign skin conditions Actinic keratosis Squamous cell carcinoma in situ
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Nonmelanoma Epidemiology
Incidence 13 million new cases each year 80% basal cell carcinoma (BCC) 20% squamous cell carcinoma (SCC) Deaths 1000 to 2000 deaths
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Nonmelanoma Etiology Sun exposure Genetics Radiation Chemical agents
Ultraviolet B (UVB) Artificially produced ultraviolet A (UVA) Genetics Hair color Complexion Xeroderma pigmentosum Radiation Chemical agents Viruses Human papillomavirus (HPV) Chronic irritations
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Nonmelanoma Clinical Presentation
Asymmetry Border Color Diameter Elevation
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Nonmelanoma Detection and Diagnosis
Screening Clinical examination Self-examination Inspect face Check hands including nails Women should examine under breasts Use two mirrors to inspect back Check legs and feet
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Nonmelanoma Disease Classification
Staging BCC often not staged Pathologic staging Tumor Node Metastasis (TNM) Clinical staging
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Nonmelanoma Pattern of Spread
Slow growing Direct extension Embryologic fusion planes Perineural space Nodes and metastases
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Nonmelanoma Treatment
Surgery Curettage and electrodesiccation Scraping and burning Mohs’ microscopic surgery Cryosurgery Temperature −50° Celsius Recommended for bleeding or oozing skin cancers
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Nonmelanoma Treatment
Laser surgery Typically performed by a dermatologist Chemotherapy Topical 5-fluorouracil (5-FU) Systemic Salvage Investigative methods Immunotherapy Photodynamic therapy
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Nonmelanoma Treatment
Radiation therapy treatment Treatment volume localization Visualization Palpation Treatment margins
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Nonmelanoma Treatment
Radiation therapy treatment Simulation Patient positioning Immobilization devices Treatment parameters Blocking Beam arrangement Special considerations
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Nonmelanoma Treatment
Radiation therapy treatment Treatment delivery Beam energy Superficial Electrons Photons Brachytherapy
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Nonmelanoma Treatment
Radiation therapy treatment Treatment delivery Dose schedule BCC Smaller than 2 cm – 4500 cGy 2 to 5 cm – 5000 cGy Larger than 5 cm – 6000 cGy SCC Smaller than 2 cm – 5000 cGy 2 to 5 cm – 5500 cGy Larger than 5 cm – 6500 cGy Lesions larger than 8 cm or with bone invasion – 6500 to 7500 cGy
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Nonmelanoma Side Effect Management
Acute Types of injuries Management Avoid trauma Cleansing Ointments Chronic Telangiectasis Hyperpigmentation Hair loss Necrosis
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Melanoma Epidemiology
Incidence is on the rise 54,200 new cases in 2003 62,190 new cases in 2006 Only 3% of all skin cancers Most deadly skin cancer
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Melanoma Etiology Sun exposure Moles Genetics Family history
UVB Artificially produced UVA Moles Genetics Hair color Complexion Family history Immune suppression Age Gender Xeroderma pigmentosum History of melanomas
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Melanoma Clinical Presentation
Types Superficial spreading melanoma Lentigo maligna Acral lentiginous melanoma Nodular melanoma
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Melanoma Detection and Diagnosis
Screening Physical examination Imaging studies
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Melanoma Pattern of Spread
Rapid vertical growth typical Risk of nodal or metastatic involvement increases with increased tumor depth
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Melanoma Disease Classification
American Joint Committee on Cancer (AJCC) − TNM Clark’s Breslow measurement
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Melanoma Treatment Surgery Chemotherapy Radiation therapy
Simple excision Reexcision Mohs’ surgery Amputation Chemotherapy Radiation therapy Dose schedule Hypofractionation
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Melanoma Survival Survival by stage Stage 0 Stage I Stage II Stage III
Stage IV
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