1. S KIN C ANCER Amy Stinson ENT Resident Affinity Medical Center

2. S KIN C ANCER Most common human malignancy US: >1,300,000 cases annually 2,000 deaths annually (non-melanoma) Most common location – sun exposed areas of head and neck Basal Cell accounts for 90% (baileys) Squamous cell next most common, then melanoma Pearls: What is the reported ratio of BCC to SCC in the US? 4:1

3. S KIN C ANCER R ISK F ACTORS Age > 60 UV light exposure Pearls: specifically UV B (280-320nm) Specific Traits: fair complexion, blue/green eyes, light hair, inability to tan, celctic ancestry Hx of multiple or severe sunburns Tanning bed use Mainly UV A – UV A synergistically augments UV B response Arsenic exposure Chronic radiodermatits ( pearls ) Immunosuppression ( pearls ) Trauma: burns, ulcers or scars Pearls : Marjolin Ulcer

4. R ISK F ACTORS

5. Genetic disorders ( Pearls ) Basal Cell-Nevoid Syndrome (Grolin’s) Aut Dom, multiple BCC, odontogenic keratocysts, rib abnormailties, palmar/plantar pits, calcification of falx cerebri Xeroderma pigmentosa Albinism Epidermisdysplastic verruciformis Epidermolysis bullosa dystrophica Dyskeratosis congenital

6. N ORMAL S KIN

7. 5 layers of epidermis from superficial to deep ( Pearls ) Stratum Corneum Stratum Lucidum Stratum Granulosum Stratum Spinosum Stratum Basale Pneumonic: C ome, L et’s G et S un B urned

8. B ASAL C ELL Slowly growing malignancy of the epidermis Extends peripherally without vertical invasion Rarely metastasizes Cells appear histologically similar to basal cells of epidermis (small dark blue cells with little cytoplasm) BCC – clefting, lack of intracellular bridges, nuclear pallisading, peritumoral lucunae

9. Basal Cell Growth pattern (pearls) Follows the path of least resistance Typically along embryonic fusion planes Susceptible areas: Inner canthus Philtrum Mid - Lower chin Nasolabial groove Periauricular area Retroauricular sulcus

10. B ASAL C ELL Clinical subtypes (pearls ) Nodular – Most Common Pearly, telangiectatic papule, central ulceration, rolled border Superficial Rare in H & N, scaly, waxy, indurated, irregular More common on extremeties and trunk Pigmented/Cystic Similar to nodular type, more pigmented resembling melanoma or benign nevus Morpheaform Common on face, flat or depressed, indurated, aggressive with high rate of recurrence, worst prognosis, can resemble scar Keratotic aggressive

11. B ASAL C ELL Nodular Superficial Pigmented

12. B ASAL C ELL Morpheaform Post - excision

13. B ASAL C ELL Management Avoid excess sun – sunblock Careful follow-up for recurrence Pearls : After having one (BCC or SCC) what are the chances of developing another within 5 yrs? 50% Curettage with Electrodisiccation Cryosurgery Scalpel excision – need 5 mm margins Radiation therapy – poor operative candidates Mohs – for high risk areas, morpheaform 1/3 of incompletely excised BCC will recur

14. S QUAMOUS C ELL More aggressive Higher recurrence rates Vertical extension 1-4% metastatic potential Scar/chronic inflam > de novo > from AK Signs: Erythematous, hyperkeratotic, opaque nodule, ulcerative, granular base, bleeds easily SCC that arise in sun exposed areas have better prognosis than those arising de novo

15. S QUAMOUS C ELL Histopath Keratin pearls Broder Classification 1 – well differentiated 4 – poorly differentiated Types : Adenoid Bowenoid Verrucus – mc in oral mucosa Spindle-pleomorphic – least common Generic – from actinic change

16. S QUAMOUS C ELL Premalignant Lesions Actinic Keratosis Most common Sun exposed skin Less than 1 cm Chance of progression – 20% Erythematous patch with scale Can have cutaneous horn Pearls : Most common premalignant lesion of H & N? AK

17. T YPICAL AK

18. C UTANEOUS H ORN

19. S QUAMOUS C ELL Premalignant Lesions Bowen Disease Pearls: Squamous cell carcinoma in situ of the skin Full thickness dysplasia of epidermis Well circumscribed Common with hx of arsenic exposure Keratoacanthoma ( pearls ) Benign, usually self limited Common in older males 2-6 mo hx of rapid growth – usually on nose Central area of ulceration – volcano-like Spontaneous involution

20. K ERATOACANTHOMA

21. S QUAMOUS C ELL The following are features of high-risk SCC: Size Width greater than 2 cm Depth greater than 4 mm Location Ear Lip Histologic features Perineural invasion Lymphovascular invasion Poorly differentiated grade Recurrence Immunosuppression

22. M ANAGEMENT Initial evaluation involves Assessment of location Punch or excisional biopsy Staging

23. AJCC C LASSIFICATION TNM staging system for NMSC Primary tumor (T) TX - Primary tumor cannot be assessed. T0 - No evidence of primary tumor Tis - Carcinoma in situ T1 - Tumor 2 cm or less T2 - Tumor larger than 2 cm but smaller than 5 cm T3 - Tumor larger than 5 cm T4 - Tumor invades deep extradermal structures (bone, muscle, cartilage). Regional lymph nodes (N) NX - Regional lymph nodes cannot be assessed. N0 - No regional lymph node metastasis N1 - Regional lymph node metastases Distant metastasis (M) MX - Distant metastasis cannot be assessed. M0 - No distant metastasis M1 - Distant metastasis

24. M ANAGEMENT - C RYOSURGERY Cryogen such as liquid Nitrogen to kill tumor cells Typical temperature of -50°C. Tissue-sparing, but leave open wound Hypopigmentation and scarring may result Limited to favorable small lesions with well- defined borders

25. M ANAGEMENT – R ADIATION T HERAPY Used extensively in the past, now sparingly High cure rate (95%) Does not allow surgical staging Protracted treatment course, and expensive Radiodermatitis, delayed carcinogenesis Currently reserved for poor operative candidates, adjuvant in high risk malignancy

26. P HOTODYNAMIC T HERAPY Photosensitizing drug (porphyrin, 5-ALA) applied topically, orally or parenterally and localizes into tumor cells Drug is activated by exposure to light (laser) Efficacy is low (45%) Side effects include local edema, erythema, blistering, ulceration Used as palliation

27. M ANAGEMENT - E XCISIONAL S URGERY Most often used by surgeons, esp for larger lesions Can be with cold steel or laser Can allow reconstruction in the same sitting Frozen sections decrease recurrence rate Can be time consuming and inconvenient If more than 1/3 of a cosmetic facial unit is excised, better cosmesis with removal of entire unit Success rate 93-95%

28. M ANAGEMENT – E XCISIONAL S URGERY

29. M OHS S URGERY - I NDICATIONS Recurrent skin cancer Skin cancer in “high risk anatomic areas” and cosmetically important areas Histologically aggressive skin cancer Large skin cancers Skin cancer with ill-defined clinical margins Irradiated skin Dermatofibrosarcoma Protuberans Selected mucosal squamous cell cancers

30. L YMPHATIC D ISSECTION No hard and fast rules governing lymphatic dissection in N0 Necks Elective Parotidectomy for deeply invasive tumors of the periauricular region Large SCCA (>2cm), recurrent SCCA, Marjolin’s ulcer, perineural invasion may require regional lymphadenectomy Prophylactic neck when SCC >4 cm with deep invasion arising on cheek, neck, scalp

31. R ARE C UTANEOUS M ALIGNANCIES Merkel’s Cell Carcinoma Tumor arising from pluripotential basal cells within or around hair cells (pearls ) Poorly differentiated histology High rate of recurrence and lymph node metastasis requires excisional surgery with adjuvant radiation and treatment of lymphatic drainage in most cases NO neck should be treated Solitary erythematous to deep purple plaque or nodule of up to several centimeters in size

32. R ARE C UTANEOUS M ALIGNANCIES Dermatofibrosarcoma Protuberans Arises in dermis, spreads deeply Large indurated plaque with firm irregular flesh colored nodules Mohs is treatment of choice Pilomatrix Carcinoma Arises from Pilomatricoma, a benign tumor of hair matrix origin Aggressive wide local excision is treatment

33. THE END Questions?