Skin Cancers and Common Spots Common lesions Skin cancers Non - PDF document

Outline Skin Cancers and Common Spots • Common lesions • Skin cancers – Non ‐ melanoma Lindy P. Fox, MD – Melanoma Associate Professor Director, Hospital Consultation Service Department of Dermatology University of California, San Francisco lindy.fox@ucsf.edu I have no conflicts of interest to disclose 1 Common Skin Lesions Seborrheic Keratoses • Seborrheic keratosis • BENIGN • Dermatofibroma • Appear beginning at age 40, earlier in • Pyogenic granuloma sunny regions • Stuck-on morphology (above the skin) • Sebaceous hyperplasia • Greasy/waxy/warty texture, horn cysts • Face, under breasts, trunk • 0.1 to 2.0 cm in diameter • Treatment: Reassure, cryotherapy 1

Dermatofibroma Cherry Angioma • Firm, 3 ‐ 7 mm slightly rough surfaced, slightly elevated • Very Common papules • Increases with age (senile angioma) • Overlying hyperpigmentation • F>M (?hormonal) • Firm to palpation; Dimple sign • Often at sites of minimal trauma • 1 ‐ 5 mm bright red dome ‐ shaped papule – Bug bite, ingrown hair, etc • Not easily compressible • Treatment : Reassure, cryotherapy, removal • Association: None • Often recur after removal • Complications: None • Association: Multiple (>15) of sudden onset may rarely signal T cell dysregulation (Lupus, HIV) Pyogenic Granuloma Sebaceous Hyperplasia • Friable, 5 ‐ 10 mm papule • Common, benign • Occurs after trauma • Single or multiple pink to yellow papules on the face, • Children and adults often with telangiectasias and central dell • Biopsy: Excess granulation tissue • May mimic BCC • Treatment: Surgical removal (curette), • Multiple associated with calcineurin inhibitors electrodessication of base • When associated with sebaceous adenoma or • Complication: Rarely may recur and form satellites sebaceous carcinoma, rule ‐ out Muir Torre (Lynch) syndromes • Treatment ‐ low dose isotretinoin, electrodessication, laser, shave removal, PDT, cryotherapy 2

Nonmelanoma Skin Cancer Actinic Keratosis (NMSC) • In-situ dysplasia from ultraviolet exposure. • Sign of sufficient sun injury to develop NMSC. • Actinic Keratosis • Precancerous (low rate <1%) • Basal Cell Carcinoma • Prevented by sun screen use, even in adults. • Squamous Cell Carcinoma • Caused primarily by ultraviolet radiation • SCC and Actinic Keratoses – P53 tumor suppression gene mutated by UV • BCC – PTCH gene Actinic Keratoses- Treatment Actinic Keratosis • Liquid nitrogen (single freeze ‐ thaw cycle) • • Topical treatment Diagnosis ‐ Clinical • 5 ‐ fluorouracil (0.5 ‐ 5%) (Efudex) inspection • 5% qd or BID for 2 ‐ 4 weeks • • Red, scaly patch < 6mm. Imiquimod 5% cream (Aldara) • TIW x 4 weeks, with repeated cycles PRN • Tender to touch. • BIW or TIW x 16 weeks • QW x 24 weeks • Sandpaper consistency. • Diclofenac (Solareze) • Location ‐ Scalp, face, dorsal • BID x 60 ‐ 90 days • Long term treatment (>120 days), moderately effective, side hands, lower legs (women) effects • Picato (ingenol mebutate); 0.015%, 0.05% • When very thick, suspect • Face/scalp ‐ 0.015% QD x 3d hypertrophic AK or SCC • Trunk/extrem ‐ 0.05% QD x 2d • Photodynamic therapy 3

AKs treated with 5-fluorouracil Actinic Keratoses ‐ Treatment • Always biopsy if an AK is not responding to appropriate therapy – r/o SCC, superficial BCC http://www.crutchfielddermatology.com Basal Cell Carcinoma Basal Cell Carcinoma ‐ Clinical Subtypes • Most common of all cancers • Nodular (classic) – > 1,000,000 diagnosed annually in USA • Superficial – Lifetime risk for Caucasians: up to 50% • Pigmented • Intermittent intense sun exposure and • Morpheaform (scar ‐ like) overexposure (sunburns) • Locally aggressive, very rarely • Clinical subtypes have different biologic metastasize behavior • Histologic subtypes also influence behavior 4

Basal Cell Carcinoma ‐ Superficial Basal Cell Carcinoma ‐ Pigmented • Clinically pink, slightly scaly, slightly shiny • May be entirely pigmented or there may patch be specks of pigment within what otherwise looks like a nodular or • Looks like an actinic keratosis superficial BCC • May be treated with imiquimod, ED+C • Melanoma is on the differential!! Basal Cell Carcinoma ‐ Treatment Basal Cell Carcinoma ‐ Morpheaform Location, Size, and Subtype Guide Therapy • Superficial • Clinically scar-like • Imiquimod • Difficult to determine clinically where • Electrodesiccation and curettage (ED+C) lesion begins and ends • Nodular or pigmented • Treat with excision (have pathologist • ED+C check margins) or Mohs micrographic • Excision (4mm margins) surgery • Mohs micrographic surgery • Radiation ‐ comorbidities, tumor size and location – DO NOT ED+C • Morpheaform, infiltrative, micronodular • Excision (4mm margins) • Mohs micrographic surgery 5

Topical Treatment of Skin Cancer Topical Treatment of Skin Cancer • Nonsurgical approaches for managing some • Imiquimod 5% cream can effectively treat skin cancers are available superficial BCC ’ s and SCC in situ • Patient selection is the key • Treatment regimen is 5X per week for 6-10 weeks depending on the host reaction • Topical treatments work for superficial • Efficacy is relatively high (75%-85%) cancers (not invasive ones) • Scarring may be reduced compared to surgery • Superficial BCC, SCC in situ • Long courses of treatment (months) may be required • Biopsy to confirm diagnosis before treating Basal Cell Carcinoma ‐ Treatment Squamous Cell Carcinoma Mohs micrographic surgery • Presents as red • Recurrent or incompletely excised tumors plaque, ulceration, or • Aggressive histologic subtype (infiltrative, wart like lesion morpheaform, micronodular) • Risk factors: • Poorly defined clinical margins – Fair skin • High risk location (face, ears, eyes) – Inability to tan – Chronic sun exposure • Large (>1.0 cm face, >2.0 cm trunk, extrem) • Special situations: • Tissue sparing location (face, hands, genitalia) – Organ transplant • Immunosuppressed patients recipients • Tumors in previously irradiated skin or scar • Tumors arising in setting of genetic diseases 6

Keratoacanthoma Squamous Cell Carcinoma Treatment • SCC in situ – 5FU, imiquimod, liquid nitrogen, electrodesiccation and curettage • Invasive SCC – Excision with 4 mm margins – Mohs micrographic surgery • Rapidly growing (1month) • Dome-shaped nodule with central core of keratin • May spontaneously regress, but treat as an SCC Squamous Cell Carcinoma ‐ Treatment Skin Cancers on the Lower Legs Mohs micrographic surgery • • BCC and SCC in situ is common on the Recurrent or incompletely excised tumors • lower legs, especially in women Aggressive histologic subtype (perivascular, perineural) • Poorly defined clinical margins • They presents as a fixed, red, scaly • High risk location (face, ears, eyes) patch(es) • Large (>1.0 cm face, >2.0 cm trunk, extrem) • It looks very much like a spot of eczema • Tissue sparing location (face, hands, genitalia) • Think of skin cancer when red patches on • Immunosuppressed patients the lower legs don ’ t clear with • Tumors in previously irradiated skin or scar moisturizing. • Tumors arising in setting of genetic diseases 7

Case • Skin Biopsy = Squamous • 64 year old man with Cell Carcinoma psoriasis, hypertension, s/p • Chronic phototherapy and renal transplant immunosuppressive • 3 months of ulceration of treatments have led to skin medial aspect of left lower cancer leg, thought to be due to • If leg ulcer doesn ’ t heal with venous insufficiency appropriate treatment—refer • 3 months of topical treatment or biopsy fails to improve ulceration Question: Which of the following is FALSE Question: Which of the following is FALSE about skin cancer in organ transplant about skin cancer in organ transplant recipients recipients 1. Basal cell cancers are more common 1. Basal cell cancers are more common than squamous cell cancers than squamous cell cancers 2. Voriconazole use is associated with 2. Voriconazole use is associated with skin cancer in transplant patients skin cancer in transplant patients 3. The skin cancers are more 3. The skin cancers are more aggressive aggressive 4. The skin cancers are potentially fatal 4. The skin cancers are potentially fatal 5. Skin cancers are the most common 5. Skin cancers are the most common type of malignancy in this group type of malignancy in this group 8