Skin Cancer Crash Course:
Recognition and Management of Nonmelanoma Skin Cancer
Victor Neel, MD, PhD Director, Dermatologic Surgery, MGH Disclosures
Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to disclose.
Blood Vessels sebaceous Pyogenic granuloma glomus tumor neural sebaceous carcinoma Kaposi’s sarcoma Angiosacoma sebaceous adenoma Neurofibroma Epitheliod hemangioendothelioma Masson tumor sebaceoma Neurothekeoma Targetoid hemosiderotic hemangioma Angiokeratoma Schwannoma immune cell Glomangioma AV hemangioma Palisaded encapsulated neuroma Lymphoma Merkel cell carcinoma Mast cell disease histiocytosis epithelial
actinic keratosis squamous cell carcinoma eccrine keratoacanthoma seborrheic keratosis Microcystic adnexal ca porokeratosis Mucinous eccrine carcinoma Eccrine spriradenoma fibroblasts Cylindroma follicular Atypical fibroxanthoma Basal cell carcinoma Poroma Malignant fibrous histiocytoma Trichoepithelioma Porocarcinoma Pilar sheath acanthoma Nodular hidradenoma fat smooth muscle Tricholemmoma Syringoma Lipoma Leiomyoma Trichofolliculoma Chondroid syringoma angiolipoma Leiomyosarcoma Pilomatricoma Digital papillary adenocarcinoma Spindle cell lipoma angioleiomyoma Trichoblastoma Extramammarary Paget’s liposarcoma Fibrofolliculoma pleomorphic lipoma metastatic Desmoplastic trichoepithelioma Goals of This Talk
• Discuss the most common NMSC tumors you will see and possibly diagnose & treat • Convince you to consider performing skin biopsies in your practice Primary Care & Dermatology
• Too many patients, too many tumors • Delayed diagnosis, delayed treatment • Many skin cancers can be diagnosed and treated in primary care setting • PCPs must definitively diagnosis and have treatment algorithms in place
US Skin Cancer Incidence
• >5 million new cases of NMSC each year
• BCC about 80%, SCC about 20%
• About 15,000 deaths per year from SCC, more than twice as many than melanoma Causes of Nonmelanoma Skin Cancer
• Chronic UV exposure –> genetic mutations • Immunosuppression – Organ transplant patients and CLL patients – 80% of transplant patients develop skin cancers – 200-fold increased risk of SCC • Human papillomavirus - HPV 6,16 (vaccine may affect)
• Inherited diseases - XP, BCNS, albinism Basal Cell Carcinoma Stats
• most common cancer in humans • 3 million new cases a year, increasing 5% per year • 1/3 of all Caucasians will develop at least one lesion • billions of healthcare $$ spent Basal Cell Carcinoma Biology • very indolent growth – perhaps decades until clinically apparent • rarely metastatic (<0.01%) but very lethal – usually in neglected or multiply-recurrent tumors – locally destructive (cosmetically devastating) • >75% most sporadic tumors have defects in Sonic hedgehog signaling pathway (oral drug, vismodegib, topicals in develpoment) Which Is BCC? Basal Cell Carcinoma
• Subtypes – Nodulo-ulcerative (most common) – Morpheaform (sclerosing, infiltrative) – Micronodular – Metatypical (basosquamous) – Superficial (“multicentric”) Basal Cell Carcinoma
• Subtypes – Nodulo-ulcerative (most common) Basal Cell Carcinoma
• Pigmented BCC • Can mimic MM Basal Cell Carcinoma
• Subtypes – Morpheaform BCC – Can look like scar
Basal Cell Carcinoma
• Subtypes – Superficial “multicentric” – Can be misdiagnosed as psoriasis, tinea or eczema – Most common type on trunk and extremities BCC or Tinea? Tinea BCC
itchy & scaly crusts/bleeds often multiple usually single antifungals sun-exposed BCCs? Basal Cell Carcinoma
• Course – Slow, progressive growth – Bleeding, ulceration, superinfection – Enlarges over months to years – Is capable of extensive tissue destruction (invading into muscle, cartilage, and bone)
Suspected lesion Differential ?biopsy Treatment diagnosis ?refer options Actinic keratosis SK, wart, porokeratosis, NO 5-FU, imiquimod, trichilemmoma NO cryotherapy, PDT-ALA Squamous cell AK, discoid lupus, tinea YES 5-FU, imiquimod, PDT-ALA, carcinoma, in situ psoriasis, SK YES cryotherapy, curettage surgery Squamous cell SK, AK, BCC, pyoderma YES surgery, Mohs surgery, carcinoma, invasive gangrenosum YES radiation (rarely) BCC, superficial tinea, SCC in situ, discoid lupus, ? 5-FU, imiquimod, (body) porokeratosis, SCC in situ ? cryotherapy, curettage, surgery BCC, nodular nevus (melanocytic), molluscum YES cryo, curettage, surgery (body) YES BCC, infiltrative or scar YES recurrent (body) YES BCC, any type nevus, rosacea, angiofibroma, YES Mohs surgery (head & neck) syringoma, sebaceous YES hyperplasia, tinea, discoid lupus, SCC, trichoepithelioma, telangiectasia, scar Squamous Cell Carcinoma
• Second most common skin cancer in the general population • Most common skin cancer in transplant recipients • Appears on sun-exposed skin • Red, scaly, firm, may ulcerate • 1-15% metastasize (lip & ear) Squamous Cell Carcinoma
• Arises primarily on sun-damaged skin – Precursor is actinic keratosis (AK) on sun-exposed sites – 90% of AKs spontaneously resolve
• May occur anywhere on skin • Face • Lips (usually lower) • Ears • Dorsal hands • Chest Diffuse AKs? 5-FU!! Two Weeks of Topical 5-FU Squamous Cell Carcinoma
• Metastasis more likely in: – Recurrent tumors – Those with diameter > 2 cm – Those with depth > 6 mm – Mucosal sites, periauricular skin (lip & ear) – SCC arising from chronic wounds (Marjolin’s ulcer) – Perineural invasion of larger nerve fibers – Immunocompromised patients Squamous Cell Carcinoma
• Subtypes – Keratoacanthoma • Rapid initial growth • May be painful (unlike most NMSCs) • Exophytic nodule with central keratin-filled crater • Remains stable for a few months • May spontaneously resolve – new research!! • Dermpath reports as well-differentiated SCC
Time to get the derm surgeon on the phone Squamous Cell Carcinoma
• Subtypes – Bowen’s Disease • Squamous cell carcinoma in situ • Thin, erythematous, scaling plaques • Can progress into, and/or coincide with invasive SCC • Can be misdiagnosed as psoriasis, tinea, eczema or BCC Incidence Ratios of Skin Cancer in Transplant Recipients
• Squamous cell 100-fold increase carcinoma
• Basal cell carcinoma 10-fold increase
• Melanoma 3.4-fold increase Mortality from Metastatic Skin Cancer in Transplant Patients
Country Organ Cancer Mortality Rate type Australia Kidney SCC 5% of all patients with SCC New Zealand
Australia Heart All 27% total deaths occurring after the 4th yr post transplant USA All SCC 3 yr cause specific survival 54%, n = 71
USA All Melanoma 30% (compared to 15% in general population) A Lethal Tumor in a Transplant Patient
Please have your transplant patients see a dermatologist for baseline evaluation Surgical Emergencies in Dermatology • SCC in immunosuppressed population – Iatrogenic (organ transplant, anti-inflammatory states) – CLL or other leukemias/marrow failures
AML – 80% blast, 0%PMNs Suspected lesion Differential ?biopsy Treatment diagnosis ?refer options
Actinic keratosis SK, wart, porokeratosis, NO 5-FU, imiquimod, trichilemmoma NO cryotherapy, PDT-ALA
Squamous cell AK, discoid lupus, tinea YES 5-FU, imiquimod, PDT- carcinoma, in situ psoriasis, SK YES ALA, cryotherapy, curettage surgery
Squamous cell SK, AK, BCC, pyoderma YES surgery, Mohs surgery, carcinoma, invasive gangrenosum YES radiation (rarely)
BCC, superficial tinea, SCC in situ, discoid lupus, ? 5-FU, cryotherapy. (body) porokeratosis, ? curettage, surgery
BCC, nodular nevus (melanocytic), YES cryo, curettage, surgery (body) molluscum YES
BCC, infiltrative or scar YES recurrent (body) YES
BCC, any type nevus, rosacea, angiofibroma, YES Mohs surgery (head & neck) syringoma, sebaceous YES hyperplasia, tinea, discoid lupus, SCC, trichoepithelioma, telangiectasia, scar Less Common Tumors DFSP Dermatofibroma
Extramammary Paget’s Extramammary Paget’s A Challenge to Primary Care:
DO YOUR OWN BIOPSIES! Primary Care & Dermatology Delay in Diagnosis & Treatment
• Community dermatology shortage: 2-6 months • Community surgical dermatology shortage (Mohs surgery): 1-3 months
Typical delay from Primary care to definitive treatment: 3-9 months!!! Essentials for Serious PCPs
Do a “real” skin exam
Document lesions and take a pre-biopsy photo & measurement
Do not be afraid to biopsy early – low-risk of complications
If the biopsy is inadequate or doesn’t fit the clinical picture, re-biopsy! Essentials for Serious PCPs
• Don’t worry if your biopsies come back with benign diagnoses – steep learning curve • If you treat a lesion, see the patient back to confirm improvement. If not improving biopsy or refer, DON’T KEEP TREATING!! This Is Not an Actinic Keratosis! In-Office Biopsy Cost: $1.50 Time: 5-10 minutes. CLEAN not STERILE prep Reimbursement: $60-100 (CPT 11102) sterile #15 blade clean gauze & Q-tips 3cc lido/epi bottle Drysol in room vaseline & plaster obtain signed consent Biopsy Video Please refer biopsy-proven skin cancers to dermatologic surgery, not plastics
Nicotinamide for Prevention
• Nicotinamide (vitamin B3) 500mg BID • ~25% reduction of SCC/BCC in high risk skin cancer patients at 1 yr • low side effect profile • (NOT NIACIN) The dermatologist will see you!