Skin Cancer Robert A. Schwartz Skin Cancer Recognition and Management

With 245 Illustrations, 8 in Full Color

Springer-Verlag New York Berlin Heidelberg London Paris Tokyo Robert A. Schwartz, M.D., M.P.H., EA.C.P. Associate Professor and Chairman of UMDNJ-New Jersey Medical School Dermatologist-in-Chief UMDNJ University Hospital Founding Program Director Dermatology Residency Training Program New Jersey Medical School Newark, New Jersey 07103, USA

Library of Congress Cataloging-in-Publication Data Skin Cancer. Includes index. 1. Skin-Cancer. I. Schwartz, Robert A., 1947- [DNLM: 1. Skin -diagnosis. 2. Skin Neoplasms-therapy. WR 500 S628] RC280.S5S58 1988 616.99'477 87-36945 ISBN-13 :978-1-4612-8352-2 e-ISBN-13 :978-1-4612-3790-7 DOl: 10.1007/978-1-4612-3790-7

© 1988 by Springer-Verlag New York Inc. Softcover reprint of the hardcover 1st edition 1988 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag, 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dis• similar methodology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc. in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

Typeset by Publishers Service, Bozeman, Montana.

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ISBN-13 :978-1-4612-8352-2 To my wife Camila, our beloved Klara, and Jeffrey A. Klurfeld, J.D., for his unflinching friendship and support for so many years. Preface

The skin, uniquely positioned at the interface between the human body and the external world, plays a multifaceted role in the expression of cancer. Primary skin cancer is the most common cancer afflicting mankind and is rising in inci• dence, despite the fact that it is often preventable. Besides primary cancer, the skin may show direct and indirect evidence of internal cancer, thus serving as a window to the body for both laymen and physicians alike. In addition, the acces• sibility of the skin is useful for the study of carcinogenesis as well as cancer treat• ment options. lowe much of my interest in skin cancer to Dr. Leon Goldman, the father of dermatologic laser surgery, and to Dr. Edmund Klein, the father of modern immunotherapy. We, at the Roswell Park Memorial Institute, were indeed for• tunate to have a wealth of patients available for study. Many of the illustrations used in this book were of my patients at the Institute, and I kindly thank the fol• lowing publications and their respective publishers for allowing me to reuse some of my photographs, most notably: Cancer (2nd edition), Journal of Surgical Oncology, Journal of the American Academy of Dermatology, Archives of Dermatology, Cancer, and Journal of Dermatologic Surgery and Oncology. We are very fortunate in this work to have some of the world's foremost authorities in their areas as contributors, such as Drs. Zackheim, Lambert, J.W. Trimble, J.R. Trimble, Jackson, Crutcher, Mashberg, Wick, Sidell, F. Helm, G. Hill, H. Hill, and Goldman. I am also blessed with the strong support and encouragement of my colleagues at this medical school (founded in 1954 as Seton Hall College of Medicine; New Jersey College of Medicine 1965-1970; New Jersey Medical School, since 1970). I have been honored to be elected to three consecutive terms as secretary of the medical school faculty and to serve as the first permanent head of dermatology in the history of this medical school, being able with many colleagues including Drs. W. Clark Lambert (Vice Chairman of Dermatology, Chief of Dermatopathology, Deputy Residency Training Program Director), Roger H. Brodkin (founding and acting Head of Dermatology 1966-1983; Clinical Professor 1979 to present), George Kihiczak, Marcus T. Block, and Tamotsu Imaeda to establish the first dermatology residency training program in the history of New Jersey. With the addition to our faculty of Drs. Michael P. Bagley, David J. Goldberg, John Kwittken, and others we have achieved full five year dermatology residency training program accreditation in viii Preface

1987. The entire dermatology faculty including our dermatology residents are pleased to teach dermatology to the 200 students per class in our medical school. We all take pride that some of our premier medical students (and one from the Albert Einstein College of Medicine-Suguru Imaeda, MD) are pursuing a dermatology career. It is to our dermatology residents past and present as well as our medical students, faculty, and staff that we look to our future. Thus, we are very proud of Michael P. Bagley, MD (Rutgers Medical School, Class of 1982), Hector Wiltz, MD (Temple University Medical School, Class of 1983), Philip 1. Cohen, MD (New Jersey Medical School, Class of 1985), Lynn K. Bickley, MD (Johns Hopkins Medical School, Class of 1985), Carnila K. Janniger, MD (Medical Academy of Warsaw, Class of 1984), and Martha 1. Maso, MD, MPH (New Jersey Medical School, Class of 1986). Special thanks goes to Dr. Philip 1. Cohen, who has expended enormous energy assisting me in this project. Clark Lambert and I have full confidence in Dr. Cohen, who someday will be a medical school head of dermatology. Additional expressions of gratitude are in order for many people, especially the contributors to this work, as well as many others for a wide variety of reasons, including but not limited to Jacob E. Berger, MD, Carroll Moton Leevy, MD, Lynn K. Bickley, MD, David 1. Goldberg, MD, David M. Arbesfeld, MD, Esther Meiboom, MLS, Jackie Bush, Martha 1. Maso, MD, MPH, Robert W. Lockwood-Gonzalez, Peter 1. Lynch, MD, Halina Milgrom, MD, Arthur P. Birn• krant, MD, Karen Birnkrant, Marlene Merzacco, Sheldon B. Gertner, PhD, Mar• garet Prindle, Bennett S. Greenspan, MD, Sandra M. DePadova, MD, Gina Marfieet, Lillian F. Pliner, MD, George Sprung, MLS, Dandamudi Rao, PhD, and Stanley Von Hagen, PhD.

Robert A. Schwartz Contents

Preface ...... vii Contributors ...... ix Chapter 1 Introduction Robert A. Schwartz ...... 1 Chapter 2 Robert A. Schwartz...... 4 Chapter 3 Other Premalignant Cutaneous Robert A. Schwartz ...... 11 Chapter 4 Bowen's Robert A. Schwartz ...... 25 Chapter 5 Squamous Cell Carcinoma Robert A. Schwartz ...... 36 Chapter 6 Keratocanthoma Robert A. Schwartz ...... 48 Chapter 7 Basal Cell Epithelioma (Basal Cell Carcinoma) Robert A. Schwartz ...... 57 Chapter 8 Appendageal Carcinomas, Merkel Cell Carcinoma, and Cutaneous Sarcomas Robert A. Schwartz ...... 71 Chapter 9 Kaposi's Sarcoma Robert A. Schwartz...... 80 x Contents

Chapter 10 Philip J. Cohen, W. Clark Lambert, George J. Hill, and Robert A. Schwartz ...... 99 Chapter 11 The Dysplastic Nevus Syndrome William A. Crutcher and Philip J. Cohen ...... 141 Chapter 12 Dermatitic Precursors of Mycosis Fungoides W. Clark Lambert and Robert A. Schwartz ...... 152 Chapter 13 Cutaneous Lymphoma, Leukemia, and Related Disorders Herschel S. Zackheim ...... 162 Chapter 14 Metastatic Carcinoma of the Skin Robert A. Schwartz...... 185 Chapter 15 Cutaneous Markers of Internal Malignancy Robert A. Schwartz...... 194 Chapter 16 Early Oral and Oro-Pharyngeal Cancer: Diagnosis and Management Arthur Mashberg and Alan M. Samit ...... , 226 Chapter 17 Histopathologic Considerations in the Management of Skin Cancer Mark R. Wick, Carlos Manivel, and John L. Millns...... 246 Chapter 18 Historical Survey of Methods of Treatment of Skin Cancer Robert Jackson and Sharyn Laughlin...... 276 Chapter 19 Electrodesiccation and Curettage Robert Jackson and Sharyn Laughlin...... 292 Chapter 20 Electrosurgery Robert Jackson and Sharyn Laughlin...... 296 Chapter 21 Cryosurgery of Cutaneous Malignancies William A. Crutcher ...... 299 Chapter 22 Excision of Skin Cancer Chester Sidell ...... 311 Chapter 23 Local Flap Closure in the Management of Skin Cancer James W. Trimble and James R. Trimble...... 321 Contents xi

Chapter 24 The Role of Skin Grafts in the Management of Malignancies James R. Trimble and James W. Trimble...... 330 Chapter 25 Mohs Micrographic Surgery James W. Trimble and Robert A. Schwartz 339 Chapter 26 Current Developments of Laser Surgery for Skin Cancer Leon Goldman and Robert A. Schwartz...... 346 Chapter 27 Treatment of Cutaneous Cancer by Radiotherapy Frederick Helm, Thomas N. Helm, and Robert A. Schwartz ...... 353 Chapter 28 Immunotherapy KrzysztoJ Dabski and Frederick Helm ...... 363 Chapter 29 Topical Chemotherapy KrzysztoJ Dabski and Frederick Helm ...... 378 Chapter 30 Treatment of Melanoma George 1. Hill, Helene Z. Hill, and Martin Blumenreich ...... 390 Index...... 419 Contributors

Martin Blumenreich, M.D., FA.CP. Associate Professor of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA

Philip J. Cohen, M. D. Clinical Fellow, Dermatology Branch, National Institutes of Health, Bethesda, Maryland, USA

William A. Crutcher, M.D. Clinical Assistant Professor of Dermatology, University of California, San Fran• cisco School of Medicine, San Francisco, California, USA

KrzysztoJ Dabski, M.D. Assistant Professor of Dermatology, Department of Dermatology, State Univer• sity of New York at Buffalo School of Medicine, Buffalo, New York, USA

Leon Goldman, M.D. Emeritus Professor and Former Chairman, Department of Dermatology, Univer• sity of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Laser Consul• tant, U.S. Naval Hospital, San Diego, California, USA

Frederick Helm, M.D., F.A.CP., FR.CP. (C) Professor and Chairman, Department of Dermatology, State University of New York at Buffalo School of Medicine, Buffalo, New York, USA

Thomas N. Helm, M.D. Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio, USA

George J. Hill, II, M.D. Professor of Surgery; Chief, Section of Surgical Oncology, UMDNJ, New Jersey Medical School, Newark, New Jersey, USA

Helene Z. Hill, PH.D. Professor of Radiology; Chief, Section of Cancer Biology, UMDNJ, New Jersey Medical School, Newark, New Jersey, USA

Robert Jackson, M.D., FR.CP. (C) Clinical Professor of Dermatology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada xiv Contributors

W. Clark Lambert, M.D., PH.D., F.A.C.P. Associate Professor of and Dermatology and Director, Division of Dermatopathology; Vice Chairman, Dermatology, UMDNJ, New Jersey Medi• cal School, Newark, New Jersey, USA

Sharyn A. Laughlin, M.D., ER.CP. Assistant Professor of Dermatology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada

Carlos Manivel, M.D., ECA.P. Instructor, Department of Laboratory Medicine and Pathology, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA

Arthur Mashberg, D.D.S. Chief, Oral and Maxillofacial Surgery, Veterans Administration Medical Center, East Orange, New Jersey; Professor of Surgery, UMDNJ, New Jersey Medical School, Newark, New Jersey; Clinical Professor of Dentistry, Fairleigh S. Dick• inson, Jr., College of Dental Medicine, Hackensack, New Jersey, USA

John L. Millns, M.D., EA.CP. Assistant Clinical Professor of Dermatology, University of Florida School of Medicine, Tampa, Florida, USA

Alan M. Samit, D.D.S. Staff Oral and Maxillofacial Surgeon, Veterans Administration Medical Center, East Orange, New Jersey, USA

Robert A. Schwartz, M.D., M.P.H., EA.CP. Associate Professor and Chairman of Dermatology, UMDNJ-New Jersey Medi• cal School; Dermatologist-in-Chief, UMDNJ University Hospital, Founding Program Director, Dermatology Residency Training Program, New Jersey Medi• cal School, Newark, New Jersey, USA

Chester Sidell, M.D. Former Assistant Professor of Dermatology, University of Southern California School of Medicine, Los Angeles, California, USA

James R. Trimble, MD Former Chief of Dermatology and Dermatologic Surgery, Methodist Hospital, Jacksonville, Florida, USA

James W. Trimble, M.D. Clinical Assistant Professor of Dermatology, University of Florida School of Medicine; Chief, Dermatologic and Mohs Surgery, University Hospital, Jack• sonville, Florida, USA

Mark R. Wick, M.D., ECA.P. Associate Professor of Laboratory Medicine and Pathology, University of Min• nesota School of Medicine, Minneapolis, Minnesota, USA

Herschel S. Zackheim, M.D. Clinical Professor of Dermatology, University of California San Francisco School of Medicine, San Francisco, California, USA