Non-Melanoma Dermpath Ron Rapini MD Chairman, Dept Dermatology Univ Texas Medical School at Houston MD Anderson Cancer Center

Conflict of Pearly, interest translucent, statement: telangiectatic, I have no stock in NODULE of grocery stores that basal cell sell Rapini carcinoma, the No other most common conflicts malignancy of man

Ulcerated basal cell carcinoma with rolled-up pearly edge

1 BCC BCE • The most primitive adnexal tumor? • Please don’t call it basal cell • Pluripotential basaloid cells EPITHELIOMA (literature • Differentiation toward sweat ducts, of the ancients) follicles, sebaceous glands common and does not usually • Carcinoma BCC preferred change prognosis

Most important types of BCC BCC • Nodular •Pigmented • Superficial (“multicentric”) • Sclerosing (morpheaform) • Basosquamous (metatypical) • Many other less important variants

Toluidine Pigmented basal cell carcinoma blue with Mohs surgery: purple mucin

2 Pigmented BCC: “passenger melanocytes”

Superficial multifocal BCC not really multifocal

Infiltrating, Infiltrating BCC sclerosing, or morpheaform? • Definition depends upon the user • Synonym for sclerosing or morpheaform? • Or any deeply invasive BCC?

Mixed nodular BCC main features and sclerosing • Basaloid tumor cells • Cytologic atypia, mitoses, necrosis • Peripheral palisading • Stromal retraction • Mucin, stromal changes • Inflammatory reaction (“smart bombs”)

3 Micronodular BCC Micronodular BCC • In vogue - mainly based upon one paper • Defined as aggregates less than 0.15 mm in Hendrix&Parlette Arch Dermatol 1996 diameter • Small nodules less than 0.15 mm • Supposed to be more aggressive but overrated in my opinion diameter • ANY BCC can be aggressive or non- • Up to 15% of BCCs? aggressive • Less stromal retraction • Nodular BCC can go into bone • Sclerosing BCC can be puny and no big deal

Nodular BCC with poor palisading Micronodular in bone

Margin evaluation – scan with LOW power – 2x Black sheep and white sheep • Need special condenser to get 2x – more expensive but worth it • Basal cell CA vs adnexal • Get in your blimp and learn to fly over the • Ugly duckling sign (sort of like sections scanning for dysplastic nevi • Then hone in on higher power on things suspicious clinically) • Back and forth from low to high • Look for the bluish aggregates • Find tumor first, then note the ink, THEN that don’t belong correlate with map

4 Mohs Mohs margin: margin: find the find the black black sheep sheep (toluidine blue)

More types of BCC - the world according to the splitters • Cystic, adenoid • Clear cell • Fibroepithelioma of Pinkus • Pleomorphic (giant atypical cells) • Granular cell • Adamantinoid • Keratotic (infundibulocystic, follicular) • BCC with sebaceous differentiation

BCC vs adnexa • Deeper levels • Cytologic atypia, mitoses, necrosis • Peripheral palisading, stromal retraction • Mucinous stroma • Inflammatory reaction (“smart bombs”) • shafts, trichohyalin •Lumina • Papillary mesenchymal bodies and follicular layers

5 Follicular (proliferative) BCC

Other situations resembling BCC • Inflammatory cell aggregates (may resemble BCC or mean that BCC is near) - judgment whether to take another layer • Tangential adnexa • Tangential • Prominent blood vessels or endothelial Inflammatory cell strands aggregate

BEST special stain • Deeper levels!

6 = AK • Very common pre-cancer • Rough ill-defined scaly spots • Only 1 out of 100 become cancer • Freeze with liquid nitrogen or scrape them off

Actinic keratosis = AK Actinic keratosis = AK • Trying to eradicate totally is like • Total 0.6% progressed to SCC at 1 playing “whack a mole” so goal is to year; 2.6% at 4 years, but they counted eradicate most significant areas SCC-in situ (25% of the cases). • But studies do show eradicating AKs • Total 0.5% progressed to BCC in 1 decreases incidence of year; 1.6% to BCC at 4 years. Older study in Lancet 1988;8589:795 found 0.075% progression to skin cancer.

Actinic keratosis Rx • Freeze with liquid nitrogen or curette them off

Actinic cheilitis

7 Actinic keratosis mythology

• Dogma: AKs spare the follicles • And Bowen’s (SCC in situ) regularly goes down the follicles The truth: AKs CAN extend down follicles: “follicular AKs” – reason for liquid nitrogen failure Actinic keratosis – usually spares follicle

Keratinocytic intraepithelial Bowen’s disease (squamous neoplasia = KIN 1, 2, 3 cell carcinoma in situ) • Analogous to CIN, PIN, VIN 1,2,3 • Can resemble or eczema • Really in SKIN with most popular • Resembles superficial BCC system, we don’t have a “2”: • Not an indication for routine Mohs per AK = KIN-1 Medicare policy in most states SCC in situ (Bowen’s) = KIN-3

8 Well- differentiated Basal cell is BLUE – easier to find SCC

• Squamous cell is PINK (so it can hide more easily in the pink DERMIS)

Poorly differentiated SCC

Acantholyic or pseudoglandular SCC

9 High risk squamous cell carcinoma • Large size (> 2 cm) or depth (> 1 cm) • Poorly differentiated, spindle cell • Perineural invasion • Recurrent • Scar, burn, osteomyelitis, post-radiation • Immunosuppression (CLL, drugs ) • Pseudoglandular (acantholytic) ? • Location on lip, ear, temple ?

10 Where to start? Where are the invasive SCCs and which are just Aks?

Keratoacanthomas usually are squamous cell carcinomas • Exception: Multiple KA syndromes • Most important criterion: tendency toward spontaneous resolution – not often seen! • Rapid growth: not always present, and can occur with SCC too! • -filled crater – not specific • If lots of atypia, never call it KA! • Eosinophils, more with KA, per Dr Ackerman

Keratoacanthoma (a Keratoacanthoma well-differentiated SCC in most cases) • Dr Goltz: If margin involved, never called it KA • Lawsuits over KA that did bad things • “Squamous cell carcinoma (KA-type)”

11 Basosquamous cell carcinoma (metatypical BCC) • Features of both SCC and BCC • Probably has intermediate prognosis • Use the term sparingly • Some cases are a “collision” • BCCs will keratinize under ulcers and those are just BCCs – not true basosquamous Basosquamous carcinoma

Perineural invasion Verrucous carcinoma • ?10-20% of SCCs – over or underdiagnosed? • Pale and glassy with minimal atypia • Real examples have tumor tracking down • Pushing border rather than infiltrative nerve – not just innocent bystander nerve • Most common if tumor recurrent or > 2 cm • Mainly is a huge wart (HPV) • 40% of pts have pain, dysesthesia, nerve • Does not metastasize palsy • Epithelioma cuniculatum - sole • S-100 can find nerve • Buschke-Lowenstein tumor of genitals • 5 year local control only 55% (Head Neck Surg 25:1027, 2003) • Oral florid papillomatosis of mouth

Verrucous carcinoma resembles giant wart, even with koilocytes

Verrucous carcinoma

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