Skin Cancer

Terms to Know

Formication

an abnormal skin sensation similar to that of insects crawling over or within the skin. Symptoms suggestive of perineural invasion in the setting of skin cancer.

columella

skin between the openings of the nares

Epidemiology

• 1,000,000 cases a year 2005
• 90% are located in the head and neck
• Mortality rate is 0.45% a year.
• Associations include: sun exposure, radiation exposure, burn scar, fistulous tracts, immune disorders (CML), chemical exposure, hereditary factors (xeroderma pigmentosum)

Incidence

• Skin cancer incidence have doubled in last 25 years.
• Skin cancer incidence is rising faster than any other solid tumor

Skins Cancers	Incidence of Skin Cancer
Basal Cell Carcinoma	65%
Squamous Cell Carcinoma	30%
Melanoma	6%

Clinical Description Skin Cancers

Major Skin Cancers

Skins Cancers	Description	Other forms
Basal Cell Carcinoma	pearly border telangiectasia	Morphea-form single, flat, indurated, ill-defined macules Nodular Ulcerated
Merkel Cell	firm painless pink-red nodule or plaque
Melanoma	Asymmetric Irregular border color variations enlargement	Superficial spreading Nodular Lentigo maligna Acral-lentiginous
Squamous Cell Carcinoma	ulcerate with a raised border scaly, crusted plaque

Note on basal cell carcinoma: Sclerosing or mopheaform resembles scleroderma and subclinical extension on average is 7.2 mm. RT borders may be difficult to assess in these cases.

Adnexal carcinoma

Sebaceous Gland carcinoma:

tumors from the sebaceous glands of eyelid regions. Nodal metastases in 20% of cases. Frequent perineural invasion.

Eccrine (Sweat Gland) carcinoma:

Typically in the eyelid, face and scalp. They can grow indolently or rapidly. More aggressive than SCCA or basal cell carcinoma

Apocrine carcinoma:

most commonly from apocrine glands of the axilla. Presents as red-purple, single or multinodular, firm or cystic dermal mass in elderly individuals. Because of its rarity, natural history is not well known.

Kaposi’s Sarcoma:

• hyper proliferation of endothelial derived spindle cells induced by angiogenic and other factors. Associated with AIDS. Single doses of 8-10Gy or fractionated to 25-30Gy. CR of 70%. Can use chemotherapy including actinomycin D, DTIC, doxirubicin, and VP-16.

Mycosis Fungoides

• T cell cutaneous lymphoma

Skin Cancer Syndromes

Basal cell nevus syndrome

• Associated with Basal Cell Carcinoma
• an inherited group of multiple defects involving the skin, nervous system, eyes, endocrine glands, and bones.
• basal cell carcinoma at or about puberty.
• Nervous system involvement may include hydrocephalus
• wide set eyes
• Defects include bones cysts in the upper jaw (maxilla) and lower jaw (mandible)

Epidermodysplasia verruciformis

• Associated with Squamous Cell Carcinoma
• is a rare, lifelong, viral-mediated, autosomal recessive (Sex-linked and autosomal dominant inheritance patterns have also been reported.) hereditary disorder characterized by
• chronic infection with human papillomavirus (HPV).
• Widespread skin eruptions of flat-to-papillomatous, wartlike lesions and reddish-brown pigmented plaques on the trunk, the hands, the upper and lower extremities, and the face are characteristic.

Xeroderma pigmentosum

• Associated with Squamous Cell Carcinoma and Basal Cell Carcinoma

Cell of Origin

Skins Cancers	Orignal Normal Cell
Basal Cell Carcinoma	Basal Layer
Squamous Cell Carcinoma	Epithelial Layer
Merkel Cell	neuroendocrine, reticular and subcutaneous tissues with sparing of epidermis
Melanoma	melanocytes

Work-up

• CT scan used for suspicion for nodal metastases or bone erosion
• MRI scan is used for possible nerve involvement in the H/N region.
• Biopsy lesion but can surgically excise tumor at the same time.
• H/P

Treatment Modalities

• Topical chemotherapy: usually 5-Fu for only superficial epidermal lesions.
• Surgical excision: if positive margin then can re-excise, RT or observe (if basal cell). Curettage with electrosurgery Electrofulguration and curettage
• Cryotherapy: freeze the lesion

Moh's

• Advantages
  • ability to determine if the entire tumor has been removed
  • only minimal excess normal tissue removed.
• Disadvantage
  • multiple injections of anesthesia and can take up to 2 hours.

Radiation therapy

• used for lesions in certain locations where surgery cannot preserve a good cosmetic result
• large lesions
• medically unfit for surgery
• Use orthovoltage or electrons.

Selection of treatment modality

• When selecting the modality, priority list includes 1) cure 2) function 3) cosmesis 4) treatment time 5) cost.
• Must also consider anatomic site, size, invasion into structures, grade, recurrent status, and medical condition of patient.

• Surgery is typically done for favorable lesions as long as there is not a compromise of function or cosmesis.
• RT is typically chosen for lesions larger than 3cm, small lesions near the eyelids/canthus/pinna/nose ala or tip/ upper lip, multiple lesions, alone or in combination with surgery if lesion invades cartilage/bone/nerve.

Results

• T1 95%
• T2 95%
• T3 85%
• T4 50%

Recurrence^[2]

BCC

• recur late (median, 40 months in this report)
• do not spread to regional nodes even upon recurrence, and are rarely fatal even if treatment fails.

SCCA

• recur early (median 5 months in our series)
• have a higher locoregional failure rate
• cause of death in two-thirds of patients when radiotherapy fails.

Bibliography

1. Veness MJ, Palme CE, Morgan GJ. High-risk cutaneous squamous cell carcinoma of the head and neck: results from 266 treated patients with metastatic lymph node disease.

Cancer. 2006 Jun 1;106(11):2389-96. PMID: 16649220

2. Kwan W, Wilson D, Moravan M. Radiotherapy for locally advanced basal cell and squamous cell carcinoma of the skin. Int J Radiat Oncol Biol Phys. 2004;60:406-411.