Skin Cancer
Table of Contents
|
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.
page revision: 76, last edited: 04 Jul 2008 22:09