SKIN CANCER CRASH COURSE: RECOGNITION AND MANAGEMENT OF NONMELANOMA SKIN CANCER VICTOR NEEL, MD, PHD DIRECTOR, DERMATOLOGIC SURGERY, MGH
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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 Neurofibroma
sebaceous adenoma
Epitheliod hemangioendothelioma Masson tumor Neurothekeoma
sebaceoma
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 Malignant fibrous histiocytoma
Poroma
Trichoepithelioma
Porocarcinoma
Nodular hidradenoma
Pilar sheath acanthoma fat smooth muscle
Tricholemmoma Lipoma
Syringoma Leiomyoma
Trichofolliculoma angiolipoma
Chondroid syringoma Leiomyosarcoma
Pilomatricoma Spindle cell lipoma
Digital papillary adenocarcinoma angioleiomyoma
Trichoblastoma liposarcoma
Extramammarary Paget’s
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 $$ spentBasal Cell Carcinoma
Biology
• very indolent growth – perhaps decades until
clinically apparent
• rarely metastatic (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 extremitiesBCC 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, scarSquamous 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
• ChestDiffuse 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 SCCTime to get the derm surgeon
on the phoneSquamous 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 BCCIncidence Ratios of Skin Cancer
in Transplant Recipients
• Squamous cell 100-fold increase
carcinoma
• Basal cell carcinoma 10-fold increase
• Melanoma 3.4-fold increaseMortality 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 evaluationSurgical Emergencies
in Dermatology
• SCC in immunosuppressed population
– Iatrogenic (organ transplant, anti-inflammatory states)
– CLL or other leukemias/marrow failures
AML – 80% blast, 0%PMNsSuspected 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, scarLess 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 consentBiopsy 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!
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