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Skin Caner
Fernando Vega, M.D. 1
Skin Cancer
Fernando Vega, MDSeattle Healing Arts
Precancerous lesions
Clinical characteristics
Precancerous lesionsCommon skin cancers
Precancerous skin lesionsActinic keratosesActinic keratoses
Dysplastic melanocytic nevi
ACTINIC KERATOSISCommon sun-induced premalignant neoplasm of the epidermis that occurs primarily on exposed skin
Consequence of cumulative qlong-term sun exposure
Prevalence ↑with ↑age
Men > women
Also genetic factors - ↑in fair skin and in genetic syndromes eg xeroderma pigmentosum
NATURAL HISTORY
Some lesions (10%) spontaneously regress
Some (majority) remain unchangedSome (majority) remain unchanged
Others (1-10%) progress and develop into SCC – risk increased with continued sun exposure or concurrent immunosuppression
CLINICAL FEATURESEarliest evidence is a tiny red telangiectatic spot
Then dry, rough and adherent scale
Ski l d/ d/ ll / bSkin coloured/ red/ yellow/ brown
Usually multiple
Lesions on hands and forearms tend to be thicker
Actinic change on lips=actinic chelitis
Associated with other signs of sun damage – solar elastosis, wrinkled skin, solar lentigines
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Skin Caner
Fernando Vega, M.D. 2
Actinic keratoses Actinic keratoses
Actinic keratoses and SCC Actinic keratoses and SCC
Actinic keratoses and BCC Actinic keratoses
10% risk of malignant transformation
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Skin Caner
Fernando Vega, M.D. 3
Hypertrophic AK’s Actinic cheilitis
Liquid nitrogen cryotherapy
Topical therapies
Treatment of AK’s
5-FU (Efudex)
Imiquimod (Aldara)
Curettage for hypertrophic lesions
Residual hypopigmentation
Liquid nitrogenCryotherapy
Blister formation
Topical therapiesEfudex or Aldara
* 3-5 times per week* 6-8 weeks
Dysplastic nevi
•Precursors for melanoma•When to biopsy
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Skin Caner
Fernando Vega, M.D. 4
Biologic Events and Molecular Changes in the Progression of Melanoma
Miller A and Mihm M. N Engl J Med 2006;355:51-65
Clinical Images of Pigmented Lesions
Tsao H et al. N Engl J Med 2004;351:998-1012
Non-melanoma skin cancers
Basal cell carcinoma
Squamous cell carcinomaSquamous cell carcinoma
Keratoacanthoma
Risk factors for development of BCC and SCC
Fair skin (Fitzpatrick’s types I-III)Blue eyesRed hair
Family historyy yGenetic syndromes
Chronic sun exposure
Old age
Arsenic, tar
Basal cell carcinoma
BCC- clinical types
Nodular
SuperficialSuperficial
Morpheaform
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Skin Caner
Fernando Vega, M.D. 5
Nodular BCCChronic lesion
Easy bleeding
Pearly border
Surface telangiectasias
Head and neck, trunk, and extremities
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Skin Caner
Fernando Vega, M.D. 6
Superficial BCCErythematous scaly plaque
Slow growth
Asymptomatic
Trunk, extremities, face
Superficial BCC Morpheaform BCC
Resembles scar
Asymptomatic and slow growinggrowing
Ill-defined margins
Marked subclinical extension
BCC is the most frequent skin cancer (80%)
BCC is 4x more frequent than SCC
Metastases are rare (<1% of cases)
Local destruction of tissue
Treatment of BCCCurettage electrodessication (ED/C)
Surgical excisionTraditional
95% Cure Rate
Mohs surgery
Radiation therapy
Topical therapyimiquimod
50-75% Cure Rate
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Skin Caner
Fernando Vega, M.D. 7
Squamous cell carcinoma
SCC types
In-situBowen’s disease
f QErythroplasia of QueyratInvasive SCCKeratoacanthoma
Bowen’s disease
In-situ SCC
Arsenic HPV 16Arsenic, HPV 16, radiation
Invasive SCC
Erythematous nodule
Indurated lesion
Sun-exposed skinMen > women
Slow growth
Invasive SCC Keratoacanthoma Low grade SCC
Rapid growth over weeks
Trauma, sun exposure, HPV 11 and 16
May progress to invasive SCC
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Skin Caner
Fernando Vega, M.D. 8
SCC is locally invasive and destructive
Metastases in 1-3% of casescases
To lymph nodes50-73% survival
Distant sites (lungs)Incurable
Malignant Melanoma
Risk factorsFair skin, red hair, and blue eyes
Intermittent sun exposureSunburnsTanning beds
Freckles and melanocytic nevi
Family history of melanoma
Clinical types- MM
Superficial spreading melanomaSuperficial spreading melanoma
Lentigo maligna melanoma
Acral lentiginous melanomaNodular melanoma
ABCD of Melanoma
Asymmetry
Border irregularityBorder irregularity
Color variegation
Diameter >6mm
Clinical Images of Pigmented Lesions
Tsao H et al. N Engl J Med 2004;351:998-1012
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Skin Caner
Fernando Vega, M.D. 9
Biologic Events and Molecular Changes in the Progression of Melanoma
Miller A and Mihm M. N Engl J Med 2006;355:51-65
Benign Melanocytic Neoplasms
Benign Melanocytic Neoplasms
Benign Melanocytic Neoplasms
Benign Melanocytic Neoplasms
Congenital nevus
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Skin Caner
Fernando Vega, M.D. 10
Malignant Melanoma Malignant MelanomaWith Regression
Malignant MelanomaSupeerficial Spreading
Malignant Melanoma
Malignant MelanomaCiliary Body
Malignant Melanoma
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Skin Caner
Fernando Vega, M.D. 11
Malignant Melanoma Malignant Melanoma
Malignant Melanoma Malignant Melanoma
Malignant Melanoma Malignant Melanoma
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Skin Caner
Fernando Vega, M.D. 12
Malignant Melanoma Malignant Melanoma
Malignant Melanoma Malignant Melanoma
Malignant Melanoma LENTIGO MALIGNA
An in situ pattern of malignant melanomaOften reaches a large size before the diagnosis is madeLentigo → lentigo maligna →lentigo maligna melanoma
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Skin Caner
Fernando Vega, M.D. 13
CLINICAL FEATURESBegins as a flat pigmented lesion
Usually on sun-yexposed skin of head and neck
With time the colour and border become more irregular
MANAGEMENT Surgery – excision with a wide margin
Radiotherapy
Cryotherapy (deviation from rule)
Immiquimod (by report)
Prognostic features- MMGood prognosis
Breslow < 1mm
Intermediate prognosisBreslow 1-4mm
Bad prognosisBreslow >4mm