Skin cancer DR ARIF ABID Basal Cell Carcinoma

Skin cancer DR. ARIF ABID

Basal Cell Carcinoma Description: Basal cell carcinoma is a skin cancer derived from the basal layer of keratinocytes of the epidermis. It is the most common cutancous malignancy in humans. lf left untreated, basal cell carcinomas will locally invade surrounding skin, destroying underlying tissue. Rarely basal cell carcinomas can metastasize.

History Basal cell carcinoma may occur at any age but is more common in later life. The highest incidence occurs in people with Caucasian or fair skin types I and II It is less common in Hispanic and Asian skin, and is rare in African- Americans. Cumulative ultraviolet light exposure is the major risk factor in developing basal cell carcinoma. Tumors occur most commonly on the sun-exposed skin of the face, scalp, ears, and neck, and less often on the trunk and extremities. There are several clinical variants of basal cell carcinoma: nodular basal cell carcinoma, pigmented basal cell carcinoma, superficial basal cell carcinoma micronodular basal cell carcinoma, and morpheaform and sclerosing basal cell carcinomas. Each type varies in clinical appearance, histology and aggressiveness

Skin Findings In general, basal cell carcinomas are pink violaceous or pearly sometimes They papules or nodul may have a smooth surface with overlying telangiectasias. The papule or nodule enlarges slowly, flattens centrally, or may develop a raised, rolled border. Tumors frequently bleed, become erosive crusted and ulcerate in the center Basal cell carcinomas may contain melanin that appears speckled brown, black, or blue in color. Curettage demonstrates the characteristically soft texture of the tumor as compared to the surrounding normal skin.

Nodular Basal Cell Carcinoma The lesion begins as a pearly white o pink, dome shaped pa or nodule with telangiectasia. The center frequently ulcerates and bleeds and subsequently accumulate hemorrhagic crust and scale.

Pigmented Basal Cell Carcinoma This is the clinical equivalent to nodul basal cell carcinoma, with the addition speckled melanin pigment within. The pigment may be sparse or diffuse, and resemble malignant melanoma. The natural history and aggressiveness the tumor is similar to a non-pigmente basal cell carcinoma. A smooth pearly nodule with an diffuse gray pigmentation, which is characteristi of a pigmented basal cell carcinoma. Lesions suspected of being a pigmented basal cell carcinoma should be biopsied to ensure they ar not melanoma.

Basal Cell Carcinoma superficial This is the thinnest and the least aggressive form of basal cell carcinoma These lesions are typically multiple and appear earlier in life, compared to nodular basal cell carcinoma. This is found more commonly on the trunk and extremities compared to nodular basal cell carcinoma. The lesions are flatter, sometimes atrophic and not as deeply invasive as t lesions of nodular basal cell carcinoma

The borders are less distinct but have the pearly pink quality. Stretching the skin may accentuate the raised border he tumor spreads peripherally, Sometimes for several centimeters, and invades only after considerable time. The circumscribed, round to oval, red, scaling plaques may be confused with: eczema psoriasis extramammary Paget's disease Bowen's disease (squamous cell carcinoma in situ)

Micromodular Basal Cell Carcinoma Micromodular basal cell carcinoma resembles nodular basal cell carcinoma clinically, but microscopically there are islands of tumor cells extending beyond the clinical margins. Because this histologic variant extends beyond the suspected clinical borders, recurs more frequently after traditional treatment.

Morpheaform and sclerosing Basal Cell Carcinomas Morpheaform and sclerosing basal c carcinomas are the most subtle and least common variants of basal cell carcin These types of basal cell are also the most difficult to eradicate Lesions resemble scar tissue clinically and may appear pale white to yellow, and waxy on palpation. Because of the innocuous appearance of these variants, biopsy and diagnosis are often delayed. The margins are indistinct, and tumor cells may extend more than 7 mm from the clinically apparent border. Thus, unlike the nodular variant, tumors are more likely to recur after narrow excision. Both the morpheaform and sclerosing forms are more aggressive, tend to recur more often and should be followed more closely.

Tratment Cryotherapy Curettage Electrosurgery Excision Mohs micrographic surgery Radiation therapy Non surgical therapy ( Imoquimod, 5 fu or Flurouracel , photodynamic therapy

squamous cell carcinoma it is an invasive, primary cutaneous malignancy arising from keratinocytes of the skin and mucosal surfaces. commonly found on the face, head neck, or hands of elderly patients lesions may develop from precursor actinic keratoses or may arise de novo.

History squamous cell carcinoma is the socond most common form of skin cancer in the United States it comprises all primary cutaneous malignancies. The lifetime risk of developing a cutaneous squamous cell carcinoma is estimated to be between 5% and 15%, More than 100, 000 new cases of primary cutaneous squamous cell carcinoma are diagnosed in the United States each year Primary cutaneous squamous cell carcinomas usually occur on sun exposed skin from years of actinic damage.

History Nearly 90% of SCC in men and 80% in women occur on the face, head, neck, and hands. the legs Squamous cell carcinoma on occurs more often in women than in men Caucasian patients with fair skin are at greatest risk of squamous cell The majority of squamous cell carcinomas are caused by ultraviolet light exposure, Other extrinsic factors can play a causal role, and include: other forms of radiation, chemicals such as hydrocarbons and arsenic, tobacco, chronic infections such as osteomyelitis, chronic inflammation, burns(Marjolin's ulcer) and human papilloma virus infection.

History… Historically, squamous cell carcinoma has been considered as a low-grade tumor with a metastatic rate of less than 1%. Transplant and other immunocompromised patients develop squamous cell carcinoma much more frequently than the general population and these tumors can be more aggressive and more likely to metastasize. – Conduit spread refers to the perivascular or perineural extension of tumor cells Ultimately the tumors may metastasize, usually via the lymphatics, to local lymph nodes.

Skin Findings As with actinic keratoses, typically occur on sun exposed areas. Tumors are found within a of sun damaged skin with atrophy, and blotchy hyperpigmentation. Early invasive squamous cell carcinoma may have the appearance of a hypertrophic actinic keratosis. The typical lesion has a pink to dull red firm, poorly defined dome-shaped nodule with an adherent yellow-white scale. The untreated lesion becomes larger and more raised, developing into a firm, red nodule with a necrotic crusted center.

Skin Findings Removal of the crust reveals a central cavity filled with necrotic keratin debris sometimes with a foul odor. Multiple lesions may appear on the sun- exposed bald scalp, and in some cases lesions may be too numerous to count. Actinic keratoses are aggregates of atypical keratinocytes contained within the epidermis. At the very least, actinic keratoses represent squamous atypia, if not squamous cell carcinoma in situ.

Course and Prognosis The long-term prognosis for adequately treated, non-metastatic squamous cell carcinoma of the skin is excellent. Such patients are at increased risk of developing additional primary skin malignancies, so periodic follow-up is warranted in all patients. The metastatic rate of squamous cell Th carcinomas arising on sun-exposed skin is now estimated to be between 2% and 6%. The Risk factors for metastasis include the following: Tumor larger than 2. 0 cm in diameter. invasion deeper than 0. 4 cm, or both. Decreased degree of differentiation of tumor cells. Recurrent tumors. Perineural invasion. T Adenoid-producing or mucin-producing variant of squamous cell carcinoma

Laboratory and Testing Skin biopsy and histologic confirmation should be performed for all suspected squamous cell carcinomas.

Treatment Local excision Mohs micrographic surgery Lymphnode bopsy Radiation therapy

Malignant Melanoma, Lentigo Maligna Description Melanoma is an increasingly common malignancy of melanocytes, most often arising in the skin. It is potentially curable with early detection and treatment. Late diagnosis of melanoma carries a poor prognosis.

History Melanoma represents 4% of all cancers in men and 3% of all cancers in women. Currently the most common malignancy in women aged 25 -29 years and second only to breast cancer in women aged 30 -35 years. Incidence of melanoma continues to rise at a faster rate than that of any other human cancer, and the increase in its mortality is second only to that of lung cancer.

Factors that increase one's risk of developing melanoma include: Fair skin(skin types I and II Presence of atypical nevi in both sun-exposed and sun-protected areas. Personal history of melanoma. Family history of atypical nevi or melanoma. History of blistering sunburn Congenital nev

Skin Findings It cannot be over-emphasized that melanomas vary considerably in appearance single color or change is diagnostic. Fortunately, there are clinical clues that increase the index of suspicion and warrant biopsy. 30% of melanomas develop within a pre-existing nevus while the remaining 70% develop de novo. The following well-known guidelines are helpful in deciding which lesions are suspicious for malignant change.

When melanoma develops in a pre existing lesion, there is usually a focal area of color change. It is the distinction in color from the remainder of the lesion, not necessarily the color itself that is the clinical clue. Not one specific color is by itself diagnostic but should raise one's index of suspicion. Slate gray, to black or deep blue indicate melanin pigment deep within the dermis. Pink red may indicate inflammation White may indicate regress or scaring

Major Subtypes of Melanoma Four major clinical subtypes of melanoma are recognized, defined by clinical appearance, progression, anatomic site, and histologic appearance.

Superficial Spreading Melanoma This is the most common subtype, accounting for 70 -80% of all melanomas Of melanomas arising in a pre-existing lesion, most are of superficial spreading type. Slightly more common in females than males, usually affecting Caucasian people. Any cutaneous site but most often on the trunk and extremities Lesions tend to be greater than 6 mm in diameter, flat and asymmetric with varying coloration Lesions appear and tend to spread laterally within the skin over a few years, before nodules develop within the lesion.

Nodular Melanoma These account for roughly 10 -15% of all melanomas m They are equally common in males and females. They affect any cutaneous site, but are more often found on the extremities, Lesions tend to be raised, brown to black, rapidly appearing and rapidly growing papules. They may suggest vascular lesion clinically; they may have focal hemorrhage. Lesions appear and evolve over months and tend to extend vertically in the skin.

Lentigo Maligna and Lentigo Maligna Melanoma These account for about 5 -10% of all melanoma, Lentigo maligna represents in situ (intraepidermal) melanoma. Progression to invasive lentigo maligna melanoma occurs in 5% of patients. They are equally common in males and females, usually in older people. skin, They develop over years or decades on sun-exposed Caucasian skin, most often affecting the sun-exposed face, neck or dorsal arms. Lesions tend to be flat and irregularly outlined. The color is usually brown with some variation in epidermal pigment density. Lesions tend to look mottled or washed out and may contain areas or normal pigmentation.

Acral Lentiginous Melanoma This accounts for 7% of all melanomas. Acral lentiginous melanoma is more common in males than females, and usually occurs in older people. It occurs primarily on the hands and feet, including nails of people with darker skin types IV-VI. Similar lesions also occur on the modified skin around the mouth, anus and genitalia. This is the most common form of melanoma in the skin of Asian and Black people, accounting for more than half of melanomas in these groups. It is the least common form of melanoma in Caucasian people. Other than location, the lesion is similar in appearance to lentigo maligna and lentigo maligna melanoma a flat, slowly expanding macule with a fairly uniform, mottled coloration. It appears and evolves over years.

Amelanotic melanoma is a descriptive term for a non-pigmented melanoma; any subtype may be amelanotic. 2% of all melanomas are amelanotic. Biopsy and diagnosis are often delayed. Malignant cells produce little(if any) melanin pigment. The lesion is an innocent-appearing, enlarging, pink-red papule-like an insect bite.

Course and Prognosis In general, the thinner the melanoma, the better the prognosis Localized disease has a far better prognosis than metastatic disease. Female patients and younger patients tend to have a more favorable prognosis. A melanoma on an extremity has a more favorable prognosis than a melanoma on the trunk, head or neck. Melanoma on the scalp has a worse prognosis than melanoma elsewhere on the head or neck

Treatment Surgical excision Interferon