Skin Layers

2. Skin Layers 1) Epidermis 5 strata Stratum basale Stratum spinosum Stratum granulosum Stratum lucidum Stratum corneum

3. Skin Layers 2) Dermis Connective tissue under the epidermis Contains nerves, blood vessels, glands and hair follicles 2 layers Reticular layer Thick deep layer providing collagen for strength elasticity and pliability Papillary layer Papilla or projections responsible for finger prints

4. Skin Layers 3) Subcutaneous Layer Not part of the skin Function Anchors the skin to deeper structures Insulates and protects Made of Fat (adipose) Loose connective tissue

5. Basal cell carcinoma Basal cell carcinoma Carcinoma arising from the germinating basal cell layer of epithelial cells. Slow growing tumor that rarely metastasizes If left untreated can cause extensive local tissue destruction and slow death

6. Epidemiology Basal cell carcinoma constitutes approximately 80% of nonmelanoma skin cancer Age-standardized yearly rates in the United States have been estimated at up to 407 cases of basal-cell carcinoma per 100,000 white men and 212 cases per 100,000 white women. Rates are higher in elderly men however there is now an increasing trend in younger women

7. Risk Factors Fair, dry skin, blue or green eyes history of sunburning history of cigarette smoking Sun exposure (sun exposure more important in squamous cell CA) Immunosupression previous BCC �10x increased risk� age >60 at first presentation, male

8. Predisposing Conditions X-irradiation (including fluoroscopy) BCC most often arises after irradiation of the head and neck Arsenic ingestion � usually multiple and found on trunk Steroid use and other drugs following organ transplantation

9. Distribution Lower trunk and arms and legs (15%) Occur also in unusual site > axillae, breasts, perianal area, genitalia, palms and sole Within the Head and neck most common sites are nose (25.5%) cheek (16%) periorbital region (14%), scalp (11%) and periauricular region (11%) rare on hands, lower lip and penis When located on hand, more commonly on dorsum � can be mistaken for Paronychia when near nail bed Malignant tumors of the upper lip are almost always basal cell CA and those of the lower lip are usually squamous cell CA

11. Types � all types may show ulceration, with rolled smooth pearly borders Nodular well-defined �rodent ulcer� Usually begin as a small pink �pearly� papule Develop a depression in the centre Rolled edge Overlying telangiectasia

12. Superficial BCC Second most common type of BCC with highest recurrence rates Usually found on the trunk May be multiple Flat red patches

13. Pigmented resembles melanoma

14. Morpheform Type (sclerosing) poorly defined borders high recurrence rates White or waxy Always on face Presents as a spontaneous �scar�

15. Differential Diagnosis squamous cell carcinoma malignant melanoma (pigmented basal cell carcinoma) melanocytic naevi (pigmented) Bowen�s disease (especially superficial basal cell carcinoma) psoriasis (superficial) eczema (superficial) sebaceous hyperplasia molluscum contagiosum

16. Treatment Standard Surgical excision : Safe margin is 3 � 5 mm Mohs Surgery Chemotherapy: 5 fluorouracil Topical cream : imiquimod Cryosurgery : Liquid nitrogen

17. Preferred Treatment Nodular BCC less 1cm diameter in non-high risk area (curettage, cryosurgery, excision) greater than 1cm in non-high risk area (excision, cryosurgery, (for lesions <2cm) Mohs surgery (lesions >2cm) in high risk area (Mohs surgery, excision with frozen section) Superficial BCC shave excision with curettage, curettage and electrodessection , cryosurgery, excision Morpheaform BCC Mohs surgery, excision with frozen section BCC with aggressive growth Mohs surgery, excision with frozen section Recurrent BCC Mohs surgery, excision with frozen section Incompletely excised BCC re-excision and frozen section, Mohs surgery

18. Following up Overall recurrence rate for BCC is around 5% Thus patients are followed up for 2 years � at least 6 monthly However risk of second primary � 5 years after excision 36% patients develop a second primary and 20% develop multiple new BCCs

19. Basal Cell nevus Syndrome (Gorlin�s Syndrome) autosomal dominant typical nevus � red, brown papular and various size 76% transform into BCC Syndrome features: Multiple scattered BCC (face, neck and jaw) jaw cysts skeletal abnormalities (palmer and plantar pits)

20. Xeroderma Pigmentosum First described in 1874 by Hebra and Kaposi. XP is a rare disorder transmitted in an autosomal recessive manner. It is characterized by photosensitivity, pigmentary changes, premature skin aging, and malignant tumor development. These manifestations are due to a cellular hypersensitivity to ultraviolet (UV) radiation resulting from a defect in DNA repair.

21. Epidemiology In the US: 1 case per 250,000 population. Internationally: 1 case per 250,000 population. Mortality/Morbidity: . The mean patient age of skin cancer is 8 years in patients with XP compared to 60 years in the healthy population. Actinic damage occurs between 1 and 2 years of age. Race: Cases of XP are reported in all races. Sex: An equal incidence has been reported in males and females. Age: The disease is usually detected at age 1 or 2 years.

22. Symptoms Areas exposed to the sun such as the face show a reddening of the skin with scaling and freckling. Irregular dark spots may also begin to appear. These skin changes progress the neck and lower legs. In severe cases the trunk may be involved.

23. Treatment There is no cure for XP. The main goal of treatment is to protect oneself from UV exposure and thus prevent the damaging effects it can have on the skin. Yearly testing (through to age 20) for potential neurological problems.

24. Any questions?

25. Cutaneous Squamous Cell Carcinoma Abdulrahman Saleh Alrashed 261015

26. Definition Malignant proliferation of the keratinocytes of the epidermis

27. Types

28. Epidemiology SCC is the second most common form of skin cancer. Incidence: 200,000 cases per year (USA) Sex: M>F usually affects the elderly 2% of SCC metastasize

29. Risk factors UV light exposure Ionizing radiation Immunosuppression Chronic inflammation Scars & chronic wound (Marjolin�s ulcer) Arsenic exposure� Family history

30. Precursor Lesions Bowen disease Erythroplasia of Queyrat Actinic keratosis

31. Bowen�s disease SCC in situ ( premalignant) 3- 11% progress to SCC Associated with arsenic compound and HPV 16 It may occur anywhere on the mucocutaneous surface of the body. presents as a slowly enlarging, erythematous, scaly patch or plaque

32. Erythroplasia of Queyrat SCC in situ arises from the squamous epithelial cells of the glans penis or inner lining of the prepuce seen exclusively in uncircumcised men and represents an in situ form of squamous cell carcinoma

33. Keratoacanthoma Tumor that originates in the pilosebaceous glands Present as rapidly growing smooth firm nodule with central keratin plug Many dermatopathologist will diagnose these lesions as squamous cell carcinoma

34. Clinical presentation head and neck (55 %), dorsum of the hands and forearms (18 %), legs (13 %) Less frequent sites arms (3 %), shoulder or back (4 %), and chest or abdomen (4 %). Genital SCC lesions are rare

35. Invasive SCC Well-differentiated cutaneous SCCs usually appear as indurated or firm papules, plaques, or nodules with hyperkeratosis or ulceration.

36. Invasive SCC Poorly differentiated lesions are usually fleshy, soft, granulomatous papules or nodules, without the keratinization. In addition, poorly-differentiated tumors may have ulcerations, hemorrhage, or areas of necrosis.

37. DDx Actinic keratosis BCC Keratoacanthoma Pyoderma gangrenosum warts

38. Diagnosis The definitive diagnosis of SCC is confirmed by histologic examination of a biopsy or excision specimen

39. TNM

40. Sites of metastases regional lymph nodes Lungs Liver Brain Skin Bone

41. Treatment Cryotherapy Electrosurgery (ie, curettage and electrodesiccation) Topical treatment (5-fluorouracil, photodynamic therapy, or imiquimod) Radiation therapy Surgical excision Mohs surgery

42. High risk lesions

43. Low-risk lesions Cutaneous SCCs that are small, do not invade into the subcutaneous tissue, arise from actinic keratoses or as a consequence of sun exposure, and do not have any of other high-risk features have a low frequency of recurrence and regional or distant metastases. Excisional surgery, cryotherapy, electrosurgery, superficial RT, and topical chemotherapy are all highly effective in properly selected patients

44. High-risk lesions Aggressive treatment is required for high-risk lesions to maximize the likelihood of cure with the initial treatment. Surgery, using either conventional excision or the Mohs technique, is the primary approach in this setting. Postoperative RT is an important supplement when regional lymphatic spread is present or local excision cannot completely remove the primary lesion.

45. Surgical Excision Well differentiated tumors 2 cm in diameter or less ? a margin of 5mm around the clinical border of the lesion has been recommended to achieve 95% clearance Tumors in high risk areas or larger than 2 cm ? 10 mm margin is recommended

46. Mohs surgery performed in the outpatient setting under local anesthesia and is generally well-tolerated. The tumor, together with a small rim of clinically normal-appearing tissue, is excised at an oblique angle in a series of stages, and microscopically evaluated by the surgeon. Histologic findings are then precisely correlated with the lesion through the use of a diagram (Mohs map) drawn by the surgeon following the stepwise excision of the tumor. If microscopic margins are positive, their precise locations are noted on the Mohs map and another specimen is taken only from the involved areas. This tissue is evaluated in a similar fashion, and the process is repeated until all margins are negative for residual tumor.

48. Advantages Offers highest rates of cure for patients with high risk primary or recurrent SCC technique of horizontal frozen sectioning provides a view of 100% of peripheral and deep margins

49. Prognosis The overall prognosis for patients with a primary cutaneous SCC is excellent, with an overall five-year cure rate of greater than 90 percent .In the United States, the estimated yearly disease-specific mortality rate is about 1 percent.

50. Prognostic factors Invasion Histological grade Site Etiology immunosupression

51. Follow up Follow up every 3-6 months for the first two years, then yearly thereafter. inspection of the treated area for visible signs of recurrence and palpation of the skin and adjacent structures (including lymph nodes) to evaluate for possible deeper recurrence or regional metastasis

52. Summary SCC is a common skin malignancy The primary risk factor for cutaneous SCC is UV light exposure If treated early and properly, the cure rate for SCC is greater than 90 percent SCC metastases are seen in 2%

53. Any Question?