Skin ca

Skin Cancer and Melanoma
Chapter 24

Skin Cancer: How common is it?
 Skin cancer including melanoma,
basal and squamous cell skin cancers
[nonmelanoma]-most commonly
diagnosed of all types of cancers
 Other: Actinic or solar Keratosis
 Accounts for at least ½ of all cancers
 Melanoma cases have been
increasing over the yearsCopyright © 2014 by Mosby, an imprint of Elsevier Inc.
2

What is Skin Cancer?
 Skin-largest organ in
body
 3 layers & many cells
1. _________________
2. _________________
3. _________________
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
3

Skin Care
Health Promotion
 Avoidance of environmental hazards
 Adequate hygiene and nutrition
 Skin self-examination
4

Skin Care
Environmental Hazards
 Overexposure to sunlight
 Major cause of skin cancer
 Irritants and allergens
 Radiation
 Sleep
 Exercise
 Hygiene
 Nutrition Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
5

Pathophysiology
 Overexposure to
sunlight
 Ultraviolet radiation
(UV) to exposed area
 UV radiation changes
genetic (DNA)
material in cells
6

Wave Lengths of Sun & Effects on
Skin
7

Malignant Skin Neoplasms
 Self-examination
 ABCDE Rule
 Asymmetry
 Border irregularity
 Color change
 Diameter >6 mm
 Evolving in
appearance
8

Risk Factors
 Chronic UV light
exposure
 Fair skin, freckles,
light hair
 Family hx of skin CA
 Exposure to tar and
systemic arsenicals
9

Fitzpatrick Classification of Skin
Type
 Type I (very white or
freckled): Always
burn
 Type II (white):
Usually burn
 Type III (white to
olive): Sometimes
burn
 Type IV (brown):
Rarely burn
 Type V (dark brown):
Very rarely burn
 Type VI (black):
Never burn
10

Nonmelanoma Skin Cancers
 Basal cell or squamous cell-most common
 Actinic or solar keratosis
 Most common etiologic factor: ___________
 Develop in the __________________________
 Sites:
 __________________________
 _________________________________
11

 Actinic keratosis [____________]
 Premalignant skin lesions
 Common chronically sun damaged skin
 Population affected: _____________________
 Small [1-10 mm] macule or papule w/dry, rough
adherent yellow or brown scale
[_________________________]
 Clinical appearance:
 Irregularly shaped, flat or elevated, slightly erythematous
base with indistinct borders; hard keratotic scale or horn
 Distribution:
___________________________________________Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
12

 Actinic Keratosis
 Rx/Prognosis
 Cryosurgery [liquid nitrogen], chemical
peels, laser resurfacing
 Photodynamic therapy followed by
light irradiation
 Chemotherapy agents
 Fluorouracil [5-FU] topical & Imiquimod
[Aladara]Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
13

Nonmelanoma Skin CA
 Basal cell carcinoma [BCC]
 Arises from the basal cell layer of skin
 Population: __________________
 Metastasis is rare
 Risk factors: genetic skin type
disposition and chronic irritation [x-
ray, radiation, scars and some types of
nevi [moles];
 most common: _____________Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
14

Nonmelanoma Skin CA
 Clinical findings: BCC
 Nodular & ulcerative: small, slow
enlarging pearly papule w/central
crater and rolled waxy borders
 Borders semi-translucent or “pearly”
with overlying telangiectasia &
freckles visible on inspection
15

Nonmelanoma Skin CA
 Clinical findings: BCC
 Superficial: erythematous, pearly,
sharply defined, barely elevated
plaques
 Distribution:
 Sun-exposed areas
 ____________________________________
16

Nonmelanoma Skin CA
 Diagnostic: tissue bx-confirms
 Multiple Rx modalities
 Surgical excision, electrodessication,
curettage, cryosurgery, radiation
 Topical or systemic chemotherapy
 5-Fu and imiquimod: superficial lesions
 Vismodegib [Erivedgel]:
 Photodynamic therapy
 Small lesionsCopyright © 2014 by Mosby, an imprint of Elsevier Inc.
17

Basal Cell Carcinoma
18

 Squamous cell carcinoma [SCC]
 Malignant neoplasm of the epidermis
 Aggressive; potential to metastasize;
death if untreated
 Most frequent: __________________
 _____________: formation of lesions on
mouth and lips; ear and external
genitalia [more likely to invade &
spread] Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
19

20

 SCC
 Superficial: thin, scaly, red plaque
w/out invasion into dermis
 Early: firm nodules w/indistinct
borders, scaling and ulceration
 Late: lesion covered w/scale or horn
from keratinization ulceration;
indurated margins
 Distribution:___________________Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
21

 SCC
 Course: Rapid invasion w/mets via
lymphatics
 Tx
 Surgical excision, cryosurgery,
radiation, chemo, electrodessication,
curettage
22

Atypical/Dysplastic Nevus
 Dysplastic nevi (DN):
______________
 Greater than 5 mm
across; irregular borders
 Various shades
 Same ABCD
characteristics as
melanoma
 May be precursor of
malignant melanomaCopyright © 2014 by Mosby, an imprint of Elsevier Inc.
23

 Pigmented CA arising in melanin-producing epidermal
cells
 Irregularly shaped pigmented papule or plaque
w/varied colors: red, white and blue, black, gray or
brown; flat or elevated; eroded or ulcerated
 Highly metastatic; survival depends on early dx &
treatment
 Cause unknown
 Environmental factors
 Genetic factors
 1ST DEGREE relative: parent, sibling
Malignant Melanoma
24

Malignant Melanoma
 Distribution: anywhere on body/ or where
moles or birthmarks are evident
 Commonly found: ________________
_______________________________________
_________________________
 Course
 Horizontal growth pattern followed by vertical growth pattern
 Rapid invasion & mets w/high morbidity/mortality
25

 Risk factors
 Red or blonde hair
 Light-colored eyes; Fair skin that
freckles
 Chronic sun exposure
 Artificial sources of UV radiation
 Family history
 Use of immunosuppressive drugs and
hx of nevi: increase risk
Malignant Melanoma
26

 Diagnosis
 Suspicious, pigmented lesions: NOT
Shave-biopsied, shave-excised,
electrocauterized
 MelaFind
 Tumor thickness
 Breslow measurement:________________
 Clark level:___________________________
Malignant Melanoma
27

Breslow
Breslow measurement of tumor thickness. A,
Thin (0.08 mm) superficial spreading melanoma,
good prognosis. B, Thick nodular melanoma
with lymph node involvement, poor prognosis.
28

Copyright © 2014 by Mosby, an imprint of
Elsevier Inc.
 Collaborative care
 Treatment determined by
 Site of original tumor
 Stage of the cancer
 Patient’s age and general health
 Includes surgical incision and adjuvant therapy
[chemo, biologic therapy [i.e. interferon,
interleukin-2 or radiation]
 Chemo: dacarbazine [DTIC], temozolomide
[Temodar], procarbazine [Matulane], carmustine
[BCNU] and lomustine [CCNU]
 Newer t
Malignant Melanoma
29

Collaborative Care
 Assessment
 H&P
 Family hx of skin CA
 Hx past sx for removal of skin growths
 Recent changes in size, color or sensation of any mole, birthmark,
wart or scar
 Ask about geographical location of residence; occupational and
recreational activities
 Ask if severe skin injury has resulted in a scar
 Examine skin surface for any unusual lesions, moles, warts,
birthmarks and scars & Palpate lesions to determine surface
textue
 Document location, size/color/surface & subjective reports of
tenderness/itching
 Use ABCDE method to evaluateCopyright © 2014 by Mosby, an imprint of Elsevier Inc.
30

Collaborative Care
 Collaborative care
 Treatment determined by
 Site of original tumor
 Stage of the cancer
 Patient’s age and general health
 Includes surgical incision and adjuvant therapy [chemo, biologic
therapy [i.e. interferon, interleukin-2 or radiation]
 Chemo:
 dacarbazine [DTIC], temozolomide [Temodar], procarbazine [Matulane],
carmustine [BCNU] and lomustine [CCNU]
 Newer [metastatic]
 Ipilimumab [Yevoy]- monoclonal AB-locks onto CTL-4
 vemurafenib [Zelboral], dabrafenib [Tafinlar], trametinib
[Mekinist]:gene mutation BRAF V600
31

Collaborative Care
 Topical chemotherapy
 5-fluorouracil [5-Fu] cream
 Multiple actinic keratosis
 Widespread superficial BCC
 As lesions crust,ooze and erode: treated
areas more tender & inflamed
 Unsightly appearance
 Post D/C tx: coop com;resses
 Topical steroidCopyright © 2014 by Mosby, an imprint of Elsevier Inc.
32

 Tumor staging
 O–IV
 Tumor size
 Nodal involvement
 Metastasis
 T-N-M
Malignant Melanoma
33

Elsevier Inc.
Diagnostic and Surgical Therapy
 Electrodesiccation
 Curettage
 Cryosurgery
 Excision—
 Mohs procedure or surgery
 Wide excision
34

Health Promotion & Maintenance
 Avoid or reduce exposure to sun
 Avoiding direct sunlight
 Using sunscreen
 Wear protective clothing [hats]
 TEACH ALL TO AVOID TANNING BEDS & SALONS
 Secondary prevention, early detection-critical-
 Teach to be aware of their skin markings
 Keep total body spot & lesion map
 Monthly total skin self-examination [TSSE]
 Teach ABCDE guide for melanoma
35

Elsevier Inc.
Case Study
 E.N., a 45-year-old white female
with strawberry blonde hair and blue
eyes, works at a garden center.
 She has come to the dermatology
clinic because she noticed that the
mole on her left shoulder has
increased in size and darkened in
color.
Jupiterimages/Comstock/Thinkstock
36

Case Study
 You assess E.N.’s mole and note
that it is 5 mm x 8 mm in diameter,
shaped like a jagged pebble.
 She describes the changes she has
noticed: the color has changed from
brown to black and it has increased
in size and feels bumpy.
37

Case Study
 A shave biopsy is done on E.N.’s
mole.
 Diagnosis of malignant melanoma is
confirmed.
 What factors will determine the next
steps in treatment?
38

Case Study
 E.N. has her mole excised and her
axillary lymph nodes on the right
side are dissected to assess for
metastasis.
 Lymph nodes are negative for cancer
cells.
39

Case Study
 E.N. questions the type of surgery
that was performed and how it was
determined that all of the tumor was
excised.
 What type of surgical procedure was
likely used to excise the mole?
40

Case Study
 Postoperatively, E.N. examines her
shoulder.
 She tearfully expresses concern
regarding the size of the incision and
its location on her shoulder.
41

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