Transcript Chapter 111: Cutaneous Neoplasms

Chapter 111:
Cutaneous Neoplasms
Lisa Spiguel, MD
True or False: Cutaneous melanomas
account for 4 % of skin cancer diagnosis,
but 75% of skin cancer deaths
Which of the following below is NOT a
risk factor for cutaneous melanoma?
1. UVA exposure
2. UVB exposure
3. Tanning beds
4. Seborrheic Keratosis
5. All of the above
What is the most common site of distant
metastasis in melanoma?
1. Liver
2. Small Bowel
3. Brain
4. Lung
What is the most common type of melanoma?
1. Lentigo maligna
2. Superficial spreading
3. Nodular
4. Acral lentiginous
What is the most indolent type of
melanoma?
1. Lentigo maligna
2. Superficial spreading
3. Nodular
4. Acral lentiginous
What is the most aggressive type of
melanoma?
1. Lentigo maligna
2. Superficial spreading
3. Nodular
4. Acral lentiginous
Which type of melanoma most
commonly arises from a pre-existing
nevus?
1. Lentigo maligna
2. Superficial spreading
3. Nodular
4. Acral lentiginous
Which of the following is NOT an
indication for sentinel lymph node
biopsy in a patient with a thin
melanoma?
1. Presence of ulceration
2. Presence of regression
3. Invasion into reticular dermis
4. Increased mitotic rate
5. All of the above are indications
for sentinel lymph node biopsy
A patient presents to your office with a
lesion suspicious for a melanoma. You
perform a biopsy that demonstrates a
1.25 mm thick melanoma. What margin
is necessary during surgical excision?
1. 0.5 cm
2. 1 cm
3. 2 cm
4. 3 cm
A 55 you right-handed male is diagnosed
with a subungual melanoma of his left
index finger. The appropriate surgical
resection is?
1. Amputation at the DIP joint
2. Amputation at the PIP joint
3. Amputation at the MCP joint
4. Excision with negative microscopic
margins
Which of the following below is NOT a
immunostain for melanoma?
1. S-100
2. Melan-A
3. HMB-45
4. Melatonin
Which of the following therapies have
been approved by the FDA for the
treatment of Stage IV melanoma?
1. IL-2
2. IFN α
3. IFN δ
4. Traztuzamab
Which of the below adjuvant therapies is
used for Stage IIB or Stage III melanoma?
1. IL-2
2. IFN α
3. IFN δ
4. Traztuzamab
Best treatment of a single in-transit
melanoma of the right lower extremity
involves which of the following below?
1. Isolated limb perfusion
2. Systemic chemotherapy with
Melphalan
3. Surgical excision
4. None of the above
I solated limb perfusion involves
hyperthermic administration to the limb
involved using which chemotherapeutic
agent?
1. IL-2
2. IFN α
3. Cisplatin
4. Melphalan
Skin Cancer
• 1.4 million new cases of skin cancer annual in
US
• Nonmelanoma skin cancer types: Basal cell
and Squamous cell (4:1)
• Melanoma accounts for 4%, but up to 75% of
skin cancer deaths
• Incidence of melanoma is on the rise
Melanoma
• Risk Factors:
– UVA/UVB exposure: sun exposure, occupation, history of
sunburns, tanning beds
– Fair complexion (inversely related to skin pigmentation)
– Atypical Nevi
– Dysplastic nevus syndrome: > 100 , one mole > 8 cm, 1 mole w/
atypical histology
• Genetic Causes:
– Mutation in CDKN2A (p16)
– MC1R gene mutation
– FAMM (Familial Atypical Multiple Mole Melanoma syndrome):
AD
– Xeroderma Pigmentosa: AR
– Congenital Melanocytic Nevi (CMN)
Congenital Melanocytic Nevi
• Appear at birth or within 1st 6 months of infancy
• Incidence is 1-6%
• Classification/ Risk of Malignancy:
– Small < 1.5 cm
– Medium 1.5-19.9 cm
– Giant > 20 cm/ 5-20% risk, 70% dx prior to age 10
• Risk of Neurocutaneous melanocytosis:
– Occurs with Giant CMN on posterior axis
– Benign ormalignant leptomeningeal tumors
– Dx: MRI
Melanoma Characteristics
– A (Asymmetry) one portion of
the mole does not match the
other
– B (Border) edges are irregular,
notched, or blurred
– C (Color) different shades of
black or brown, patchy colors
– D (Diameter) spot is 6
millimeters across, or growing
larger
Melanoma Subtypes
• Lentigo maligna melanoma
– 10-15%
– Chronically sun exposed areas
• Superficial spreading melanoma
– 70%
– Typically arises in pre-existing nevus
• Nodular melanoma
– 15%
– Most aggressive form due to rapid growth
• Acral Lentiginous Melanoma
– Subungual melanoma
– 2-8% in Caucasians, 35-60% in African Americans
– Worse prognosis is related to delayed detection not
aggressiveness of tumor
• Others:
– Mucosal, Anal, Vulvovaginal
Staging
• Breslow Staging:
– Classifies tumor according to
thickness in millimeters
– Inverse correlation between
thickness and survival
• Clark level of Invasion:
– Classifies based on level of
invasion into the histologic
layer of the skin
– I-V
• Independent Prognostic
Factors:
– Tumor stage, ulceration,
nodal status, distant
metastasis
TNM
Stage 0: in situ
Stage I: Local Disease
Stage II: Local Disease
Stage III: Regional nodal disease, in-transit, or satellite metastasis
Stage IV: Distant Disease
Evaluation
• Clinical Exam: ABCD
• Biopsy:
– Full thickness biopsy to the adipose tissue:
• Punch biopsy if > 2 cm lesion
• Excisional biopsy if < 2 cm lesion with 1-2 mm margins
• Never superficial shave biopsy
Treatment
•
Surgical Excision: (Margins) - Fascia
–
–
–
–
•
Melanoma in situ: 0.5 cm
Thin Melanoma (≤1 mm): 1 cm
Intermediate Melanoma (1-4mm): 2 cm
Thick Melanoma (>4mm): 2 cm
Treatment of In-transit disease:
–
–
–
Surgical excision when the feasible and number of lesions is small
Ablative therapes
Isolated limb perfusion
•
•
•
•
Indications for Sentinel Lymph Node Biopsy:
–
–
All melanomas > 1 mm (Intermediate and Thick)
Thin Melanomas/ or 0.75-1mm, if:
•
•
•
•
•
Delivery of 15-25times higher than systemic doses
Melphalan chemotherapy delivered at hyperthermic temperatures 38 degree C
80-90 % response rates with complete response rates 40-60%
Ulceration
Regression
Into reticular dermis
Increased Mitotic Rate: > 1mitosis/mm2
Indications for Axillary Node dissection
–
–
Clinically positive nodes
+ Sentinel Lymph Node
•
MSLT II: + SLN  ALND vs Serial US
Treatment
• Role for Adjuvant Therapy:
– IFN-α2b
– RCT: Thick melanomas or + Nodal disease:
• Increased median overall survival by 1 year
• 24% improvement in 5 yr survival
• Indications for Systemic Staging: (Serum LDH, MRI
Head, CT C/A/P or PET/CT)
– Clinically positive nodes (FNA +)
– Pathologically positive nodes
• Systemic Therapy in Stage IV disease:
– IL-2
• Cytokine secreted by Thelper cells
True or False: The most common
non-melanoma skin cancer is
squamous cell carcinoma.
A 75 yo old man presents with the lesion
imaged below. What is the margin need
during excision?
1. 0.5 cm
2. 2 cm
3. 4 cm
4. 6 cm
Immunohistochemical staining is
positive for which of the below for
merkel cell tumors?
1. S-100
2. Melanin
3. cKit
4. CK-20
Which of the following below spreads via
lymphatic flow?
1. Merkel cell carcinoma
2. Squamous cell carcinoma
3. Basal cell carcinoma
4. 1 & 2
5. All of the above
Which of the follow below does NOT
require a 2 cm margin for the treatment of
squamous cell carcinomas?
1. Squamous cell carcinoma of the
neck
2. Squamous cell associated with
Marjolin’s ulcer
3. Penile squamous cell carcinoma
4. Vulvar squamous cell carcinoma
A 68 yo male presents to your clinic with
the lesion below on his right upper arm.
What margin of excision is needed for
treatment of this lesion?
1. 0.5 cm
2. 1 cm
3. 2 cm
4. 4 cm
A 38 yo male is diagnosed with 8 mm
penile squamous cancer at the tip of
his penis. What is the treatment of
choice?
1. Total penectomy
2. Partial penectomy
3. Exicsion with negative
microscopic margins
4. None of the above
Ture or False: Moh’s surgery can be
used for both basal cell and squamous
cell carcinomas.
A 75 yo man presents to your office with a
new lesion on his face. Your exam
demonstrates the lesion below. What is
your diagnosis?
1. Squamous cell cardcinoma
2. Merkel cell carcinoma
3. Basal cell carcinoma
4. Melanoma
True or False: Morpheaform basal cell
carcinoma has the worst prognosis.
A 75 yo man is diagnosed with a basal cell
carcinoma of the right neck. What margin
of excision is needed for treatment?
1. 0.5 cm
2. 1.0 cm
3. 1.5 cm
4. 2.0 cm
NonMelanoma Skin Cancers
• Basal Cell
– Four times more common than squamous cell
– Risk Factors
•
•
•
•
Same as melanoma
UVA/UVB exposure, higher risk in fair individuals
Radiation
Gorlin Syndrome: AD, multiple BCC, palmoplantar pits, jaw cysts,
frontal bossing, hypertelorism
• Squamous Cell
– Risk Factors: Sun exposure, Chemicals : Arsenic,
hydrocarbons (coal tars, soot, asphalt), Tobacco, HPV,
Radiation
Basal Cell Carcinoma
• Exam:
– Pearly papules
– Nodules with telangiectases
– Central ulceration with “rolled” borders
• Pathology:
– Isolated areas of basaloid tumor islands arising from
epidermis with peripheral palisading nuclei and stromal
retraction
• Surgical Excision:
– 0.3-0.5 mm margin
• Worst Diagnosis: Morpheaform, sclerosing, or fibrosing
Squamous Cell
•
•
•
•
2nd most common form of skin cancer
Derived from epithelial keratinocyte
Most common skin cancer in immunocompromised patients/transplant patients
Precursor lesions:
– Actinic keratoses
– Bowen disease (in situ SCC)
•
Exam:
– Nonhealing sore with ulceration and inflammatory pink borders
– Erythematous papulonodule with overlying keratotic crust or ulceration
•
Pathology:
– Malignant degeneration of epithelial cells with differentiation toward keratin formation
•
Surgical Excision:
– 1 cm margin
– 2 cm margin for Marjolin’s ulcer, penile and vulvar squamous cell carcinomas
•
Prognosis:
– Metastasis to regoinal LN
– Poor prognosis with 10 year survival < 20%
– Distant disease 10 year survival < 10%
Merkel Cell Carcinoma
• Primary cutaneous neuroendocrine cancer
• Highly aggressive with high mortality
• Risk Factors:
– UVA/UVB, immunosuppression,
– Merkel cell polyovirus
• Exam:
– New-onset growing red or purple dome-shaped subcutaenous nodule
• Pathology:
– Blue cell tumor with positive immunohistochemical staining for CK-20
– Absent staining of thyroid transcription factor-1 TTF-1
• Treatment:
–
–
–
–
–
Wide local excision with 1-2 cm margins
Adjuvant XRT for Stage II disease
SLNB and staining for CK-20
ALND or regional radiation therapy if SLNB +
Adjuvant chemotherapy for Stage IV disease