Transcript Malignant Melanoma

Tumors of the Skin:
Benign and Malignant
Dr. Robert Norman, DO, MPH, MBA
Dr. Robert Norman & Associates
Tampa, Florida
PCOMS 2015
Disclosure: I have no financial relationship in regard to the
content of this presentation
Learning Objectives

1.
2.
3.
Gain an understanding of benign and
malignant tumors of the skin as it relates to:
Differentiating between benign and malignant
tumors
Appreciating a basic understanding of the
tumors discussed in the lecture
Knowledge of the basic statistics and
diagnostic tools related to malignant
melanoma
Benign Tumors of the Skin





Seborrheic keratosis
Cherry angioma
Spider angioma
Melanocytic nevus
Halo nevus
Seborrheic Keratosis





Most common benign
epithelial tumor
Hereditary
Start at around age 30
Can be few or multiple
Vary in morphology and
color depending on
location of body
Seborrheic Keratoses: many faces
Cherry Angioma






Very common, bright red
to violaceous domed
papules
Can thrombose and
appear black
Most commonly on the
trunk
Develop around age 30
Can be multiple
Only a cosmetic nuisance
Spider Angioma




Focal telangiectatic
network of dilated
capillaries radiating from
a central arteriole
Most common on face
May be assoc with
hyperestrogenic states, ie.
Pregnancy, OC use
Common in children
Acquired Melanocytic Nevus




One of the most
common lesions in
Caucasians
Most adults have 20
Appear in early
childhood
Gradually involute
around 60
Halo Nevus






Nevus surrounded by a halo of leukoderma or
depigmentation
Immunologic phenomenon via action of
cytotoxic lymphocytes
Nevus will usually disappear in months-years
Skin repigments in months-years
May occur on one or multiple nevi
Possible precursor to vitiligo
Halo Nevi
Halo Nevus?
Malignant Tumors of the Skin



Basal cell carcinoma
Squamous cell carcinoma
Malignant melanoma
Basal Cell Carcinoma




Most common type of
skin cancer
Slow growing
Locally invasive and
destructive but not
metastatic
Usually in sun-exposed
areas in fair-skinned
people
Basal Cell Carcinoma



Typically looks like a
‘pearly’ shiny papule with
overlying telangiectasia
and rolled borders
Center may be ulcerative
Several variants:
superficial, sclerosing,
pigmented
Superficial BCC
Think superficial BCC when
You think you are looking at
Eczema but it does not clear with
Steroids.
Good Rule Of Thumb in
Dermatology

If something does not look or respond like you
think it should, ie. “it looks like eczema but
doesn’t respond to steroids”…you should
always consider a biopsy as your next move
Destructive skin cancers
Actinic Keratosis




Aka. solar keratosis
Seen in sun exposed
areas: face, scalp, ears,
hands, arms
Erythematous, scaly
papule; tender
Can possibly evolve into
SCC if not treated
Squamous Cell Carcinoma



2nd most common type
of skin cancer
Sun exposed areas in
fair-skinned people
Erythematous, keratotic
nodule, may ulcerate
SCC



Can metastasize (3-4%)
Most common skin
cancer in black patients
Can occur in burn scarsMarjolin’s ulcer- met rate
is 20%
SCC Secondary to HPV Infection




HIV +
History of condyloma
Giant condyloma of
Buschke and Lowenstein
HPV types 16,18,31,33,
35 and 45 are liked to
carcinoma
SCC



52 year old woman with
growth on the breast
Biopsy showed SCC
Pt. lost to follow up
SCC

8 year old boy with
history of Xeroderma
Pigmentosum with
multiple SCC’s on the
face and severe actinic
damage
SCC


7 year old with
Xeroderma
Pigmentosum
Multiple actinic keratoses
and SCC’s
Malignant Melanoma


Most deadly form of skin cancer
2% of all cancer deaths are from Melanoma
Melanoma



One person dies of melanoma every hour
One in 55 people will be diagnosed with melanoma
during their lifetime
Melanoma is the most common form of cancer for
young adults 25-29 years old and the second most
common form of cancer for young people 15-29 years
old.
There were 123,590 new case of melanoma in the U.S.
in 2011
Melanoma is the 6th most common cancer in the U.S.
for females and the 5th for males
Oh, by the way…..
DON’T LET THIS ONE
WALK OUT YOUR DOOR….
THIS ONE DOESN’T BOTHER
ME
Lentigo Maligna
Malignant Melanoma


The most common
occurring cancer death in
women between 25 and
29
Usually triggered by the
sun, but also has a strong
genetic component
Melanoma



In the U.S. your chance of getting melanoma in
1940 was 1 in 1500. By 2004, it was 1 in 67.
Now it’s 1/55
If caught in the earliest stages, melanoma is
entirely treatable with a survival rate of nearly
100%. If untreated and allowed to spread, there
is no known treatment or cure.
Early identification is key….
Does this lesion
fit the A,B,C’s
of melanoma?
Another good rule of thumb


If your patient tells you that a mole is changing
and you cannot be 100% certain that it is
benign, you need to biopsy it or document that
you have sent that patient somewhere to have it
biopsied.
Even if a patient isn’t saying that a mole has
changed but that it ‘worries” them, you need to
biopsy it.
Mohs Micrographic Surgery



1.
2.
3.
Developed in 1930’s by Frederick Mohs
Greater than 99% cure rate for many skin
cancers
Recommended for:
Cancers on the face
Large cancers
Recurrent cancers, esp. of face
Tanning Beds=A VERY BAD Idea!






Since the introduction of indoor
tanning in the 1970’s the incidence
of skin cancer has rocketed
Dose of UVA in a tanning bed is
10-100 times greater than what you
get outside
There is no such thing as a safe tan,
unless it comes from a bottle or
spray
Tanning more than 12 times per
year increases the risk of melanoma
by 40-75%
30 million people tan indoors every
year, 2.3 million are teens
Indoor tanning industry has yearly
revenues of 5 billion dollars
UV Camera Reveals Damage
In a 4 year old
A 17 year old
And a 64 year old
Don’t assume that you don’t have any
Damage…it starts a a very young age!
Cutaneous Lesions – SCC & BCC

Skin Cancer is 2.5 X Greater than all other
cancers combined.

4M lesions will have been treated in 2013.

50% Increase by 2020 / 6M

1 in 2 over the age of 60 will have skin
cancer, according to MD Anderson.

1/3 of the US Population will have skin
cancer by 2025.
SRT in Dermatology: Back to the Future

Need for SRT in Dermatology:
 Dramatic increase in NMSC
 Comorbidities, anticoagulation in aging population
 Increased larger tumors in difficult areas such as tibial and
scalp
 Perceived overutilization and decreased reimbursement of
Moh’s
 Need to make sure that Dermatology has access to all
modalities
 SRT offers high cure rate low morbidity and scaring
Tumor Margin, Energy, Fractionation
Guidelines
Treatment margins, energy, and fractionation schemes are selected based upon certain parameters
to insure optimal dosage is delivered across the tumor and marginal volume. Factors influencing
prognosis of NMSC:

Tumor size (increasing size confers higher risk of recurrence)

Tumor site (location of lesions on the central face, especially around the eyes, nose, lips and
ears, are at higher risk of recurrence)

Tumor thickness

Definition of clinical margins (poorly defined lesions are at higher risk of recurrence)

Histological subtype (certain subtypes confer higher risk of recurrence)

Histological features of aggression (perineural and ⁄ or perivascular involvement confers
higher risk of recurrence)

Failure of previous treatment (recurrent lesions are at higher risk of further recurrence)

Immunosuppression (possibly confers increased risk of recurrence)
1.Nonmelanoma skin cancer Current Treatment Options in Oncology
2002, Volume 3, Issue 3, pp 193-203Tri H. Nguyen MD, Diana Quynh-Dao Ho MD
Fractionation

Fractionation is a method of treating cancer,
with ionizing radiation therapy, where the total
dose is divided into several smaller doses over a
period of time.

An optimal fractionation scheme will maximize
the effects of radiation on cancer and minimize
the negative side effects.
Fractionation
Dose /
Fraction
TDF Table Time Dose Fractionation Factors for Three Fractions per Week
TDF # Between 90 and 110 for NSMC Skin Lesions - NUMBER OF FRACTIONS
(cGy)
4
5
6
8
20
40
60
80
100
110
120
130
140
150
160
170
180
190
200
210
220
230
240
250
260
270
280
290
300
320
340
360
380
400
420
440
460
480
500
520
540
560
580
600
700
800
900
1000
0
0
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
4
1
1
2
2
3
3
4
4
4
5
5
6
6
6
7
7
8
8
9
9
9
10
2
2
3
4
5
6
7
7
8
9
10
10
11
12
12
13
14
15
16
17
17
19
3
4
4
6
7
9
10
11
12
13
15
16
18
19
19
21
22
24
25
26
27
30
4
5
6
8
10
13
15
16
17
19
21
23
25
26
27
29
31
33
36
37
38
42
5
6
7
10
12
15
17
18
19
22
24
27
29
30
32
34
36
39
41
42
44
48
6
7
8
11
14
17
19
21
22
25
28
30
33
35
36
39
42
44
47
48
50
55
6
8
9
13
16
19
22
24
25
28
31
34
38
39
41
44
47
50
53
55
56
63
7
9
11
14
18
21
25
26
28
32
35
39
42
44
46
49
53
56
60
61
63
70
8
10
12
16
20
23
27
29
31
35
39
43
47
49
51
55
59
62
66
68
70
78
9
11
13
17
22
26
30
32
35
39
43
47
52
54
56
60
65
69
73
75
78
86
9
12
14
19
24
28
33
36
38
43
47
52
57
59
62
66
71
76
80
83
85
95
10
13
16
21
26
31
36
39
41
47
52
57
62
65
67
72
78
83
88
90
93
103
11
14
17
22
28
34
39
42
45
51
56
62
67
70
73
79
84
90
96
98
101
112
12
15
18
24
30
36
43
46
49
55
61
67
73
76
79
85
91
97
103
106
109
122
13
16
20
26
33
39
46
49
52
59
66
72
79
82
85
92
98
105
111
115
118
131
14
18
21
28
35
42
49
53
56
63
70
77
84
88
92
99
106
113
120
123
127
141
15
19
23
30
38
45
53
57
60
68
75
83
90
94
98
106
113
121
128
132
136
151
16
20
24
32
40
48
56
60
64
72
80
89
97
101
105
113
121
129
137
141
145
161
17
21
26
34
43
51
60
64
69
77
86
94
103
107
111
120
129
137
146
150
154
18
23
27
36
46
55
64
68
73
82
91
100
109
114
118
127
137
146
155
19
24
29
39
48
58
68
72
77
87
96
106
116
121
125
135
145
154
20
25
31
41
51
61
71
76
82
92
102
112
122
127
133
143
153
22
27
32
43
54
65
75
81
86
97
108
118
129
135
140
151
23
28
34
45
57
68
79
85
91
102
113
125
136
142
147
159
25
31
38
50
63
75
88
94
100
113
125
138
150
157
163
27
34
41
55
69
82
96
103
110
124
137
151
30
38
45
60
75
90
105
113
120
135
150
165
33
41
49
65
82
98
114
122
131
147
163
35
44
53
71
88
106
124
132
141
159
38
48
57
76
95
114
133
143
152
41
51
61
82
102
123
143
153
44
55
66
88
109
131
153
47
58
70
93
117
140
164
50
62
75
100
124
149
174
53
66
79
106
132
159
56
70
84
112
140
168
59
74
89
118
148
178
63
78
94
125
156
82
99
132
165
66
83
104 125 167
103
128 154
123
154
145
181
10 12 14 15 16 18 20 22 24 25 26 28 30 32 34 35 36 40
Versatile Solution
Treatment
Applicators/RADCheck
•
8 Standard sizes
– 1.0,1.5, 2.0, 2.5, 3.0, 4.0, 5.0 and 10cm
– Safety X-Ray Port Block
– Ease of use – Turn & Lock
– Size display – Console
•
Replaceable safety contact shields
– Treated area visibility
– Margin clearance
– Clinical safety
•
Dual collimated design
– Precise X-ray delivery
•
RAD Check – same design for pretreatment verification
Applicator Port
Ring and Sensors
Position
Locking
Knob
• 180 degree Horizontal & Vertical
Articulation
180
180
Versatile X-Ray Port
• Turn & Lock
• Electromagnetic Applicator Sensor
Auto Filter
Magazine Control
• Auto Filter Assembly
• Interchangeable Applicators
• Elevator Controlled
• Precise Arm Locking in Position
Field Proven Mobile Platform
Under-Seat
Inverter
Lift
Sliding Side Door
Lift Actuator
Patient Treatment Bench
Electrical Panel in
Upper Bulkhead Wall
Extracting
Laptop Table
SRT-100™
Operator Console
36” x 24” Bench
with Storage Access
Patient Treatment Area
Overhead Cabinet
Storage
120v/30A Inlet
2 Under-Floor Batteries
A/C and Vent Unit
Lead-Lined Shielded Area