Transcript Cancer of the Skin



rising incidence
the precise relationship between skin cancer
and the risk of internal malignancy is not yet
completely defined, and the issue remains
controversial
 Shave
Biopsy
 Punch Biopsy
 Excisional Biopsy
 Excision
 Mohs
Micrographic Surgery
 Curettage and Electrodesiccation
 Cryosurgery
 biologic



and histologic nature of the tumor,
the anatomic site,
the underlying medical status of the patient
tumor is primary or recurrent.
 Breadloaf
fashion,
 occasionally result in a false-negative
assessment of clear margins in cases of
1. infiltrating
2. aggressive-growth cancers
3. vertically prepared frozen specimens
 Excision,
especially when performed in a physician's
office rather than in a hospital operating
room, is effective and cost-efficient when
the cancer is small (less than 1 cm),
nonrecurrent, or noninfiltrative.
A
key defining feature of MMS is that the
surgeon excises, maps, and reviews the
specimen personally, minimizing the chance
of error in tissue interpretation and
orientation.

 recurrent
skin cancers,
 primary skin cancers located on anatomic
sites that require maximal tissue
conservation for preservation of function and
cosmesis
 less expensive
 Curettage
and Electrodesiccation
 Cryosurgery
 Imiquimod
 5-Fluorouracil
 Photodynamic
Therapy
 Radiation Therapy
 an
immune-response modifier
 induction of cytokine production Ifα ,Ý ,IL 12
 (FDA) for treatment of AKs and superficial
BCCs on the trunk, neck, or extremities.
 postoperatively
 a significant inflammatory reaction.
 FDA
for the treatment of actinic keratoses
and superficial BCCs
 it remains a standard topical treatment for
actinic keratoses.
Total clearance rates range from roughly 10%
to 98%.
 Topical 5-FU induces erythema, epidermal
pain, and erosion in the treatment area that
may be exacerbated by prolonged ultraviolet
irradiation
 ultimately
cell death
 direct effects on blood vessels :tumor
destruction
 only FDA approved for the treatment of AKs.
Several studies report clearance rates of 81%
to 100% for AKs.
 electrons
(with bolus •to bring the skin
surface dose to 100%) or with superficially
penetrating photons (x-rays).
 Appropriate margins around gross disease or
surgical scars should be carefully considered
and should generally be at least 2 cm when
using electrons.
 Depending on the histology and nature of the
lesion, margins may be wider




Late effects on normal tissues are related to fraction
size, and can be minimized with a protracted
fractionation scheme utilizing 2 Gy fractions to a
total of 60 to 66 Gy for BCC or SCC.
Treatment may be accelerated with excellent local
control but with greater risk of fibrosis, atrophy, and
poor cosmesis.
Consideration of the permanent tissue effects of
radiation therapy, such as chronic radiation
dermatitis, delayed radiation necrosis, alopecia, and
secondary cutaneous malignancies must be
anticipated and managed.
Lesions involving the foot, skin over the tibia, or of
the dorsum of the hand should be considered with
care as they may require more intensive wound care
and may not heal as readily following radiation.
a
history of BCC or SCC should be evaluated
on an annual basis
 more aggressive tumor, evaluation should be
more frequent
 in the case of SCC, should include
examination of draining lymph nodes
 Laboratory evaluation, may be necessary
for types of particularly aggressive tumors.
 Imaging studies
Actinic Keratosis
 very common lesions
 on sun-exposed areas
 in blond or red-haired, fair-skinned individuals
with green or blue eyes
 SCC in situ
 caused by exposure to ultraviolet B (UVB) light
 p53 mutations
 spontaneous regression, persistence, or
progression into invasive SCC
 Molecular
characterization of the role of the
p53 tumor suppressor gene in AK, and its
similar finding in SCC and BCC, suggests that
the AKs represent an early stage in the
molecular carcinogenesis of NMSC.
 The risk for transformation of a single AK has
been estimated to be as low as 1 per 1,000
per year. However, the long-term risk of the
development of invasive SCC in patients with
multiple AKs has been estimated to be as
high as 10%.
 AKs
are red, pink, or brown papules with a
scaly to hyperkeratotic surface
 sun-exposed areas and are especially
common on the balding scalp, forehead,
face, and dorsal hands
 increase in prevalence with advancing age.
 Bowenoid
AK is indistinguishable from
Bowen's disease (BD), also known as SCC in
situ
 Use
of broad-brimmed hats, sun-protective
clothing, sunscreen, and judicious avoidance
of sunlight can protect patients from sunlight
and prevent the formation of AKs.
 Due to their potential to develop into
invasive SCC and the inability to determine
which lesions will do so, AKs should usually
be treated.
 cryosurgery,
C&D,
 topical 5-FU,
 immune modulators such as imiquimod,
 photodynamic therapy,
 chemical cauterization using trichloroacetic
acid,
 excision

 Treatment
of solitary lesions is
straightforward with cryosurgery, which has
been reported to have cure rates of 98%.
 initially,
the largest lesions are often treated
by C&D.
 Raised lesions of smaller size are then
treated by destructive methods, especially
the open-spray cryosurgery technique.
 topical application of 5-FU with or without
topical retinoids
 Topical imiquimod
 laser and chemical exfoliation,
 Lesions
that do not respond to treatment and
show signs of bleeding, induration, rapid
growth, or pain suggest progression to SCC
and should be biopsied.
 75%
of all NMSCs and almost 1/4of all cancers
diagnosed in the United States.
 rarely metastasize
 with 30% of lesions occurring on the nose.
 Anywhere
 BCCs are becoming more common in younger
individuals.
 exposure
to ultraviolet light (UVL), which
trigger mutations in tumor suppressor genes.
Individuals
 white individuals
 mutations in regulatory genes;
 exposure to ionizing radiation
 Arsenicals
 polyaromatic hydrocarbons
 psoralen-plus-UVA therapy
 alterations in immune surveillance.
 BCC
can be a feature of inherited conditions:
nevoid BCC syndrome (NBCCS)
Bazex's syndrome
Rombo syndrome
unilateral basal cell nevus syndrome.
a
rare autosomal dominant genetic disorder
characterized by a predisposition to multiple
BCC and other tumors, as well as a wide
range of developmental defects. Patients
with this syndrome may exhibit a broad nasal
root, borderline intelligence, jaw cysts,
palmar pits, and multiple skeletal
abnormalities in addition to hundreds of
BCCs .
 This syndrome has significantly helped to
elucidate the molecular pathogenesis of BCC.
1.
2.
a mutation in a tumor suppressor gene,
hit is inactivation of the normal homologue
by environmental mutagenesis or random
genetic rearrangement.
 Inactivation
 mutations
of the patched gene (PTCH gene)
in the p53 gene, in up to 60% of
BCCs as well
 This
biologic behavior depends on angiogenic
factors, stromal conditions, and the
propensity for the cancer to follow anatomic
paths of least resistance. In addition, size
may play a role, as larger primary BCCs have
higher recurrence rates.
 BCCs
can elicit angiogenic factors
 telangiectatic vessels
 antiangiogenic factors may play a potential
therapeutic role
 Necrosis
 Tumor stroma is critical for both initiating
and maintaining the development of BCC.
 The concept of stromal dependence is
supported by the low incidence of metastatic
BCC.
perichondrium,
 periosteum,
 fascia,
 tarsal plate
eyelid, nose, and scalp
 Embryonic fusion planes :
inner canthus
philtrum,
middle to lower chin
nasolabial groove
preauricular area
the retroauricular sulcus.

 Perineural
spread is infrequent but occurs
most often in recurrent, aggressive lesions.
 perineural extension :
periauricular and malar areas.
 Perineural invasion may present with
paresthesia, pain, and weakness or, in some
cases, paralysis.
 lung,
lymph nodes
 esophagus
 oral cavity
 skin.
survival of 8 to 10 months after diagnosis being
the norm.

Tx Platinum-based chemotherapy
 Nodular
a raised translucent papule or nodule with
telangiectasia and has a propensity for
involving sun-exposed areas of the face.
 superficial,
presents as an erythematous scaly or eroded
macule on the trunk ,DDx: AK, SCC in situ, or
a benign inflammatory lesion.
 Morpheaform
(also termed aggressive-growth
BCC or infiltrative BCC)
a flat, slightly firm lesion, without welldemarcated borders, and may be difficult to
differentiate from a scar. Symptoms of
bleeding, crusting, and ulceration are often
not present in these tumor subtypes and can
lead to a delay in diagnosis. The aggressive
growth pattern of this subtype is highlighted
by the fact that the actual size of the cancer
is usually much greater than the clinical
extent of the tumor
 Pigmented
variant of nodular BCC and may be difficult to
differentiate from nodular melanoma. The
presence of pigment may be of value in
determining adequate margins for excision.
 fibroepithelioma
of Pinkus (FEP)
FEP usually presents as a pink papule on the
lower back. It may be difficult to distinguish
clinically from amelanotic melanoma.
 superficial,
nodular
 micronodular,
 infiltrative BCC
 FEP, a polypoid lesion
 Mixed histology

 The
recurrences are more frequent in BCCs
with infiltrative and micronodular histology,
 general, incompletely excised BCCs should be
removed completely, preferably by MMS,
especially if they occur in anatomically
critical areas such as the central zone of the
face, retroauricular sulcus, or periocular
area.
 The
results indicate that patients with small
BCCs that appear to be completely removed
by initial biopsy may be at risk for
recurrence if not treated further.
 The
nose is the most common site for
cutaneous malignancies (30%), and BCCs
involving the nose may be aggressive.
 MMS may be the treatment of choice for all
BCCs involving the nose, especially those
exhibiting aggressive growth characteristics
 Periocular
BCC represents a significant
therapeutic challenge and is the most
common tumor affecting the eyelid.
 Approximately
6% of BCCs involve the ear, a
site notable for high rates of recurrence. A
multidisciplinary approach combining MMS
with the skills of otolaryngology may be
optimal for the treatment of such tumors
 Excisional
surgery, C&D, and cryosurgery
have been used to treat circumscribed,
noninfiltrating BCCs
 MMS is the treatment method of choice for
all recurrent and infiltrative BCCs,
particularly if a tumor is located on the face.
 RT is best suited for older patients,
particularly those with extensive lesions on
the ear, lower limbs, or eyelids.
 Radiation therapy is not indicated for
recurrent or morpheaform lesions.
 It
has been demonstrated that 4-mm margins
are adequate for removal of BCC in 98% of
cases of nonmorpheaform BCC of less than 2
cm in diameter. Extending the excision into
fat generally is adequate for a small primary
BCC. It should be noted that the majority of
BCCs are well treated with conventional
excision or C&D.
 MMS
permits superior histologic verification
of complete removal, allows maximum
conservation of tissue, and remains costeffective as compared to traditional
excisional surgery for NMSCs.
 MMS is the preferred treatment for
morpheaform; recurrent, poorly delineated,
high-risk, and incompletely removed BCC;
and for those sites in which tissue
conservation is imperative.
 C&D
is frequently used by dermatologists in
the treatment of BCC.
 Although C&D is simple and cost-effective, it
is dependent on operator skill. Some
practitioners advocate that the procedure be
repeated for three cycles, but histology,
location, and behavior of the tumor should
dictate the number of cycles. C&D should be
reserved for small or superficial BCCs, not
located on the midface, in patients who may
not tolerate more extensive surgery.
 When
surgery is contraindicated, radiation
therapy is an option for treating primary
BCC. Radiation therapy may be indicated
postoperatively if margins are ambiguous or
involved and may also be considered when
surgery could cause functional impairment or
require a substantial reconstructive
procedure, such as in the case of a lesion at
the eyelid, canthus, or nasal ala.
 Advantages
of RT :
minimal discomfort
Non invasive procedure
 Disadvantages RT:
lack of margin control,
possible poor cosmesis over time,
a drawn-out course of therapy
possible increased risk of future skin cancers.
 Disadvantages
RTThe recurrence rate : 5% to
10% over 5 years
A
margin of normal skin also should be frozen
 Complications include
hypertrophic scarring and postinflammatory
pigmentary changes.
 Fractional cryotherapy has been used with
success in treating eyelid lesions. The
method has been described as quick and
cost-effective.
 A serious potential adverse outcome is
recurrent BCC that can become extensive
because of concealment by the fibrous scar
created when aggressive cryosurgery is used.
 MMS
is recommended for aggressive , in highrisk anatomic sites or sites that require
maximum conservation of normal tissue.
 For nonaggressive-growth BCCs on the trunk
and extremities, fusiform excision with
margins of 3 to 5 mm or C&D are
appropriate.
 MMS may be helpful for BCC of the lower
extremities where healing difficulties are
anticipated. The smaller wound that results
from MMS may obviate the need for complex
reconstruction and facilitate healing.
 For
patients with numerous BCCs, including
patients with NBCCS, curettage and
cauterization for smaller, superficial lesions
is effective. Cryosurgery can be helpful in
the management of multiple, small BCCs of
NBCCS.
 annual
full-body skin examinations
 Although most recurrences appear within 1
to 5 years, they can develop later.
 Subsequent new primary BCC can present at
rates of approximately 40%, with 20% to 30%
of these developing within 1 year of
treatment of the original lesion.
 SCC
in black populations arises most often on
sites of pre-existing inflammatory conditions,
burn injuries, scars, or trauma.
 Patients taking immunosuppressive
medications
 Another high-risk group includes patients
treated with psoralens and UVA light for
psoriasis.
 Patients exposed to arsenic
exposure to UVL,
 genetic mutations,
 immunosuppression,
 viral infection
 radiation exposure
 burn scars,
 chronic inflammatory dermatoses
 , ulcers,
 osteomyelitis
 arsenic ingestion
 Heritable conditions

 xeroderma

pigmentosum
oculocutaneous albinism
 The
overall invasiveness and depth of the
neoplasm is important when determining the
risk of recurrence.
 invade the reticular dermis and subcutis
 Degree of differentiation
 limited
to the epidermis and lacks invasion
into the dermis.
 0.05%
to 16.0%
 Tumors arising in areas of chronic
inflammation have a 10% to 30% rate of
metastasis
 The extent of cellular differentiation
 SCCs
on the midface and lip are prone to
neural involvement.
 Regional lymph node and distant metastases
may increase with perineural involvement.
 SCCs on the skin of the head and neck may
metastasize to cervical lymph nodes and
distantly to the central nervous system
 SCC
appears as a slightly raised, red,
hyperkeratotic macule or papule on sunexposed sites but may occur anywhere (
 DDx
hypertrophic actinic keratosis
benign seborrheic keratosis
benign inflammatory lesion
 Verrucous
carcinoma
 Bowen Disease
 Bowenoid papulosis classically presents as a
reddish brown verrucous papule and is
associated with HPV-16 and -18. Bowenoid
papulosis usually involves the genitals but
may present elsewhere
 Grade
1 tumors :more than 75% welldifferentiated cells,
 grade 2 SCC, 50% to 75% of cells are
described as well-differentiated
 grade 3 SCC, 25% to 50% of cells are
described this way.
 grade 4 SCC fewer than 25% welldifferentiated cells
1.
2.
3.
4.
5.
6.
7.
8.
9.
Treatment modality
prior treatment
location
Size
Depth
histologic differentiation
evidence of perineural involvement
precipitating factors other than UVL
immunosuppression.
 Treatment
of nodal disease may involve
radiation, lymph node dissection, or both.
 Treatment of metastatic SCC may include
systemic chemotherapy or treatment with
biologic response modifiers.
 Many
of the treatments for BCC are also
appropriate for SCC The type of therapy
should be selected on the basis of size of the
lesion, anatomic location, depth of invasion,
degree of cellular differentiation, and history
of previous treatment.
 There
are three general approaches to
treatment of SCC:
(1) C&D or cryosurgery,
(2) removal by traditional excisional surgery or
MMS,
(3) radiation therapy.
 small
lesions arising on sun-damaged skin.
 Well-differentiated,
 less than 1 cm
 SCC in situ;
 C&D
 cryotherapy.
 Imiquimod
?
 Surgical
excision is a well-accepted
treatment modality for SCC.
 Surgical excision is the treatment of choice
for verrucous carcinoma.
 invasive
lesions,
 poorly differentiated lesions
 lesions occurring in high-risk anatomic sites
or sites in which conservation of normal
tissue is essential for preservation of
function or cosmesis.
 head
and neck cutaneous SCC
 perineural
involvement
 involved margins
 involvement of bone and or subcutaneous
soft tissues
 Prophylactic radiation therapy to a dose in
the range of 50 Gy may be considered to
nodal basins considered at high risk
 close
follow-up.
every 3 months during the first year
every 6 months during the second year
at least annually thereafter
 Evaluation
total body cutaneous examination
palpation of draining lymph nodes
 Immunosuppressed
(lymphoma or leukemia
,HIV )show a higher frequency of infiltrative
BCC.
 organ transplants SCC > BCC

Other cutaneous tumors may also be
increased in organ transplant recipients.
 Merkel
cell carcinoma (MCC) is a rare and
aggressive tumor of neuroendocrine cell
origin
 more men than women
 whites more than blacks
 most often occurs between the seventh and
ninth decades of life.
 UVL
 Most
tumors occur on the head and neck, the
extremities, or the trunk
 Immunosuppression
 increased malignant neoplasm rate among
patients with MCC
a
rapidly growing, firm, redviolaceous, dome-shaped papule or
plaque on sun-exposed skin
 in sun-exposed head and neck skin,
extremities, and less often on the
trunk.
 Clinical
1.
2.
3.
4.
5.
DDx includes
leukemia cutis
amelanotic melanoma
metastatic carcinoma
pyogenic granuloma
SCC.
 Histologic
1.
2.
3.
4.
5.
DDx includes
lymphoma,
BCC
metastatic oat cell carcinoma
noncutaneous neuroendocrine tumors
Melanoma
 MCC
warrants aggressive therapy.
 a high propensity for local recurrence (20% to
75%)
 regional node metastases (31% to 80%),
 distant metastases (26% to 75%),
 one third of patients eventually die of the
disease.
 full-body
skin examination
 lymph node evaluation,
 CBC,
 LFT
 CT S
chest, pelvis, and abdomen may be indicated
to rule out the presence of small cell
carcinoma of the lung. CT scanning of the
head and neck may prove valuable in
detection of nodal disease.
 Octreotide scans
 stage


I (primary tumor alone)
stage II (locoregional metastases),
stage III (metastatic disease).
 wide
local excision (WLE) with 1- to 3-cm
margins
 NO guidelines
 Recurrence rates after surgery alone are 22%
to 100%.
 MMS
 adjuvant radiation therapy :a substantial
benefit in both time to recurrence and
disease-free survival had
 LND
or sentinel LND may be advisable
 sentinel LN+
WLE, therapeutic LND, and RT
if no LND, RTto the nodal region to a dose of
at least 50 Gy should be considered
 sentinel
LN- WLE with margins of up to 3 cm
and, possibly, adjunctive radiation therapy.
 Many
have likened MCC to melanoma
because both derive from the neural crest
and both malignancies have a propensity for
initial lymphatic, then distant spread. Given
these similarities, it is suggested that
perhaps depth of tumor may be more of a
prognostic indicator than the actual diameter
of the primary tumor.
 MCC
tends to spread in a cascade pattern,
 spreads to regional lymph nodes within 2
years in up to 70% of cases.The overall 5-year
survival rate for patients with this condition
is only 50% to 68%.
 Lymph node metastases have been identified
in up to 20% of cases of MCC at initial
presentation. Approximately 50% of patients
experience nodal disease at some point in
the disease course.

Distant metastases have been reported in up to
52% of patients at presentation.
skin
 lymph nodes
 lung,
 liver,
 brain,
 intestine
 bladder,
 stomach
 abdominal wall.

 MCC
is chemosensitive but rarely
chemocurable in patients with metastasis or
locally advanced tumors.
 the most common regimens :
cyclophosphamide, doxorubicin, and
vincristine and cisplatin and etoposide.
 brief responses : with carboplatin and
etoposide.
poor prognostic factors:
 Age older than 65 years
 male sex
 greater than 2 cm
 truncal site
 nodal/distant disease
 duration of disease before presentation (less
than or equal to 3 months)
 MAC
originates from pluripotent adnexal cells
 Synonyms for MAC include sclerosing sweat
duct carcinoma, sweat duct carcinoma with
syringomatous features, syringomatous
carcinoma, malignant syringoma, and
combined adnexal tumor of the skin.
 MAC
is an aggressive, locally destructive
cutaneous appendageal neoplasm with a high
rate of recurrence.
 It primarily affects
white,
middle-aged individuals,
women outnumber affected men
a
sclerotic or indurated plaque with an intact
epidermis and yellow hue
 central face and lip
 usually asymptomatic
 DDX
Desmoplastic trichoepitheliomas
sclerosing epithelial neoplasm
 Correct
diagnosis of MAC is imperative, as
the tumor can be highly invasive and may
involve adipose, vascular adventitia, muscle,
perichondrium, or bone
 WLE
as well as MMS.
 Standard wide-local excision is associated
with recurrence rates of 47% to 59%.
 The recurrence rate observed with MMS
ranges from 0% to 12%.
 resistant to radiation therapy,
patients must be evaluated regularly for
recurrence and for development of other skin
cancers.
 Evaluation should include examination of skin
and lymph nodes and, due to the potential
for recurrence long after treatment,
continue indefinitely

 variable
sites of origin, histologic growth
patterns, and clinical presentations.
 Ocular SC is more common
 The upper eyelids are most frequently
involved.
 SC is the second most common eyelid
malignancy after BCC and is the second most
lethal after melanoma
 sebaceous
adenomas
 radiation exposure
 BD,
 Muir-Torre syndrome.
 SC and, more commonly, sebaceous adenoma
(or sebaceous epithelioma) are associated
with a second internal malignancy, usually a
carcinoma of the colon or urogenital tract.
 SC has been reported after radiation therapy
for retinoblastoma, eczema, and cosmetic
epilation.
a
slowly growing, deeply seated nodule of
the eyelid
 The most common clinical misdiagnosis is
chalazion.
 SC
can spread by lymphatic or hematogenous
routes or by direct extension.
 traditional
excisional surgery and extirpation
by MMS.
 The local recurrence rate after WLE has been
reported to be as high as 36%.123
 Potential difficulties arise because tumors
are often multicentric with discontinuous
foci of tumor,
 Patients
with SC should be evaluated by an
internist(stool for occult blood, analysis of
urine, colonoscopy)
 A family history for internal malignancy
should be sought and family members
screened,
 Poor
prognostic indicators:
multicentric origin,
poor differentiation
infiltrative pattern
pagetoid changes
vascular invasion,
lymphatic channel involvement,
previous radiation,
orbital spread.
 most
common soft tissue tumor in the
elderly,
 primarily affecting the extremities.
 a subcutaneous mass(On microscopic are
deep tumors that are located beneath the
fascia )
 ulcerative nodule
 aggressive and has high metastatic potential
 after
radiation
 in scar tissue.
 in a burn scar has also been
 Decreased immune surveillance ?
 Factors
that appear to influence metastasis
include depth and size of tumor, histologic
grade, and inflammatory response
WLE, (recurrence rates of up to 40% have
been reported with this approach)
 MMS
 Adjuvant radiotherapy

a
low-grade cutaneous sarcoma with
aggressive local behavior and low metastatic
potential
 as a plaque on the trunk
 during early or middle adulthood,
 WLE
and MMS
Most authors advocate surgical excision with a
minimal margin of 2 to 3 cm of surrounding
skin, including the underlying fascia, without
elective lymph node dissection.
The likelihood of local recurrence is related to
the adequacy of surgical margins.
recur locally, 50%.
 DFSP of the head and neck has been reported to
have a higher local recurrence rate (50% to 75%)
than DFSP in other locations.
 Although metastases are rare, multiple local
recurrences appear to predispose to distant
metastases.
 A fibrosarcomatous variant, FS-DFSP, represents
an uncommon form of DFSP that tends to follow
a more aggressive clinical
 DFSP is a radioresponsive tumor, and combined
conservative resection and postoperative
radiation should also be considered in situations
in which adequate wide excision alone would
result in major cosmetic or functional deficits.

 AS
is a biologically aggressive tumor with
high metastatic potential. Metastases to
lung, lymph nodes, and brain are common.
 Prognosis for metastatic disease is poor.
Although prognosis does not correlate with
degree of cellular differentiation,
 size
at presentation
 Because
of the aggressiveness and poor
prognosis of AS, treatment options are
limited.
 Radical excision is choice
 Amputation with shoulder disarticulation or
hemipelvectomy are recommended for
tumors involving the extremities.
 AS tends to extend far beyond clinically
appreciated margins
 MMS?
 Radiation therapy should be considered
 Lymphedema-associated
AS (LAS)
 The risk for developing LAS 5 years after
mastectomy is approximately 5%.
 The most common site is the medial aspect
of the upper arm.
 The
prognosis is poor,
 survival rates are comparable to AS involving
the scalp and face.
 Long-term survival has been reported after
amputation of the affected limb.
 Radiation-induced
AS has been reported to
occur after radiation therapy for benign or
malignant conditions.
 AS may occur from 4 to 40 years after
radiation therapy for benign conditions,
 Prognosis
is poor
 involve
the lower extremities.
 Epithelioid AS results in widespread
metastases within 1 year of presentation.
 Prognosis, is poor.
 an
indolent vascular tumor
 including
1. classic KS,
2. African endemic KS,
3. iatrogenic KS,
4.
epidemic, AIDS-associated KS.
 KS-associated herpesvirus (human
herpesvirus 8) The risk of developing KS in
immune-deficient conditions is strictly
related to the human herpesvirus 8
prevalence in each region.
 affects
elderly men,
 Ashkenazic Jews
 Mediterranean descent
 asymptomatic
 Slow progression
 Up to one third develop a second primary
malignancy, most often a lymphoproliferative
disorder, such as non-Hodgkin's lymphoma,
which may antedate or follow the
appearance of KS lesions
indolent nodular
2.
locally aggressive
3. disseminated aggressive
clinically and behaves similarly to classic KS.
1.

fulminant lymphadenopathic disease
 occurs
in the context of immunosuppressive
drug therapy.
 usually chronic
 On
microscopic examination, KS varies
according to patch, plaque, and nodular
subtypes. The histologic changes in early
patch-stage KS are inconspicuous, leading to
misdiagnosis of a benign inflammatory
process.
 The
most frequently observed cutaneous
metastatic cancers are breast, colon, and
melanoma in women and lung, colon, and
melanoma in men.
 Cutaneous metastatic disease as the first sign
of internal cancer is most commonly seen
with cancers of the lung, kidney, and ovary.
 The scalp is a common site for cutaneous
metastatic disease
 Radiotherapy
may be utilized with palliative
intent for painful, ulcerated, or bleeding
lesions, and generally provides rapid
palliation with 1 to 2 weeks of therapy.
a
dermatologist for evaluation.
 sent to a dermatopathologist
 full-body skin examinations performed by a
dermatologist for the development of
recurrences as well as new primary skin
cancers