Cancer of the Skin rising incidence - PowerPoint Presentation

Slide1

Cancer of the Skin

Slide2

rising incidence

the precise relationship between skin cancer and the risk of internal malignancy is not yet completely defined, and the issue remains controversial

Slide3

Skin Cancer Diagnosis

Shave Biopsy

Punch Biopsy

Excisional

Biopsy

Slide4

Slide5

General Approach to Management of Skin Cancer

Excision

Mohs

Micrographic Surgery

Curettage and

Electrodesiccation

Cryosurgery

Slide6

The management of skin cancer is guided by

biologic and

histologic

nature of the tumor,

the anatomic site,

the underlying medical status of the patient

tumor is primary or recurrent.

Slide7

Excision

Breadloaf

fashion,

occasionally result in a false-negative assessment of clear margins in cases of

infiltrating

aggressive-growth cancers

vertically prepared frozen specimens

Slide8

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

.

Slide9

Mohs

Micrographic Surgery

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.

Slide10

MMS choice for

recurrent skin cancers,

primary skin cancers located on anatomic sites that require maximal tissue conservation for preservation of function and

cosmesis

less expensive

Slide11

Slide12

Slide13

Curettage and

Electrodesiccation

Slide14

Cryosurgery

Slide15

Topical Therapy

Imiquimod

5-Fluorouracil

Photodynamic Therapy

Radiation Therapy

Slide16

Imiquimod

an immune-response modifier

induction of cytokine production If

α

,

Ý ,IL 12

(FDA) for treatment of AKs and superficial BCCs on the trunk, neck, or extremities.

postoperatively

a significant inflammatory reaction.

Slide17

5-Fluorouracil

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

Slide18

Photodynamic Therapy

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.

Slide19

Radiation Therapy

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

Slide20

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.

Slide21

Treatment Follow-Up

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

Slide22

Precancerous Lesions

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

Slide23

Slide24

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%.

Slide25

Clinical Features

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

Slide26

Treatment

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.

Slide27

Tx

aks

cryosurgery,

C&D,

topical 5-FU,

immune modulators such as

imiquimod

,

photodynamic therapy,

chemical cauterization using

trichloroacetic

acid,

excision

Slide28

Treatment of solitary lesions is straightforward with cryosurgery, which has been reported to have cure rates of 98%.

Slide29

management of patients with hundreds of lesions

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,

Slide30

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.

Slide31

Slide32

Basal Cell Carcinoma

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.

Slide33

pathogenesis of BCC

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.

Slide34

BCC can be a feature of inherited conditions

:

nevoid BCC syndrome (NBCCS)

Bazex's

syndrome

Rombo

syndrome

unilateral basal cell nevus syndrome.

Slide35

NBCCS

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.

Slide36

NBCCS

a mutation in a tumor suppressor gene,

hit is inactivation of the normal homologue by environmental mutagenesis or random genetic rearrangement.

Slide37

Sporadic BCCs

Inactivation of the patched gene (PTCH gene)

mutations in the p53 gene, in up to 60% of BCCs as well

Slide38

Slide39

Clinical Behavior of Basal Cell Cancer

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.

Slide40

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.

Slide41

the path of least resistance

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

.

Slide42

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.

Slide43

Metastatic BCC

lung,

lymph nodes

esophagus

oral cavity

skin.

survival of 8 to 10 months after diagnosis being the norm.

Tx

Platinum-based chemotherapy

Slide44

Basal Cell Carcinoma Subtypes

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.

Slide45

Morpheaform

(also termed aggressive-growth BCC or infiltrative BCC)

a flat, slightly firm lesion, without well-demarcated 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

Slide46

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.

Slide47

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.

Slide48

Histologic

subtypes of BCC include

superficial,

nodular

micronodular

,

infiltrative BCC

FEP, a

polypoid

lesion

Mixed histology

Slide49

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.

Slide50

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.

Slide51

Characteristics Related to Anatomic Site

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

Slide52

Periocular

BCC represents a significant therapeutic challenge and is the most common tumor affecting the eyelid.

Slide53

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

Slide54

Treatment

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.

Slide55

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.

Slide56

Slide57

MMS

MMS permits superior

histologic

verification of complete removal, allows maximum conservation of tissue, and remains cost-effective 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.

Slide58

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.

Slide59

RT

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

.

Slide60

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

Slide61

Cryosurgery

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.

Slide62

laser

Slide63

MMS

is recommended for aggressive , in high-risk 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.

Slide64

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.

Slide65

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.

Slide66

Squamous

Cell Carcinoma

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

Slide67

Pathogenesis

exposure to UVL,

genetic mutations,

immunosuppression

,

viral infection

radiation exposure

burn scars,

chronic inflammatory

dermatoses

, ulcers,

osteomyelitis

arsenic ingestion

Heritable conditions

Slide68

Heritable conditions

xeroderma

pigmentosum

oculocutaneous

albinism

Slide69

Biologic Behavior

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

Slide70

SCC in situ

limited to the epidermis and lacks invasion into the dermis.

Slide71

regional lymph node metastasis

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

Slide72

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

Slide73

Clinical Features

SCC appears as a slightly raised, red,

hyperkeratotic

macule

or papule on sun-exposed sites but may occur anywhere (

DDx

hypertrophic actinic

keratosis

benign

seborrheic

keratosis

benign inflammatory lesion

Slide74

Verrucous

carcinoma

B

owen

D

isease

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

Slide75

A grading system

Grade 1 tumors :more than 75% well-differentiated 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% well-differentiated cells

Slide76

Recurrence and Metastatic Risk

Treatment modality

prior treatment

location

Size

Depth

histologic

differentiation

evidence of

perineural

involvement

precipitating factors other than UVL

immunosuppression

.

Slide77

Treatment

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.

Slide78

Treatment

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.

Slide79

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.

Slide80

Slide81

C&D

small lesions arising on sun-damaged skin.

Well-differentiated,

less than 1 cm

SCC in situ;

Slide82

SCC in situ

C&D

cryotherapy

.

Imiquimod

?

Slide83

Surgical excision is a well-accepted treatment modality for SCC.

Surgical excision is the treatment of choice for

verrucous

carcinoma.

Slide84

MMS

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

.

Slide85

Radiation therapy

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

Slide86

Invasive SCC

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

Slide87

Immunosuppression

and

Nonmelanoma

Skin Cancer

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

.

Slide88

Merkel Cell Carcinoma

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.

Slide89

pathogenesis

UVL

Most tumors occur on the head and neck, the extremities, or the trunk

Immunosuppression

increased malignant neoplasm rate among patients with MCC

Slide90

MCC

a rapidly growing, firm, red-

violaceous

, dome-shaped papule or plaque on sun-exposed skin

in sun-exposed head and neck skin, extremities, and less often on the trunk.

Slide91

mcc

Clinical

DDx

includes

leukemia cutis

amelanotic

melanoma

metastatic carcinoma

pyogenic

granuloma

SCC.

Slide92

mcc

Histologic

DDx

includes

lymphoma,

BCC

metastatic oat cell carcinoma

noncutaneous

neuroendocrine

tumors

Melanoma

Slide93

Slide94

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

.

Slide95

Evaluation

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

Slide96

STAGING

stage I (primary tumor alone)

stage II (

locoregional

metastases),

stage III (metastatic disease).

Slide97

Management of MCC

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

Slide98

regional nodE

, MCC

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.

Slide99

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

.

Slide100

MCC

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.

Slide101

Metastases

Distant metastases have been reported in up to 52% of patients at presentation.

skin

lymph nodes

lung,

liver,

brain,

intestine

bladder,

stomach

abdominal wall.

Slide102

CHT

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

.

Slide103

followed up ,RISK FACTOR

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)

Slide104

Microcystic

Adnexal

Carcinoma

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.

Slide105

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

Slide106

MAC

a sclerotic or

indurated

plaque with an intact epidermis and yellow hue

central face and lip

usually asymptomatic

Slide107

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

Slide108

MAC :

tX

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,

Slide109

FOLLOW

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

Slide110

Sebaceous Carcinoma

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

Slide111

SC is associated with

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

.

Slide112

SC

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.

Slide113

Treatment,SC

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,

Slide114

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,

Slide115

Poor prognostic

indicators:

multicentric

origin,

poor differentiation

infiltrative pattern

pagetoid

changes

vascular invasion,

lymphatic channel involvement,

previous radiation,

orbital

spread.

Slide116

Malignant Fibrous

Histiocytoma

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

Slide117

pathogenesis of MFH

after radiation

in scar tissue.

in a burn scar has also been

Decreased immune surveillance ?

Slide118

MF

Factors that appear to influence metastasis include depth and size of tumor,

histologic

grade, and inflammatory response

Slide119

Treatment options for MFH

WLE, (recurrence rates of up to 40% have been reported with this approach)

MMS

Adjuvant radiotherapy

Slide120

Dermatofibrosarcoma

Protuberans

a low-grade

cutaneous

sarcoma with aggressive local behavior and low metastatic potential

as a plaque on the trunk

during early or middle adulthood,

Slide121

Treatment options for DFSP include

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.

Slide122

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.

Slide123

Angiosarcoma

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,

Slide124

size at presentation

Slide125

TX

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

Slide126

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.

Slide127

LAS

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.

Slide128

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

Slide129

Epithelioid

AS

involve the lower extremities.

Epithelioid

AS results in widespread metastases within 1 year of presentation.

Prognosis, is poor.

Slide130

Kaposi's Sarcoma

an indolent vascular tumor

including

classic KS,

African endemic KS,

iatrogenic KS,

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.

Slide131

Classic KS

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

Slide132

African endemic KS

indolent nodular

locally aggressive

disseminated aggressive

clinically and behaves similarly to classic KS.

fulminant

lymphadenopathic

disease

Slide133

Iatrogenic KS

occurs in the context of immunosuppressive drug therapy.

usually chronic

Slide134

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.

Slide135

Slide136

Carcinoma Metastatic to Skin

The most frequently observed

cutaneous

metastatic cancers are

breast

,

colon

, and

melanoma

in women and

lung

,

colo

n, 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

Slide137

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.

Slide138

Conclusion

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