Cancer of the Skin

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

SKIN CANCER DIAGNOSIS Shave Biopsy Punch Biopsy Excisional Biopsy

GENERAL APPROACH TO MANAGEMENT OF SKIN CANCER Excision Mohs Micrographic Surgery Curettage and Electrodesiccation Cryosurgery

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.

EXCISION Breadloaf fashion, occasionally result in a false-negative

assessment of clear margins in cases of 1. infiltrating 2. aggressive-growth cancers3. 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.

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.

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

Curettage and Electrodesiccation

Cryosurgery

TOPICAL THERAPY

Imiquimod 5-Fluorouracil Photodynamic Therapy Radiation Therapy

IMIQUIMOD

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.

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

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.

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

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.

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

PRECANCEROUS LESIONSActinic 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%.

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

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.

TX AKS 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%.

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,

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.

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.

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.

BCC can be a feature of inherited conditions :

nevoid BCC syndrome (NBCCS) Bazex's syndromeRombo syndrome unilateral basal cell nevus syndrome.

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.

NBCCS1. a mutation in a tumor suppressor

gene, 2. hit is inactivation of the normal

homologue by environmental mutagenesis or random genetic rearrangement.

SPORADIC BCCS Inactivation of the patched gene (PTCH

gene)

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

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.

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.

THE PATH OF LEAST RESISTANCE perichondrium, periosteum, fascia, tarsal plate eyelid, nose, and scalp Embryonic fusion planes :inner canthus philtrum, middle to lower chinnasolabial 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.

METASTATIC BCC lung, lymph nodes esophagus oral cavity skin. survival of 8 to 10 months after diagnosis

being the norm.

Tx Platinum-based chemotherapy

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.

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

Pigmentedvariant 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.

HISTOLOGIC SUBTYPES OF BCC INCLUDE 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.

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

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

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.

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 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.

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.

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.

Advantages of RT : minimal discomfort Non invasive procedure Disadvantages RT: lack of margin control,possible poor cosmesis over time,a drawn-out course of therapypossible increased risk of future skin

cancers.

Disadvantages RTThe recurrence rate : 5% to 10% over 5 years

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.

LASER

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.

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.

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

PATHOGENESIS

exposure to UVL, genetic mutations, immunosuppression, viral infection radiation exposure burn scars, chronic inflammatory dermatoses , ulcers, osteomyelitis arsenic ingestion Heritable conditions

HERITABLE CONDITIONS

xeroderma pigmentosum oculocutaneous albinism

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

SCC IN SITU limited to the epidermis and lacks

invasion into the dermis.

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

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

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 keratosisbenign 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

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

RECURRENCE AND METASTATIC RISK1. Treatment modality2. prior treatment3. location4. Size5. Depth6. histologic differentiation7. evidence of perineural involvement8. precipitating factors other than UVL9. immunosuppression.

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.

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.

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.

C&D small lesions arising on sun-damaged

skin. Well-differentiated, less than 1 cm SCC in situ;

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.

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.

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

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

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.

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.

PATHOGENESIS UVL Most tumors occur on the head and

neck, the extremities, or the trunk Immunosuppression increased malignant neoplasm rate

among patients with MCC

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.

MCC Clinical DDx includes 1. leukemia cutis2. amelanotic melanoma3. metastatic carcinoma4. pyogenic granuloma5. SCC.

MCC Histologic DDx includes 1. lymphoma,2. BCC3. metastatic oat cell carcinoma4. noncutaneous neuroendocrine tumors5. 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.

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

STAGING stage I (primary tumor alone) stage II (locoregional metastases), stage III (metastatic disease).

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

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.

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 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.

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.

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.

FOLLOWED UP ,RISK FACTORpoor 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)

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.

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

MAC a sclerotic or indurated plaque with an

intact epidermis and yellow hue central face and lip usually asymptomatic

DDXDesmoplastic 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

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,

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

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

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.

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.

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,

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 patternpagetoid changes vascular invasion, lymphatic channel involvement, previous radiation, orbital spread.

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

PATHOGENESIS OF MFH after radiation in scar tissue. in a burn scar has also been Decreased immune surveillance ?

MF Factors that appear to influence

metastasis include depth and size of tumor, histologic grade, and inflammatory response

TREATMENT OPTIONS FOR MFH WLE, (recurrence rates of up to 40%

have been reported with this approach) MMS Adjuvant radiotherapy

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,

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.

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.

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,

size at presentation

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

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.

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.

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

EPITHELIOID AS

involve the lower extremities. Epithelioid AS results in widespread

metastases within 1 year of presentation.

Prognosis, is poor.

KAPOSI'S SARCOMA 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.

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

AFRICAN ENDEMIC KS1. indolent nodular2. locally aggressive 3. disseminated aggressiveclinically and behaves similarly to classic

KS.

fulminant lymphadenopathic disease

IATROGENIC KS 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.

CARCINOMA METASTATIC TO SKIN 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.

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