CAPA 2015 Annual Conference 1 Review of Cutaneous Malignancies Tanya Nino, MD Department of Dermatology Did You Know? • More than 3.5 million skin cancers are diagnosed in the US annually • Melanoma incidence rates have been increasing for at least 30 years • 1 in 5 Americans will develop some form of skin cancer during their lifetime Rogers, HW, Weinstock, MA, Harris, AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 2010; 146(3):283- 287. American Cancer Society. Cancer Facts and Figures 2014. http://www.cancer. org/research/cancerfactsstatistics/cancerfactsfigures2014/index Why is this important? • In 2015, it is estimated that 137,310 new melanomas will be diagnosed in the US and that 9,940 deaths will occur from melanoma… • Nearly every hour, an American dies from Melanoma. • US melanoma incidence has increased approximately 15 fold in the past 50 years. • This represents a substantial public health problem American Cancer Society. Cancer Facts and Figures 2014. http://www.cancer. org/research/cancerfactsstatistics/cancerfactsfigures2014/index Bolognia JL, Jorizzo JL, Rapini RP, eds. Mosby: St. Louis, Dermatology, 2nd edition
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CAPA 2015 Annual Conference
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Review of CutaneousMalignancies
Tanya Nino, MDDepartment of Dermatology
Did You Know?• More than 3.5 million skin cancers are
diagnosed in the US annually• Melanoma incidence rates have been
increasing for at least 30 years• 1 in 5 Americans will develop some form of
skin cancer during their lifetime
Rogers, HW, Weinstock, MA, Harris, AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 2010; 146(3):283-287.
American Cancer Society. Cancer Facts and Figures 2014. http://www.cancer. org/research/cancerfactsstatistics/cancerfactsfigures2014/index
Why is this important?• In 2015, it is estimated that 137,310 new melanomas
will be diagnosed in the US and that 9,940 deaths willoccur from melanoma…
• Nearly every hour, an American dies from Melanoma.• US melanoma incidence has increased approximately
15 fold in the past 50 years.• This represents a substantial public health problem
American Cancer Society. Cancer Facts and Figures 2014. http://www.cancer. org/research/cancerfactsstatistics/cancerfactsfigures2014/index
• The edges of the cancer (clinical margins) cannot be clearly defined• Prior treatment has failed, i.e. recurrent tumor• The cancer is located in a cosmetically sensitive or functionally
critical area of the body (such as eyelids, nose, ears, lips, fingers,toes, and genitals)
• The histologic pattern of the cancer is aggressive (e.g.,morpheaform, infiltrative, metatypical BCC, anaplastic SCC)
• The patient is immunosuppressed• The cancer is > 2cm on the trunk or extremities• The patient has a genetic syndrome with high risk for skin cancer
• Chronic, non-healing wounds, DLE, LP, LSA• Organ transplantation
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Melanoma
Melanoma
• Malignant tumor arising from melanocytes
• Majority are brown-black due to melanindeposition, but some are skin-colored to pink-red (i.e. amelanotic)
Photographs courtesy of Kenneth Linden, MD, PhD
Melanoma
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Melanoma
The ABCDE’s of Melanoma
ASSYMETRY:-If you were to fold it in half, the two sides
wouldn’t match up.
BORDER IRREGULARITY:-Jagged or blurred edges rather than smooth,
continuous line.
COLOR VARIATION:-Two or more different colors are present.
DIAMETER:-Any sudden or continuing growth
-Any mole larger than 6mm (pencil-top eraser)
EVOLUTION:-Change over time
Melanoma
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Melanoma
Superficial Spreading Melanoma
• Most common type• Age 30-50• Trunk of men, legs of women• 50% arise de novo and 50% arise in a
pre-existing nevus• Can be < 5mm
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Nodular Melanoma
• Arises as a de novo vertical growthphase tumor without the pre-existinghorizontal growth phase
• Diagnosed at a thicker, moreadvanced stage
• Poorer prognosis
Lentigo Maligna Melanoma
• Chronically sun damaged skin• Mostly on the face• Slow growing• In situ precursor to invasive lentigo
maligna melanoma
Acral Lentiginous Melanoma
• Palms, soles, around nails
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Pigmented nail streaks
• Possibility of melanomashould be considered for allpigmented nail bands in fair-skinned individuals,especially if darklypigmented, irregularlypigmented, or width > 3mm
• Hutchinson sign:Pigmentation of theperiungual tissues andvaluable clue to diagnosis ofsubungual melanoma
If melanoma is suspected:
• Excisional biopsy with 1-2mm margins is best
– Prevents sampling error
– Enables pathologist to assess overall architecture ofthe lesion
– Impractical to perform a full excision (i.e. tumor istoo large to be excised, sensitive location)
• Urgent Derm Referral if uncomfortable doing biopsy
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Surgical Excision – How big do themargins need to be?
Who gets a Sentinel Lymph Node Biopsy?
• Primary melanomas > 0.75mm Breslow Depth
• Reasons to proceed with SLN biopsy
– Obtain most complete and accurate diagnostic andstaging information
– Institute early therapeutic complete lymph nodedissection
• Impacts disease-free survival but not overall survival
– Institute adjuvant therapy
– Gain entry into clinical trial for new adjuvanttherapies
• Disadvantage of SLN biopsy
– Morbidity from completion lymphadenectomy chronic lymphedema
Treatments for metastatic melanoma
• Chemotherapy– i.e. interferon, dacarbazine
• Immunotherapy– IL-2
– CTLA-4 blockade
– PD-1 inhibition
• Molecularly targeted therapy – targeting the cellsignaling pathways involved in melanomaprogression– BRAF/MEK inhibitors
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Prognosis• Patients with Stage IA melanoma have 10 year survival
expectancy of > 95%
• Median survival time for stage IV patients is 9 months
Other Types of Skin Cancer
• Atypical fibroxanthoma
• Microcystic adnexal carcinoma
• Merkel cell carcinoma
• Dermatofibromasarcoma protuberans
• Undifferentiated pleomorphic sarcoma
• Sebaceous carcinoma
• And many more…..
Encourage self skin exams…
(Images and text from the AmericanAcademy of Dermatology)
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Encourage self skin exams…
(Images and text from the AmericanAcademy of Dermatology)
Sunlight consists of two types of harmful ultraviolet (UV) rays that reach the earth –ultraviolet A (UVA) rays and ultraviolet B (UVB) rays. Exposure to either can lead toskin cancer. In addition to causing skin cancer:
UVA rays can prematurely age your skin, causing wrinkles and age spots and canpass through window glass.
UVB rays are the primary cause of sunburn and are blocked by window glass.
Ultraviolet Radiation
Ultraviolet Radiation
The sun emits harmful UV rays year round. Even on cloudy days, UV rays canpenetrate the skin.
The United States Department of Health & Human Services and theInternational Agency of Research on Cancer have declared ultraviolet (UV)radiation from the sun and artificial sources, such as tanning beds and sunlamps, as a known carcinogen (cancer causing substance).
There is no safe way to tan. Every time you tan, you damage your skin. As thisdamage builds, you speed up the aging of your skin and increase your risk for alltypes of skin cancer.
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What is SPF?
DETERMINATION OF THE SUN PROTECTION FACTOR:
• 20 human subjects
• Skin type I or II
• Instrumentation: light source which mimics solarspectrum
• The best sunscreen is the one that you will actuallyuse again and again!
• Creams are best for dry skin and face
• Sticks are good to use around the eyes
• Combination products: cosmetics and moisturizers
• Avoid combination sunscreens/insect repellants
• Sprays… current FDA regulations on testing andstandardization do not pertain to spray sunscreens
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Sunscreen Recommendations
• The American Academy of Dermatologyrecommends everyone use sunscreen thatoffers the following:– Broad-spectrum protection (protects against
UVA and UVB rays).– Sun Protection Factor (SPF) 30 or greater.– Water resistance.
• Sunscreen helps to protect your skin fromsunburn, early skin aging, and skin cancer.
• Seek shade when your shadow is shorterthan you are
• Wear sleeves, pants, a wide-brimmed hat,and sunglasses whenever possible.
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When should patients use sunscreen?
• Every day. The sun emits harmful ultraviolet (UV)rays year round.
• Even on cloudy days, harmful UV rays canpenetrate your skin.– On a cloudy day, up to 80 percent of the sun’s UV rays
can pass through the clouds.
• Snow and sand increase the need for sunscreen.– Snow reflects 80 percent of the sun’s rays, and sand
reflects 25 percent of the sun’s rays.
How much suncreen should be used?
• Use enough sunscreen to generously coat all skin that will be not becovered by clothing. Ask yourself, “Will my face, ears, arms, orhands be covered by clothing?” If not, apply sunscreen.
• To be sure you use enough, follow this guideline:– One ounce, enough to fill a shot glass, is considered the amount
needed to cover the exposed areas of the body. Adjust the amount ofsunscreen applied depending on your body size.
– Most people only apply 25-50 percent of the recommended amount ofsunscreen.
• Apply the sunscreen to dry skin 15 minutes BEFORE going outdoors.• To protect your lips, apply a lip balm or lipstick that contains
sunscreen with an SPF of 30 or higher.• Re-apply sunscreen approximately every two hours or after
swimming or sweating heavily
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New FDA Sunscreen Regulations
• On the label, you’ll see whether the sunscreen:– Protects against UVB and/or UVA rays.– Reduces the risk of skin cancer and early skin aging in addition
to helping prevent sunburn, or just protects against sunburnalone.
– Is water-resistant up to 40 or 80 minutes.• Sunscreen manufacturers will no longer claim that a sunscreen is
“waterproof” or “sweat proof.” This is not possible because allsunscreen eventually washes off.
• In order to reduce the risk of skin cancer and early skin aging, thesunscreen must offer two things: broad-spectrum protection(protects against UVA and UVB rays) and an SPF of 30 or higher.Without both, the sunscreen only helps prevent sunburn.
Will using sunscreen limit levels of Vitamin D?
• Using sunscreen may decrease skin’s production of vitamin D.
• Vitamin D in sunscreen users vs. non-users
• Vitamin D in dark-skinned individuals, women, and people innorthern climates in winter
• Controversy about Vitamin D – optimum levels, healthbenefits
• Tanning salon industry
• Nevertheless: Adequate vitamin D should be obtained fromdiet and supplements, NOT UV radiation
More on Vitamin D
• Many people can get the vitaminD they need from foods and/orvitamin supplements. Thisapproach gives you the vitamin Dyou need without increasing yourrisk for skin cancer.
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Foods rich in Vitamin D
• Fish oils (salmon, mackerel, tuna)
• Fortified milk/yogurt
• Egg yolks
• Cheese
• Beef or calf liver
• Mushrooms exposed to UV light
Conclusion
• Exposure to UV light is the most preventablerisk factor for skin cancer
• Many skin cancers are curable if diagnosedand treated early
• Remember the ABCDEs of Melanoma
• Encourage patients to use sunscreen/sunprotective clothing regularly
• Incorporate a skin exam in your routine whenpossible