Transcript PowerPoint 簡報 - Introduction

CC Wong
PYNEH
Skin cancer
 Non-melanoma
Basal cell carcinoma
Squamous cell carcinoma
Dermatofibrosarcoma
Merkel cell carcinoma
Kaposi sarcoma
Angiosarcoma
Melanoma
Non-melanoma skin
cancer
Non-melanoma skin cancer
Most common cancer in the USA
 Over 1,000,000 new cases in the USA per year
 Fair skinned population
Risk factors
 Environmental factors
 Sunlight exposure (Ultraviolet radiation)
 Ionizing radiation
 Chemical exposure eg. arsenic agent
 Patient factors
 Genetics disease
 Precursor lesion
 HIV and HPV infection
UV radiation
More carcinogenic
95%
Basal cell carcinoma
Basal cell carcinoma
75% of non-melanoma skin cancer
Male : female = 3:2
Sunlight exposure
Head & neck
Slow growing
Rarely metastasizes
Basal cell carcinoma
Nodular
 most common, pearly appearing papule
Pigmented
 more frequent in darker-skinned population
Cystic
 bluish or gray cystic nodule
Superficial
 scaly patch-like lesion
 pink to red to brown
Basal cell carcinoma
 Micronodular
aggressive variant
 Morpheaform (infiltrating)
aggressive variant
scar-like appearance with
ill-defined border
Squamous cell
carcinoma
Squamous cell carcinoma
Second most common skin cancer
Male : female = 2-3:1
Sunlight exposure
Old scar, chronic inflammation and
ulcer
Area of pre-exiting skin damage
Faster growing
Squamous cell carcinoma
Actinic keratosis: precursor
Bowen's disease: SCC in-situ
Unhealed ulcer with "heaped up" edge
Enlarging lesion irregular border
Cranial nerve dysfunction
perineural invasion
Diagnosis
 Clinical diagnosis
 Incisional / excisional biopsy
 Imaging
Treatment
Surgical excision
Major treatment method
High clearance rate
~95% in both SCC and BCC
Low recurrence rate (in 5 year)
5.8% in SCC, <2% in BCC
N.R. Telfer et al. British J of Dermatology. 2008
Murad Alam et al. N Engl J Med. 2001
How much margin should we
take?
BCC
Lesion
 Low risk
Margin (mm)
 Trunk & extremities <2cm
 Head &neck <1cm
 Around eyes, ears, nose, mouth, hand
and feet <6mm
4-5
 High risk
 Recurrent tumor
 Immunocompromised
 Previous radiation site
 Perineural invasion
 Micronodular, sclerosing, morpheaform
10
SCC
Lesion
 Low risk
 Trunk & extremities <2cm
 Head &neck <1cm
Margin (mm)
4-5
 Around eyes, ears, nose, mouth, hand and
feet <6mm
 High risk
 Recurrent tumor
 Immunocompromised
 Previous radiation site
 Perineural invasion
 Poorly differentiated
 Adenoid, adenosquamous, desmoplastic
10
Facial H area
Mohs' micrographic surgery
 Frederic E. Mohs in 1938
 Complete circumferential peripheral and deep
margin assessment
 Performed in stages / single day
 5 year local control rate
SCC
BCC
Primary
96.9%
99%
Recurrent
90-93.3%
94.4%
Murad Alam et al. N Engl J Med. 2001
Nicole W.J. et al. The Lancet 2004
Mohs' micrographic surgery
 Preserve healthy skin tissue
 Time consuming
 High cost
Mohs' micrographic surgery
Important site:
eyelids, ear, nose, lips, nasolabila fold,
forehead, scalp or embryonic fusion plane
Recurrence
Size >2cm
Perineural involvement
Poorly defined margins in high-risk area
Nicole W.J. et al. The Lancet 2004
Radiation therapy
Primary vs adjuvant
5-year local control rate ~90%
Multiple visits
No histological result
Side effect: dermatitis, telangiectasia
Contraindication:
 Genetic condition eg. xeroderma pigmentosa
 Connective tissue disease
I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010
Electrodesiccation and
Curettage
Indication:
Small lesion <1cm
Superficial
Well-defined
5-year local control rate: 95% in
low risk BCC
Multiple attempts
No histopathology
I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010
N.R. Telfer et al. British J of Dermatology. 2008
Cryotherapy
Liquid nitrogen
Frozen the skin -> tissue necrosis
Multiple cycles
5-year recurrence rate: 8% in low risk
BCC
No histopathology
Good cosmetic result
I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010
N.R. Telfer et al. British J of Dermatology. 2008
Cryotherapy
Indication: Low risk BCC
Size <1cm
Superficial, nodular
Well-defined margin
I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010
N.R. Telfer et al. British J of Dermatology. 2008
Topical immunotherapy
 Imiquimod
 Toll-like receptor 7 agonist
 Modify the immune response ->
antitumor activity -> tumor cell
apoptosis
 5 application a week for 6 week
 Indication: Small superficial BCC
 Initial response rate 89.6%
 Lack of long term data
 Excellent cosmetic result
I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010
Photodynamic therapy
Photosensitizing agent followed by
illumination of visible light
Produced activated oxygen molecule
-> destroy target cell
Usually 2 cycles
5-year recurrence rate: 14%
Excellent cosmetic effect
I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010
Photodynamic therapy
Limited penetration
Indication:
Superficial lesion
Depth <2mm
I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010
5-Fluorouracil
 Topic chemotherapeutic agent
 Blocking DNA synthesis
 Apply twice a day for minimum 6 week
 Cure rate: 93%
 Indications:
 Superficial BCC
 Small ~1cm
 Local inflammatory response
I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010
Interferon
Intralesional injection
Induce apoptosis
3 injections per week for 3 week
Complete response rate: 50-80%
Indications:
Surgery could be disfiguring
Not a surgical candidate
Influenza-like symptom
I.R. Aguayo-Leiva et al. Actas Dermosifiliogr. 2010
Conclusion
Non-melanoma skin cancer
 Common
 Rate of cure is high with proper treatment in
local disease
 Surgical excision is associated with lowest
recurrence rate
 Other non-surgical treatment
 Early superficial disease
 Non-surgical candidates
Thank you
SLN
 No definite guideline
 Lack of large scale study on nonmelanoma skin cancer
 Renzi et al.: 22 patients
 Reschly et al.: 9 patients
 Useful in high risk SCC
Involved margin
 ~30-41% do not recur
 Re-excision of margin
 Mohs micrographic surgery
 Radiotherapy