Skin Cancer

Epidemiology

Skin cancer is the third of all cancers, although only 0.1% of the patients die due to cancer.

In Romania in 1996 the incidence was 14.42 to 100,000 inhabitants

            Most skin cancers are either basal cell or squamous cell carcinomas.

            Risk Factors

            1. Sun exposure is the most important. It has a direct and indirect carcinogenic effect of immunosuppression.

            2. Irradiation for benign conditions.

            3. Immunosuppression (kidney transplantation, AIDS)

            4. Exposure to arsenic

            5. Genetic Diseases: – xeroderma pigmentosum

                                         – Basal cell nevus syndrome

            6. Infection with human papilloma virus

7. Precancerous lesions:

· Actinic keratosis, the risk of malignancy is <1%

· Bowen Disease

· Quéré Erytroplasia

· Cutaneous horn

Classification of skin tumors

            1. Basal cell carcinoma (the most common)

                        a) Ulcerated nodular basal cell carcinoma

                        b) Superficial basal cell carcinoma

c) Sclerosing basal cell carcinoma (morfeiform) with aggressive growth

                        d) Pigmented basal cell carcinoma

            2. Squamous cell carcinoma

                        a) Squamous cell carcinoma

                        b) Bowen’s disease (carcinoma in situ)

            3. Rare Skin Tumors:

                        a) apocrine carcinoma

                        b) ecrinous carcinoma

                        c) sebaceous carcinoma

                        d) Merkell cell tumor

                        e) extramammary Paget disease

            Signs and Symptoms: node translucent, translucent pearls usually face (basal cell carcinoma), indurated ulcer edges that do not heal (squamous cell carcinoma).

            The diagnosis is confirmed based on histopathological examination.

            Tumor biopsy or curettage may be by shaving, puncture biopsy and excisional biopsy.

            Screening consists of historical and whole body examination in daylight. For the general population over the

Prevention is by avoiding sun exposure between the hours of 1000 and 1600, the use of protective substances, protective clothing, self-examination.

            Staging

            Basal cell carcinoma. There is no staging system for basal cell carcinoma metastases due to the low. The rate of metastasis is 0.0028% -0.02%. Most lymph node metastasis were, but appeared in the lung, bone, liver. They appeared in the case of large primary tumors with long development resistant to treatment. Morbidity basal cell carcinoma is given mainly by the destruction of local structures: eye, ear, nose, intracranial extension.

            Squamous cell carcinoma

            Squamous carcinoma metastasis rate is between 7-12%, mostly lymph node metastases. Or carcinomas in immunosuppressed patients with squamous appearing on burn scars, metastasis rate is higher 20-30%

            Outside the TNM staging system, Broders classification system also has important prognostic that stages tumor according to the proportion of differentiated cells.

                        Grade 1:> 75% differentiated cells

                        Grade 2: 50-75% differentiated cells

                        Grade 3: 25-50% differentiated cells

                        Grade 4: <25% differentiated cells

            For staging of squamous cell carcinoma recommended clinical examination of the lesion and regional lymph nodes. It is not recommended that an assessment of metastasis.

– Table no. 41 staging skin cancers (AJJCC)

(Excluding eyelid lesions, vulva, penis)

            Primary Tumor (T)

            TX- tumor cannot be assessed

            T0- no evidence of primary tumor

            Tis- carcinoma in situ

            T1 tumor ≤ 2 cm in greatest diameter

            T2 tumor> 2 cm but <5 cm in greatest diameter

T3- tumor> 5 cm in greatest diameter

T4 – tumor invades deeper extradermal structures (cartilage, muscle, bone).

            Regional lymph nodes (N)

            Nx – regional lymph nodes cannot be assessed

            N0- no regional lymph node metastasis

            Regional lymph node metastases N1-

Distant metastasis (M)

MX presence of distant metastases cannot be assessed

M0- no distant metastases

M1 distant metastasis

            Stages:

            Tis N0 M0 Std.0

            T1 N0 M0 Std.I

            T2 N0 M0 Std.II

                                    T3 N0 M0

            T4 N0 M0 Std.III

                             oanyriceT N1 M0

            Std.IV any T any N M1

TREATMENT

Therapeutic Indication

Actinic keratosis. It is recommended liquid nitrogen cryosurgery, curettage with or without electrocautery or topical applications with 5FUR.

Bowen’s disease (intraepidermall squamous cell carcinoma). Indications:  curettage with electrocautery or surgical excision.

            Basal cell carcinoma

a) To increase non-aggressive tumors located on the trunk or extremities, treatment options are surgical excision or curettage with electrocoagulation.

b) To increase aggressive tumors located on the trunk or extremities Mohs micrographic surgery is recommended.

c) tumors localized periorbital, nasolabial groove, periauricular,  Mohs micrographic surgery is indicated.

d) For recurrent tumors of any size and location Mohs micrographic surgery is recommended.

Squamous cell carcinoma

a) For tumors less than 1 cm therapeutic options are surgical excision or curettage of electrocoagulation.

b) For tumors> 1 cm is recommended surgical excision or Mohs micrographic surgery.

c) For tumors located in the nasolabial groove, periorbital or periauricular Mohs micrographic surgery is indicated.

d) For recurrent tumors at any site and size Mohs micrographic surgery is recommended.

Therapeutic Modalities

            Surgical Excision

            For small lesions (<2cm) treatment option is surgical excision with margins of safety of 4-6mm.

For large tumors is recommended safety margin 5-10mm. The margins of resection are examined histologically. If the margins are positive or Mohs micrographic surgery is recommended reexcizie.

The cure rate for both basal cell carcinoma and squamous cell carcinoma is almost 90%.

Mohs micrographic surgery has the advantage of removing the entire tumor, with minimal sacrifice of normal tissue.

Mohs surgery has the advantage that the entire surface of the tumor including deep uttermost side and are histologically fully examined. It is indicated in large infiltrative lesions involving the periorbital region, fingers, penis, recurrent tumors. The cure rate is 94-97%.

            Curettage associated with electrocauterisation

It is useful in superficial basal cell carcinoma and Bowen disease torso. Under local anesthesia and tumor curettage is the base and edges are electrocauterised.

The wound heals in 3-6 weeks. The cure rate is 90%. Not recommended in morphea type of basal cell carcinoma and tumor recurrences.

Cryosurgery uses liquid nitrogen to destroy tumor by freezing them at -250C, -400C. It is indicated in patients who refuse surgery. It is contraindicated in sclerosing basal cell carcinoma. The lesions treated by cryosurgery heal in 30 days.

Radiation therapy is useful in treating lesions for which no tissue destruction desired cosmetic or functional reasons: eyelids, nose wing, nose, ear.

It is recommended in the treatment of metastatic lymph nodes with or without the associated surgical treatment.

It is contraindicated in sleep basal cell carcinoma and cutaneous horn appears on the irradiated area.

The doses used are between 3000-5000cGy in 15-20 fractions over 3-4 weeks.

Topical chemotherapy. 5 Fluorouracil is used in the form of a cream 5% or 5%. It is indicated for the treatment of superficial basal cell carcinoma as an alternative to standard methods. Produce a healing rate of 93%. Not recommended in recurrent lesions.

Systemic chemotherapy. Use 5 Fluorouracil, Cisplatin, methotrexate, doxorubicin. It is indicated in metastatic tumors.

 Chemotherapy regimens

PF 5 FUR 1g / m2 / day IV continuous infusion, days 1-5

        Cisplatin 100 mg / m2 / day, i.v. infusion, on day 1

                     Is repeated after 28 days.

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DP: doxorubicin 60 mg / m2 / day IV infusion, day 1

Cisplatin 100 mg / m2 / day, pefuzie i.v., day 1

        Is repeated after 28 days.

Prognostic

Basal cell carcinoma

Unfavorable prognostic factors:

v type morfeiform

v tumor> 2 cm

v ulcer disease

Squamous cell carcinoma

Unfavorable prognostic factors:

v scar appearing on cancer

v recurrent tumor

v tumors> 4 cm or diameter> 2 cm

v histological markers:

a poorly differentiated tumor

a nodal invasion

perineural invasion

            Tracking patients by clinical examination is 3 months in the first 2 years, 6 months next 3 years and annually thereafter.