Basal Cell Carcinoma Mark H. Tseng MD SUNY Downstate University Hospital June 17, 2005

History

Discrete, raised, circular ulceration.

History Pt was admitted to xx Hospital in 2005 for bleeding. He was transfused 5 units of blood.

History Pt arrived at SUNY Downstate on xx 2005. He was evaluated and biopsies of the margins was taken. Path came back negative and surgery was scheduled.

History PMH: None PSH: Tonsillectomy Family Hx: None Social Hx: -Habits: ------Allergies: NKDA MEDS: Multivitamins

Vitals Temperature: 98.8F Blood Pressure: 120/73 Heart Rate: 90 Respiratory Rate: 14 Saturation: 99% on room air

Physical Exam General: Appears age appropriate HEENT: large ulcer extending to left neck, friable, no active bleeding. Chest: large left mass/ulcer approx. 3 feet x 3 feet extending from: Anterior: chest Lateral: shoulder Medial: neck Posterior: Back Lung: CTA bilaterally, no wheezing, no rales Heart: S1S2 Abdomen: soft, nt, nd, +bs

LABS 5/3/05 pre-op: Wbc: 9 H/H: 10/33 Plt: 408 Na: 136 K: 4.6 Cl: 101 HCO3: 23 BUN: 21 Crea: 1.1 Glucose: 69 Alb: 3.1 PT: 14.5 INR: 1.2 PTT: 26

Shoulder X- RAY „

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Aggressive osteolytic lesions @ distal clavicle and acromion

History Because of the large area of ulceration, the depth of invasion, and the vital structures involved. A team of surgeon from various surgical specialties were involved. - General Surgery - Plastic Surgery - Orthopedics Surgery - Vascular Surgery

Operating Team

Dr. Bakshandeh

Dr. Schwartzman

Dr. Deitch

Intra-op

Taken to OR and intubated.

Intra-op: resection

Incision through skin, subQ, fat, to level of fascia.

Intra-op: resection

Dissection carried deep to the pectoralis major.

Intra-op: resection „

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Dissection carried up to clavicle superiorly, medially into the neck, and posterior back along latissimus. Deepest part of incision was @ level of the shoulder. Tumor invading the supraclavicular space.

Intra-op: resection

Resection of lateral clavicular head and acromion

Intra-op: reconstruction

Transverse incision made 1 cm below the nipple. Pectoralis major was dissected off the pectoralis minor.

Intra-op: reconstruction

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Once pectoralis major was freed Muscle flap was adv. superiorly covering the defect

Intra-op: reconstruction

STSG at 13,000 of inch harvest from left thigh

Intra-op: reconstruction

1000 sq. cm of STSG used to cover the open area.

Hospital course Immediate post-op: extubated and hemodynamically stable. POD #1 Transfer to floor POD #9 Rehab was started POD #14 Discharge

Pathology

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Ulcerating basal cell carcinoma with squamous and adenoid foci Margins are free of tumor

Basal Cell Carcinoma: Overview and Management Mark H. Tseng MD SUNY Downstate University Hospital June 17, 2005

Overview „ „

Introduction Epidemiology „ „

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Incidence Risk factors

Anatomy/Histology Clinical presentation Diagnosis Treatment Prognosis Conclusion References

Introduction „

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Most common skin cancer arising from the basal layer of epidermis and its ppendages Low metastatic potiential Locally invasive, aggressive, and destructive to skin and bone

Epidemiology „ „ „ „ „ „

Skin cancer: approx. 1.5 million cases per year BCC is most common skin cancer 80% is BCC White >> Black Men >> women BCC increase with age „

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Aged 55-70 has 100 fold higher incidence of BCC than age 20 and younger

15% 4% 1% 80%

Basal Cell Squamous Cell Melanoma Etc.

Striking geographic variation „ Higher incidence closer to the equator „ *Australia is 40X that of Finland

* Marks, R, Staples, M, Giles, GG. Trends in nonnon-melanocytic skin cancer treated in Australia: the second national survey. Int J Cancer 1993; 53:585.

Risk Factors: Environmental Sun exposure is the most important environmental cause of BCC. Ultraviolet light – Sun Exposure „ Ionizing radiation causes mutation of tumor suppressor genes „ UV B light: 280-320nm, UV A light 320400nm But, UVA rays pass deeper into the skin. UVB radiation is thought to be the cause of melanoma and other types of skin cancer. UVA radiation may cause skin damage that can lead to skin cancer and cause premature aging of the skin.

Amount of UV B exposure during childhood and adolescence is directly proportional to risk for BCC

Risk Factors: Sunburns The Behavior Risk Factor Surveillance System provided data showing nearly 32% of all adults in the US report having had a sunburn in 1999. More than 57% of adults age 18 to 29 reported having had a sunburn. Over 40% of children are reported to have had sunburns over the preceding year.

Risk Factor: Sun exposure „

Childhood sun exposure is more important than exposure during adult life. „ „

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*Canadian case control study 226 men with BCC and 406 age-match controls

Aggressive sun protection before age 18 reduce nonmelanoma skin cancer by 78%. The type, quantity and timing of sun exposure necessary to increase the risk of BCC are not clearly defined.

*Gallagher, Bajdik, Bajdik, CD, et al. Sunlight exposure, Basal cell carcinoma. Arch Dermatol 1995; 131:157.

How can it be PREVENTED? „ „

For most of us, it’s too late !! But we can keep our kids from getting sunburns. USE SUNSCREEN „

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*Large randomized trial evaluating sunscreen and betacarotene (oral antioxidant) on prevention of BCC and SCC followed over 4 years. Users of sunscreen has 40% reduction in skin cancer over non-users Beta carotene failed to decrease incidence over placebo.

*Green, A, Williams, G, Neale, R, et al. Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: a randomised controlled trial. Lancet 1999; 354:723.

Risk Factors „

The following groups have the least melanin and are at greatest risk for BCC: fair complexion, „ light hair, „ blue/green eyes, „ inability to tan, „ history of multiple or severe sunburns, „ frequent use of tanning beds, ladies! „ Celtic ancestry „

Risk Factors „ „ „ „ „

Smoking Arsenic Radiation Therapy Burns, Scars, Ulcers Chronic immunosuppression „ „

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*Transplant patients Incidence is increased 10 fold in transplant patients compare to nontransplant patients

Albinism Mutation of PTCH gene (tumor suppressor gene) on chromosome 9 in patients with familial basal cell nevus syndrome. Bazex's syndrome (basal cell carcinomas, follicular atrophoderma, hypotrichosis, and hypohidrosis or hyperhidrosis) Gorlin's syndrome (multiple basal cell carcinomas, pitting of the palms and the soles of the feet, mandibular cysts, spine and rib anomalies, calcification of the falx cerebri, and cataracts )

*Hartevelt, MM, Bavinck, JN, Kootte, AM, et al. Incidence of skin cancer after renal transplantation in the Netherlands. Transplantation 1990; 49:506.

Skin Structure „ „ „ „

Epidermis Dermis Hypodermis Epidermal appendages

Skin Histology „ „ „ „ „

Stratum corneum stratum lucidum stratum granulosum stratum spinosum stratum basale

Clinical Presentation „

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Slowly growing malignancy of the epidermis Rarely metastasizes (.028-.55%) Cells appear histologically similar to basal cells of epidermis

Clinical Presentation „

Distribution of BCC: 70% on face „ 25% on trunk „ 5% on penis, vulva, or perianal skin „

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Clinical subtypes (4) Nodular „ Superficial „ Pigmented „ Morpheaform „

Clinical Presentation „

Nodular „ „ „ „

Discrete, raised, circular Central ulceration Pink, waxy rolled borders Relatively non-aggressive

Clinical Presentation „

Superficial „ „ „ „

Threadlike, waxy border Red, scaling patches Spread by radial extension Uncommon in Head and Neck

Clinical Presentation „

Pigmented „

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Resemble nevus or melanoma Behave the same as nodular variant

Clinical Presentation „

Morpheaform „ „ „ „

Macular, whitish, or yellowish plaque Indistinct clinical margins Aggressive behavior Worst prognosis

Clinical Presentation „

Histologic Subtypes (4) Solid „ Cystic „ Adenoid „ Keratotic (Basosquamous) „

Clinical Presentation „

Solid – no cellular differentiation

Clinical Presentation „

Cystic „

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Differentiation towards sebaceous glands Cystic spaces within tumor lobules

Clinical Presentation „

Adenoid „ „

Glandular pattern Lacelike pattern

Clinical Presentation „

Keratotic (Basosquamous) „

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Basal cell CA with differentiation towards hair structures Shows feature of both basal cell and squamous cell carcinomas More aggressive clinically Undifferentiated cells in combination with parakeratotic cells and horn cysts

Diagnosis „

Initial evaluation involves „ „

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Assessment of location Punch or excisional biopsy Staging

Diagnosis - Staging

Treatment: Techniques „ „ „ „ „ „

Electrodessication and curettage Cryosurgery Radiation therapy Photodynamic therapy Excisional surgery Mohs surgery

Treatment

Treatment: Electrodessication and Curettage „

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Used to remove tumor by feel with small margin of normal tissue Reserved for histologically and clinically favorable basal cell carcinomas. Not used for squamous cell lesions

Treatment: Cryosurgery „ „ „ „ „

Uses liquid Nitrogen to kill tumor cells Typical temperature of -50°C . Tissue-sparing, but leave open wound Hypopigmentation and scarring may result Limited to favorable small lesions with welldefined borders

Treatment: Radiation Therapy „ „ „ „

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Used extensively in the past, now sparingly High cure rate (95%) Does not allow surgical staging Currently reserved for poor operative candidates, adjuvant in high risk malignancy Protracted treatment course, and expensive Radiodermatitis, delayed carcinogenesis

Treatment: Photodynamic Therapy „

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Photosensitizing drug (porphyrin, 5-ALA) applied topically, orally or parenterally and localizes into tumor cells Drug is activated by exposure to light (laser) Efficacy is low (45%) Side effects include local edema, erythema, blistering, ulceration Used as palliation

Treatment: Excisional Surgery „ „ „ „ „ „

Most often used by surgeons, especially for larger lesions Can be with cold steel or laser Can allow reconstruction in the same sitting Frozen sections decrease recurrence rate Can be time consuming and inconvenient If more than 1/3 of a cosmetic facial unit is excised, better cosmesis with removal of entire unit

Mohs Surgery „ „

First described by Frederic E. Mohs in 1941 Mohs micrographic surgery (MMS) Gold standard for treating high-risk skin cancers „ Series of precise excision and microscopic evaluation „ 99% 5 year cure rate for BCC „ Lowest recurrence rate „ Advantages: precision, excellent cure rate, better cosmesis because it spares normal tissue „ Disadvantages: time consuming and expensive „

Mohs Surgery: Indications

Treatment: Recurrence Rate „

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All of the non-Mohs' modalities have roughly equal and excellent cure rates for BCC without high-risk prognostic factors Recurrence rates for tumors treated by Moh’s Micrographic Surgery appear to be lower at all points in time and averages between 1-2%. The key predictors of tumor recurrence are size and site of the lesion, histology of tumor, and skill of the operator There is an increased risk of BCC recurrence regardless of treatment modality with increasing time.

Prognosis „ „ „

Excellent Significant morbidity and disfigurement Pt with BCC are susceptible to other skin cancer „

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*40% over 3 years

Slow-growing tumor Metastasis is rare: 0.1% „ „ „

Usually deeply invasive or large ( 10 x 10 cm or greater ) Fatal within eight months Routine metastatic workup is not recommend unless symptoms supervene

*Marcil, Marcil, I, Stern, RS. Risk of developing a subsequent nonmelanoma skin cancer in patients with a history of nonmelanoma skin cancer: a critical review of the literature and metameta-analysis. Arch Dermatol 2000; 136:1524.

Conclusion „ „ „ „ „

BCC is the most common malignancy Risk factors: sunlight Use sunscreen Moh’s surgery is gold standard High risk of developing a second BCC

References Marks, R, Staples, M, Giles, GG. Trends in non-melanocytic skin cancer treated in Australia: the second national survey. Int J Cancer 1993; 53:585. Gallagher, Bajdik, CD, et al. Sunlight exposure, Basal cell carcinoma. Arch Dermatol 1995; 131:157 Green, A, Williams, G, Neale, R, et al. Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: a randomised controlled trial. Lancet 1999; 354:723. Hartevelt, MM, Bavinck, JN, Kootte, AM, et al. Incidence of skin cancer after renal transplantation in the Netherlands. Transplantation 1990; 49:506. Marcil, I, Stern, RS. Risk of developing a subsequent nonmelanoma skin cancer in patients with a history of nonmelanoma skin cancer: a critical review of the literature and meta-analysis. Arch Dermatol 2000; 136:1524.

The End