75% Most common

plastic
surgeons

one in five

3.5 million new cases

 Other risk •
Epidemiology •
factor
Risk
Most common factor •
Predominant •
80% risk factor •
•
•
•
light-
•
skinned populations
highest UV
exposure sporadically

several clinical
Mortality is rare syndromes
• SHH signaling
• pathway
•
Tumor type →

Nodular BCC

Most common

•
•

Rodent ulcer appearance →

Variations:
• Cystic BCC →

• Pigmented BCC →
Superficial BCC

Second most common

trunk
extremities

scaly ulcerated with

erythema
Morpheaform or sclerosing BCC

numerous thin linear

extensions reach into the deep dermis →
 Staging

Diagnosis

Histopathology
•

Additional workup
• →
•

Prognosis
•
 Destructive treatment Surgical or excisional treatment

Low-risk cases High-risk cases

→ trunk Facial Area
extremities
Direct excisional biopsy
• 95%
•
•

•
• • <1 cm
• Mohs’ micrographic surgery
4
• to 5 mm • most definitive modality and treatment of choice
• • >1 cm
• 5
• to 10 mm • serially excised entire
margin of resection is examined histologically

• Cure rate →
 Direct Excision
• better outcomes
recurrent
• no significant statistical differences
primary BCC

Prognosis Recurrences

• good prognosis

• morbidity
local invasion every 6 months for the first year
annually thereafter
 Epidemiology Risk factor

Environmental risk factors Host risk factors

second
• • →
most common → 15-
20% • •
• •
•
•
primary tumors •
locally invasive • •
diagnosed in the early stages
highly curable disease

3,000 patients die

 incidence
Pathogenesis

→
 sun-exposed skin premalignant actinic keratosis →

80% of cSCC tumors arise in association with a Cutaneous horn

preexisting actinic keratosis
•
• hyperkeratotic protuberance
cone

• • • 15%
• • contain cSCC
•
 cSCC in situ (Bowen’s disease)

Frequently diagnosed in older patients (>60 Progression to invasive cSCC

slowly growing
years) and can occur anywhere on the body 33%
erythematous scaly patch
including the mucosal surfaces

Erythroplasia of queyrat Leukoplakia

• mucocutaneous epithelium • oral or genital mucosa
glans of the penis labia majora adherent white patches
• uncircumcised men •
• chronic irritation,
infection with HPV, immunosuppression
• velvety red plaque • biopsy
• 10-20%
 Keratoacanthoma Invasive cSCC
• Rapidly growing nodule • Penetrates the basement • actinic
central ulceration membrane keratosis →
keratin plug de novo
actinic keratosis
• • De novo invasive cSCC →
clinically difficult to distinguish Well-differentiated
→ surgical excision
→

Poorly-differentiated
→
 Diagnosis of cSCC Staging of cSCC

Tissue biopsy American Joint

TNM staging
Committee on
• system
Cancer (AJCC)
T staging (Tumor Characteristics)

Fine needle aspiration •

•
•

•
Routine imaging studies

•
N component (Regional Lymph Nodes)
•
 diagnosed
Tumor-specific features that are
cured early stages
considered “high risk”:
regional metastasis
0.5-10%
•

•
More likely to exhibit more aggressive •
tumor types and disease progression:
•

• • •
•
• • •

•
 Destructive treatment Surgical or excisional treatment

• both low-risk
Mohs’ micrographic surgery
high-risk lesions
• Recommended surgical margin Treatment of choice
•
•

Sentinel lymph node biopsy Systemic chemotherapy

 steadily
increasing
114,900 patients
fifth most
most deadly
common
→ >75% of
→
1/52 skin cancer deaths
 Host Factors Environmental Risk Factor
• • • Intermittent and intense sun exposure
•
• • • One or more blistering sunburns
•
Regular broad spectrum sunscreen → 

ABCDE diagnostic tool

A B C D E
 Classified into five clinical and histologic growth patterns

Superficial Nodular Lentigo Acral Desmoplastic

spreading maligna lentiginous melanoma
•
• • •
•
• •
• •
•
•

•
• →
• • →

•

•

 Diagnosis

Definitive biopsy Screening workup

• •
• diagnosis • •
staging and prognosis
• Histologic characteristics →
5- and 10-year survival rate CT or PET scan
• Method of choice → • Further imaging studies

• nodal involvement
head and neck primary tumors
Incisional biopsy or Shave biopsies
multiple punch
biopsies Metastatic workup
• •
• •
•
 Staging

AJCC Staging and Classification TNM classification system

guidelines (2009)
N component M component
(Regional Lymph (Distant Metastasis)
Nodes)
Tumor Mitotic rate Ulceration site of
thickness metastatic distant metastasis
nodes overall tumor 
burden ulceration of
the primary lesion

microscopic nodal metastasis

sentinel lymph node biopsy

Stage III
 →

• •
•
•
 →

Ear Face Fingers and toes

→
 Subungual melanoma of Palmar or plantar
the index, middle, ring, or
little fingers

Dorsal lesions on the hands/feet or

Great toe (most common site of digital web-space lesions
melanoma) and remaining toes
 →

Technical limitations:

• •

• •
•
•
• • • γ-
 Sentinel lymph node biopsy process

Preoperative Direct intraoperative visualization of draining

lymphoscintigraphy lymphatic patterns using a blue dye

Identifies the anatomic

location of the sentinel
γ →
node, but gives no
γ
information as to
→
whether it contains
metastatic melanoma
 γ

→
Routine histologic examination Immunohistochemical staining
with H&E staining

S-100 HMB-45 and MART-1

 Complete surgical Elective lymph node dissection
lymphadenectomy In patients with clinically uninvolved nodes

• →
examination, fine needle
aspiration, and/or sentinel lymph node biopsy
• Nodal status → the most important prognostic factor
in staging malignant melanoma
•

• lymphedema axillary and

inguinal lymphadenectomy →
• →
 A number of modalities have been studied in clinical trials
• •
• •
• •
• •
• •
•

There are no provocative data indicating that any of these treatments

reliably prolongs survival in stage IV melanoma