SKIN CANCER

SKIN CANCER

Dr. Ismeldi, SpB (K) Onk

KANKER KULIT

MELANOMA MALIGNA (8,5%)

NON MELANOMA MALIGNA (89,5%)
- KANKER SEL BASAL (75-80 %)
- KANKER SEL SKUAMOSA (20 %)
KANKER KULIT LAIN (2-3 %)
 Precancer Lesion

SKIN CANCER

Actinic keratosis ( KSS insitu)

Kerato acanthoma
Bowens disease
Xeroderma pigmentosum
Hyperplasia pseudo epi
Dysplastic naevi
Solar keratotic intraepidermal kss
Erythroplasia of Queyrat
Lentigo Maligna
Brown plaque on skin face older people
Bowens Disease
Ssquamous cell
carcinoma (SCC) in situ.

Etiology : uv, chronic

arsenicism,
radiation,
immsup,
infection.
Xeroderma Pigmentosum
Actinic Keratosis

Actinic keratoses (AKs) :

proliferation of aberrant epidermal

keratinocytes in response to
prolonged exposure to ultraviolet
(UV) radiation
 ETIOLOGIC FACTORS
ENDOGEN : Genes
SKIN CANCER

EXOGENS: UV radiation
Ionizing radiation
Viruses
Chemicals : industrial oils, dyes, solvents
arsenic, pesticides, tobacco
Chronic irritation
Hyperthermia

OTHERS : outside activity, changing clothes design,

ozon reducing, imunosupresi
Indication for biopsi

Precancer lession
Susp Malignancy
 BIOPSY TECHNIQUES
SKIN CANCER

Excisional biopsy
Incisional biopsy
Punch biopsy
Pemilihan Terapi
Tergantung :
Tipe histopatologi

Lokasi

Ukuran tumor

Faktor penderita

TERAPI UTAMA :
EKSISI BEDAH (Eksisi Luas
 PRINSIP TERAPI
BEDAH (EKSISI LUAS)
Pengangkatan tumor dengan sempurna
Morbiditas minimal
Preservasi jaringan kulit sehat disekitar
tumor
Kosmetik
Sesuai prinsip Onkologi pembedahan
Follow up ketat
PRIMARY PREVENTION
Sun avoidance between 10.00 16.00 hrs
Sun protective clothing
Sun screens / sun-protecting factor, avoid
sun between 10am-2pm or between 11am-
3pm
Slip, Slop, Slap.
Wear high sleeve shirt
Use broad edge hat
Sunscreen pplication still has many pro-cons
Self checking every 6-8 weeks
Nevus excision.
 BASAL CEL CARCINOMA
SKIN CANCER

USA > 1.200.000 or more new cases NMSC

annually
75 80% basal cell carcinomas.
Kromphecer first describe BCC
Local invasion
Local destruction
Very rare metastasis
Commonly occurred on sun-exposed body area
Can occur on non-exposed area (eg: vulva, penis,
scrotum, perineal)
Karsinoma Sel Basal

Resiko Tinggi Terjadi Rekurensi

Lokasi :
H-zone daerah wajah :
Periorbital, kelopak mata, hidung, perioral, nasolabial
fold,pre auricula, retroauricula.
Histologi :
Mikronoduler, infiltratif, morpheoform
Ukuran : diameter > 2 cm
Tumor Rekurens pasca operasi atau radioterapi
Immunosupresi
Sajjad Rajpar, ABC of Skin Cancer, 2008
 PREDISPOSE FACTORS
Fair skin (TIPE I & II)
SKIN CANCER

Albino
UV Exposure
Sindrome nevus basal
LE kronis
Ulkus kronis
Fistula
 Clinical appearance
SKIN CANCER

Node, usual size 2 cm, with higher

edge
Teleangiectasia
Transparant node with pearl-like
edge
Ulceration
Rhoden ulcer
Slow growing
 TREATMENT
SKIN CANCER

Excision (surgeon)
Recontruction
Radiation therapy
Topical chemotherapy (5 FU)
Systemic chemotherapi (metastase & uncontrolled
Squamose sel carcinoma

Locally invasif
Fast growing
Ability to metastase (limf node,
visceral 5-10%)
Can occur in fibrotic tissue (Marjoline
ulcer)
Recurrency depends on differentiation,
tumor depth, nerve invasion.
 Squamous Cell Carcinoma

Clinical appearance :
-Ulcerative type (ulcer)
- Papillary type (cauliflower)
Histologic :
Cornificans, non cornificans
&
undifferentiated
Risk factors for SCC
Fair skin (burn easily, never or rarely tan)
Chronic cumulative UV exposure
Geography (closer to equator)
Hystory of prior NMSC
Age > 50 y
Male gender
Genodermatoses
Smoking (lip SCC)
Intense PUVA therapy (>300)
Chemicals carcinogen
Chronic scarring/inflamatory condition
Immunosupresan
Human papiloma virus infection
> 10 AK
 Predisposing SCC
- lupus erythematosus
- lichen planus
. - lymphedema
- chronic leg ulcer
1 Chronic inflamatory
- Osteomyelitis
- chronic deep fungal infection
2.Chronic infection : - lymphogranuloma venereum
- granuloma inguinale

3.Chronic scarring - burn scars

- thermal injury
- irradiated skin

4.Genetic syndrome : xeroderma pigmentosum

 CLINICAL STADIUM

T : primary tumor N ( limf node)

T1 :< 2 cm N1 : metastase to
regional limf node
T2 > 2-5 cm
M (distant
metastase)
T3 > 5 cm M1 distant metastase
T4 cartilage,
muscle, and bone
infiltration.
 SCC TREATMENT

Surgery :
Wide excision (2-3 cm) & reconstruction
Lymphnode dissection
Radiotherapy : poor surgical candidates
refuse surgery
inoperable lesion
Chemotherapy : inoperable lesion
metastase
SCC TREATMENT
Treatment depends on :
- Tumor size

- Location

- Depth of invasion

- Grade

- History of prior treatment.

PROGNOSIS

TUMOR SIZE
LOCATION
Grade of differentiation
Metastase to limf node (ten year
survival < 20 % )
DISTANT METASTASE < 10 %
MALIGNANT MELANOMA

Definition :A malignant
transformation of melanocyt.
4 % from all skin malignancies
79 % from all death cause in skin cancer
2,3 / 100000
Ethiology : ultra violet ( Armstrong & Kricker)
Biological characters are unique and very
unpredictable
CARCINOGENESIS MECHANISM FACTOR
IN MELANOMA
Genetic factor :
Melanocytic nevi: 30-90% from all
nevus
Biologic factor : chronic iritation,
immunorespon, hormonal factor
Environment factor : ultra violet.
 RISK FACTORS OF MM
White skin
Sun Ray
Numbers of nevus ( 5 nevus > 6 mm ) , 50 nevi
Diameter 3mm
Congenital nevus ( giant kongenital nevi 6 % ),
detection is quite difficult beacause the location is
quite deep
Family factor : 8 12 %
Immunosuppresion : risk 3 x
Xeroderma pigmentosum
Clinical signs suggestive MM
Change in color
Change in size
Change in shape
Change in elevation
Change in surface
Change in surronding skin
Change in sensation
Change in consistency
 Nevus Diagnosis

Lesion on skin that change in months

years.
A : asymmetric
B : border irregularity
C : color variability
D: diameter > 6 mm
E : evolution , elevation, enlargment
F: Funny looking

Other signs : easily bleeding, itchy,

ulceration. ulserasi
 A = Asymmetry

Asymmetric
Symmetric (benign)
(malignant
melanoma)
B = Border irregularity

Borders are even Borders are

(benign) irregular
(malignant
melanoma)
 C = Color variation

One shade/even color Two or more shades
(benign) / uneven color
(malignant melanoma)
 D = Diameter

Diameter <6 mm Diameter >6mm

(benign) (malignant melanoma)
 Clinical types- MM

Superficial spreading melanoma

Lentigo maligna mela

Acral lentiginous melanoma

Nodular melanoma
 CLARK LEVEL
LEVEL I : Melanoma limited to the epidermis
LEVEL II : Invasive melanoma with superficial
infiltration to the papillary dermis
LEVEL III : Melanoma extending to the superficial
vasculer plexus in the dermis
LEVEL IV : Primary melanoma involving the
reticular dermis
LEVEL V : Melanoma involving the subcutaneous
fat
 Conventional Surgery

Wide Excision
Lymph node dissection
 Therapy
Operation : Primary lesion wide
excision 2 cm ; limf node dissection
Radiation
Chemotherapy
Isolated regional perfusion
Paliative treatment
Vaccine therapy, Interferron & Interleukin
 PROGNOSTIC FACTORS

CLINICAL
Age
Gender
Anatomic site
Distant metastasis
 PROGNOSTIC FACTORS

HISTOLOGIC
Tumor thickness Angiogenesis
ClarkS level Vascular invasion
Ulceration Microsatellites
Nodal Status Mitotic rate
lymph node status Regression
Tumor type Tumor infiltrating
lymphocytes
Growth patterns

MOLECULER & BIOCHEMICAL

Mortality from Skin Cancer

Malignant Melanoma ~
20%
Squamous Cell 2%
Carcinoma
Basal Cell Carcinoma < 1%