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Nonmelanoma Skin Cancer (NMSC) Classification

  • More than 80 histologic subtypes

    1. Basal cell carcinoma (BCC) accounts for 70% to 75%

    2. Cutaneous squamous cell carcinoma (cSCC) accounts for 20%

    3. Merkel cell carcinoma (MCC) accounts for 5%

  • Overall excellent prognosis (90% 5-year survival rate)

  • Subset of aggressive NMSC

    1. 10% locally recur

    2. 3% to 5% develop regional metastasis

    3. 2,500 deaths per year

  • $4.8 billion/year spent in NMSC diagnosis and treatment in the United States

  • Lacking large, prospective NMSC registries

NMSC Risk Factors

  • Environmental

    1. Sun exposure (ultraviolet radiation [UVR]) remains leading cause

    2. Fitzpatrick type I: fair skin, red/blonde hear, marked freckling, moles

    3. Tanning booths

  • Genetics

    1. Xeroderma pigmentosa (XP): rare, autosomally recessive disease associated with cutaneous cancers secondary to inability to repair DNA damaged by UVR

    2. Fanconi anemia

    3. BCC: PTCH1 (patched 1) mutation on chromosome 9q

      • Encodes sonic hedgehog receptor

      • Underlying cause of nevoid BCC syndrome

    4. Nevoid basal cell carcinoma syndrome

    5. Avoid radiation in this at-risk patient population

  • Immunosuppression (solid organ transplant, lymphoproliferative disorders, human immunodeficiency virus infection/acquired immunodeficiency syndrome, iatrogenic)

    1. Work closely with transplant team to decrease level of immunosuppression

    2. mTOR inhibitors may be considered in rapidly growing, life-threatening cancers

  • Merkel cell carcinoma: polyomavirus (MCPyV)

NMSC Work-Up

  • History

    1. Change in lesion color, size, or shape

    2. Bleeding, ulceration, or pain

    3. Personal and family history of melanoma

    4. Sun exposure, occupation, sunburns, tanning booth use

    5. Immunosuppression

    6. Previous “moles” removed

  • Physical examination

    1. Full body skin examination to include draining lymphatics

    2. Cranial nerve examination to assess perineural spread

  • Thorough 12-point review of systems

  • Biopsy

    1. Shave biopsies reserved for nonpigmented superficial lesions.

    2. Narrow margin (1-3 mm) excisional biopsy is indicated for concerning lesions which appear more than superficial.

    3. Full-thickness punch biopsy or incisional biopsy indicated for lesions not amenable to excisional biopsy due to large size or location.

    4. Wide margin excision without diagnosis is discouraged because it may preclude further workup and treatment such as sentinel node biopsy.

    5. Fine-needle aspiration for concerning metastatic lymph nodes.

  • Radiographic imaging

    1. Contrasted CT scan (or MRI with gadolinium for patients with contrast allergy) to assess cervical and parotid bed lymphadenopathy for advanced NMSC to include regional metastasis, involvement of bone, perineural invasion, or concern for deep tissue extension

    2. Additional dedicated radiographic studies as warranted for positive review of systems

    3. PET/CT

      • Considered for advanced metastatic disease

      • Warranted in patients with regional nodal metastasis of unknown origin

      • Used to restage patients with tumor recurrence

  • Advanced NMSC should be discussed at a multidisciplinary oncology tumor board to include review of clinical trials

Basal Cell Carcionoma (BCC)

  • Overview

    1. Most common cutaneous cancer

    2. Twice as common as cSCC

    3. 2.8 million cases diagnosed per year

    4. No formal American Joint Committee on Cancer Staging

  • Low-risk BCC

    1. Nodular or superficial subtype

    2. No perineural invasion

    3. Well-defined borders

    4. Primary disease

    5. No prior radiation

    6. Less than 10-mm diameter on the cheek, forehead, scalp, or neck (M-area)

  • High-risk BCC

    1. Less than or equal to 10-mm diameter on the cheek, ...

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