Skin Cancer, Emergency Medicine

Basics

Description

Most common cancer in US
Increasing incidence
1 in 6 will have skin cancer during their lifetime
Actinic keratosis:
- Premalignant lesion
- Thickened scaly growth caused by sunlight or other artificial light source
- Found on areas of body with high sun exposure
- 0.1 " 10% may transform into squamous cell carcinoma (SCC)
Nonmelanoma skin cancer:
- Less commonly fatal
- Fast growing
- May be destructive if left untreated
- Basal cell carcinoma (BCC):
  - Cells arise from epidermis
  - Most common skin cancer
  - Account for 75% of all nonmelanoma skin cancers
  - Male > female, 3:2.
  - Locally invasive without risk of distant metastasis
  - Most important risk factor is sun exposure
  - More common in fair-skinned patients
  - Most lesions are on the head and neck
- SCC:
  - 2nd most common skin cancer
  - 20% of cases of skin cancer
  - Most arise from precancerous actinic keratosis lesions
  - Male > female
  - Most important risk factor is sun exposure, especially sunburn
  - 70% occur on head and neck
  - More common in older, fair-skinned patients
  - Risk of regional lymph node and distant metastasis
  - SCC lesions of mucosal surfaces are more aggressive
Melanoma:
- 5% of all diagnosed skin cancer in US
- 62,000 new cases in 2008
- 15% are fatal
- 75% of skin cancer cause deaths
- Arises from melanin-producing cells
- Most important risk factor is sun exposure, especially sunburn
- Additional risk factors:
  - Fair skin; blond/red hair
  - Multiple common melanocytic nevi
  - Atypical nevi
  - Immunosuppression
  - Positive family history
  - History of nonmelanoma skin cancer (BCC or SCC)
  - ≥5 sunburns in early life doubles the risk for malignant melanoma
- Risk of regional lymph node and distant metastasis

Etiology

UV irradiation:
- Both UVA and UVB rays
- Sun exposure
- Tanning beds
SCC often associated with human papilloma virus (HPV)
Immunosuppression may predispose to SCC
Vitamin D metabolism may play a role

Diagnosis

Signs and Symptoms

Actinic keratosis:
- Rough, pink, circumscribed lesions <1 cm in diameter
- A lesion may have both actinic keratosis and SCC
BCC:
- May be single or multiple
- Usually painless
- Usually appears in sun-exposed areas of skin
- Erosion or bleeding with mild trauma may be 1st symptoms
- Nodular BCC:
  - Most common
  - Waxy or pearly papule, possibly with telangiectasia
  - Well-demarcated borders
  - May have central ulceration
- Pigmented BCC:
  - Similar to nodular BCC with brown, blue, or black coloration
  - Often mistaken for superficial spreading or nodular melanoma
- Cystic BCC:
  - Bluish/gray cystic nodules
  - May be mistaken for benign cysts
- Superficial BCC:
  - Scaly patch-like or papule surrounded by small, clear micropapules
  - Pink, red, or brown
- Micronodular BCC:
  - Well-defined border
  - Aggressive
  - Rarely with ulceration
- Morpheaform BCC:
  - Poorly defined borders
  - May appear "scar like "
  - Aggressive
  - Ulceration and bleeding are rare
SCC:
- Characteristic lesion is raised, firm, keratotic papule or plaque
- Often enlarging
- Usually asymptomatic but may be ulcerated and painful as invasion occurs
- Ulcers often crust and ooze
- Cranial nerve involvement may indicate an aggressive tumor with perineural invasion:
  - Facial numbness, asymmetry, weakness, or pain
Melanoma:
- Pigmented skin lesion:
  - 2% will be amelanotic
- Features suggestive of melanoma (the ABCDEs of melanoma):
  - Asymmetry (not regularly round or oval)
  - Border irregularity (notched or poorly defined)
  - Bleeding (spontaneous)
  - Color variegation (shades or combinations of brown, tan, red, white, or blue-black)
  - Diameter >6 mm
  - Elevation/Enlargement
- Lesions rarely symptomatic unless ulcerated
- Superficial spreading melanoma:
  - 70% of all malignant melanomas
  - May have a wide variety of colors
  - Often arise from dysplastic nevus
  - Usually <3 cm
  - Slight elevation and induration is common
  - Often have satellite lesions
- Nodular melanoma:
  - 10 " 15% of melanomas
  - The most symmetric of the different melanomas
  - Dark brown or black
  - Often exophytic
- Lentigo maligna melanomas (LMM):
  - Always starts as lentigo maligna, a macular insitu malignancy which is an evolving lesion of melanoma
  - LMM occurs after the lesion begins vertical growth into the dermis " typically indicated by papular or nodular areas
  - Irregular shape and multiple colors
- Acral lentiginous melanoma:
  - Equal among black and white patients
  - Most common form of melanoma found in Asians and African Americans
  - Occur on palms, soles, and subungual region with predilection for soles of feet
  - May be mistaken for subungual hematoma
  - Involvement of the proximal nail fold (Hutchinson sign) is an indicator of melanoma
- Mucosal lentiginous melanoma:
  - Develops from mucosal epithelium in respiratory, GI, and GU tracts
  - Often diagnosed at a later stage of disease
  - Very rare
- Metastatic melanoma:
  - Presentation related to affected organ system
  - Lymphangitic spread with local to regional lymphadenopathy
  - Typical visceral sites of hematogenous spread include liver, lung, bone, brain, and intestines

Essential Workup

All suspicious lesions require biopsy, a procedure rarely done in ED

Diagnosis Tests & Interpretation

Lab
No specific testing is required
Imaging

CXR may show pulmonary involvement by metastatic melanoma
Head or body CT scan may show visceral involvement by metastatic SCC or melanoma
Cross-sectional imaging does not rule out metastasis

Diagnostic Procedures/Surgery
Biopsy usually performed by consultant

Differential Diagnosis

For BCC:
- SCC
- Bowen disease
- Actinic keratosis
- Paget disease
- Benign nevus
- Melanoma
For SCC:
- Actinic keratosis
- BCC
- Keratoacanthoma
- Melanoma
- Wart
For melanoma:
- Atypical nevus
- Common nevus
- Actinic keratosis
- Pigmented BCC
- SCC

Treatment

Pre-Hospital

No specific pre-hospital care is required

Initial Stabilization/Therapy

No specific stabilization is usually required beyond basic wound care
Stabilization may be required for invasion into vascular structures or edema from intracranial metastasis

Ed Treatment/Procedures

Skin lesions themselves require no specific ED treatment
Treat complications of visceral involvement by metastatic melanoma, SCC or locally invasive BCC.

Follow-Up

Disposition

Admission Criteria

Admission typically only occurs due to complications associated with visceral involvement or invasive spread
Admission is rarely required because of the dermatologic lesions themselves

Discharge Criteria
Patients are generally discharged with instructions on obtaining biopsy and/or further evaluation
Issues for Referral
Discharged patients should be advised to consult a dermatologist or primary care physician experienced with skin biopsy.

Follow-Up Recommendations

Biopsy is required for diagnosis of skin cancer
Urgent follow-up with dermatologist or primary care physician is advised
Ensure adequate documentation of conversation with patient regarding urgency of follow-up
Patients with nonmelanoma skin cancer have a 30 " 50% chance of developing additional skin cancer within 5 yr

Pearls and Pitfalls

Advise patient to obtain urgent follow-up for any suspicious lesion
1 in 6 people will have skin cancer during their lifetime
Protection from UVA and UVB rays is key to preventing skin cancer

Additional Reading

Arora A, Attwod J. Common skin cancers and their precursors. Surg Clin North Am. 2009;89:703 " 712.
Califano J, Nance M. Malignant melanoma. Facial Plast Surg Clin North Am. 2009;17:337 " 348.
Firnhaber JM. Diagnosis and treatment of basal cell and squamous cell carcinoma. Am Fam Physician. 2012;86:161 " 168.
Lee DA, Miller SJ. Nonmelanoma skin cancer. Facial Plast Surg Clin North Am. 2009;17:309 " 324.
Ricotti C, Bouzari N, Agadi A, et al. Malignant skin neoplasms. Med Clin North Am. 2009;93:1241 " 1264.

Codes

ICD9

173.90 Unspecified malignant neoplasm of skin, site unspecified
173.91 Basal cell carcinoma of skin, site unspecified
173.92 Squamous cell carcinoma of skin, site unspecified
172.9 Melanoma of skin, site unspecified
173.30 Unspecified malignant neoplasm of skin of other and unspecified parts of face
173.40 Unspecified malignant neoplasm of scalp and skin of neck
173.99 Other specified malignant neoplasm of skin, site unspecified
173.9 Other and unspecified malignant neoplasm of skin, site unspecified
702.0 Actinic keratosis

ICD10

C44.90 Unspecified malignant neoplasm of skin, unspecified
C44.91 Basal cell carcinoma of skin, unspecified
C44.92 Squamous cell carcinoma of skin, unspecified
C43.9 Malignant melanoma of skin, unspecified
C44.300 Unsp malignant neoplasm of skin of unspecified part of face
C44.40 Unspecified malignant neoplasm of skin of scalp and neck
C44.99 Other specified malignant neoplasm of skin, unspecified
C44.9 Other and unsp malignant neoplasm of skin, unspecified
L57.0 Actinic keratosis

SNOMED

372130007 Malignant neoplasm of skin (disorder)
254651007 Squamous cell carcinoma of skin (disorder)
254701007 Basal cell carcinoma of skin (disorder)
372244006 Malignant melanoma (disorder)
201101007 Actinic keratosis (disorder)
372122006 Malignant neoplasm of skin head and neck (disorder)
443136000 malignant neoplasm of skin of face (disorder)

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