Doctor123.org

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

- 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

- 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

- Cystic BCC: - Bluish/gray cystic nodules - May be mistaken for benign cysts

- 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

- 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

- 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

  • Most common cancer in US
  • Increasing incidence
  • 1 in 6 will have skin cancer during their lifetime
  • Actinic keratosis:Premalignant lesionThickened scaly growth caused by sunlight or other artificial light sourceFound on areas of body with high sun exposure0.1 " 10% may transform into squamous cell carcinoma (SCC)
  • Nonmelanoma skin cancer:Less commonly fatalFast growingMay be destructive if left untreatedBasal cell carcinoma (BCC):Cells arise from epidermisMost common skin cancerAccount for 75% of all nonmelanoma skin cancersMale > female, 3:2.Locally invasive without risk of distant metastasisMost important risk factor is sun exposureMore common in fair-skinned patientsMost lesions are on the head and neckSCC:2nd most common skin cancer20% of cases of skin cancerMost arise from precancerous actinic keratosis lesionsMale > femaleMost important risk factor is sun exposure, especially sunburn70% occur on head and neckMore common in older, fair-skinned patientsRisk of regional lymph node and distant metastasisSCC lesions of mucosal surfaces are more aggressive
  • Melanoma:5% of all diagnosed skin cancer in US62,000 new cases in 200815% are fatal75% of skin cancer cause deathsArises from melanin-producing cellsMost important risk factor is sun exposure, especially sunburnAdditional risk factors:Fair skin; blond/red hairMultiple common melanocytic neviAtypical neviImmunosuppressionPositive family historyHistory of nonmelanoma skin cancer (BCC or SCC) ≥5 sunburns in early life doubles the risk for malignant melanomaRisk of regional lymph node and distant metastasis

Etiology

  • UV irradiation:Both UVA and UVB raysSun exposureTanning 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 diameterA lesion may have both actinic keratosis and SCC
  • BCC:May be single or multipleUsually painlessUsually appears in sun-exposed areas of skinErosion or bleeding with mild trauma may be 1st symptomsNodular BCC:Most commonWaxy or pearly papule, possibly with telangiectasiaWell-demarcated bordersMay have central ulcerationPigmented BCC:Similar to nodular BCC with brown, blue, or black colorationOften mistaken for superficial spreading or nodular melanomaCystic BCC:Bluish/gray cystic nodulesMay be mistaken for benign cystsSuperficial BCC:Scaly patch-like or papule surrounded by small, clear micropapulesPink, red, or brownMicronodular BCC:Well-defined borderAggressiveRarely with ulcerationMorpheaform BCC:Poorly defined bordersMay appear "scar like "AggressiveUlceration and bleeding are rare
  • SCC:Characteristic lesion is raised, firm, keratotic papule or plaqueOften enlargingUsually asymptomatic but may be ulcerated and painful as invasion occursUlcers often crust and oozeCranial nerve involvement may indicate an aggressive tumor with perineural invasion:Facial numbness, asymmetry, weakness, or pain
  • Melanoma:Pigmented skin lesion: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 mmElevation/EnlargementLesions rarely symptomatic unless ulceratedSuperficial spreading melanoma:70% of all malignant melanomasMay have a wide variety of colorsOften arise from dysplastic nevusUsually <3 cmSlight elevation and induration is commonOften have satellite lesionsNodular melanoma:10 " 15% of melanomasThe most symmetric of the different melanomasDark brown or blackOften exophyticLentigo maligna melanomas (LMM):Always starts as lentigo maligna, a macular insitu malignancy which is an evolving lesion of melanomaLMM occurs after the lesion begins vertical growth into the dermis " typically indicated by papular or nodular areasIrregular shape and multiple colorsAcral lentiginous melanoma:Equal among black and white patientsMost common form of melanoma found in Asians and African AmericansOccur on palms, soles, and subungual region with predilection for soles of feetMay be mistaken for subungual hematomaInvolvement of the proximal nail fold (Hutchinson sign) is an indicator of melanomaMucosal lentiginous melanoma:Develops from mucosal epithelium in respiratory, GI, and GU tractsOften diagnosed at a later stage of diseaseVery rareMetastatic melanoma:Presentation related to affected organ systemLymphangitic spread with local to regional lymphadenopathyTypical 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:SCCBowen diseaseActinic keratosisPaget diseaseBenign nevusMelanoma
  • For SCC:Actinic keratosisBCCKeratoacanthomaMelanomaWart
  • For melanoma:Atypical nevusCommon nevusActinic keratosisPigmented BCCSCC

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)