Case Presentation

1
Case Presentation

• John Francis McGuire III, MD, MBA
• Department of Otolaryngology/Head and Neck
  Surgery
• University of California, Irvine

2
History

• 68 year old male is sent to you for evaluation of
  an infection on his ear. The lesion seems has
  been there for around 3-4 weeks and has not
  improved on 7 days of Keflex.

3
History

• PMHx ESRD, HTN.
• PSHx Kidney transplant 7 years ago, several
  skin freezing procedures by dermatology in the
  past, none on the ear.
• Meds Prograft, other meds.
• Allg NKDA
• PHx Quit tobacco 7 years ago.

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Exam TM clear bilaterally, TF exam WNL. The
left auricle is warm to touch and erythematous.
It is tender to palpation. There is no
fluctuance. Nasal mucosa WNL. Partially
edentulous, otherwise oral exam WNL. Neck shows
no adenopathy. Mirror exam WNL. Cranial nerves
5 and 7 are intact. There are diffuse scaly
changes over the scalp.
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Differential Diagnosis of Auricluar Lesions

• V
• I
• T
• A
• M
• I
• N
• C

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Differential Diagnosis of Auricluar Lesions

• V hemangioma
• I Otitis Externa, otomycosis, furunculosis,
  cellulitis, papilloma
• T Neurotic excoriation, auricular
  hematoma/seroma
• A eczema, polychondritis, WG
• M gout
• I amyloidosis, seborrheic keratosis
• N SCC, BCC, AK, MCC, T-Cell cutaneous lymphoma,
  neurofibroma, chondroid syringoma, pilomatrix
  carcinoma, other adnexal carcinomas
• C 1st BCC

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Biopsy Results
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Cutaneous SCC

• General Facts about SCC of skin
• 2nd most common skin cancer, around 20 of
  cutaneous malignancies
• Lifetime risk of SCC in the United States was
  estimated to be 9 to 14 in men and 4 to 9 in
  woman.
• UV exposure is greatest RF
• fair skinned increased risk (Fitzpatrick).
• Childhood exposure (est. 80 of sundamage before
  18 y/o).
• Other factors Thermal injury (Marjolins ulcer),
  chemical carcinogenesis, chronic radiation
  dermatitis, human papillomavirus (types 16, 18,
  30, and 33)
• Hereditary xeroderma pigmentosa, oculocutaneous
  albinism

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Fitzpatrick Skin Types
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Mechanism of UV Damage

• UVA (320-400 nm) and UVB (280-320 nm) both
  function as initiators and promoters in
  carcinogenesis as well as immunosuppressors.
• UVB causes direct DNA damage and mutations by
  promoting cyclobutane pyrimidine dimers and 6-4
  photoproducts. It also decreases Langerhans cell
  activity.
• UVA stimulates the production of reactive oxygen
  species and cellular photosensitizers.
• For SCC, cumulative UV exposure leads to
  increased risk (as opposed to melanoma).

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Progression of SCC

• AK CIS Invasive SCC Metastatic
  cutaneous SCC

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Actinic Keratosis

• AKA Solar keratosis
• Premalignant appx 10 become SCC
• Assc. with dermatoheliosis
• Clinical Features
• Flat to slightly raised, scaly patches.
• Color from pink to red to brown, or flesh-colored
• Often felt better than seen scale is thick and
  firmly adherent
• Can be painful

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AK

• Histology
• Noninvasive proliferation of atypical
  keratinocytes in the basal layers of the
  epidermis with overlying parakeratosis.
• Usually accompanied by underlying elastosis.

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AK Cutaneous Horn

• Usually associated with AK, although can have
  other causes.
• Histologically show hyperkeratosis and
  parakeratosis.
• Should be excised because higher risk of
  progression to SCC

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AK Rx

• Prevention
• Can resolve with sun avoidance/protection
• Ablative Intervention
• Cryotherapy
• Surgical excision
• important for dx as well
• All CH should be biopsied
• Laser resurfacing/dermabrasion
• PDT
• Topical meds
• 5-FU Pyrimidine analog, painful.
• Imiquimod Activates macrophages to induce
  secretion of pro-inflammatory cytokines
  (IFN-alpha,TNF, IL-12) Th1 response.
• Diclofinac an anti-inflammatory

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CIS

• AKA Bowens Disease
• -Usually presents as a reddish patch or plaque
  and may have scales. These often arise in sites
  of old burns or scars. Often mistaken for
  psoriasis.

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CIS

• Histology
• Keratinocytes lose polarity, have atypia and and
  increased mitotic rate, and involve the entire
  epidermis, but without invasion of the basement
  membrane. There can be also be acanthosis and
  elongation of the rete ridges.
• RX
• Surgical Excision
• Other cyrotherapy, 5-FU.

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Invasive SCC

• Characteristics
• Reddish, scaling, opaque nodules, ulcerative,
  granular base, bleed easily...

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Invasive SCC

• by definition has invaded the basement membrane.
• Side Note
• Highly differentiated SCC will show singes of
  keratinization within orn on the surface of the
  tumor, therefore firm to palpation.
• Poorly differentiated will not show signs of
  keratinization, and will therefore appear more
  fleshy, granulomatous, and are soft to palpation.

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SCC can look like BCC

• These nodular lesions mimic BCC, but they lack
  opalecent borders and telangectasias need biopsy
  and excision in any case.

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Surgical Rx Margins

• Depends on risk factors
• High risk
• Size of 2 cm or larger
• More aggressive histologic subtypes
• Invasion of the subcutaneous tissue
• Location in high-risk areas (i.e. embryonic
  fusion planes).
• Margins
• Low risk margins 4 mm,
• High risk start with 6 mm, but need frozen
  control.
• Brodland et al 1992
• SCC diameter less than 2 cm 95 complete
  resection, greater than 2 cm, a 0.6cm margin
  required to achieve 95 complete resection.
• Histological grade of 1, 2 or 3 had tumors
  invading subcutaneous fat were 18, 56 and 100
  of the time, respectively.
• Tumors less than 1 cm, between 1 and 2 cm, and
  greater than 2 cm invaded subcutaneous fat 15,
  39, and 52 of the time, respectively.

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Mohs

• Mohs
• Recurrence of SCC for Mohs vs. non-Mohs
  excisions (Rowe 1992)
• skin and lip, 3.1 versus 10.9
• ear, 5.3 versus 18.7
• locally recurrent SCC, 10 versus 23.3
• SCC greater than 2cm in diameter, 25.2 versus
  41.7
• Poorly differentiated SCC, 32.6 versus 53.6.

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Metastatic Spread

• Behavior is determined by location, size, depth
  and grade of histologic differentiation.
• The central zone of the face, temple, lips, ear
  and scalp are at significant risk for local
  recurrence and metastases.
• Spread
• Along perichondrium, periosteum, fasia, nerve,
  and embryonic fusion planes. Loves to go to
  parotid
• Risk Factors for Metastatic Spread (30-50)
• Width greater than 2 cm
• Depth greater than 4mm
• Recurrence
• Perineural invasion
• Poorly differentiated histologic features

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Metastatic Spread Parotid

• Elective parotidectomy not recommended but
• Only 20 of cases of parotid involvement are
  clinically apparent
• must get imaging studies with high risk
  lesions.
• 20 occult parotid disease after elective
  parotidectomy
• So if neck disease, parotidectomy indicated.
• If disease usually superficial parotidectomy
  indicated.
• The majority of nodes are in the lateral lobe.
• No increase in survival or decreased recurrance
  with bigger resection (including nerve
  sacrifice).
• If radical parotidectomy with nerve sacrifice,
  immediate reanimation procedures is recommended.

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Metastatic Disease Neck

• Facts and Concepts
• The incidence of clinical neck disease in the
  absence of clinical parotid involvement is
  approximately 30.
• But remember that if neck disease, superficial
  parotidectomy should be performed.
• Occult neck disease in the face of parotid
  metastasis is between 20-44.
• Therefore, elective neck dissection is warrented
  if there are parotid mets.
• Metastatic cutaneous SCC goes levels I, II, and
  III.
• Therefore, supraomohyoid neck dissection is
  recommended.
• Dermal mets
• present in 20 of cases of metastatic SCC
• Rx resect involved skin

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Perineural Invasion (PNI)

• PNI is seen in 5-14 of cutaneous squamous cell
  carcinomas of the head and neck.
• Most common in the auricular area (25.7), cheek
  and maxilla (21.4), and forehead (18.6).
• Dx
• Clinical deficits
• but 60-80 of metastatic lesions involving the
  facial nerve present with no symptoms.
• Pathology
• May demonstrate skip lesions
• Radiological
• CT scan with bone windows enlargement of skull
  base foramina
• MRI with gad and fat suppression enhancement
  of major nerve trunks or nerve enlargement.

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Metastatic Disease XRT

• Indications for post-operative XRT
• Large or recurrent primary lesion
• Close or positive surgical margins
• PNI
• Multiple levels of lymphatic spread
• Histology poorly differentiated or spindle cell
  SCC.
• Vanness et al (2005) Mets to Neck
• Combined XRT vs. Surgery Alone
• Locoregional recurrence 20 vs. 43
• 5-year disease-free survival rate 73 vs. 54
• Taylor (1991) Mets to paroitid
• Parotidectomy alone was 63
• XRT alone was 46
• Combined RX 89.

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Organ Transplant Recipients (OTRs)

• Facts
• 35 to 70 of organ transplant patients develop
  skin cancer within 20 years following transplant
  surgery
• Increases for different lesions
• Squamous cell carcinoma (SCC) 65-100 fold
• Basal Cell Carcinoma (BCC) 10 fold
• Melanoma 4 fold

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OTRs

• Further Skin cancer in OTRs tends to behave more
  aggressively
• The rate of invasive skin cancer in transplant
  patients can be up to 80 times greater than in
  the general population.
• Skin cancers in OTRs grow rapidly and tend to be
  multiple and metastatic.
• Mortality from cutanteous SCC is over 50 times
  higher than in the general population.
• Once a transplant patient develops a single skin
  cancer, 50 will develop additional skin cancer
  within 3.5yrs

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OTR

• Risk factors
• Common to the general population
• history of skin cancer,
• history of actinic keratoses,
• fair skin,
• a history of chronic sun exposure and/or sun
  burns,
• older age
• Specific for to transplant patients
• duration and intensity of immunosuppression,
• Heart kidney liver transplantation (related
  to above)
• a history of HPV infection,
• CD4 lymphocytopenia.

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Care for the OTR patient

• Prevention 1
• Some Guidelines
• Sunprotection
• Sun avoidance
• Avoid sunlight from 10am to 3pm
• Sunblock
• UV protective clothing
• Long sleeved shirts
• Long pants
• Sunglasses with UV protective coating
• Tanning beds expressly prohibited

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Care for the OTR patient

• Sunblock Recommendations
• SPF / 30 with broad UVA/UVB protection.
• Sunblock Use
• Apply 20 minutes prior to sun-exposure.
• Apply to all sun-exposed areas. Don't forget
  lips, ears, back of neck, or back of legs.
• Apply a sufficient coat of sunscreen- most common
  mistake is being too stingy
• Reapply every 2 hours when out in the sun- more
  frequently if in water or sweating

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Care for the OTR patient

• Self examination
• Keep log of suspicious lesions

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OTR Clinics UCSF Guidelines