اhead and neck skin cancer

1. SKIN CANCER OF HEAD AND NECK
DR . Mamoon

2. Introduction
• Skin cancers account for almost 50 % of all cancers diagnosed annually in the USA.
• Basal cell carcinomas account for approximately 80 % of all nonmelanoma skin cancers
• squamous cell accounts for the further 20 percent
• Most tumors arise on the sun-exposed regions of the head and neck
• Aggressive and metastatic cutaneous cancers should be managed in a multidisciplinary setting.

3. Largest organ of the body (15% of body
weight)
Two main layers
– epidermis
stratified squamous epithelium
contains 5 layers
– dermis
connective tissue layer
Rests on subcutaneous layer or hypodermis
Normal thickness of 1-2 mm, up to 6 mm
– thicker skin (palms & soles) has stratum
lucidum, no hair follicles or sebaceous
glands

5. Types of skin cancer
Skin cancer
Non-Melanoma
Basal cell ca
Squamous cell ca
Melanoma

6. Non-Melanoma
RISK FACTORS
BCC
SCC
GENETIC
PREMALIGNANT
LESIONS
INVIROMENTAL

7. GENETIC PREDISPOSITION
 Fair skin
 Syndromes
• Xeroderma pigmentosum
• Gorlins’ syndrome (BCC)
• Epidermodysplasia verruciformis (BCC)
• Albinism (SCC)
• Epidermolysis bullosa (SCC)
• Porokeratosis (SCC)

8. ENVIRONMENTAL EXPOSURE
• Sun exposure
• Ionizing radiation
• Chemicals (polycyclic aromatic hydrocarbons, psoralens and arsenic exposure)
• Immune suppression

9. PREMALIGNANT LESIONS
• Sebaceous naevus of Jadassohn (bcc)
• Actinic keratosis (scc)

10. BASAL CELL CARCINOMA ( BCC)
• BCC is the most common malignancy in humans
• Most commonly on the nose
• Typically slow-growing
• Rarely metastasizes (<0.1%)
• Very low mortality
• Significant morbidity with direct invasion of adjacent tissues, especially when
on face or near an eye

11. • There are five histological
subtypes their clinical behaviour is
distinc
• Types of BCC
• – Nodular (most common)
• – Superficial
• – Basosquamous
• – Pigmented
• – Morpheic

12. • Nodular :(Most common)
• small pearly dome-shaped nodule with
surface telangiectasia and a raised rolled
edge
• As these increase in size they may ulcerate
and become locally invasive and have been
termed a ‘rodent ulcer

13. • Superficial BCC is also common and the least aggressive
subtype
• scaly, dry, erythematous plaques which are round or oval in
shape
• Basosquamous BCC is a more aggressive tumour, often
ulcerated with histologic features of SCC and BCC and has
metastatic potential

14. • Pigmented BCC is seen in darker skinned individuals
• The pigment is due to melanin and easily confused
with melanoma
• Morpheic (sclerosing) BCC characteristically appear as
an indurated pale plaque with indistinct borders
• These are locally aggressive tumours where margin
control is particularly difficult and as such have a high
propensity for local recurrence

15. SQUAMOUS CELL CARCINOMA
• Classically occur in elderly males on sun-exposed sites
• They may arise from precursor lesions such as actinic keratosis
• Early lesions appear as an enlarging erythematous nodule or scaly plaque
• Ulceration and crusting occur later followed by invasion of deep structures
• Regional metastases are uncommon, occurring in 5 %

16. • The parotid gland represents an important receptacle for regional disease in the
head and neck
• Lymphatic spread is related to depth of invasion
• Overall mortality for cutaneous SCC is only 3.4 % but increases in patients with
regional metastases

18. Risk of lymphatic spread
• Size > 2cm
• Invasion into subcutaneous fat
• Poorly differentiated
• Perineural invasion
• Lymphovascular invasion
• Site: ear or lip
• Incomplete excision
• Local recurrence
• Immunosuppression

19. ASSESSMNET AND STAGING
Patient examination
• Assessment of skin lesion
• Complete head and neck examination
• Cranial nerve examination
• Examination of regional lymph nodes

20. Biopsy
• Excisional with 3-4 mm margins for small, in non critical regions
• Incisional biopsy Where diagnosis is uncertain and excision is likely to be morbid
• FNAC for enlarged lymph nodes

21. IMAGING
• Not indicated in early stage
• Mandatory in advanced and recurrent lesions
 HRCT with I /v contrast (standard choice)
 MRI (the modality of choice for neurotropic cancer and in tumours with intracranial, orbital or
parapharyngeal extension)
 Ultrasound

23. STAGING

24. MANAGEMET
Treatment for early stage NMSC
• Surgery remains the mainstay of treatment
• The recommended margins for SCC are 4 mm for lesions under 2 cm and 6 mm for greater than 2 cm
• BCCs should be excised with a minimum 3 mm margin.

25. • Radiotherapy where surgical excision with reconstruction may produce significant cosmetic
and/or functional sequelae
• Topical drug therapies including 5 fluorouracil cream for treatment of SCC/BCC in situ
• Cryotherapy should be reserved for superficial, nonpigmented lesions only

26. MANAGEMET
Advanced NMSC (T3/T4)
• Require en-bloc resection of Tumor
• Reconstruction with graft or flaps
• Neck dissection if regional metastasis
• One of the most important nodes in head and neck cutaneous malignancy is the external jugular
node and this must be removed during lymphadenectomy

27. Adjuvant therapy
The standard indications for postoperative radiotherapy for SCC are
• close or positive margins,
• perineural invasion,
• two or more positive nodes,
• extracapsular spread and
• nodes greater than 3 cm in size
• Parotid nodal metastases and poorly differentiated tumors are also considered to be
high risk groups

28. CUTANEOUS MELANOMA OF THE HEAD AND NECK
• Melanoma is cancer of the melanocytes.
• Malignant melanoma accounts for 3 % of all reported cancers
• It causes most skin cancer-related deaths.
• The head and neck account for 11–18 % of all melanomas
• 20 % of patients develop regional metastases.

29. • The risk of metastases increases with depth of invasion.
• Lymphatic spread predominates.
• Suspected lesions should be excised with a 2 mm margin and confirmed
tumors widely excised later.
• Radiotherapy has no part to play in treatment
• The mortality for cutaneous melanoma of the head and neck is high, with overall survival
being 66 per cent at ten years.

30. Risk factors
• Sun exposure is the most important risk factor for melanoma
• Family history of melanoma
• Dysplastic nevi (noncancerous, but unusual- looking moles)
• Previous melanoma
• Multiple nevi (ordinary moles): more than 50
• Severe, blistering sunburns
• Fair skin

31. Morphological types of melanoma
• Superficial spreading 70%
• Nodular
• Lentigo Maligna
• Acral lentiginous
• Amelanotic
• Desmoplastic

32. Diagnosis
• The majority of melanomas can be detected by the history of the lesion, and comparison with other
pigmented lesions
• Surface microscopy with a hand-held dermatoscop is used by some clinicians to improve the clinical
diagnosis of skin lesions
• In expert hands, a sensitivity of 92 per cent and specificity of 71 per cent can be achieved
• Any suspicious lesion should be biopsied with a 2–3 mm margin of normal skin.

34. STAGING SYSTEMS
• CLARK LEVEL
• BRESLOW THICKNESS
• AJCC TNM CLASSIFICATION

39. Management of cutaneous melanoma
• Wide surgical excision
• Melanoma in the head and neck region provides more
of a challenge because wide excision is often not
physically possible or may increase morbidity and
disfigurement.
• A compromise on margins is thus considered acceptable
in the region.

40. • If the melanoma measures thicker than
1.0mm, then there is at least a 10% risk
of lymph node involvement and
a Sentinel Node Biospy is often
recommended to detect if lymph node
involvement is present

41. Sentinel Node Biopsy
• Firstly the site of the Sentinel Node is determined by injecting a small dose of a radio-active
isotope into the primary site wound.
• The tracer then moves from the primary site to the lymph node that drains that particular
area of skin, namely the sentinel node.
• The site is detected using a radiological isotopic scanner and marked.
• The lymph node/s excised and biopsied

42. Neck dissection
• Clinically N+ disease
• Positive sentinel lymph node
• No role for elective node dissection (N0 or SLNB negative)
• Patients presenting with palpable metastatic nodes should undergo a comprehensive
neck dissection after confirmation with fine needle aspiration biopsy
• Completion node dissection for positive sentinel node

43. ADJUVANT RADIOTHERAPY
• Desmoplastic neurotropic melanomas
• microscopically involved or close to margins
• surgical margins where further resection is impractical.
• perineural spread

44. ADJUVANT CHEMOTHERAPY/ IMMUNOTHERAPY
• Dacarbazine, temozolamide and fotemustine are the most commonly used single
agents for metastatic melanoma
• Interferon alpha 2 B

45. FOLLOW UP
• To identify recurrence or new primaries (melanoma or NMSC)
• Education and for psychosocial support plus reassurance

47. Merkel cell carcinoma
• MCC is a rare neuroendocrine tumour of skin
• The annual incidence is 0.23 per 100 000 and mainly affects elderly males
• MCC is thought to arise from mechanoreceptor (Merkel) cells
• however the exact aetiology of MCC is unknown.
• MCC is difficult to identify clinically and is frequently passed over as a benign lesion
• MCCs are very aggressive malignancies with a high metastatic potential
• Sites of distant disease include liver, bone, lung, brain and skin.

50. Thank you