FIGURE 34-14  Cryosurgery being performed on a superficial BCC of the arm. A 5-mm margin of freeze is the goal with two freezes each of 30 seconds duration. (Copyright Richard P. Usatine, MD.)

FIGURE 34-16  Large quickly growing SCC on the lip of a patient on immunosuppression after a renal transplant. (Copyright Richard P. Usatine, MD.)

Photodynamic Therapy (PDT)

•PDT has a number of limitations in the treatment of BCC.9

Special Considerations/Billing

•High risk of additional and future BCC and SCC, so frequent reexamination for additional lesions is required at least annually.10

•CPT codes for destruction or excision of malignancy should be used.

SQUAMOUS CELL CARCINOMA

Diagnoses

•Erythematous plaque with scale and/or ulceration, frequently found on the face, ears, and lower lip (Figure 34-15). May occur in any sun-exposed area or on mucous membranes of the mouth and anus.

FIGURE 34-15  Squamous cell carcinoma of the lower lip related to sun exposure. (Copyright Richard P. Usatine, MD.)

•Transplant patients on chronic immunosuppression are at high risk to develop SCC (Figure 34-16).

•May be at the base of actinic horns or thick actinic keratoses.

•May occur in areas of chronic irritation or burns.

•A shave or punch biopsy is useful for diagnosis.

Treatment

See video on the DVD for further learning. 

(See Table 34-2 for cure rates of SCC treatment modalities.)

•Electrodesiccation and curettage (for three cycles just as in BCC) may be used for Bowen’s disease and for early small SCC (see Chapter 14).

•5-FU combined with epinephrine injected weekly has shown success in small trials.5 This is not a mainstay of therapy.

•Removal margins for elliptical excision:

•4 mm if clinically feasible with SCC less than 2 cm in diameter.11

•6 mm if high-grade lesions or with SCC greater than 2 cm in diameter.11

•SCC can metastasize and the mainstay of treatment is surgical with assessment of the margins by conventional or Mohs micrographic surgery.

•On the trunk or extremities, SCC can be excised with an elliptical excision.

Special Considerations/Billing

•Consider referral for Mohs micrographic surgery if lesions affect sensitive structures including the eyelids, ala of the nose, and the ear canal.11

•Consider referral for Mohs if aggressive lesion or if recurrent lesion.

•High risk of additional and future BCC and SCC so frequent reexamination for additional lesions is required at least annually.10

•See Table 38-3 for ICD-9 coding and CPT coding that is specific­ to the procedure used to treat the malignancy.

KERATOACANTHOMA

Most pathologists and skin experts consider KA to be one type of SCC. The controversy revolves around the fact that it was considered a precancer for years, in part, because some KAs will spontaneously resolve.

Diagnosis

•Rapidly enlarging, often erythematous dome-shaped lesion (Figure 34-17).

•A central keratin plug is the classic distinguishing feature.

•Frequently on the hands or face.

•Considered a type of squamous cell cancer.

•Use a shave biopsy for pathology.

•An unknown percentage may spontaneously regress over 2 to 12 months, but it is safer to remove it than wait.

FIGURE 34-18  Superficial spreading melanoma with all features of ABCDE. (Courtesy of Skin Cancer Foundation, New York, NY.)

Removal

•Electrodesiccation and curettage (see pages 177– 178).

•Excision by ellipse with 3 to 5 mm margins.

•Inject 5-FU, methotrexate, or interferon.

•Radiation therapy if unable to treat by measures above.

Billing

•Bill using CPT codes for destruction or excision of malignant lesions.

MELANOMA

Diagnosis

•Use the ABCDE guidelines for diagnosing melanoma (Figure 34-18).

FIGURE 34-17  Keratoacanthoma-type SCC growing rapidly over the temple region of the face. The central keratin core is a distinct feature of a keratoacanthoma. (Copyright Richard P. Usatine, MD.)

•A = Asymmetry. Most melanomas are asymmetrical: a line through the middle will not create matching halves.

•B = Border. The borders of melanomas are often uneven and may have scalloped or notched edges.

•C = variation in Color. Melanomas are often varied shades of brown, tan, or black. As melanomas progress, they may appear red, white, and blue.

•D = Diameter greater than or equal to 6 mm. Melanomas tend to grow larger than most nevi. (Note: Congenital nevi are often large.)

•E = Evolving or Elevated. Any enlarging nevus is suspect for melanoma even though benign nevi may also grow. Melanoma is often elevated, at least in part, so that it is palpable.

•A prospective controlled study compared 460 cases of melanoma with 680 cases of benign pigmented

tumors and found significant differences for all individual ABCDE criteria (p < 0.001) between melanomas and benign nevi.12

•Sensitivity of each criteria (percentage of melanomas that were positive for each one of the ABCDE criteria): A, 57%; B, 57%; C, 65%; D, 90%; E, 84%.12

•Specificity of each criteria (percentage of benign nevi that were negative for each one of the ABCDE): A, 72%; B, 71%; C, 59%; D, 63%; E, 90%.12

•Sensitivity of ABCDE criteria varies depending on the number of criteria needed: Using two criteria, the sensitivity was 89.3; with three criteria, 65.5% (i.e., 34.5% did not have at least three criteria positive so melanomas should not be expected to meet all criteria).

•Specificity was 65.3% using two criteria and 81% using three.12

•The number of criteria present was different between benign nevi (1.24 ± 1.26) and melanomas (3.53 ± 1.53; p < 0.001). No significant difference was found between melanomas and atypical nevi.12

FIGURE 34-19  The “ugly duckling” sign with one pigmented lesion standing out on the upper right side of the back. This was indeed a malignant melanoma caught early by careful observation. (Copyright Richard P. Usatine, MD.)

FIGURE 34-21  Nodular melanoma on the shoulder of a young woman. After being missed by a previous doctor, the nodular melanoma was excised with an elliptical excision and found to be 8.5 mm in depth. (Copyright Richard P. Usatine, MD.)

Clinical Appearance

•The “ugly duckling” rule: If a mole looks different than the patient’s other moles, there is a higher likelihood that it is malignant (Figure 34-19).

•May be friable, ulcerating, nonhealing, or bleeding.

The four major categories of melanomas are as follows:

1.Superficial spreading melanoma is the most common type of melanoma, accounting for about 70% of melanomas in the United States.13 This melanoma has a radial growth pattern before dermal invasion occurs (Figure 34-20). The first sign is the appearance of a flat macule or slightly raised discolored plaque that has irregular borders and is somewhat geometrical in form. The color varies with areas of tan, brown, black, red, blue, or white. These lesions can arise in an older nevus. The melanoma can be

seen almost anywhere on the body, but is most likely to occur on the trunk in men, the legs in women, and the upper back in both. Most melanomas found in the young are of the superficial spreading type.

2.Nodular melanoma occurs in 15% of melanoma cases.13,14 The color is most often black, but occasionally is blue, gray, white, brown, tan, red, or nonpigmented (Figure 34-21). It is often ulcerated and bleeding at the time of diagnosis. The nodule in Figure 34-21 is multicolored. Although it is often evolving and elevated, it may lack the ABCD criteria.

3.Lentigo maligna melanoma (LMM) is found most often in the elderly and arises on the chronically sundamaged skin of the face. The term lentigo maligna is used for the melanoma precursor in the setting of atypical melanocytic hyperplasia alone and the term melanoma in situ, LM type, is used to represent the true in situ melanoma. LM is the precursor to LMM and

not a nevus (Figure 34-22). Globally, LM/LMM is estimated to account for 4% to 15% of all melanomas, and 10% to 26% of all head and neck melanomas.15

FIGURE 34-20  Superficial spreading melanoma in its radial growth phase on the back of the patient above (0.35 mm in depth). (Copyright Richard P. Usatine, MD.)

FIGURE 34-22  Lentigo maligna melanoma on the face. (Courtesy of Skin Cancer Foundation, New York, NY.)

FIGURE 34-23  Acral lentiginous melanoma on the heel of a young woman. (Copyright Richard P. Usatine, MD.)

FIGURE 34-25  Amelanotic melanoma arising on the scalp. (Courtesy of the University of Texas Health Science Center San Antonio, Division of Dermatology, San Antonio, TX.)

4.Acral lentiginous melanoma is the least common subtype of melanoma and accounts for 2% to 3% of melanomas.13 It occurs under the nail plate or on the soles or palms (Figure 34-23). Acral lentiginous melanoma has 5- and 10-year melanoma-specific survival rates of 80.3% and 67.5%, respectively, which is less than those for all cutaneous malignant

melanomas overall (91.3% and 87.5%, respectively; p < 0.001).13 Subungual melanoma may manifest as diffuse nail discoloration or a longitudinal pigmented band within the nail plate. When subungual pigment spreads to the proximal or lateral nail fold, it is referred to as Hutchinson’s sign and is highly suggestive of acral lentiginous melanoma (Figure 34-24).

Less common types of melanomas include the following:

•Amelanotic melanoma (<5% of melanomas) is nonpigmented and appears pink or flesh colored, often

FIGURE 34-24  Subungual melanoma that has spread to the proximal nail fold producing a positive Hutchinson sign. (Courtesy of Ryan O’Quinn, MD.)

mimicking BCC or SCC or a ruptured hair follicle. It may be a nodular melanoma subtype or melanoma metastasis to the skin, because of the inability of these poorly differentiated cancer cells to synthesize melanin pigment (Figure 34-25).

•Other rare melanoma variants include (1) desmoplastic/neurotropic melanoma, (2) mucosal (lentiginous) melanoma, (3) malignant blue nevus, and (4) melanoma arising in a giant congenital nevus.

Diagnosis starts with history (change) and physical exam (ABCDE).

•Use dermoscopy if available (see Chapter 32,

Dermoscopy).

•Biopsy per recommendations in Chapter 8, Choosing the Biopsy Type.

•It is better to give the pathologist the whole lesion or a large representative portion of the lesion rather than a few small punch biopsies.

•A broad deep shave is often better than a single punch biopsy unless the punch biopsy will remove the whole lesion.

Treatment

Definitive treatment is based on Breslow depth.

•Surgical excision is based on the recommendations given in Table 34-3.

•If depth greater than 1.0 cm, refer to surgical oncologist for excision and simultaneous sentinel node biopsy.

•When dealing with facial, acral, or anogenital melanomas, Mohs surgery may be preferable to allow reduced margins and conservation of tissue.16,17

•Staging of the melanoma is accomplished using the TNM system.

Oncology referral is based on staging (including if sentinel node positive or >4 mm in depth). Close clinical