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    Kuliah BRH Kanker Kulit

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    Nofia Gustiani Indra
    This document discusses various types of skin cancer. It notes that non-melanoma skin cancers like basal cell carcinoma and squamous cell carcinoma are more common than melanoma. It provides details on risk factors, clinical presentation, diagnosis, and treatment options for different skin cancers. Prevention through sun protection and early detection of suspicious lesions is emphasized.

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    Kuliah BRH Kanker Kulit

    Uploaded by

    Nofia Gustiani Indra
    97 views78 pages
    This document discusses various types of skin cancer. It notes that non-melanoma skin cancers like basal cell carcinoma and squamous cell carcinoma are more common than melanoma. It provides details on risk factors, clinical presentation, diagnosis, and treatment options for different skin cancers. Prevention through sun protection and early detection of suspicious lesions is emphasized.

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    This document discusses various types of skin cancer. It notes that non-melanoma skin cancers like basal cell carcinoma and squamous cell carcinoma are more common than melanoma. It provides details on risk factors, clinical presentation, diagnosis, and treatment options for different skin cancers. Prevention through sun protection and early detection of suspicious lesions is emphasized.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    97 views78 pages

    Kuliah BRH Kanker Kulit

    Uploaded by

    Nofia Gustiani Indra
    This document discusses various types of skin cancer. It notes that non-melanoma skin cancers like basal cell carcinoma and squamous cell carcinoma are more common than melanoma. It provides details on risk factors, clinical presentation, diagnosis, and treatment options for different skin cancers. Prevention through sun protection and early detection of suspicious lesions is emphasized.

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    of 78

    SKIN CANCER

    SKIN CANCER

    Dr. Ismeldi syarief, SpB (K) Onk


    SKIN CANCER
    SKIN CANCER

    Most common male malignancy 17,4% (IND)


    Fifth most common maale malignamcy (USA)
    Third common malignancy 11,5% (M&F)
    Seventh most common female
    malignancy(USA)
    Lesion melanoma & non melanoma
    Non melanoma : BCC & SCC
    Total cost 600 milion dolar / year
    KANKER KULIT

    MELANOMA MALIGNA (8,5%)


    NON MELANOMA MALIGNA (89,5%)
    - KANKER SEL BASAL (75-80 %)
    - KANKER SEL SKUAMOSA (20 %)
    KANKER KULIT LAIN (2-3 %)
    Precancer Lesion
    Actinic keratosis ( KSS insitu)
    SKIN CANCER

    Kerato acanthoma
    Bowens disease
    Xeroderma pigmentosum
    Hyperplasia pseudo epi
    Dysplastic naevi
    Solar keratotic intraepidermal kss
    Erythroplasia of Queyrat
    Lentigo Maligna
    Brown plaaque on skin face older people
    Bowens Disease
    Ssquamous cell
    carcinoma (SCC) in situ.

    Etiology : uv, chronic


    arsenicism,
    radiation,
    immsup,
    infection.
    Xeroderma Pigmentosum
    Actinic Keratosis

    Actinic keratoses (AKs) :

    proliferation of aberrant epidermal


    keratinocytes in response to prolonged
    exposure to ultraviolet (UV) radiation
    Keratoachantoma
    Low grade SCC

    Rapid growth over


    weeks

    Trauma, sun exposure,


    HPV 11 and 16

    May progress to
    invasive SCC
    ETIOLOGIC FACTORS
    ENDOGEN : Genes
    SKIN CANCER

    EXOGENS: UV radiation
    Ionizing radiation
    Viruses
    Chemicals : industrial oils, dyes, solvents
    arsenic, pesticides, tobacco
    Chronic irritation
    Hyperthermia

    OTHERS : outside activity, changing clothes design,


    ozon reducing, imunosupresi
    Indication for biopsi

    Precancer lession

    Susp Malignancy
    BIOPSY TECHNIQUES

    SKIN CANCER

    Excisional biopsy
    Incisional biopsy
    Shave biopsy
    Punch biopsy
    Principles in Therapy
    Identify high risk patients
    Recognize the cases in early stadium
    SKIN CANCER

    Biopsies should be performed under


    general/regional anaesthesia.
    Remove the tumor completely with limf
    node
    dissection
    Any pre-cancerous lesion should be treated
    correctly
    Good follow up.
    Pemilihan Terapi
    Tergantung :
    Tipe histopatologi
    Lokasi
    Ukuran tumor
    Faktor penderita
    TERAPI UTAMA :
    EKSISI BEDAH (Eksisi Luas
    PRINSIP TERAPI
    BEDAH (EKSISI LUAS)

    Pengangkatan tumor dengan sempurna


    Morbiditas minimal
    Preservasi jaringan kulit sehat disekitar
    tumor
    Kosmetik
    Sesuai prinsip Onkologi pembedahan
    Follow up ketat
    EKSISI LUAS :
    SAFETY MARGIN

    Safety margin : tepi sayatan dan dasar


    operasi BEBAS sel TUMOR
    Ditentukan durante operasi dengan
    froozen section.
    Ditentukan juga oleh sifat masing
    masing kanker, diameter dan ketebalan
    tumor, derajat keganasan tumor /agresifitas
    tumor.
    Rekomendasi bervariasi
    STRATEGIES FOR PREVENTION

    Primary prevention : risk factor


    modification
    Secondary prevention : improved disease
    surveillance & earlier detection
    PRIMARY PREVENTION

    Sun avoidance between 10.00 16.00 hrs


    Sun protective clothing
    Sun screens / sun-protecting factor, avoid
    sun between 10am-2pm or between 11am-
    3pm
    Slip, Slop, Slap.
    Wear high sleeve shirt
    Use broad edge hat
    Sunscreen pplication still has many pro-cons
    Self checking every 6-8 weeks
    Nevus excision.
    BASAL CEL CARCINOMA
    SKIN CANCER

    USA > 1.200.000 or more new cases NMSC


    annually
    75 80% basal cell carcinomas.
    Kromphecer first describe BCC
    Local invasion
    Local destruction
    Very rare metastasis
    Commonly occurred on sun-exposed body area
    Can occur on non-exposed area (eg: vulva, penis,
    scrotum, perineal)
    Karsinoma Sel Basal

    Resiko Tinggi Terjadi Rekurensi


    Lokasi :
    H-zone daerah wajah :
    Periorbital, kelopak mata, hidung, perioral,
    nasolabial
    fold,pre auricula, retroauricula.
    Histologi :
    Mikronoduler, infiltratif, morpheoform
    Ukuran : diameter > 2 cm
    Tumor Rekurens pasca operasi atau radioterapi
    Immunosupresi
    Sajjad Rajpar, ABC of Skin Cancer, 2008
    PREDISPOSE FACTORS

    Fair skin (TIPE I & II)


    SKIN CANCER

    Albino
    UV Exposure
    Sindrome nevus basal
    LE kronis
    Ulkus kronis
    Fistula

    a
    Subtype dan Rekurensi
    BCC
    Clinical appearance
    Node, usual size 2 cm, with
    SKIN CANCER

    higher
    edge
    Teleangiectasia
    Transparant node with pearl-like
    edge
    Ulceration
    Rhoden ulcer
    Slow growing
    BCC
    BCC
    BCC
    CLINICAL VARIANTS BCC
    SKIN CANCER

    o Noduler (nodulo urcerative, rodent ulcer )


    o Superficial (multicentric)
    o Infiltrative or micronodular (morpheaform)
    o Pigmented BCC
    o Cystic BCC
    o Fibroepitelioma pinkus
    o Squameus metaplasia
    TREATMENT
    Curettage & Electrodesiccation (dermatologist)
    SKIN CANCER

    Mohs micrographic surgery


    Excision (surgeon)
    Recontruction
    Radiation therapy
    Topical chemotherapy (5 FU)
    Systemic chemotherapi (metastase & uncontrolled
    BASAL CEL CARCINOMA
    BCC REKONSTRUKSI
    Squamose sel carcinoma

    Locally invasif
    Fast growing
    Ability to metastase (limf node, visceral 5-
    10%)
    Can occur in fibrotic tissue (Marjoline ulcer)
    Recurrency depends on differentiation,
    tumor depth, nerve invasion.
    Squamous Cell Carcinoma

    Clinical appearance :
    -Ulcerative type (ulcer)
    - Papillary type (cauliflower)
    Histologic :
    Cornificans, non cornificans &
    undifferentiated
    Risk factors for SCC
    Fair skin (burn easily, never or rarely tan)
    Chronic cumulative UV exposure
    Geography (closer to equator)
    Hystory of prior NMSC
    Age > 50 y
    Male gender
    Genodermatoses
    Smoking (lip SCC)
    Intense PUVA therapy (>300)
    Chemicals carcinogen
    Chronic scarring/inflamatory condition
    Immunosupresan
    Human papiloma virus infection
    > 10 AK
    Predisposing SCC
    - lupus erythematosus
    - lichen planus
    . - lymphedema
    - chronic leg ulcer
    1 Chronic inflamatory - Osteomyelitis
    - chronic deep fungal infection
    2.Chronic infection : - lymphogranuloma venereum
    - granuloma inguinale

    3.Chronic scarring
    - burn scars
    - thermal injury
    - irradiated skin
    4.Genetic syndrome : xeroderma pigmentosum
    CLINICAL STADIUM
    T : primary tumor
    T1 :< 2 cm N ( limf node)
    N1 : metastase to
    T2 > 2-5 cm regional limf node

    T3 > 5 cm M (distant
    metastase)
    T4 cartilage, muscle,
    and bone infiltration. M1 distant metastase
    SCC TREATMENT

    Surgery :
    Wide excision (2-3 cm) & reconstruction
    Lymphnode dissection
    Radiotherapy : poor surgical candidates
    refuse surgery
    inoperable lesion
    Chemotherapy : inoperable lesion
    metastase
    SAFETY MARGIN
    Karsinoma Sel Skuamosa
    Karsinoma Sel Skuamosa
    Tumor < 2 cm : 4 mm
    < 2 cm ,High risk tumor : 6 mm
    Tumor > 2 cm : 4-10 mm
    PERABOI : 1-2 cm
    Treatment of Localized SCC

    Topical chemotherapy :
    5 flourouracil
    Imiquoimod
    Destruction (no margin control)
    Cryotheraphy
    Curretage
    Electrodisection
    Co2 laser ablation
    Intralesional interferon, bleomycin
    Radiation therapy
    Margin control resection :
    Excision & Mohs micrographic surgery
    KSS
    SCC TREATMENT
    Treatment depends on :
    - Tumor size
    - Location
    - Depth of invasion
    - Grade
    - History of prior treatment.
    PROGNOSIS

    TUMOR SIZE
    LOCATION
    Grade of differentiation
    Metastase to limf node (ten year survival <
    20 % )
    DISTANT METASTASE < 10 %
    MALIGNANT MELANOMA

    Definition :A malignant transformation of


    melanocyt.
    4 % from all skin malignancies
    79 % from all death cause in skin cancer
    2,3 / 100000
    Ethiology : ultra violet ( Armstrong & Kricker)
    Biological characters are unique and very
    unpredictable
    CARCINOGENESIS MECHANISM FACTOR IN
    MELANOMA
    Genetic factor :
    Melanocytic nevi: 30-90% from all nevus
    Biologic factor : chronic iritation,
    immunorespon, hormonal factor
    Environment factor : ultra violet.
    RISK FACTORS OF MM
    White skin
    Sun Ray
    Freckles
    Numbers of nevus ( 5 nevus > 6 mm ) , 50 nevi
    Diameter 3mm
    Congenital nevus ( giant kongenital nevi 6 % ),
    detection is quite difficult beacause the location is
    quite deep
    Family factor : 8 12 %
    Immunosuppresion : risk 3 x
    Psoriasis therapy with PUVA
    Xeroderma pigmentosum
    Clinical signs suggestive MM
    Change in color
    Change in size
    Change in shape
    Change in elevation
    Change in surface
    Change in surronding skin
    Change in sensation
    Change in consistency
    Nevus Diagnosis

    Lesion on skin that change in months years.


    A : asymmetric
    B : border irregularity
    C : color variability
    D: diameter > 6 mm
    E : evolution , elevation, enlargment
    F: Funny looking

    Other signs : easily bleeding, itchy, ulceration.


    ulserasi
    A = Asymmetry

    Asymmetric
    Symmetric (benign)
    (malignant melanoma)
    B = Border irregularity

    Borders are even Borders are irregular


    (benign) (malignant melanoma)
    C = Color variation

    One shade/even color Two or more shades


    (benign) / uneven color
    (malignant melanoma)
    D = Diameter

    Diameter <6 mm Diameter >6mm


    (benign) (malignant melanoma)
    CLINICAL TYPE MORFOLOFY MM

    Superfisial spreading melanoma /SSM(


    70%,)
    Nodular melanoma/NM ( 15 % )
    Acral lentiginous melanoma/ALM ( 10 % )
    Lentigo maligna /LM( 5 % )
    Desmoplastik melanoma ( 1-2% )
    Clinical types- MM

    Superficial spreading melanoma

    Lentigo maligna melanoma

    Acral lentiginous melanoma


    Nodular melanoma
    MM of Foot Sole + Limf Node
    CLARK LEVEL
    LEVEL I : Melanoma limited to the epidermis
    LEVEL II : Invasive melanoma with superficial
    infiltration to the papillary dermis
    LEVEL III : Melanoma extending to the superficial
    vasculer plexus in the dermis
    LEVEL IV : Primary melanoma involving the
    reticular dermis
    LEVEL V : Melanoma involving the subcutaneous
    fat
    Microscope with micrometer
    Conventional Surgery

    Wide Excision
    Lymph node dissection
    Therapy
    Operation : Primary lesion wide excision 2 cm ;
    limf node dissection
    Radiation
    Chemotherapy
    Isolated regional perfusion
    Paliative treatment
    Vaccine therapy, Interferron & Interleukin
    MD Anderson Recomendation

    Safety Margin for Malignant Melanoma

    Deep Safety Margin


    <1 mm 1 cm

    1 - 2 mm 1 < 2 cm

    2 - 4 mm 2 cm

    >4 mm 2 cm
    MM of Foot Sole
    MM Plantar Pedis + KGB
    PROGNOSTIC FACTORS

    CLINICAL
    Age
    Gender
    Anatomic site
    Serum LDH
    Distant metastasis
    PROGNOSTIC FACTORS

    HISTOLOGIC
    Tumor thickness Angiogenesis
    ClarkS level Vascular invasion
    Ulceration Microsatellites
    Nodal Status Mitotic rate
    lymph node status Regression
    Tumor type Tumor infiltrating
    lymphocytes
    Growth patterns

    MOLECULER & BIOCHEMICAL


    Mortality from Skin Cancer

    Malignant Melanoma ~ 20%


    Squamous Cell 2% Carcinoma
    Basal Cell Carcinoma < 1%

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