Rosen & Barkin's 5-Minute Emergency Medicine Consult (653 page)

CODES

• 461.9 Acute sinusitis, unspecified
  
• 473.0 Chronic maxillary sinusitis
  
• 473.9 Unspecified sinusitis (chronic)
  

BASICS

• 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
      
  • SCC:
    
    • 2nd most common skin cancer
      
    • 20% of cases of skin cancer
      
    • Most arise from precancerous actinic keratosis lesions
      
    • Male > female
      
    • Most important risk factor is sun exposure, especially sunburn
      
    • 70% occur on head and neck
      
    • More common in older, fair-skinned patients
      
    • Risk of regional lymph node and distant metastasis
      
    • SCC lesions of mucosal surfaces are more aggressive
      
• 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
      
  • Risk of regional lymph node and distant metastasis
    

• UV irradiation:
  
  • Both UVA and UVB rays
    
  • Sun exposure
    
  • Tanning beds
    
• SCC often associated with human papilloma virus (HPV)
  
• Immunosuppression may predispose to SCC
  
• Vitamin D metabolism may play a role
  

DIAGNOSIS

• Actinic keratosis:
  
  • Rough, pink, circumscribed lesions <1 cm in diameter
    
  • A lesion may have both actinic keratosis and SCC
    
• 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
      
  • Pigmented BCC:
    
    • Similar to nodular BCC with brown, blue, or black coloration
      
    • Often mistaken for superficial spreading or nodular melanoma
      
  • Cystic BCC:
    
    • Bluish/gray cystic nodules
      
    • May be mistaken for benign cysts
      
  • Superficial BCC:
    
    • Scaly patch-like or papule surrounded by small, clear micropapules
      
    • Pink, red, or brown
      
  • Micronodular BCC:
    
    • Well-defined border
      
    • Aggressive
      
    • Rarely with ulceration
      
  • Morpheaform BCC:
    
    • Poorly defined borders
      
    • May appear “scar like”
      
    • Aggressive
      
    • Ulceration and bleeding are rare
      
• 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
      
• Melanoma:
  
  • Pigmented skin lesion:
    
    • 2% will be amelanotic
      
  • Features suggestive of melanoma (the
    ABCDEs
    of melanoma):
    
    • A
      symmetry (not regularly round or oval)
      
    • B
      order irregularity (notched or poorly defined)
      
    • B
      leeding (spontaneous)
      
    • C
      olor variegation (shades or combinations of brown, tan, red, white, or blue-black)
      
    • D
      iameter >6 mm
      
    • E
      levation/
      E
      nlargement
      
  • 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
      
  • Lentigo maligna melanomas (LMM):
    
    • Always starts as
      lentigo maligna
      , a macular insitu malignancy which is an evolving lesion of melanoma
      
    • LMM
      occurs after the lesion begins vertical growth into the dermis – typically indicated by papular or nodular areas
      
    • Irregular shape and multiple colors
      
  • 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
      

All suspicious lesions require biopsy, a procedure rarely done in ED

No specific testing is required

• 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
  

Biopsy usually performed by consultant

• For BCC:
  
  • SCC
    
  • Bowen disease
    
  • Actinic keratosis
    
  • Paget disease
    
  • Benign nevus
    
  • Melanoma
    
• For SCC:
  
  • Actinic keratosis
    
  • BCC
    
  • Keratoacanthoma
    
  • Melanoma
    
  • Wart
    
• For melanoma:
  
  • Atypical nevus
    
  • Common nevus
    
  • Actinic keratosis
    
  • Pigmented BCC
    
  • SCC
    

TREATMENT

No specific pre-hospital care is required

• No specific stabilization is usually required beyond basic wound care
  
• Stabilization may be required for invasion into vascular structures or edema from intracranial metastasis