Cutaneous malignancies are the most common neoplasms seen in patients. The majority occur in patients over the age of 50 years. They are most frequently curable if recognized and treated at an early stage. For this reason, prompt diagnosis of cutaneous lesions and medical intervention is an important aspect of complete medical care in the elderly population. This article will review the major cutaneous malignancies, their epidemiologic characteristics, clinical appearances, potential for aggressive behavior, and therapeutic alternatives.
BASAL CELL CARCINOMA
Basal cell carcinoma (BCC) is by far the most frequently seen malignant neoplasm (Silverberg, 1986). The majority of these lesions occur in patients over 50 years of age. The risk for developing a BCC is directly proportional to an individual's cumulative lifetime sun exposure (Wolf, 1975). Fair-skinned people are at significantly greater risk for developing BCC than are those with deeper skin tones. There is a slightly increased incidence in men compared with women. Immunosuppression is another factor that predisposes individuals to the development of BCC (Hoxtell, 1977). Although there is a stronger relationship between squamous cell carcinoma and immunosuppression, the incidence of BCC is also greatly increased in patients with immunosuppression from infectious causes such as AIDS (Sitz, 1987), on chemotherapeutic regimens, or following organ transplantation.
BCC are most commonly seen in sun-exposed areas. They frequently occur in a background of sundamaged skin, such as is seen in many elderly fair-skinned individuals. They most frequently appear as 0.5 cm to 1.0 cm crusted lesions that may be flat or raised, and may have a rolled, somewhat scaly border (Figure 1). There is frequently underlying, widely dilated blood vessels that can be seen clinically within the lesions.
Figure 1. Basal cell carcinoma, superficial type.
Figure 2. Squamous cell carcinoma.
Figure 3. Malignant melanoma, superficial spreading type.
BCC are slow growing lesions that are usually asymptomatic, and they are frequently considered by patients to be nonhealing wounds at the sites of repeated trauma. Patients will often give a history of the lesions having been present for a few years with essentially no change. The rate of growth is more rapid in immunosuppressed individuals.
BCC tend to be locally recurrent, eventually becoming invasive and destructive. It is quite rare (0.028%) for a BCC to metastasize to regional lymph nodes (Mikhail, 1977). More commonly, the tumors infiltrate surrounding normal-appearing skin into deceptively large areas, necessitating disfiguring surgical procedures to remove them. Given the propensity for these lesions to occur on the head and neck, structures such as the eyes, mucosal surfaces of the nasal cavity, and ultimately even portions of the central nervous system become involved.
Until a BCC has metastasized, it is completely curable by surgical excision. For more complicated and invasive lesions, Moh's chemosurgical technique has been shown to yield the highest cure rates. This is a surgical technique in which the dermatologie surgeon maps the extent of the BCC with serial frozen sections done at the time of the surgical procedure, and continues to remove small pieces of tissue until all surgical margins appear free of tumor. Virtually all surgical procedures for removing BCC can be done on an outpatient basis with local anesthesia. There is very low morbidity from these procedures and virtually no mortality. Experimental therapies, such as injection of intralesional interferon, have been employed with some success in treating BCC, but these are not yet available in all centers (Greenway, 1986).
Once carcinomas spread to local lymph nodes, they are notoriously resistant to standard forms of chemotherapy and are thus associated with a high mortality rate. However, there is usually an extensive time lag (often in excess of 20 years) between initial presentation and death from metastatic carcinoma. The more serious concern is for the locally aggressive and destructive nature of the lesions.
SQUAMOUS CELL CARCINOMA
Squamous cell carcinoma (SCC ranks second only to BCC in thenfrequency of occurrence (Sober, 1983). They also occur predominately on sun-exposed areas of elderly and fair-skinned individuals. Some investigators have found a slight predominance in women. The majority of SCC occur from within a background of extensively sun-damaged skin. However, SCC are more likely to occur on mucosal surfaces and nonexposed areas of the skin than are BCC. In addition, SCC have been associated more intimately with immunosuppression (Gupta, 1986). SCC also occur with increased frequency at the sites of chronic draining sinuses, burn scars, and other nonhealing wounds (Sedlin, 1963).
SCC appear somewhat different than BCC. The lesions are generally more scaly and may be ulcerated or crusted 0.5 cm to 1.5 cm lesions (Figure 2). They frequently appear and grow with more rapidity than do BCC, although they, too, can have an indolent course. In contrast to BCC, SCC have a significant potential for metastasis. Although only 0.5% of SCC will metastasize, this figure goes up to 1 1 % for SCC occurring on mucosal surfaces, such as lips, and up to 31% for SCC occurring on the sites of chronic nonhealing wounds (Sedlin, 1963). SCC occurring on sun-damaged skin have a relatively low likelihood of metastasizing.
As with BCC, simple surgical excision is the standard treatment for SCC. These lesions are usually readily amenable to simple excision under local anesthesia and require no subsequent treatment. Once metastasis has occurred, the prognosis is dismal.
Malignant melanoma is the least common of the three major primary cutaneous malignant tumors. These tumors arise from melanocytes normally present within the epidermis. Melanomas affect patients of all ages, but they are rare in pre-pubertal children. The incidence, however, increases progressively with the age of the patient population. Thus, they occur most frequently in an elderly age group. There is an unclear relationship between sun exposure and the development of melanoma; however, most melanomas do develop in fair-skinned individuals. Other factors associated with increased risk for developing melanoma include family history; presence of many melanocytic nevi (moles), especially atypical or dysplastic ones; and immunosuppression (Lynch 1975; Greene 1985).
Four clinical and histologic subtypes of melanoma have been described with different epidemiologic and biologic qualities. The most common type, superficial spreading melanoma, accounts for approximately 70% of all melanomas (Lopansri, 1979). These are usually 0.5 cm to 1.0 cm brown, flat lesions that may arise on sun-exposed or nonexposed skin (Figure 3). They are characterized by variegated pigmentation, irregular borders, and indistinct margins. Ulceration, recent growth, or recent change in a longstanding mole are ominous signs.
Nodular melanomas account for approximately 10% to 15% of all melanomas. These lesions arise de novo as raised, brown nodular lesions, with frequent ulceration and relatively rapid growth. The grim prognosis associated with these lesions is related to the fact that there is a very short course between appearance of the lesion and dermal invasion.
Lentigo maligna melanoma is the subtype most intimately associated with sun exposure (Pitman, 1979). Although the other subtypes of melanoma have been associated with intense sun exposure (ie, sunburn) during childhood, the exact relationship between sunlight and the development of melanoma is not as well established as that between sunlight and BCC or SCC. Lentigo maligna melanomas occur almost extensively on the head and neck of elderly patients with sun-damaged skin. They often present as flat, brown, irregularly pigmented and contoured brown lesions that patients claim have been present for years. This is due to an in situ phase of the tumor, during which time surgical excision is completely curative.
The final subtype of melanoma, aerai lentiginous melanoma, is the least frequent. It is a neoplasm that occurs on hands and feet, most often close to or underneath fingernails.
Although subtyping melanomas offers some prognostic value in the early stages of tumor development and helps in recognizing the lesions, the tumors have been shown clinically to behave identically once invasion into the underlying dermis is observed histologically. In marked contrast to BCC and SCC, aggressive early medical intervention is essential in preventing metastasis and death from melanoma. Melanoma is a malignant tumor with known propensity for widespread metastasis to internal organs, especially the lungs, liver, and brain. Survival rate is directly related to extent of dermal invasion. Thus, early detection is the best chance for cure.
Melanomas that have invaded the dermis to a depth of less than 0.75 mm may have a cure rate of greater than 90% (Balch, 1979). This rate drops to less than 50% by the time the tumor has invaded to a depth of 3.0 mm (Breslow, 1979). The only way to determine the depth of invasion, and thus predict survival, is to biopsy these lesions. Thus, it is important that every atypical pigmented lesion be examined histologically for the presence of malignancy and for the presence of dermal invasion. As is the case with BCC and SCC, most of these initial surgical procedures can be done under local anesthesia either on an outpatient basis or at the patient's bedside.
Subsequent therapy is dependent on the initial findings. Standard therapies include wide excisions of lesions with margins of normal appearing skin, prophylactic regional lymph node dissections in some cases, and adjuvant chemotherapy regimens for advanced cases. Melanomas typically respond poorly to conventional chemotherapeutic regimens. Many immunotherapies have recently been reported with varying degrees of success (Smoller, 1991).
PREMALIGNANT LESIONS: ACTINIC KERATOSES
Actinic keratoses are premalignant lesions that occur on sun-exposed areas of elderly patients. These lesions are believed in many cases to be the precursor lesions to squamous cell carcinomas. They appear as "cutaneous horns," which are mounds of increased keratin overlying crusted, erythematous patches or plaques. Actinic keratoses are extremely common and can be found in the majority of fair-skinned elderly patients. Although malignant transformation is uncommon, the actual incidence is not known. Most actinic keratoses will not progress to SCC. Nonetheless, given the possibility of this occurring, most dermatologists feel comfortable in treating actinic keratoses with minimally invasive therapies, such as cryosurgery or electodessication. These procedures require little to no local anesthetic and can be easily performed in an outpatient setting or at a patient's bedside. The hope is that by eradicating precursor lesions, the incidence of invasive SCC will be diminished.
A thorough examination of the elderly patient's skin may result in the detection of a myriad of dermatologie lesions. In addition to the malignant and premalignant ones discussed above, tumors such as seborrheic keratoses (the most common lesion), keratoacanthomas, Verrucae, and benign appendage tumors are frequently encountered. Although these lesions are beyond the scope of this article, correct identification and appropriate medical intervention for these lesions is also important for complete care of the elderly patient.
The ability to correctly identify, diagnose, and provide the proper treatment of skin tumors is an essential part of patient care in the elderly population. Residents in nursing homes must depend on careful and adept skin assessments made by nurses for the identification of skin aberrations. Because dermatologists do not generally frequent nursing homes on a regular basis, it is necessary for nurses to be able to recognize possible subtle skin abnormalities and make appropriate referrals for dermatology consultation.
Although precise classification of skin neoplasms may be beyond the range of nurses not specifically trained in dermatology, it is certainly within their expected capabilities to suspect abnormal lesions and act appropriately in seeking expert consultation. To this end, nurses and nursing assistants who provide care for the elderly, either through home care or to nursing home residents, should avail themselves of all opportunities for sharpening their diagnostic skills in evaluating skin tumors. Pictures of common skin malignancies should be made readily available as reference material to all nurses practicing in these situations.
Cutaneous malignancy in the elderly is common, and if detected early, most often curable. Providing nurses and nursing assistants with information regarding skin, changes seen in aging skin, and malignant transformation will result in the detection and early treatment for these potentially fatal neoplasms.
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