Table Of ContentCanCer
of the
skin
Commissioning Editors: Claire Bonnett and Russell Gabbedy
Development Editor: Rachael Harrison
Project Manager: Jess Thompson
Design: Kirsteen Wright
Illustration Manager: Merlyn Harvey
Illustrator: Ethan Danielson
Marketing Manager: Gaynor Jones and Helena Mutak
CanCer
skin
of the
Second Edition
Darrell S. Rigel MD Clay J. Cockerell MD
Clinical Professor of Dermatology Clinical Professor, Dermatology and Pathology;
New York University Medical Center Director, Cockerell and Associates Dermpath
New York, NY, USA Diagnostics;
Director, Division of Dermatopathology
June K. Robinson MD University of Texas Southwestern Medical Center
Dallas, TX, USA
Professor of Clinical Dermatology
Feinberg School of Medicine Henry W. Lim MD
Northwestern University
Chairman and C. S. Livingood Chair
Chicago, IL, USA
Department of Dermatology
Merrick Ross MD Henry Ford Hospital
Senior Vice President for Academic Affairs
Professor of Surgery Henry Ford Health System
Chief, Melanoma Section Detroit, MI, USA
Department of Surgical Oncology
University of Texas Eggert Stockfleth MD, PhD
MD Anderson Cancer Center
Professor of Dermatology
Houston, TX, USA
Head of Skin Cancer Center Charité
Vice-chair of Department of Dermatology, Venereology
Robert J. Friedman MD, Msc (Med)
and Allergy
Clinical Professor Charité – University Medical Center Berlin
Department of Dermatology Berlin, Germany
New York University School of Medicine
John M. Kirkwood MD
New York, NY, USA
Usher Professor of Medicine, Dermatology,
and Translational Science
University of Pittsburgh School of Medicine
Director, Melanoma and Skin Cancer Program
University of Pittsburgh Cancer Institute
Pittsburgh, PA, USA
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Courtesy of Harold S. Rabinovitz
Copyright of all figures and tables in Chapter 49: Surgical excision of melanoma is retained by
Robert Andtbacka and The Huntsman Cancer Institute, University of Utah
First edition 2005
Second edition 2011
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Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional p ractices,
or medical treatment may become necessary. Practitioners and r esearchers must always rely
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ISBN: 978-1-4377-1788-4
Cancer of the skin. – 2nd ed.
1. Skin–Cancer.
I. Rigel, Darrell S.
616.9’9477-dc22
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
FOREWORD
It is now over two decades ago that several of the editors Major emphasis in this text is on the diagnosis and man-
and myself (Robert J. Friedman, Darrell S. Rigel and Alfred agement of cutaneous malignancies so that the reader is
W. Kopf) published the seminal comprehensive text entitled provided with the most advanced diagnostic and therapeu-
Cancer of the Skin. The current text is an update on the enor- tic measures available to date for each type of skin cancer.
mous progress that has been made on all levels, including Thus, the editors and authors have made every effort to pro-
clinical, therapeutic, epidemiologic, genetic and histopatho- vide not only the commonly used therapeutic approaches,
logic, and on all levels of basic sciences with emphasis on but also those modalities considered on the ‘cutting edge’ of
neoplastic cellular biology. our present therapeutic armamentaria.
Cancers of the skin in the United States of America The backbone of Cancer of the Skin is the remarkable pro-
have the highest incidence of malignancies of any organ ductivity of the many authors who have been selected by the
system – and the incidence keeps rising inexorably. In editors because of their interest and recognition of the specific
addition to the over 2,000,000 non-melanoma skin can- malignant neoplasm dealt with in each of the chapters. Their
cers anticipated in 2010, it is expected there will be over broad experience in cutaneous etiology and the therapeutic
68,000 new invasive melanomas diagnosed and over guidelines they have documented are valuable assets to any
8700 deaths from melanomas. This translates to a life- individual involved in the multi-disciplinary needs of these
time risk for melanoma of 1 in 37 for men and 1 in 56 for patients. Thus, Cancer of the Skin serves as a valuable resource
women! not only to physicians but also to all others who deal with the
A broad array of cancers of the skin is included in this consequences of malignant tumors of the skin.
comprehensive work. Special emphasis is placed on those It is our aspiration that you will find this comprehensive
cutaneous cancers that are particularly prevalent (e.g. basal textbook a valuable summary of the current knowledge
cell carcinoma) and those which are responsible for the gleaned by the literally thousands of years of combined
highest number of fatalities (e.g. melanoma and squamous clinical and therapeutic experience coupled with extensive
cell carcinoma). reviews of literature by the multiple authors who have so
In order to relay to the reader in the most vivid way, arduously presented in written and pictorial form the very
all of the clinical images are published in full color. Every best of what is known today.
attempt has been made to provide clinical and histologic
images of the highest quality. Alfred W. Kopf MD
viii
Preface
Skin cancer rates are rising dramatically. In the United factors of skin cancer are critical in counseling patients to
States each year there are over 2 million newly diagnosed facilitate prevention. Skin cancer is also one of the most
cases – more than all other cancers combined! One in five clear-cut cases of a disease where early detection and treat-
Americans will develop at least one skin cancer during their ment are critical. Skin cancers treated early are virtually
lifetime and similar rates are found in many other countries 100% curable with simple therapies, while lesions that
worldwide. This continued increase in skin cancer incidence are advanced often have no effective treatment available.
is even more dramatic as it is occurring at a time when most Therefore, the need for medical practitioners to be able to
other cancers are either stable or decreasing in rate. recognize and treat skin cancer in its earliest phase cannot
The public health ramifications of these facts are pro- be overstated.
found. Skin cancer, once viewed as a relatively uncom- The changing demographics of skin cancer have also
mon disease limited to dermatologists and surgeons, is led to a need to focus prevention efforts on subsets of the
now being seen on a daily basis by primary care physicians, population and to alter therapy for these groups. We have
oncologists and other healthcare professionals. The result- tried to meet this need through providing information on
ing need to educate all of these groups on recognizing and such topics as the management of melanoma in the preg-
managing patients with this cancer is also increasing. nant patient. To develop an inclusive understanding of skin
In addition, the advances that have occurred even in the cancer, one must remember that there are more than basal
past decade alone in our understanding of the basic biol- and squamous cell carcinoma and melanoma. This text has
ogy, genetics, diagnosis, and treatment of skin cancer have been designed to provide an inclusive review of precursor
been staggering. In sitting down to review the layout of lesions, other non-melanoma skin cancers and cutaneous
this text, we were amazed at the multitude of topics that neoplasms related to other disorders.
had changed extensively or did not even exist for inclusion Cancer of the Skin has been designed to meet the afore-
in our prior textbook 12 years ago. The advent of dermos- mentioned needs in a format that is conducive to effectively
copy, confocal microscopy, computer-aided diagnosis, digi- transmitting relevant data to the reader. Through the use
tal photographic documentation, topical immune response of representative color clinical images, photomicrographs
modulators, and advances in immunotherapy, lymph node and flow diagrams, information on diagnosing and treating
biopsies, photoprotection agents and our understanding of skin cancer is portrayed in an easy-to-understand manner.
the biologic basis of this cancer all demonstrate the incred- We hope that you will find Cancer of the Skin useful in the
ible dynamism of this field. Social issues that have arisen treatment of your patients with skin cancer and a help in
such as genetic testing and the deleterious effects of tanning reaching the goal that we all strive for – lowering the mor-
salons also emphasize our need to understand this cancer bidity and mortality from this disease.
within a broader context. All of these topics are covered in
depth in this textbook to facilitate a wide-ranging under- Darrell S. Rigel MD
standing of skin neoplasms. June K. Robinson MD
Primary prevention efforts are also becoming increas- Merrick Ross MD
ingly important. Skin cancer is one of the few cancerswhere Robert J. Friedman MD
we know the cause of the vast majority of neoplasms – Clay J. Cockerell MD
excess ultraviolet exposure whether from the sun or arti- Henry Lim MD
ficial sources. Simple behavioral changes can lead to a Eggert Stockfleth MD
significant decrease in a person’s chance of developing John Kirkwood MD
skin cancer. An understanding of the mechanisms and risk Robert J. Friedman MD
ix
