Expect unexpected aggression from common malignancies

"While the majority of basal cell and squamous cell carcinomas are amenable to curative treatments, there are certain subtypes, such as those tumors located around the ear or central face, having an aggressive histology or having already undergone multiple treatment modalities that present challenges in the majority of patients," says Dr. Fosko, speaking here at the 64^th Annual Meeting of the American Academy of Dermatology in March.

"The question then becomes the best way to properly identify and manage the unsuspected aggressive or high-risk tumor, what we often call the 'bad actors.' "

With more common cutaneous malignancies, such as basal cell carcinoma (BCC) or squamous cell carcinoma (SCC), a less aggressive treatment maybe chosen, and fortunately the majority of tumors respond well, with local recurrence being the biggest concern and most common risk. Based on the information provided in the dermatopathologist's report, initial decisions are made that may be suboptimal due to lack of detailed information in the report.

"Communication with your dermatopathologist directly and through the reports is critical when it comes to identifying the higher-risk tumors," Dr. Fosko tells Dermatology Times.

"While overall, the majority of the most commonly encountered cutaneous malignancies rarely cause extensive local morbidity or have a propensity to spread locally to lymph nodes, or even metastasize, when you start to sort out this higher-risk group of tumors, such events become much more common. Early identification and effective treatment become the keys to minimizing such events," Dr. Fosko says.

"Dermatologists should be aware of those tumors that are 'bad actors' - friendly-looking clinically or from the initial pathology reports - that can be much more aggressive in nature. We often think about this with unusual tumors such as Merkel cell carcinoma, dermatofibroma sarcoma protuberans and angiosarcoma - but probably BCC and SCC become the tumors that can surprise us more."

Case in point: Although BCC outnumbers it in prevalence, more than 40,000 new cases of SCC are diagnosed per year in the United States, with two-thirds of patients presenting locally advanced disease, according to the University of Texas Medical Branch.

"We should never underestimate the importance of a complete evaluation based on clinical presentation, physical examination and diagnostic histopathologic features, in addition to always checking the lymph nodes of every patient with high-risk tumors," Dr. Fosko says. "You don't find lymph node involvement very often, but if you're not checking every time, you most likely may miss the few times it presents."

Two-way communication

While delivering a viable biopsy is crucial to gaining the complete picture of any tumor, a reliable path of communication between the dermatologist and dermatopathologist is just as essential.

The dermatopathologist should not be simply delivering a diagnosis. Rather, he or she should offer complete details regarding the tumor, Dr. Fosko says.

"Are they really telling you as much about the tumor as can be known? In some cases you need to know more specifics about the tumor, such as the depth of the tumor and if the base is poorly differentiated or has a more infiltrative pattern, or is this is a potentially high-risk tumor because of other histopathologic features? This information is critical and can be relied upon only when a good understanding of these tumors and a strong relationship is formed between the dermatologist and dermatopathologist," Dr. Fosko says.