On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.79 no.5 Rio de Janeiro Sept./Oct. 2004
CLINICAL, EPIDEMIOLOGICAL, LABORATORY AND THERAPEUTIC INVESTIGATION
Distribution of diagnosis of neoplastic and preneoplastic skin lesions at Evangelical Hospital in Curitiba*
Ana Paula DerghamI; Caren Cristiane MuraroI; Elisângela Aparecida RamosI; Lismary Aparecida de Forville MesquitaII; Luiz Martins CollaçoIII
IMedical student, 5th year, Evangelical
University of Paraná (Fepar)
IIAuxiliary Professor of Pathology, Fepar, MD Dermatopathologist at Hospital Santa Casa de Misericórdia de Curitiba, MSc in Surgery
IIIProfessor responsible for Pathology Department, Fepar, PhD in Internal Medicine, UFPR
BACKGROUND: Skin cancer is the most common
cancer in Caucasians. It is estimated that there are one million new cases a
year of nonmelanoma skin cancer (Basal Cell Carcinoma - BCC and Squamous Cell
Carcinoma - SCC) all over the world. Regarding skin tumors, BCC is the most
frequent. Among precancerous lesions, Actinic Keratosis - AK is the most common.
OBJECTIVE: To analyze the incidence and parts of the body most affected by cancerous skin lesions and also Actinic Keratosis in our environment.
METHODS: Retrospective study that analyzed skin biopsies of 491 patients with a diagnosis of AK, BCC, SCC or melanoma, resulting in 531 diagnoses registered by Pathologic Anatomy Service of Evangelical Hospital in Curitiba during 2002.
RESULTS: Regarding sex, 270 were female (54.99%) and 221 were male (45.01%). BCC (58.46% - 114/195) and melanoma (61.5% - 16/26) were most prevalent among females, as well as AK dermatosis (60.79% - 107/176). SCC were prevalent in males (64.39% - 61/94). From 531 diagnoses, 62.90% (334) were malignant skin tumors. The most common tumor was BCC (39.74% - 211). In relation to dermatosis, 37.10% (197) corresponded to AK. The mean age was 59.81 years old. In relation to the location of the lesions, there was a higher occurrence in the cephalic extremity with 50.47% (268) of the cases. The most affected areas (11.50% - 3/26) in melanoma were the malar region, back and feet.
CONCLUSIONS: BCC was the most common tumor. The prevalence was higher in the 6th decade of life. Females were most affected. Cephalic extremity was the most common location among the studied lesions, except for melanoma, which prevailed in the malar region back and feet.
Key words: skin neoplasms; epidemiology; keratosis.
Skin cancer, characterized by abnormal and uncontrolled growth of the cells that compose the skin, is most common in white-skinned populations, surpassing even the sum of all the other skin types.1
Its exact incidence is not known, because many cases pass undiagnosed or are not notified by the doctor. Nevertheless it can be considered the most frequent type of cancer involving human beings.
According to data from the Ministry of Health's National Registration of Tumoral Pathology and Diagnoses of Cancer, this type of cancer is the most common among Brazilians of both sexes. In general, the lesions are easy to diagnose and have cure rates over 95% provided they receive early and correct treatment.
Precancerous dermatoses are those that are acquired or genetic and can develop into cutaneous cancer.2
Both skin cancer and precancerous dermatoses are related to excessive solar radiation exposure, predominantly affecting in this form, those parts of the body most exposed to the sun (head, neck and limbs). The onset of these lesions is also related to factors such as: age, sex, ethnic origin, smoking, alcohol abuse, geographical distribution, old scars, persistent physical aggression, exposure to radioactive agents etc.
Solar exposure is the greatest environmental agent implicated in inducing nonmelanoma skin cancer, denominated squamous cell carcinoma (SCC) and basal cell carcinoma (BCC).3 Although solar exposure is present as a habit in the early phases of an individual's life, the average age of patients with nonmelanoma skin cancer is 60 years.1
Of the precancerous dermatoses, the most frequent is actinic keratosis, that becomes cancerous in a percentile that varies from 20 to 25%.4 Regarding skin tumors, the most frequent is BCC (approximately 65% of total cutaneous neoplasias). In Brazil, out of the total incidence of cancer, it accounts for 68% and 73.3% among males and females, respectively. Followed by SCC (approximately 25.1% for males and 19.4% for females). Melanoma amounts to approximately 5%.5
It is estimated that nonmelanoma skin cancer is increasing at a rate of one million new cases every year. Studies have demonstrated that 40 to 50% of the people in the USA that survive up to 65 years of age will develop nonmelanoma skin cancer. It is typically found in the head, neck, face and arms, but can occur in any location. The largest cause of nonmelanoma cancer is ultraviolet radiation (UV) and mainly UV-b. Although cellular damage can occur in the initial phases of life, most of the cancer appears after 50 years, as a result of the cumulative exposure to UV.6 The objective of this study was to analyze the incidence and location of the body most involved by cancerous lesions of the skin and also by actinic keratosis.
MATERIAL AND METHODS
In this retrospective study, 607 patients that underwent skin biopsies with a diagnosis of actinic keratosis, BCC, SCC or melanoma were selected from 8,287 reports registered at the Service of Pathological Anatomy of the Evangelical Teaching Hospital in Curitiba during 2002. From these records the following data were collected: patient's name and registration number at the Pathological Anatomy Sector, age, sex, diagnosis and biopsy site. The lack of any one of the above data resulted in exclusion of the case from the sample. In all 24 patients were excluded (4.66%). The present study analyzed skin biopsies from 491 patients, giving a total of 531 diagnoses. The description of the data was expressed in the form of percentages.
Age varied between eight and 94 years, with a mean of 59.81 years. There was a narrow difference between the mean age of patients with malignant tumors (60.02 years) and those with dermatoses (58.6 years). From the total of 491 patients, 270 were women (54.99%), and 221, men (45.01%). BCC (58.46% - 114/195) and melanoma (61.54% - 16/26) occurred more among the female sex (Graph 1), as did actinic keratosis (60.79% - 107/176) (Graph 1). Males prevailed in SCC (64.89% - 61/94). Of the 531 diagnoses, 62.90% (334) corresponded to malignant skin tumors (Graph 2). The tumor found most frequently was BCC (39.74% - 211), followed by SCC (18.27% - 97) and melanoma (4.89% - 26) (Graph 3). Regarding the dermatoses, 31.10% (197) corresponded to actinic keratosis (Graph 2). As for the location of the studied lesions, there was a greater occurrence in the cephalic extremity (frontal region, face, scalp and ears), representing 50.47% (268) of the cases. In the face (43.5% - 231), the location most found was the nasal region, with 91 cases (39.39%), BCC was the most prevalent in that area (59.34% - 54/91). Melanoma involved mostly the back, the malar region and the feet (11.50% - 3/26). There were also two cases of collision tumor, both in the face.
BCC is the most frequent of the malignant skin tumors (70%), a fact confirmed by the current sampling, that found 63.17%. Most of the lesions occurred in the cephalic region. However the predominant site is considered to be in the central two thirds of the face, while the authors found the nasal apex and wings to be the most frequently involved; while it rarely occurred in the back of the hand and forearms, as well as the palmar and plantar regions and mucous membranes. The present study did not register any case that referred to these locations. It most frequently involves individuals after the fifth decade of life,7 however in the present work the sixth decade was registered as the most affected. It occurs mostly in females, as corroborated in this study. SCC is located most commonly in the lower lip, ear, face, back of the hands, mucous membranes and external genitalia. Likewise, the current study presented a higher occurrence in the face, mainly the nose and lower lip. It was most frequent in the seventh decade, contradicting data in the literature that demonstrated the highest number of cases in the sixth decade. Collision tumors (SCC in proximity with BCC) are rarely found. The authors found two cases, in the face.
Although melanoma represents between 3 to 5% of malignant tumors,5 we registered 7.78%. Melanoma is rare before puberty. Its peak involvement is between 40 and 60 years of age, information compatible with the findings in this study, which demonstrated a mean age of 50 years. The greater occurrence among male individuals is debatable. For some authors, the prevalence is in females.2 Due to this fact, it is questioned whether there is a possible relationship between the production of melanocyte-stimulating hormone (MSH) and the higher occurrence of such tumors in women.8 Hormonal influences have been considered in the onset and development of melanoma, since estrogen receptors have been found in melanocytes of the nevi and of the melanoma, and progesterone and androgen receptors in the melanocytes of melanomas.9 The current study found two thirds of the cases in women.
Actinic keratosis was located mainly in the face, in the scalp (bald areas) and back of the arms and hands, in agreement with the literature. Studies have shown that there is a correlation between SCC and actinic keratosis.10 In a study, Cockerell affirms that actinic keratosis and SCC represent the same lesion at a different stage of development, considering actinic keratosis to be the earlier stage. Literature reports that only 1:1,000 cases of actinic keratosis develops into SCC.11 Others studies have calculated that between 10 and 25% of actinic keratosis cases develop into carcinoma.12,13,14
Thus, one questions which is the most frequent malignant tumor, BCC or SCC, since, summing the occurrence of actinic keratosis and SCC in this study, there is a higher number of cases of SCC than BCC.
BCC was the tumor most frequently found in the records analyzed. Females were the most affected. There was a higher prevalence in the sixth and seventh decades of life. The cephalic extremity was the most common location of the lesions studied, except for melanoma, that predominated in the back, malar region and feet.
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Ana Paula Dergham
Av. República Argentina, 3995 - Bairro Novo Mundo
81050-000 Curitiba Paraná
Telefone: (41) 363-7551
Received on January 05, 2004.
Approved by the Consultive Council and accepted for publication on August 07, 2004
* Work done at Department of Pathological Anatomy, Evangelical University Hospital of Curitiba