Dermatopathology
A clinicopathologic review of lethal nonmelanoma skin cancers in Western Australia

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Background

Nonmelanoma skin cancer (NMSC) comprises a heterogeneous group of cancers. A comprehensive review of NMSC mortality has not been performed previously in this region.

Objective

We sought to document the population affected by lethal NMSC, the types of tumors involved, and their histopathologic features.

Methods

Death certificates of all patients who died from NMSC were examined. Histology of the primary lesion was reviewed in cases when the primary lesion was identified and sections were available.

Results

A total of 120 NMSC deaths occurred, including 89 caused by squamous cell carcinoma, 22 by Merkel cell carcinoma, and 9 others. The median age at death was 79 years, unless the patients were immune deficient (68 years). When the primary lesion was identified (n = 45), the median survival after diagnosis was 17 months; 75% of patients died within 3 years. Lethal neoplasms were deeply invasive and infiltrated into the reticular dermis and beyond. Three squamous cell carcinomas were reclassified as adenosquamous carcinoma.

Conclusion

Lethal NMSC occurs in the elderly and consists mainly of 3 types of deeply invasive cancers.

Section snippets

Patient selection

The WA state cancer registry records all cancer-related deaths in the state. Individuals are considered to have died from skin cancer when the diagnosis is listed as a cause of death on the death certificate. Further clarification is sought from the attending clinicians by the registry if doubt exists as to the role of a cancer in the patient's death. Incidence rates are collected for cutaneous malignant melanoma but not SCC or BCC.9

All patients classified as dying from biopsy-proven skin

Demographic characteristics

During the 5 years of 1994 to 1998, 120 patients died from NMSC based on WA cancer registry information. In the same period, 14,562 patients died from cancer in WA15; thus, 0.8% of all cancer deaths were caused by NMSC. The median age of death was 79 years, ranging from 46 to 101 years (Fig 1). Men were affected more commonly (n = 80) than women (n = 40). Cause of death was recorded on death certificates as: 89 SCC; 22 MCC; 6 sarcomas including two malignant fibrous histiocytomas, two

Discussion

This review documents the number of deaths from NMSC in WA during a 5-year period and describes macroscopic and histopathologic features of the primary neoplasms. During the study period, 0.8% of cancer-related deaths in WA were caused by NMSC, which were mainly of 3 types: SCC, MCC, and ASC. Importantly, both macroscopically small and large neoplasms have caused death whereas most neoplasms invaded deeply, suggesting that depth of invasion is a more accurate prognostic indicator than surface

Conclusion

NMSC deaths in WA are caused mainly by SCC, MCC, or ASC. Many of these neoplasms, especially MCC, are small but have invaded deeply at the time of excision and not all have the classic markers of a poor prognosis. Data generated from this and subsequent studies on larger numbers of lethal NMSC should assist pathologists and clinicians to recognize indicators of poor prognosis in NMSC.

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    Funding sources: None.

    Conflicts of interest: None identified.

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