Pattern of skin cancer at Dammam Medical Complex in Dammam, Saudi Arabia

Accepted Manuscript Pattern of skin cancer at Dammam Medical Complex in Dammam, Saudi Arabia Khalid M. Alwunais, Sohail Ahmad PII: DOI: Reference:

S2352-2410(15)00046-8 http://dx.doi.org/10.1016/j.jdds.2015.06.002 JDDS 38

To appear in:

Journal of Dermatology & Dermatologic Surgery

Received Date: Accepted Date:

9 February 2015 5 June 2015

Please cite this article as: K.M. Alwunais, S. Ahmad, Pattern of skin cancer at Dammam Medical Complex in Dammam, Saudi Arabia, Journal of Dermatology & Dermatologic Surgery (2015), doi: http://dx.doi.org/10.1016/ j.jdds.2015.06.002

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Research Article Pattern of skin cancer at Dammam Medical Complex in Dammam , Saudi Arabia Khalid M. Alwunais , Dermatology Consultant (1) , sohail Ahmad, Histopathology Consultant (2). (1) Dermatology Department , Dammam Medical Complex , Saudi Arabia. (2) Histopathology Department, Dammam Regional Laboratoy.

Pattern of skin cancer at Dammam Medical Complex in Dammam , Saudi Arabia

Abstract objective : This study was performed to determine the pattern of skin malignancies in Dammam Medical Complex , Dammam , Kingdom of Saudi Arabia. and to compare these results with those from other parts of the world .

Materials and methods : Histologically diagnosed skin cancers between June 2008 and May 2014 were reviewed and analyzed. Dammam Medical Complex is the main hospital in Dammam that receives most of the malignant cases in this area. Trends in incidence of skin cancers by their age, sex and anatomic location were examined.

Results : Of the 27 cases of skin cancer majority (74%) were Saudis, and males (59.2%). The most common malignant skin lesion was BCC followed by SCC , dermatofibrosarcoma protuberans (DFSP) , skin secondaries from stomach , breast and lung , mycosis fungoides (MF) , malignant melanoma (MM) . The most common site was head and neck for BCC, trunk for SCC, and trunk for DFSP .

Conclusion: Low occurrence of malignant skin tumors in dermatology practice in dammam . nevertheless BCC , SCC and MM should be considered in the dermatology practice locally .

The most common skin cancers seen are BCC and SCC followed by DFSB and MF . The site of distribution of BCC and SCC in our study is similar to studies from various other regions of Saudi Arabia and other countries.

Introduction malignant skin tumors constitute an important part of the dermatology practice . they have been studies in different areas of the world. In Saudi Arabia , Dammam there are no studies about the pattern and prevalence of malignant skin tumors . A study from Asir showed that skin cancer the most common malignancy in both gender (1) . A study from Qassim reported BCC as the most common skin cancer (2). A study from Jeddah most common skin cancer seen are BCC and SCC followed by MF and MM (3) . In our study we report the finding on the prevalence and pattern of malignant skin tumors in Dammam. and compare these results with those from other regions of Saudi Arabia and other countries. The World Health Organization (WHO) estimates 2---3 million cases of Nonmelanoma skin cancer (NMSC) per year (4), Caucasians have been reported to be most commonly affected (5). Considerable geographical and racial variations have been reported, with very high incidence in some countries. Australia has the highest skin cancer incidence rate in the world (6). Skin cancers the most common

malignancy and represent approximately half of all cancers in the united states (7). Studies from Saudi Arabia; however, indicate skin cancer accounting for 3.2% of all newly diagnosed cases in year 2010, This cancer ranked ninth in both genders (8). BCC is the most common skin malignancy, mostly found on face. SCC is less common but is more aggressive than BCC. Majority of SCCs are found on parts of the body other than face (9). Malignant Melanoma is the least common of the three skin malignancies but most aggressive. Other infrequently found skin cancers are Dermatofibroma Protuberans (DFSP), mycosis fungoidis (MF).

Method : A retrospective study including all cases with a histological diagnosis of skin cancer among patients, biopsied or excised, was performed between June 2008 and May 2014. Relevant clinical and histopathological data were gathered from the hospital records.

Results : -A total of 27 cases of primary and secondary malignant skin tumors were diagnosed including 23 (85%) primary and 4 (15%) secondary malignant skin tumors. - median age of the patients was 53 years. - 16 (59.2%) patients were males. - there were 20 saudi patients and 7 non Saudi patients. - pattern of the skin tumors , demographic data and sites shown in ( table 1). - the predominant tumor was BCC (7 cases ) , the cases of DFSP were 5 , 4 cases of secondary malignancy in the skin and only one case of superficial spreading melanoma.

Table 1 Demographic data including tumor characteristics

Clinical and pathology data

Frequency

Percent

Ages (years) Median Range M/F Saudi / Non Saudi Primary / Secondary H&N Extremities Trunk BCC SCC MF MM DFSP secondary cancer lung secondary cancer stomach secondary cancer breast Total

53 25-88 16/11 20/7 23/4 10 5 12 7 6 4 1 5 1

59.2/40.8 74/26 85/15 37 18.5 44.5 26 22.2 14.8 3.7 18.5 3.7

2 1 27

7.4 3.7 100

BCC was the most common NMSC affecting 7 (26%) cases. SCC was reported among 6 (22.2%) cases and was the second commonest primary skin malignancy. DFSP was reported in 5 (18.5%) cases. MF and Malignant Melanoma were other primary skin malignancies reported in 4 (14.8%) and 1 (3.7%) case, respectively. Secondaries in the skin were reported in 4 (14.8%) cases. These included 2 (7.4%) cases secondaries from Carcinoma of stomach and one (3.7%) case each of secondary from Carcinoma of lung and breast . The most frequent site of primary skin cancer was in the trunk recorded in 12 (44.5%) cases, followed by

the head and neck region and extremities in 10 (37%) and 5 (18.5%) cases, respectively.

common cancer encountered in head and neck region was BCC (55.5%), followed by SCC (22.2%). Also seen in head and neck region were DFSP and skin cancer secondary from lung , one (11.1%) case each. All types of skin malignancies were found in the extremities and trunk. SCC, DFSP and MF was recorded in equal proportions (22.2%) followed by BCC and skin cancer secondary from stomach in equal proportions (11.1%). Also seen in extremities and trunk were MM and skin cancer secondary from breast. 4 cases were skin type II , 9 cases were skin type III and 14 cases were skin type IV. 11 cases have history of exposure to the sun through work and spend lots of time outdoors, unprotected, during their lifetime . 6 cases have history of many moles and abnormal moles . 8 cases have history of Precancerous skin lesions (actinic keratoses) on the face, head and hands. 9 cases have history of using immunosuppressive treatment (Methotrexate,

Cyclosporine, Azathioprine and Mycophenolate mofetil) during a period in their lifetime. 7 cases have positive family history of skin cancer.

Table 2 shows a comparison between the two genders, with regards to types and location of skin tumors. extremities and trunk were observed

to be favoured sites in both the genders, 81.2% in males and 81.8 % in females. BCC was more commonly seen in males. SCC and MF were reported similar in both the genders. DFSP was reported more in males. One case of MM reported in males . skin secondaries were limited to females only.

Table 2 Comparing male vs female cases with skin tumors regarding site and character of the tumor. Males n = 16

Females n = 11

Total

Primary vs Secandry 15 (93.7%) 1 (6.3%)

8 (72.7%) 3 (27.3%)

23 (85.2%) 4 (14.8%)

Extremities

3 (18.7%)

2 (18.2%)

5 (18.5%)

Head& neck

6 (37.5%)

3 (27.3%)

Trunk

7 (43.7%)

6 (54.5%)

9 (33.3%) 13 (48.1%)

BCC

6 (37.5%)

1 (9%)

7 (26%)

SCC

3 (18.7%)

3 (27.2%)

6 (22.2%)

DFSP

3 (18.7%)

2 (18.2%)

5 (18.5%)

MF

2 (12.5%)

2 (18.2%)

4 (14.8%)

MM Secondary Cancer Stomach Secondary Cancer Lung Secondary Cancer Breast

1 (6.2%)

0 (0%)

1 (3.7%)

0 (0%)

2 (18.2%)

2 (7.4%)

0 (0%)

1 (9%)

1 (3.7%)

0 (0%)

1 (9%)

1 (3.7%)

Primary Secondary Site

Pathology

Discussion: The number of cases of skin cancer in this study was low (total 27 cases), although ,the cases were collected over 6 years. in Saudi Arabia almost all known cancers have been seen to occur, though with some variations. This is the first study of skin cancer in Dammam. the most common type of skin malignancy in our study was BCC . similar pattern have been reported in studies from Qassim, Jeddah and Asir (2,3,10) . The frequency of BCC and SCC in the head and neck region in our study is similar to other studies from Saudi Arabia (2,3,10) . BCC is the most common type of skin cancer in Caucasians, Hispanics, and Asians (11). In contrast, BCC represents the second most common skin cancer in Blacks (12). The frequency of BCC appears to be directly correlated with the degree of pigmentation in the skin, being most common in fair Caucasians and least common in African blacks(13). BCC incidence varies globally. The highest rates of skin cancer occur in South Africa and Australia, areas that receive high amounts of UV radiation(14).

The distribution of BCC over the body was mainly limited to the head and neck region, in (71.4%) of the cases. SCC, the second most frequent skin malignancy in our study, was predominantly seen to affect trunk and extremities (66.7%). These findings also seem comparable to previous studies. The highest incidence of SCC occurs in Australia, where nonmelanoma skin cancer incidences as high as 1.17 per 100, a rate 5 times greater than all other cancers combined, have been reported (15). The high incidence is likely due to the large numbers of light-skinned people in this region who have had extensive sun exposure (16) . The third cancer in the order of frequency was DFSP, Dermatofibrosarcoma protuberans is a relatively uncommon skin cancer with Blacks (6.4 per 1,000,000 person-years) having higher incidence rates of DFSP than

Caucasians and Asians (4.4 and 2.7 per 1,000,000 person-years, respectively) (17). The fourth skin cancer in the order of frequency was MF. Cutaneous T-cell lymphoma has a worldwide distribution; some studies have identified an increase in the diseases prevalence in industrial populations. The incidence of cutaneous T-cell lymphoma in the United States was reported to be 6.4 persons per million population annually (18). In Kuwait, a study found that the annual incidence rate of mycosis fungoides was found to be significantly higher among Arabs than among non-Arab Asians (19). Malignancies known to metastasize to skin are carcinoma of breast, lung, kidneys, colon and some other solid tumours (20). The frequency of secondaries to the skin in our study was 14.8%. Two patients had metastates from breast and lung, respectively, while two patients had had metastates from stomach . Two cases of secondaries to the skin (one from stomach and one from breast) develop after the initial diagnosis of the primary malignancy. and two cases of secondaries to the skin (one from stomach and one from Lung) metastases discovered prior to the diagnosis of a primary tumor. Cutaneous metastases from carcinoma are relatively uncommon in clinical practice, but they are very important to recognize. Cutaneous metastasis may herald the diagnosis of internal malignancy, and early recognition can lead to accurate and prompt diagnosis and timely treatment . The recognition of cutaneous metastases often dramatically alters therapeutic plans, especially when metastases signify persistence of cancer originally thought to be cured. Skin metastases usually appear as non specific groups of discrete firm painless nodules. Histologically, the skin metastases usually show features of the primary malignancy, but with variable degrees of differentiation . Only one case of MM was reported in these study (3.7%). Although melanoma accounts for only approximately 5% of skin cancers, it is responsible for 3 times as many deaths each year as nonmelanoma skin cancers. The American Cancer Society estimates that 9,710 people in the US (6,470 men and 3,240 women) will die of melanoma in 2014 (21). Melanoma is more common in whites than in blacks and Asians. The rate of melanoma in blacks is estimated to be one twentieth that of whites.

We concluded that the most common skin cancers seen are BCC and SCC followed by DFSB and MF . The site of distribution of BCC and SCC in our study is similar to studies from various other regions of Saudi Arabia and other countries. Melanoma is a rare skin neoplasm in Saudi Arabia which is different from incidence and pattern of MM in the west .

References : 1-Khan AR, Hussain NK, Al Saigh A, Malatani T, Sheikha AA. Pattern of cancer at Asir Central Hospital, Abha, Saudi Arabia. Ann Saudi Med. 1991;11:285–88. 2- Abdullateef A. Alzolibani, Hani A. Al Shobaili, Ahmad Al Robaee, , Athar Khan, Imran Ul Haque, , Nagendra Seethapathi Rao, Mch, Abdulaziz Alrejaie. Clinical and histopathologic characteristics of skin malignancies in Qassim Region ,Saudi Arabia, International Journal of Health Sciences, Qassim University,2013, Vol. 7, No. 1 . 3- Shagufta Tahir Mufti . Pattern of skin cancer among Saudi Patients who attended King AbdulAziz University Hospital between Jan 2000 and Dec 2010, Journal of the Saudi Society of Dermatology & Dermatologic Surgery (2012) 16, 13–18. 4-World Cancer Report 2014 , World Health Organization. 2014 pp. chapter 5.14. 5-Diepgen TL, Mahler V. The epidemiology of skin cancer. Br J Dermatol. 2002;146:1–6. 6- Australian Institute of Health and Welfare (2012). Cancer in Australia: an overview 2012. AIHW cat no. 70.

7- Xie, J., Qureshi, A.A., Li, Y., Han, J., 2010. ABO Blood Group and Incidence of Skin Cancer. J PLoS ONE 5 (8), e11972. 8-Saudi Cancer Registry , cancer incidence report , Saudi Arabia 2010 . 9- Murphy GF, Elder DE. Atlas of Tumor Pathology: Non-melanocytic Tumors of the Skin 3rd series. Armed Forces Institute of Pathology; Washington DC: 1991. pp. 266–68.

10- Al-Maghrabi JA, Al-Ghamdi AS, Elhakeem HA. Pattern of skin cancer in Southwestern Saudi Arabia .Saudi Med J. 2004 Jun; 25(6):776-9. 11- Rubin, A.I., Chen, E.H., Ratner, D., 2005. Basal cell carcinoma. N Engl J Med 353 (21), 2262–2269. 12- Gloster, H.M., Neal, K., 2006. Skin cancer in skin of color. J Am Acad Dermatol 55 (5), 741–760. 13- Bradford, P.T., 2009. Skin Cancer in Skin of Color. Dermatol Nurs 21 (4), 170–178. 14- Marks R, Jolley D, Dorevitch AP, Selwood TS. The incidence of nonmelanocytic skin cancers in an Australian population: results of a fiveyear prospective study. Med J Aust. May 1 1989;150(9):475-8. 15- Staples MP, Elwood M, Burton RC, Williams JL, Marks R, Giles GG. Non-melanoma skin cancer in Australia: the 2002 national survey and trends since 1985. Med J Aust. Jan 2 2006;184(1):6-10. 16- Buettner PG, Raasch BA. Incidence rates of skin cancer in Townsville, Australia. Int J Cancer. Nov 23 1998;78(5):587-93.

17- Rouhani, P., Fletcher, C.D., Devesa, S.S., Toro, J.R., 2008. Cutaneous soft tissue sarcoma incidence patterns in the U.S.: an analysis of

12,114 cases. Cancer 113 (3), 616–627. 18- Criscione VD, Weinstock MA. Incidence of cutaneous T-cell lymphoma in the United States, 1973-2002. Arch Dermatol. Jul 2007;143(7):854-9. 19- Alsaleh QA, Nanda A, Al-Ajmi H, Al-Sabah H, Elkashlan M, AlShemmari S, et al. Clinicoepidemiological features of mycosis fungoides in Kuwait, 1991-2006. Int J Dermatol. Dec 2010;49(12):1393-8. 20- Brownstein MH, Helwig EB. Metastatic tumors of skin. Cancer. 1972;29:1298–07. 21- American Cancer Society. Cancer Facts & Figures 2014. American Cancer Society.