Skin Cancer - Airedale Gp Training
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Transcript Skin Cancer - Airedale Gp Training
Skin Malignancies in General Practice
The Anatomy of Skin
Melanoma vs Non-Melanoma
MELANOMA
NON-MELANOMA
Superficial Spreading
SCC
Nodular
BCC
Lentigo
Others
Acral
Melanoma
Melanoma - Epidemiology
Incidence tenfold in past 70 years
Queensland, New Zealand, South Africa.
Female > Male
Higher income, & higher education
Melanoma - Aetiology
Sun Exposure
Melanoma - Aetiology
Skin Type
Melanoma - Aetiology
Intermittent sun-burn
Melanoma – Clinical Features
Try and avoid spot diagnosis
Melanoma – Clinical Features
MAJOR
Change in Size
Change in Shape
> 95% of presentations
Change in Colour
But not specific. Many moles change slowly over time.
Melanoma – Clinical Features
MINOR
Diameter ≥ 7mm
Itching or bleeding
Crusting or oozing
< 50% of presentations
Inflammation
But these are signs that patients are most concerned about.
American Cancer Society
A – Asymmetry
B – Border Irregularity
C – Colour Irregularity
D – Diameter > 6mm
E – Elevation / Evolution
Key Feature
An irregular edge is the single most important clinical feature.
Superficial Spreading Melanoma
70% of all melanomas
Younger age group
Will eventually become nodular
Normal skin or pre-existing mole
Nodular melanoma (EFG)
Elevated, Firm, Growing
(usually all three)
20% of melanomas
Older age group
Usually darker (may be amelanocytic)
Lentigo Malignant Melanoma
> 60 yrs old
Sun-damaged skin (usually the face)
Pre-malignant horizontal growth phase (Hutchinson’s
melanotic freckle)
Gradual enlargement, indistinct edges
Acral Malignant Melanoma
Rare in the West (10% melanomas)
Palms, soles & around nails
Consider melanoma in any pigmented lesion under a
nail (particularly if no trauma)
Histology
Pre-malignant if confined to epidermis
CLARK LEVEL OF INVASION
o Defined in anatomical terms
BRESLOW THICKNESS
o Depth from Granular Layer of Epidermis to deepest
depth of presentation
Prognosis
Breslow Thickness
Approximate 5 year survival
< 1 mm
95-100%
1-2 mm
80-96%
2.1-4 mm
60-75%
>4 mm
50%
Other Prognostic Indicators
•Ulceration
•Vascular infiltration
•High mitotic index
•Regression
Treatment
Surgery – Excision margin depends on depth
Chemotherapy
Radiotherapy
Interferon
Sentinel Lymph Node Biopsy
Isolated Limb Perfusion
Basal Cell Carcinoma
Most common cancer in humans
Basal Cell Carcinoma
Develops from basal keratinocytes of the epidermis.
Basal Cell Carcinoma
Infiltrates skin in contiguous three dimensional
fashion (like expanding golf ball)
Slow growing
Locally invasive
Rarely metastasise
Aetiology
Cumulative or chronic sun exposure
Clinical Features
Background of chronic sun-damaged skin
Well-defined
Erythematous
“Pearly” / flesh-toned
Central ulcer
Rolled edge
Telangectasia
Treatment
Surgical excision
Cryotherapy
Curettage and Cautery
Moh’s Micrographic Surgery
Radiotherapy
5-Fluorouracil
Intralesional interferon
Photodynamic therapy
Imiquimod
Treatment
Dependent on site, patient & available services
“High risk” vs “Low risk”
Site (mid-face or ear)
Size > 2cm
Aggressive histology
Recurrence
Long duration / neglected
Previous radiotherapy
Immunosuppressed patient
Excisional Surgery
Primary aim: complete removal of tumour
Secondary aim: Retention of function & cosmesis
Lesion
Margin
<2cm
5mm
>2mm (or morpheaform)
15mm
Recurrent
Wider / Moh’s
Moh’s Micrographic Surgery
Examination of frozen horizontal section within 30-60 minutes
Time-consuming, costly, specialist
Low recurrence, conserves normal skin, provides evidence of excision
Superficial BCC
On trunk of middle aged to elderly patients.
Well-defined border
Red, scaley plaque (cf eczema and psoriasis)
Morpheaform (aka Sclerosing)
May resemble a scar
Ill-defined border
More aggressive
Squamous Cell Carcinoma
Actinic Keratosis
Chronic sun exposure
o Men
o Older
o Outdoor work / hobbies
• Hands & Forearms
• Head and neck
Squamous Cell Carcinoma
Aktininc Keratoses
Single or multiple
Scaly erythematous papules
< 1cm diameter
Rough
Sore
Irritating
Painful
Actinic Keratosis
Approx 10%
Malignant Change
Approx 25% resolve spontaneously
Treatment
Cryotherapy - cheap, quick, easy, 98% effective
5-Fluorouracil – can light up clinically invisible lesions
Diclofenac 3% (Solaraze)
Curattage and Cautery
Surgical Excision – not usually necessary unless diagnosis in
doubt, cutaneous horn or suspected SCC
Bowen’s Disease
SCC confined to the epidermis ie: carcinoma in situ
Slow growing
Sharply demarcated
Scaly
Erythematous patch
Asymptomatic
Diagnosis
Differentials
o Psoriasis
o Discoid Eczema
o Lichen Simplex chronicus
o Actinic Keratosis
o Superficial BCC / SCC
• Biopsy to Confirm
Treatment
Do Nothing
5-Fluorouracil
Cryotherapy
Curattage and Cautery
Surgery
Radiotherapy
Photodynamic therapy
Squamous Cell Carcinoma
Clinical Features
Varied!
Firm, flesh toned
Papules, nodule, non-healing “lump”
Sore / painful
Oozing / bleeding
Enlarging rapidly
Smooth, scaly, crusted, ulcerated or hyperkeratotic
Biopsy for diagnosis and histological staging
Risk Factors
UV radiation (Sun exposure!)
Immunosuppression
Leukaemia / Lymphoma
PUVA treatment
Previous radiotherapy
Chronic skin inflammation
Chronic ulcers
Arsenic
Poor Prognostic Indicators
Poorly Differentiated (Broder’s Grading 1-4)
Site (ear or lip)
Size > 2cm
Depth
Aetiology (non-sun exposed, chronic inflammation)
Host immunosuppression
Mucosal SCC worse than cutaneous SCC
Perineural invasion
Treatment
Surgical Excision
Curettage & cautery
Cryotherapy
Radiotherapy
95% of recurrences detected within 5 years therefore
follow up
Case One
This lesion has been on the back of a
33 yo solicitor for 5months. It is not
itching or bleeding, but his wife tells
him it’s growing in size. He says he
has always had a mole there.
What is the diagnosis?
What are the salient parts of the
history & examination which lead you
to this conclusion?
What do you do now?
What do you tell him to expect to
happen?
Case Two
This lesion has been
growing rapidly on the
face of a 58 yo
construction worker who
is also a keen angler. It
not painful or itchy.
What is your diagnosis?
What clinical features
lead you to this
conclusion?
Is this a high risk lesion?
What do you do now?
Six Months Later
Case Three
This lesion has been
slowly growing on the
forehead of a 67 yo retired
sailor who is a keen
gardener.
What is your diagnosis?
What clinical features
lead you to this
conclusion?
Is this a high risk lesion?
What do you do now?
What treatment options
might he be offered?
Case Four
This 73yo man has
developed a number of
these itchy lesions on his
scalp.
What is your diagnosis?
What clinical features lead
you to this conclusion?
What do you do now?
What treatment options
might he be offered?
Is there any other advice
you might give him?
Case Five
This 64yo farmer has
developed this lesion on
his forearm
What is your diagnosis?
What clinical features lead
you to this conclusion?
What do you do now?
What treatment options
might he be offered?
Is there any other advice
you might give him?
DPD
http://www.dermatology.org.uk/
Useful Resources
DERMNET
o http://dermnetnz.org
• BRITISH ASSOCIATION OF DERMATOLOGIST
o www.bad.org.uk