Transcript Skin Cancer - Bradfordvts

Skin Pre-Cancer and Cancer
Dr. Mary Cuthbert
GPSI Dermatology
Sun, sea and sand….
There’s no such thing as a healthy
tan
The effects of UV exposure
-ageing of skin
-skin cancer
This presentation will cover :
Actinic keratosis
Bowen’s disease
Basal cell carcinoma
Squamous cell carcinoma
Malignant melanoma
NICE guidance on skin cancer prevention
Actinic keratosis
Rough ,scaly spots on sun-damaged skin
Represent abnormal skin development
due to exposure to UV radiation
Should be considered potentially
precancerous(>10 AKs = 10-15% risk
SCC)
Common on exposed sites eg backs of
hands,face,scalp and ears of bald men
Actinic keratosis
Actinic keratosis-treatment
Diclofenac gel (Solaraze)
Cryotherapy
Curettage/Excision
5-Fluorouracil cream (Efudix)
Imiquimod 5% cream (Aldara)
Photodynamic therapy (not available in
Bradford)
Bowen’s disease
Bowen’s disease is intraepidermal
squamous cell carcinoma
It is effectively carcinoma-in situ
It may progress into squamous cell
carcinoma (approximately 5%)
Because of this, it is very important to treat
it effectively
Bowen’s disease
Presents as a pink or red ,irregular scaly
patch
Usually develops in a sun –exposed area
of skin
Common sites include hands and face in
both sexes, scalp in men, lower legs in
women
Diagnosis should be confirmed by biopsy
Bowen’s disease
Bowen’s disease
Bowen’s disease-causes:
UV radiation causes mutation in genes
controlling skin cell growth
UV radiation suppresses immune
response in skin
Arsenic ingestion
Ionising radiation-very common in early
20th century radiologists
HPV virus causes genital IEN
Bowen’s disease-treatment:
Cryotherapy
Curettage/excision
5 Fluorouracil cream (Efudix)
Imiquimod 5% cream (Aldara)
Photodynamic therapy
Basal cell carcinoma
Affects fairskinned adults who have had a lot of
sun exposure or repeated episodes of sunburn
Gorlin’s syndrome-inherited tendency to multiple
BCCs
BCCs usually arise in normal-looking skin
BCCs grow slowly over months or years
Metastasis exceedingly rare but BCCs can
cause destructive changes in surrounding
tissues
Basal cell carcinoma-types:
Nodular BCC-most common type
Superficial BCC-common
Morphoeic BCC-waxy,scar-like
Pigmented BCC- can resemble melanoma
Basisquamous BCC-mixed BCC/SCC
Only the first two types are seen
commonly in GP
Nodular BCC
Most common type on face
Small, shiny, skin-coloured swelling
Telangiectasia cross the edge
May have central ulcer or scab so edges appear
rolled
Often bleed spontaneously, then heal over
Rodent ulcer is an open sore
Facial BCC should be referred to plastic surgeon
Nodular basal cell carcinoma
Superficial BCC
Often multiple
Upper trunk or shoulders commonest site
but can appear anywhere
Pink or red scaly patch with raised edge
on close examination
Slowly growing over months or years
Bleed or ulcerate easily
Superficial basal cell carcinoma
Why BCCs need treatment
BCC- treatment:
Shave,curettage,cautery
Excision biopsy, may need grafting or flap.
Moh’s micrographic excision
Photodynamic therapy
Imiquimod 5% cream-highly effective for
superficial BCCs
Cryotherapy
Radiotherapy
Remember-BCCs don’t kill but can
be locally destructive
Squamous cell carcinoma
SCC is a common type of skin cancer
It develops in the epidermis from
squamous cells which produce keratin
Usual presentation is a slowly –growing
scaly or crusted lump
Can present as a non-healing sore or ulcer
“punched out” in appearance
Sometimes growth is rapid over a matter
of weeks
Squamous cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma
Squamous cell carcinoma,or is it?
Squamous cell carcinoma-causes:
UV radiation-damages DNA in skin
SCC may develop in an actinic keratosis or patch of Bowen’s
disease
Genetic predisposition to develop SCCs
Smoking-especially SCC lip
Thermal burns
Chronic leg ulcers
Immunosuppression-Azathioprine/Ciclosporin.
Organ transplantation patients highly susceptible
HPV infection implicated in genital SCCs
Pre-existing skin conditions eg lichen sclerosus and lichen planus
can predispose to development of genital and oral SCCs
Squamous cell carcinomatreatment
If you suspect a possible SCC, refer via
FAST TRACK pathway
Histological diagnosis confirmed in
Dermatology department
Joint dermatologist/plastic surgeon
assessment ideal, as happens in Bradford.
Specialist Skin Cancer Nurse input helpful
Surgery, possibly with skin graft
Radiotherapy may be needed
Metastatic Squamous cell
carcinoma
5% SCCs metastasise, most commonly
from primary lesion on ear or lip
Commoner in transplant patients
Patients with CLL
Associated with increasing age
Associated with alcoholism
More likely if multiple skin cancers present
Malignant melanoma
Melanocytes are found in the basal layers
of the epithelium
Non-cancerous growth of melanocytes
results in moles or freckles
Cancerous growth of melanocytes results
in malignant melanoma
Malignant melanoma-risk factors:
Sun exposure, particularly during
childhood
Fair skin which burns easily
Blistering sunburn, especially when young
Previous melanoma
Family history of melanoma
Previous non-melanoma skin cancer
Large numbers of moles/ dysplastic moles
Common sites for melanoma:
In men commonest site is the back
In women commonest site is the leg
Can occur on mucous membranes, eg lips
or genitals
Can occur under the nail
Can occur in eye, brain or mouth
BEWARE AMELANOTIC MELANOMA
Glasgow 7 point checklist:
MAJOR FEATURES:
MINOR FEATURES:
Change in size
Diameter > 7mm
Irregular shape
Inflammation
Irregular colour
Oozing
Change in sensation
The ABCDE of melanoma
A
B
C
D
E
Asymmetry
Border irregularity
Colour variation
Diameter over 6mm
Evolving (enlarging or changing)
Malignant melanoma
Growth of melanomas
Horizontal growth within
epidermis=melanoma in situ
Vertical growth through basement
membrane into dermis=invasive
melanoma
Once melanoma penetrates dermis,it
spreads via lymphatic and blood stream
= metastatic melanoma
Malignant melanoma
Histological classification:
Breslow thickness:
This is the thickness of the melanoma in mm
Clark’s level:
This describes which layer of skin has been
breached
Clark’s level 1-epidermis-melanoma in situ
Clark’s level 2-dermal invasion
Clark’s level 5- invasion of subcutaneous fat
Treatment of melanoma
Refer suspected melanoma via FAST-TRACK
pathway
Surgical excision by Dermatologist with 2-3 mm
margin
Wider excision if histology confirms melanoma
Thicker melanomas> 1mm-wider excision +/sentinel node biopsy
Widespread melanoma-surgery/chemotherapy
Prognosis of melanoma
Breslow thickness< 1mm, almost 100%
5 year survival
Breslow thickness > 4mm, only 50%
5 year survival
Remember, melanoma is a major cause of
death from malignancy in young people
Malignant melanoma
Malignant melanoma
Malignant melanoma
Malignant melanoma
Advanced melanoma
How can we advise our patients regarding
skin cancer prevention?
NICE Guidance- January 2011
Benefits of sun exposure:
Increases people’s sense of wellbeing
Allows synthesis of Vitamin D
Provides the opportunity for physical
activity to improve fitness
Skin cancer prevention measures:
Should not discourage outdoor activities
Should encourage people to use sensible
skin protection
Who should be involved?
Commissioners, organisers, planners of
national primary prevention campaigns
Local bodies including environmental
health, education sector, workplaces
Local practitioners eg GPs, HVs,school
nurses, pharmacists, dermatologists
At-risk groups:
Fair-skinned individuals
Children and babies
Outdoor workers
Immunosuppressed
People with personal/FH of skin cancer
People with > 50 moles
People who overexpose skin by
sunbathing/use of sunbeds
What action should be taken?
Ensure advice contains simple explanation
of how UV light damages skin
Ensure advice explains how people can
assess their individual risk
Ensure advice is balanced, including both
risks and benefits of sun exposure
Ensure advice includes a range of options
to protect skin against UV light
Advice:
Avoid sunburn
If you need to be out in sun due to work,
protect skin as much as possible
Spend time in shade between 11.00 and
15.00
Wear broad-brimmed hat, long sleeves
and trousers
Choose close-weave fabrics
Advice:
Sunscreens should be used IN ADDITION to
above measures
Choose sunscreen with UVA and UVB protection
It should be at least SPF 15 to protect against
UVB
It should be at least 4 stars to protect against
UVA
Use water –resistant products,applied every 2
hours
How to give advice in a positive
manner:
Positive statements are more likely to help
people to change behaviour:
“using sunscreen helps to keep skin
healthy and young-looking”
Keep it simple
Mention ageing effects of sun-sometimes
has more impact than cancer risks
(remember the old lady on the beach!)
In summary:
We have looked at the effects of UV radiation
and other risk factors on the skin
We have discussed the management of premalignant actinic damage
We have considered the locally destructive
nature of BCCs
We have looked in depth at SCC and
melanoma, both of which are potentially fatal
We have looked at current NICE guidance on
skin cancer prevention
And finally…………
Remember-there’s no such thing as
a healthy tan!