g - Skin Cancer

8/10/2019 g - Skin Cancer

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SKIN CANCER

Dr. D. Czarnecki MD MBBS


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Skin Cancer

Skin cancer is a major health problem in Australia

The most common skin cancer is the Basal CellCarcinoma (BCC)

The next most common is the Squamous Cell

Carcinoma (SCC) The least common is the Melanoma (MM)

BCC and SCC are often grouped together as non-

melanoma skin cancer (NMSC) Skin cancer dose not kill many Australians but

treating cancers causes considerable morbidity.


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Skin Cancer

Not all races have an equal risk of developing skincancer

Skin cancers overwhelmingly develop in white people

The following slide has the incidences of NMSC in

different races in different parts of the world The highest incidence found was in white Australian

men living in tropical Queensland

The incidence in coloured people was lower, evenwhen they lived in the tropics.


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Tropical Australia (men

only)

3090 per 100,000

Hawaii (white- both

sexes)

927

Hawaii (Japanese)

55

Hawaii (Filipino) 14

Arabian Peninsula 2

South Africa (Blacks)


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Skin Cancer

A BCC nodular type. Most of

these occur on the head.

BCCs slowly grow

BCCs rarely metastasize

about 1 in 100,000

It is often difficult to tell BCCs

from SCCs on clinical grounds


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Skin Cancer

A BCC superficial type

This is now the most common

type of BCC and most occur

on the back

It is pink, well demarcated, and

slightly scaly

There is a small area ofulceration


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A morphoeic BCC it looks like marble

The red area is the biopsy site

The BCC grows between collagen bundles

hence the indistinct margin


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BCC

Treatment of BCCs: Surgery has the lowest recurrence rate (5-8%)

Radiotherapy has a 12% recurrent rate

Imiquimod fails in 20-40% (higher failure rate inthicker tumours)

Photodynamic therapy fails in 40% after 4 years offollow up

Cryotherapy has a high failure rate and should not be

used unless a thermocouple is used (to measure skintemperature at a set depth)


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Skin Cancer

An SCC on the forehead

SCCs are most often found on

the head or hands

SCCs metastasize in about 5%

of cases

The regional lymph node is the

most common site ofmetastasis


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SCC

The average age for an SCC to develop in Melbourne is 71. This

means that many patients die of other causes before metastases

are obvious.

The Metastatic rate could be higher.

The risk factors for metastasis are

Thickness > 4 mm

male sex

located on the ear

a recurrent SCC

perineural spread is present

the patient is immunosuppressed


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SCC

An SCC on the nose

There are metastases in

the submental lymph

nodes

The patient had chronic

lymphocytic leukaemia

and died shortly after of

the leukaemia

metastases


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SCC

A recurrent SCC in front

of the ear.

The initial pathology

report stated that it was

incompletely excised

A wider, deeper excision

is mandatory


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Skin Cancer

A safety margin is needed

A 4 mm margin of normal looking tissue isrecommended for BCCs (not morphoeic) and SCCs

A 4 mm margin will give a 95% chance of removing thetumour

For morphoeic BCCs a 10 mm margin is

recommended


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Skin Cancer

You must review the patient

Overall 2/3rds will develop a new skin cancer within5 years

The risk is higher the greater the number of skincancers a patient has had removed

Patients with skin cancer have an increased risk ofdeveloping non-Hodgkins lymphoma

Regular review enables the doctor examine forcancers and to re- inforce the message aboutprotection from sunburn.


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You must review your patients

A recurrent skin cancer


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Melanoma

Melanomas are the least common skincancers. There were fewer than 10,000 invasivemelanomas registered in Australia in 2003.There were about 40% more melanomas-in-

situ. In 2003 there were about 14,000melanomas removed from Australians

About 1000 Australians die each year ofmelanoma. This is fewer than commit suicideor die in car accidents.


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The number of invasive melanomas excised

from Australians AIHW (www.aihw.gov.au)


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Melanoma

Not all races are at risk of melanoma. The disease isoverwhelmingly one of white people.

The main risk factors for a melanoma are (in

decreasing order of importance:A previous melanoma

A previous BCC or SCC

More than 150 moles

A skin that sun burns easily and tans poorlyA first degree relative with a melanoma

Immunosuppression


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The incidence of melanoma in different

countries (cases per 100,000)

Victoria

37.00

India 0.1

Hong Kong 0.1

China 0.1

Arabian Peninsula 0.1

Japan 0.4


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Melanoma

Had a melanoma?

10% get another

A family history (FH) increases the risk

1 first degree relative

doubles the risk

2 first degree relatives 5 times the risk

3 first degree relatives 35 to 70 times the risk

Had a BCC or SCC? greater risk than a +ve FH

x 8 for men x 4 for women


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Melanoma

A typical melanoma

It is asymmetrical

The A B of melanoma:

A asymmetry

B biopsy asymmetrical

pigmented lesions


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Melanoma

When you see a

pigmented lesion

Draw a line down the

middle

If one half does not look

like the other half -

TAKE A BIOPSY

It is asymmetrical


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Melanoma

Taking a punch biopsy or a shave biopsy

Will not increase the risk of metastases

Studies have found no risk if such a biopsy is taken andthe definitive surgery is carried out within two weeks

Punch or shave biopsies are not encouraged becausethickness is the main prognostic factor and a biopsy maymiss the thickest area

However, if unsure, and you do not wish to excise thelesion, take a biopsy


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Melanoma

This melanoma is thick

at the inferior end

It is ulcerated

Thickness and ulceration

are the two most

important prognostic

factors


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Melanoma

If you think the lesion is a melanoma

excise it

Guides lines

Excise with a 2 mm margin, await the pathology

report, and if it is a melanoma, carry out a widerexcision Margins Melanoma-in-situ 5 mm margin

Melanoma < 1 mm thick 1 cm margin

Melanoma > 1 mm thick

2 cms margin


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Melanoma

Prognostic factors (a worse prognosis)

Thickness

Ulceration

Male sex

Site ear, palms, soles

Old age Level IV in thin melanomas


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Melanoma

This melanoma developed

on the toe. The patient

had many naevi and had

had a BCC.

Melanomas on the feet

are uncommon.

You need to examine theentire body.


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Melanoma

Symmetrical

A blue naevus

Asymmetrical

A thin melanoma

Carefully look the shape and

colouring of each half are different


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Melanoma

Symmetrical

Pear shaped

Asymmetrical melanoma next

to a seborrhoeic keratosis

Growing into the seborrhoeic keratosis


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Melanoma

Asymmetrical Asymmetrical

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