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 Cell
  Carcinoma (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
  skin cancer
• 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, even
  when they lived in the tropics.

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NMSC - incidence
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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 of ulceration

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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 in
  thicker tumours)
• Photodynamic therapy fails in 40 after 4 years
  of follow up
• Cryotherapy has a high failure rate and should
  not be used unless a thermocouple is used (to
  measure skin temperature 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
  of metastasis

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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 gt 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 is
  recommended for BCCs (not morphoeic) and SCCs
• A 4 mm margin will give a 95 chance of removing
  the tumour
• 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
  within 5 years
• The risk is higher the greater the number of skin
  cancers a patient has had removed
• Patients with skin cancer have an increased risk
  of developing non-Hodgkins lymphoma
• Regular review enables the doctor examine for
  cancers and to re- inforce the message about
  protection 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 skin cancers.
  There were fewer than 10,000 invasive melanomas
  registered in Australia in 2003. There were about
  40 more melanomas-in-situ. In 2003 there were
  about 14,000 melanomas removed from Australians
• About 1000 Australians die each year of melanoma.
  This is fewer than commit suicide or 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 is overwhelmingly 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
  poorly
• A first degree relative with a melanoma
• Immunosuppression

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The incidence of melanoma in different countries
(cases per 100,000)
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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 and the definitive surgery is carried out
  within two weeks
• Punch or shave biopsies are not encouraged
  because thickness is the main prognostic factor
  and a biopsy may miss the thickest area
• However, if unsure, and you do not wish to excise
  the lesion, 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
  wider excision
• Margins
• Melanoma-in-situ 5 mm margin
• Melanoma lt 1 mm thick 1 cm margin
• Melanoma gt 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 the entire body.

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Melanoma
Asymmetrical
A thin melanoma Carefully look the shape and
colouring of each half are different
Symmetrical A blue naevus
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Melanoma
Asymmetrical melanoma next to a seborrhoeic
keratosis Growing into the seborrhoeic keratosis
Symmetrical Pear shaped
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Melanoma
Asymmetrical
Asymmetrical