SKIN CANCERSKIN CANCER

Dr. D. Czarnecki MD MBBSDr. D. Czarnecki MD MBBS

Skin CancerSkin Cancer

• Skin cancer is a major health problem in AustraliaSkin cancer is a major health problem in Australia• The most common skin cancer is the Basal Cell The most common skin cancer is the Basal Cell

Carcinoma (BCC)Carcinoma (BCC)• The next most common is the Squamous Cell The next most common is the Squamous Cell

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

• BCC and SCC are often grouped together as non-BCC and SCC are often grouped together as non-melanoma skin cancer (NMSC)melanoma skin cancer (NMSC)

• Skin cancer dose not kill many Australians but Skin cancer dose not kill many Australians but treating cancers causes considerable morbidity.treating cancers causes considerable morbidity.

Skin CancerSkin Cancer

• Not all races have an equal risk of developing skin Not all races have an equal risk of developing skin cancercancer

• Skin cancers overwhelmingly develop in white Skin cancers overwhelmingly develop in white peoplepeople

• The following slide has the incidences of NMSC in The following slide has the incidences of NMSC in different races in different parts of the worlddifferent races in different parts of the world

• The highest incidence found was in white Australian The highest incidence found was in white Australian men living in tropical Queenslandmen living in tropical Queensland

• The incidence in coloured people was lower, even The incidence in coloured people was lower, even when they lived in the tropics.when they lived in the tropics.

Tropical Australia (men Tropical Australia (men only)only)

3090 per 100,0003090 per 100,000

Hawaii (white- both Hawaii (white- both sexes)sexes)

927927

Hawaii (Japanese)Hawaii (Japanese) 5555

Hawaii (Filipino)Hawaii (Filipino) 1414

Arabian PeninsulaArabian Peninsula 22

South Africa (Blacks)South Africa (Blacks) <1<1

Californian ChineseCalifornian Chinese 11

JapanJapan 11

NMSC - incidenceNMSC - incidence

Skin CancerSkin Cancer

• A BCC – nodular type. Most A BCC – nodular type. Most of these occur on the head.of these occur on the head.

• BCCs slowly growBCCs slowly grow

• BCCs rarely metastasize – BCCs rarely metastasize – about 1 in 100,000about 1 in 100,000

• It is often difficult to tell It is often difficult to tell BCCs from SCCs on clinical BCCs from SCCs on clinical groundsgrounds

Skin CancerSkin Cancer

• A BCC – superficial typeA BCC – superficial type

• This is now the most This is now the most common type of BCC and common type of BCC and most occur on the backmost occur on the back

• It is pink, well demarcated, It is pink, well demarcated, and slightly scalyand slightly scaly

• There is a small area of There is a small area of ulcerationulceration

A morphoeic BCC – it looks like marbleA morphoeic BCC – it looks like marble

The red area is the biopsy siteThe red area is the biopsy site

The BCC grows between collagen bundles The BCC grows between collagen bundles hence the indistinct marginhence the indistinct margin

BCCBCC

• Treatment of BCCs:Treatment of BCCs:• Surgery has the lowest recurrence rate (5-8%)Surgery has the lowest recurrence rate (5-8%)• Radiotherapy has a 12% recurrent rateRadiotherapy has a 12% recurrent rate

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

• Photodynamic therapy fails in 40% after 4 years of Photodynamic therapy fails in 40% after 4 years of follow upfollow up

• Cryotherapy has a high failure rate and should not Cryotherapy has a high failure rate and should not be used unless a thermocouple is used (to measure be used unless a thermocouple is used (to measure skin temperature at a set depth)skin temperature at a set depth)

Skin CancerSkin Cancer

• An SCC on the foreheadAn SCC on the forehead

• SCCs are most often found SCCs are most often found on the head or handson the head or hands

• SCCs metastasize in about SCCs metastasize in about 5% of cases5% of cases

• The regional lymph node is The regional lymph node is the most common site of the most common site of metastasismetastasis

SCCSCC

• The average age for an SCC to develop in Melbourne is 71. This The average age for an SCC to develop in Melbourne is 71. This means that many patients die of other causes before means that many patients die of other causes before metastases are obvious.metastases are obvious.

• The Metastatic rate could be higher.The Metastatic rate could be higher.

• The risk factors for metastasis areThe risk factors for metastasis are

Thickness > 4 mmThickness > 4 mm

male sexmale sex

located on the earlocated on the ear

a recurrent SCCa recurrent SCC

perineural spread is presentperineural spread is present

the patient is immunosuppressedthe patient is immunosuppressed

SCCSCC

• An SCC on the noseAn SCC on the nose• There are metastases in There are metastases in

the submental lymph the submental lymph nodesnodes

• The patient had chronic The patient had chronic lymphocytic leukaemia lymphocytic leukaemia and died shortly after of and died shortly after of the leukaemiathe leukaemia

metastasesmetastases

SCCSCC

• A recurrent SCC in front A recurrent SCC in front of the ear.of the ear.

• The initial pathology The initial pathology report stated that it was report stated that it was incompletely excisedincompletely excised

• A wider, deeper A wider, deeper excision is mandatoryexcision is mandatory

Skin CancerSkin Cancer

• A A safety marginsafety margin is needed is needed

• A 4 mm margin of normal looking tissue is A 4 mm margin of normal looking tissue is recommended for BCCs (not morphoeic) and SCCsrecommended for BCCs (not morphoeic) and SCCs

• A 4 mm margin will give a 95% chance of removing A 4 mm margin will give a 95% chance of removing the tumourthe tumour

• For morphoeic BCCs a 10 mm margin is For morphoeic BCCs a 10 mm margin is recommendedrecommended

Skin CancerSkin Cancer

• You must review the patientYou must review the patient

• Overall – 2/3rds will develop a new skin cancer Overall – 2/3rds will develop a new skin cancer within 5 yearswithin 5 years

• The risk is higher the greater the number of skin The risk is higher the greater the number of skin cancers a patient has had removedcancers a patient has had removed

• Patients with skin cancer have an increased risk of Patients with skin cancer have an increased risk of developing non-Hodgkins lymphomadeveloping non-Hodgkins lymphoma

• Regular review enables the doctor examine for Regular review enables the doctor examine for cancers and to re- inforce the message about cancers and to re- inforce the message about protection from sunburn. protection from sunburn.

You must review your patientsYou must review your patients

A recurrent skin cancerA recurrent skin cancer

MelanomaMelanoma

• Melanomas are the least common skin Melanomas are the least common skin cancers. There were fewer than 10,000 cancers. There were fewer than 10,000 invasive melanomas registered in Australia invasive melanomas registered in Australia in 2003. There were about 40% more in 2003. There were about 40% more melanomas-in-situ. In 2003 there were about melanomas-in-situ. In 2003 there were about 14,000 melanomas removed from Australians14,000 melanomas removed from Australians

• About 1000 Australians die each year of About 1000 Australians die each year of melanoma. This is fewer than commit suicide melanoma. This is fewer than commit suicide or die in car accidents.or die in car accidents.

                                                                                                                                                                                                                                           

                                                                                                                  

The number of invasive melanomas excised The number of invasive melanomas excised from Australians – AIHW (www.aihw.gov.au)from Australians – AIHW (www.aihw.gov.au)

MelanomaMelanoma

• Not all races are at risk of melanoma. Not all races are at risk of melanoma. The disease is The disease is overwhelmingly one of white peopleoverwhelmingly one of white people..

• The main risk factors for a melanoma are (in The main risk factors for a melanoma are (in decreasing order of importance:decreasing order of importance:

A previous melanomaA previous melanoma A previous BCC or SCCA previous BCC or SCC More than 150 molesMore than 150 moles A skin that sun burns easily and tans poorlyA skin that sun burns easily and tans poorly A first degree relative with a melanomaA first degree relative with a melanoma ImmunosuppressionImmunosuppression

The incidence of melanoma in different The incidence of melanoma in different countries (cases per 100,000)countries (cases per 100,000)

VictoriaVictoria 37.0037.00

India 0.1

Hong KongHong Kong 0.10.1

ChinaChina 0.10.1

Arabian PeninsulaArabian Peninsula 0.10.1

JapanJapan 0.40.4

MelanomaMelanoma

• Had a melanoma? – Had a melanoma? – 10% get another10% get another

• A family history (FH) increases the riskA family history (FH) increases the risk

• 1 first degree relative – doubles the risk1 first degree relative – doubles the risk• 2 first degree relatives – 5 times the risk2 first degree relatives – 5 times the risk• 3 first degree relatives – 35 to 70 times the risk3 first degree relatives – 35 to 70 times the risk

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

• x 8 for menx 8 for men• x 4 for womenx 4 for women

                                                                                                                                                                                                                                           

                                                                                                                  

 

            

     

MelanomaMelanoma

• A typical melanomaA typical melanoma

• It is It is asymmetricalasymmetrical

• The A B of melanoma:The A B of melanoma:• A – asymmetryA – asymmetry• B – biopsy B – biopsy

asymmetrical asymmetrical pigmented lesionspigmented lesions

MelanomaMelanoma

• When you see a When you see a pigmented lesionpigmented lesion

• Draw a line down the Draw a line down the middlemiddle

• If one half does not look If one half does not look like the other half -like the other half -

• TAKE A BIOPSYTAKE A BIOPSY

It is asymmetricalIt is asymmetrical

MelanomaMelanoma

• Taking a punch biopsy or a shave biopsyTaking a punch biopsy or a shave biopsy

• Will not increase the risk of metastasesWill not increase the risk of metastases

• Studies have found no risk if such a biopsy is taken and Studies have found no risk if such a biopsy is taken and the definitive surgery is carried out within two weeksthe definitive surgery is carried out within two weeks

• Punch or shave biopsies are not encouraged because Punch or shave biopsies are not encouraged because thickness is the main prognostic factor and a biopsy thickness is the main prognostic factor and a biopsy may miss the thickest areamay miss the thickest area

• However, if unsure, and you do not wish to excise the However, if unsure, and you do not wish to excise the lesion, take a biopsylesion, take a biopsy

 

            

     

MelanomaMelanoma

• This melanoma is thick This melanoma is thick – at the inferior end– at the inferior end

• It is ulceratedIt is ulcerated

• ThicknessThickness and and ulcerationulceration are the two are the two most important most important prognostic factorsprognostic factors

MelanomaMelanoma

• If you think the lesion is a melanoma – excise itIf you think the lesion is a melanoma – excise it

• Guides linesGuides lines• Excise with a 2 mm margin, await the pathology Excise with a 2 mm margin, await the pathology

report, and if it is a melanoma, carry out a wider report, and if it is a melanoma, carry out a wider excisionexcision

• MarginsMargins• Melanoma-in-situ – 5 mm marginMelanoma-in-situ – 5 mm margin• Melanoma < 1 mm thick – 1 cm marginMelanoma < 1 mm thick – 1 cm margin• Melanoma > 1 mm thick – 2 cms marginMelanoma > 1 mm thick – 2 cms margin

 

            

     

MelanomaMelanoma

• Prognostic factorsPrognostic factors (a worse prognosis) (a worse prognosis)

• ThicknessThickness• UlcerationUlceration• Male sexMale sex

• Site – ear, palms, solesSite – ear, palms, soles• Old ageOld age• Level IV in thin melanomasLevel IV in thin melanomas

 

            

     

MelanomaMelanoma

• This melanoma This melanoma developed on the toe. developed on the toe. The patient had many The patient had many naevi and had had a naevi and had had a BCC.BCC.

• Melanomas on the feet Melanomas on the feet are uncommon.are uncommon.

• You need to You need to examine examine the entire bodythe entire body..

MelanomaMelanoma

SymmetricalSymmetrical

A blue naevusA blue naevus

AsymmetricalAsymmetrical

A thin melanomaA thin melanoma

Carefully look the shape and Carefully look the shape and colouring of each half are differentcolouring of each half are different

MelanomaMelanoma

SymmetricalSymmetrical

Pear shapedPear shaped

Asymmetrical – melanoma next Asymmetrical – melanoma next to a seborrhoeic keratosisto a seborrhoeic keratosis

Growing into the seborrhoeic keratosisGrowing into the seborrhoeic keratosis

MelanomaMelanoma

AsymmetricalAsymmetrical AsymmetricalAsymmetrical