Skin Cancer. Skin cancer is a major health problem in AustraliaThe 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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1. SKIN CANCER Dr. D. Czarnecki MD MBBS
2. 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.
3. 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.
5. 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
6. 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
8. 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)
9. 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
10. 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
located on the ear
a recurrent SCC
perineural spread is present
the patient is immunosuppressed
11. 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
12. 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
13. 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
14. 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.
16. 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.
18. 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
19. The incidence of melanoma in different countries (cases per 100,000)
20. 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
21. Melanoma A typical melanoma
It is asymmetrical
The A B of melanoma:
A – asymmetry
B – biopsy asymmetrical pigmented lesions
22. 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
23. 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
24. Melanoma This melanoma is thick – at the inferior end
It is ulcerated
Thickness and ulceration are the two most important prognostic factors
25. Melanoma If you think the lesion is a melanoma – excise it
Excise with a 2 mm margin, await the pathology report, and if it is a melanoma, carry out a wider excision
Melanoma-in-situ – 5 mm margin
Melanoma < 1 mm thick – 1 cm margin
Melanoma > 1 mm thick – 2 cms margin
26. Melanoma Prognostic factors (a worse prognosis)
Site – ear, palms, soles
Level IV in thin melanomas
27. 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.