1. SKIN CANCER Dr. D. Czarnecki MD MBBS

2. Skin 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 Carcinoma (BCC)The most common skin cancer is the Basal Cell Carcinoma (BCC) The next most common is the Squamous Cell Carcinoma (SCC)The next most common is the Squamous Cell 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- melanoma skin cancer (NMSC)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.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 cancerNot all races have an equal risk of developing skin cancer Skin cancers overwhelmingly develop in white peopleSkin cancers overwhelmingly develop in white people The following slide has the incidences of NMSC in different races in different parts of the worldThe 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 QueenslandThe 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.The incidence in coloured people was lower, even when they lived in the tropics.

4. Tropical Australia (men only) 3090 per 100,000 Hawaii (white- both sexes) 927 Hawaii (Japanese) 55 55 Hawaii (Filipino) 14 14 Arabian Peninsula 2 South Africa (Blacks) <1 <1 Californian Chinese 1 Japan 1 NMSC - incidence

5. Skin Cancer A BCC – nodular type. Most of these occur on the head.A BCC – nodular type. Most of these occur on the head. BCCs slowly growBCCs slowly grow BCCs rarely metastasize – about 1 in 100,000BCCs rarely metastasize – about 1 in 100,000 It is often difficult to tell BCCs from SCCs on clinical groundsIt is often difficult to tell BCCs from SCCs on clinical grounds

6. Skin Cancer A BCC – superficial typeA BCC – superficial type This is now the most common type of BCC and most occur on the backThis is now the most common type of BCC and most occur on the back It is pink, well demarcated, and slightly scalyIt is pink, well demarcated, and slightly scaly There is a small area of ulcerationThere is a small area of ulceration

7. A morphoeic BCC – it looks like marble The red area is the biopsy site The red area is the biopsy site The BCC grows between collagen bundles hence the indistinct margin

8. BCC 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 thicker tumours)Imiquimod fails in 20-40% (higher failure rate in thicker tumours) Photodynamic therapy fails in 40% after 4 years of follow upPhotodynamic 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)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 foreheadAn SCC on the forehead SCCs are most often found on the head or handsSCCs are most often found on the head or hands SCCs metastasize in about 5% of casesSCCs metastasize in about 5% of cases The regional lymph node is the most common site of metastasisThe 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 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 Metastatic rate could be higher. The risk factors for metastasis areThe risk factors for metastasis are Thickness > 4 mm Thickness > 4 mm male sex male sex located on the ear located on the ear a recurrent SCC a recurrent SCC perineural spread is present perineural spread is present the patient is immunosuppressed the patient is immunosuppressed

11. SCC An SCC on the noseAn SCC on the nose There are metastases in the submental lymph nodesThere are metastases in the submental lymph nodes The patient had chronic lymphocytic leukaemia and died shortly after of the leukaemiaThe patient had chronic lymphocytic leukaemia and died shortly after of the leukaemia metastases

12. SCC A recurrent SCC in front of the ear.A recurrent SCC in front of the ear. The initial pathology report stated that it was incompletely excisedThe initial pathology report stated that it was incompletely excised A wider, deeper excision is mandatoryA wider, deeper excision is mandatory

13. Skin Cancer A safety margin is neededA safety margin is needed A 4 mm margin of normal looking tissue is recommended for BCCs (not morphoeic) and SCCsA 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 tumourA 4 mm margin will give a 95% chance of removing the tumour For morphoeic BCCs a 10 mm margin is recommendedFor morphoeic BCCs a 10 mm margin is recommended

14. Skin Cancer You must review the patientYou must review the patient Overall – 2/3rds will develop a new skin cancer within 5 yearsOverall – 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 removedThe 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 lymphomaPatients 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.Regular review enables the doctor examine for cancers and to re- inforce the message about protection from sunburn.

15. You must review your patients A recurrent skin cancer

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

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

18. Melanoma Not all races are at risk of melanoma. The disease is overwhelmingly one of white people.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:The main risk factors for a melanoma are (in decreasing order of importance: A previous melanoma A previous melanoma A previous BCC or SCC A previous BCC or SCC More than 150 moles More than 150 moles A skin that sun burns easily and tans poorly A skin that sun burns easily and tans poorly A first degree relative with a melanoma A first degree relative with a melanoma Immunosuppression Immunosuppression

19. The incidence of melanoma in different countries (cases per 100,000) Victoria37.00 India 0.1 Hong Kong 0.1 0.1 China Arabian Peninsula 0.1 0.1 Japan 0.4

20. Melanoma Had a melanoma? – 10% get anotherHad a melanoma? – 10% 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 men x 8 for men x 4 for women x 4 for women

21. Melanoma A typical melanomaA typical melanoma It is asymmetricalIt is asymmetrical The A B of melanoma:The A B of melanoma: A – asymmetryA – asymmetry B – biopsy asymmetrical pigmented lesionsB – biopsy asymmetrical pigmented lesions

22. Melanoma When you see a pigmented lesionWhen you see a pigmented lesion Draw a line down the middleDraw a line down the middle If one half does not look like the other half -If one half does not look like the other half - TAKE A BIOPSYTAKE A BIOPSY It is asymmetrical

23. Melanoma 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 the definitive surgery is carried out within two weeksStudies 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 areaPunch 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 biopsyHowever, if unsure, and you do not wish to excise the lesion, take a biopsy

24. Melanoma This melanoma is thick – at the inferior endThis melanoma is thick – at the inferior end It is ulceratedIt is ulcerated Thickness and ulceration are the two most important prognostic factorsThickness and ulceration are the two most important prognostic factors

25. Melanoma 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 report, and if it is a melanoma, carry out a wider excisionExcise with a 2 mm margin, await the pathology report, and if it is a melanoma, carry out a wider excision 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

26. Melanoma Prognostic factors (a worse prognosis)Prognostic factors (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

27. Melanoma This melanoma developed on the toe. The patient had many naevi and had had a BCC.This melanoma developed on the toe. The patient had many naevi and had had a BCC. Melanomas on the feet are uncommon.Melanomas on the feet are uncommon. You need to examine the entire body.You need to examine the entire body.

28. Melanoma Symmetrical A blue naevus Asymmetrical Asymmetrical A thin melanoma A thin melanoma Carefully look the shape and colouring of each half are different Carefully look the shape and colouring of each half are different

29. Melanoma Symmetrical Pear shaped Pear shaped Asymmetrical – melanoma next to a seborrhoeic keratosis Growing into the seborrhoeic keratosis

30. Melanoma AsymmetricalAsymmetrical