1st step is to determine if melanoma

Surgical excision is the first-line treatment for all skin cancer

• has the highest rate of cure

• skin cancer = 80% all NZ cancers (new)/year

• majority non-melanoma skin cancers

  • BCC

  • SCC

• Non-melanoma skin cancers are rarely fatal

  • grow if not treated early

  • result in substantial destruction of local tissue

  • disfigurement

• NZ one of highest rates of skin cancer

• UVR

• 4 risk factors:

  • increasing age

  • individual patterns of skin exposure

  • skin type and genetic make-up

  • immune system function

• Male 2:1 die from melanoma

• outdoor occupation = high contributing factor

• UVB:

  • damage DNA P53 tumour supressor gene

• UVA:

  • greater amounts of sunlight

  • penetrates more deeply into skin - longer wavelength

  • pass through glass

• intermittent high dose sun exposure assoicated with an increased risk of developing melanoma in young adults

  • esp with many melanocytic naevi

• cumulative exposrue - higher with chornic sxposure to sunlight

• mulitple melanocytic naevi (>100 and more than 5 atypical) = risk factors for melanoma

• family history: doubles risk

• inc. rate of skin cancer in people who are immunosuppressed

First assess for melanoma

• ABCDE

• A: Asymmetry

• B: Border irregularity

• C: Colour variation

• D: Diameter >6mm

• E: Evolution

• “How long has it been there?”

  • the lesion has developed and persisited over a period of months then clnical suspicion of cancer increased (melanoma or non-melanoma)

• Have you noticed any changes in size, shape or colour?

  • suggestive of melanoma

• Does this mole look different from others?

  • “ugly duckling”

• Flat/superficial = most common types of melanoma

  • asymmetrical structure and multiple colours

  • areas of depigmentation are often present

    • indicator of regression

  • Amelanotic melanoma = pink

    • small focal point of irregular pigmentation on periphery of lesion

• Nodular melanoma

  • progressive enlargement, sympoms(pain, bleeding), firma nd raised appearance

    • usually single colour, uniform in shape

  • often misdiagnosed

• Diagnostic excision with narrow margin (2mm)

• 2nd wider excision up to 2cm may bne required

• Observation for 1-2 months (no more than 3) may be appropriate wiht flat,prigmented lesions where clinical uncertainty

• \<1mm thick and without histological evidence of mitoses or ulceration considered low-risk of metasisis - can be managed in primary care

Solar keratoses (actinic keratoses)

• frequently encountered

  • esp. elderly

• pre-cancerous form of SCC

  • to SCC in up to 16%

• evidence of chornic sun exposure

appearance

• multiple, pin-red flat spots

• skin coloured, rough, scaly spots

  • scale = adherent and difficult to detach

  • if removed: painful bleeding points

• colour:

  • skin colorued

  • yellow-brown

  • brown

  • ofter with redddish tinge

• most \<1cm

• more easily felt cf. skin

• 80% on head,neck, back of hands/forearms

• often report tenderness

• Dermatoscopy:

  • small, irregular white circles

  • “strawberry” patternL concentric red and white rings

-

Management:

• Keratolytic emollients can be applied to provide symptomatic relief

  • Urea cream 10%

• fluorouracil cream more effective long-term > cryotherapy

• Imiquimod cream tolerated better than fluorouracil

  • better cosmetic results

• If multiple lesions:

  • target thickest/symptomatic with cryotherapy

• Wider areas of ksin with fluorouracil / imiquimod

• Can be useful to freeeze thicker,tender lesions two to three weeks before starting therapy

• seborrhoeic keratoses do not respond to topical treatment

• SPF 50+ sunscreens

Cryotherapy

• liquid nitrogen 2-5 seconds

• Repeat in 4 weeks or as necesary

• can remove 70% of treated solar keratoses

Fluorouracil (5%) cream - Efudix

• apply od/bd for 2-4 weeks

• monitor weekly

Imiquimod cream (5%) - Aldara - unsubsidised for this indication

• 2-3 times/week for 4-6 weeks

• Assess local response after 3 weeks and adjust treatment frequency if necessary

• Review again after 4 week treatment-free interval

• can be repeated

Basal cell carcinoma

• Is the most frequent occuring cancer in humans

• locally invasive

• rarely metastasiss

  • \<1%

• almost never fatal

• personal history of BCC -> inc. risk of devloping melanoma

• 80% face and neck:

  • particularly around eyes and nasolabial fold

Appearance:

• “rodent ulcer”

  • raised pearly edges and central atrophy/ulceration

• peraly, shiny nodule with prominent capillary networks = common

  • Telangiectasia

• superifical BCC

  • irregular red, scaly patch/plaque with short linear blood vessels

• Pigmented forms may be observed in people with dark skin / people who tan easily

• Alow growing over months/years

• Morphoeic or scleroising BCC may go unnoticed until they are several cm in diameter and penetrated deeply

• Advanced: large, deep ulcers

• BCC located near eyes, nose, ear:

  • invade orbital rim, nasal vault, middle ear

  • may be larger than expected

• Types:

  • Nodular (cystic)

    • most common = face

    • 18-40% higher incidence in men

  • Micronodular

  • Superficial

  • Morphoea-form/sclerosing

  • Pigmented

  • Infiltrative

  • Basosquamous

• Dermatoscopy:

  • loss of normal skin features and asymmetry of structure and colour

  • microerosions may also be present

  • Pigmentation at edge of lesion in form of irregular light brown,grey,blue

  • blood vessels of BCC branched lines

  • While lines without pigmented network

Management:

Surgical excision

• first line treatment

• supreior cure rates to topical treatments

• aggressive, recurrent, or large tumours >6mm on face:

  • Mohs margin-controlled micrographic surgery

• Indications for Mohs:

  • Recurrent non-melanoma skin cancer

  • Tumours more than 2cm - particularly on high risk body sites

  • Poorly defined clinical margins

  • Aggressive histological subtype - perineural/perivascular involvment

  • Areas where tissue conservation is essential for closure of defect with minimal anatomic distortion

Superficial BCC

• may be treated topically

• punch biopsy may be considered -

  • assess tumour thickness and confirm dx

• Non surgical treatments should not be used if diagnosis of BCC unclear

Cryotherapy:

• freeze-thaw cycles

• Apply LN for 20-30sec

  • allow to thaw 3-5min

• refreeze

• unsuitable for facial lesions, due to poor response rates, distal lower limbs

  • persistent ulceration

Imiquimod (subs under SA):

• confirmed with punch

• no indicated for:

  • recurrent

  • invasive

  • infiltrating

  • nodular BCC

• no evidence cryo vs. imiquimiod

• Apply to lesion and 1cm beyond OD on 5 days each week for 6 weeks

• review by at least week 3

• After 4 week treatment break

  • repeat for further 6 weeks if incomplete

• Can cure 70-80% small superficial BCC

• Punch to fulfill SA criteria

• indicated: neck, chest, distal upper limbs

5FU

• not routinely used

• apply thinly to affected area bd for 12 weeks

Gorlin’s syndrome:

• Multiple basal cell carnicoma

• Pitting of palms and soles

• Jaw cysts

• Spine and rib abN

• Calcification of flax cerebri

• Cataracts

• Oral retinoids may help dec. development of BCC in this disorder

• Albinism also inc. risk of BCC

Squamous cell carcinoma

• Develop from flat, scale-like (squamous) cells that form outermost layer of epidermis

• SCC limited to dermis:

  • intraepidermal carcinoma (IEC)

  • Bowen’s disease no longer used

• IEC generally flat

  • several mm in thickenss

  • slow growing months; years

  • Usually multiple irregular orange-red/brown plaques with variable scaling or crusting

  • Dermatoscopy:

    • light pigmentation in linear array

    • blood vessels appear as groups of irregular large,red dots and coils

• SCC

  • tender

  • rarely go unnoticed

  • chronic leg ulcers + HPV infection = inc. risk

  • Chronic leg ulcers may progress into aggressive ulcerating SCC - Marjolin’s ulcer

  • Smoking inc. risk of SCC on lip and genetalia

  • SCC also inc risk of melanoma

  • \~80% develop on face and neck

    • other sun exposed places

  • Well differentiated:

    • firm slow growing skin coloured nodules

      • with scaling or a protruding horn

  • Less differentiated:

    • grow more quickly

    • irregular crusted plaque

      • often ulcerated

  • Metastasise in \~ 5% of cases

    • risk higher if lesion large/deep or ear,lip,genitals,mucosal surfaces or involves nerve fibres

    • Also if immune system suppressed

    • Consider regional lympnode exam:

      • poor differentiation

      • perineural invasion

      • symptoms:

        • pain, burning, stinging, anaesthesia, paraesthesia, facial paralysis, diplopia, blurred vision

    • ?role of sentinal node biopsy

• Keratoacanthoma

  • symmetrical nodules

  • central crater or keratin core

  • grow rapidly - diameter of 2cm in a few weeks

  • can cause immune reaction and resolve within months

  • may be indistinguishable from aggressive tumours

  • should be excised

Management:

Surgical excision

• first line

• well differentitated, low risk tumours \<2cm

  • *4mm margin - sufficient for 95% all primary SCC

  • 6mm margin - or for Mohs

    • >2cm

    • Classified as moderately or poorly differentiated

    • Extending into subcutaneous tissues

    • ear, lip, scalp, eyelid or nose

    • recurrent

Cryotherapy

• IEC where diameter, location, number make surgery unsuitable

• single freeze 5-10 sec

5FU

• apply thinly to affected area OD/BD

• initial duration 8 weeks or longer

• occlusive dressing - inc. penetration if tisseu reaction is mninimla

Imiquimod cream

• Apply to lesion and 1cm beyond

• OD on 5 days each week for 6 weeks

• review 3rd week

• 4 week break treatment may be repeated for another 6 weeks if incomplete resolution

Follow-up

• regular self-examination

• sun smart:

  • Slip long-sleeved shirt

  • Slop on broad spec sunscreen 15 min prior to going outdoors

  • Slap on hat with wide rim

  • Wrap on pair of wrap-around sunflasses

• every 6-12 months

• 1/3 - 1/2 develop another malignancy within 5 years

• SCC 70-80% develop recurrence within this time period

5FU

• toxic to dividing cells

  • incorporated into DNA nad RNA stopping cell cycle

  • max area = 22cm x 22cm

• Avoid exposure to sun

  • thus best used during winter

• Hyperkeratotic lesions:

  • covered with occlusive dresisng

• Expected to cause:

  • local irritation and photosensitivity

  • permanent hyperpigmentation and scarring

• Erythema multiforme may also occur

• Inflammation continue for 102 weeks after treatment finished

• greater inflammatory reaction: more effective treatment

• pain can be substantial

• Severe discomfort - treated with topical corticosteroid and analgesia

• Contraindicated:

  • women who are pregnant or breastfeeding

Imiquimod

• immune modifier that causes removal of skin cells by inducing local cytokine production

• local irration

• shouldn’t be applied to croken skin

• packs of 12 sachet

  • each sachet an area of skin up to 25cm2

• well absobed

  • left on treated area for 7 horus

  • any residue washed off

• may become inflammed, itchy,ulverated and flaky

• painful eroisions on mucous membranes

  • > 1cm from eye, nose, lips

• inflammation = effective

• Steroid cream may reduce treatment efficacy

• stop = black coloured ulceration or systemic flu-like symptoms