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Skin Pre-Cancer and Cancer

Skin Pre-Cancer and Cancer. Dr. Mary Cuthbert GPSI Dermatology. Sun, sea and sand…. There’s no such thing as a healthy tan. The effects of UV exposure -ageing of skin. -skin cancer. This presentation will cover :. Actinic keratosis Bowen’s disease Basal cell carcinoma

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Skin Pre-Cancer and Cancer

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  1. Skin Pre-Cancer and Cancer Dr. Mary Cuthbert GPSI Dermatology

  2. Sun, sea and sand….

  3. There’s no such thing as a healthy tan

  4. The effects of UV exposure-ageing of skin

  5. -skin cancer

  6. This presentation will cover : • Actinic keratosis • Bowen’s disease • Basal cell carcinoma • Squamous cell carcinoma • Malignant melanoma • NICE guidance on skin cancer prevention

  7. Actinic keratosis • Rough ,scaly spots on sun-damaged skin • Represent abnormal skin development due to exposure to UV radiation • Should be considered potentially precancerous(>10 AKs = 10-15% risk SCC) • Common on exposed sites eg backs of hands,face,scalp and ears of bald men

  8. Actinic keratosis

  9. Actinic keratosis-treatment • Diclofenac gel (Solaraze) • Cryotherapy • Curettage/Excision • 5-Fluorouracil cream (Efudix) • Imiquimod 5% cream (Aldara) • Photodynamic therapy (not available in Bradford)

  10. Bowen’s disease • Bowen’s disease is intraepidermal squamous cell carcinoma • It is effectively carcinoma-in situ • It may progress into squamous cell carcinoma (approximately 5%) • Because of this, it is very important to treat it effectively

  11. Bowen’s disease • Presents as a pink or red ,irregular scaly patch • Usually develops in a sun –exposed area of skin • Common sites include hands and face in both sexes, scalp in men, lower legs in women • Diagnosis should be confirmed by biopsy

  12. Bowen’s disease

  13. Bowen’s disease

  14. Bowen’s disease-causes: • UV radiation causes mutation in genes controlling skin cell growth • UV radiation suppresses immune response in skin • Arsenic ingestion • Ionising radiation-very common in early 20th century radiologists • HPV virus causes genital IEN

  15. Bowen’s disease-treatment: • Cryotherapy • Curettage/excision • 5 Fluorouracil cream (Efudix) • Imiquimod 5% cream (Aldara) • Photodynamic therapy

  16. Basal cell carcinoma • Affects fairskinned adults who have had a lot of sun exposure or repeated episodes of sunburn • Gorlin’s syndrome-inherited tendency to multiple BCCs • BCCs usually arise in normal-looking skin • BCCs grow slowly over months or years • Metastasis exceedingly rare but BCCs can cause destructive changes in surrounding tissues

  17. Basal cell carcinoma-types: • Nodular BCC-most common type • Superficial BCC-common • Morphoeic BCC-waxy,scar-like • Pigmented BCC- can resemble melanoma • Basisquamous BCC-mixed BCC/SCC • Only the first two types are seen commonly in GP

  18. Nodular BCC • Most common type on face • Small, shiny, skin-coloured swelling • Telangiectasia cross the edge • May have central ulcer or scab so edges appear rolled • Often bleed spontaneously, then heal over • Rodent ulcer is an open sore • Facial BCC should be referred to plastic surgeon

  19. Nodular basal cell carcinoma

  20. Superficial BCC • Often multiple • Upper trunk or shoulders commonest site but can appear anywhere • Pink or red scaly patch with raised edge on close examination • Slowly growing over months or years • Bleed or ulcerate easily

  21. Superficial basal cell carcinoma

  22. Why BCCs need treatment

  23. BCC- treatment: • Shave,curettage,cautery • Excision biopsy, may need grafting or flap. • Moh’s micrographic excision • Photodynamic therapy • Imiquimod 5% cream-highly effective for superficial BCCs • Cryotherapy • Radiotherapy

  24. Remember-BCCs don’t kill but can be locally destructive

  25. Squamous cell carcinoma • SCC is a common type of skin cancer • It develops in the epidermis from squamous cells which produce keratin • Usual presentation is a slowly –growing scaly or crusted lump • Can present as a non-healing sore or ulcer “punched out” in appearance • Sometimes growth is rapid over a matter of weeks

  26. Squamous cell carcinoma

  27. Squamous cell carcinoma

  28. Squamous cell carcinoma

  29. Squamous cell carcinoma,or is it?

  30. Squamous cell carcinoma-causes: • UV radiation-damages DNA in skin • SCC may develop in an actinic keratosis or patch of Bowen’s disease • Genetic predisposition to develop SCCs • Smoking-especially SCC lip • Thermal burns • Chronic leg ulcers • Immunosuppression-Azathioprine/Ciclosporin. Organ transplantation patients highly susceptible • HPV infection implicated in genital SCCs • Pre-existing skin conditions eg lichen sclerosus and lichen planus can predispose to development of genital and oral SCCs

  31. Squamous cell carcinoma-treatment • If you suspect a possible SCC, refer via FAST TRACK pathway • Histological diagnosis confirmed in Dermatology department • Joint dermatologist/plastic surgeon assessment ideal, as happens in Bradford. • Specialist Skin Cancer Nurse input helpful • Surgery, possibly with skin graft • Radiotherapy may be needed

  32. Metastatic Squamous cell carcinoma • 5% SCCs metastasise, most commonly from primary lesion on ear or lip • Commoner in transplant patients • Patients with CLL • Associated with increasing age • Associated with alcoholism • More likely if multiple skin cancers present

  33. Malignant melanoma • Melanocytes are found in the basal layers of the epithelium • Non-cancerous growth of melanocytes results in moles or freckles • Cancerous growth of melanocytes results in malignant melanoma

  34. Malignant melanoma-risk factors: • Sun exposure, particularly during childhood • Fair skin which burns easily • Blistering sunburn, especially when young • Previous melanoma • Family history of melanoma • Previous non-melanoma skin cancer • Large numbers of moles/ dysplastic moles

  35. Common sites for melanoma: • In men commonest site is the back • In women commonest site is the leg • Can occur on mucous membranes, eg lips or genitals • Can occur under the nail • Can occur in eye, brain or mouth • BEWARE AMELANOTIC MELANOMA

  36. MAJOR FEATURES: Change in size Irregular shape Irregular colour MINOR FEATURES: Diameter > 7mm Inflammation Oozing Change in sensation Glasgow 7 point checklist:

  37. The ABCDE of melanoma • A Asymmetry • B Border irregularity • C Colour variation • D Diameter over 6mm • E Evolving (enlarging or changing)

  38. Malignant melanoma

  39. Growth of melanomas • Horizontal growth within epidermis=melanoma in situ • Vertical growth through basement membrane into dermis=invasive melanoma • Once melanoma penetrates dermis,it spreads via lymphatic and blood stream = metastatic melanoma

  40. Malignant melanoma

  41. Histological classification: Breslow thickness: • This is the thickness of the melanoma in mm Clark’s level: • This describes which layer of skin has been breached • Clark’s level 1-epidermis-melanoma in situ • Clark’s level 2-dermal invasion • Clark’s level 5- invasion of subcutaneous fat

  42. Treatment of melanoma • Refer suspected melanoma via FAST-TRACK pathway • Surgical excision by Dermatologist with 2-3 mm margin • Wider excision if histology confirms melanoma • Thicker melanomas> 1mm-wider excision +/- sentinel node biopsy • Widespread melanoma-surgery/chemotherapy

  43. Prognosis of melanoma • Breslow thickness< 1mm, almost 100% 5 year survival • Breslow thickness > 4mm, only 50% 5 year survival Remember, melanoma is a major cause of death from malignancy in young people

  44. Malignant melanoma

  45. Malignant melanoma

  46. Malignant melanoma

  47. Malignant melanoma

  48. Advanced melanoma

  49. How can we advise our patients regarding skin cancer prevention?

  50. NICE Guidance- January 2011

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