Skin Malignancies in General Practice
The Anatomy of Skin
Melanoma vs Non-Melanoma
 MELANOMA
 NON-MELANOMA
 Superficial Spreading
 SCC
 Nodular
 BCC
 Lentigo
 Others
 Acral
Melanoma
Melanoma - Epidemiology
 Incidence  tenfold in past 70 years
 Queensland, New Zealand, South Africa.
 Female > Male
 Higher income, & higher education
Melanoma - Aetiology
 Sun Exposure
Melanoma - Aetiology
 Skin Type
Melanoma - Aetiology
 Intermittent sun-burn
Melanoma – Clinical Features
Try and avoid spot diagnosis
Melanoma – Clinical Features
 MAJOR
 Change in Size
 Change in Shape
> 95% of presentations
 Change in Colour
But not specific. Many moles change slowly over time.
Melanoma – Clinical Features
 MINOR
 Diameter ≥ 7mm
 Itching or bleeding
 Crusting or oozing
< 50% of presentations
 Inflammation
But these are signs that patients are most concerned about.
American Cancer Society
 A – Asymmetry
 B – Border Irregularity
 C – Colour Irregularity
 D – Diameter > 6mm
 E – Elevation / Evolution
Key Feature
 An irregular edge is the single most important clinical feature.
Superficial Spreading Melanoma
 70% of all melanomas
 Younger age group
 Will eventually become nodular
 Normal skin or pre-existing mole
Nodular melanoma (EFG)
Elevated, Firm, Growing
(usually all three)
 20% of melanomas
 Older age group
 Usually darker (may be amelanocytic)
Lentigo Malignant Melanoma
 > 60 yrs old
 Sun-damaged skin (usually the face)
 Pre-malignant horizontal growth phase (Hutchinson’s
melanotic freckle)
 Gradual enlargement, indistinct edges
Acral Malignant Melanoma
 Rare in the West (10% melanomas)
 Palms, soles & around nails
 Consider melanoma in any pigmented lesion under a
nail (particularly if no trauma)
Histology
 Pre-malignant if confined to epidermis
 CLARK LEVEL OF INVASION
o Defined in anatomical terms
 BRESLOW THICKNESS
o Depth from Granular Layer of Epidermis to deepest
depth of presentation
Prognosis
Breslow Thickness
Approximate 5 year survival
< 1 mm
95-100%
1-2 mm
80-96%
2.1-4 mm
60-75%
>4 mm
50%
Other Prognostic Indicators
•Ulceration
•Vascular infiltration
•High mitotic index
•Regression
Treatment
 Surgery – Excision margin depends on depth
 Chemotherapy
 Radiotherapy
 Interferon
 Sentinel Lymph Node Biopsy
 Isolated Limb Perfusion
Basal Cell Carcinoma
 Most common cancer in humans
Basal Cell Carcinoma
 Develops from basal keratinocytes of the epidermis.
Basal Cell Carcinoma
 Infiltrates skin in contiguous three dimensional
fashion (like expanding golf ball)
 Slow growing
 Locally invasive
 Rarely metastasise
Aetiology
 Cumulative or chronic sun exposure
Clinical Features
 Background of chronic sun-damaged skin
 Well-defined
 Erythematous
 “Pearly” / flesh-toned
 Central ulcer
 Rolled edge
 Telangectasia
Treatment
 Surgical excision
 Cryotherapy
 Curettage and Cautery
 Moh’s Micrographic Surgery
 Radiotherapy
 5-Fluorouracil
 Intralesional interferon
 Photodynamic therapy
 Imiquimod
Treatment
 Dependent on site, patient & available services
 “High risk” vs “Low risk”
 Site (mid-face or ear)
 Size > 2cm
 Aggressive histology
 Recurrence
 Long duration / neglected
 Previous radiotherapy
 Immunosuppressed patient
Excisional Surgery
 Primary aim: complete removal of tumour
 Secondary aim: Retention of function & cosmesis
Lesion
Margin
<2cm
5mm
>2mm (or morpheaform)
15mm
Recurrent
Wider / Moh’s
Moh’s Micrographic Surgery
 Examination of frozen horizontal section within 30-60 minutes
 Time-consuming, costly, specialist
 Low recurrence, conserves normal skin, provides evidence of excision
Superficial BCC
 On trunk of middle aged to elderly patients.
 Well-defined border
 Red, scaley plaque (cf eczema and psoriasis)
Morpheaform (aka Sclerosing)
 May resemble a scar
 Ill-defined border
 More aggressive
Squamous Cell Carcinoma
 Actinic Keratosis
 Chronic sun exposure
o Men
o Older
o Outdoor work / hobbies
• Hands & Forearms
• Head and neck
Squamous Cell Carcinoma
Aktininc Keratoses
 Single or multiple
 Scaly erythematous papules
 < 1cm diameter
 Rough
 Sore
 Irritating
 Painful
Actinic Keratosis
 Approx 10%
Malignant Change
 Approx 25% resolve spontaneously
Treatment
 Cryotherapy - cheap, quick, easy, 98% effective
 5-Fluorouracil – can light up clinically invisible lesions
 Diclofenac 3% (Solaraze)
 Curattage and Cautery
 Surgical Excision – not usually necessary unless diagnosis in
doubt, cutaneous horn or suspected SCC
Bowen’s Disease
 SCC confined to the epidermis ie: carcinoma in situ
 Slow growing
 Sharply demarcated
 Scaly
 Erythematous patch
 Asymptomatic
Diagnosis
 Differentials
o Psoriasis
o Discoid Eczema
o Lichen Simplex chronicus
o Actinic Keratosis
o Superficial BCC / SCC
• Biopsy to Confirm
Treatment
 Do Nothing
 5-Fluorouracil
 Cryotherapy
 Curattage and Cautery
 Surgery
 Radiotherapy
 Photodynamic therapy
Squamous Cell Carcinoma
Clinical Features
 Varied!
 Firm, flesh toned
 Papules, nodule, non-healing “lump”
 Sore / painful
 Oozing / bleeding
 Enlarging rapidly
 Smooth, scaly, crusted, ulcerated or hyperkeratotic
 Biopsy for diagnosis and histological staging
Risk Factors
 UV radiation (Sun exposure!)
 Immunosuppression
 Leukaemia / Lymphoma
 PUVA treatment
 Previous radiotherapy
 Chronic skin inflammation
 Chronic ulcers
 Arsenic
Poor Prognostic Indicators
 Poorly Differentiated (Broder’s Grading 1-4)
 Site (ear or lip)
 Size > 2cm
 Depth
 Aetiology (non-sun exposed, chronic inflammation)
 Host immunosuppression
 Mucosal SCC worse than cutaneous SCC
 Perineural invasion
Treatment
 Surgical Excision
 Curettage & cautery
 Cryotherapy
 Radiotherapy
 95% of recurrences detected within 5 years therefore
follow up
Case One
 This lesion has been on the back of a
33 yo solicitor for 5months. It is not
itching or bleeding, but his wife tells
him it’s growing in size. He says he
has always had a mole there.
 What is the diagnosis?
 What are the salient parts of the
history & examination which lead you
to this conclusion?
 What do you do now?
 What do you tell him to expect to
happen?
Case Two
 This lesion has been
growing rapidly on the
face of a 58 yo
construction worker who
is also a keen angler. It
not painful or itchy.
 What is your diagnosis?
 What clinical features
lead you to this
conclusion?
 Is this a high risk lesion?
 What do you do now?
Six Months Later
Case Three
 This lesion has been
slowly growing on the
forehead of a 67 yo retired
sailor who is a keen
gardener.
 What is your diagnosis?
 What clinical features
lead you to this
conclusion?
 Is this a high risk lesion?
 What do you do now?
 What treatment options
might he be offered?
Case Four
 This 73yo man has
developed a number of
these itchy lesions on his
scalp.
 What is your diagnosis?
 What clinical features lead
you to this conclusion?
 What do you do now?
 What treatment options
might he be offered?
 Is there any other advice
you might give him?
Case Five
 This 64yo farmer has
developed this lesion on
his forearm
 What is your diagnosis?
 What clinical features lead
you to this conclusion?
 What do you do now?
 What treatment options
might he be offered?
 Is there any other advice
you might give him?
DPD
http://www.dermatology.org.uk/
Useful Resources
 DERMNET
o http://dermnetnz.org
• BRITISH ASSOCIATION OF DERMATOLOGIST
o www.bad.org.uk