MINISTRY OF HEALTH OF UKRAINE
VINNITSA NATIONAL PIROGOV MEMORIAL MEDICAL
UNIVERSITY
"CONFIRM"
at the methodical meeting
Department of Ray diagnostics,
Ray therapy and Oncology
Head of the department
As. of Prof., M.S.D. Kostyuk A.G.
________________________
"______" ________ 2013 year
METHODICAL GUIDELINES
For self-study for students in preparing for the practical (seminary) lessons
Subject of Study
Oncology
Module No
1
Theme No
13
Topic of Lesson
Skin cancer.
Risk factors. Classification by TNM. Methods of
diagnostics. Clinics. Treatment: surgery, radiotherapy,
chemotherapy, combined.
Course
5
Faculty
General Medicine
2
Topicality. Cancer of the skin is the most common cancer affecting people of
European descent. It is especially common in fair-skinned people who live in sunny
climates. Australians and New Zealanders have the world’s highest incidence of skin
cancer, followed by the white populations of the southern regions of the United
States. In fact more than half of the white-skinned people living in these climates can
expect to get one or more of the common skin cancers during their lifetime. There
are three common types of skin cancer – basal cell carcinoma (BCC), squamous cell
carcinoma (SCC) and melanoma . BCC is by far the most common and fortunately,
the least dangerous. SCC is the next most common but is more aggressive than BCC.
Melanoma is fortunately the least common of the three but is the most dangerous.
Learning Objectives:
1 Incidence and epidemiology
2. Etiology and Risk factors.
3. Differential diagnosis.
4. The ways of spreading Skin cancer.
5. Classification. Stages of Skin cancer.
6. Clinical forms of Skin cancer.
7. Main symptoms.
8. Treatment tactics
9. Surgical treatment of Skin cancer
10. Choice the method of treatment (surgical, chemo- and radiotherapy).
11. Indications and contraindications for chemo- and radiotherapy.
12. Survival and prognosis.
Skin Cancer
Prevention. As for any health problem, the best treatment for skin cancer is
prevention. BCCs and SCCs of skin can be largely prevented by avoiding too much
ultraviolet irradiation from strong sunlight or artifi cial light in solariums. It is
particularly important for fair-skinned people, and especially fair and red-headed
people, who live in sunny tropical or subtropical climates, to take preventative
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measures in their everyday lives. If exposed to strong sunlight they are advised to
wear protective clothing, broad brimmed-hats, long-sleeved shirts, and long skirts or
trousers, and apply sun-screening lotions on exposed skin if any time isspent in
strong sunlight. They are advised to confi ne outdoor swimming or beach activities
to early mornings or late afternoons. They are especially advised to protect nose, lips
and face in general and the backs of their forearms and hands, because of the risk of
long periods of exposure. By taking such measures, the risk of developing BCCs and
SCCs can be greatly reduced.
Basal Cell Carcinoma (BCC)
A BCC is usually fi rst noticed as a small, crusty patch or pearly grey nodule or an
ulcer on the skin surface. These cancers occur most commonly in skin that has been
constantly exposed to sunshine over many years. Hence they are not common before
the age of 40 and become increasingly common with increasing age.
More than 70% occur on the face because the skin of the face is most
constantlyexposed to the sun. The next most common sites are on the skin of the
neck, the backs of the hands or forearms, lower legs, chest, shoulders and back.
BCCs are painless, usually slowly growing and may have been noticed for months
or even a year or more before medical attention is sought. If neglected, they usually
develop as slowly enlarging ulcers, sometimes called rodent ulcers because of the
appearance that may look as though a rat had gnawed out a piece of skin. Although,
fortunately, they almost never metastasise to lymph nodes or other distant tissues,
they do tend to erode locally into tissues around them. Thus if neglected for a long
time they may become incurable or even fatal by causing destruction to such tissues
as underlying cartilage of the nose or ear, underlying bone of the skull, or large blood
vessels in the neck. They can sometimes invade the orbit and paranasal sinuses and
may even erode into the brain.
Treatment
Very smal l superfi cial BCCs are often treated by cryotherapy, usually with a liquid
nitrogen spray. If larger or extending deeper, they are better treated by simple
surgical excision, usually under local anaesthesia. The tissue excised is examined by
a pathologist to confi rm that it was a BCC and that it was completely excised with
an adequate margin of normal tissue. Radiotherapy can also be an effective method
of treating BCCs but preferably after a small biopsy has been taken to confi rm the
4
diagnosis. Radiotherapy has the advantage of avoiding a surgical operation and of
being a painless procedure. Radiotherapy has the disadvantage of requiring
expensive specialised equipment and personnel, requiring several treatment
attendances (often 20 or more) and leaving some permanent radiation damage to a
small patch of skin. It also has the disadvantage that if no tissue is removed, there
may be some doubt about the exact diagnosis of the lesion and whether it was
completely eradicated. Nevertheless, for many small lesions, especially in elderly
patients and in diffi cult places such as over a lacrimal duct, it may be the most
appropriate form of treatment. Sometimes small BCCs are removed by
dermatologists using cauterisation or a small curette.
These techniques should be left to experienced specialists because a mistake in
diagnosis or incomplete removal can lead to a greater problem. BCCs that have
recurred after previous attempts at treatment or BCCs that occur close to vital
structures such as a lacrimal duct or in an eyelid, present special problems and
require expert attention.
Large BCCs invading bone or other tissues may require extensive surgical
procedures including reconstructive surgery. Very occasionally they may even be
incurable and are possibly best treated by palliative radiotherapy. (Palliative
treatment will give a patient relief by reducing the tumour or lessening its symptoms
without being likely to cure). Although such advanced lesions are not common, they
are disastrous when they do occur and can easily be prevented by correct treatment of
BCCs in their early stages. Hence it is important for people with small lesions to seek
medical help early, at which time BCCs are easily and completely curable.
Squamous Cell Carcinoma (SCC)
SCCs are also most common on the skin of the face, especially the lower part of the
face and lower lip. However they also commonly occur on the neck, the backs of the
hands or forearms, or skin of other frequently exposed areas such as the lower legs,
back or chest. They often develop in skin lesions called hyperkeratoses that are
small, crusty or fl aky thickened areas of skin, resulting from previous repeated sundamage over a long period.
An SCC is usually first noticed as a small painless, often crusty, lump growing on
the surface of the skin or as an ulcer in the skin. Intra-epithelial hyperplasia
(Bowen’s disease) is a very early non-penetrating SCC confi ned to the most superfi
5
cial skin layer. It is a carcinoma “in-situ” and often presents as a small red patch of
skin, possibly superfi cially ulcerated.
SCCs usually grow more rapidly than BCCs and, unlike BCCs, after a time they do
tend to metastasise to nearby draining lymph nodes. Later, they may spread further to
more distant lymph nodes or to other distant tissues or organs such as the lung. They
also grow locally and are likely to invade surrounding tissues causing ulceration,
bleeding and pain.
Fortunately, however, most SCCs of skin have not metastasised when first diagnosed
and treatment of draining lymph nodes is usually not required. However, draining
lymph nodes must be kept under close observation and if they enlarge they should be
treated without delay – usually by surgical excision.
Treatment
As for all cancers, the earlier SCCs are diagnosed and treated, the less radical
treatment they need and the greater the likelihood of cure. For any lesion suspected
of being an SCC, it is important for a biopsy to be taken. In the case of a small lesion,
this may be best achieved by surgical excision of the whole lesion – an excision
biopsy. For a large lesion it is usually more appropriate for a small piece of tissue to
be taken from its edge for microscopic examination – this is called an incision
biopsy. A frozen section examination of a biopsy specimen, is sometimes appropriate
to allow immediate complete treatment to be carried out without delay.
Very superfi cial SCCs (Bowen’s disease) can now be treated effectively by
photodynamic therapy. The lesion is painted with a photosensitising cream and
subsequently exposed to a strong light beam. Cryotherapy is also effective. Once the
diagnosis of an invasive or potentially invasive SCC in skin is established, treatment
is usually by surgical excision or sometimes by radiotherapy. Surgical excision is
usually the most effective and appropriate treatment. The lesion is widely excised
and examined microscopically to confirm that a margin of normal tissue surrounding
the cancer has also been excised to be sure that total removal of all the primary
cancer has been achieved. If draining lymph nodes are enlarged without evidence that
this is due to infection, then the lymph nodes too should be removed in one block of
tissue and examined histologically. Depending on the site and how much tissue has
to be excised, cosmetic surgery such as a skin graft may be needed to repair the
tissue and close the defect.
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As in the case of BCCs, radiotherapy is sometimes used to treat some SCCs of skin,
especially in elderly patients or in other patients in whom an operation might be
risky, or occasionally as palliative treatment when cure by surgery is considered to be
impossible.
People occasionally are seen with large SCCs of skin that appear not likely to be
curable by radiotherapy or surgery (or only curable by mutilating surgery such as
amputation of a limb). These can sometimes be reduced in size and extent by fi rst
administering chemotherapy.
An advanced SCC of the lower lipintra-arterial
infusion or perfusion. After the use of chemotherapy, the tumours are usually so
reduced in size, extent and viability that they can then be cured by radiotherapy
and/or local surgical excision and usually with surgical excision of any involved
regional lymph nodes.
Occasionally when a SCC of skin is very advanced, possibly invading local vital
organs or tissues, or if there is metastatic spread into distant organs or tissues, it may
be incurable. However, it may still be appropriate to use anti-cancer drugs and
radiotherapy as part of a palliative-care program to reduce the extent and size of the
cancer and to relieve symptoms.
Suggested Reading:
1. Manual Of Clinical Oncology, - Dennis A. Casciato, Barry B. Lowitz, 2000
2. Oxford Handbook of Oncology, - Oxford University Press, 2002
3. Basics of Oncology, - Frederick O. Stephens · Karl R. Aigner, 2009
4. HARRISON’S Manual of Oncology, - Bruce A. Chabner, Thomas J. Lynch,
Jr., Dan L. Longo, 2008