Skin Pre-Cancerand Cancer Dr. Mary Cuthbert GPSI Dermatology.

Skin Pre-CancerSkin Pre-Cancer and Cancerand Cancer

Dr. Mary Cuthbert Dr. Mary Cuthbert

GPSI DermatologyGPSI Dermatology

Sun, sea and sand….Sun, sea and sand….

There’s no such thing as a healthy There’s no such thing as a healthy tantan

The effects of UV exposureThe effects of UV exposure-ageing of skin-ageing of skin

-skin cancer-skin cancer

This presentation will cover :This presentation will cover :

Actinic keratosisActinic keratosis

Bowen’s diseaseBowen’s disease

Basal cell carcinomaBasal cell carcinoma

Squamous cell carcinomaSquamous cell carcinoma

Malignant melanomaMalignant melanoma

NICE guidance on skin cancer preventionNICE guidance on skin cancer prevention


Rough ,scaly spots on sun-damaged skinRough ,scaly spots on sun-damaged skin

Represent abnormal skin development Represent abnormal skin development due to exposure to UV radiationdue to exposure to UV radiation

Should be considered potentially Should be considered potentially precancerous(>10 AKs = 10-15% risk precancerous(>10 AKs = 10-15% risk SCC)SCC)

Common on exposed sites eg backs of Common on exposed sites eg backs of hands,face,scalp and ears of bald menhands,face,scalp and ears of bald men


Actinic keratosis-treatmentActinic keratosis-treatment

Diclofenac gel (Solaraze)Diclofenac gel (Solaraze)

CryotherapyCryotherapy

Curettage/ExcisionCurettage/Excision

5-Fluorouracil cream (Efudix)5-Fluorouracil cream (Efudix)

Imiquimod 5% cream (Aldara)Imiquimod 5% cream (Aldara)

Photodynamic therapy (not available in Photodynamic therapy (not available in Bradford)Bradford)


Bowen’s disease is intraepidermal Bowen’s disease is intraepidermal squamous cell carcinomasquamous cell carcinoma

It is effectively carcinoma-in situIt is effectively carcinoma-in situ

It may progress into squamous cell It may progress into squamous cell carcinoma (approximately 5%)carcinoma (approximately 5%)

Because of this, it is very important to treat Because of this, it is very important to treat it effectivelyit effectively


Presents as a pink or red ,irregular scaly Presents as a pink or red ,irregular scaly patchpatch

Usually develops in a sun –exposed area Usually develops in a sun –exposed area of skinof skin

Common sites include hands and face in Common sites include hands and face in both sexes, scalp in men, lower legs in both sexes, scalp in men, lower legs in womenwomen

Diagnosis should be confirmed by biopsyDiagnosis should be confirmed by biopsy



Bowen’s disease-causes:Bowen’s disease-causes:

UV radiation causes mutation in genes UV radiation causes mutation in genes controlling skin cell growthcontrolling skin cell growth

UV radiation suppresses immune UV radiation suppresses immune response in skinresponse in skin

Arsenic ingestionArsenic ingestion

Ionising radiation-very common in early Ionising radiation-very common in early 2020thth century radiologists century radiologists

HPV virus causes genital IENHPV virus causes genital IEN

Bowen’s disease-treatment:Bowen’s disease-treatment:

CryotherapyCryotherapy

Curettage/excisionCurettage/excision

5 Fluorouracil cream (Efudix)5 Fluorouracil cream (Efudix)

Imiquimod 5% cream (Aldara)Imiquimod 5% cream (Aldara)

Photodynamic therapyPhotodynamic therapy

Basal cell carcinomaBasal cell carcinoma

Affects fairskinned adults who have had a lot of Affects fairskinned adults who have had a lot of sun exposure or repeated episodes of sunburnsun exposure or repeated episodes of sunburn

Gorlin’s syndrome-inherited tendency to multiple Gorlin’s syndrome-inherited tendency to multiple BCCsBCCs

BCCs usually arise in normal-looking skinBCCs usually arise in normal-looking skin

BCCs grow slowly over months or yearsBCCs grow slowly over months or years

Metastasis exceedingly rare but BCCs can Metastasis exceedingly rare but BCCs can cause destructive changes in surrounding cause destructive changes in surrounding tissuestissues

Basal cell carcinoma-types:Basal cell carcinoma-types:

Nodular BCC-most common typeNodular BCC-most common typeSuperficial BCC-commonSuperficial BCC-commonMorphoeic BCC-waxy,scar-likeMorphoeic BCC-waxy,scar-likePigmented BCC- can resemble melanomaPigmented BCC- can resemble melanomaBasisquamous BCC-mixed BCC/SCCBasisquamous BCC-mixed BCC/SCC

Only the first two types are seen Only the first two types are seen commonly in GPcommonly in GP

Nodular BCCNodular BCC

Most common type on faceMost common type on face

Small, shiny, skin-coloured swellingSmall, shiny, skin-coloured swelling

Telangiectasia cross the edgeTelangiectasia cross the edge

May have central ulcer or scab so edges appear May have central ulcer or scab so edges appear rolledrolled

Often bleed spontaneously, then heal overOften bleed spontaneously, then heal over

Rodent ulcer is an open soreRodent ulcer is an open sore

Facial BCC should be referred to plastic surgeonFacial BCC should be referred to plastic surgeon

Nodular basal cell carcinomaNodular basal cell carcinoma

Superficial BCCSuperficial BCC

Often multipleOften multiple

Upper trunk or shoulders commonest site Upper trunk or shoulders commonest site but can appear anywherebut can appear anywhere

Pink or red scaly patch with raised edge Pink or red scaly patch with raised edge on close examinationon close examination

Slowly growing over months or yearsSlowly growing over months or years

Bleed or ulcerate easilyBleed or ulcerate easily

Superficial basal cell carcinomaSuperficial basal cell carcinoma

Why BCCs need treatmentWhy BCCs need treatment

BCC- treatment:BCC- treatment:

Shave,curettage,cauteryShave,curettage,cauteryExcision biopsy, may need grafting or flap. Excision biopsy, may need grafting or flap. Moh’s micrographic excisionMoh’s micrographic excisionPhotodynamic therapyPhotodynamic therapyImiquimod 5% cream-highly effective for Imiquimod 5% cream-highly effective for superficial BCCssuperficial BCCsCryotherapyCryotherapyRadiotherapyRadiotherapy

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


SCC is a common type of skin cancerSCC is a common type of skin cancerIt develops in the epidermis from It develops in the epidermis from squamous cells which produce keratinsquamous cells which produce keratinUsual presentation is a slowly –growing Usual presentation is a slowly –growing scaly or crusted lumpscaly or crusted lumpCan present as a non-healing sore or ulcer Can present as a non-healing sore or ulcer “punched out” in appearance“punched out” in appearanceSometimes growth is rapid over a matter Sometimes growth is rapid over a matter of weeksof weeks




Squamous cell carcinoma,or is it?Squamous cell carcinoma,or is it?

Squamous cell carcinoma-causes:Squamous cell carcinoma-causes:

UV radiation-damages DNA in skinUV radiation-damages DNA in skinSCC may develop in an actinic keratosis or patch of Bowen’s SCC may develop in an actinic keratosis or patch of Bowen’s diseasediseaseGenetic predisposition to develop SCCsGenetic predisposition to develop SCCsSmoking-especially SCC lipSmoking-especially SCC lipThermal burnsThermal burnsChronic leg ulcersChronic leg ulcersImmunosuppression-Azathioprine/Ciclosporin.Immunosuppression-Azathioprine/Ciclosporin.

Organ transplantation patients highly susceptibleOrgan transplantation patients highly susceptibleHPV infection implicated in genital SCCsHPV infection implicated in genital SCCsPre-existing skin conditions eg lichen sclerosus and lichen planus Pre-existing skin conditions eg lichen sclerosus and lichen planus can predispose to development of genital and oral SCCscan predispose to development of genital and oral SCCs

Squamous cell carcinoma-Squamous cell carcinoma-treatmenttreatment

If you suspect a possible SCC, refer via If you suspect a possible SCC, refer via FAST TRACK pathwayFAST TRACK pathwayHistological diagnosis confirmed in Histological diagnosis confirmed in Dermatology departmentDermatology departmentJoint dermatologist/plastic surgeon Joint dermatologist/plastic surgeon assessment ideal, as happens in Bradford.assessment ideal, as happens in Bradford.Specialist Skin Cancer Nurse input helpfulSpecialist Skin Cancer Nurse input helpfulSurgery, possibly with skin graftSurgery, possibly with skin graftRadiotherapy may be neededRadiotherapy may be needed

Metastatic Squamous cell Metastatic Squamous cell carcinomacarcinoma

5% SCCs metastasise, most commonly 5% SCCs metastasise, most commonly from primary lesion on ear or lipfrom primary lesion on ear or lip

Commoner in transplant patientsCommoner in transplant patients

Patients with CLLPatients with CLL

Associated with increasing ageAssociated with increasing age

Associated with alcoholismAssociated with alcoholism

More likely if multiple skin cancers presentMore likely if multiple skin cancers present


Melanocytes are found in the basal layers Melanocytes are found in the basal layers of the epitheliumof the epithelium

Non-cancerous growth of melanocytes Non-cancerous growth of melanocytes results in moles or frecklesresults in moles or freckles

Cancerous growth of melanocytes results Cancerous growth of melanocytes results in malignant melanomain malignant melanoma

Malignant melanoma-risk factors:Malignant melanoma-risk factors:

Sun exposure, particularly during Sun exposure, particularly during childhoodchildhoodFair skin which burns easilyFair skin which burns easilyBlistering sunburn, especially when youngBlistering sunburn, especially when youngPrevious melanomaPrevious melanomaFamily history of melanomaFamily history of melanomaPrevious non-melanoma skin cancerPrevious non-melanoma skin cancerLarge numbers of moles/ dysplastic molesLarge numbers of moles/ dysplastic moles

Common sites for melanoma:Common sites for melanoma:

In men commonest site is the backIn men commonest site is the backIn women commonest site is the legIn women commonest site is the legCan occur on mucous membranes, eg lips Can occur on mucous membranes, eg lips or genitalsor genitalsCan occur under the nailCan occur under the nailCan occur in eye, brain or mouthCan occur in eye, brain or mouth

BEWARE AMELANOTIC MELANOMABEWARE AMELANOTIC MELANOMA

Glasgow 7 point checklist:Glasgow 7 point checklist:

MAJOR FEATURES:MAJOR FEATURES:

Change in sizeChange in size

Irregular shapeIrregular shape

Irregular colourIrregular colour

MINOR FEATURES:MINOR FEATURES:

Diameter > 7mmDiameter > 7mm

InflammationInflammation

OozingOozing

Change in sensationChange in sensation

The ABCDE of melanomaThe ABCDE of melanoma

A AsymmetryA Asymmetry

B Border irregularityB Border irregularity

C Colour variationC Colour variation

D Diameter over 6mmD Diameter over 6mm

E Evolving (enlarging or changing)E Evolving (enlarging or changing)


Growth of melanomasGrowth of melanomas

Horizontal growth within Horizontal growth within epidermis=melanoma in situepidermis=melanoma in situ

Vertical growth through basement Vertical growth through basement membrane into dermis=invasive membrane into dermis=invasive melanomamelanoma

Once melanoma penetrates dermis,it Once melanoma penetrates dermis,it spreads via lymphatic and blood streamspreads via lymphatic and blood stream

= metastatic melanoma= metastatic melanoma


Histological classification:Histological classification:

Breslow thickness:Breslow thickness:This is the thickness of the melanoma in mmThis is the thickness of the melanoma in mm

Clark’s level:Clark’s level:This describes which layer of skin has been This describes which layer of skin has been breachedbreachedClark’s level 1-epidermis-melanoma in situClark’s level 1-epidermis-melanoma in situClark’s level 2-dermal invasionClark’s level 2-dermal invasionClark’s level 5- invasion of subcutaneous fatClark’s level 5- invasion of subcutaneous fat

Treatment of melanomaTreatment of melanoma

Refer suspected melanoma via FAST-TRACK Refer suspected melanoma via FAST-TRACK pathwaypathway

Surgical excision by Dermatologist with 2-3 mm Surgical excision by Dermatologist with 2-3 mm marginmargin

Wider excision if histology confirms melanomaWider excision if histology confirms melanoma

Thicker melanomas> 1mm-wider excision +/- Thicker melanomas> 1mm-wider excision +/- sentinel node biopsysentinel node biopsy

Widespread melanoma-surgery/chemotherapyWidespread melanoma-surgery/chemotherapy

Prognosis of melanomaPrognosis of melanoma

Breslow thickness< 1mm, almost 100% Breslow thickness< 1mm, almost 100% 5 year survival5 year survival

Breslow thickness > 4mm, only 50%Breslow thickness > 4mm, only 50%

5 year survival5 year survival

Remember, melanoma is a major cause of Remember, melanoma is a major cause of death from malignancy in young peopledeath from malignancy in young people





Advanced melanomaAdvanced melanoma

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

NICE Guidance- January 2011NICE Guidance- January 2011

Benefits of sun exposure:Benefits of sun exposure:

Increases people’s sense of wellbeingIncreases people’s sense of wellbeing

Allows synthesis of Vitamin DAllows synthesis of Vitamin D

Provides the opportunity for physical Provides the opportunity for physical activity to improve fitnessactivity to improve fitness

Skin cancer prevention measures:Skin cancer prevention measures:

Should not discourage outdoor activitiesShould not discourage outdoor activities

Should encourage people to use sensible Should encourage people to use sensible skin protectionskin protection

Who should be involved?Who should be involved?

Commissioners, organisers, planners of Commissioners, organisers, planners of national primary prevention campaignsnational primary prevention campaigns

Local bodies including environmental Local bodies including environmental health, education sector, workplaceshealth, education sector, workplaces

Local practitioners eg GPs, HVs,school Local practitioners eg GPs, HVs,school nurses, pharmacists, dermatologistsnurses, pharmacists, dermatologists

At-risk groups:At-risk groups:

Fair-skinned individualsFair-skinned individualsChildren and babiesChildren and babiesOutdoor workersOutdoor workersImmunosuppressedImmunosuppressedPeople with personal/FH of skin cancerPeople with personal/FH of skin cancerPeople with > 50 molesPeople with > 50 molesPeople who overexpose skin by People who overexpose skin by sunbathing/use of sunbedssunbathing/use of sunbeds

What action should be taken?What action should be taken?

Ensure advice contains simple explanation Ensure advice contains simple explanation of how UV light damages skinof how UV light damages skin

Ensure advice explains how people can Ensure advice explains how people can assess their individual riskassess their individual risk

Ensure advice is balanced, including both Ensure advice is balanced, including both risks and benefits of sun exposurerisks and benefits of sun exposure

Ensure advice includes a range of options Ensure advice includes a range of options to protect skin against UV lightto protect skin against UV light

Advice:Advice:

Avoid sunburnAvoid sunburn

If you need to be out in sun due to work, If you need to be out in sun due to work, protect skin as much as possibleprotect skin as much as possible

Spend time in shade between 11.00 and Spend time in shade between 11.00 and 15.0015.00

Wear broad-brimmed hat, long sleeves Wear broad-brimmed hat, long sleeves and trousersand trousers

Choose close-weave fabricsChoose close-weave fabrics

Advice:Advice:

Sunscreens should be used IN ADDITION to Sunscreens should be used IN ADDITION to above measuresabove measuresChoose sunscreen with UVA and UVB Choose sunscreen with UVA and UVB protectionprotectionIt should be at least SPF 15 to protect against It should be at least SPF 15 to protect against UVBUVBIt should be at least 4 stars to protect against It should be at least 4 stars to protect against UVAUVAUse water –resistant products,applied every 2 Use water –resistant products,applied every 2 hourshours

How to give advice in a positive How to give advice in a positive manner:manner:

Positive statements are more likely to help Positive statements are more likely to help people to change behaviour:people to change behaviour:

“ “using sunscreen helps to keep skin using sunscreen helps to keep skin healthy and young-looking”healthy and young-looking”

Keep it simpleKeep it simple

Mention ageing effects of sun-sometimes Mention ageing effects of sun-sometimes has more impact than cancer riskshas more impact than cancer risks

(remember the old lady on the beach!)(remember the old lady on the beach!)

In summary:In summary:

We have looked at the effects of UV radiation We have looked at the effects of UV radiation and other risk factors on the skinand other risk factors on the skinWe have discussed the management of pre-We have discussed the management of pre-malignant actinic damagemalignant actinic damageWe have considered the locally destructive We have considered the locally destructive nature of BCCsnature of BCCsWe have looked in depth at SCC and We have looked in depth at SCC and melanoma, both of which are potentially fatalmelanoma, both of which are potentially fatalWe have looked at current NICE guidance on We have looked at current NICE guidance on skin cancer preventionskin cancer prevention

And finally…………And finally…………

Remember-there’s no such thing as Remember-there’s no such thing as a healthy tan!a healthy tan!

Skin Pre-Cancerand Cancer Dr. Mary Cuthbert GPSI Dermatology.

Documents

skin slide

treatment slide

skin cancer slide

squamous cell carcinoma

biopsy slide

destructive slide

bradford slide

gp slide