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SKIN CANCER Powered By Docstoc
Dr. D. Czarnecki MD MBBS

Skin Cancer
• Skin cancer is a major health problem in Australia • The most common skin cancer is the Basal Cell Carcinoma (BCC) • The next most common is the Squamous Cell Carcinoma (SCC) • The least common is the Melanoma (MM) • BCC and SCC are often grouped together as nonmelanoma skin cancer (NMSC) • Skin cancer dose not kill many Australians but treating cancers causes considerable morbidity.

Skin Cancer
• Not all races have an equal risk of developing skin cancer • Skin cancers overwhelmingly develop in white people • The following slide has the incidences of NMSC in different races in different parts of the world • The highest incidence found was in white Australian men living in tropical Queensland

• The incidence in coloured people was lower, even when they lived in the tropics.

NMSC - incidence

Tropical Australia (men only)
Hawaii (white- both sexes) Hawaii (Japanese)

3090 per 100,000
927 55

Hawaii (Filipino) Arabian Peninsula South Africa (Blacks) Californian Chinese Japan

14 2 <1 1 1

Skin Cancer
• A BCC – nodular type. Most of these occur on the head. • BCCs slowly grow • BCCs rarely metastasize – about 1 in 100,000 • It is often difficult to tell BCCs from SCCs on clinical grounds

Skin Cancer
• A BCC – superficial type

• This is now the most common type of BCC and most occur on the back • It is pink, well demarcated, and slightly scaly
• There is a small area of ulceration

A morphoeic BCC – it looks like marble

The red area is the biopsy site

The BCC grows between collagen bundles hence the indistinct margin

• Treatment of BCCs: • Surgery has the lowest recurrence rate (5-8%) • Radiotherapy has a 12% recurrent rate

• Imiquimod fails in 20-40% (higher failure rate in thicker tumours) • Photodynamic therapy fails in 40% after 4 years of follow up • Cryotherapy has a high failure rate and should not be used unless a thermocouple is used (to measure skin temperature at a set depth)

Skin Cancer
• An SCC on the forehead

• SCCs are most often found on the head or hands
• SCCs metastasize in about 5% of cases • The regional lymph node is the most common site of metastasis

• The average age for an SCC to develop in Melbourne is 71. This means that many patients die of other causes before metastases are obvious. • The Metastatic rate could be higher.

• The risk factors for metastasis are Thickness > 4 mm male sex located on the ear a recurrent SCC perineural spread is present the patient is immunosuppressed

• An SCC on the nose • There are metastases in the submental lymph nodes • The patient had chronic lymphocytic leukaemia and died shortly after of the leukaemia


• A recurrent SCC in front of the ear.

• The initial pathology report stated that it was incompletely excised • A wider, deeper excision is mandatory

Skin Cancer
• A safety margin is needed

• A 4 mm margin of normal looking tissue is recommended for BCCs (not morphoeic) and SCCs
• A 4 mm margin will give a 95% chance of removing the tumour • For morphoeic BCCs a 10 mm margin is recommended

Skin Cancer
• You must review the patient

• Overall – 2/3rds will develop a new skin cancer within 5 years • The risk is higher the greater the number of skin cancers a patient has had removed • Patients with skin cancer have an increased risk of developing non-Hodgkins lymphoma • Regular review enables the doctor examine for cancers and to re- inforce the message about protection from sunburn.

You must review your patients

A recurrent skin cancer

• Melanomas are the least common skin cancers. There were fewer than 10,000 invasive melanomas registered in Australia in 2003. There were about 40% more melanomas-in-situ. In 2003 there were about 14,000 melanomas removed from Australians

• About 1000 Australians die each year of melanoma. This is fewer than commit suicide or die in car accidents.

The number of invasive melanomas excised from Australians – AIHW (

• Not all races are at risk of melanoma. The disease is overwhelmingly one of white people.

• The main risk factors for a melanoma are (in decreasing order of importance: A previous melanoma A previous BCC or SCC More than 150 moles A skin that sun burns easily and tans poorly A first degree relative with a melanoma Immunosuppression

The incidence of melanoma in different countries (cases per 100,000)
Victoria 37.00

Hong Kong China

0.1 0.1

Arabian Peninsula Japan

0.1 0.4

• Had a melanoma? – 10% get another

• A family history (FH) increases the risk • 1 first degree relative – doubles the risk • 2 first degree relatives – 5 times the risk • 3 first degree relatives – 35 to 70 times the risk • Had a BCC or SCC? – greater risk than a +ve FH
• • x 8 for men x 4 for women

• A typical melanoma • It is asymmetrical • The A B of melanoma: • A – asymmetry • B – biopsy asymmetrical pigmented lesions

• When you see a pigmented lesion

• Draw a line down the middle • If one half does not look like the other half • TAKE A BIOPSY
It is asymmetrical

• Taking a punch biopsy or a shave biopsy

• Will not increase the risk of metastases • Studies have found no risk if such a biopsy is taken and the definitive surgery is carried out within two weeks
• Punch or shave biopsies are not encouraged because thickness is the main prognostic factor and a biopsy may miss the thickest area • However, if unsure, and you do not wish to excise the lesion, take a biopsy

• This melanoma is thick – at the inferior end

• It is ulcerated • Thickness and ulceration are the two most important prognostic factors

• If you think the lesion is a melanoma – excise it

• Guides lines • Excise with a 2 mm margin, await the pathology report, and if it is a melanoma, carry out a wider excision • Margins • Melanoma-in-situ – 5 mm margin • Melanoma < 1 mm thick – 1 cm margin • Melanoma > 1 mm thick – 2 cms margin

• Prognostic factors (a worse prognosis)

• Thickness • Ulceration • Male sex • Site – ear, palms, soles • Old age • Level IV in thin melanomas

• This melanoma developed on the toe. The patient had many naevi and had had a BCC.

• Melanomas on the feet are uncommon.
• You need to examine the entire body.


Symmetrical A blue naevus

Asymmetrical A thin melanoma Carefully look the shape and colouring of each half are different


Pear shaped

Asymmetrical – melanoma next to a seborrhoeic keratosis
Growing into the seborrhoeic keratosis