Skin cancer: Fundamentals of diagnosis and treatment Surgical training meeting, Worcester,6 th September 2017 Simon De Vos, FRCS MRCGP Specialty Dr, skin cancer, Worcester and Oxford, GPwSI skin lesions and skin surgery Member of West Midlands skin cancer expert advisory group GP partner, Corbett Medical Practice, Droitwich

Quiz Green card: Benign Amber card: Routine surgery, Cryotherapy, GP treatment advice Red card: 2ww – urgent surgery

Overview of diagnosis “Does it produce keratin?” Squamous cell line Pathological process: think of cell of origin : Squamous cell line from keratinocytes: produces keratin Basal cell line from basal stem cells: usually does not produce keratin, soft, ulcerates Melanocytic cell line from melanocytes: produces melanin not keratin “Does it produce keratin?”

SCC Keratin producing Hard keratin – like nails – adherent Quicker growing – 6 weeks to 12 months classically SCC has dermal induration or ‘meat’ arising from dermis – not flat No sheen of BCC Can be sore (BCCs and melanomas tend not to be) Treat Keratoacanthomas (quick growth, stabilising) as SCC

Actinic (Solar) Keratosis Keratin producing No dermal induration (no ‘meat’) Mild, moderate and severe dysplaisa Severe dysplaisia / in situ SCC = Bowen’s or Bowenoid Actinic Keratosis 1:500 to 1:1000 chance of invasive transformation

BCC Not keratin producing May have scab (fibrin) – picks off easily, ulcer under Slow growing – years Pull tight – look for sheen / reflection of light, pearly grey Not generally painful Bleeds / ulcerates early as soft ‘base’ cells Can arise in flat superficial BCC

Melanoma From melanocytes – not keratotic (unlike Seborrhoeic Keratosess) Change in 3-12m significant Think ‘ink in skin’ before nodular / thickened Beware ‘ugly duckling’ mole ‘Blue naevus’ that is new or not seen on back should raise suspicion ABCD of moles – does not work for seb Ks

ABCD of melanocytic lesions change within 3,6,12m : Asymmetry: Ectopic focus of pigment is significant Pizza analogy for symmetry Border Change to irregular Colour More than one colour, lighter or darker Diameter increasing

Cancer mimics Irritated Seborrhoeic Keratoses (?SCC) – Betnovate for 2 weeks Pigmented seb Ks (?MM) – look for others / stuck-on (side light) Sebaceous Hyperplaisia (?BCC) – multiple on face, no loss of sweat pore dimpling, symmetrical florets Dermatofibroma (? SCC)– no growth, marble in skin Lichenoid keratosis: (?LM) – solar lentigo  inflammation  slate grey ‘iron filings’ after (tricky)

Urgent excision / biopsy Melanoma Melanoma in situ Lentigo Maligna SCC and hypertrophic Actinic Keratoses Keratoacanthoma pigmented BCC if unsure Other nodular lesions of uncertain pathogenesis (think Merkel cell etc)

Routine excision / biopsy BCC of all types (NICE – critical sites excluded) Actiinic Keratoses and Bowen’s resistant to 5-FU (‘Efudix’)

BCC treatment options Nodular: 4mm margin excision – beware critical sites Superficial (face): 4mm margin excision – beware critical sites Superficial (body): 1. Shave Currettage and cautery x2 or x3 2 . Imiquimod cream 3. Photodynamic Therapy (PDT) Infiltrative: T-zone of face: Mohs micrographic surgery http://www.bad.org.uk/shared/get-file.ashx?id=107&itemtype=document Other: Radiotherapy MDT referral for incomplete excisions Follow up: Not always required

SCC treatment options <2cm diameter: 4mm margin excision Transplant patients: consider Shave C&Cx3 to preserve skin MDT referral for all cases unless Keratoacanthoma confirmed Follow up (low risk): 2-3months (x1) Follow up (high risk): 2 years (x4) High risk sites: ears, lips, scars High risk features: >2cm, poorly diff, perineural invasion, depth>4mm, desmoplastic, recurrent

Actinic Keratosis treatment options Nothing 5% 5-Fluorouracil (Efudix cream) – twice daily until flare Shave C&Cx2 or x3 Cryotherapy Less commonly ‘Picato’ topical treatment 2-3 doses

Melanoma treatment options 2mm excision margin initially Re-excision dependant on depth and MDT review (all cases) Full body photos Insitu (includes LM): 5mm margin re-excisison <1mm: 10mm margin re-excision >1mm or MDT: 20mm margin re-excision consider sentinal lymph node biopsy Follow up Insitu / LM: 3months (x1) Stage 1a: 1 year (x2-4) Stage 1b+: 5 years

Histopath forms Details Excision or Incisional biopsy… speed of growth Nodular / flat Pigmented / pink Keratotic / not keratotic Excision or Incisional biopsy…

Excision vs Incisional biopsy

Quiz repeat Green card: Benign – back to GP Amber card: Routine management Red card: 2ww – urgent management

Any Questions?