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

Sun, sea and sand….

There’s no such thing as a healthy tan

The effects of UV exposure -ageing of skin

-skin cancer

This presentation will cover : Actinic keratosis Bowen’s disease Basal cell carcinoma Squamous cell carcinoma Malignant melanoma NICE guidance on skin cancer prevention

Actinic keratosis Rough ,scaly spots on sun-damaged skin Represent abnormal skin development due to exposure to UV radiation Should be considered potentially precancerous(>10 AKs = 10-15% risk SCC) Common on exposed sites eg backs of hands,face,scalp and ears of bald men

Actinic keratosis

Actinic keratosis-treatment Diclofenac gel (Solaraze) Cryotherapy Curettage/Excision 5-Fluorouracil cream (Efudix) Imiquimod 5% cream (Aldara) Photodynamic therapy (not available in Bradford)

Bowen’s disease Bowen’s disease is intraepidermal squamous cell carcinoma It is effectively carcinoma-in situ It may progress into squamous cell carcinoma (approximately 5%) Because of this, it is very important to treat it effectively

Bowen’s disease Presents as a pink or red ,irregular scaly patch Usually develops in a sun –exposed area of skin Common sites include hands and face in both sexes, scalp in men, lower legs in women Diagnosis should be confirmed by biopsy

Bowen’s disease

Bowen’s disease

Bowen’s disease-causes: UV radiation causes mutation in genes controlling skin cell growth UV radiation suppresses immune response in skin Arsenic ingestion Ionising radiation-very common in early 20th century radiologists HPV virus causes genital IEN

Bowen’s disease-treatment: Cryotherapy Curettage/excision 5 Fluorouracil cream (Efudix) Imiquimod 5% cream (Aldara) Photodynamic therapy

Basal cell carcinoma Affects fairskinned adults who have had a lot of sun exposure or repeated episodes of sunburn Gorlin’s syndrome-inherited tendency to multiple BCCs BCCs usually arise in normal-looking skin BCCs grow slowly over months or years Metastasis exceedingly rare but BCCs can cause destructive changes in surrounding tissues

Basal cell carcinoma-types: Nodular BCC-most common type Superficial BCC-common Morphoeic BCC-waxy,scar-like Pigmented BCC- can resemble melanoma Basisquamous BCC-mixed BCC/SCC Only the first two types are seen commonly in GP

Nodular BCC Most common type on face Small, shiny, skin-coloured swelling Telangiectasia cross the edge May have central ulcer or scab so edges appear rolled Often bleed spontaneously, then heal over Rodent ulcer is an open sore Facial BCC should be referred to plastic surgeon

Nodular basal cell carcinoma

Superficial BCC Often multiple Upper trunk or shoulders commonest site but can appear anywhere Pink or red scaly patch with raised edge on close examination Slowly growing over months or years Bleed or ulcerate easily

Superficial basal cell carcinoma

Why BCCs need treatment

BCC- treatment: Shave,curettage,cautery Excision biopsy, may need grafting or flap. Moh’s micrographic excision Photodynamic therapy Imiquimod 5% cream-highly effective for superficial BCCs Cryotherapy Radiotherapy

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

Squamous cell carcinoma SCC is a common type of skin cancer It develops in the epidermis from squamous cells which produce keratin Usual presentation is a slowly –growing scaly or crusted lump Can present as a non-healing sore or ulcer “punched out” in appearance Sometimes growth is rapid over a matter of weeks

Squamous cell carcinoma

Squamous cell carcinoma

Squamous cell carcinoma

Squamous cell carcinoma,or is it?

Squamous cell carcinoma-causes: UV radiation-damages DNA in skin SCC may develop in an actinic keratosis or patch of Bowen’s disease Genetic predisposition to develop SCCs Smoking-especially SCC lip Thermal burns Chronic leg ulcers Immunosuppression-Azathioprine/Ciclosporin. Organ transplantation patients highly susceptible HPV infection implicated in genital SCCs Pre-existing skin conditions eg lichen sclerosus and lichen planus can predispose to development of genital and oral SCCs

Squamous cell carcinoma-treatment If you suspect a possible SCC, refer via FAST TRACK pathway Histological diagnosis confirmed in Dermatology department Joint dermatologist/plastic surgeon assessment ideal, as happens in Bradford. Specialist Skin Cancer Nurse input helpful Surgery, possibly with skin graft Radiotherapy may be needed

Metastatic Squamous cell carcinoma 5% SCCs metastasise, most commonly from primary lesion on ear or lip Commoner in transplant patients Patients with CLL Associated with increasing age Associated with alcoholism More likely if multiple skin cancers present

Malignant melanoma Melanocytes are found in the basal layers of the epithelium Non-cancerous growth of melanocytes results in moles or freckles Cancerous growth of melanocytes results in malignant melanoma

Malignant melanoma-risk factors: Sun exposure, particularly during childhood Fair skin which burns easily Blistering sunburn, especially when young Previous melanoma Family history of melanoma Previous non-melanoma skin cancer Large numbers of moles/ dysplastic moles

Common sites for melanoma: In men commonest site is the back In women commonest site is the leg Can occur on mucous membranes, eg lips or genitals Can occur under the nail Can occur in eye, brain or mouth BEWARE AMELANOTIC MELANOMA

Glasgow 7 point checklist: MAJOR FEATURES: Change in size Irregular shape Irregular colour MINOR FEATURES: Diameter > 7mm Inflammation Oozing Change in sensation

The ABCDE of melanoma A Asymmetry B Border irregularity C Colour variation D Diameter over 6mm E Evolving (enlarging or changing)

Malignant melanoma

Growth of melanomas Horizontal growth within epidermis=melanoma in situ Vertical growth through basement membrane into dermis=invasive melanoma Once melanoma penetrates dermis,it spreads via lymphatic and blood stream = metastatic melanoma

Malignant melanoma

Histological classification: Breslow thickness: This is the thickness of the melanoma in mm Clark’s level: This describes which layer of skin has been breached Clark’s level 1-epidermis-melanoma in situ Clark’s level 2-dermal invasion Clark’s level 5- invasion of subcutaneous fat

Treatment of melanoma Refer suspected melanoma via FAST-TRACK pathway Surgical excision by Dermatologist with 2-3 mm margin Wider excision if histology confirms melanoma Thicker melanomas> 1mm-wider excision +/- sentinel node biopsy Widespread melanoma-surgery/chemotherapy

Prognosis of melanoma Breslow thickness< 1mm, almost 100% 5 year survival Breslow thickness > 4mm, only 50% 5 year survival Remember, melanoma is a major cause of death from malignancy in young people

Malignant melanoma

Malignant melanoma

Malignant melanoma

Malignant melanoma

Advanced melanoma

How can we advise our patients regarding skin cancer prevention?

NICE Guidance- January 2011

Benefits of sun exposure: Increases people’s sense of wellbeing Allows synthesis of Vitamin D Provides the opportunity for physical activity to improve fitness

Skin cancer prevention measures: Should not discourage outdoor activities Should encourage people to use sensible skin protection

Who should be involved? Commissioners, organisers, planners of national primary prevention campaigns Local bodies including environmental health, education sector, workplaces Local practitioners eg GPs, HVs,school nurses, pharmacists, dermatologists

At-risk groups: Fair-skinned individuals Children and babies Outdoor workers Immunosuppressed People with personal/FH of skin cancer People with > 50 moles People who overexpose skin by sunbathing/use of sunbeds

What action should be taken? Ensure advice contains simple explanation of how UV light damages skin Ensure advice explains how people can assess their individual risk Ensure advice is balanced, including both risks and benefits of sun exposure Ensure advice includes a range of options to protect skin against UV light

Advice: Avoid sunburn If you need to be out in sun due to work, protect skin as much as possible Spend time in shade between 11.00 and 15.00 Wear broad-brimmed hat, long sleeves and trousers Choose close-weave fabrics

Advice: Sunscreens should be used IN ADDITION to above measures Choose sunscreen with UVA and UVB protection It should be at least SPF 15 to protect against UVB It should be at least 4 stars to protect against UVA Use water –resistant products,applied every 2 hours

How to give advice in a positive manner: Positive statements are more likely to help people to change behaviour: “using sunscreen helps to keep skin healthy and young-looking” Keep it simple Mention ageing effects of sun-sometimes has more impact than cancer risks (remember the old lady on the beach!)

In summary: We have looked at the effects of UV radiation and other risk factors on the skin We have discussed the management of pre-malignant actinic damage We have considered the locally destructive nature of BCCs We have looked in depth at SCC and melanoma, both of which are potentially fatal We have looked at current NICE guidance on skin cancer prevention

And finally…………

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