1. 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

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

3. 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?”

4. 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

5. 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

6. 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

7. 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

8. 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

10. 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)

11. 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)

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

13. 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 Photodynamic Therapy (PDT)
Infiltrative: T-zone of face: Mohs micrographic surgery
Other: Radiotherapy
MDT referral for incomplete excisions
Follow up: Not always required

15. 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

16. 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

17. 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

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

19. Excision vs Incisional biopsy

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

21. Any Questions?