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

2. Sun, sea and sand….

3. There’s no such thing as a healthy tan

4. The effects of UV exposure -ageing of skin

5. -skin cancer

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

7. 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

8. Actinic keratosis

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

10. 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

11. 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

12. Bowen’s disease

13. Bowen’s disease

14. 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

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

16. 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

17. 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

18. 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

19. Nodular basal cell carcinoma

20. 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

21. Superficial basal cell carcinoma

22. Why BCCs need treatment

23. 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

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

25. 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

26. Squamous cell carcinoma

27. Squamous cell carcinoma

28. Squamous cell carcinoma

29. Squamous cell carcinoma,or is it?

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

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

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

38. Malignant melanoma

39. 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

40. Malignant melanoma

41. 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

42. 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

43. 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

44. Malignant melanoma

45. Malignant melanoma

46. Malignant melanoma

47. Malignant melanoma

48. Advanced melanoma

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

50. NICE Guidance- January 2011

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

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

53. 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

54. 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

55. 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

56. 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 and 15.00
Wear broad-brimmed hat, long sleeves and trousers
Choose close-weave fabrics

57. 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

58. 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!)

59. 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

60. And finally…………

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