I have a skin lump doc! What’s next? 12 th August 2017 Dr. Sue-Ann Ho Ju Ee
Some thoughts… • Is this skin cancer? • How common is this? • How likely is this in this patient? • What happens next if it’s something suspicious?
Skin cancer in Singapore 6 th in males 7 th in females 1719 new cases 1381 new cases Trends in Cancer Incidence in Singapore 2010-2014 (Singapore Cancer Registry)
• Broadly divided into non melanoma skin cancers (NMSCs) and melanomas • NMSCs • Basal call carcinomas (BCCs) • Squamous cell carcinoma (SCC)
In Singapore, NMSC are much more common than melanoma
• In normal population, BCCs > SCCs • In solid organ transplant patients, SCCs more common • 65-250x more often in transplant patients • More aggressive and more likely to metastasize Jensen P, Hansen S, Moller B, et al. Skin cancer in kidney and heart transplant recipients and different long-term immunosuppressive therapy regimens. J Am Acad Dermatol 1999; 40(2 Pt 1):177-86. Hayashida MZ, Fernandes DM, Fernandes DR, et al. Epidemiology and clinical evolution of non- melanoma skin cancer in renal transplant recipients: a single-center experience in Sao Paulo, Brasil. Int J Dermatol 2015 May 13
RISK FACTORS Fair skin • Family history • Personal history • • Lifetime cumulative sun exposure • History of tanning Weakened immune system • Exposure to radiation • Exposure to certain substances eg. Arsenic • • Smoking • Rare genetic disorders eg. Gorlin syndrome, xeroderma pigmentosa
Basal cell carcinoma (nodular) • Pearly • Translucent • Rolled edge • Telangiectasia • As it grows centre starts to ulcerate • Wound that just refuses to heal • Usually Slow growing • Pigmented variant (common in Asian population)
Distribution • Head and neck region, sun exposed areas • Do not forget to check behind the ears, under the nose piece of spectacle frames
BCC (MORPHEIC) • Ill defined waxy yellow white plaque • Poorly defined edges • Indurated/ firm to palpation • Scar like • Areas of ulceration may be visible
High risk NMSC • Considered high risk NMSC • Poorly defined edges with tumour extending far deeper and wider than what is clinically perceived • Much greated morbidity • Histologically different from nodular BCC – infiltrative strands of BCC • Head and neck distribution
SUPERFICIAL BCC • Red patch/ thin plaque • Focal erosions and crust as enlarge • Fine raised edge, more evident on stretching skin • Can be multiple • Commonly on trunk and extremities
• Beware the solitary (discrete multiple) red lesion that doesn’t respond to topical steroids
Actinic keratosis • Premalignant • Multiple rough red scaly papules on sun-exposed sites • Initially, slight erythema with impercepticle scale or may just feel scaly (better felt than seen) • Background sun damaged skin
• Sun exposed site eg. Face, dorsum of hands, bald head, upper back, V of neck • Suspicious for malignancy • Underlying induration, firm papule/nodule, ulcer • Lesions become tender • Remove scale to examine
Bowen’s disease SCC in situ • Slow growing • • Generally asymptomatic Well defined red scaly plaques • May become crusty, eroded • • Sun exposed sites • Lower legs common site eso in women
SCC • 2 nd common skin cancer • Grows more quickly than BCC • Can metastasize so early diagnosis is essentual • Mets potential increases with • Size • Site: lips and ears, sites of scars and repeated inflammation • Patient : immune suppressed,
Induration not well defined • Nodules, plaques • Keratotic • • Sometimes may see adjacent Bowen’s,/ AK Well differentiated SCC • Keratotic surface, later ulcerates with eroded margin • Poorly differentiated SCC • Surface ulceration • • Look like granulation tissue ** always send for histology PG like lesion in elderly •
Poorly differentiated SCC
Cutaneous horn • Firm white yellow horn • Descriptive term – may be viral wart, AK, SCC • Examine the base for induration, nodule SCC transformation
RED, BROWN, BLACK
• Evolving • Surface bleeding • New lump from old mole • Ulceration • Change in sensation • Ugly duckling sign
What happens next? • Diagnostic punch biopsy or excision biopsy
TREATMENT MODALITIES Topicals • 5Fluorouracil • • Imiquimod Ingenol mebutate • Cyrotherapy • • Surgery • Cautery and Curettage Wide local excision • • Mohs Micrographic Surgery Radiation Therapy • Photodynamic therapy • Targeted Therapy •
Focus on NMSC • Most NMSCs can be removed by surgery • Depending on size, site and type of skin cancer • Wide local excision • Mohs Micrographic Surgery
Wide Local Excision • 4-5mm margin of clinical evident tumour • Assumption that tumour is growing symmetrically in all directions at a similar rate and that safe amount of normal margin is taken all around to ensure clearance
Potential problems • Margins of clearance • <1% of the surface interface is actually examined • Risk of incomplete tumour excision and recurrence • Recurrent tumours can be silent, more extensive and difficult to cure
• High risk NMSC eg morpheic (infiltrative) BCC or large tumours require 9-10mm margins to achieve adequate clearance • Head and neck area sensitive sites with minimal tissue to achieve adequate margin without significant morbidity • Difficult to achieve clearance in these sites with these margins risk of recurrence/incomplete removal
More subclinical extension / larger More challenging to treat Higher risk of invasion Functionally or cosmetically unacceptable Recurrent/incomplete excision Increase anxiety Decreased patient satisfaction Higher cost of treatment Increase load on public healthcare
• Tumours in the H zone of face are high risk tumours
Mohs Micrographic surgery (MMS) • In these cases, MMS is recommended • MMS first performed for Dr Frederich Mohs • Highly specialized technique • Permits the immediate and complete microscopic examination of the removed cancerous tissue, so that all “roots” and extensions of cancer can be eliminated • Allows for removal of as little healthy skin around and below the cancer as possible, which keeps the wound as small possible
Mohs Micrographic surgery
• The visible tumour is outlined with a pen with a narrow margin • It is removed • The tissue is colour coded and a facial map is drawn corresponding to the colour codes. • Tissue is processed. It is flattened and cut layer by layer upwards towards the surface so the the whole deep margin and peripheral margin can be visualised • The slides are read by the dermatologic surgeon • If there are any residual tumous at any point, we can map it out and go in again to specifically remove that area only. • This continues until everything is out
Indications for MMS For BCCs : tumors ≥6 mm in other H zone of the) face; ≥10 mm in other areas of the face (cheeks, forehead, scalp, and neck); tum ors ≥20 mm on trunk or limbs Adapted from uptodate
Take home message Beware the… • … pyogenic granuloma like lesion presenting as SCC in the elderly (always send for histology) • …the solitary ( or sometimes multiple discrete) rash that doesn’t respond to topical steroids • …the non healing wounds, repeatedly scabs • …complaints of pain / tenderness • …immunesuppressed patient, phototherapy patients, plenty of backgrond sun damage, fair • ... hidden tissue under the keratosis. ( remove the keratosis to examine underneath for induration, nodule, ulcers)
• High risk NMSCs • Tumour factors – site, size, poorly defined borders, recurrent tumours, incompletely excised tumours, aggressive histology subtype • Patient factors – Immune suppressed, irradiated pts, genetic conditions predisposing to multiple skin cancers • MMS is the treatment of choice for these high risk non melanoma skin cancers
Thank You Sue-ann_ho@nuhs.edu.sg
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