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Skin Cancers & the lower limbA brief overview of some examples

Martin Harvey PgCert BSc(Hons) MInstChPVice Dean, Faculty of Education, Institute of Chiropodists & Podiatrists

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Cancers of the Skin

Skin layers involved in various types of skin cancer

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What – Cancer of the basal epidermis Where - Light exposed sites; Face, bald

scalps, arms, backs of hands and lower legs. Who – Male = Female. c80% >60 yrs. of age Incidence (UK) - >60,000 cases per annum

(incomplete often anecdotal data*) Clinical features – Often painless. Slowly

enlarging. Smooth and pearly or waxy. Crusted scab or bleeding non-healing lesion. Often superficial telangiectasia if nodular.

Basal Cell Carcinoma

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Basal Cell CarcinomaAnterior shin

Right Temple

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What – Cancer of the superficial epidermis Where – Sun damaged skin sites. Who – Mainly elderly with a history of sun

exposure Incidence - > 25,000 cases per annum

(incomplete often anecdotal data*) Clinical Features – Up to half develop from

untreated actinic keratoses. Scaly appearance and may be tender to the touch. Often looks like a scab. There may be a thick, adherent scale on a red, inflamed base

Squamous Cell Carcinoma

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Squamous Cell Carcinoma

SCC can be more malignant than BCC, lymphatic spread and metastatic disease can arise

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Look for its companions!Refer for diagnosis and treatment

Complete surgical excision is usual Ellipse if direct skin closure possible Split graft or secondary healing if not Specialists may treat very superficial BCC

with cryosurgery or cautery (sponge cautery)

Treatment BCC / SCC

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Excision

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If direct closure not possible

©Martin Harvey 2011

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AKA. Intraepithelial Squamous Cell Carcinoma& Squamous Cell Carcinoma in Situ What - Atypical squamous cells proliferate

through the whole thickness of the epidermis

Where – Commonest on lower leg Who – typically white female > 60yrs age Incidence – reported to be 14 – 140/100,00 Clinical Features – persistent scaly,

erythematous plaque. Almost inevitable progression to SCC (may take many years)

Bowens Disease

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Bowens Disease

NIH Library

©Martin Harvey 2011

?

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Should only be undertaken by a practitioner qualified to diagnose it

Flourouracil cream (Efudex®) Imiquimod cream (Aldara®) Cryosurgery Sponge hyfrecation

Treatment of Bowens*

*These methods can also be used to treat Actinic Keratoses

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What – Invasive malignant tumour comprised of dysfunctional melanocytes altered by genetic and environmental factors. (? U.V)

Where – Commonest trunk(M), legs (F) Who – > 1 male: 2 females, fair skin types.

Commonest cancer 15-34 age group Incidence – 11,767 cases in 2008. ASR/100K

(M+F) Scotland 18.7. England 15.8 Clinical Features – Asymmetry (different

halves), irregular reticulum, variable colours black/brown/pink/red, irregular margin.

Malignant Melanoma (MM)

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Incidence of MM by site*

In 2008 there were 2,067 deaths in the UK from Malignant Melanoma, 110 of those were under 40 years of age*. Over 50% of deaths were in people aged under 70.

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Acronyms abound, such as A.B.C.D.E etc.The 7 point system works well:

Major changes (2 points each):Shape, size colour.

Minor changes (1 point each):Inflammation, crusting/bleeding, sensory change, diameter >7mm.

3 points or more – referA major point change and looks ‘wrong’ - refer

Pigmented lesions - concern

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Melanocytes are highly mobile compared to Keratinocytes ( they originate from the neural crest and migrate to the dermis in wks 8 -10)

High mobility accounts for the potential of rapid metastasis of Melanocytes which have become malignantly dysplasic - compared to BCC or SCC which affect keratinocyte derived cells which are much less mobile and comparatively much less likely to metastasise.

Dangers of MM

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Wide Local Excision

Treatment of choice

◦Stage pT1 (melanoma less than 1 millimetre): margin 1 centimetre◦Stage pT2 (melanoma 1 to 2 millimetres): margin 1-2 centimetres◦Stage pT3 (melanoma 2 to 4 millimetres): margin 2 centimetres◦Stage pT4 (melanoma over 4 millimetres): margin 2 centimetres

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Stage 0: Melanoma in Situ (Clark Level I), 99.9% Survival

Stage I/II: Invasive Melanoma, 85–99% Survival

T1a: Less than 1.00 mm primary tumour thickness, w/o Ulceration and mitosis < 1/mm2

T1b: Less than 1.00 mm primary tumour thickness, w/Ulceration or mitoses ≥ 1/mm2

T2a: 1.00–2.00 mm primary tumour thickness, w/o Ulceration Stage II: High Risk Melanoma, 40–85% Survival

T2b: 1.00–2.00 mm primary tumour thickness, w/ Ulceration T3a: 2.00–4.00 mm primary tumour thickness, w/o Ulceration T3b: 2.00–4.00 mm primary tumour thickness, w/ Ulceration T4a: 4.00 mm or greater primary tumour thickness w/o Ulceration T4b: 4.00 mm or greater primary tumour thickness w/ Ulceration Stage III: Regional Metastasis, 25–60% Survival

Removed tumours are ‘staged’ histologically against 5 yr survival

Additional staging for metastatic disease

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Sequelae of incomplete excision

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Gallery

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Gallery

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Gallery

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Gallery

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Gallery

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Gallery

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Look up from the feet sometimes!

Central keratotic SCC with raised periphery. Sun damaged skin. Full excision with plastic surgery reconstruction of helix

Walking behind a long-term patient who had just had his long hair trimmed. Noted this lesion on helix of his right pinna.

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So Hey! lets be vigilant out there.