I have a skin lump doc! Whats next? 12 th August 2017 Dr. Sue-Ann - - PowerPoint PPT Presentation

I have a skin lump doc! What’s next?

12th 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

6th in males 1719 new cases 7th in females 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
• f 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

• 2nd 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

Recurrent/incomplete excision More subclinical extension / larger More challenging to treat Higher risk of invasion Functionally or cosmetically unacceptable 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); tumors ≥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