Melanoma: tx
Nonmelanoma skin cancer
• Excision with 2-3mm margin • Re-excision margins depend on Breslow depth on pathology • Sentinel node biopsy if >1mm thick • Lymph node clearance if palpable or positive SNB • Further mx depends on staging
Nonmelanoma skin cancer
Biology of the skin
• 50,000 lesions treated each year • No incidence statistics available • ~150 deaths from squamous cell carcinoma Mainly lip or ear Mainly elderly
Biology of keratinocyte • Basal layer proliferative cells • Spinous layer desmosomes to stick cells together • Granular cell layer creates keratin • Horny cell layer provides hard surface of dead cells and wax
Questions to ask • • • •
When did the lesion appear? Why is it concerning you? Describe change you have observed. Has this change occurred over days, weeks, months or years?
13
Questions to ask • • • •
Have you ever had skin cancer, melanoma? Family history of melanoma Medical history Medications Immunosuppressives e.g. azathioprine, ciclosporin Photosensitisers e.g. diuretics, NSAIDs
Benign keratinocytic lesions • Seborrhoeic keratoses ‘Senile warts’
• Solar (actinic) keratoses ‘Sun spots’
Questions to ask • Does your skin tan easily? • If you don’t protect yourself, does your skin burn easily in the sun? • Have you ever had blistering sunburn? • Do you have or have you had an outdoor job? • Do you spend much time outdoors? Sports? Gardening?
Seborrhoeic keratoses • Arrive during adult life • Few, to thousands of lesions • Stuck-on flat to warty, scaly lesions ‘Barnacles’
• Skin coloured, pink, white, yellow, tan, brown, black, multi-coloured • Often become inflamed • May resolve spontaneously
Seborrhoeic keratoses
Seborrhoeic keratoses: tx • Generally, none is required • Excise if suspicious of melanoma • If symptomatic or unsightly: Keratolytic creams Cryotherapy Shave, curette, electrosurgery Laser ablation
14
Solar keratoses
Solar keratoses
• Firm scaly spots due to chronic sun damage • Face > hands /neck > forearms /lower legs / feet • Often tender • Skin coloured, red, brown
Solar keratoses: tx • Treatment not always required • If symptomatic or unsightly: Keratolytic creams Cryotherapy Skin surgery Fluorouracil cream Imiquimod cream Photodynamic therapy
Basal cell carcinoma • • • • •
Nonmelanoma skin cancer • Basal cell carcinoma Nodular or cystic BCC Superficial BCC Morphoeic or sclerosis BCC
• Squamous cell carcinoma SCC in situ (Bowen’s disease) Invasive SCC Keratoacanthoma
Nodular basal cell carcinoma
Slow growing lesions (months to years) Non-metastasising but locally invasive Shiny ‘pearly’ margin Telangiectasia (prominent capillaries) White or pink nodules on face Early ulceration, bleeding
• Pink dry patches on trunk and limbs Frequently multiple Regression is common
15
Superficial basal cell carcinoma
Morphoeic basal cell carcinoma
Basal cell carcinoma: tx
SCC: in situ
• Nodular, cystic, morphoeic types Excision biopsy including Mohs, sometimes requiring complex reconstruction with skin grafts and flaps
• Slowly-growing red scaly patches • Lower legs > face / trunk / upper limbs • Small risk of invasive SCC (crusty lump)
• Superficial BCC Shave, curettage, electrosurgery Cryotherapy Topical imiquimod Photodynamic therapy
SCC in situ
SCC in situ: tx • • • • •
Surgical excision, curettage, electrosurgery Cryotherapy Topical fluorouracil Topical imiquimod Photodynamic therapy
16
SCC: invasive
Squamous cell carcinoma
• Tender scaly lumps, may ulcerate • Most arise from solar keratoses or Bowen’s disease • Range from well- (scaly) to poorlydifferentiated tumours • Prognosis is poor when arising on mucosal surfaces or ears
Squamous cell carcinoma
Keratoacanthoma • Self-healing SCC • Volcano-like appearance • May be triggered by minor injury • Rapid growth over weeks to months • May resolve spontaneously • Surgically removed because look the same as SCC
Squamous cell carcinoma: tx • Surgical: Excision Shave, curettage, electrosurgery
Fluorouracil cream: Efudix® • Indications: SK, SCC is, (sBCC) • Applied as spot or field tx for 2-6 wks, may be repeated • Anticipated inflammatory reaction • Sometimes severe reaction with systemic side effects
17
Fluorouracil
Imiquimod: Aldara™ • • • •
Solar keratoses
Immune response modifier Cream applied by patient & washed off after 6-10 hours Enhances natural immune response at site of application Effective in an increasing number of skin conditions
Treatment of AK with Imiquimod 5% cream
• 2-3x/wk for 12 weeks results in 84% clearance • 10% have recurred at 1 yr follow-up
• Cycle tx: 3x/wk for 4 wks: 46% clear Rest for 4 wks Repeat cycle: another 36% clear
Pre-treatment
Week 6 of treatment with imiquimod
Courtesy of Prof E. Stockfleth
Courtesy of Prof E. Stockfleth
2 Weeks – Post-treatment (week 14)
Courtesy of Prof E. Stockfleth
18
Imiquimod in my patients
Superficial BCC
Superficial BCC + imiquimod
• Best frequency is 5x/week Reduced efficacy if less often Too much irritation if applied more often
• 6 -16 weeks treatment course • This cures up to 88% sBCC • Less effective for nBCC (~71% cure rate) Pre-Treatment J Am Acad Dermatol 2002; 47: 390-8
Superficial BCC + imiquimod
Superficial BCC + imiquimod
Week 4, Daily Treatment
Week 6, Post Daily Treatment
19
Superficial BCC + imiquimod
Superficial BCC + imiquimod
Biopsy, Post Daily Treatment (no evidence of sBCC)
Pre-treatment
Superficial BCC + imiquimod
Superficial BCC + imiquimod
Daily application at week 2
Daily application at week 6
(mild itching and tenderness observed)
Superficial BCC + imiquimod
Nodular BCC + imiquimod
Pre-treatment 6 weeks post-treatment prior to excision
Arch Dermatol 2002;138:1165-1171
20
Nodular BCC + imiquimod
Recurrent sBCC in my patients
Week 6 - Once daily treatment
April 2003
Excess inflammatory reaction
October 2004
In-situ SCC • Off-label indication for imiquimod
isSCC + imiquimod
21
Systemic side effects • ‘Flu-like • Dizziness, headache, fever, myalgia, nausea • Clinical trial data indicates these are uncommon • My experience is that they are not infrequent
Photodynamic therapy • Photosensitising agent accumulates in actively metabolising tissue
• + Oxygen • + Light of appropriate wavelength • Singlet state - Reactive triplet state - Free radicals + O2 • Damaging mitochondria, endoplasmic reticulum, and/or plasma membranes • Suppress T-cell activation
Photodynamic therapy • Relatively new non-surgical treatment for skin lesions • Reported cures for superficial BCC and in situ SCC ~85% (similar to cryotherapy & imiquimod) • Excellent cosmetic results
Indications for PDT • Malignant skin lesions: solar keratoses, actinic cheilitis, squamous cell carcinoma, basal cell carcinoma, melanoma, CTCL, Kaposi’s sarcoma, Paget’s • Inflammatory skin diseases: psoriasis, acne • Infections: HPV, leishmaniasis, infected leg ulcers • Other: vascular malformations
22
PDT
Apply photosensitiser
• Doctor marks out treatment area • Nurse applies cream and delivers light dose • Repeat one week later • Review at three months and as necessary
3 hrs later, irradiate
Excellent cosmetic results sBCC
• Red light • Painful during exposure (8 mins) • Crusting for 7 days • Repeat process in 7 days • Rapid healing
Excellent cosmetic results sBCC
Excellent cosmetic results Pre PDT
7 days
isSCC
24 hr
3 months
23
Quiz answers To the quiz answers!
24
