1 Skin cancer: Fundamentals of diagnosis and treatment Surgical training meeting, Worcester,6 th September 2017 Simon De Vos, FRCS MRCGP Specialty Dr, skin cancer, Worcester and Oxford, GPwSI skin lesions and skin surgery Member of West Midlands skin cancer expert advisory group GP partner, Corbett Medical Practice, Droitwich

2 Quiz Green card: BenignAmber card: Routine surgery, Cryotherapy, GP treatment advice Red card: 2ww – urgent surgery

3 Overview of diagnosis “Does it produce keratin?” Squamous cell linePathological process: think of cell of origin : Squamous cell line from keratinocytes: produces keratin Basal cell line from basal stem cells: usually does not produce keratin, soft, ulcerates Melanocytic cell line from melanocytes: produces melanin not keratin “Does it produce keratin?”

8 ABCD of melanocytic lesionschange within 3,6,12m : Asymmetry: Ectopic focus of pigment is significant Pizza analogy for symmetry Border Change to irregular Colour More than one colour, lighter or darker Diameter increasing

10 Cancer mimics Irritated Seborrhoeic Keratoses (?SCC) – Betnovate for 2 weeks Pigmented seb Ks (?MM) – look for others / stuck-on (side light) Sebaceous Hyperplaisia (?BCC) – multiple on face, no loss of sweat pore dimpling, symmetrical florets Dermatofibroma (? SCC)– no growth, marble in skin Lichenoid keratosis: (?LM) – solar lentigo  inflammation  slate grey ‘iron filings’ after (tricky)

11 Urgent excision / biopsyMelanoma Melanoma in situ Lentigo Maligna SCC and hypertrophic Actinic Keratoses Keratoacanthoma pigmented BCC if unsure Other nodular lesions of uncertain pathogenesis (think Merkel cell etc)

12 Routine excision / biopsyBCC of all types (NICE – critical sites excluded) Actiinic Keratoses and Bowen’s resistant to 5-FU (‘Efudix’)

13 BCC treatment options Nodular: 4mm margin excision – beware critical sites Superficial (face): 4mm margin excision – beware critical sites Superficial (body): 1. Shave Currettage and cautery x2 or x3 2 . Imiquimod cream Photodynamic Therapy (PDT) Infiltrative: T-zone of face: Mohs micrographic surgery Other: Radiotherapy MDT referral for incomplete excisions Follow up: Not always required

15 SCC treatment options <2cm diameter: 4mm margin excisionTransplant patients: consider Shave C&Cx3 to preserve skin MDT referral for all cases unless Keratoacanthoma confirmed Follow up (low risk): 2-3months (x1) Follow up (high risk): 2 years (x4) High risk sites: ears, lips, scars High risk features: >2cm, poorly diff, perineural invasion, depth>4mm, desmoplastic, recurrent

16 Actinic Keratosis treatment optionsNothing 5% 5-Fluorouracil (Efudix cream) – twice daily until flare Shave C&Cx2 or x3 Cryotherapy Less commonly ‘Picato’ topical treatment 2-3 doses

17 Melanoma treatment options2mm excision margin initially Re-excision dependant on depth and MDT review (all cases) Full body photos Insitu (includes LM): 5mm margin re-excisison <1mm: 10mm margin re-excision >1mm or MDT: 20mm margin re-excision consider sentinal lymph node biopsy Follow up Insitu / LM: 3months (x1) Stage 1a: 1 year (x2-4) Stage 1b+: 5 years

18 Histopath forms Details Excision or Incisional biopsy… speed of growthNodular / flat Pigmented / pink Keratotic / not keratotic Excision or Incisional biopsy…

19 Excision vs Incisional biopsy

20 Quiz repeat Green card: Benign – back to GPAmber card: Routine management Red card: 2ww – urgent management

21 Any Questions?