Presentation given at UK primary care exhibition May 2011

1. Skin Cancers & the lower limb A brief overview of some examples Martin Harvey PgCert BSc(Hons) MInstChP Vice Dean, Faculty of Education, Institute of Chiropodists & Podiatrists 1

2. Cancers of the Skin Skin layers involved in various types of skin cancer 2

3. 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 3

4. Basal Cell Carcinoma Anterior shin Right Temple 4

5. 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 5

6. Squamous Cell Carcinoma SCC can be more malignant than BCC, lymphatic spread and metastatic disease can arise 6

7. 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 7

8. Excision 8

9. If direct closure not possible ©Martin Harvey 2011 9

10. 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 10

11. Bowens Disease ©Martin Harvey 2011 NIH Library ? 11

12. 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 12

13. 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) 13

14. Incidence of MM by site* 14 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.

15. 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 – refer A major point change and looks ‘wrong’ - refer Pigmented lesions - concern 15

16. Melanocytes are highly mobile compared to Keratinocytes ( they originate from the neural crest and migrate to the dermis in wks8 -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 16

17. 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 17

18. 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 18

19. Sequelae of incomplete excision 19

20. Gallery 20

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25. 25 Gallery

26. 26 Look up from the feet sometimes! Walking behind a long-term patient who had just had his long hair trimmed. Noted this lesion on helix of his right pinna. Central keratotic SCC with raised periphery. Sun damaged skin. Full excision with plastic surgery reconstruction of helix

27. 27 So Hey! lets be vigilant out there.