Skin Cancer And The Lower Limb

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Presentation given at UK primary care exhibition May 2011

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Skin Cancer And The Lower Limb

  1. 1. Skin Cancers & the lower limb<br />A brief overview of some examples<br />Martin Harvey PgCert BSc(Hons) MInstChP<br />Vice Dean, Faculty of Education, Institute of Chiropodists & Podiatrists<br />1<br />
  2. 2. Cancers of the Skin<br />Skin layers involved in various types of skin cancer<br />2<br />
  3. 3. What – Cancer of the basal epidermis<br />Where- Light exposed sites; Face, bald scalps, arms, backs of hands and lower legs. <br />Who – Male = Female. c80% >60 yrs. of age<br />Incidence (UK) - >60,000 cases per annum (incomplete often anecdotal data*)<br />Clinical features – Often painless. Slowly enlarging. Smooth and pearly or waxy. Crusted scab or bleeding non-healing lesion. Often superficial telangiectasia if nodular.<br />Basal Cell Carcinoma<br />3<br />
  4. 4. Basal Cell Carcinoma<br />Anterior shin<br />Right Temple<br />4<br />
  5. 5. What – Cancer of the superficial epidermis<br />Where – Sun damaged skin sites.<br />Who – Mainly elderly with a history of sun exposure<br />Incidence - > 25,000 cases per annum (incomplete often anecdotal data*)<br />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<br />Squamous Cell Carcinoma<br />5<br />
  6. 6. Squamous Cell Carcinoma<br />SCC can be more malignant than BCC, lymphatic spread and metastatic disease can arise<br />6<br />
  7. 7. Look for its companions!<br />Refer for diagnosis and treatment<br />Complete surgical excision is usual<br />Ellipse if direct skin closure possible<br />Split graft or secondary healing if not<br />Specialists may treat very superficial BCC with cryosurgery or cautery (sponge cautery)<br />Treatment BCC / SCC<br />7<br />
  8. 8. Excision<br />8<br />
  9. 9. If direct closure not possible<br />©Martin Harvey 2011<br />9<br />
  10. 10. AKA. Intraepithelial Squamous Cell Carcinoma<br />& Squamous Cell Carcinoma in Situ<br />What- Atypical squamous cells proliferate through the whole thickness of the epidermis<br />Where – Commonest on lower leg <br />Who – typically white female > 60yrs age<br />Incidence – reported to be 14 – 140/100,00<br />Clinical Features – persistent scaly, erythematous plaque. Almost inevitable progression to SCC (may take many years)<br />Bowens Disease<br />10<br />
  11. 11. Bowens Disease<br />©Martin Harvey 2011<br />NIH Library<br />?<br />11<br />
  12. 12. Should only be undertaken by a practitioner qualified to diagnose it<br />Flourouracil cream (Efudex®)<br />Imiquimod cream (Aldara®)<br />Cryosurgery<br />Sponge hyfrecation<br />Treatment of Bowens*<br />*These methods can also be used to treat Actinic Keratoses<br />12<br />
  13. 13. What – Invasive malignant tumour comprised of dysfunctional melanocytes altered by genetic and environmental factors. (? U.V)<br />Where – Commonest trunk(M), legs (F)<br />Who – > 1 male: 2 females, fair skin types. Commonest cancer 15-34 age group<br />Incidence – 11,767 cases in 2008. ASR/100K (M+F) Scotland 18.7. England 15.8<br />Clinical Features – Asymmetry (different halves), irregular reticulum, variable colours black/brown/pink/red, irregular margin. <br />Malignant Melanoma (MM)<br />13<br />
  14. 14. Incidence of MM by site*<br />14<br />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.<br />
  15. 15. Acronyms abound, such as A.B.C.D.E etc.<br />The 7 point system works well:<br />Major changes (2 points each):<br />Shape, size colour.<br />Minor changes (1 point each):<br />Inflammation, crusting/bleeding, sensory change, diameter >7mm. <br />3 points or more – refer<br />A major point change and looks ‘wrong’ - refer<br />Pigmented lesions - concern<br />15<br />
  16. 16. Melanocytes are highly mobile compared to Keratinocytes ( they originate from the neural crest and migrate to the dermis in wks8 -10)<br />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.<br />Dangers of MM<br />16<br />
  17. 17. Wide Local Excision<br />Treatment of choice<br />◦Stage pT1 (melanoma less than 1 millimetre): margin 1 centimetre<br />◦Stage pT2 (melanoma 1 to 2 millimetres): margin 1-2 centimetres<br />◦Stage pT3 (melanoma 2 to 4 millimetres): margin 2 centimetres<br />◦Stage pT4 (melanoma over 4 millimetres): margin 2 centimetres<br />17<br />
  18. 18. Stage 0: Melanoma in Situ (Clark Level I), 99.9% Survival<br />Stage I/II: Invasive Melanoma, 85–99% Survival<br />T1a: Less than 1.00 mm primary tumour thickness, w/o Ulceration and mitosis < 1/mm2<br />T1b: Less than 1.00 mm primary tumour thickness, w/Ulceration or mitoses ≥ 1/mm2<br />T2a: 1.00–2.00 mm primary tumour thickness, w/o Ulceration<br />Stage II: High Risk Melanoma, 40–85% Survival<br />T2b: 1.00–2.00 mm primary tumour thickness, w/ Ulceration<br />T3a: 2.00–4.00 mm primary tumour thickness, w/o Ulceration<br />T3b: 2.00–4.00 mm primary tumour thickness, w/ Ulceration<br />T4a: 4.00 mm or greater primary tumour thickness w/o Ulceration<br />T4b: 4.00 mm or greater primary tumour thickness w/ Ulceration<br />Stage III: Regional Metastasis, 25–60% Survival<br />Removed tumours are ‘staged’ histologically against 5 yr survival<br />Additional staging for metastatic disease<br />18<br />
  19. 19. Sequelae of incomplete excision<br />19<br />
  20. 20. Gallery<br />20<br />
  21. 21. Gallery<br />21<br />
  22. 22. Gallery<br />22<br />
  23. 23. Gallery<br />23<br />
  24. 24. Gallery<br />24<br />
  25. 25. 25<br />Gallery<br />
  26. 26. 26<br />Look up from the feet sometimes!<br />Walking behind a long-term patient who had just had his long hair trimmed. Noted this lesion on helix of his right pinna. <br />Central keratotic SCC with raised periphery. Sun damaged skin. Full excision with plastic surgery reconstruction of helix<br />
  27. 27. 27<br />So Hey! lets be vigilant out there.<br />

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