Skin Cancer: Keeping it in Check

Skin Cancer: Keeping it in Check


Hello, I’m Norman Swan.
Welcome to this program on skin cancer. Two out of three Australians will be
diagnosed with skin cancer by the time they’re 70. That’s the highest incidence
in the world and it’s vital to detect and treat
skin cancer in its early stages, not to mention prevent it
in the first place. So tonight we’re going to discuss
the prevention of skin cancer, risk factors, detection, diagnosis
and evidence-based treatment. We’re going to focus primarily on the
three most common types of skin cancer, certainly the most serious forms –
basal cell carcinoma, squamous cell carcinoma and melanoma. As always,
you’ll find a number of useful resources available on the Rural Health
Education Foundation’s website – rhef.com.au. But let me introduce our panel to you. Jeff Keir is a general practitioner
working full-time in primary care skin cancer practice. – Welcome, Jeff.
– Thank you. Jeff’s a clinical tutor for the International Dermatology
Post Graduate Programs at University of Cardiff and teaches
for the North Coast GP Training scheme. Ian McColl is a consultant dermatologist
from Tugan in Queensland. – Welcome, Ian.
– Thanks, Norman. His main interests are,
well, one of his main interests are in online general practitioner
education in skin diseases. Ian Olver is a medical oncologist and Chief Executive
of the Cancer Council of Australia. – Welcome, Ian.
– Thank you. Ian’s Clinical Professor
of the Department of Medicine at the University of Sydney. Jan Riley has specialised
in Dermatology Nursing for a long time. – Jan, we won’t say since when. Welcome.
– Thank you, Norman. Jan has certificates in Primary Care
of Skin Cancer Medicine, Advanced Dermoscopy and Dermal Imaging
through the University of Queensland. So welcome to you all. So, Ian, truly the world’s highest
incidence here, we all talk about it but is it true? Yes, it is,
we vie with New Zealand for that and the sad figure
is that 1,700 Australians die each year of skin cancer – 1,300 melanoma and
400 non-melanoma skin cancer. We have about 11,000 Australians
being diagnosed with melanoma each year and we’re not quite sure
of the number of non-melanoma because most of the cancer registries
don’t record them but it is estimated at over 430,000
so it’s a huge burden of disease. And is the belief that it’s commoner
in rural and coastal areas true? Yeah, there are some areas around the
coast for example in New South Wales, the North Coast is higher than Sydney. The reasons for that
are not immediately apparent but, yes, there certainly are higher
melanomas reported in coastal areas. NORMAN: It’s commoner, the sun’s closer,
Jeff, up your area, isn’t it? Unfortunately,
the correlation was thought that the closer you got to the equator, the higher the melanoma rates
were going to be but studies –
particularly recent ones in Queensland – and also the raw data here
from New South Wales show that coastal
and then that temperate band between about the Sunshine Coast
and the Northern Rivers actually has the higher instances of
melanoma than either side of it. So it does seem that probably
some lifestyle issues there with regards to pleasant temperatures
year-round to be out in the sun as well. Ian McColl, the risk factors are what we
know or are there some surprising ones? For melanoma? NORMAN: Well, melanoma or I mean,
indeed, are they the same for melanoma and non-melanoma skin cancers?
– No, they vary a bit. Certainly for squamous cell skin cancer, ultraviolet light is
the major potentiating cause. Other factors come in. Patients that are immunosuppressed
and the like are very susceptible
to get any type of skin cancer because your immune system
is helping you all the time to stop skin cancers developing. But ultraviolet light certainly plays
a part with melanoma as well but everyone knows of patients
who’ve got melanomas in places where the sun never reaches
and unfortunately it happens. What’s the latest research on that,
Ian Olver? The melanomas in places like
the sole of your foot or your scalp? Well, I think there’s a combination
of genetic factors as well as the environmental factors and you need several hits usually
on your genetic material to actually trigger off a cancer, so it’s not just one cause or the other. NORMAN: What about protective factors? Well, I think the protective factors are things that organisations
like cancer councils have been talking about for 30 years. It’s the ‘Slip, Slop, Slap’ campaign which was ‘Slip on a shirt, slop on some 30+ sunscreen and put on a hat’ and we added two more. That was the rather obvious one, seek shade during the hottest part of the day if you can and slip on some sunglasses because your eyes need protection during the summer as well. JAN: I think, just something to add to that, though, is when we are giving sun avoidance and sun protection advice to people now, there’s always a question about,
‘What about my vitamin D, I’ve got to get some sun, haven’t I?
That’s what I’ve been told.’ So people are confused a little bit
about that message. Look, I think
that’s a very important question and I think the sun protection messages
in most of Australia are summertime messages
when the sun is at its most intense. Certainly, they don’t apply
at other times, but during the summer,
you probably only need a few minutes’ exposure to the equivalent of your face and arms
during the day to generate vitamin D and during the winter, it’s probably two
to three hours a week. What is the story, Ian McColl,
about children’s sunburn? Is it still true that your risk goes up the more sunburn episodes
your child has had? Yeah, it’s probably
one of the most important factors in assessing someone’s risk
of developing melanoma – the number of blistering sunburns
that they have had and it’s been seen throughout the world,
it’s not just in Australia. Jeff, we’ve seen an explosion and, somewhat controversially
in some people’s views, of skin cancer in your primary care
skin cancer clinics. Have we improved the detection rate? The data’s actually not clear on that because the various states of Australia
don’t particularly differentiate between the levels and stages of
non-melanoma skin cancer for a start and also the level and stages of
melanoma that they report. Certainly, the figures we have for the
skin cancer audit and research database, which is a very large database
that’s currently under investigation, is that for people who are motivated
to find skin cancer early, we’re finding a greater percentage
of early melanoma than has been reported
in the literature before so it’s optimistic that
if you’re looking more carefully for it, you’re going to find it
at an early stage but the full data is not completed yet. NORMAN: Ian McColl, do you agree? Yes, I do.
I know about the SCARD database and certainly, if you look at melanomas that are reported
to the cancer societies, the cancer councils I should say, then you find that of the 70 per 100,000
here in Queensland, 50 are invasive, 20 are in situ. If you look at the SCARD database, in fact there are two in situ melanomas
being found to every one invasive so these guys
are finding these lesions earlier, the ones who are trained
are certainly doing that. So is there an argument for screening?
Ian Olver? There’s an argument for screening
but I think the important thing is that people should know what their skin is
like and report any change immediately. They shouldn’t wait until
another screening interval but there’s no data that actually proves
the efficacy of screening and probably won’t be so it’ll have
to be a common sense thing. In terms of the natural history,
Ian McColl, of these conditions, do we know
what is a reasonable checking interval? I suppose it depends on your skin type
and how many lesions you’ve got. Very much so, it depends on
your family history, your skin type. If you’re Scottish with skin type 1,
you never tan and you always burn, then if you’ve had a lot of sunburn…
NORMAN: We Scots are invincible! Well, perhaps. Not here to the sun, there’s an awful lot of Scots
die from melanoma in Australia. JAN: I think though with screening, I mean, I think
we could encourage nurses particularly, we have people undress
for many reasons… NORMAN: Most of them legitimate.
– ..with health situations. So if you’ve got them undressed, then take the opportunity
to look at their skin. So, encourage your practice nurses
to become skin literate in a sense. Opportunistic – if they’re undressed,
look. Quite easy to encourage patients if they’ve got the risk factors for it
and let’s face it, if you’ve got a history of blistering,
of sunburns in your childhood, if you’ve got a first-degree relative
with melanoma, if you’ve had a previous skin cancer, if you’ve had exposure to things such as arsenicals
and other chemicals on the farm, you’re at increased risk. These people should be encouraged
to self-present and what we’ve certainly found is
that when we’re getting people to appropriately self-present
for screening, they may not have a particular lesion
of concern, we’re finding an extremely high rate of skin cancers and melanoma
in these people. So let’s go to our first case study. It’s Mary – 56 years old, fair skin,
she swims a lot, she comes to see Jeff
with a flat red lesion that’s scaly and itchy
on her upper back. Let’s have a look at it. JEFF KEIR: Well, this is a fairly common
presentation in general practice and that’s a pink, flat, scaly lesion which could be any one
of a number of things. You’ve got to sort of think
of the things such as the non-skin cancer
such as dermatitis, you’ve got to think of things
such as psoriasis, you’ve then got to think
of the skin cancer possibilities which commonly in these areas would be intraepidermal carcinoma
or Bowen’s disease or possibly even looking at superficial
basal cell cancer and the rarer things such as primary cutaneous lymphoma
or mycosis fungoides and a melanoma. NORMAN: So you’re seriously
scaring me now. JEFF KEIR: Well, it is a problem
because all of these things are… NORMAN: Could this be a piece
of discoid eczema? It could indeed just be
a piece of discoid eczema. There’s two ways to approach it. You can approach it either empirically
and say, ‘Look, I think it’s discoid…’ NORMAN: ‘Have a steroid
and come back in two weeks.’ Exactly, but as long as you follow up
the patient because you’ll find that a number of
lesions that don’t respond to that, i.e. you’ve got the diagnosis wrong
and you’re having to look to biopsy it. But you can short-circuit that
a little bit if you’re actually skilled with the use
of a dermascope and dermoscopy. Sometimes you can actually make
a fairly confident and firm diagnosis of what it is using the dermascope. NORMAN: So you two have brought
a show-and-tell here with dermascopes. Show me what you’re talking about here. Well, there’s a number of these
simple little handheld magnifiers and this is called a Heine Delta 20 and the Heine Delta 20 is a non-polarising dermascope
that requires contact with the skin and what it does is shine a bright light and you can examine the skin
under magnification. NORMAN: And do you need oil or water
on it? Yeah, it’s best to have a contact media such as, you can use 70% alcohol,
isopropyl alcohol or you can use oil. But the alcohol is much easier to use, it’s simple to evaporate
off the patient. Or you can use a non-contact method. There are polarised dermascopes,
simple little items called the DermLite and with these ones, you don’t even have
to touch the skin to get an image. It uses polarised light
to reduce reflection, you can see a lot more detail and some of them are even able to be
attached to cameras and for example this is an old Coolpix and there’s quite a few adaptors
that can be used. You can actually attach that then
to your camera and take a photograph of the image
in question and put it in the patient record – quite easy to do with Medical Director
or any other medical software programs. And what’s that you’ve got, Ian McColl? IAN: It’s just another type
of dermatoscope. This one’s a DermLite Fluid,
so non-polarising one. The thing about polarising, polarising light penetrates
deeper into the skin so you can see deeper structures with it but you sometimes miss
little milliard cysts that you see in the surface
of seborrheic keratosis which is a common pigment lesion
that’s benign and you don’t see blue structures, melanin deeper in the skin as well
with polarising dermatoscopes but… NORMAN: So you might want to use both? It’s good,
there’s a new one out called a DL3 that has both polarising
and non-polarising, you can just switch between the two. It’s a very good dermatoscope
and it easily connects, as Jeff shows, to cameras because taking photography
is an important thing. Jan, you’ve been trained in this.
I mean, how difficult is it to use, I mean, a lot of GPs think,
‘Oh, gosh, you know, I’m not quite sure what I’m looking at
with the naked eye and then I’m going to actually compound
the difficulty by magnifying it. God knows what I’m looking at!’ They’re not difficult to use but getting your eye in,
making sure that you practise enough and correlate what you see
and what you believe a lesion to be and if then you go on and biopsy it, and gain proof of your accuracy or not
is quite important, otherwise you don’t get your skill up
so you have to work at it. NORMAN: Ian McColl? Look, I’d agree.
I think ongoing learning, taking the opportunity
to look at everything that you can in fact
put your dermatoscope on is very good and at first you… NORMAN: So you’re going to over-biopsy
poor patients or what? Not necessarily at first. Certainly, if you look at
when dermatoscopes are introduced, some people do over-biopsy at first,
they get alarmed at first but as they learn just by reconciling what the results are
from their biopsies, they biopsy less
and they become much more selective at in fact picking up early melanomas and in using it in
other non-melanoma skin cancer as well. Jeff, if you’re a rural GP and you can’t
get locums to go off on courses, are there other ways of learning? There are, there are online resources,
some of them are actually free. For example,
there are short courses online for the International Dermoscopy Society
– IDS Org, there’s also DermNet New Zealand, they also have them. The Skin Cancer College of Australia and New Zealand have also courses which people can participate online and Learn Dermatology as well has various resources for this kind of training. It’s important to get some level of training either, at the very least, over the internet because it is a very, very visual field and if you’re able to attend one of the courses, that will reinforce what you’ve learnt online. So let’s look at what Mary’s lesion
looks like under the dermascope. JEFF KEIR: So here you can see
a totally different view. All that reflection from the scale
is gone, you’ve used some liquid
on the dermascope and you can actually now look
at the structure of this lesion within the epidermis and the dermis
and what you can see is some classical features
of superficial basal cell cancer and there are some browney grey globules
of colour or blobs of colour there and that’s commonly seen
in basal cell carcinoma. There’s also these white lines which are
highly reflective with polarised light, crisscrossing the background, almost
making it look like mother-of-pearl. You’ve also got some tiny ulcerations. What you can’t see here is other typical
features of basal cell cancer, is very, very finely focused blood
vessels but there’s enough features there
to make a firm diagnosis that this is going to be
a superficial basal cell cancer. NORMAN: You’re certainly not dealing
with a piece of eczema? JEFF KEIR: You’re not dealing with
eczema or psoriasis, intraepidermal carcinoma
or Bowen’s Disease, you’re dealing
with basal cell cancer here. NORMAN: So, Ian,
what would you do about it here? Would you need to biopsy
if it’s so obvious on…? IAN McCOLL: Depends on how experienced
you are. That’s quite a big BCC
and it’s an unusual superficial BCC because of the amount of scale. The larger BCCs are like that. The longer they’ve been around,
the more that there may be an infiltrate of component within this and if you’re thinking of using topical
therapies to treat this, then you don’t want to do it
if there’s an infiltrative component, you only want to do it
if there’s a superficial BCC that these topical therapies
will deal with. So a biopsy is not a bad idea
in a big lesion like that, you probably should take
two or three little punch biopsies to make sure that it’s a uniform
histology before you do your treatment. In fact, there’s a question
from a general practitioner in Queensland asking, ‘Is there a minimum punch biopsy size
and should you suture a punch biopsy?’ Well, the pathologist won’t thank you
if you give him a 2mm punch biopsy, it’s too small a bit of tissue. A 3mm I think is the minimum
and I usually do suture a punch biopsy, especially if it is going to be
in the leg so you’ll just have a trail of blood
along the carpet when the patient is walking out unless you put a big plug over it
and tape it on. So, yes, 3mm should be
your minimum punch biopsy size. JEFF: On a practical basis,
sometimes for these superficial lesions, if you’re countenancing treating them
with curettage and cautery, just beware that a punch biopsy goes
through to the deeper layers of the skin and you can actually get your curette
caught so sometimes it’s even worthwhile doing shave biopsies which don’t go
through that full thickness. You actually preserve
some of your treatment alternatives for these lesions. How important is the history, Jan,
in terms of diagnosis or understanding what might be wrong
with Mary – the history of the lesion? Well, the history is going to give you
an idea of whether you’re going for something
like eczema or psoriasis, or whether this is more specifically
a sun lesion if it’s an isolated lesion. It’s really quite important
for an overall view of the person. I mean, a lesion is on the person,
it’s not something that stands alone so you need a view of what is going on
with that person. Solitary lesions – it’s unusual to get
a solitary lesion of eczema or a solitary lesion of psoriasis. There’s usually multiple lesions so when
you get a solitary lesion, you know, skin cancer should spring to mind
straightaway. Let’s go back to the picture
of the dermoscopy here of Mary. Where would you biopsy it? IAN: Generally in a BCC like that, it really doesn’t matter. You might avoid an area that looks as if it’s been scarred because, remember, your immune system’s reacting all the time to skin cancers. It’s trying to get rid of things as well and sometimes you’ll get bits of regression, bits of scarring, so if you go for a white area there that’s scarring, you may get scarring in your report. NORMAN: And of course, Jeff, you can get pigmented BCCs? JEFF: Yes, they are quite common and they’re actually very beautiful under the dermascope. Pity we don’t have any images tonight. But they’re quite common and again, the features of those, if you put a dermascope on them, are not dissimilar to what we’re seeing here. You’ve got areas of ulceration, you’ll have much larger pigment globules and you’ll have finely focused blood vessels across the tumour. We’ll see some of those examples I think later tonight. NORMAN: So, Ian McColl, what are the treatment options here? For a superficial BCC like this,
you’ve got topical therapy… NORMAN: Well, as it turns out… Yes, you’ve got topical therapies
that you can in fact use and the major topical therapies for that
would be Imiquimod or Aldara, a topical therapy that enhances
the body’s immune attack to these tumour cells or there’s another therapy called PDT
therapy – photodynamic therapy – where a cream is used that’s selectively
taken up photosensitising cream, which is selectively taken up
by the tumour cells… NORMAN: We’ll come back to that later. ..and then they can get treated
with that. Efudex I don’t usually use
for superficial BCCs, I’ll use it for superficial SCCs. You can excise a lesion, obviously, you can curette a lesion
as Jeff said as well. NORMAN: It’s a BCC we’re talking about?
– Sure. NORMAN: But we’ll come back
to how that works later. And what about Mohs surgery? Well, Mohs surgery is reserved for
those basal cell skin cancers that are less well-defined, that are infiltrating BCCs
where you can’t determine the edge. You may think the edge is
at a certain point but in fact there’s little spicules
going out and that extends out a lot further
than you think. And often the margins of excision
have to be between 5mm and 7mm and Mohs surgery is particularly used where you’ve got sensitive areas
round the nose, round the eyes, where you’re trying to conserve tissue and make sure
you’re taking out all the tumour but not taking out more tissue
than you need to because it makes the repair much easier. Let’s go on to our next case study. Robert is 34, he’s got a family history of BCC and he noticed a lesion on his nose and it’s bled once or twice in the last six months. He’s not sure how long it’s been there and doesn’t have any other symptoms. Let’s have a look. God, you could easily miss that one,
Jeff. JEFF KEIR: It’s one of these small
lesions that you can easily miss and certainly with the naked eye
and clinical examination over the years, I’ve missed plenty of them. But again, it’s one of these things
that show the utility of looking closer with a dermascope and again these small BCCs,
even though they’re very small, do show classic features. In particular – and I’ve said this
before – finely focused, often branching or serpentine blood vessels
across the lesion, and they’ll often look pink
and structureless and if you look at them
under magnification, often almost have a jelly-like quality
to what you are looking at and this shows quite clearly
in this image. NORMAN: This is a dermascope.
JEFF: Yes. This is a magnified view
of this very small lesion, it’s only about 2mm – 2.5mm in diameter, but you can clearly make the diagnosis
by looking at the setting, you can see this finely focused,
fine branching blood vessels, you can compare that to the thicker, less well-focused
background blood vessels and you can see the difference. There are some benign things
that can look like this but you’re going to be pretty sure
in this area that it’s going to be a BCC and not an eccrine poroma
or something similar to that. NORMAN: What’s the treatment here,
Ian McColl? IAN McCOLL: Well, again, this is
a well-defined, very small nodular BCC. You can take that out
with narrow margins. I mean, we sometimes say BCCs
have to be taken out with 4mm margins but obviously, on the nose, and a
well-defined one like this, 2mm is fine. So you may only need to take that out with three little sutures
to close the defect, it’s well within the province
of any general practitioner to do that. NORMAN: Do you want to comment, Jan? No, I was just thinking if we were going
to get onto topical treatments with, say, the superficial BCCs –
just to backtrack for two seconds – is that a lot of those treatments,
the patient response is very individual and it’s really important
that people are supported in that care but we might get onto that
in a further case study. And, Jeff, once you’ve actually treated
someone like this with a small lesion, how often do you follow them up? Well, already they’ve put themselves
into the high risk category. They’ve got a previous history of
non-melanoma skin cancer now. At the very minimum, even if you’re not following up
this particular instance of care, they should have an annual skin check but for this particular instance
of care, it’s worthwhile following up
in three to six months to make sure there’s clinical clearance. You can have a look at that
dermascopically, if there’s any suspicious areas, it’s worthwhile re-biopsying those. Let’s look at our next case study
who is Sue. She’s 75 years old,
she’s the wife of a cattle farmer, she’s always worked around the property and she’s got a lesion
that’s always irritated by her collar. What do you think should be done
about this? Let’s have a look. Jeff? JEFF: Well, you’re having a quick glance
at this one. These types of lesions will often come
in with a fairly indeterminate history – they don’t know
how long it’s been there, it’s only recently been irritating and you look at it
just on the clinical image and you say, ‘Well, this is a little unusual,
a pink patch that has the suggestion
of something paler around the outside.’ It’s got very indeterminate margins
and you think, ‘Well, I really want a closer look
at this to decide what it is.’ It could be anything from a superficial
skin irritation from her collar to something more significant and again, this dermascopy view
shows quite clearly that we’re going to be dealing
with a possible malignancy. You’ve got finely focused
branching blood vessels which immediately make you think
of basal cell carcinoma. The other thing you can’t see, as
opposed to the previous ones we’ve seen, there is no well-demarcated edge. It’s not fine and nodular, it looks
a bit scar-like in the background – those white shiny areas
in the background – and it’s quite consistent
with sheets of collagen which you see
in these infiltrating BCCs. NORMAN: How do you know
this is infiltrating by looking at it? JEFF: By looking at this, you can… Combined with the clinical view,
you would look close, you’d have found
it would’ve felt a little bit firmer if you ran your fingers across it, you wouldn’t have seen
a clear edge to it and that is the pattern
that you see with infiltrating BCCs. There’s not much else that mimics this
apart from scleroderma occasionally. NORMAN: A bit harder to remove when you don’t know where the edge is,
Ian McColl? Indeed it is, that’s always the problem
with infiltrating BCCs and that’s why you talked about
Mohs surgery earlier on when you were doing this on the face because it’s a way of histologically
determining where that edge is by doing serial excisions and examining
it under frozen sections at the time and that’s why it’s an excellent
technique for these infiltrating BCCs if they’re on the face
or other sensitive areas but… Now of course this sort of area
is bad for curettage as well because it doesn’t have a firm base. You can’t curette that, you need to have
a firm dermis to curette and anyway, an infiltrating BCC
has already got fibrous tissue. The cells are going between
the collagen bundles so, you know, you can’t feel the soft tumour tissue
there so you certainly wouldn’t try
and curette. If you’d biopsied something
that was an infiltrating BCC, you don’t try and curette them. So this one you excised, Ian? – Jeff. Yes.
– Jeff, sorry. With these particular lesions,
when you’ve got rural patients who often don’t come into town
very often, sometimes you’ve got to leap in
and biopsy and treat all in one… NORMAN: So this was an excision biopsy? JEFF: This was indeed
a very wide excision biopsy, the presumptive diagnosis
was made dermascopically. Normally if I have time, I’d actually prefer to biopsy these
to confirm the diagnosis but unfortunately, I think we’ve got
to be practical in rural areas. NORMAN: What sort of margin
did you take here? JEFF: When you’re looking at these, you’ve really got to take 5 to 10mm
clinical margins to be sure that… NORMAN: So quite a big margin.
JEFF: Quite a big margin. But again,
if you’ve got the minor surgical skills, and many of us in rural general practice
do have these minor surgery skills, you can safely remove these
in most areas of the body. Obviously, there will be areas
you won’t be comfortable and you will have to refer. NORMAN: She’s got a fair scar. JEFF: She certainly has,
it’s a longish excision but I think once you see that it was able to be closed
with just simple nylon suturing, and longer term – I think we have an image
of about six months down the line – you actually can’t see
what’s been done there and crepe-y skin can do quite well,
thank goodness. NORMAN: And how often
would you follow someone like this up? JEFF: I’d definitely follow this lady up
3, 6 and then 12 monthly thereafter, depending on her incidence
of other skin cancers. Frequently, we find that basal cell
carcinomas occur almost in batches in the first two to three years. After having had one BCC,
they will well have one or two or three and the more BCCs they have
within that period, the closer your review times have to be. It’s just common sense. Common sense and there have been
some good studies showing that. Doug Czarnecki did a great study
earlier in the ’90s on this. Let’s go to our next picture –
a quiz slide. Jan, what do you think? JAN: A very nastily sun-damaged hand, lots of hyperkeratosis which is the thick, scaly,
very spiky sort of areas on her skin so she’s certainly got some sun spots
there, some actinic keratosis, and if any of those on examination
were painful or felt indurated, you know, felt thickened under the skin, then perhaps some of those are turning into little squamous cell carcinomas
as well. NORMAN: Ian McColl? IAN McCOLL: Look, I’d agree. I mean,
there’s a lot of sun damage here. NORMAN: This is a Scottish hand. IAN McCOLL: It may well be
a Scottish hand, they’ve certainly had it out in the sun
too much. But that thick hyperkeratotic area
in the middle there, you’d be feeling the base of that. As Jan said, if it’s infiltrated,
if it feels thicker there and it’s a bit painful when you’re
gently moving it from side to side, it almost certainly is an invasive SCC. It’s not just a hypertrophic solar
keratosis so a hand like that, it’s a very difficult condition
to deal with something when you’ve got such extensive damage. You often have to do it in stages and you’d go for the ones with
a thicker base and are indurated, you’d go for those first. Ian Olver, what’s the difference
in terms of natural history cancer-wise of these two tumours, SCCs and BCCs? Well, very simply, BCC spends most
of its natural history as local disease and causes its problem
by locally infiltrating and spreading whereas squamous cell cancer tends to spread earlier
in the course of its disease not only to local lymph nodes
but to other organs such as the lungs. But the whole message
is that these don’t spread at all if you can get them early enough so the whole aim of treatment is not only to prevent the thing
but if you can’t prevent it, its very early detection
when they are surgically curable. How amenable to chemo or radiation
are SCCs particularly when they’ve spread? Well, I think radiation
is a local treatment and it can be used in lesions
in difficult places or perhaps in older people where you want to avoid
plastic surgical flaps and so on. Chemotherapy is really the last resort when either you can’t do local therapy
on a squamous cell or local therapy has been done
multiple times and we wouldn’t expect chemotherapy
to cure the lesions. There’s usually platinum-based therapy
and that can shrink disease down to relieve symptoms and buy another few months usually
but it’s not curative therapy. But compared to melanoma,
it spreads later, it metastasises later? Very much later usually than melanoma,
which tends to spread early depending on how deeply it’s invaded. NORMAN: Which is why
it’s only 25% of the skin cancer deaths rather than more than that? That’s correct. Let’s go to our next case study
who is John, who’s a 62-year-old Scottish migrant with the sort of skin that Ian McColl
and I have been talking about. He takes about three or four beers
a night, he smokes, he’s an itinerant outdoor rural worker, he comes to see you, Jeff, with a white spot on the back of his hand, let’s have a look at it. JEFF: And this is fairly common
in presentation. These patients will come along, ‘I’ve
got this scaly thing on my hand and, Doc, it hurts every time I knock it,
every time I put my hand in a pocket,’ which is of course unusual for a Scots. But these are common lesions that
the patient will commonly present with and they’ll say,
‘This hurts, Doc, it’s sore.’ And the other interesting thing
in the history we were talking about is that the patient has a decent alcohol
intake and he also smokes and both of these have also been shown
to be risk factors for squamous cell cancer
and in fact a high-fat diet. So these are a couple of other things
we didn’t mention that perhaps people can change
in their lifestyles, which will reduce
their skin cancer risks. But anyway, this particular kind
of thing, you put your hand on it and you’ll see if you squeeze it,
the patient yelps, they’re tender. The tumour started to invade, the body’s
got an inflammatory reaction against it. In fact, most of that mounted pink area
is actually not tumour, it’s actually inflammatory reaction
to the invading tumour. And management is very, very simple. It’s too thick to freeze, you wouldn’t curette thin, crepe-y skin
here to get rid of it, it really needs to be surgically excised and it’s simple to do
with 3mm – 4mm margins. NORMAN: So,
an excision biopsy, basically? JEFF: A curettive excisional biopsy. NORMAN: So you wouldn’t try
and biopsy it first? JEFF: No, there’s no need
for these small lesions. NORMAN: And again, well,
we’ll come back to this in a moment. Just a quick question,
a GP from rural NSW asks, Ian, about the instances of skin cancer
in the Indigenous population and the problems of detection. Well, often it’s very uncommon
to get melanoma in pigmented skin but they can still get melanoma
on their palms or soles, inside the mouth,
on the unpigmented areas but of course
they’re more suited to the climate by having the pigment in their skin and so you’ve got to be careful, they certainly can get it
but it’s very uncommon. A question from rural South Australia,
Ian McColl, if you’re going to be using
a dermatoscope, should you dermatoscope
every skin lesion you see? Look, that can be awfully difficult
if you’ve got someone coming in with, you know,
literally hundreds of moles. What tends to happen is you look,
you scan someone, you look for a lesion that’s lonely,
that’s on its own, there’s no other similar ones
around about or you look for
what we call the ugly duckling, the one that stands out, that’s different from the other naevi
and you tend to look at those. You can actually scan naevi
with a dermatoscope – it could be very quickly,
the non-contact ones – so you’ll get used to examining
20 to 30 of those patients very quickly. Ian McColl, what different kinds
of squamous cell carcinoma are there? Well, some people would argue
that even a solar keratosis is a squamous cell skin cancer, it’s an incipient squamous cell
skin cancer, but then you have the SCC in situ,
Bowen’s disease, where your skin cancer
is just in the epidermis itself, the abnormal keratosis acts as though there’s nothing
through the basement membrane, it hasn’t invaded into where
the blood vessels and lymphatics are. But then you get your invasive SCC when it goes through
the basement membrane and histologically that’s defined
as being well differentiated, moderately differentiated,
poorly differentiated. Most of the ones that arise
from pre-existing solar keratosis are well differentiated, have a low risk actually
of spreading elsewhere and can be taken out
with 2mm – 3mm margins. NORMAN: So this comes back
to the history again? Part of the history of where
they have come from in the beginning. If you’ve got something
that’s slowly arisen and they’ve got
a lot of solar keratoses there, then it’s likely to be
well differentiated. If you’ve got a lesion
that’s arisen very quickly and you’ve suddenly got
a big ulcerated lesion that’s there and it’s grown in two months, then that ain’t going to be
a well differentiated SCC, that’s going to be poorly
differentiated, a potential problem. And when people use the word ‘actinic’,
what do they actually mean? – Sun-induced.
– So it’s just another word for solar. Ultraviolet-induced, I mean, you could
say solariums are actinic as well, PUVA treatment is actinic as well. Yes, indeed.
They are on solariums certainly. We’ve got the message across that it’s not a good idea to go
to a solarium to get a tan. Now, John moves from
community to community and four years later
he presents to another GP with a non-healing ulcerated lesion
on his lip and he’s got palpable submental
lymph nodes, let’s have a look. – Jeff, you’re the other GP.
JEFF: I see. NORMAN: Could the other GP
have missed this? Four years ago, would he have been
likely to have had the early lesion? JEFF: It’s a good question.
SCCs can grow extremely quickly and it’s quite likely there was nothing
like this three, four months ago at all. It is possible however to have
a fairly long prodrome of leukoplakia which is really actinic cheilitis which is solar keratosis
or actinic keratosis of the lip. But quite frequently,
these things can erupt quite quickly and these are things
that patients usually present to a little bit earlier
than this poor chap has. NORMAN: And, Ian McColl,
what’s the treatment here? IAN McCOLL: This is a big lesion on
the lip. Initially, you’d biopsy this. I mean,
it’s almost certainly a punch biopsy, it’s going to come back
as a poorly differentiated SCC especially if he’s already got
submental lymph glands. This isn’t something
that you can handle in country practice, this really needs referral
to a tertiary centre because he’ll need probably a wedge,
a big wedge – half of his lip getting taken out there
for that to be removed – plus the lymph nodes
will need to be removed and may need radio therapy to the band. And there may well even be
perineural spread with this, you know, it can go via a nerve as well and can spread
well beyond the areas of the excision so this isn’t one you would deal with
in country practice. It’s in the danger areas – SCCs that are
moderately to poorly differentiated on the scalp, ears, lip, nose
can do very, very poorly indeed. And as you said, Ian Olver, earlier,
systemic therapy may have some role but if it doesn’t,
you can’t hold out much hope. Yeah, I think it particularly has a role
if this becomes symptomatic, if it was failed to be controlled with the local therapies of surgery
and radio therapy. Let’s go to our next picture. NORMAN: Jan? JAN: OK, a nice, scaly plaque… NORMAN: I like the way all you people
involved in just skin call them ‘nice’. (Laughter) JAN: Well, I mean,
I guess I am imagining myself feeling it, it would feel… (Laughter) NORMAN: Yum, yum, yum! JAN: It would have a firmness to it. It’s not going to be soft, it’s going to
feel a little bit indurated and a little bit tender
and that’s probably Bowen’s disease, intraepidermal carcinoma, yes, IEC. NORMAN: So this is carcinoma in situ,
Jeff? JEFF: That’s right so it’s squamous
cell carcinoma right on the epidermis and as Jan has intimated, they often look very,
very bright red indeed but some of the scaly ones
have that redness masked, somewhat. NORMAN: And diagnosis? Apart from visual, are you going to take a punch biopsy
here, what are you going to do? JEFF: It’s certainly worthwhile
taking a punch biopsy to make sure you don’t have
any invasive component. It’s a difficult area
to treat surgically and if it’s one of these ones that can be
treated with topical therapies and you can prove that
by a reasonable biopsy, then it’s worthwhile trying to preserve
the skin and function of the hand. You could proceed to
that topical therapy in general practice without a referral to a dermatologist,
do you think? Certainly with using treatments
such as 5FU or Efudex, absolutely. That’s something that’s well within
the realms of general practice. NORMAN: Ian McColl?
– Yeah, I’d agree with that. The areas where you’ve got to watch
SCC in situ like this is if it’s near hair-bearing areas because it does go down
the hair follicle as well and sometimes
you won’t get the bits further down. Later on, if it re-occurred, it will occur growing up
out of the hair follicles, little red spots within the scarred area
where you have in fact treated it. NORMAN: Difficult to remove
in a position like this. Oh, look, it is,
it’s difficult to treat there. Efudex can be used, Aldara,
Imiquimod can also be used although in Australia it is recommended
mainly for superficial BCCs but it actually works very well for SCC
in situ as well. And we mentioned photodynamic therapy. So let’s just see the picture here,
a couple of pictures down the track but let’s go to it straight now. We’ve got a photograph of a photodynamic
therapy, just explain again what it is. Well, photodynamic therapy is where
you use a photosensitising cream – it’s usually
methyl-aminolevulinic acid – and you apply it over
the offending lesion, occlude it, send the patient away
for three to four hours and in that time the tumour cells,
the surface tumour cells, take up the photosensitising chemical
much better than the surrounding skin and they come back after four hours,
wipe it off and you shine a red light on it which actually activates
the photosensitising chemical that’s now been taken up
by the tumour cells and it’s delivered over a period
of about nine minutes and then the tumour cells basically
just die and it peels off as a scar. NORMAN: Magical.
– It can be. It can look very good at first
but like everything, initial looks can be deceiving because the problem is that
the success rate further down the track, two to three years out,
is somewhere between 75% and 80% so there’s perhaps 25% in fact
that it doesn’t really cure. NORMAN: So, Jan,
follow-ups are important. JAN: Absolutely. Support during that sort of treatment
is important but certainly follow-up as well and I think, it’s probably
one of the important areas where nurses can support people
in understanding why they need their follow-up
and that they do need to come back because it’s in discussion with nurses perhaps where the patient
will really sound it out as to is this important and is the
doctor really over-emphasising this to no real requirement? Let’s flick through
just two or three quick shots of SCC. Jeff, just talk us through them
just so that people at home, viewers can actually get a sense
of the spectrum here. JEFF: Well, what we are looking at here
again is a scaling lesion just like the first one we saw tonight. Your question is,
is it going to be a little patch of dermatitis or tinea or psoriasis? You’ve got multiple ones
scattered around, you’ve gotta perhaps
even think of psoriasis and if you’re uncertain, biopsy at least one or two of them
before you start treatment. If you’re going to try
any non-ablative therapies, you really need to get a biopsy proof
first of these lesions and these ones can do quite well if they are on a firm base
with curettage, they can do quite well with Efudex. On drier skin with Efudex,
the trick sometimes you need to do is apply the Efudex under occlusion
twice a day for slightly longer periods. NORMAN: So this is somebody obviously,
Ian McColl, with older skin, more difficult to
treat, of diffuse nature… IAN: This is, as Jeff said,
in the lower legs like this, it can be very difficult to curette. These are elderly people, thin skin, on anticoagulants, you know,
a lot of sun damage, you try and curette that and you’ll be down into the fat layer
before you know what’s happening ’cause there isn’t any firm base
underneath so you just end up with an ulcer. This was a lady
who’s got a giant SCC in situ and it was initially treated
as a fungal infection. She was a patient with severe rheumatoid
on methotrexate so, you know, her immune system
was affected as well by that and they didn’t pick this
as a superficial SCC, it’s now covering about
almost up to half her lower leg. NORMAN: How did you treat that? IAN McCOLL: It’s awfully difficult. Radiotherapy would probably be
about the only treatment you could use. We did try PDT, we tried some Efudex as well
but she’s an elderly lady in her 70s and very thin, confined to a wheelchair
with her rheumatoid arthritis and the dear lady in the end said, ‘No,
look, I’ll quietly just live with this.’ We keep watching it
and if there’s any bit that thickens and it looks like it’s an invasive SCC,
we do a little excision on that. NORMAN: And just the last one now, Jeff. JEFF: Again,
very similar to the previous ones, almost isolated lesion, that. NORMAN: Hard to tell apart from a BCC? JEFF: It is. Again, this is where
the dermascope can indeed help. If I applied a dermascope to this, we’d most likely see that
we are going to have multiple coiled or what used to be called
glomerular vessels, little roundish glomerular-like vessels
if you look under magnification. NORMAN: Sort of curled. JEFF: All curled up
in a nice tight little ball and you’ll find that of varying sizes
within the lesion. Again, it’s worthwhile biopsying
initially to be sure before you do start treatment but Ian made a point with this lady
on methotrexate, these are becoming… The patients who are
on immunosuppressants for various autoimmune diseases and patients also with chronic
myelodysplasia, chronic lymphoma, are an increasingly large group of patients in our practices,
in general practice and in skin cancer clinics,
and they do deserve special attention because they are at high risk
of widespread multiple lesions. How much attention, Ian Olver,
does the skin get in oncology clinics when you’re not treating the skin
but you’re treating other things that might induce skin cancer? Well, I think it doesn’t perhaps get
as much as it should because you’re often dealing with metastatic disease
in a medical oncology clinic and the skin lesion in the context
of widely spread other cancers may not get the attention it deserves. However, the same things apply
as applied to any examination. You should try and examine the patients
thoroughly by exposing the area, taking their shirt off and
examining them in their underwear, which is very useful
for all sorts of cancers but gives you a chance of identifying
a skin lesion and these patients are often
immunosuppressed on chemotherapy or other treatments. I suppose it’s another message for GPs
who have patients on cancer treatment – to keep an eye on the skin. I think they’ve got to be particularly
careful and not allow skin lesion to… Or not watch it for too long
if they are worried about it. Let’s move on and go to our next case
study who is Joe, 68, a retired labourer and he’s got an isolated lesion
on his upper arm. He didn’t notice it himself
but Jeff found it on skin examination. Let’s have a look at it. JEFF: This is a lesion that stands out
clinically and it attracts your eye, it’s a very lonely lesion, there’s
nothing else quite like it on his arm. It’s also typical of a lot of things
that we see once you start undressing your patients
and having a look at them but 50% of the melanomas we find
are on the trunk and under clothing and if you don’t at least get their
shirt off, you are going to miss those as he would have missed this. And if we look at it even closer
with the naked eye, this is a macro shot as it would look as if
you were looking at it quite closely and already we are starting to see
some clues and the clinical clues that are used
for melanoma – the ABCDE – which is asymmetry, border irregularity, multiple colours,
a diameter greater than 6mm and perhaps a history of E for evolution and we can see that
this is probably consistent with that. NORMAN: So the person, if they knew that it was there,
would tell you that it’s changed. JEFF: They may well do indeed or if you’d noticed earlier
and you’re monitoring it as well. Now if you look at it even closer again
with the dermascope, you can be pretty sure you’re dealing
now with a melanoma. What we’ve got is a lesion
that’s quite obviously, it’s chaotic, it’s asymmetric in colour,
it’s asymmetric in pattern and it does actually have
some of the several clues that you can find in melanoma. NORMAN: So why don’t you
run through the clues? JEFF: Well, there’s a whole list of them
and they’re not totally agreed upon but in this particular lesion for
example, we’ve got this asymmetric area where you’ve got loss of structure,
it’s pale and structureless, and you’ve also got
some blue-grey structureless areas. You’ve got some brown dots which are irregularly distributed
on the lesion, it’s a bit harder to see
at this magnification but there’s also some thickened network. We can also see in melanomas,
we often see grey areas of any type, they can be an alarm button
for you to press. Black dots and blobs around the edges
of a lesion like this can make you think it’s a melanoma,
lines streaking away – brown lines streaking away
at the edge of a lesion, what we call radial streaming, can be a clue. Blood vessels
that have different patterns, we call polymorphous vessels, are a clue and also white lines which look
almost like a negative network. They are a white mesh pattern
instead of the brown mesh pattern we normally see in a mole. NORMAN: And how’s that different from,
say, a junctional naevus? Well, junctional naevi, when you look
at them with dermoscopy, usually are a single colour,
a single pattern and because of melanocytes
at the derma-epidermal junction, they’re flat, they’re impalpable,
they’ve got no raised areas there and you’ll see that the network
of these particular naevi fade out into the surrounding skin rather than having an abrupt cut-off
like a lentigo. If we’re then looking at something that is more towards possibly
being a melanoma – and not everything that’s irregular
is a melanoma – but you’d better have your antenna up
and think about biopsying it, it’s going to have irregularities
in its structure such as we’ve detailed
in that little list there. So how do you diagnose this? This was obviously made
by a diagnosis clinically. It was a suspect lesion
of those features and according to the guidelines that are published now in Australia
and New Zealand for melanoma management, this was excised with a 2mm margin
as an excisional biopsy. It’s important to get all the lesion because the edges of the lesion
often give clues to the histopathologist as to whether
the lesion is circumscribed or not. That’s one of the features they look for and once you actually have that
information from the excisional biopsy, they’ll tell you
what its Breslow thickness is. Now the Breslow thickness
is the thickness from the stratum, the granular layer of the skin down to the deepest level
of the actual melanoma and from that information, you’ll know
what kind of margins this needs, whether you need to refer the lesion. So it came back as a Breslow 0.2. It did indeed
so it’s quite a thin melanoma. Less that 1mm is considered
a thin melanoma and the guidelines state that you’re wanting to have your excision
margins for in situ melanomas 5mm clinical margins need to be done
down to the fat underneath. – If you’re looking at up to 1mm…
– Just down to the fat. Just down to the fat underneath. Some
people will argue to the deep fascia but for in situ lesions
that really is not necessary. If you’re looking then at a lesion
that’s invasive up to 1mm in depth, you need to go a little bit wider, you’re looking at 10mm margins and
down to the deep fascia or at least 1cm, probably whichever comes first there. Ian Olver, there’s the story around,
a common story – surgery can induce cancer worsening. Can excision biopsy actually provoke
metastatic spread or more aggression? No, this has always been a theory
that could potentially happen but we’ve never actually seen it. There is no evidence
that this would occur so, in this situation,
if you follow the guidelines and do an excision biopsy and then
later on, according to the depth, deal with the margin so you can be sure that you’re not going to exacerbate
the cancer. So what about the role,
people are saying more and more, you should do a sentinel node biopsy
with melanoma just as you increasingly are doing
with breast cancer just to see whether
there is lymphatic spread. Well, this is a controversial area. It clearly depends on
the whole situation of the patient and there are some people
arguing for it and against it. A lot of the trials that did sentinel
node biopsies were looking at prognosis, they were looking at it
to choose the arm of the study to go in and I think we’re in a period now
where people are trying to determine when to do a sentinel node biopsy. In a very severe melanoma,
a very deep melanoma that’s likely to spread
with a high possibility, the sentinel node biopsy
isn’t going to help at all. So I think we’ve got to refine because we don’t have enough evidence
to tell us precisely when to do this. So this is doing melanoma surgeons
out of business? I mean, if a GP can handle this
quite well in a rural town. A GP can handle this
perfectly adequately. Let me go back to the beginning, though. The important thing not to do here
is to do a punch biopsy, the important thing is to do
the excisional biopsy. Punch biopsies can be
very misrepresentative of the underlying nature
of a melanocytic lesion if they’re not chosen correctly. And a lot of mistakes have been made
that way in punch biopsy and getting a report back
that’s relatively benign and leaving it, and it’s a melanoma. So they have to be excisional biopsies
and this one, a 0.2mm thick melanoma, no-one is going to do
a sentinel lymph node, the chances of that being anywhere near
a sentinel lymph node are exceedingly small
so there’s no need to do that. It’s only when a lesion is 1mm thicker
that you would really consider at least discussing the issue
of sentinel lymph node and referring the patient. If the sentinel lymph node is negative, then certainly
the patient’s prognosis is better and that reassures a lot of patients. The unfortunate thing is,
if the sentinel lymph node is positive, then most surgeons,
the conventional treatment now is to then go and cut out
all the rest of the lymph nodes and there’s no evidence
that that actually improves a patient’s prognosis at all… NORMAN: And then there’s the lymphedema
to be concerned about? Yeah, and they get all the complications
so it’s the following step, knowing the prognosis aspect is good
but going that step further and having all the glands taken out
is the really contentious thing that there’s no good evidence for. And what about adjuvant therapy
in melanoma? Well, we’re at a stage now where there’s no recognised
adjuvant therapy in melanoma outside a clinical trial. For a while, interferon was looked at
but subsequent trials suggest that that wasn’t actually
improving the outcome so we don’t offer adjuvant therapy and I think one of the difficulties is,
up until very recently, we haven’t had much promise
in therapy of widespread disease so we’ve really had nothing that
gives us any encouragement to use in the adjuvant situation. NORMAN: And in widespread disease? In widespread disease, chemotherapy has been
very disappointing. Dacarbizine has been the cornerstone
of it for years, barely a 15% response rate
with little influence on survival, but just recently we’ve started to see
some targeted therapies come through. One is targeted at a mutation
in the BRAF gene that up to about 50% of melanomas have and we’re starting to see response rates
in some small studies of about 70%. Now, we still need to know
how durable they will be… NORMAN: With extended survival? Well, it’s extended survival but we can’t suggest that
that’s anywhere near cure yet because they’re not achieving as many
complete responses as you’d like. And you’re getting
some rather odd side effects – the strangest one,
about a quarter of them are getting squamous cell cancers
of the skin, so that’s a strange one. There’s another antibody, CTLA-4
antibody, that’s directed against an antigen
on a T lymphocyte that’s actually stopping
the immune system from doing its job on the melanoma so if you can block it, maybe the immune
system can take over and, although that’s got
a smaller response rate, that’s where we’re beginning to see
some complete responses that are durable so I think there’s hope that in the next
few years with targeted therapies, we’ll see an advance
in the treatment of widespread disease, which I hope would subsequently
then translate to adjuvant therapy. What’s the chances
he’ll develop a second melanoma, Jeff? Chances are actually relatively high and the studies are showing that
a patient who’s had a primary melanoma has a 5% – 10% chance at least
of another melanoma in the following four to five years. This is actually one of the main reasons
for us to follow up these patients, is to detect
their next primary melanoma earlier. NORMAN: Do you photograph them
top to toe, do you? It depends on the patient. Total body photography,
which is what you are referring to, is extremely useful for people
with multiple naevi so lots and lots of moles, some of which
may or may not look abnormal, and you’re having trouble tracking them. It’s worthwhile doing
a total body photography to look for new or changed moles
and, remember, only about 20% of melanomas
in patients with multiple moles will actually come
from a pre-existing naevus. The rest will come out of the blue which is why the total body photography
will help you spot that new naevus for a closer look
with a dermascope. You can also image things
dermascopically serially for patients
who have just had the sun damage and they’ve got the isolated sun damage
lesion there that’s been removed, then total body photography’s
not really going to help because there’s nothing to photograph but the follow-up
will pick up that next lesion. Let’s go to Frederick who’s aged 73. He’s an outdoor person, farms,
he’s a fisherman, he’s got a lower leg lesion which
he’s noticed has bled from time to time, he just thought
he’d knocked it in the paddock when he came to see you, Jan,
in your clinic because he couldn’t get in
to see the doctor as he has a three-month waiting list. Let’s have a look. JAN: Ah, well, this is a nice…
No, I won’t say that. It’s a red lump. (Laughter) NORMAN: Looks pretty yucky,
to be honest. JAN: Yes, but it’s elevated and
it’s firm and it may well be growing. A lesion like that,
I would consider it suspicious. NORMAN: Of what? JAN: Well, I guess I know the slide
but it’s amelanotic melanoma, so it would be demonstrating
a rapid growth rate, I would imagine. NORMAN: Jeff? JEFF: Well, absolutely, this is
what I call in Latin a Lumpus pinkus and there’s a fairly wide range
of things it could be, most of them are quite nasty. And amelanotic melanoma
is top of the list, and thick melanomas, nodular melanomas,
are killers of elderly people. And quite often they present like this. The other things that can look like this
that can also be nasty are things such as Merkel cell carcinoma or atypical fibroxanthoma and poorly differentiated
squamous cell cancers. So if you’re seeing a pink growing lump and you’re not sure
that it’s clearly benign, you’ve got to remove it. NORMAN: So, Ian McColl,
an excision biopsy here? IAN McCOLL: Yeah, an excision biopsy. Now, we’ve talked about ABCD and then
EFG – elevated, firm and growing – and certainly all these conditions
that Jeff’s mentioned, you really can’t tell clinically
and you’ve got to do an excision biopsy. NORMAN: So this is a dermascopic view?
IAN McCOLL: Yeah. JEFF: And it doesn’t help at all, it’s elevated, firm,
it’s a clinical diagnosis. – So he had a Breslow of 4mm thickness.
JEFF: That’s correct, yes. So that’s serious stuff? It is serious stuff, his five-year survival rate
is probably 50-60% range with this and we’re keeping a close eye on him. Right. Let’s go to Brenda who’s 56, she presents with a lesion that’s not responding to treatment for dermatitis, it’s been treated
over the last six or so months with antifungals
and topical corticosteroids but not getting any response and she’s come to see you, Jeff, because she’s concerned. Let’s have a look. JEFF: Again, this is another one
of those isolated, pink, scaly patches that causes so much consternation whether it’s actually
a patch of dermatitis or tinea or is it a skin cancer? And this particular one
was quite cryptic, it really wasn’t clear clinically
what it was but it was certainly clear
it wasn’t responding to presumptive treatments
that were given to it. Again your alarm bells should be ringing
that this could be a skin cancer, anything from a superficial BCC
or superficial squamous cell cancer to amelanotic melanoma and in fact, this was biopsied to see
which one of those it was and… NORMAN: So we’ve got a close-up here? JEFF: We have.
NORMAN: So this is the dermoscopy? JEFF: That’s right
and you can see clues to the fact this was in fact amelanocytic lesion and we’ve got what are called
dot vessels. They’re like the glomerular vessels, the little coiled vessels you see in intraepidermal carcinoma
and psoriasis but they’re much smaller so they look like dots and also what we call
linea irregular vessels. So it’s got multiple vessels. NORMAN: The clear things or dark things? JEFF: The dots are
the little dark red spots or dark pink spots in the white there within that circle, they are the dotted vessels and it’s a subtle clue, I’ll give you, this is quite a subtle lesion… NORMAN: To my little eye, this doesn’t look too different from that BCC we saw at the beginning? JEFF: For all practical purposes,
it doesn’t matter. It’s been identified it’s malignant and a biopsy will then end up telling you exactly… NORMAN: Except you told me to do
a punch biopsy in BCC and I’ve just been told not to do
a punch biopsy when you think it’s melanoma. So what do I do, Doctor? JEFF: Absolutely, and I think
it’s very, very difficult to be sure that this is going to be a melanoma. If you’re not very dermascopically
skilled, and these are subtle lesions and these vessel types have only been
recently described, so we certainly wouldn’t expect everyone
to pick that as a melanoma with a dermascope without a bit of extra training but
clinically you really should be thinking that it is a skin cancer
and you should be looking to biopsy it. NORMAN: Right, but Ian, you’re… IAN McCOLL: This is different, though, this isn’t a pigmented lesion,
this is a non-pigmented lesion and most times when you see a lesion
like this and you biopsy it, it’s going to be a superficial BCC
or it’s going to be an SCC in situ… NORMAN: So you do several
punch biopsies here? Yes, but even just one in this is still likely to show you that it’s
not the BCC or SCC you were thinking. The pathologist will say… NORMAN: So what do you do if the
pathologist comes back and says, ‘No, didn’t find anything,’ and you were really worried about it
when you looked at it? Generally, you’d re-biopsy it again or you’d ask the pathologist to do
some more cuts in it, it depends what sort of biopsy
you send down. If you send a biggish piece of tissue, when a pathologist looks at specimens
in a biggish bit, he may only be taking three or four cuts
through it, you know, bread loaf
cuts through an area, so you ask them to do some more cuts
and have a look further down. NORMAN: So you trust your clinical
judgement. Yeah, you always back your clinical
judgement against a pathologist anyway. Now we’ve got Darlene
who’s 45 years old. She’s a netballer,
lives on a rural property, she didn’t notice this lesion
on her left arm but Jeff did. Let’s have a look at it. Jeff? JEFF: Again,
this is one of those lesions which is not very impressive clinically
on the long view. It is isolated and it’s one
of these things that argues that you really should put
your dermascope on as many lesions as possible. But certainly to the naked eye
from here, it doesn’t fulfil many of the criteria
of the ABCD that we used to make us think
of melanoma. If you look at it a little more closer
up on another image here… NORMAN: Still with the naked eye?
JEFF: With a naked eye, that’s right. What you can see
is a little bit of irregularity, asymmetrical and border patterns, it’s not greater than 6mm. Now, what is striking is
it’s got an area of pink in the middle of this brown lesion so you really need to put a dermascope
on this and have a closer look and see
whether you can convince yourself that this needs to come off. NORMAN: Let’s have a look. JEFF: And if we look at this, what we’re
seeing is a lesion around about five… NORMAN: Did it feel raised to the touch? JEFF: No, it was absolutely impalpable
to touch but if you looked at it, you can see
that there’s a lot of irregularity in the way that pigment is distributed
in the lesion. It’s all clumped into funny patterns
around the edges and on an even closer view, you’re actually able to see
some of the abnormal area where we’ve got no pigment at all,
it looks a bit pinker with these, what we call corkscrew vessels. Now, vessels, as you can gather, in skin lesions
that have no colour in them, blood vessels are your only clue and it’s important when you do take up
dermoscopy to educate yourself about these and so, this particular lesion was considered
as being suspicious for melanoma. It had atypical network,
it had the structureless area which was a little bit eccentrically
placed with the abnormal vessels so it was taken out and sent along
to the pathologist. NORMAN: And what did they find? The pathologist’s initial report was
that this was a benign compound naevus, which was really quite discordant with what we thought it was
dermascopically, and so because of the discordance, we called the pathologist
and asked them to take more sections. It was actually proven to be,
on the further sections, a fairly obvious invasive melanoma
about 0.35mm Breslow, still early, still thin but that could
have gone through to the keeper. And what we find is extremely useful is for any pigmented lesion
that you remove, is to photograph it. It’s useful for yourself, it’s useful
for your pathology reconciliation and it’s useful for your referrals
if you have to refer a patient on. We’ve only got a couple of minutes left
but I think we can’t leave the program without talking about dysplastic naevis
where GPs feel the most nervous. Are they missing something
or aren’t they? Let’s whizz through a few pictures and just talk through them as we go.
Jeff? JEFF: Well, this gentleman
has obviously got multiple naevi and these patients can be a real
destroyer of your appointment schedule with the number of lesions
that need to be looked at and this patient is a great candidate
for total body photography of which this is an image. You’d look at comparing this kind of
picture for images down the line, perhaps a year later
or six months later. The patient can also do examinations
with a partner, matching up the photograph
they have in their hand with what the partner can see
on the photograph. NORMAN: Could reinvigorate
their relationship. JEFF: Indeed, if you put numbers
against each particular… NORMAN: So let’s look at the picture,
is this eye or dermoscopy? This is dermoscopy. So again, first sight,
is this that different from a melanoma? I’m seeing clear bits in the middle,
I’m seeing uneven pigmentation, I’d be getting the shivers down my spine
that this is a melanoma. Well, this is one of the problems
with dysplastic or atypical naevi, that they do somewhat look like that
but the thing is, if one of them looked like that
then all the other naevi were different, you know, looked benign,
then you would go for this but the problem here
is a lot of them will look like this but that’s also a good sign
because they’re not all melanomas. This is just the pattern
that this particular patient has for the dermoscopy of their naevi. And again, that’s not too chaotic
but you’ll get to a certain one later… NORMAN: So it’s got a smooth edge to it. IAN McCOLL: Again, this particular one, it’s within the pattern
of the other naevi that this patient in fact had but sometimes you’ll come on one
that is very, very chaotic in comparison to any of the others or it has some of the dermatoscopic
features of melanoma that Jeff was talking about… NORMAN: So all these
are dysplastic naevi? IAN McCOLL: All of these are dysplastic
naevi, the dermoscopy of them. This is another patient. Now, those are two big lesions
that you’d certainly be concerned about. But the patient had said that
these had been stable for years, they hadn’t changed. You, in fact, photograph them
and the next time you see him back, you look at them again and you keep looking at them and just
because these are very big lesions doesn’t necessarily mean
that they’re melanomas, they’re not. That was that particular patient there
with these two big lesions on the side. So photography is useful in following
these up but as Jeff said earlier on, the thing about dysplastic naevi is that often the melanoma doesn’t arise
from the dysplastic naevus, it’s a new pigmented lesion that’s come
up. That’s what you’re looking for. NORMAN: But in a patient
who’s had dysplastic naevi, so their skin is primed, if you like? JEFF: You’re looking for both.
– I agree. You’re looking for both. So what are your take-home messages?
Jan? I think for good patient outcomes, it is that, cultivate an educated,
multidisciplinary team. NORMAN: So get your nurses involved
and have a friendly pathologist. And keep the education up,
keep it going. NORMAN: Ian Olver? Well, my primary message is prevention. It’s so simple to cover yourself up
and use sunscreen during the summer. My other message though is get to know
what your skin looks like and anything that you’re worried about
that’s changed, seek advice without delay. NORMAN: Ian McColl? The people who are dying
are often the elderly males who have things arising on their back so my take-home message
would be to ask yourself, who’s looking at my back? NORMAN: Hmm. Jeff? In primary care,
I’d say get yourself one of these, get your patient undressed
down to their underwear, get some basic surgical skills and you’ll be able to take care
of the bulk of the skin cancers that walk through your door. Thank you very much to you all,
great program and I hope you’ve enjoyed it too. Our thanks to the Department Of Health
And Ageing for making it possible, thanks to you for taking time
to attend and contribute. If you’re interested in obtaining more
information about the issues raised, there are a number of resources
available on the Rural Health Education
Foundation’s website – www.rhef.com.au. Don’t forget to complete
and send in your evaluation forms to register for CPD points. I’m Norman Swan, I’ll see you next time�

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