British Journal of Plastic Surgery (1976), 29, 61-67

Transcription

1 British Journal of Plastic Surgery (1976), 29, SKIN CANCER IN SUNNY QUEENSLAND By TREVOR J. HARRIS, F.R.C.S.(Glasg.), F.R.A.C.S. Plastic Surgical Department, Royal Brisbane Hospital, Queensland, Australia "SUNNY" Queensland has the highest recorded incidence of skin cancer in the world. The fair, blond skin of most of the population, inherited from their North European Celtic forebears, is ill-adapted to withstand the annual 2,5o0 to 3,00o hours of subtropical sunshine with its high content of ultraviolet radiation. Increasing leisure and the cult of spending it nearly nude in the brilliant sunshine is reflected in a still increasing yearly incidence. In 7 years I have excised 6,615 lesions believed to be skin cancers from 2,420 patients. Previous surgical series have been published and a comparison of the figures and time intervals provides further evidence of the magnitude of the problem in Queensland. Some represent the work of several surgeons: Churchill-Davidson and Johnson (1954) (St Thomas Hospital, London, England), 12 years, 613 patients, 711 lesions. Hayes (1962) (East Grinstead, England), 20 years, 477 patients, 5o6 lesions. Monballiu (1968) (Nottingham, England), 6 years, 478 patients, 633 lesions. Shanoff et al. (1967) (Houston, USA), 15 years, 625 patients, 1,168 lesions. Rank and Wakefield (1958) (Melbourne, Australia), io years, 425 patients, 514 lesions. Gibson (1968) (Sydney, Australia), 14 years, 6,854 lesions. Number of patients unspecified. While many aspects of these cases and their care in Queensland is similar to those of skin cancer elsewhere in the world, they present some novel features. Multiplicity of lesions. Only 47 per cent presented with a single skin cancer. Of the others, 42 per cent had 2 to 5, 8"45 per cent had I I to 20, o-i per cent (12 patients) had 21 to 50. These numbers are only those lesions excised at a single operation. The total removed from any individual patient over a period may be many times greater. One, commencing at the age of 27, has had more than 15o lesions excised in 4 years; another from the age of 18 has had 84 basal cell carcinomas removed in 5 years. There are often multiple types of skin lesions in the same patient. Basal cell carcinoma may be found adjacent to intra-epidermal carcinomas, frankly invasive carcinoma, or malignant melanoma. It seems reasonable to assume therefore that the same aetiological factors are at work. The highest figure for patients with multiple skin cancers previously published was 34"8 per cent (Shanoff et al., 1967). Age and sex. The age distribution is shown for males (70 per cent) and females (30 per cent) in Figure I. More lesions occur after 40 but there are still many in the under 40 age-group and even in the under 20 age-group (Fig. 2). Although there are many fallacies in comparing personal series it should be noted thatthe incidence of 70 per cent in males is higher than in most other series (e.g. Monballiu, 1968, 55 per cent; Gordon et al., 1972, 60 per cent). 61

2 6~ BRITISH JOURNAL OF PLASTIC SURGERY 400 -[ Male 70% Female 30% " "~ z FIG. I. Age A Age distribution in males and females for all lesions removed. Clinical and histological types. All lesions were believed to be malignant when excised. It was inevitable that a few should prove histologically to be simple. The percentages of the various kinds were: Basal cell carcinoma 58 Squamous cell carcinoma 23 Keratoacanthomas 0. 7 Basi-squamous carcinomas i. 3 Hyperkeratoses I2 Malignant melanomas 0" 7

3 S K I N CANCER IN S U N N Y Q U E E N S L A N D FIG " T y p i c a l " cystic basal cell carcinoma on the lower eyelid o f a I6-year-old girl. FIG. 3. " T y p i c a l " papulo-pearly type o f basal cell carcinoma o n the left temple of a 5o-year-old woman. FIG. 4. Cicatrical type basal cell carcinoma with an active growing edge on the sternal region o f a 45year-old man. This type may present as an ectropion o f the lower eyelid.

4 64 BRITISH JOURNAL OF PLASTIC SURGERY FIG. 5. Pigmented basal cell carcinoma on the chin of a 5z-year-old man. The longer history is usually sufficient to distinguish it from malignant melanoma. FIG. 6. Giant basal cell carcinomas on the trunk of a 46-year-old bank clerk. The lesion overlying the clavicle showed basi-squamous change, and later metastasised to the left axilla as a squamous carcinoma. The other lesions were pure basal cell carcinomas. Miscellaneous, simple or premalignant lesions 1.9 Histology unknown 2"4 Basal cell carcinomas. Many basal cell carcinomas appear atypical in the sense that they do not fit the classical textbook descriptions of the cystic type or the rolled pearly edged ulcer (Figs. 2 and 3). Some of the other commoner varieties are shown in Figures 4 to 7. In addition, there are varieties difficult to see or photograph: the sclerosing type more palpable than visible and the dangerous subcutaneous type. The latter sometimes occurs following radiotherapy when the skin has healed on the surface but the extension of the tumour proceeds unchecked underneath and may infiltrate along such neural pathways as the infra-orbital or mental nerves. It may also present de novo with what may appear to be a punctum resembling that of a sebaceous cyst and a large subcutaneous lump beneath. Squamous cell carcinomas. The majority of these were of the well-differentiated, not-too-aggressive type and only 12 of them produced metastases in the regional lymph nodes. Carcinomas of the lip arising on the vermilion are not included in this series. Keratoacanthomas. This diagnosis was only made histologically. I believe that it is a dangerous diagnosis in a climate where skin cancer is so common, and I treat them as if they were well-differentiated carcinomas without delay to see if they will regress. Basi-squamous carcinomas. Although there is some doubt about the exact nature of squamous cell changes in basal cell lesions there is no doubt that it occurs, particularly in long-standing cases, and may increase the malignancy of the lesion (Murphy, 1975) (Fig. 6). Hyperkeratoses. Operation was not carried out for these alone but if noticed when other lesions were excised, they were removed. Malignant melanoma. Because of the existence of the Queensland Melanoma

5 SKIN CANCER IN SUNNY QUEENSLAND 6 5 Project to which nearly all cases are referred, very few were seen personally. In fact Queensland has one of the highest incidences of malignant melanoma in the world. Site. Most skin cancers of the face requiring excision are referred to a plastic surgeon akhough many elsewhere on the body are removed by other specialists. Seventy-eight per cent of all lesions in this series occurred on the head and neck. The incidence of basal cell carcinomas and squamous cell carcinomas shown in Figure 8 are therefore probably exact. The classical dogma that basal cell carcinomas only occur above a line joining the lobe of the ear to the angle of the mouth is obviously quite untrue. Treatment. The incidence of basal cell carcinomas in Queensland is so high that there are insufficient surgeons and theatre time available for all of them to be excised. All new cases are therefore first referred to the Dermatology Clinic where they are sorted; some are treated by dermatological applications, some are referred for radiotherapy and some are sent for operation. New cases of squamous cell carcinomas are preferably excised and certainly if there are metastases; malignant melanomas are of course also excised. FIG. 7. Multiple giant basal cell carcinomas of the head and neck. Similar lesions covered the other side of his face and his trunk, except for the area covered by shorts. Aged 45, his early life had been spent as a professional fisherman. He died from extension of basal cell carcinoma along both ear canals and eroding the temporal bones. 29/I--E

6 66 BRITISH JOURNAL OF PLASTIC SURGERY There is a large pool of patients who, over the years before the present system of management was instituted, have been treated and followed up by the radiotherapy department. In these cases, if recurrence or new lesions which are not considered suitable for radiotherapy present, then they are referred to the surgeon. Surgery therefore has to deal not only with fresh lesions but with recurrences after irradiation and irradiation necrosis. About 7 per cent of the lesions in this series were small enough to allow the wound to be sutured directly after excision. In the remainder the defect was closed by the appropriate free graft or flap. The only point of difference from the surgery of skin cancer in areas with lesser incidences is that it is often wise to excise the whole of the skin of a facial unit such as the nose or forehead, rather than remove separately several lesions. Results of surgery. There is no doubt that surgery gives better cosmetic results than radiotherapy. Surgical scars improve with time, while irradiated areas deteriorate and may finally produce a secondary cancer. In addition, basal cell carcinomas recurring after radiotherapy have a more sinister reputation than those treated by surgery only (Binns and Sheriff, I975). Because of the multifocal nature of the disease, it is not possible to give figures for "recurrences". In most instances it is impossible to distinguish a recurrence of an old lesion from a fresh primary. DISCUSSION It was estimated by Carmichael and Silverstone in I96I that the proportion of males between 2o and 8o years of age, who might be expected to produce at least r skin cancer or have a history of r lesion, varied from about 6 per cent in the subtropical areas around Brisbane to about I3 per cent in the tropical North Queensland, some I,OOO miles nearer the equator. Rates for females were about half of those for males. A similar study today would produce still higher figures. Although there is a growing awareness of the relationship between sunlight and skin cancer the position is analogous to that of smoking and the lung cancer which might develop many years in the future, and bodies are still bared to the sun on every FIG. 8. A, Site distribution of basal cell carcinomas on the head and neck. Each dot represents 5 lesions. B, Site distribution of squamous cell carcinomas on the head and neck. Each x represents 5

7 SKIN CANCER IN SUNNY QUEENSLAND 6 7 beach in Queensland. But sunbathing is only one factor; daily exposure during routine occupations is probably more significant and the appearance of skin lesions on teenagers (Fig. 2) suggests that prophylactic screening should begin in infancy and much more care taken during school days. SUMMARY The incidence of skin cancer in Queensland, Australia, is the highest in the world. More than half the patients have more than one lesion when first seen and many continue to produce new cancers throughout their life. The cause is almost certainly exposure to subtropical and tropical sunlight for which their fair skins were never intended. I am grateful to Dr Bruce Cottee for his help with'the statistical details. REFERENCES BINNS, J. H. and SHERIFF, H. M. (I975). Low incidence of recurrence in excised but non-irradiated basal cell carcinomas. British Journal of Plastic Surgery, 28 (in press). CHURCHILL-DAvIDSON, I. and JOHNSON, E. (I954). British Medical Journal, I, I465. GIBSON, E. ~7. (I968). Malignant turnouts of the skin. In "Plastic Surgery", p. 577, edited by Grabb, ~g. C. and Smith, J. Vd. Boston: Little Brown and Company. GOgDON, D., SILVERSTONE, H. and SMITHURST, B. A. (I972). The epidemiology of skin cancer in Australia. "Proceedings of the International Cancer Conference, N.S.V.", p. 23. Sydney: Government Printer. HAYES, H. (I962). Basal cell carcinoma of the head and neck--the East Grinstead experience. Plastic and Reconstructive Surgery, 30, 273. MONBALLIU, G. (I968). Basal cell carcinomata of the head and neck. British Journal of Plastic Surgery, zr, 200. Mum'Hx', K. J. (I975). Metastatic basal-cell carcinoma with squamous appearances in the naevoid basal-cell carcinoma syndrome. British Journal of Plastic Surgery, z8 (in press). RA_N~, B. K. and WAKEFIELD, A. R. (I958). Surgery of basal cell carcinoma. British Journal of Surgery, 45, 53I. SHANOFF, L. B., SPIgA, M. and HARDY, S. B. (r967). Basal cell carcinoma: a statistical approach to rational management. Plastic and Reconstructive Surgery, 39, 619. Address for reprints: Dr Trevor J. Harris, Morris Towers, I49 Wickham Terrace, Brisbane, Australia.