Skin Cancer A Personal Approach Dr Matthew Strack Dunedin New Zealand
Outline Dermoscopy Instruments and setup Photochemosurgery Clinical Aim: Leave with 2-3 ideas
JLE
Benign Junctional Nevus
Management Resect Reassure Refer Rebook
My struggle with Dermoscopy The Scream Edvard Munch 1895
Terms Dermatoscopy Epiluminescent Microscopy Skin Surface Microscopy Dermoscopy
Dermoscopy - Brilliant for: Small Angiomas Seborrhoeic Keratosies
Dermatologists: In total, 4691 lesions were examined. The overall mean NNT was 6.3, with a range of 4.9-11.3 for each of nine consultant dermatologists. The mean NNT was 7.6 for female and 4.8 for male patients. Clin Exp Dermatol. 2012 Jan;37(1):6-9. doi: 10.1111/j.1365-2230.2011.04148.x. Epub 2011 Oct 7. The number of benign moles excised for each malignant melanoma: the number needed to treat. Sidhu S, Bodger O, Williams N, Roberts DL.
Benign Nevus: Melanoma Excision Ratios by Time NSCS = Non Specialized Skin Clinic SCS = Specialized Skin Clinic Accuracy in melanoma detection: A 10-year multicenter survey Giuseppe Argenziano, MD et al, Journal of the American academy of Dermatology, 2011.07.019
General Practice, New Zealand All excisions, semirural practice, 3 year period B Wood, NZFP, 2006;v6, n4, pp256-8
jrm
Melanoma in situ
Dysplastic nevus
92y M
Biopsies Lower: Pigmented Keratosis Upper: BCC
Algorithms You see but you do not observe
ABCD rule Stolz method Criteria Asymmetry In perpendicular axes: contour, colours and structures Borders 8 segments: abrupt ending of pigment pattern Colours White, red, light-brown (tan), dark-brown, blue-grey, black Score X Factor = Results 0-2 1.3 0-2.6 0-8 0.1 0-0.8 1-6 0.5 0.5-3.0 Differential structural components 1-5 0.5 0.5-2.5 Total score Benign <4.76 Suspicious 4.76-5.45 Melanoma >5.45
Blum's modified ABC-point list A B C D E lesion asymmetry of outer shape or differential structures inside the in at least 1 axis the abrupt cutoff of network at the border in at least one quarter of circumference 3 or more colors 3 or more differential structures noticed change (evolution) in the last 3 months
Menzies method Negative features (benign lesions): Symmetrical pattern (colours, structure) Single colour Positive features (melanoma): Blue-white veil Multiple brown dots Pseudopods Radial streaming Scar-like depigmentation Multiple (5-6) colours Multiple blue/grey dots Broadened network
Seven-point rule Three or more indicates melanoma Atypical pigment network (2) Blue-whitish veil (2) Atypical vascular pattern (2) Irregular streaks (1) Irregular dots/globules (1) Irregular blotches (1) Regression structures (1)
ABCD
Did you look twice?
More Cases
RMS
jcd
HB
PJM
MAP
Pigmented Lesion Assessment
Pigmented Lesion Assessment
The Dance of Life Aasgardstrand
1:5-10
Lesion was benign Seborrhoeic Keratosis
91y M
Melanoma In-Situ 0.6mm Diagnosis
73y M My Diagnosis: Seborrhoeic Keratosis Benign Solar Lentigo
Instruments
Blades
Sutures Ask for free samples!
Curettage Relies on physical differences between affected and normal tissue Diathermy - hemostasis Useful for BCC Histology will report incomplete removal
Lighting
Eyewear Try before you buy!
Local Anaesthetic 2.2ml cartridge 27g 22g 18g
Most important things: Use enough Time Reassurance
Photography
Consent Lighting System
Examinaton
Examination
Photochemosurgery for Basal Cell Carcinoma
Photodynamic Therapy
d
BCC, pre Photochemosurgery
Post Photochemosurgery
Basal Cell Carcinoma Commonest Skin Cancer Rarely Life Threatening Treatment ranges from easy to very challenging Many treatment options
Treatment Options Surgery Excison Curetage Mohs Radiotherapy Photochemosurgery (Photodynamic Therapy) Topical No Treatment rare
Waxy with capillaries
BCC
BCC post Imiquimod
Bowen s Disease Squamous Cell Carcinoma in Situ Prognosis unclear? 10% progress to SCC Main Treatment Options: Cryotherapy Topical 5 Flourouracil Scaring may be due to lesion not treatment
Post 5FU
Cutaneous Horn?Cause Often Painful
What I think of:
What s Under a Cutaneous Horn Solar Keratosis Basal Cell Carcinoma Squamous Cell Carcinoma This Case Nonspecific Change
BCC
Subungual Pigmented Lesions
Lab Write brief details of history Diagnosis Differential Diagnosis Consider ringing pathologist Consider second opinion
Trapdoor Problem with a Flap 94y F, result painful and not happy with appearance
Squamous Cell Carcionma
84y F Summer Winter
Actinic Chelitis High risk for SCC Topical treatment OK Follow up mandatory
94y M, confused
66y M, change over 2 months
Wart, present 6/12
Wart GP x1 first seen >1y ago Nurse x2 Podiatrist x1
Take Home Messages #1 Have equipment you enjoy using Get chaperone consent in writing When in doubt refer but you can sometimes reassess Biopsies are your friend If you don t have loupes get some on loan Have your eyes checked
Take Home Messages #2 Consider Polarizing Dermoscope Printed Handouts Last Point: call me Follow up Surgery incl Sutures Cryotherapy