Oncology Week 11: Skin Cancer PDF

**ONCOLOGY WEEK 11: SKIN CANCER** Close-up of a skin with a red blister Description automatically generated    A close-up of a sore Description automatically genera...

**ONCOLOGY WEEK 11: SKIN CANCER** Close-up of a skin with a red blister Description automatically generated    A close-up of a sore Description automatically generated  **What is Skin Cancer?** - Skin cancer refers to any cancer that starts in your skin. This can happen anywhere on your skin, including the palm of your hands, sole of your feet, and even your scalp. Skin cancer is also able to metastasize, spreading to nearby tissues and organs as the disease advances. - Melanoma often starts in genital region - Often starts in the labia major and minora - A lot of skin cancer missed since they happen on the back or scalp - Will spread to lymphatics or bloodstream\* **Melanin** - Eumelanin -- gives rise to a range of brown skin tones as well as black, brown, and blonde hair - Pheomelanin -- causes reddish browns of freckles and red hair **Vitamin D** - Comes from UV - Strengthens bones and helps absorb minerals - Lack of Vit D causes Rickets **Facts** - 1 in every 3 cancers diagnosed worldwide is skin cancer with 80-90% of it being caused by UV radiation - Canadians born in the 1990s have a 2-3x higher risk of getting skin cancer in their lifetimes ( 1 in 6) compared to those in the 1960s (1 in 20) - There are more new cases of skin cancer each year than the number of breast, prostate, lung and colon cancers combined  - Most skin cancer is in Australia - MELANOMA NUMBERS ARE DECREASING IN CANADA **Prevention** - Cover up- when the UV index is 3 or higher, protect your skin as much as possible  - Light coloured, long sleeved shirts pants and a wide brimmed hat from breathable fabric  - Sunglasses- ensure they have protection against both UVA and UVB rays  - Limit time in the sun  - UV index is generally 3 or higher between 11am to 3pm so the suggestion is to stay out of the sun during these periods of times  - If your shadow is shorter than you than the sun Is very strong at that time  - Find places with shade, bring an umbrella to the beach  - Use sunscreen  - Put sunscreen on when the UV index is 3 or higher - Use sunscreen that has the label broad spectrum and water resistant with an SPA of at least 30 - Regularly reapply it every 2-3 hours  - Don't use tanning equipment  - There is no such thing as a healthy tan- it all increases your risk for skin cancer  **Risk Factors** - Fair skinned complexion -- people have less melanin in their skin and have less defense against the UV rays  - Increased number of moles- the risk of developing skin cancer is greater for people who have 50 or more moles  - Tanning bed use- Fact; people are more likely to develop skin cancer from using a tanning bed than developing lung cancer from smoking  - Family history; having a family member who has had skin cancer increases your risk of developing skin cancer; especially if it's a first degree relative (Canadian Skin Cancer Foundation)  - History of sunburn -- those who have had one or more severe, blistering sunburns as a child or teenager are more at risk of developing melanoma. Sunburns in adulthood are also at risk for melanoma  - History of skin Cancer: once you've had skin cancer you are at an increased risk of developing more skin cancers in other places **Screening People of Colour** - Dark spot, growth, or darker patch of skin that is growing, bleeding, or changing in any way - Sore that won't heal --- or heals and returns - Sore that has a hard time healing, especially if the sore appears in a scar or on skin that was injured in the past - Patch of skin that feels rough and dry - Dark line underneath or around a fingernail or toenail - Make sure to examine places that get little sun- such as the bottoms of your feet, toenails, lower legs, groins and buttocks -- even inside the mouth!  ***[New spots or moles that itch, bleed, or change color must be investigated as they are often early warning signs of skin cancer]*** **[Melanoma is more about DNA changes than sunlight!]** **[Whenever you see a dark, demarcated line on the nail, this needs to be looked at right away as this is a very aggressive form of skin cancer in the family of melanomas]** ***[Anything that is non-healing and continues to scab and then bleed is a big red flag and needs to be checked immediately]*** **Types of Skin Cancer** - Basal Cell Carcinoma - Squamous Cell Carcinoma - Melanoma - Merkel Cell Carcinoma **Self-Assessment** Basal Cell - Dome shaped growth - Shiny pinkish area - Black or brown growth - Sore that heals and returns Squamous Cell - Crusted or rough bump - Red, rough flat area - Dome shaped bump that grows and bleeds - Sore that doesn't heal **Precancerous Lesions** [Actinic keratosis ] - Presents as red patches of scaly, poorly demarcated skin - Predominantly on sun exposed lesions - Usually in middle aged people - Can be singular or multiple (most times multiple little ones) - Can be precancerous or not [Bowens disease] - Well demarcated plaques with surface crusting & scaling  - Usually solitary lesions (single) - Well demarcated outlines - Affected area looks swollen and elevated ***Basal Cell Carcinoma *** - Basal cell carcinoma (BCC) is a common skin cancer arising from the basal layer of epidermis and its appendages - Accounts for approx. 80% of skin cancers - Locally invasive, aggressive, and destructive of skin and the surrounding structures, including bone - Approx. 70 % of BCCs occur on the face &  15 % present on the trunk [Nodular BCC] - Around 80% of cases - Typically present on the face as pink or flesh coloured papule - The lesion typically has a pearl like quality - It may have a rolled border, with edges higher than centre - Ulceration is frequently seen - Blood vessels cross over the centre - **The hallmark for the nodular is that it is raised up on the perimeter, but the center is depressed and ulcerated** - **Will not turn black in colour!** [Superficial BCC] - Accounts for approx. 15% of cases - Higher incidence in men than women - Most common type in young adults - Most seen on the trunk - Presents as scaly  non-firm macules, patches or thin plaques. - Occ. there can be a spotty brown or black pigment is present which can lead to confusion with melanoma - Grow slowly and can vary in size from a few millimeters to a few centimeters. *[Morphoeic BCC]* - Accounts for approx 5-10% of BCC  - Typically smooth, flat, flesh coloured or very light pink - Firm or **indurated** quality with ill defined borders - Very hard to identify ***Squamous Cell Carcinoma *** - Second most common type of skin cancer - Starts in the epidermis -- if left untreated will penetrate the underlying tissue  - Found in areas most often exposed to UV rays  - Face, neck, scalp, hands, shoulders, arms & back  - Often looks like a wart growth -- can crust & will bleed  - Persistent red patch with uneven irregular borders  - Open sore that can persist for weeks  - Elevated growth that rapidly increases in size  - Easily treated when detected early but can easily spread to other parts of the body  - Will crust and bleed even if you don't pick  NO LONGER USED SINCE PEOPLE HAVE DIFFERENT SIZED DERMIS\^  **Malignant Melanoma** - Most serious type of cancer- aggressive neoplasm - Responsible for the most deaths  - Develops from the same cells that creates moles  - Where does it occur? - most commonly appears on the back and legs- but can appear anywhere apart from the mouth and eyes -- even areas not really exposed to the sun  - Deadliest form of skin cancer but when discovered early the 5-year survival rate is 99%  - What does it look like? - Can develop from a pre-existing mole  - Can also appear as a new irregular spot on the skin  - Start as superficial indolent tumour that are confined to the epidermis where they reside for several years  A picture containing application Description automatically generated Stage 0- surface level Stage 4- organs **[ABCDE]** - For melanoma specifically, a simple way to remember the warning signs is to remember the A-B-C-D-Es of melanoma--- - **Asymmetrical:** Does the mole or spot have an irregular shape with two parts that look very different? - **Border:** Is the border irregular or jagged? - **Color:** Is the color uneven? - **Diameter:** Is the mole or spot larger than the size of a pea? - **Evolving:** Has the mole or spot changed during the past few weeks or months? ***[Mainly, however, melanoma loves to go to the brain!]*** **Breast --** likes the bones but can also go to liver and lung **Lung --** likes the brain and bones **CRC --** likes the liver **Ovarian --** likes the lungs and liver **Further Tests to Diagnose Squamous Cell Carcinoma** - CT scan - X-Ray - PET scan  - Injected with a form of radioactive glucose- the scanner follows the glucose within the body to see where its being used up -- malignant tumour cells light up more because they take up more glucose  - Ultrasound exam  - Eye exam (spread to brain) - Sentential Lymph node biopsy (hot and blue) **Treatment** - Skin [biopsy ](https://www.youtube.com/watch?v=450035zqinA) - all or a part of the abnormal growth is punched out using a special tool and it is sent for pathology  - 4 main types of biopsy\'s  - Shave biopsy- sterile razor "shaves" off the growth  - Punch Biopsy- special instrument takes out a punch and takes out a circle from the skin  - Incisional biopsy- Scalpel is used to remove part of the growth  - Excisional biopsy- scalpel is used to remove the full growth  **\ Treatment for Basal Cell** - [Simple excision]: Tumour & normal tissue are cut away from the skin  - **[Mohs Surgery]: The tumour is cut away layer by layer. During the surgery the tumour and edges of the tumour are placed under a microscope  to check for cancer cells (BEST)** - [Curretage:] Tumour is cut from the skin with a curette a needle shaped electrode is then used to treat the are with an electric current is used to stop the bleeding and destroy any remaining cancer cells (Can be repeated 1-3 times)  - [Cryosurgery]: a treatment that uses an instrument to freeze & destroy abnormal tissue (only for very superficial cancers)  **Treatment for Actinic Keratosis** - **Shave excision: Abnormal area is shaved off the skin with a small blade (BEST)** - Laser Surgery: Surgical procedure that uses a laser beam as a knife to make bloodless cuts in tissue to remove a surface lesion such as a tumour - Dermabrasion: Removal of the top layer of skin using a rotating wheel to rub away skin cells **Other Treatment Options** - Radiation therapy - only used for basal cell carcinoma and squamous cell carcinoma of the skin  - Topical fluouracil - topical chemotherapy that is used to treat basal cell carcinoma - Photodynamic therapy- cancer treatment that uses a drug and a certain type of light to kill cancer. A drug that is not active until it is exposed to light and injected into a vein or put onto the skin. The drug itself collect more in cancer cells than it does normal cells. The light is then shined onto the skin allowing the drug to become active and kills the cancer cells -- used to treat actinic keratinosis  - Immunotherapy - a treatment that uses that patient\'s immune system to fight cancer -- form of biologic therapy. Cemiplimab & pembrolizumab are PD-1 inhibitors used to treat squamous cell carcinoma of the skin that has advanced and spread to other part of the body.  - Interferon may be used to treat squamous cell carcinoma of the skin - Topical iquimoid therapy is an immune response modifier that that can be used to treat basal cell carcinoma  - Used in melanoma with distant metastases - Chemical peel - Chemical solution is put on the layer of skin to dissolve the top layers. Used to treat actinic keratinosis   - **RAD never used!** **Factors that can Influence Prognosis** - Recurrence - Size and Depth - Location - Type or Subtype - Immunosuppression - Stage