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1.

BASAL CELL CARCINOMA


The most common cancer
affecting humans

Slow growing

At least 75% first tumours are


on the face

Relatively benign in most


cases but if left untreated can
be disfiguring and life
threatening
AETIOLOGY AND
EPIDEMIOLOGY
The most important risk factor is solar ultraviolet radiation

Type 1 skin

Episodes of painful sunburn in early life

Mechanism of injury by UV radiation is complex:


direct DNA damage
damage to repair mechanisms
immune dysregulation
mutations in p53 suppressor genes
TYPES OF BCC (1)
NODULAR
Usually begin as a small
pink pearly papule

Develop a depression in
the centre

Rolled edge

Overlying telangiectasia
TYPES OF BCC (2)
SUPERFICIAL
Usually found on the trunk

May be multiple

Flat red patches

Usually have typical


beaded edge
TYPES OF BCC (3)
MORPHOEIC
White or waxy

Always on face

Presents as a spontaneous
scar

Margins are usually much


wider than what is
clinically visible
TYPES OF BCC (4)
Multifocal

Bowenoid usually found on lower legs of


women with sun damaged skin. Diagnosis
by biopsy

Poorly differentiated
DIFFERENTIAL DIAGNOSIS
Cyst Bowens disease

Infected spot Tinea

Sebaceous hyperplasia Eczema/psoriasis

Naevus Malignant melanoma

Molluscum contagiosum Seborrhoeic keratosis

Wart Erosions and leg ulcers


MANAGEMENT
Surgical excision with 4mm margins complete excision of 98%
tumours less than 2cm in diameter

Mohs micrographic surgery immediate histological analysis. If


residual tumour further surgery. Ensures precise and conservative
tumour removal. Usually reserved for high risk lesions eyelids, nose,
lips, ears. 5 year cure rate 99%

Photodynamic therapy

Radiation therapy

Topical therapy imiquimod (aldara) immune modulator


FOLLOW UP POLICY
Overall recurrence rate for BCC is around
5%
Thus patients are followed up for 2 years
at least 6 monthly
However risk of second primary 5 years
after excision 36% patients develop a
second primary and 20% develop multiple
new BCCs
2.SQUAMOUS
CELLCARCINOMA
Less common than
BCC but more
aggressive
The incidence is rising
Most important
aetiological agent is
UV radiation total
life time exposure
AETIOLOGY
Sunlight exposure

Therapeutic radiation

Chemical carcinogens arsenic

Immunosuppression

Viral infection

Scars and chronic inflammation

Premalignant lesions

Genetic syndromes
CLINICAL FEATURES
May be seen at any body
site

Disorganised keratin

Keratin horn on a fleshy


tumourous base

Surface tends to ulcerate


SCC on lower leg -
Marjolins ulcer

Failure to respond to
nursing care

Heaped up margin
METASTASES
SCC may spread in several ways:

Local invasion
Along tissue plains, between muscles, over
periosteum
Along nerves and blood vessels
Distant mets
RISK FACTORS FOR
METASTASES
Most SCCs behave in a relatively benign fashion

SCC arising from sun-damages skin has a low propensity to


metastasize 0.5% compared to 2% of all SCCs

SCCs arising in certain situations have a much higher rate of spread:


>2cm
poorly differentiated
scars and ulcers
immunosuppression
perineural invasion
recurrent lesions
DIFFERENTIAL DIAGNOSIS
Solar keratosis

Bowens disease

Viral warts

Cutaneous horn

Keratoacanthoma

Basal cell carcinoma

Leg ulcers
MANAGEMENT
Intention to cure primary lesion and prevent recurrences

No one treatment has been shown to be effective in all


patients

Thus treatment should be tailored to the individual as much


as possible

Ideally multidisciplinary oncology team clinical


oncologist, dermatologist, pathologist, appropriate surgeon
TREATMENT METHODS
Excision margins 2-10mm

Mohs micrographic surgery

Curretage and cautery

Cryotherapy

Laser

Photodynamic therapy

Retinoids

Radiation therapy
FOLLOW UP POLICIES
75% SCCs recur within 2 years

95% recurrences are within 5 years

Most clinicians follow up for at least 4 years

3 monthly for first year then every 6 months

Close examination of the scar site and draining lymph node


areas is recommended