Skin cancer and surgical dermatology



Skin cancer: Basal cell carcinoma

Basal Cell Carcinoma (BCC), the most common skin cancer in human. Of 100 skin cancers that we see daily:- 70-80 will be BCCs, the rest will be Squamous cell carcinoma (20-30) and the left over will be melanoma (~5 or less). 
 BCCs generally don't kill however, they do give you scars to remember them by.
The worse areas for troublesome BCCs are: scalp,nose,eyelid,temple.
The least trouble area is the back.  
BCCs  are slow growing cancers. 
There is no urgency in trying to fish them out
 If you don't catch them today - you will catch them tomorrow!
basal cell carcinoma
If a red rash had not resolved with topical steroid, antibiotic or watch-full waiting  then it should be presumed skin cancer esp. basal cell carcinoma. Using a dermatoscope may allow sooner diagnosis.  
basal cell carcinoma
Seborrhoeic dermatitis ( dandruft to the chest ) ? or Bcc. Shining bright light at an angle will reveal a very slight raised shiny undulating surface (better appreciated when the skin is stretched). Notice those tiny specks of blood.
basal cell carcinoma
More of the same.  Bccs displaying same old features of ulceration (blood specs, crustiness), shiny bumps (papules), undulating terrain and irregular edges.

noular and superficial basal cell carcinoma
When a BCC is fully developed it will be very obvious. Here side by side are 2 BCCs, one is a simple red rash and the other is a shiny skin bump with a recurring sore in the middle of the lobulated nodule.

Diagnosing bcc is relatively easy as shown; biopsy of these  cancer is really an unnecessary burden to the patient.

Skin cancer: Squamous cell carcinoma

Squamous cell carcinoma (SCC). This cancer is very common ( ~30% of all skin cancer) but, not as common as Basal cell carcinoma. It is however, more dangerous but not as bad as some melanomas. For an SCC to spread, it tends to be very large >1cm and usually on the scalp/lip/ears and .... of the "moderate to poorly differentiated variety"

Scc can be tricky to pick up but, we do not go mole mining or sunspot mining for them. Why ? when they come they will come and they will be easily picked up and removed. There is no point in biopsying every single scaly spots on some one's skin, creating more business for the pathology lab. Skin cancer practitioners shouldn't need to biopsy 3,6, or even 14 lesions for diagnosis of something so simple as skin cancer.

Some even argue for sunspots to be pushed into the SCC variety... creating  more work through further more unnecessary surgeries, particularly when those pathology reports are read by inexperienced practitioners.

And as every one knows sunspots ( technically is an SCC ) but will take millennium (~ maybe <1-5% over the patients life time)  to become something so "deadly" as an INSITU SCC or INVASIVE SCC.

As a patient you should ask if biopsy is REALLY necessary and  is invasive surgery really necessary for lower risk skin lesions.

Solar keratosis / Actinic Keratosis/  Sunspots
Solar Keratosis or better known as Sunpots. These arise from chronically sun damaged skin. They are an indicator of your skin having accumulated excessive amount of UV light, They do become cancerous but, the risk of that is very low. In Australia most will get one or two or more by the age of 30. In the UK, Their doctors will get very excited when they see one, something very exotic ! But, in Australia they are as common as weeds.

Squamous cell carcinoma or SCC
When a solar keratosis becomes cancerous. It tends to become swollen, red, tender or sore to touch. This Squamous cell carcinoma has a prickly horn . The more horny-hyperkeratotic an SCC the better - indicating a low risk carcinoma.  
This non tender horny lesion looks sinister but is the least dangerous of the SCC family. It's called a hypertrophic actinic keratosis ( or simply as a thickened sunspot) . Easily treated in less than 2 minutes ! 

Squamous cell carcinoma to the leg
This one is bad. It grows rapidly over a few week, bleeds easily and most doctors will be at a lost of what to do about them. These troublesome SCCs tend to occur on the lower legs and they are difficult to treat. Another one will pop up as soon one is treated. 
Squamous cell carcinoma to the ear
Despite it's aggressive appearance, this solid Squamous cell carcinoma to the ear is pretty ordinary and easily treated. This Scc has been around for more than a year. It's just gotten too big for the blood supply to keep up hence the necrosis ( dead black charred skin , non smelly one at that - dry necrosis)
Squamous cell carcinoma to the lip
Squamous cell carcinoma to the lip. Every body jumps up and down when seeing scc on the lip. The first thing that comes to mind is - METASTASIS - but, from our experience ( backed up by academia) these nice firm crusty, prickly and mildly tender small <1cm SCCs are easily treated and have low risk of blood born spread. SO RELAX ! just quickly remove them to minimise the risk of microstomia ( smaller mouth opening )
This lesion looks alarming and grows all most overnight. It's a KERATOACANTHOMA. The natural history of these type of lesions is of rapid growth and destruction then involution over a few weeks.  Get rid of them fast or permanent nasal deformity will ensure.

Skin cancer : Melanoma

Melanoma ... every body jumps up and down about melanoma. The word 'melanoma' generates fear in doctors and patients. But, really it is that common ? The regular physician would see one every few years! and skin cancer practitioners/dermatologists would see one every few months and, most of these are  early melanomas.
Out of 100 cancers we see ~70 will be BCCs, 23-30% SCCs and the rest ~< 5% Melanomas.
SCCs Kill more people than melanomas !  But, melanomas kill quicker and in younger population and this is why people panic.
The majority of melanomas arise out of the blue and only about ~20% arise in an already existing mole. There is no point in excising funny looking moles for preventative care. Pathology owners would love doctor to biopsy every funny looking moles but for the patient and the healthcare system it's simply a big rort.
Prophylactic excision of all atypical  moles in a patients with multiple moles is totally wrong.  This simply encourage a false sense of security. This does not remove the back ground increased risk of melanomas. 
You would need to remove ~14,000 funny looking moles to pick up just 10 thin  melanomas and 5 of these will be very very thin melanomas ( melanoma insitu). And, at our clinic the majority of melanomas we see are very thin i.e.. "melanoma insitu". The cost to the health system at bulking billing rate would be $714,000 per NON-insitu-thin-melanomas!!!!! 
How do we diagnose melanoma:
1: Inspect for ugly duckling
2. Dermatocopic examination of lesion in question
3. Biopsy the lesion concerned.
    A, Incisional if lesion is very big
    B. Excisional if lesion is small
    C. Shave or saucerise if lesion is superficial & in thick skinned area
 How we manage melanoma:
One last note:

The majority of thin melanomas are easily treated by family doctors/dermatologist. Thick melanomas belong to the surgeons. Don't waste your time and money seeing non hospital surgeons for melanomas > 0.75mm-1mm thick. You will just be referred again, robbing you of time and bacons.
Melanoma on the back
 Melanoma insitu. These type of melanomas are very common. They can be very difficult to diagnose as they can be very banal in appearance. They RARELY cause death. There is no way of predicting when they will growing deeper. They can hang around for months and years.  It's best to get of them to minimise scaring and deeper invasion into the skin and blood vessels.
melanoma insitu
 Melanoma insitu
  Melanoma insitu
melanoma insitu on the face
Melanoma insitu