Skin cancer

Question 1

Nodular BCC

Answer 1

• commonly on face
• small, shiny
• skin-coloured or pinkish
• pearly, rolled edge
• may have central ulcer/necrotic region (so edges appear rolled)
• open sore = rodent ulcer
• telangectasia
• often bleed spontaneously then heal over/grow back
• continually get bigger

Question 2

Superficial BCC

Answer 2

• often multiple
• upper trunk and shoulders/anywhere
• pink/red scaly irregular plaques
• grow slowly over months-years
• bleed or ulcerate easily

Question 3

Morphoeic/sclerosing BCC

Answer 3

• usually mid-facial sites
• skin-coloured, waxy, scar like
• prone to recur after treatment
• may infiltrate cutaneous nerves

Question 4

Pigmented BCC

Answer 4

• brown, blue, greyish
• nodular or superficial
• may resemble melanoma

Question 5

Management of BCC

Answer 5

• surgical excision with 4mm margins (and send to lab for histological/margin analysis)
• Mohs micrographic surgery for high risk/recurrent (e.g. morphoeic/sclerosing BCC)
• radiotherapy if surgery not appropriate

For small/low risk lesions:

• cryotherapy
• curettage and cautery
• topical photodynamic therapy
• topical Mx e.g. imiquimod (Aldara)

Question 6

What is Mohs micrographic surgery?

Answer 6

excision of the lesion where tissue borders progressively excised until specimens are microscopically free of tumour

Question 7

When to refer BCC

Answer 7

• routine referral to derm for all BCCs

- 2WW only if delay would be problematic e.g. due to size/site of lesion

Question 8

Who should radiotherapy be avoided in and why?

Answer 8

<60s as causes long-term breakdown of skin

Question 9

What are precursors to SCC?

Answer 9

Bowen’s disease (SCC in situ) and actinic keratoses

Question 10

Bowen’s disease

Answer 10

• SCC in situ
• precursor to SCC
• bright red scaly patch
• well-demarcated

Question 11

Management of actinic keratoses and Bowen’s disease

Answer 11

• Imiquimod (Aldara), diclofenac gel, Efudix, etc.
• cryotherapy
• curettage and cautery
• photodynamic therapy

Question 12

Management of SCC

Answer 12

• surgical excision
• Mohs if indicated (ill-defined, large, recurrent)
• radiotherapy for large, non-resectable tumours

Question 13

SCC description

Answer 13

• irregular, keratotic (e.g. scaly, crusty), ill-defined nodule
• or firm erythematous plaque
• often ulcerates

Question 14

When to refer SSC?

Answer 14

2WW for all SCC

Question 15

Suspicious features of pigmented lesions

Answer 15

ABCDE (* = MAJOR suspicious feature)
*Asymmetrical shape
Border irregularity
*Colour irregularity (3+)
Diameter >6mm
*Evolution of lesion (change)
Symptoms e.g. bleeding, itching

Question 16

When to do 2WW for ?melanoma

Answer 16

• looks like melanoma on dermoscopy
• consider if particular concerns
• or 3+ points on Glasgow checklist:

Major features (2 points each)

• change in size
• irregular shape
• irregular colour

Minor features (1 point each)

• diameter >7mm
• inflammation
• oozing
• change in sensation

Question 17

Where do superficial spreading melanomas commonly occur?

Answer 17

lower limbs

Question 18

Where do nodular melanomas commonly occur?

Answer 18

trunk

Question 19

Where do lentigo melanomas commonly occur?

Answer 19

face

Question 20

Where do acral melanomas commonly occur?

Answer 20

palms, soles, nailbeds

Question 21

Management of malignant melanoma

Answer 21

Surgical excision in 2 stages:
1. Excise with 2mm margin, analyse and stage the tissue
2. WLE with margin dependant on stage:
0.5cm stage 0
1cm stage 1
2cm stage 2

• plus sentinal lymph node biopsy is Breslow thickness 1mm+
• radiotherapy may be useful
• chemotherapy for metastasis

Question 22

Risk of recurrence of malignant melanoma based on Breslow thickness

Answer 22

<0.76mm low risk
0.76-1mm medium risk
>1mm high risk

Question 23

Standard follow up for melanoma

Answer 23

5 years:

• every 3 months for 3 years
• every 6 months for 2 years