Skin Cancer

Skin cancer is usually categorised as melanoma or nonmelanoma skin cancer, the latter including squamous cell (SCC) and basal cell carcinoma (BCC).

Risk factors

Basal cell carcinomaSquamous cell carcinomaMalignant melanoma
Ultraviolet radiation exposureUltraviolet radiation exposureUltraviolet radiation exposure
Increasing ageIncreasing ageIncreasing age
Previous BCCPrevious SCCPrevious melanoma (8-10 fold >risk)
ImmunosuppressionImmunosuppressionImmunosuppression
Fitzpatrick skin type I + IIFitzpatrick skin type I + IIFitzpatrick skin type I + II
Xeroderma pigmentosumChronic inflammation and woundsFamily history melanoma (10% have positive family history)
Gorlin SyndromeBowens disease (pre-malignant condition)Atypical mole syndrome
 Actinic keratoses (pre-malignant condition)Albinism
 SmokingXeroderma pigmentosum

Basal Cell Carcinoma

BCC’s are the most common form of skin cancer. They are slow growing and locally invasive but rarely metastasise (<0.5%).

Clinical features

Characteristically present on sun exposed areas such as the face, scalp, back and shoulders. Typically have raised pearly edges with associated telangiectasia. May appear scaly with areas of atrophy which may bleed or ulcerate. If left untreated can become locally invasive and destructive.

There are different subtypes: nodular (most common), superficial, morphoeic, infiltrative and basosquamous.

image 1 6

Figure 1: A basal cell carcinoma with raised pearly edges and evidence of central bleeding (image source https://skinsight.com/skin-conditions/basal-cell-carcinoma-bcc/)

Treatment

Treatment can be surgical (lowest failure rate) or non-surgical (low risk lesions, patient choice). Non-surgical treatments include photodynamic therapy, topical immunotherapy and radiotherapy. Surgical treatment involves excision of the lesion with an appropriate margin of clearance (usually 4-5mm). Mohs micrographic surgery can be considered in those with recurrent or incompletely resected BCC’s or in BCC’s presenting in an anatomically or cosmetically sensitive area for example those close to the eye. 

Squamous cell carcinoma

SCC’s are the second most common type of skin cancer. They arise from keratinocytes in the epidermis and have the potential to metastasise via lymphatics although this remains low (3%).

Clinical features

Like BCC’s, they arise in sun-exposed areas. Their presentation is variable but often show as a nodular plaque with erythema and raised borders. They may ulcerate and bleed.

SCC’s can develop in areas of chronic inflammation or scarring and are known as Marjolin’s ulcers. Bowen’s disease is the growth of cancerous cells confined to the outer layer of skin, also known as SCC in-situ, this is a pre-malignant lesion which can progress to SCC.

image 1 7

Figure 2: A squamous cell carcinoma, appearing as a scaly erythematous plaque (image source https://www.juniperderm.com/conditions/squamous-cell-carcinoma-scc/)

Treatment

Treatment is via surgical excision. Margins for excision are usually 4-6mm depending upon risk. 

Malignant melanoma

Although it is the least common form of skin cancer, it represents the majority of skin cancer related deaths. Arise from melanocytes, primarily in the epidermis. There are four subtypes: superficial spreading, nodular, lentigo maligna melanoma and acral lentignous.

Clinical features

Usually presents as a new lesion, or as a change to an existing lesion. It may also be associated with bleeding or itching. The ABCDE rule can be used to assess a lesion:

  • Asymmetry
  • Border irregularity
  • Colour uneven
  • Diameter >6mm
  • Evolving lesion
image 1 8

Figure 3: A malignant melanoma with an irregular border and colour asymmetry (image source (https://www.nhs.uk/conditions/melanoma-skin-cancer/symptoms/)

Investigations and management

Excision biopsy is used to confirm the diagnosis. Once confirmed, a further wider local excision is performed, the size of which is dependent upon the depth of the lesion, known as the Breslow thickness.

A sentinel lymph node biopsy is offered to those with a Breslow thickness of >1mm to assess for spread to draining lymph nodes.

In those with stage III and IV disease, a staging CT-CAP and MRI brain should be performed.

Immunotherapy and chemotherapy agents are used in those with metastatic disease.

References

Gordon R. Skin cancer: an overview of epidemiology and risk factors. Semin Oncol Nurs. 2013 Aug;29(3):160-9. doi: 10.1016/j.soncn.2013.06.002. PMID: 23958214.

Gruber P, Zito PM. Skin Cancer. 2023 May 14. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 28722978.

Nasr, I., McGrath, E.J., Harwood, C.A., Botting, J., Buckley, P., Budny, P.G., Fairbrother, P., Fife, K., Gupta, G., Hashme, M., Hoey, S., Lear, J.T., Mallipeddi, R., Mallon, E., Motley, R.J., Newlands, C., Newman, J., Pynn, E.V., Shroff, N., Slater, D.N., Exton, L.S., Mohd Mustapa, M.F., Ezejimofor, M.C. and (2021), British Association of Dermatologists guidelines for the management of adults with basal cell carcinoma 2021*. Br J Dermatol, 185: 899-920

Written by Ms Jennifer Mackay (CT2 Plastic Surgery) Checked and reviewed by Miss Alexandra Sutcliffe (ST4 Plastic Surgery

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