Basal Cell Skin Cancer Treatment

hello, i'm norman swan.welcome to this program on skin cancer. two out of three australians will bediagnosed with skin cancer by the time they're 70. that's the highest incidencein the world and it's vital to detect and treatskin cancer in its early stages, not to mention prevent itin the first place. so tonight we're going to discussthe prevention of skin cancer, risk factors, detection, diagnosisand evidence-based treatment. we're going to focus primarily on thethree most common types of skin cancer,

certainly the most serious forms -basal cell carcinoma, squamous cell carcinoma and melanoma. as always,you'll find a number of useful resources available on the rural healtheducation foundation's website - rhef.com.au. but let me introduce our panel to you. jeff keir is a general practitionerworking full-time in primary care skin cancer practice. - welcome, jeff.- thank you.

jeff's a clinical tutor for the international dermatologypost graduate programs at university of cardiff and teachesfor the north coast gp training scheme. ian mccoll is a consultant dermatologistfrom tugan in queensland. - welcome, ian.- thanks, norman. his main interests are,well, one of his main interests are in online general practitionereducation in skin diseases. ian olver is a medical oncologist and chief executiveof the cancer council of australia.

- welcome, ian.- thank you. ian's clinical professorof the department of medicine at the university of sydney. jan riley has specialisedin dermatology nursing for a long time. - jan, we won't say since when. welcome.- thank you, norman. jan has certificates in primary careof skin cancer medicine, advanced dermoscopy and dermal imagingthrough the university of queensland. so welcome to you all.

so, ian, truly the world's highestincidence here, we all talk about it but is it true? yes, it is,we vie with new zealand for that and the sad figureis that 1,700 australians die each year of skin cancer - 1,300 melanoma and400 non-melanoma skin cancer. we have about 11,000 australiansbeing diagnosed with melanoma each year and we're not quite sureof the number of non-melanoma because most of the cancer registriesdon't record them

but it is estimated at over 430,000so it's a huge burden of disease. and is the belief that it's commonerin rural and coastal areas true? yeah, there are some areas around thecoast for example in new south wales, the north coast is higher than sydney. the reasons for thatare not immediately apparent but, yes, there certainly are highermelanomas reported in coastal areas. norman: it's commoner, the sun's closer,jeff, up your area, isn't it? unfortunately,the correlation was thought that the closer you got to the equator,

the higher the melanoma rateswere going to be but studies -particularly recent ones in queensland - and also the raw data herefrom new south wales show that coastaland then that temperate band between about the sunshine coastand the northern rivers actually has the higher instances ofmelanoma than either side of it. so it does seem that probablysome lifestyle issues there with regards to pleasant temperaturesyear-round to be out in the sun as well. ian mccoll, the risk factors are what weknow or are there some surprising ones?

for melanoma? norman: well, melanoma or i mean,indeed, are they the same for melanoma and non-melanoma skin cancers?- no, they vary a bit. certainly for squamous cell skin cancer, ultraviolet light isthe major potentiating cause. other factors come in. patients that are immunosuppressedand the like are very susceptibleto get any type of skin cancer because your immune systemis helping you all the time

to stop skin cancers developing. but ultraviolet light certainly playsa part with melanoma as well but everyone knows of patientswho've got melanomas in places where the sun never reachesand unfortunately it happens. what's the latest research on that,ian olver? the melanomas in places likethe sole of your foot or your scalp? well, i think there's a combinationof genetic factors as well as the environmental factors and you need several hits usuallyon your genetic material

to actually trigger off a cancer, so it's not just one cause or the other. norman: what about protective factors? well, i think the protective factors are things that organisationslike cancer councils have been talking about for 30 years. it's the 'slip, slop, slap' campaign which was 'slip on a shirt, slop on some 30+ sunscreen

and put on a hat' and we added two more. that was the rather obvious one, seek shade during the hottest part of the day if you can and slip on some sunglasses because your eyes need protection during the summer as well. jan: i think,

just something to add to that, though, is when we are giving sun avoidance and sun protection advice to people now, there's always a question about,'what about my vitamin d, i've got to get some sun, haven't i?that's what i've been told.' so people are confused a little bitabout that message. look, i thinkthat's a very important question and i think the sun protection messagesin most of australia are summertime messageswhen the sun is at its most intense.

certainly, they don't applyat other times, but during the summer,you probably only need a few minutes' exposure to the equivalent of your face and armsduring the day to generate vitamin d and during the winter, it's probably twoto three hours a week. what is the story, ian mccoll,about children's sunburn? is it still true that your risk goes up the more sunburn episodesyour child has had?

yeah, it's probablyone of the most important factors in assessing someone's riskof developing melanoma - the number of blistering sunburnsthat they have had and it's been seen throughout the world,it's not just in australia. jeff, we've seen an explosion and, somewhat controversiallyin some people's views, of skin cancer in your primary careskin cancer clinics. have we improved the detection rate? the data's actually not clear on that

because the various states of australiadon't particularly differentiate between the levels and stages ofnon-melanoma skin cancer for a start and also the level and stages ofmelanoma that they report. certainly, the figures we have for theskin cancer audit and research database, which is a very large databasethat's currently under investigation, is that for people who are motivatedto find skin cancer early, we're finding a greater percentageof early melanoma than has been reportedin the literature before so it's optimistic thatif you're looking more carefully for it,

you're going to find itat an early stage but the full data is not completed yet. norman: ian mccoll, do you agree? yes, i do.i know about the scard database and certainly, if you look at melanomas that are reportedto the cancer societies, the cancer councils i should say, then you find that of the 70 per 100,000here in queensland, 50 are invasive, 20 are in situ.

if you look at the scard database, in fact there are two in situ melanomasbeing found to every one invasive so these guysare finding these lesions earlier, the ones who are trainedare certainly doing that. so is there an argument for screening?ian olver? there's an argument for screeningbut i think the important thing is that people should know what their skin islike and report any change immediately. they shouldn't wait untilanother screening interval but there's no data that actually provesthe efficacy of screening

and probably won't be so it'll haveto be a common sense thing. in terms of the natural history,ian mccoll, of these conditions, do we knowwhat is a reasonable checking interval? i suppose it depends on your skin typeand how many lesions you've got. very much so, it depends onyour family history, your skin type. if you're scottish with skin type 1,you never tan and you always burn, then if you've had a lot of sunburn...norman: we scots are invincible! well, perhaps. not here to the sun,

there's an awful lot of scotsdie from melanoma in australia. jan: i think though with screening, i mean, i thinkwe could encourage nurses particularly, we have people undressfor many reasons... norman: most of them legitimate.- ..with health situations. so if you've got them undressed, then take the opportunityto look at their skin. so, encourage your practice nursesto become skin literate in a sense. opportunistic - if they're undressed,look.

quite easy to encourage patients if they've got the risk factors for itand let's face it, if you've got a history of blistering,of sunburns in your childhood, if you've got a first-degree relativewith melanoma, if you've had a previous skin cancer, if you've had exposure to things such as arsenicalsand other chemicals on the farm, you're at increased risk. these people should be encouragedto self-present

and what we've certainly found isthat when we're getting people to appropriately self-presentfor screening, they may not have a particular lesionof concern, we're finding an extremely high rate of skin cancers and melanomain these people. so let's go to our first case study. it's mary - 56 years old, fair skin,she swims a lot, she comes to see jeffwith a flat red lesion that's scaly and itchyon her upper back.

let's have a look at it. jeff keir: well, this is a fairly commonpresentation in general practice and that's a pink, flat, scaly lesion which could be any oneof a number of things. you've got to sort of thinkof the things such as the non-skin cancersuch as dermatitis, you've got to think of thingssuch as psoriasis, you've then got to thinkof the skin cancer possibilities which commonly in these areas

would be intraepidermal carcinomaor bowen's disease or possibly even looking at superficialbasal cell cancer and the rarer things such as primary cutaneous lymphomaor mycosis fungoides and a melanoma. norman: so you're seriouslyscaring me now. jeff keir: well, it is a problembecause all of these things are... norman: could this be a pieceof discoid eczema? it could indeed just bea piece of discoid eczema. there's two ways to approach it. you can approach it either empiricallyand say, 'look, i think it's discoid...'

norman: 'have a steroidand come back in two weeks.' exactly, but as long as you follow upthe patient because you'll find that a number oflesions that don't respond to that, i.e. you've got the diagnosis wrongand you're having to look to biopsy it. but you can short-circuit thata little bit if you're actually skilled with the useof a dermascope and dermoscopy. sometimes you can actually makea fairly confident and firm diagnosis of what it is using the dermascope. norman: so you two have broughta show-and-tell here with dermascopes.

show me what you're talking about here. well, there's a number of thesesimple little handheld magnifiers and this is called a heine delta 20 and the heine delta 20 is a non-polarising dermascopethat requires contact with the skin and what it does is shine a bright light and you can examine the skinunder magnification. norman: and do you need oil or wateron it? yeah, it's best to have a contact media

such as, you can use 70% alcohol,isopropyl alcohol or you can use oil. but the alcohol is much easier to use, it's simple to evaporateoff the patient. or you can use a non-contact method. there are polarised dermascopes,simple little items called the dermlite and with these ones, you don't even haveto touch the skin to get an image. it uses polarised lightto reduce reflection, you can see a lot more detail

and some of them are even able to beattached to cameras and for example this is an old coolpix and there's quite a few adaptorsthat can be used. you can actually attach that thento your camera and take a photograph of the imagein question and put it in the patient record - quite easy to do with medical directoror any other medical software programs. and what's that you've got, ian mccoll? ian: it's just another typeof dermatoscope.

this one's a dermlite fluid,so non-polarising one. the thing about polarising, polarising light penetratesdeeper into the skin so you can see deeper structures with it but you sometimes misslittle milliard cysts that you see in the surfaceof seborrheic keratosis which is a common pigment lesionthat's benign and you don't see blue structures, melanin deeper in the skin as wellwith polarising dermatoscopes but...

norman: so you might want to use both? it's good,there's a new one out called a dl3 that has both polarisingand non-polarising, you can just switch between the two. it's a very good dermatoscopeand it easily connects, as jeff shows, to cameras because taking photographyis an important thing. jan, you've been trained in this.i mean, how difficult is it to use, i mean, a lot of gps think,'oh, gosh, you know, i'm not quite sure

what i'm looking atwith the naked eye and then i'm going to actually compoundthe difficulty by magnifying it. god knows what i'm looking at!' they're not difficult to use but getting your eye in,making sure that you practise enough and correlate what you seeand what you believe a lesion to be and if then you go on and biopsy it, and gain proof of your accuracy or notis quite important, otherwise you don't get your skill upso you have to work at it.

norman: ian mccoll? look, i'd agree.i think ongoing learning, taking the opportunityto look at everything that you can in factput your dermatoscope on is very good and at first you... norman: so you're going to over-biopsypoor patients or what? not necessarily at first. certainly, if you look atwhen dermatoscopes are introduced, some people do over-biopsy at first,they get alarmed at first

but as they learn just by reconciling what the results arefrom their biopsies, they biopsy lessand they become much more selective at in fact picking up early melanomas and in using it inother non-melanoma skin cancer as well. jeff, if you're a rural gp and you can'tget locums to go off on courses, are there other ways of learning? there are, there are online resources,some of them are actually free. for example,there are short courses online

for the international dermoscopy society- ids org, there's also dermnet new zealand, they also have them. the skin cancer college of australia and new zealand have also courses which people can participate online and learn dermatology as well has various resources for this kind of training.

it's important to get some level of training either, at the very least, over the internet because it is a very, very visual field and if you're able to attend one of the courses, that will reinforce what you've learnt online.

so let's look at what mary's lesionlooks like under the dermascope. jeff keir: so here you can seea totally different view. all that reflection from the scaleis gone, you've used some liquidon the dermascope and you can actually now lookat the structure of this lesion within the epidermis and the dermisand what you can see is some classical featuresof superficial basal cell cancer and there are some browney grey globulesof colour or blobs of colour there and that's commonly seenin basal cell carcinoma.

there's also these white lines which arehighly reflective with polarised light, crisscrossing the background, almostmaking it look like mother-of-pearl. you've also got some tiny ulcerations. what you can't see here is other typicalfeatures of basal cell cancer, is very, very finely focused bloodvessels but there's enough features thereto make a firm diagnosis that this is going to bea superficial basal cell cancer. norman: you're certainly not dealingwith a piece of eczema? jeff keir: you're not dealing witheczema or psoriasis,

intraepidermal carcinomaor bowen's disease, you're dealingwith basal cell cancer here. norman: so, ian,what would you do about it here? would you need to biopsyif it's so obvious on...? ian mccoll: depends on how experiencedyou are. that's quite a big bccand it's an unusual superficial bcc because of the amount of scale. the larger bccs are like that. the longer they've been around,the more that there may be

an infiltrate of component within this and if you're thinking of using topicaltherapies to treat this, then you don't want to do itif there's an infiltrative component, you only want to do itif there's a superficial bcc that these topical therapieswill deal with. so a biopsy is not a bad ideain a big lesion like that, you probably should taketwo or three little punch biopsies to make sure that it's a uniformhistology before you do your treatment. in fact, there's a questionfrom a general practitioner

in queensland asking, 'is there a minimum punch biopsy sizeand should you suture a punch biopsy?' well, the pathologist won't thank youif you give him a 2mm punch biopsy, it's too small a bit of tissue. a 3mm i think is the minimumand i usually do suture a punch biopsy, especially if it is going to bein the leg so you'll just have a trail of bloodalong the carpet when the patient is walking out unless you put a big plug over itand tape it on.

so, yes, 3mm should beyour minimum punch biopsy size. jeff: on a practical basis,sometimes for these superficial lesions, if you're countenancing treating themwith curettage and cautery, just beware that a punch biopsy goesthrough to the deeper layers of the skin and you can actually get your curettecaught so sometimes it's even worthwhile doing shave biopsies which don't gothrough that full thickness. you actually preservesome of your treatment alternatives for these lesions. how important is the history, jan,in terms of diagnosis

or understanding what might be wrongwith mary - the history of the lesion? well, the history is going to give youan idea of whether you're going for somethinglike eczema or psoriasis, or whether this is more specificallya sun lesion if it's an isolated lesion. it's really quite importantfor an overall view of the person. i mean, a lesion is on the person,it's not something that stands alone so you need a view of what is going onwith that person. solitary lesions - it's unusual to geta solitary lesion of eczema or a solitary lesion of psoriasis.

there's usually multiple lesions so whenyou get a solitary lesion, you know, skin cancer should spring to mindstraightaway. let's go back to the pictureof the dermoscopy here of mary. where would you biopsy it? ian: generally in a bcc like that, it really doesn't matter. you might avoid an area that looks as if it's been scarred because, remember,

your immune system's reacting all the time to skin cancers. it's trying to get rid of things as well and sometimes you'll get bits of regression, bits of scarring, so if you go for a white area there that's scarring, you may get scarring in your report. norman: and of course, jeff,

you can get pigmented bccs? jeff: yes, they are quite common and they're actually very beautiful under the dermascope. pity we don't have any images tonight. but they're quite common and again, the features of those, if you put a dermascope on them, are not dissimilar

to what we're seeing here. you've got areas of ulceration, you'll have much larger pigment globules and you'll have finely focused blood vessels across the tumour. we'll see some of those examples i think later tonight. norman: so, ian mccoll, what are the treatment options here?

for a superficial bcc like this,you've got topical therapy... norman: well, as it turns out... yes, you've got topical therapiesthat you can in fact use and the major topical therapies for thatwould be imiquimod or aldara, a topical therapy that enhancesthe body's immune attack to these tumour cells or there's another therapy called pdttherapy - photodynamic therapy - where a cream is used that's selectivelytaken up photosensitising cream, which is selectively taken upby the tumour cells...

norman: we'll come back to that later. ..and then they can get treatedwith that. efudex i don't usually usefor superficial bccs, i'll use it for superficial sccs. you can excise a lesion, obviously, you can curette a lesionas jeff said as well. norman: it's a bcc we're talking about?- sure. norman: but we'll come backto how that works later. and what about mohs surgery?

well, mohs surgery is reserved forthose basal cell skin cancers that are less well-defined, that are infiltrating bccswhere you can't determine the edge. you may think the edge isat a certain point but in fact there's little spiculesgoing out and that extends out a lot furtherthan you think. and often the margins of excisionhave to be between 5mm and 7mm and mohs surgery is particularly used where you've got sensitive areasround the nose, round the eyes,

where you're trying to conserve tissue and make sureyou're taking out all the tumour but not taking out more tissuethan you need to because it makes the repair much easier. let's go on to our next case study. robert is 34, he's got a family history of bcc and he noticed a lesion on his nose and it's bled once or twice

in the last six months. he's not sure how long it's been there and doesn't have any other symptoms. let's have a look. god, you could easily miss that one,jeff. jeff keir: it's one of these smalllesions that you can easily miss and certainly with the naked eyeand clinical examination over the years, i've missed plenty of them. but again, it's one of these thingsthat show the utility

of looking closer with a dermascope and again these small bccs,even though they're very small, do show classic features. in particular - and i've said thisbefore - finely focused, often branching or serpentine blood vesselsacross the lesion, and they'll often look pinkand structureless and if you look at themunder magnification, often almost have a jelly-like qualityto what you are looking at and this shows quite clearlyin this image.

norman: this is a dermascope.jeff: yes. this is a magnified viewof this very small lesion, it's only about 2mm - 2.5mm in diameter, but you can clearly make the diagnosisby looking at the setting, you can see this finely focused,fine branching blood vessels, you can compare that to the thicker, less well-focusedbackground blood vessels and you can see the difference. there are some benign thingsthat can look like this

but you're going to be pretty surein this area that it's going to be a bcc and not an eccrine poromaor something similar to that. norman: what's the treatment here,ian mccoll? ian mccoll: well, again, this isa well-defined, very small nodular bcc. you can take that outwith narrow margins. i mean, we sometimes say bccshave to be taken out with 4mm margins but obviously, on the nose, and awell-defined one like this, 2mm is fine. so you may only need to take that out with three little suturesto close the defect,

it's well within the provinceof any general practitioner to do that. norman: do you want to comment, jan? no, i was just thinking if we were goingto get onto topical treatments with, say, the superficial bccs -just to backtrack for two seconds - is that a lot of those treatments,the patient response is very individual and it's really importantthat people are supported in that care but we might get onto thatin a further case study. and, jeff, once you've actually treatedsomeone like this with a small lesion, how often do you follow them up?

well, already they've put themselvesinto the high risk category. they've got a previous history ofnon-melanoma skin cancer now. at the very minimum, even if you're not following upthis particular instance of care, they should have an annual skin check but for this particular instanceof care, it's worthwhile following upin three to six months to make sure there's clinical clearance. you can have a look at thatdermascopically,

if there's any suspicious areas, it's worthwhile re-biopsying those. let's look at our next case studywho is sue. she's 75 years old,she's the wife of a cattle farmer, she's always worked around the property and she's got a lesionthat's always irritated by her collar. what do you think should be doneabout this? let's have a look. jeff? jeff: well, you're having a quick glanceat this one. these types of lesions will often comein with a fairly indeterminate history -

they don't knowhow long it's been there, it's only recently been irritating and you look at itjust on the clinical image and you say, 'well, this is a little unusual,a pink patch that has the suggestionof something paler around the outside.' it's got very indeterminate marginsand you think, 'well, i really want a closer lookat this to decide what it is.' it could be anything from a superficialskin irritation from her collar to something more significant

and again, this dermascopy viewshows quite clearly that we're going to be dealingwith a possible malignancy. you've got finely focusedbranching blood vessels which immediately make you thinkof basal cell carcinoma. the other thing you can't see, asopposed to the previous ones we've seen, there is no well-demarcated edge. it's not fine and nodular, it looksa bit scar-like in the background - those white shiny areasin the background - and it's quite consistentwith sheets of collagen

which you seein these infiltrating bccs. norman: how do you knowthis is infiltrating by looking at it? jeff: by looking at this, you can... combined with the clinical view,you would look close, you'd have foundit would've felt a little bit firmer if you ran your fingers across it, you wouldn't have seena clear edge to it and that is the patternthat you see with infiltrating bccs. there's not much else that mimics thisapart from scleroderma occasionally.

norman: a bit harder to remove when you don't know where the edge is,ian mccoll? indeed it is, that's always the problemwith infiltrating bccs and that's why you talked aboutmohs surgery earlier on when you were doing this on the face because it's a way of histologicallydetermining where that edge is by doing serial excisions and examiningit under frozen sections at the time and that's why it's an excellenttechnique for these infiltrating bccs if they're on the faceor other sensitive areas but...

now of course this sort of areais bad for curettage as well because it doesn't have a firm base. you can't curette that, you need to havea firm dermis to curette and anyway, an infiltrating bcchas already got fibrous tissue. the cells are going betweenthe collagen bundles so, you know, you can't feel the soft tumour tissuethere so you certainly wouldn't tryand curette. if you'd biopsied somethingthat was an infiltrating bcc, you don't try and curette them.

so this one you excised, ian? - jeff. yes.- jeff, sorry. with these particular lesions,when you've got rural patients who often don't come into townvery often, sometimes you've got to leap inand biopsy and treat all in one... norman: so this was an excision biopsy? jeff: this was indeeda very wide excision biopsy, the presumptive diagnosiswas made dermascopically. normally if i have time,

i'd actually prefer to biopsy theseto confirm the diagnosis but unfortunately, i think we've gotto be practical in rural areas. norman: what sort of margindid you take here? jeff: when you're looking at these, you've really got to take 5 to 10mmclinical margins to be sure that... norman: so quite a big margin.jeff: quite a big margin. but again,if you've got the minor surgical skills, and many of us in rural general practicedo have these minor surgery skills, you can safely remove thesein most areas of the body.

obviously, there will be areasyou won't be comfortable and you will have to refer. norman: she's got a fair scar. jeff: she certainly has,it's a longish excision but i think once you see that it was able to be closedwith just simple nylon suturing, and longer term - i think we have an imageof about six months down the line - you actually can't seewhat's been done there

and crepe-y skin can do quite well,thank goodness. norman: and how oftenwould you follow someone like this up? jeff: i'd definitely follow this lady up3, 6 and then 12 monthly thereafter, depending on her incidenceof other skin cancers. frequently, we find that basal cellcarcinomas occur almost in batches in the first two to three years. after having had one bcc,they will well have one or two or three and the more bccs they havewithin that period, the closer your review times have to be.

it's just common sense. common sense and there have beensome good studies showing that. doug czarnecki did a great studyearlier in the '90s on this. let's go to our next picture -a quiz slide. jan, what do you think? jan: a very nastily sun-damaged hand, lots of hyperkeratosis which is the thick, scaly,very spiky sort of areas on her skin so she's certainly got some sun spotsthere, some actinic keratosis,

and if any of those on examinationwere painful or felt indurated, you know, felt thickened under the skin, then perhaps some of those are turning into little squamous cell carcinomasas well. ian mccoll: look, i'd agree. i mean,there's a lot of sun damage here. norman: this is a scottish hand. ian mccoll: it may well bea scottish hand, they've certainly had it out in the suntoo much. but that thick hyperkeratotic areain the middle there,

you'd be feeling the base of that. as jan said, if it's infiltrated,if it feels thicker there and it's a bit painful when you'regently moving it from side to side, it almost certainly is an invasive scc. it's not just a hypertrophic solarkeratosis so a hand like that, it's a very difficult conditionto deal with something when you've got such extensive damage. you often have to do it in stages and you'd go for the ones witha thicker base and are indurated,

you'd go for those first. ian olver, what's the differencein terms of natural history cancer-wise of these two tumours, sccs and bccs? well, very simply, bcc spends mostof its natural history as local disease and causes its problemby locally infiltrating and spreading whereas squamous cell cancer tends to spread earlierin the course of its disease not only to local lymph nodesbut to other organs such as the lungs. but the whole messageis that these don't spread at all

if you can get them early enough so the whole aim of treatment is not only to prevent the thingbut if you can't prevent it, its very early detectionwhen they are surgically curable. how amenable to chemo or radiationare sccs particularly when they've spread? well, i think radiationis a local treatment and it can be used in lesionsin difficult places or perhaps in older people

where you want to avoidplastic surgical flaps and so on. chemotherapy is really the last resort when either you can't do local therapyon a squamous cell or local therapy has been donemultiple times and we wouldn't expect chemotherapyto cure the lesions. there's usually platinum-based therapyand that can shrink disease down to relieve symptoms and buy another few months usuallybut it's not curative therapy. but compared to melanoma,it spreads later, it metastasises later?

very much later usually than melanoma,which tends to spread early depending on how deeply it's invaded. norman: which is whyit's only 25% of the skin cancer deaths rather than more than that? that's correct. let's go to our next case studywho is john, who's a 62-year-old scottish migrant with the sort of skin that ian mccolland i have been talking about. he takes about three or four beersa night, he smokes,

he's an itinerant outdoor rural worker, he comes to see you, jeff, with a white spot on the back of his hand, let's have a look at it. jeff: and this is fairly commonin presentation. these patients will come along, 'i'vegot this scaly thing on my hand and, doc, it hurts every time i knock it,every time i put my hand in a pocket,' which is of course unusual for a scots. but these are common lesions thatthe patient will commonly present with

and they'll say,'this hurts, doc, it's sore.' and the other interesting thingin the history we were talking about is that the patient has a decent alcoholintake and he also smokes and both of these have also been shownto be risk factors for squamous cell cancerand in fact a high-fat diet. so these are a couple of other thingswe didn't mention that perhaps people can changein their lifestyles, which will reducetheir skin cancer risks. but anyway, this particular kindof thing, you put your hand on it

and you'll see if you squeeze it,the patient yelps, they're tender. the tumour started to invade, the body'sgot an inflammatory reaction against it. in fact, most of that mounted pink areais actually not tumour, it's actually inflammatory reactionto the invading tumour. and management is very, very simple. it's too thick to freeze, you wouldn't curette thin, crepe-y skinhere to get rid of it, it really needs to be surgically excised and it's simple to dowith 3mm - 4mm margins.

norman: so,an excision biopsy, basically? jeff: a curettive excisional biopsy. norman: so you wouldn't tryand biopsy it first? jeff: no, there's no needfor these small lesions. norman: and again, well,we'll come back to this in a moment. just a quick question,a gp from rural nsw asks, ian, about the instances of skin cancerin the indigenous population and the problems of detection. well, often it's very uncommonto get melanoma in pigmented skin

but they can still get melanomaon their palms or soles, inside the mouth,on the unpigmented areas but of coursethey're more suited to the climate by having the pigment in their skin and so you've got to be careful, they certainly can get itbut it's very uncommon. a question from rural south australia,ian mccoll, if you're going to be usinga dermatoscope, should you dermatoscopeevery skin lesion you see?

look, that can be awfully difficultif you've got someone coming in with, you know,literally hundreds of moles. what tends to happen is you look,you scan someone, you look for a lesion that's lonely,that's on its own, there's no other similar onesaround about or you look forwhat we call the ugly duckling, the one that stands out, that's different from the other naeviand you tend to look at those. you can actually scan naeviwith a dermatoscope -

it could be very quickly,the non-contact ones - so you'll get used to examining20 to 30 of those patients very quickly. ian mccoll, what different kindsof squamous cell carcinoma are there? well, some people would arguethat even a solar keratosis is a squamous cell skin cancer, it's an incipient squamous cellskin cancer, but then you have the scc in situ,bowen's disease, where your skin canceris just in the epidermis itself, the abnormal keratosis acts

as though there's nothingthrough the basement membrane, it hasn't invaded into wherethe blood vessels and lymphatics are. but then you get your invasive scc when it goes throughthe basement membrane and histologically that's definedas being well differentiated, moderately differentiated,poorly differentiated. most of the ones that arisefrom pre-existing solar keratosis are well differentiated, have a low risk actuallyof spreading elsewhere

and can be taken outwith 2mm - 3mm margins. norman: so this comes backto the history again? part of the history of wherethey have come from in the beginning. if you've got somethingthat's slowly arisen and they've gota lot of solar keratoses there, then it's likely to bewell differentiated. if you've got a lesionthat's arisen very quickly and you've suddenly gota big ulcerated lesion that's there and it's grown in two months,

then that ain't going to bea well differentiated scc, that's going to be poorlydifferentiated, a potential problem. and when people use the word 'actinic',what do they actually mean? - sun-induced.- so it's just another word for solar. ultraviolet-induced, i mean, you couldsay solariums are actinic as well, puva treatment is actinic as well. yes, indeed.they are on solariums certainly. we've got the message across that it's not a good idea to goto a solarium to get a tan.

now, john moves fromcommunity to community and four years laterhe presents to another gp with a non-healing ulcerated lesionon his lip and he's got palpable submentallymph nodes, let's have a look. - jeff, you're the other gp.jeff: i see. norman: could the other gphave missed this? four years ago, would he have beenlikely to have had the early lesion? jeff: it's a good question.sccs can grow extremely quickly and it's quite likely there was nothinglike this three, four months ago at all.

it is possible however to havea fairly long prodrome of leukoplakia which is really actinic cheilitis which is solar keratosisor actinic keratosis of the lip. but quite frequently,these things can erupt quite quickly and these are thingsthat patients usually present to a little bit earlierthan this poor chap has. norman: and, ian mccoll,what's the treatment here? ian mccoll: this is a big lesion onthe lip. initially, you'd biopsy this. i mean,it's almost certainly a punch biopsy,

it's going to come backas a poorly differentiated scc especially if he's already gotsubmental lymph glands. this isn't somethingthat you can handle in country practice, this really needs referralto a tertiary centre because he'll need probably a wedge,a big wedge - half of his lip getting taken out therefor that to be removed - plus the lymph nodeswill need to be removed and may need radio therapy to the band. and there may well even beperineural spread with this, you know,

it can go via a nerve as well and can spreadwell beyond the areas of the excision so this isn't one you would deal within country practice. it's in the danger areas - sccs that aremoderately to poorly differentiated on the scalp, ears, lip, nosecan do very, very poorly indeed. and as you said, ian olver, earlier,systemic therapy may have some role but if it doesn't,you can't hold out much hope. yeah, i think it particularly has a roleif this becomes symptomatic, if it was failed to be controlled

with the local therapies of surgeryand radio therapy. let's go to our next picture. norman: jan? jan: ok, a nice, scaly plaque... norman: i like the way all you peopleinvolved in just skin call them 'nice'. (laughter) jan: well, i mean,i guess i am imagining myself feeling it, it would feel... norman: yum, yum, yum!

jan: it would have a firmness to it. it's not going to be soft, it's going tofeel a little bit indurated and a little bit tenderand that's probably bowen's disease, intraepidermal carcinoma, yes, iec. norman: so this is carcinoma in situ,jeff? jeff: that's right so it's squamouscell carcinoma right on the epidermis and as jan has intimated, they often look very,very bright red indeed but some of the scaly oneshave that redness masked, somewhat.

norman: and diagnosis? apart from visual, are you going to take a punch biopsyhere, what are you going to do? jeff: it's certainly worthwhiletaking a punch biopsy to make sure you don't haveany invasive component. it's a difficult areato treat surgically and if it's one of these ones that can betreated with topical therapies and you can prove thatby a reasonable biopsy, then it's worthwhile trying to preservethe skin and function of the hand.

you could proceed tothat topical therapy in general practice without a referral to a dermatologist,do you think? certainly with using treatmentssuch as 5fu or efudex, absolutely. that's something that's well withinthe realms of general practice. norman: ian mccoll?- yeah, i'd agree with that. the areas where you've got to watchscc in situ like this is if it's near hair-bearing areas because it does go downthe hair follicle as well and sometimesyou won't get the bits further down.

later on, if it re-occurred, it will occur growing upout of the hair follicles, little red spots within the scarred areawhere you have in fact treated it. norman: difficult to removein a position like this. oh, look, it is,it's difficult to treat there. efudex can be used, aldara,imiquimod can also be used although in australia it is recommendedmainly for superficial bccs but it actually works very well for sccin situ as well. and we mentioned photodynamic therapy.

so let's just see the picture here,a couple of pictures down the track but let's go to it straight now. we've got a photograph of a photodynamictherapy, just explain again what it is. well, photodynamic therapy is whereyou use a photosensitising cream - it's usuallymethyl-aminolevulinic acid - and you apply it overthe offending lesion, occlude it, send the patient awayfor three to four hours and in that time the tumour cells,the surface tumour cells, take up the photosensitising chemicalmuch better than the surrounding skin

and they come back after four hours,wipe it off and you shine a red light on it which actually activatesthe photosensitising chemical that's now been taken upby the tumour cells and it's delivered over a periodof about nine minutes and then the tumour cells basicallyjust die and it peels off as a scar. norman: magical.- it can be. it can look very good at firstbut like everything, initial looks can be deceiving

because the problem is thatthe success rate further down the track, two to three years out,is somewhere between 75% and 80% so there's perhaps 25% in factthat it doesn't really cure. norman: so, jan,follow-ups are important. jan: absolutely. support during that sort of treatmentis important but certainly follow-up as well and i think, it's probablyone of the important areas where nurses can support peoplein understanding

why they need their follow-upand that they do need to come back because it's in discussion with nurses perhaps where the patientwill really sound it out as to is this important and is thedoctor really over-emphasising this to no real requirement? let's flick throughjust two or three quick shots of scc. jeff, just talk us through themjust so that people at home, viewers can actually get a senseof the spectrum here. jeff: well, what we are looking at hereagain is a scaling lesion

just like the first one we saw tonight. your question is,is it going to be a little patch of dermatitis or tinea or psoriasis? you've got multiple onesscattered around, you've gotta perhapseven think of psoriasis and if you're uncertain, biopsy at least one or two of thembefore you start treatment. if you're going to tryany non-ablative therapies, you really need to get a biopsy prooffirst of these lesions

and these ones can do quite well if they are on a firm basewith curettage, they can do quite well with efudex. on drier skin with efudex,the trick sometimes you need to do is apply the efudex under occlusiontwice a day for slightly longer periods. norman: so this is somebody obviously,ian mccoll, with older skin, more difficult totreat, of diffuse nature... ian: this is, as jeff said,in the lower legs like this, it can be very difficult to curette.

these are elderly people, thin skin, on anticoagulants, you know,a lot of sun damage, you try and curette that and you'll be down into the fat layerbefore you know what's happening 'cause there isn't any firm baseunderneath so you just end up with an ulcer. this was a ladywho's got a giant scc in situ and it was initially treatedas a fungal infection. she was a patient with severe rheumatoidon methotrexate

so, you know, her immune systemwas affected as well by that and they didn't pick thisas a superficial scc, it's now covering aboutalmost up to half her lower leg. norman: how did you treat that? ian mccoll: it's awfully difficult. radiotherapy would probably beabout the only treatment you could use. we did try pdt, we tried some efudex as wellbut she's an elderly lady in her 70s and very thin, confined to a wheelchairwith her rheumatoid arthritis

and the dear lady in the end said, 'no,look, i'll quietly just live with this.' we keep watching itand if there's any bit that thickens and it looks like it's an invasive scc,we do a little excision on that. norman: and just the last one now, jeff. jeff: again,very similar to the previous ones, almost isolated lesion, that. norman: hard to tell apart from a bcc? jeff: it is. again, this is wherethe dermascope can indeed help. if i applied a dermascope to this,

we'd most likely see thatwe are going to have multiple coiled or what used to be calledglomerular vessels, little roundish glomerular-like vesselsif you look under magnification. norman: sort of curled. jeff: all curled upin a nice tight little ball and you'll find that of varying sizeswithin the lesion. again, it's worthwhile biopsyinginitially to be sure before you do start treatment but ian made a point with this ladyon methotrexate, these are becoming...

the patients who areon immunosuppressants for various autoimmune diseases and patients also with chronicmyelodysplasia, chronic lymphoma, are an increasingly large group of patients in our practices,in general practice and in skin cancer clinics,and they do deserve special attention because they are at high riskof widespread multiple lesions. how much attention, ian olver,does the skin get in oncology clinics when you're not treating the skinbut you're treating other things

that might induce skin cancer? well, i think it doesn't perhaps getas much as it should because you're often dealing with metastatic diseasein a medical oncology clinic and the skin lesion in the contextof widely spread other cancers may not get the attention it deserves. however, the same things applyas applied to any examination. you should try and examine the patientsthoroughly by exposing the area, taking their shirt off andexamining them in their underwear,

which is very usefulfor all sorts of cancers but gives you a chance of identifyinga skin lesion and these patients are oftenimmunosuppressed on chemotherapy or other treatments. i suppose it's another message for gpswho have patients on cancer treatment - to keep an eye on the skin. i think they've got to be particularlycareful and not allow skin lesion to... or not watch it for too longif they are worried about it. let's move on and go to our next casestudy who is joe, 68, a retired labourer

and he's got an isolated lesionon his upper arm. he didn't notice it himselfbut jeff found it on skin examination. jeff: this is a lesion that stands outclinically and it attracts your eye, it's a very lonely lesion, there'snothing else quite like it on his arm. it's also typical of a lot of thingsthat we see once you start undressing your patientsand having a look at them but 50% of the melanomas we findare on the trunk and under clothing and if you don't at least get theirshirt off, you are going to miss those as he would have missed this.

and if we look at it even closerwith the naked eye, this is a macro shot as it would look as ifyou were looking at it quite closely and already we are starting to seesome clues and the clinical clues that are usedfor melanoma - the abcde - which is asymmetry, border irregularity, multiple colours,a diameter greater than 6mm and perhaps a history of e for evolution and we can see thatthis is probably consistent with that.

norman: so the person, if they knew that it was there,would tell you that it's changed. jeff: they may well do indeed or if you'd noticed earlierand you're monitoring it as well. now if you look at it even closer againwith the dermascope, you can be pretty sure you're dealingnow with a melanoma. what we've got is a lesionthat's quite obviously, it's chaotic, it's asymmetric in colour,it's asymmetric in pattern and it does actually havesome of the several clues

that you can find in melanoma. norman: so why don't yourun through the clues? jeff: well, there's a whole list of themand they're not totally agreed upon but in this particular lesion forexample, we've got this asymmetric area where you've got loss of structure,it's pale and structureless, and you've also gotsome blue-grey structureless areas. you've got some brown dots which are irregularly distributedon the lesion, it's a bit harder to seeat this magnification

but there's also some thickened network. we can also see in melanomas,we often see grey areas of any type, they can be an alarm buttonfor you to press. black dots and blobs around the edgesof a lesion like this can make you think it's a melanoma,lines streaking away - brown lines streaking awayat the edge of a lesion, what we call radial streaming, can be a clue. blood vesselsthat have different patterns,

we call polymorphous vessels, are a clue and also white lines which lookalmost like a negative network. they are a white mesh patterninstead of the brown mesh pattern we normally see in a mole. norman: and how's that different from,say, a junctional naevus? well, junctional naevi, when you lookat them with dermoscopy, usually are a single colour,a single pattern and because of melanocytesat the derma-epidermal junction, they're flat, they're impalpable,they've got no raised areas there

and you'll see that the networkof these particular naevi fade out into the surrounding skin rather than having an abrupt cut-offlike a lentigo. if we're then looking at something that is more towards possiblybeing a melanoma - and not everything that's irregularis a melanoma - but you'd better have your antenna upand think about biopsying it, it's going to have irregularitiesin its structure such as we've detailedin that little list there.

so how do you diagnose this? this was obviously madeby a diagnosis clinically. it was a suspect lesionof those features and according to the guidelines that are published now in australiaand new zealand for melanoma management, this was excised with a 2mm marginas an excisional biopsy. it's important to get all the lesion because the edges of the lesionoften give clues

to the histopathologist as to whetherthe lesion is circumscribed or not. that's one of the features they look for and once you actually have thatinformation from the excisional biopsy, they'll tell youwhat its breslow thickness is. now the breslow thicknessis the thickness from the stratum, the granular layer of the skin down to the deepest levelof the actual melanoma and from that information, you'll knowwhat kind of margins this needs, whether you need to refer the lesion.

so it came back as a breslow 0.2. it did indeedso it's quite a thin melanoma. less that 1mm is considereda thin melanoma and the guidelines state that you're wanting to have your excisionmargins for in situ melanomas 5mm clinical margins need to be donedown to the fat underneath. - if you're looking at up to 1mm...- just down to the fat. just down to the fat underneath. somepeople will argue to the deep fascia but for in situ lesionsthat really is not necessary.

if you're looking then at a lesionthat's invasive up to 1mm in depth, you need to go a little bit wider, you're looking at 10mm margins anddown to the deep fascia or at least 1cm, probably whichever comes first there. ian olver, there's the story around,a common story - surgery can induce cancer worsening. can excision biopsy actually provokemetastatic spread or more aggression? no, this has always been a theorythat could potentially happen but we've never actually seen it.

there is no evidencethat this would occur so, in this situation,if you follow the guidelines and do an excision biopsy and thenlater on, according to the depth, deal with the margin so you can be sure that you're not going to exacerbatethe cancer. so what about the role,people are saying more and more, you should do a sentinel node biopsywith melanoma just as you increasingly are doingwith breast cancer just to see whetherthere is lymphatic spread.

well, this is a controversial area. it clearly depends onthe whole situation of the patient and there are some peoplearguing for it and against it. a lot of the trials that did sentinelnode biopsies were looking at prognosis, they were looking at itto choose the arm of the study to go in and i think we're in a period nowwhere people are trying to determine when to do a sentinel node biopsy. in a very severe melanoma,a very deep melanoma that's likely to spreadwith a high possibility,

the sentinel node biopsyisn't going to help at all. so i think we've got to refine because we don't have enough evidenceto tell us precisely when to do this. so this is doing melanoma surgeonsout of business? i mean, if a gp can handle thisquite well in a rural town. a gp can handle thisperfectly adequately. let me go back to the beginning, though. the important thing not to do hereis to do a punch biopsy, the important thing is to dothe excisional biopsy.

punch biopsies can bevery misrepresentative of the underlying natureof a melanocytic lesion if they're not chosen correctly. and a lot of mistakes have been madethat way in punch biopsy and getting a report backthat's relatively benign and leaving it, and it's a melanoma. so they have to be excisional biopsiesand this one, a 0.2mm thick melanoma, no-one is going to doa sentinel lymph node, the chances of that being anywhere neara sentinel lymph node

are exceedingly smallso there's no need to do that. it's only when a lesion is 1mm thickerthat you would really consider at least discussing the issueof sentinel lymph node and referring the patient. if the sentinel lymph node is negative, then certainlythe patient's prognosis is better and that reassures a lot of patients. the unfortunate thing is,if the sentinel lymph node is positive, then most surgeons,the conventional treatment now

is to then go and cut outall the rest of the lymph nodes and there's no evidencethat that actually improves a patient's prognosis at all... norman: and then there's the lymphedemato be concerned about? yeah, and they get all the complicationsso it's the following step, knowing the prognosis aspect is goodbut going that step further and having all the glands taken outis the really contentious thing that there's no good evidence for. and what about adjuvant therapyin melanoma?

well, we're at a stage now where there's no recognisedadjuvant therapy in melanoma outside a clinical trial. for a while, interferon was looked atbut subsequent trials suggest that that wasn't actuallyimproving the outcome so we don't offer adjuvant therapy and i think one of the difficulties is,up until very recently, we haven't had much promisein therapy of widespread disease so we've really had nothing thatgives us any encouragement to use

in the adjuvant situation. norman: and in widespread disease? in widespread disease, chemotherapy has beenvery disappointing. dacarbizine has been the cornerstoneof it for years, barely a 15% response ratewith little influence on survival, but just recently we've started to seesome targeted therapies come through. one is targeted at a mutationin the braf gene that up to about 50% of melanomas have

and we're starting to see response ratesin some small studies of about 70%. now, we still need to knowhow durable they will be... norman: with extended survival? well, it's extended survival but we can't suggest thatthat's anywhere near cure yet because they're not achieving as manycomplete responses as you'd like. and you're gettingsome rather odd side effects - the strangest one,about a quarter of them are getting squamous cell cancersof the skin,

so that's a strange one. there's another antibody, ctla-4antibody, that's directed against an antigenon a t lymphocyte that's actually stoppingthe immune system from doing its job on the melanoma so if you can block it, maybe the immunesystem can take over and, although that's gota smaller response rate, that's where we're beginning to seesome complete responses that are durable so i think there's hope that in the nextfew years with targeted therapies,

we'll see an advancein the treatment of widespread disease, which i hope would subsequentlythen translate to adjuvant therapy. what's the chanceshe'll develop a second melanoma, jeff? chances are actually relatively high and the studies are showing thata patient who's had a primary melanoma has a 5% - 10% chance at leastof another melanoma in the following four to five years. this is actually one of the main reasonsfor us to follow up these patients, is to detecttheir next primary melanoma earlier.

norman: do you photograph themtop to toe, do you? it depends on the patient. total body photography,which is what you are referring to, is extremely useful for peoplewith multiple naevi so lots and lots of moles, some of whichmay or may not look abnormal, and you're having trouble tracking them. it's worthwhile doinga total body photography to look for new or changed molesand, remember, only about 20% of melanomasin patients with multiple moles

will actually comefrom a pre-existing naevus. the rest will come out of the blue which is why the total body photographywill help you spot that new naevus for a closer lookwith a dermascope. you can also image thingsdermascopically serially for patientswho have just had the sun damage and they've got the isolated sun damagelesion there that's been removed, then total body photography'snot really going to help because there's nothing to photograph

but the follow-upwill pick up that next lesion. let's go to frederick who's aged 73. he's an outdoor person, farms,he's a fisherman, he's got a lower leg lesion whichhe's noticed has bled from time to time, he just thoughthe'd knocked it in the paddock when he came to see you, jan,in your clinic because he couldn't get into see the doctor as he has a three-month waiting list. jan: ah, well, this is a nice...no, i won't say that. it's a red lump.

norman: looks pretty yucky,to be honest. jan: yes, but it's elevated andit's firm and it may well be growing. a lesion like that,i would consider it suspicious. norman: of what? jan: well, i guess i know the slidebut it's amelanotic melanoma, so it would be demonstratinga rapid growth rate, i would imagine. norman: jeff? jeff: well, absolutely, this iswhat i call in latin a lumpus pinkus and there's a fairly wide rangeof things it could be,

most of them are quite nasty. and amelanotic melanomais top of the list, and thick melanomas, nodular melanomas,are killers of elderly people. and quite often they present like this. the other things that can look like thisthat can also be nasty are things such as merkel cell carcinoma or atypical fibroxanthoma and poorly differentiatedsquamous cell cancers. so if you're seeing a pink growing lump

and you're not surethat it's clearly benign, you've got to remove it. norman: so, ian mccoll,an excision biopsy here? ian mccoll: yeah, an excision biopsy. now, we've talked about abcd and thenefg - elevated, firm and growing - and certainly all these conditionsthat jeff's mentioned, you really can't tell clinicallyand you've got to do an excision biopsy. norman: so this is a dermascopic view?ian mccoll: yeah. jeff: and it doesn't help at all,

it's elevated, firm,it's a clinical diagnosis. - so he had a breslow of 4mm thickness.jeff: that's correct, yes. so that's serious stuff? it is serious stuff, his five-year survival rateis probably 50-60% range with this and we're keeping a close eye on him. right. let's go to brenda who's 56, she presents with a lesion that's not responding to treatment for dermatitis,

it's been treatedover the last six or so months with antifungalsand topical corticosteroids but not getting any response and she's come to see you, jeff, because she's concerned. jeff: again, this is another oneof those isolated, pink, scaly patches that causes so much consternation whether it's actuallya patch of dermatitis or tinea or is it a skin cancer?

and this particular onewas quite cryptic, it really wasn't clear clinicallywhat it was but it was certainly clearit wasn't responding to presumptive treatmentsthat were given to it. again your alarm bells should be ringingthat this could be a skin cancer, anything from a superficial bccor superficial squamous cell cancer to amelanotic melanoma and in fact, this was biopsied to seewhich one of those it was and... norman: so we've got a close-up here?

jeff: we have.norman: so this is the dermoscopy? jeff: that's rightand you can see clues to the fact this was in fact amelanocytic lesion and we've got what are calleddot vessels. they're like the glomerular vessels, the little coiled vessels you see in intraepidermal carcinomaand psoriasis but they're much smaller so they look like dots

and also what we calllinea irregular vessels. so it's got multiple vessels. norman: the clear things or dark things? jeff: the dots arethe little dark red spots or dark pink spots in the white there within that circle, they are the dotted vessels and it's a subtle clue, i'll give you, this is quite a subtle lesion...

norman: to my little eye, this doesn't look too different from that bcc we saw at the beginning? jeff: for all practical purposes,it doesn't matter. it's been identified it's malignant and a biopsy will then end up telling you exactly... norman: except you told me to doa punch biopsy in bcc and i've just been told not to doa punch biopsy

when you think it's melanoma. so what do i do, doctor? jeff: absolutely, and i thinkit's very, very difficult to be sure that this is going to be a melanoma. if you're not very dermascopicallyskilled, and these are subtle lesions and these vessel types have only beenrecently described, so we certainly wouldn't expect everyoneto pick that as a melanoma with a dermascope

without a bit of extra training butclinically you really should be thinking that it is a skin cancerand you should be looking to biopsy it. norman: right, but ian, you're... ian mccoll: this is different, though, this isn't a pigmented lesion,this is a non-pigmented lesion and most times when you see a lesionlike this and you biopsy it, it's going to be a superficial bccor it's going to be an scc in situ... norman: so you do severalpunch biopsies here? yes, but even just one in this

is still likely to show you that it'snot the bcc or scc you were thinking. the pathologist will say... norman: so what do you do if thepathologist comes back and says, 'no, didn't find anything,' and you were really worried about itwhen you looked at it? generally, you'd re-biopsy it again or you'd ask the pathologist to dosome more cuts in it, it depends what sort of biopsyyou send down. if you send a biggish piece of tissue,

when a pathologist looks at specimensin a biggish bit, he may only be taking three or four cutsthrough it, you know, bread loafcuts through an area, so you ask them to do some more cutsand have a look further down. norman: so you trust your clinicaljudgement. yeah, you always back your clinicaljudgement against a pathologist anyway. now we've got darlenewho's 45 years old. she's a netballer,lives on a rural property, she didn't notice this lesionon her left arm but jeff did.

let's have a look at it. jeff? jeff: again,this is one of those lesions which is not very impressive clinicallyon the long view. it is isolated and it's oneof these things that argues that you really should putyour dermascope on as many lesions as possible. but certainly to the naked eyefrom here, it doesn't fulfil many of the criteriaof the abcd that we used to make us thinkof melanoma.

if you look at it a little more closerup on another image here... norman: still with the naked eye?jeff: with a naked eye, that's right. what you can seeis a little bit of irregularity, asymmetrical and border patterns, it's not greater than 6mm. now, what is striking isit's got an area of pink in the middle of this brown lesion so you really need to put a dermascopeon this and have a closer look and seewhether you can convince yourself

that this needs to come off. norman: let's have a look. jeff: and if we look at this, what we'reseeing is a lesion around about five... norman: did it feel raised to the touch? jeff: no, it was absolutely impalpableto touch but if you looked at it, you can seethat there's a lot of irregularity in the way that pigment is distributedin the lesion. it's all clumped into funny patternsaround the edges and on an even closer view,

you're actually able to seesome of the abnormal area where we've got no pigment at all,it looks a bit pinker with these, what we call corkscrew vessels. now, vessels, as you can gather, in skin lesionsthat have no colour in them, blood vessels are your only clue and it's important when you do take updermoscopy to educate yourself about these and so, this particular lesion

was consideredas being suspicious for melanoma. it had atypical network,it had the structureless area which was a little bit eccentricallyplaced with the abnormal vessels so it was taken out and sent alongto the pathologist. norman: and what did they find? the pathologist's initial report wasthat this was a benign compound naevus, which was really quite discordant with what we thought it wasdermascopically, and so because of the discordance,

we called the pathologistand asked them to take more sections. it was actually proven to be,on the further sections, a fairly obvious invasive melanomaabout 0.35mm breslow, still early, still thin but that couldhave gone through to the keeper. and what we find is extremely useful is for any pigmented lesionthat you remove, is to photograph it. it's useful for yourself, it's usefulfor your pathology reconciliation and it's useful for your referralsif you have to refer a patient on. we've only got a couple of minutes leftbut i think we can't leave the program

without talking about dysplastic naeviswhere gps feel the most nervous. are they missing somethingor aren't they? let's whizz through a few pictures and just talk through them as we go.jeff? jeff: well, this gentlemanhas obviously got multiple naevi and these patients can be a realdestroyer of your appointment schedule with the number of lesionsthat need to be looked at and this patient is a great candidatefor total body photography of which this is an image.

you'd look at comparing this kind ofpicture for images down the line, perhaps a year lateror six months later. the patient can also do examinationswith a partner, matching up the photographthey have in their hand with what the partner can seeon the photograph. norman: could reinvigoratetheir relationship. jeff: indeed, if you put numbersagainst each particular... norman: so let's look at the picture,is this eye or dermoscopy? this is dermoscopy.

so again, first sight,is this that different from a melanoma? i'm seeing clear bits in the middle,i'm seeing uneven pigmentation, i'd be getting the shivers down my spinethat this is a melanoma. well, this is one of the problemswith dysplastic or atypical naevi, that they do somewhat look like thatbut the thing is, if one of them looked like thatthen all the other naevi were different, you know, looked benign,then you would go for this but the problem hereis a lot of them will look like this but that's also a good signbecause they're not all melanomas.

this is just the patternthat this particular patient has for the dermoscopy of their naevi. and again, that's not too chaoticbut you'll get to a certain one later... norman: so it's got a smooth edge to it. ian mccoll: again, this particular one, it's within the patternof the other naevi that this patient in fact had but sometimes you'll come on onethat is very, very chaotic in comparison to any of the others

or it has some of the dermatoscopicfeatures of melanoma that jeff was talking about... norman: so all theseare dysplastic naevi? ian mccoll: all of these are dysplasticnaevi, the dermoscopy of them. this is another patient. now, those are two big lesionsthat you'd certainly be concerned about. but the patient had said thatthese had been stable for years, they hadn't changed. you, in fact, photograph themand the next time you see him back,

you look at them again and you keep looking at them and justbecause these are very big lesions doesn't necessarily meanthat they're melanomas, they're not. that was that particular patient therewith these two big lesions on the side. so photography is useful in followingthese up but as jeff said earlier on, the thing about dysplastic naevi is that often the melanoma doesn't arisefrom the dysplastic naevus, it's a new pigmented lesion that's comeup. that's what you're looking for. norman: but in a patientwho's had dysplastic naevi,

so their skin is primed, if you like? jeff: you're looking for both.- i agree. you're looking for both. so what are your take-home messages?jan? i think for good patient outcomes, it is that, cultivate an educated,multidisciplinary team. norman: so get your nurses involvedand have a friendly pathologist. and keep the education up,keep it going. norman: ian olver? well, my primary message is prevention.

it's so simple to cover yourself upand use sunscreen during the summer. my other message though is get to knowwhat your skin looks like and anything that you're worried aboutthat's changed, seek advice without delay. the people who are dyingare often the elderly males who have things arising on their back so my take-home messagewould be to ask yourself, who's looking at my back? norman: hmm. jeff?

in primary care,i'd say get yourself one of these, get your patient undresseddown to their underwear, get some basic surgical skills and you'll be able to take careof the bulk of the skin cancers that walk through your door. thank you very much to you all,great program and i hope you've enjoyed it too. our thanks to the department of healthand ageing for making it possible, thanks to you for taking timeto attend and contribute.

if you're interested in obtaining moreinformation about the issues raised, there are a number of resourcesavailable on the rural health educationfoundation's website - www.rhef.com.au. don't forget to completeand send in your evaluation forms to register for cpd points. i'm norman swan, i'll see you next time�