Xiaflex. Amputation, you can use it as a
So the answer has come up. I'll just go through
this. BCC can arise in a chronic
pressure ulcer, true or false? What can arise
in a chronic pressure ulcer then? Marjolin’s.
It’s called SCC. BCC doesn't metastasize.
Immunosuppressed patients are highly more
prone to develop SCC not BCC. And BCC is normally
excised at 3 cm margins - true or false?
5 cm margins? 3 mm margins. So it’s normally
excised at 3 mm, not 3 cm? So here again,
you got the answer there. But is
that malignant or not? Keratoacanthoma?
No, it is carcinoma in situ. Some pathologists
says a well defined squamous cell carcinoma.
Early, early stage. Its not pre-malignant at
all. I'll tell you why. In keratoacanthoma,
the course is, it grows very
rapidly over say 4 to 5 months. Then it plateaus
off for 3 to 5 months. Then it reduces in size
and disappears completely. But in some people,
that can stay and become a SCC. Okay, so it
is not a benign condition, it is a carcinoma
in situ. Actinic keratosis is pre-malignant.
not pre-malignant. Yes, pyogenic granuloma
in trauma, somewhere the digit, you get a
hematoma, it's neither pyogenic nor a granuloma.
But they call it pyogenic granuloma. It's just
a bit of hematoma. Just don't get mixed
up between seborrhoeic
keratosis and actinic keratosis. This is where
we see people getting confused between
those two. Seborrhoeic keratosis is benign,
that's just stuck on lesions. You see in elderly
people. Actinic keratosis also called solar
or senile keratosis is a pre-malignant lesion.
Okay. All these are risk factors for SCC, sun exposure,
ionising radiation, drugs, papillomavirus, hydrocarbons.
You can't distinguish
between the three, sun
exposure, exposure to sun tanning, sun tan.
You can get any of the three cancers.
It's very difficult to say you're getting melanoma,
you're getting SCC. Usually, I take a point,
sailors, people who have been working in the sun
for 50 years, they end up with a SCC or
a BCC. But they can always --
But sometimes you get more melanoma?
Yeah because it's much more intense. Intense.
But I would say to be bit more careful.
You can also get an SCC from the sun bath. Yeah
and you can get a melanoma in a sixty year
old who has been working in Middle East for
twenty five years. So yeah.
I won't waste too much time on this. What
do you think the diagnosis are? What are the
options with that that sort of history? Melanoma,
BCC, nodular BCC. SCC I wouldn't go,
normally BCC, melanoma. Then a pyogenic granuloma,
hematoma. These are your diagnosis. SCC you
wouldn't get it that way. SCC will have the
classically everted edges.
BCC, treatment of BCC? Excise. Surgical excision.
Three to five mm is fine.
Does it depends on the initial size as well?
That's for SCC, it depends. For BCC, it doesn't
depend on the initial size, it depends on
the type. If you have a nodular melanoma,
BCC, 3 mm is fine. But then there is something
called morphic BCC, where the margins are indistinct.
Then you have to take wider margins, in morphic.
But three to five mm is safe for
an exam. Okay, this is a classical BCC.
This is a classical
BCC with a central crater, and rolled over
edges. Central crater and rolled out edges.
So this is what the history they will give
you. Eyelid, somewhere around that area,
with a central crater, and everted edges. Types of
BCC are superficial, nodular, ulcerative,
infiltrating, morphic. But, what do you think
this might be? Ulcerative. Ulcerative BCC.
Now, this is a keratoacanthoma.
This is a keratoacanthoma. It grows so rapidly,
you're pretty much unsure what to do next.
But then with experience, you realize that
it also shrinks quite quickly. By one year,
this would have completely disappeared. So
duration, progression, sun exposure,
they'll ask the differentials of keratoacanthoma?
It could be a SCC. So if you are unsure of
the diagnosis, what do you do? Punch or incisional
biopsies. Wait and watch. Biopsy, if you're unsure.
Now this keratoacanthoma is slightly annoying
in the exam, because you really don't know
what to answer. There's a school of thought
where they say wait and watch, this is a
KAA, it will disappear. But then other people
think, how do you know it's a KAA unless you
do a biopsy? How sure are you? Imagine
that's an SCC, and you leave it for a year. They will
end up with all sorts of metastasis.
Okay. So if you get a keratoacanthoma in the
exam, just look at the options very carefully,
what are the things they have? If they have
a biopsy option, go for it.
This is a SCC. Diagnosis, you do an incision
biopsy first. Then you examine the lymph nodes
and then you do the wide local excision. Amputation
of the ear, and neck dissection.
That’s what we discussed in the morning.
Yeah, in elderly patients it’s very difficult
to reconstruct, you know you are excising
all of this. So there's probably nothing
much you can really do now. You probably have
some artificial ears.
Biopsy is the gold standard for diagnosis
of BCC. Three options are punch, incision
or excision. Excision is when you excise,
and you're sure that you can close the primary.
Otherwise if unsure, go for punch or incision.
You need to know this
because there are questions which
will ask you excision margins of BCC, three
to five millimetres. Infiltrative or morphic,
you may need a slightly larger margin.
Squamous cell carcinoma, well defined tumour,
less than two centimetres, you go for four
millimetre margin. More than two centimetre,
that's the size of the lesion, you go for
six millimetre margin. Poorly defined, one
centimetre. If the tumour is two centimetre
diameter, if this is two centimetres, then
you take four millimetres. If this is a four
centimetre tumour, big one, you take six millimetres.
So, what we normally teach is, for a BCC,
have in your head as three to five millimetres.
For an SCC, have it as six to ten millimetres.
So pretty much double. Always think double
for SCC. I'm sure you know the
diagnosis. It's a
melanoma. This is what we are are coming at.
Other things you need to examine are the
lymph nodes and the abdomen. Okay management
of that patient. If you're asked a scenario,
what you do next? The answer is do an excision biopsy.
Never mention core, incision. Nothing for
melanoma, always excision biopsy. If you
try to do a core biopsy, you'll distort the
entire architecture. Okay, so what do you
do after you excise with two millimetres?
What’s next? Breslow thickness. Then your
further management depends on the Breslow
thickness, which I'll come to the next slide.
Until you get the Breslow thickness, if you
can close the wound directly, close it. Otherwise
you leave it open.
Okay so, asymmetry. B is what? Borders or bleeding,
Colour variegation. Diameter more than six
millimetres, diameter expanding more than
six millimetres. Elevation. Ulceration, satellite
lesions. Six millimetres halo and irregular
Now, I put this slide just to
give you another type of question
they ask, what are the features in a histology
that will suggest malignancy? What are things
you look for in histology? Mitotic count,
yes, very good. Anything here?
Areas of haemorrhage and areas of necrosis.
Invasion to adjacent structures. What else?
Nuclear-cytoplasmic ratio. The nucleus will
expand, becomes larger. So these are things
you need to look for in histology. Specifically
for melanoma, these things. But you don't
really have to go into the details of knowing
it. But if you have a question related to
differentiating between a benign lesion and
a malignant lesion, the things to be looked
for are mitotic count, areas of haemorrhage
and necrosis, areas of direct invasion, breach
of the basement membrane and nuclear-cytoplasmic
Now, we've done that. We've done an
excision biopsy. Leave that for one