Oncology: Skin Cancer

Melanoma

The basics: Cancer of melanocytes. It is one of the commonest cancers in young adults, and incidence is rising.

Risk factors:

• UV exposure - especially sunburn in childhood and sunbeds.
• Fair skin, red or fair hair, freckles.
• Many moles (over 100) or atypical moles.
• Personal or family history (CDKN2A).
• Immunosuppression.

Recognising melanoma:

• Weighted 7-point checklist (NICE) - refer if the score is 3 or more:
  • Major (2 points each): Change in size, irregular shape, irregular colour.
  • Minor (1 point each): Largest diameter 7 mm or more, inflammation, oozing, change in sensation.
• ABCDE: Asymmetry, Border irregularity, Colour variation, Diameter over 6 mm, Evolving.
• "Ugly duckling" - a mole that looks different from the patient's others.

Types:

• Superficial spreading (the commonest) - a flat, irregular, multicoloured patch.
• Nodular - a raised, firm, rapidly growing nodule, sometimes amelanotic (pink). "EFG" - Elevated, Firm, Growing. Grows deep quickly; poor prognosis.
• Lentigo maligna melanoma - sun-damaged faces of older people.
• Acral lentiginous - palms, soles and under the nails (a dark streak with pigment spreading onto the nail fold - Hutchinson's sign). The commonest type in people with darker skin.
• Mucosal and uveal (eye) melanoma - not UV-related; uveal melanoma spreads to the liver.

Diagnosis:

• Urgent suspected cancer referral (dermoscopy, often teledermatology).
• Excision biopsy with a 2 mm margin - don't shave or partially remove a suspected melanoma.
• Breslow thickness (depth in mm) and ulceration are the key prognostic factors.

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Treating Melanoma

(NICE NG14)

• Wide local excision - margins of 1–2 cm (depending on thickness); 0.5 cm for in situ melanoma.
• Sentinel lymph node biopsy for melanomas thicker than about 0.8 mm (staging).
• Staging CT (or PET-CT) and MRI brain for stage III and IV.
• BRAF mutation testing (about half are BRAF V600-mutated).
• Adjuvant treatment (stage IIB–III, after surgery) - immunotherapy (pembrolizumab or nivolumab) for 1 year, or BRAF/MEK inhibitors (dabrafenib with trametinib) if BRAF-mutated. Neoadjuvant immunotherapy for some resectable stage III disease.
• Metastatic melanoma:
  • Nivolumab with ipilimumab, or single-agent PD-1 inhibitors. About half of patients on combination therapy are alive at 10 years.
  • BRAF/MEK inhibitors (rapid responses).
  • Brain metastases are common - immunotherapy and stereotactic radiosurgery.
• Uveal melanoma - tebentafusp for metastatic disease (specific HLA type); liver-directed treatments.
• Follow-up:
  • Skin self-examination.
  • Clinical review (and imaging for higher stages).
  • Sun protection.
  • Vitamin D check (avoiding the sun lowers it).
  • Examine first-degree relatives' skin if multiple melanomas run in the family.

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Basal and Squamous Cell Skin Cancers

• Basal cell carcinoma (BCC) - the commonest cancer in the UK:
  • Slow-growing; almost never spreads, but can destroy local tissue ("rodent ulcer").
  • Appearance: A pearly papule with a rolled edge and fine blood vessels (telangiectasia), often with a central ulcer or crust. Superficial BCCs are red scaly patches.
  • Mostly on sun-exposed areas of the head and neck.
  • Refer routinely (urgently if the site or size is a concern, e.g. near the eye).
  • Treatment:
    • Surgical excision.
    • Mohs micrographic surgery (high-risk face sites).
    • Superficial types: imiquimod cream, photodynamic therapy, cryotherapy, curettage.
    • Radiotherapy.
    • Vismodegib (hedgehog inhibitor) for advanced disease.
• Cutaneous squamous cell carcinoma (SCC):
  • Arises on sun-damaged skin, often from actinic keratoses or Bowen's disease (SCC in situ).
  • Appearance: A keratotic, crusted, tender nodule that grows over weeks to months; may ulcerate or bleed.
  • Can spread to lymph nodes - higher risk on the lip and ear, if large, deep, poorly differentiated, with nerve invasion, or in immunosuppressed people.
  • Organ transplant recipients have a much higher risk (up to 100 times), and more aggressive disease.
  • Urgent suspected cancer referral (NICE NG12).
  • Treatment: Surgical excision (radiotherapy if surgery isn't possible); cemiplimab (PD-1 inhibitor) for advanced disease.
• Actinic (solar) keratoses - rough, scaly, sun-damaged patches; a small risk of SCC. Sun protection, 5-fluorouracil cream, imiquimod, diclofenac gel, cryotherapy, photodynamic therapy.
• Keratoacanthoma - a rapidly growing dome-shaped nodule with a central keratin plug; treated as SCC (excision).

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Other Skin Cancers and Prevention

• Merkel cell carcinoma - a rare, aggressive neuroendocrine skin cancer in older or immunosuppressed people. A fast-growing painless red or purple nodule. Linked to Merkel cell polyomavirus. Surgery, radiotherapy, immunotherapy (avelumab).
• Kaposi sarcoma - purple patches or nodules; HHV-8; HIV, transplant, older Mediterranean men. Antiretrovirals, reduce immunosuppression.
• Cutaneous lymphoma - mycosis fungoides (see the Lymphoma chapter).
• Dermatofibrosarcoma protuberans - slow-growing firm plaque on the trunk; local recurrence.
• Prevention:
  • Sun protection - shade, clothing, hat, SPF 30 or higher with high UVA protection, avoid sunburn, no sunbeds.
  • Especially for children, people with fair skin, transplant recipients and previous skin cancer.
  • Nicotinamide (vitamin B3) may reduce new skin cancers in high-risk people (e.g. transplant recipients).
  • Regular skin checks for transplant recipients.

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Head and Neck Cancer

The basics: Cancers of the mouth, throat (pharynx), voice box (larynx), nose and sinuses, and salivary glands. Mostly squamous cell carcinoma.

Risk factors:

• Smoking and alcohol (together multiply the risk).
• HPV - oropharyngeal cancer (tonsil, tongue base). Often younger non-smokers; better prognosis.
• Betel nut and paan chewing (mouth cancer - South Asian communities).
• EBV (nasopharyngeal cancer - South-East Asian and North African origin).
• Poor oral hygiene; immunosuppression.

Red flags (NICE NG12) - urgent referral:

• Persistent unexplained hoarseness for 3 weeks or more (age 45 or over) - laryngeal cancer (or lung cancer affecting the recurrent laryngeal nerve).
• Unexplained neck lump (age 45 or over), or a persistent or growing one at any age.
• Mouth ulcer persisting over 3 weeks.
• Lump on the lip or in the mouth; red or white patches (erythroplakia, leukoplakia) - dentist or urgent referral.
• Persistent sore throat or pain on swallowing; ear pain without ear disease (referred); one-sided blocked nose with bleeding.

Assessment:

• ENT examination and nasendoscopy.
• Ultrasound-guided biopsy of neck nodes.
• CT and MRI; PET-CT.
• HPV (p16) testing.

Treatment:

• Surgery and/or radiotherapy, often with cisplatin (chemoradiotherapy).
• Immunotherapy (pembrolizumab) and cetuximab for recurrent or metastatic disease.
• Laryngectomy - a permanent stoma; voice prosthesis.

Side effects and supportive care:

• Mucositis (painful mouth during radiotherapy).
• Dry mouth (xerostomia) and dental decay - pre-treatment dental assessment; fluoride.
• Dysphagia - speech and language therapy; feeding tubes.
• Osteoradionecrosis of the jaw (avoid later extractions without specialist care).
• Hypothyroidism; neck fibrosis; lymphoedema.
• Psychological impact (appearance, speech).
• Stop smoking and drinking - improves outcomes and lowers second-cancer risk.

Thyroid cancer is covered in the Thyroid chapter.

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Sarcoma

What it is: Rare cancers of connective tissue - soft tissue sarcomas (fat, muscle, nerve, vessel) and bone sarcomas. About 1% of adult cancers, but more common in children and young adults.

• Soft tissue sarcoma:
  • A lump that is larger than 5 cm, deep to the fascia, growing, or painful. Most lumps are benign lipomas, but these features need urgent assessment.
  • NICE NG12: Urgent direct-access ultrasound for an unexplained growing lump in adults; urgent referral if the scan suggests sarcoma.
  • Types: Liposarcoma, leiomyosarcoma, undifferentiated pleomorphic sarcoma, synovial sarcoma, and others. GIST (see the Oesophagus and Stomach chapter). Retroperitoneal sarcomas are often large at diagnosis.
  • Risk factors: Previous radiotherapy, Li–Fraumeni syndrome, NF1 (malignant nerve sheath tumours), lymphoedema (angiosarcoma).
• Bone sarcomas:
  • Osteosarcoma - teenagers; around the knee (distal femur, proximal tibia); bone pain (often at night) and swelling. Also in older people with Paget's disease or after radiotherapy.
  • Ewing sarcoma - children and young adults; pelvis, long bones; fever and pain.
  • Chondrosarcoma - older adults; pelvis, shoulder.
  • NICE NG12: Very urgent X-ray for children and young people with unexplained bone swelling or pain.
• Management:
  • Refer to a specialist sarcoma centre before biopsy - a poorly placed biopsy can spread tumour and prevent limb-saving surgery.
  • MRI and CT chest (lungs are the commonest metastatic site).
  • Surgery with wide margins; radiotherapy; chemotherapy (osteosarcoma, Ewing sarcoma).

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Cancers Covered in Other Chapters

Cancer	Chapter
Lung cancer, mesothelioma	Lung Cancer and Pleural Disease
Oesophageal and gastric cancer	Oesophagus and Stomach
Colorectal and anal cancer	Bowel Disorders
Pancreatic, biliary and gallbladder cancer	Pancreas and Biliary
Hepatocellular carcinoma	Cirrhosis and Liver Tumours
Brain tumours	Brain Tumours, Spine and Other Neurology
Thyroid cancer, adrenal and pituitary tumours	Thyroid, Adrenal and Pituitary chapters
Neuroendocrine tumours, MEN syndromes	NETs and Hypoglycaemia
Leukaemia, lymphoma, myeloma	Haematology chapters
Breast and gynaecological cancers	Breast and Gynaecological Cancers

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Drug Reference Table

Drug	Key points
Carboplatin (single dose)	Stage I seminoma.
Dabrafenib + trametinib	BRAF-mutated melanoma; fever, rash.
Imiquimod / 5-fluorouracil cream	Superficial BCC, actinic keratoses, Bowen's disease; local inflammation.
Cemiplimab	Advanced cutaneous SCC.

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Spot the Diagnosis

Clue	Diagnosis
Changing irregular multicoloured mole on the back of a 35-year-old	Superficial spreading melanoma
Firm pink nodule growing over 2 months	Nodular (possibly amelanotic) melanoma
Dark streak in a nail with pigment on the nail fold	Subungual acral melanoma (Hutchinson's sign)
Pearly papule with rolled edge and telangiectasia on the nose	Basal cell carcinoma
Rapidly growing tender crusted nodule in a kidney transplant recipient	Cutaneous squamous cell carcinoma
Hoarse voice for 6 weeks in a 60-year-old smoker	Laryngeal cancer (or lung cancer)
Neck node in a 45-year-old non-smoker with a tonsil mass, p16 positive	HPV-related oropharyngeal cancer
Teenager with night-time knee pain and swelling	Osteosarcoma
Deep, painless 8 cm thigh lump that is growing	Soft tissue sarcoma (refer before biopsy)

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1. A 40-year-old has a changing 9 mm mole with irregular colour and border.
Answer: Suspected melanoma (7-point score at least 5).

• Urgent suspected cancer referral to dermatology.
• Excision biopsy with a 2 mm margin; Breslow thickness guides wide local excision and sentinel node biopsy.
• Sun protection advice; skin self-examination.

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Key Points

• Prostate cancer: commonest male cancer (1 in 4 Black men). PSA testing needs informed discussion; MRI comes before biopsy.
• PSA is raised by infection, retention, catheters and ejaculation; halved by finasteride.
• Low-risk prostate cancer: active surveillance. Metastatic: ADT plus a newer hormonal drug.
• Cover LHRH agonists with an anti-androgen; monitor bones and cardiovascular risk on ADT.
• Visible haematuria at 45 or over (no UTI): urgent cystoscopy and CT urogram. Smoking is the main cause of bladder cancer.
• Kidney cancer: often incidental; paraneoplastic polycythaemia, hypercalcaemia, hypertension; immunotherapy combinations for metastatic disease.
• Testicular cancer: young men, painless lump; AFP, hCG, LDH; inguinal orchidectomy; over 95% cured. AFP is never raised in pure seminoma.
• Melanoma: use the 7-point checklist; excise with a 2 mm margin; Breslow thickness guides prognosis; immunotherapy has transformed outcomes.
• Nodular melanoma: Elevated, Firm, Growing - may be pink.
• BCC: pearly, rolled edge, telangiectasia, rarely spreads. SCC: crusted, tender, growing - urgent referral, especially in transplant recipients.
• Head and neck red flags: hoarseness over 3 weeks, mouth ulcer over 3 weeks, neck lump, red or white patches.
• HPV-related oropharyngeal cancer has a better prognosis.
• Lump over 5 cm, deep, growing or painful - urgent ultrasound; refer suspected sarcoma before biopsy.
• Unexplained bone pain or swelling in a young person - very urgent X-ray.

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Guidelines and Further Reading

• British Association of Dermatologists guidelines: BCC, cutaneous SCC
• British Sarcoma Group guidelines
• Prostate Cancer UK; Action Bladder Cancer UK; Melanoma Focus
• BNF - for current doses

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