Oncology: Skin Cancer

• Skin: Melanoma | Treating Melanoma | Basal and Squamous Cell Skin Cancers | Other Skin Cancers and Prevention
• Other cancers: Head and Neck Cancer | Sarcoma | Cancers Covered in Other Chapters
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

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

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Drug Reference Table

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Spot the Diagnosis

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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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