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Hello. Hi. Yeah, we can hear you. Can you? Okay. I'm sorry. I don't know what's happening. Um, do you mind if I just rejoined the chat? Because it keeps like freezing for me. I don't know if it's the same on your end. No, it's fine. You can rejoin or if it's okay for you. Should I just carry one? And it sounds good to me. If anyone isn't able to hear us or hear her, then please just put in the chat and let her know, but it sounds fine. Carry on. I think it sounds good. Ok. That's great. All right. So, as I was saying, so in my own experience of having studied at University of Liverpool, skin tone skin cancer is quite a high yield exam topic both theoretically and in osk ease. So this is basically what I based this lecture off of. It's quite exam focused. So it's not going to be all you would ever need to know about skin cancer, but it should be more than enough to get you through. Your exams is aimed more so at the clinical year. So maybe years three and four, but obviously everyone is Welcome to join. Um And at the end of the Power Point is a QR code and you can access the feedback link through there. And I think then you can get access to your certificate as well. So that would be much appreciated if you would fill that out. So um without further a do I'll get started. Um I'm not going to pick on anyone but feel free to just shout out and I don't think I can see the chat box. So if you can just speak out loud or maybe Irobot or uh Amara can read them out. Uh Anyone puts anything in the comments. Okay. So things that will be covering today are some basic dermatologic anatomy just so you can understand the skin cancers better. We've got some skin types to cover um the actual cancers themselves. We'll go over some referral criteria and then round off with some exam star questions which are actually taken from past papers as well. Fine. So starting with some basic anatomy, this is essentially your skin. Can I just ask? Can everyone see my mouse? Yeah, you can see a mouse you can see. Okay. Great. So essentially this is your skin. So you have three main layers that you need to know of. So you have your epidermis at the top your dermis in the middle and then your subcutaneous fat, also known as the Hypodermic is uh so there are four main kinds of cells in your skin, all of which are in the epidermis. So you have your Claritin insights which produce um keratin and these former protective barrier. So if you look at the top here, we have something called the keratin layer. Those are produced by your keratinocytes. You have your Langerhans cells which are these pink ones here. These are responsible for immune protection. You have your melanocytes which are these uh brown ones here. So, melanocytes produce melanin, which you may already be familiar with. These are responsible for the extent of pigment in your skin. So the more melanin you have the darker your skin appears and melanin is responsible for protection against the sun. And then you have your merkel cells which are these blue ones here and these contain nerve endings. Now, in terms of skin cancer, specifically the ones that you need to be aware of or your keratinocytes responsible for the keratin layer and the melanocytes which are responsible for UV protection via melanin. Okay. Does all that make sense? Okay. So, moving onto skin types. So you may have already heard of Fitzpatrick skin types. So the Fitzpatrick classification system categorizes skin types based on how they respond to sunlight. So if we take this scale, for example, we can see type on skin is very pale and in response to sunlight, this always burns and it never tans. And if we look at the other end of the scale, for example, type six skin, this in response to sunlight never burns, but it tan's very easily. So if we tie that into the previous light and what we've just covered, we know that the darker skin types have more melanin. And like we just mentioned, melanin is responsible for protection against U V. And that is why these darker skin types are less likely to burn. And so in the context of skin cancers, you might already be extrapolating the fact that because these lighter skin types have less melanin, therefore less UV protection, they are more vulnerable to skin cancer. And just for clarification, everyone has the same number of melanocytes. It's just the darker skin types have more melanocytic activity, therefore, more melanin is produced. Okay. So moving on to the actual skin cancers themselves, there are three main cancers that make up 98% of skin malignancies. Does anyone know what they are? Great? Sorry, I think someone said something but my audio is not great. It was very broken. Melanoma B C C and sec. Yeah, perfect. So you have your B C C S, you're S CCS and your melanoma's. So all of these are related to UV exposure. So like I said, based on what we've just covered already, we know that the lighter skin types are more vulnerable because they have less melanocyte site activity, therefore, less melanin, therefore less UV protection. The incidence of these skin cancers has also markedly increased over the decades that's just something to be aware of and it's for multiple reasons. So we have an aging population. Um There has been an increase in. Um So there's been increased technology develops such as sun beds. Um The type of clothing that people were now compared to several decades ago, allow for more direct sun exposure onto the skin. Um So it's just something to be aware of. So, like I said, because these three cancers make up most uh skin malignancies. These are the ones that will be on your exam and these are the three that we're going to cover today. However, if you are interested, these are the uh some of the ones that make up the other 2% you can look at these in your own time, but that we're not going to be covering these today. So going into basal cell carcinomas. So, what I've done is I've put the key differentiators for A B C C in blue. So these are the sort of buzz words that you should be looking out for in your exams. So be CCS are the most common skin malignancy. So just for context, if you have six people with a skin cancer, three of them will have A B C C, two of them will have an SCC and then one will have a melanoma. Okay. So these are the most common there derived from the keratinocyte. So if you remember from the first diagram, um these are the cells that are responsible for producing that protective barrier. On top of the keratin layer, these have extremely slow growth and our only locally invasive they will rarely metastasized. So if you get somebody coming in with A B C C, you can pretty much reassure them that there is a 99.999% chance that this will not kill them. So in terms of how they present they are commonly on the head and neck. Does anyone know why lousy? Which one most was supposed to? Sorry, baby. Huh. Sorry. Can you say that again? So most so, so the reason that they're commonly on the head and neck is because these are sun exposed sites, as I've mentioned, um these cancers are related to sun exposure. They often have a rolled pearly edge. So if we look at this photo here, you can see that this is the entirety of the lesion, the edges of rolled and you can see that sort of pearly sheen on the, on the border as well. They can have telangiectasia. So that's basically a collection of blood vessels which you can see running across the surface of this uh BPC. Um So a common presentation is actually patient's presenting and saying that, oh, you know, I had this new sort of spot and I scratched it and it started bleeding or I knocked it and it started bleeding and that's because they are so vascular, they can often present with central ulceration. And I just want to highlight the fact that I've said centrally ulcerated because if you look at back at this first photo here, you can see that the edge of the lesion starts here, but it's only the middle that's actually ulcerated. And the reason I want to draw your attention to this is because in the past, I have had an exam question where there is no photo, but it's only a descriptor of a type of ulceration. And you have to differentiate between this and a different cancer which we will get into in a second. But just remember that be CCS are more sort of centrally ulcerated rather than the entire lesion being ulcerated. The most common types are nodular and superficial. There are several different types that we're not going to go into all of them. But these are the ones that will be coming up on your exams if they do because these are the ones that tend to present with these buzzwords here. As you can see, this is a nodule ated BCC, whereas this is slightly more superficial. So risk factors include older age as with most cancers. It's more common in men long term UV exposure. So this is quite key here. So particularly from childhood. So the way that I remember this is I think of a brick layer. So imagine somebody who's been under the direct sun for 40 odd years. Um And they have presented with A B C C on their forehead or their nose. Um So I think beef, a bricklayer and B for B C C. It's that long term cumulative exposure, pale skin as we've already established because they have less melanin and therefore less you be protection. Immune suppression has medical history of a basal cell carcinoma and some others as well in terms of management. Um Sorry, would everyone be able to meet their Mike, please? Thank you. Um, in terms of management, it really depends on the type of basal cell carcinoma that it is. So, in terms of the nodular ones, generally, you would go straight for surgical excision. So something that you might see cropping up as it's becoming more common is something called most surgery, which is essentially where you go in and you remove the cancer layer by layer until you reach healthy tissue just to ensure that you've got the entirety of the lesion out. However, if you've got a superficial BCC, which doesn't necessarily need something as invasive as surgery, you have other options as well. So for example, you could go for cryotherapy, which is essentially freezing the lesion off with liquid nitrogen and then it should fall off in a couple of days. You can go in with curettage in quartering, which is basically scraping the lesion off. And then if there are any exposed or bleeding blood vessels and you can quartering eyes them or you have topical agents as well. So the main two that you'll come across are imiquimod and five fluorouracil. So the way that these work is imiquimod essentially modifies your immune response to stimulate uh your cytokines to target cancer cells and destroy them. Whereas five fluorouracil targets sun damaged cells which are not necessarily cancerous. So the way that I remember this is Emiko Imad modifies your immune response. Take it or leave it, that's just how I remember it. Um Fine. So any questions on be CCS? No? Okay. So let's move on to the next skin cancer, which is a squamous cell carcinoma. So here I've put the key differentiators in green. So as I mentioned before, these are the second most common type of skin malignancy. These are similarly off to derive from the keratinocyte. The cell is responsible for producing that top layer. However, these do grow a little bit faster. So these grow over weeks, two months. So they do have the potential to metastasize in terms of how they present they are commonly on the head and neck again, for the same reason that they are sun exposed sites, they are often ulcerated. So if we look at this picture here, and I just want you to remember the photo that I showed you previously for A B C, see where it was centrally ulcerated. If you look in contrast here with the sec, this is where the lesion starts and the entire lesion is ulcerated. And the reason I'm bringing this to your attention is because we had an exam question that just said, um, it sort of described the lesion as uh you know, it's come on over x many months and um the lesion is sort of dark and ulcerated in its entirety. And a lot of people put a basal cell capacity because both have the potential to ulcerates. It's just S CCS on more so um ulcerated in their entirety. Whereas be CCS are more uh more often centrally ulcerated, cutaneous horns are quite uh pathognomonic of squamous cell carcinomas. So if you look here, we have a squamous cell carcinoma. And then on top here, we have a cutaneous horn. So this is actually made of keratin. Um And as you can see, because the cancer is derived from the keratinocyte which are responsible for producing that keratin and that protective barrier. A cancer is essentially over proliferation of those cells, which is why this cutaneous horn forms because it's over proliferation of the keratin. So risk factors include again, older age, again, more common in men, long term sun exposure, which is cumulative similar to the BCC. But there is a slight difference and I'll get into that in a second pale skin. Again, as we mentioned, immune suppression, past medical history, smoking, in particular for squamous cell carcinoma of the lips. And again, I just want to highlight that you can see with this lesion, the entirety is ulcerated and pre malignant lesion. So this is what I was talking about with the long term sun exposure, but there is a slight difference. So essentially squamous cell carcinomas develop up sites of long term sun exposure that has caused skin damage, which are known as these pre malignant lesion's of which there are two types that you need to be aware of. So the first one is actinic keratosis. So this is basically sun damage. And if you have more than 10 of these lesion's, then that increases your risk of a squamous cell carcinoma by about 10%. So just looking at this photo here, we can see that yes, this is the squamous cell carcinoma. But if you look at the surrounding skin, there is clear evidence of sun damage as well. The other lesion to be aware of is Bowen's disease. So this is basically a squamous cell carcinoma in situ. So it is a bit of a gray area as to whether this as to whether this is technically pre malignant, but essentially an SCC in situ means that it has uh the cancer is still confined to the cells from which it arose, it has not invaded any nearby cells. So these developments sun damaged areas as well. They're commonly on women's legs, as you can see here. Now of these lesion's 5% progressed to become invasive, so they start invading the cells around them. And of those 5% will then metastasize. So in terms of management, generally for squamous cell carcinomas, you would go straight for surgical excision. And again, with the option of mohs surgery where you remove the lesion layer by layer until you reach the healthy tissue. However, if it has metastasized or if the area is large and unresectable, then you would opt for radiotherapy. Okay. Any questions on squamous cell carcinoma? Um Sorry. Yeah, I had a question. Um Does the sec start as a central also? Is it like it starts alternating completely? Um So it is a little bit variable. Um So as you can see, not all of them are necessarily ulcerated. So if you look at this picture here, they can sometimes form of the cutaneous horn ulceration does tend to happen afterwards. Um but they are variable on how they present. But just for the purpose of your exams, if the entirety of the lesion is ulcerated, it's more likely to be an SCC than A B C C. Yeah. All right. Thank you. No worries. Okay. Any other questions? Okay. So then moving on to the third cancer which is a Melanoma. So I put the key differentiators in red here. So unlike the other two, this one is derived from the Milana sites, okay, Melanomas can definitely be invasive and they definitely have the potential to metastasize. So the way that I remember the places that they commonly metastasized to are the three elders and the two B's. So the lymph nodes, lungs, liver bones and brain, in terms of how they present commonly, a patient will come in with an unusual looking mole or freckle. And then it, they will say that it has changed in some way, whether it's become raised. There's a change in pigmentation, it's itchy, it's bleeding, you name it. There's been some sort of change. This is a pretty textbook melon. Um um it's got sort of ill defined borders, there's irregular color, there's irregular colors within it. You've got sort of darker black areas here, this pink areas, brown areas. Um This is a really textbook picture. And in fact, this was the picture that I was shown in my house key. So I would really advise you memorize this picture because I just got given this photo and was asked to identify which lesion this was in terms of where it commonly shows. Um for women, it's more commonly on the legs and for men, it's more commonly on the trunk. So risk factors, again, older age. Now, in terms of UV exposure, this is slightly different to the other two cancers. Melanomas are related to intermittent high intensity UV exposure. So in other words, some beds, there's often a history of many moles. Um and it's a risk factor because obviously, the more moles and freckles that you have, the higher the chances that one of them becomes malignant pale skin. Again, as we mentioned, immune suppression having a past history of a Melanoma. And if you have a first degree relative who had a Melanoma, then it doubles your own risk as well. So make sure to ask that in any history that you may get for skin cancer. So in terms of management, because it is potentially uh quite invasive, you would go straight for surgical decision. However, if it has spread past that point and it is at the point of uh metastatic disease, then you would opt for things like radiotherapy, chemotherapy, immunotherapy. I don't think you need to know the specifics, but I just put them in there. Any questions so far on Melanoma. Okay. So if we move onto Melanoma staging, so this is quite important. So we stage melanoma is based on the tumor node metastasis system. So this basically tells us the five year prognosis. So stage zero is basically when you have a Melanoma in situ. So it's confined to the cells from which it arose. Essentially. If you take that out, then you're cancer free and you're good to go. Stage one is when you have a tumor that's less than two millimeters thick, but it's not spread to your lymph nodes and it's not metastasized. In which case, your chance of making it to five years is about 90%. Stage two is the exact same except the tumor is thicker than two millimeters. And you can see the prognosis dips a little bit. Stage three is when it's reached one or more of your lymph nodes. In which case, five year chance of survival is about 50 50. And then stage four is when it's metastasized. And you can see that your chance of survival is quite poor for five years. Now, based on my own experience of Liverpool, example, questions, I would highly advise that you learn this. Um Often questions have come up which require you to um categorize or classify things and sort of identify which stage or which category something will fall in. Um And because the, the TNM system for Melanomas is so um specifically categorized and there's no great area. I do see it coming up as a question. Um So for example, you might get told that a patient has come in with a melanoma and it's not spread to the lymph nodes or metastasized, but it's four millimeters thick. Which stage is this at? Um I wouldn't be surprised if a question like that has would come up. Um I don't think you need to learn the associated prognoses, but maybe just what defines each individual stage. The last thing that you need to know about melanomas is the recurrent risk and that is ascertained based on the Breslow thickness. So when you do excise the Melanoma surgically and you send it for histology, the thickness is measured. So we've got another diagram here again. So just as a reminder, you got your epidermis at the top your dermis in the middle and then your hypodermic. So the subcutaneous fat at the bottom. So if it's a, uh if it's up to 9.75 millimeters thick, so just about until here in the epidermis, then you've got a low risk of recurrence. If it's from that point until 1.5 millimeters thick. So just about heading into the dermis around here, then you've got a medium risk of recurrence. But if it's any thicker than that, then you've got a high risk of recurrence. And it doesn't necessarily have to be in the dermis. It can invade further down into the subcutaneous fat as well and two other bodily areas regardless it's high risk. Does that all make sense? Does anyone have any questions about melanomas? Okay. Cool. So, just to recap quickly. So you've got basal cell carcinomas which are very slow growing at sites of cumulative sun exposure. So if you remember the bricklayer analogy, the buzz words to remember are that they have a rolled pearly edge telangiectasia and they are centrally ulcerated for squamous cell carcinomas. They grow a little bit faster over weeks to months at sites of pre malignant lesion's following cumulative sun exposure and your pre malignant lesions or you're acting at keratosis and your balance disease. They are often ulcerated and can present with the cutaneous horn with melanomas. They have invasive growth. There's often a history of moles and sun bed use and the presentation is usually with some sort of lesion evolution. Okay. It's fine. So moving on to referral criteria. Mhm. So essentially there is a two week wait pathway where patient's can be referred from their GP if they think that there is a skin cancer there, um they would then be expedited upon a pathway with it to be seen by a dermatologist within two weeks. Now, nice have put together a seven point checklist to aid in whether or not patient should be referred upon this pathway. So essentially in this seven point checklist, if the patient scores three or more points, then you would refer them upon this pathway. So with this checklist, you have major features which score two points each and you have minor features, which score one point. Now, major features include an irregular shape, irregular color or a change in size. The minor features include the largest diameter being seven millimeters or more inflammation oozing or a change in sensation. Now, this is a little bit difficult to remember. So an easier way to remember this is the A B C D E criteria. So I'm not sure if anyone's heard of this before, but it's just a way to remember the different aspects that you should ask about. So A is for a symmetry, you can see that this is quite an asymmetrical lesion here borders. So if you have a well defined regular border, then that's reassuring. But here you can see that the borders quite irregular. It's, you know, sometimes they can be diffused as well, which is a little bit worrying as well. Color is a big one for Melanoma. So you can see that there are lighter areas here and darker areas here that is quite worrisome diameter, as we mentioned, if it's greater than six or seven or more and then any sort of evolution. So you can actually use the ABCDE criteria to remember the major features and the minor features in an easier way, in my opinion. So for the major features, you have a B C D, so asymmetry and border can help you remember an irregular shape, C for color. So irregular color and then diameter and evolution can remind you of a change in size in terms of the minor features you have D and then three ease so diameter seven millimeters or more. And then all of these three are some sort of evolution. Hopefully that should help you a little bit more rather than just having to remember the checklist itself. Okay. Any questions on there? Okay, cool. So why don't we run this off with some questions? Um Like I said, at the start, some of these have been taken from actual passed papers. So what I'll do is I'll read out the question and then I will give you about 40 seconds to actually think of the answer and then we'll go through them. So question one, a 66 year old male attends the GP with a number of moles on his torso and face. He works outside all year and never wears sunscreen. He has been burnt on multiple occasions as a child. He has pale skin which burns easily and then tans which of these following features is most suggestive of a malignant melanoma. And I'll give you 40 seconds. Someone said d okay. Okay. So, yeah. Um, well done to anyone who said deep. Um Did we have any other answers in the chair? Yeah, they've all said D okay. Great, fine. Okay. Just in case anyone's ensure I'll just run through all the answers quickly. So, um a so previous sun related skin damage, so this is more indicative of an SCC um fluctuance swelling could be indicative of a melanoma because like we said, inflammation was one of the minor features, but I'll just get into that in a second. Hair growth is not really relevant and then a pearly edge with central ulceration is more indicative of A B C C. So I'm just going to go back to the referral criteria. So like I said, inflammation or fluctuance, swelling can definitely be a feature of an over melanoma. However, the reason D is correct as everyone rightly said is because an irregular color is a major feature, whereas inflammation is a minor feature. So this is one of those annoying questions where there are two correct answers, but one is more correct than the other. And hopefully the the weighted checklist can help you see why one is more correct because essentially the irregular color holds more weight fine. So well done. Everyone who said, gee, okay. Question to a 55 year old gentleman presents with a new skin lesion to the forehead. On examination. It has a rolled edge and visible blood, blood vessels across its surface. What is this likely to be? Everyone's at sea so far? Okay. Well see is correct. Well done. Yeah. So like I said, these are the sort of buzz words that you should be looking out for, for basal cell carcinoma. So the rolled edge and then the telangiectasia I either visible but vessels well done. Question three, a 28 year old woman attends her G P regarding a mall on her forearm. She's noticed that it's changed over the last three months and it's become itchy on examination. It's four millimeters in diameter with the well with a regular well timed border. It is dark brown with one area which has uneven variegated color, which feature is most suggestive of malignant Melanoma mccain has said D so far and then the D. Yeah. D is correct. Well done. So again, I'll just work through them in case anyone's unsure. So dark brown color in itself is not worrying. Um As long as it's uniform, then that's reassuring if anything um diameter, remember we said that if it's 77 millimeters or more then that is worrying. So this is less than that itch comes into one of the minor features that we mentioned. But like we said previously, the irregularity in color is a major feature, which is why this is the more correct answer. And then like I said previously as well, the well defined border is reassuring if anything. Okay question for which of these is not a feature of a squamous cell carcinoma. We've got two people saying E and another e is correct. Well done. Like we've said, this is more of a B C C feature. Okay. And final question, which of these is not a routine management option for a basal cell carcinoma? They're going to be okay. Great. Well, then everyone. Yeah, it is b in case anyone's wondering why it's because your common ones are nodular, which you would opt for search quick decision for and then the superficial ones you could consider these. But like I said earlier, basal cell carcinomas are rarely invasive and so radiotherapy wouldn't really be warranted. Yeah, that's the end of the questions. Thank you very much, everyone for listening. I hope that was helpful. Um If you have any further questions, feel free to ask me now or you can email me on the email given. Um This is just the QR code as well which will link you to the feedback form form. But yeah, I hope that was helpful every time I come back from. Hey guys, what's waiting for questions that anyone has? I'm going to also send a link with the feedback on the chat. Please let me know if you're able to access it just in case you can't access a QR code. Um And just for reference, the link, you'll need to make a medal account, which is a certified website that basically allows you to keep all your certificates and everything in one place. So it's good for when you're building a portfolio over time. And just for reference next week, we also have another um damn sock lecture going on as part of our final series again at seven PM. But we'll be posting on Facebook and Instagram. So don't forget to look out for that. If there are any questions and everyone's filled out the feedback form, then you're free to go.