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Probably going to do this session myself. Um Matthews just gonna watch um to be honest with you guys. This session could have been done as a skin lesions as opposed to skin cancer, but the problem with doing that is we'd we'd never be finished. Uh There's so many benign lesion's ultimately uh benign lesions, you cut them out for mostly cosmetic purposes unless they are functionally causing problems or they are currently being injured and uh that can increase the risk of them uh changing and becoming a cancerous lesion, so what we've done is uh focused on three main cancers um but before I jump into that, we're going to start off with this particular slide, so I think this slide is mainly a thought provoking slide more than anything else because it really does apply to most cancers, well, not mostly applies to all cancers that the image on the right the South cycle one uh Because ultimately, um so the first time that I actually felt that I understood the cell cycle very well was when my cousins, my cousin was asking me general questions about cancer. He wasn't really going into very specific things, but I explained to him in layman's in layman's terms that the cell cycle goes into specific phase and then at each phase, you have different proteins that function to allow it to progress to the next one or two, then stop at that particular phase and then when things go wrong at each phase, um you can then develop a cancer and as researchers, will not ourselves research, I'm not particularly interested in research, but researchers focus on particular aspects of a cycle break it down, understand how it functions and how it now functions, and then targets medications towards particular aspects of the cell cycle, so that's why it's important it's just to be thought provoking and then keep in mind that whenever you read about a chemotherapy medication or whatever it is um that is meant to be doing something specific, but the reason you become so unwell. In general is because it targets all cells and all cells have their own particular cell cycle or or their lack of let's say um and the image on the left is just to show you how the life cycle of a keratinocyte works. You know, it starts from the bottom as the statin basil and then it makes its way upwards so it becomes the the corneum and then eventually sheds off um and skin cancers occur at different levels. Um yeah, So these are the types of the main skin cancers I mean there are other things, but these are the ones that we've decided to focus on because they're the ones that we deal with most um So here they are listed in order of least worrying to most worrying, but also from most common, too, not least common but not as common. Let's say, so basal cell carcinomas tend to be quite common melanomas uh not so common but the most serious um and then you've got examples of images at the bottom. It's really difficult when you start looking at skin cancers. Honestly, they all look the same and then over time your eyes get used to things and then you're looking for specific things that tell you uh specific uh specific characteristics that tells you what each lesion is, but that's not going to be the aim of today, um but it's just again something to keep in mind When you're looking at lesion's although there are a lot of similarities, there are a lot of differences, but at the same time, there's a lot of overlapping um as well, so, it's not uncommon for you to look at a lesion and and and ask yourself oh what is that um and actually I had my interview for st three on friday, and one of my clinical scenarios was a melanoma and I looked at it and I was like that's a melanoma and then halfway through the scenario, I looked at it again and I was like wait is that melanoma that might that might be an sec, um but I didn't actually say that out loud, but it was just a thought that came to my mind for for a second, so starting off with the bcc, so like I said you've got the layers of the skin there you can see a nice image on the right side um be ccs ergin eight from the keratinocytes at the basal layer or the statin bezel, uh It's the most common cancer um name. In terms you call it a road in tulsa, so whenever I describe it to patient, I call it to road in tulsa, I do say basal cell carcinoma as well, um and I usually explain to them that it is slow growing, it can become math, math, a static, but that takes a couple of years and actually I had a patient with me today in clinic, a 91 year old lady who has a punch biopsy of a lesion on her lower leg that showed that it was a. B. C. C. Now usually if you're 40 50 I just say yeah let's cut it out and we can either do a local flap or put a skin graft on it, um but in her particular case, I did give her the option to just keep an eye on it. I think I just confused her to be honest and then I just booked her and told her if you don't want to uh if you don't want to proceed with the operation later on. Once you get the letter, then don't worry too much about it. We can cancel the operation. Something that's quite common is recurrences and and patient's developing multiple lesions and it's quite simple in that if you've had a specific amount of UV exposure over your period of of life over over your life, then your d. N. A. Is going to be damaged equally or almost equally. Um Again another example from today, so one of my patient's came in with a biopsy proven bcc on her ear uh. Uh One of the questions that I asked her was do you use sunscreen and she said actually I use it quite well, but I happen not to put it on my ears, so yeah that's unfortunate for her now when we see someone uh you can see in these images that these four lesions look absolutely different and yeah that unfortunately that's what you face. When you're uh when you're dealing with skin cancer, the one on the top left which looks like a nodular bcc honestly, I would probably say that that could be a melanoma. If I looked at it or at least that would be my differential diagnosis, however, it's not multi pigmented, so again difficult to say you can see the superficial basil cell carcinoma. Again, I could I could say that that's a squamous cell carcinoma in situ or bones, can bones cancer, but our bones disease, sorry, but again you see how they can present in different ways and then you got the more fake on the bottom left, which is considered one of the more serious ones as well as the basisquamous. I mean it's really difficult you know, it takes a long time and also um you learn how to use the derma to scope. Different people learn in different ways personally. I've only been self learning up until now, but I am actually booked on a course at the end of this week to help find you my clinical diagnostic skills when it comes to their math scope, So you know even I I've still got a lot of room for improvement. When it comes to skin cancer, the bottom right lesion, the basis, squamous cell carcinoma is the one that if I looked at, I'd probably say that it's a squamous cell carcinoma. You know, I'd struggle to say that that's a. B. C. C, with confidence without their matA scope and without experience Now today, sessions's you sort of sort of like jumping into clinical things, but also touching on the science, but I don't want to be too detailed either one. Um I've put this uh slide in with Matthew and just made it easier on the eyes by dividing into a non modifiable and are modifiable column. It's not really that important to focus too much because with skin cancers. You almost always ask the same questions uh If someone comes in, you know as usual, you start with the broad question, uh so I know why you're eight why you're here, but could you just tell me in your own words, um what's been happening and then you dig it deeper into skin lesions or when did you first notice this lesion, has it increased in size over that time, was there a benign lesion before it has it been bleeding, has it going into the cycle of bleeding, weeping, crusting, healing, and then just repeating over and over um and that's essentially the findings that you're looking for and itching as well. And then once once you do that, then you want to know the age, the sex and occupation of the patient occupation, tells you a lot of things it tells you uh in particular what chemicals they could have been exposed to, so when it comes to be CCS, you've got ionizing radiation or arsenic exposure um but also some exposure, I mean for example, farmers or generally people who work outdoors tend to have um more exposure to uh UV light. Ironically, people who spend more time indoors are going to be more sensitive to the sun because their body is not used to it, but anyway, in the long term people who have been exposed to some regularly over time will be the ones that end up developing skin cancers. Another important thing to ask is um the obviously genetics and hereditary conditions, not too many things there, but just something to keep in mind previous skin cancers. I mean obviously if someone as I said before, if someone's already developed a skin cancer, they're probably going to develop another one at some point uh because their skin is equally damaged across the board. Um Type of skin we've got we've got a chart at the end of the Fitzgerald skin type chart at the end of this uh lecture, so we'll just pop it up and and have you look at it for a moment just uh out of interest more than anything anita, suppression is quite important as well. Um the first thought that comes to mind, I had a friend in university who was diagnosed with uh ankylosing spondylitis and uh she was started on biological therapy and uh yeah we went through that list of side effects and it was quite depressing to look up and she was in the highest uh group of risk to skin sec, uh side effects, in particular um young female uh in her twenties taking biological therapy which causes immune suppression and uh there was a risk of developing skin cancer. I think in that scc's tend to be more common, but it's still something that you need to keep in mind with the CCS. Um I think that is all from the history to help you identify whether someone is high risk or not, but in addition to that you want to know if a patient has a pacemaker, if there are any blood thinning medication, and if they have any allergies and that's because you want to plan your surgical intervention now. Examination Again across all the skin cancers, it's quite similar. I've highlighted slight differences in each skin cancer or more additions to each one as we progressed, So looking at this particular page forget the images, but what's written down that applies to all s, ccs and melanomas, but I've also added a couple of things to Scc's and melanomas. Um It's important to always keep in mind that you can't really assess a lesion in a dim, lifted room because you're not gonna be able to pick up most things. Unfortunately, we don't have the luxury in the nhs to say oh I want a well lit room in an interview, you say I want to examine a patient in a well lit room. In reality, you want to do a math scope because it has its own light source and allows you to assess the uh lesion uh well, so when you start assessing the patient, you want to identify the location of the lesion. You can see an image of the top right. This is an image that I've pulled from the guidelines um So this is the head and neck and uh it this is a heat distribution. If you wish of where the lesions are considered high risk, where they're considered low risk and it also depends on the size, so the dark purple. If you ever have a lesion and dark purple area, it is always considered a high risk bcc, so I'm gonna repeat if it's dark purple, then it's always a high risk bcc. If it's in the light purple, then it depends on the size, the, the border is a centimeter. If it's above a centimeter, it's high risk. If it's below a centimeter, it's low risk and then on the rest of the body, it's uh two centimeters below two centimeters and above two centimeters. Um So, when you're examining a patient to identify the location you examine it. With the dramatic scope in the bottom, here, you can see some uh images with uh dramatic scope images of be CCS uh I'm just going to focus on the one on the right. There are specific findings that you look at when you're assessing a. B. C. C. So you're looking for vascular are bare, Ization, so essentially are there vessels going into the lesia you look for uh blue grey uh ovoid clusters now that's not always present but in the left image, it is is present if you can see a couple on the top right and someone the top left and then the last one that you're looking for is a leaf like uh appearance or leafy like appearance and uh all three of these lesions have leaf like appearance, um but it's again difficult to identify when you first start looking at skin lesions. The next thing you want to do is assess their lymph node basins to assess whether or not there's been meta stasis. Uh A regional lymphadenopathy for the arm. You go into the armpits for the head and neck, you go into the uh cervical lymph nodes and then finally it is sometimes worth looking at the patient's uh skin from top to bottom to assess if there are any other skin cancers that they are that you're worried about or just advise the patient to do their own scheme, surveys at home by taking images and keeping an eye on this. Now by this point, we've examined the patient, we've gotten a history and we almost have all the criteria to help us risk stratify, which means identify what is the most likely uh level of risk specific lesion is and what are the margins that you need to excise it. You know the the thing that I did it, really the thing that I didn't really absorb when I was in medical school was the fact that uh this might sound naive, but I wasn't really uh I didn't really know what evidence based medicine was. I mean I understood what research was, but I didn't really understand the strong link between practice and research and and how we can use it in so many different aspects of medicine um and particularly skin cancer. You've got the british Association of Dermatology guidelines for management of be ccS and they guide you um in deciding what margins you're gonna take when you cut something out, sorry, this is okay, so uh I don't know why this in this, this is not as clear as I was hoping that it was. I don't know if it's clear for you guys, but um anyway, so you can see here that when you're when you're deciding whether a lesion is low risk or high risk you look at this table. Obviously overtime you memorize it so uh the image that I showed you the dark purple was area H and you can see the area H is in the high risk, which means any lesion that is there. Regardless of the size is considered a high risk lesion, um and then there are clinical criteria. If you look at the left column, you can see clinical criteria you can see pathological criteria which you get from the histology, so although you make a guess of whether something is high risk or low risk. Clinically, you can only get the final uh risk strat stratification once you've done the histology itself because even the last marker is the margins and whether you've excited something fully or not, tells you that whether or not this is a higher risk or not. Other things that are important are uh immune suppression, like I said if someone is immune suppressed and they're considered high risk, if it's primary versus recurrence with recurrent lesion's, they're considered high risk so on and so forth, so just keep it in your mind. that whenever you're treating a patient for any condition, there are guidelines that you can follow and uh they're usually being up to date and if you can find guidelines that's how people start making our project, it's oh look we've got this condition, we're treating it anecdotally off of logic and we don't have a guideline and there's something to work on here and that's really how projects uh pop up out of nowhere. If you wish, it's not really from nowhere, you've just identified a problem in clinical medicine that needs a solution. It's really that simple now with regard to the management you've got uh several options, one conventional surgery, so just cut it out as per the guidelines. Um So if it's on the nose, take a five millimeter margin pop, a skin graft on it, do a local flap, whatever you think whatever you are technically capable of doing, but also whatever you're comfortable do doing in regards to removing the lesion and full um With regards to we've got nowadays, um so I wasn't gonna dig too deep into this, but I think it's quite an interesting side of medicine and actually I am considering doing it in my fellowship. Once I'm done my training, which is most micrographic surgery, is a subspecialty of dermatology, but lately plastic surgeons have been slowly creeping into it because of our reconstructive skills essentially um so with conventional surgery, When you exercise a lesion, if you take a look at the image on the right, the bottom, the bottom bit shows you what conventional histology looks like in conventional surgery, so you cut the lesion's longitudinally into slices, and then you assess them around them, but, but the the downfall of that is you can miss things if you don't look at every single margin and we don't look at every every single margin when with conventional histology, however, with micrographic surgery or most micrographic surgery in the top, in the image at the top, um what you can see is a lesion is combed out and then it's divided into four quadrants and then each quadrant is assessed with histology, usually frozen sections. Because this is done on the same day, so a patient comes in. You pop in some local anaesthetic you excise the lesion. You have them. You give them a book, given some food, sit them in the corner, do some frozen sections, assess it with the dermatology, not the pathologist and then assess which margin margin has residual disease in a, and then you go back in and you only excise that margin you that redo the process, reassess it, see if it's been fully excised and then once it's fully excised, you then do the reconstruction, so it's it's more definitive than conventional surgery and to be honest with you if I ever have a cancer on my face, I would much rather have someone excise it with most surgery than with conventional surgical excision unless it's like a small lesion you know, but I think generally, I would want to lean towards most surgery. Unfortunately, it's not available for everyone um just because for example we don't have most surgery in aberdeen, we have to refer patients to them the, and they probably have their own um their own waiting list, which I'm sure is packed at the moment. Then you have non surgical options um from experience, So this is anecdotal than rather than evidence based, so we don't really use nonsurgical options much in bcc management, so whether that's cryotherapy uh chemotherapy, creams such as fluorouracil or in the climate or and radiotherapy or even electro chemotherapy, however, uh one of the one of the trusts in England, I don't remember which one but it was uh it was, it was presented at Bathras, uh, the national Back, pre's, um, and uh they did a study using um electro chemotherapy, which showed really good success rate, so especially they inject chemotherapy into the lesion, and they buzz it with electricity over a couple of hours and then, and um and that's usually just it. I don't know just something I found interesting at the time, but I I don't remember the exact results because it's been a few months now and I didn't make note of it, so you get your histology. I'm just gonna step back here for a second you get your histology and then there are things that you want to look at so if you look at the column on the left, you've got your pathological criteria, you've got your growth pattern, your differentiation, your level of invasion, your depth, perineural invasion, so nervous are the nerves, uh is there mets on the nerves or is there cancer on the nerves and then the staging, and that's how you then confirm if something is low risk or high risk, and then you can go back and do more excisions if you wanted to, but also you've got the histological clearance margin, which is useful as well, so that's what what's important for the histology. You can then decide further management, and that's usually divided into three categories, one is watchful waiting to, is further excision and then the last one is to uh radiotherapy. This is an interesting uh slide that math, uh math you found uh it basically shows that be CCS are best treated with excision, um although most micrographic surgery has lower recurrence rate than conventional surgery, but surgical treatment is still the way to go. When it comes to be CCS okay, so what is an sec, so the main difference between s CCS and VCC s is that well the similarities that they both arise from keratinocytes. The difference is that s CCS uh don't arise from the basal layer, but do from the middle and upper layers um and it tends to be more aggressive than sec, so we usually categorize it higher when we see them in clinic and we we aid to get them into theater for excision sooner. It's important to keep in mind that squamous cell carcinoma is not unique to skin. I mean just think to yourself where do we have squamous cells basically on all of our mucosa, so you can have squamous cell carcinoma anywhere where there's squamous cells just like be CCS the more damage you have uh from u. V. S. The more DNA damage than the, the higher risk of developing um problems in your cell cycle and then eventual cancer formation um. I find that scc's tend to go into a transient or into into a transitional period where they become actinic keratosis, seborrhea keratosis, which are crusty lesion's that are benign can be managed with ointments um and then they develop into skin cancer and seat, two or bones disease, which can still be treated with creams uh chemotherapy creams, and then it develops into cancer, so any lesion that has a crust on it has the potential of becoming an sec, and here you've got again different growth patterns um With the s. E. C. S, I believe the growth patterns don't really change um the the risk stratification, it's just make note there are different types of s ccs um for example, margin in our margin linens, also the last one on the list there is usually secondary to uh prolonged room healer, um but yeah you can see how they look again. There are several ways that they look uh There's not always a keratotic plug or cutaneous horn um uh and the bottom one the bottom right one, the squamous cell carcinoma you can say that that's a basisquamous bcc and then the squamous cell carcinoma on the bottom left, looking at that you can say that it's a more fake bcc You know again uh with their mattis copy, it helps, but at the same time ultimately you excise it and you make the differentiation between the two, so I'm not gonna go too deep into this uh this slide because we've sort of already did it, but you can see here that I've added to the bottom left. Uh The sorry the left column, the non non modifiable column actinic keratosis, so again that's just an additional risk factor uh to this particular situation, and uh immune suppression tends to be more important when it comes to s CCS, but it's still important for be CCS. So the main difference when it comes to examining patient's with possible squamous cell carcinoma is because they have uh because they have a higher risk of meth, metastasis uh. Then you need to make sure to examine their liver and esteem because there's a higher possibility of them uh developing hepatosplenomegaly okay so just make sure they examine the abdomen, but also the same when it comes to uh melanomas and so you can see here that there are these, they're much they're much skopje images. Uh It shows you that you've got a keratin deposits when on s ccs um The vessels tend to be slightly different than uh b. C. C. Is. Where you just simply see vessels running into the, the, uh the lesion as opposed to here where they're sort of just going around it. Uh Finally, you've got more carbon lee, you have ulcerations in s. E. C. S. Than you do in be CCS, but you do still see them in the CCS. Now, we've got this other fancy guideline from the british Association of Dermatology for sec, I believe this was updated in 2020. The bcc one was updated in 2021 so there's still relatively fresh um and actually, I think prior to that, it was updated in 2008 and 2009. So that's a whole 10 years using a single guideline um For you guys, If you decide to pursue plastic surgery and uh the UK, it's important to be up to date with guidelines for exams, so the MRCS, but it's also important to be up to date with guidelines for the interview because they do expect you to know these things for interview. They will ask you how like they will, they will act as if they're the patient and they say oh how uh what is the margin that needs excising for this or I mean a patient will never ask that, but you know, they do expect you to know uh exactly how much of it needs to come out, so again slightly more complicated than the b. C. C. S. There are more categories and more things to keep in mind. Um Follow up is stressed a bit more with the sec s than it is with the CCS um It depends on the size, it depends on the histology. It depends on the patient and whether or not there you know you know suppressed or not. And uh they divide the immune suppression into 22 categories um into people that are just on medication or they have, uh for example hiv, and then they divided uh and then the other our patients who have actually had um organic transplantations or other damage to uh the immune system. Um s. E. C. S tend to be discussed in m. D. T. S. Only after they've been excised, I mean it's the same with melanomas, but for example, b ccs don't tend to be discussed in uh skin cancer mbts before or after their size. It's usually a clinician's decision um or the clinical, the decisions, clinical impression to make a decision on what to do moving forward now, the main difference when it comes to excising a lesion with sec, so you can see the image on the bottom art. This is an image taken from uh plastics fellow on twitter, yeah it's a good pay, it's, it's a, it's a good account on twitter. He's always uh his name is plastics fellas, I'm gonna assume he's a, he, but he uh always puts up to date information about plastic surgery and up to date research and up to date evidence and puts up random questions and random plastic surgeons end up answering them. It's one of it's quite an interesting page. I, I do like, I do follow him um now treatment of sec. Again you see the patient in clinic, you decide to risks, you decide the risk stratification and then you excise it accordingly. Now something to keep in mind when it comes to us cutting these things out if someone has a lesion on their nose and this is a cosmetically sensitive area and they don't want a huge excision. In the first instance, you can always do a two millimeter margin or a narrow margin excision just to get a diagnosis before you make your final decision on how much you want to cut out and then do the definitive uh the definitive excision and reconstruction and again you've got all these different nonsurgical options and in reality, I don't really know how many of them are actually used because in, in aberdeen, for example, we do use the floor your cell cream and the imiquimod, but mostly with things that are pre malignant unless the patient is insisting, insisting that uh we week size sorry uh they they want the ointment. Um This is uh just an outcome slide that we wanted to add them is it particularly useful. I mean yeah it just shows you that micrographic surgery has lower recurrence rate than a wide local excision or conventional surgery, which again shows you that conventional histology is not as good as the the new way in most surgery. So yeah if you want to do dermatology or if you want to do plastic surgery and you enjoy skin cancer, it's definitely the way to go nowadays, so what is melanoma, so the thing that I'm going to say about melanoma's really hot topic nowadays. You know. Obviously you know it's it causes 80% of mortalities and skin cancers, but it's only only comprises, I think 5% of skin cancers, so we've obviously not figured out how to treat this yet. You know, I mean we've got a long way, but there's still a long way to go um and again going along the same pattern of as before arises from banana side, so they're the pigment forming cells and you find them at the base of the epidermal mayor. Again, you've got different types of melanomas um The ones that catch you out the most. There isn't an image here, but we'll show you one later on in the slides uh a melanotic melanomas, some of them are actually white and there's absolutely no big events in them and that can be really confusing. Uh Looking at these subtypes lentigo melican, it tends to be a stage zero uh melanoma making it the least aggressive and the one that needs, needs the smallest margin of excision. Superficial spreading is the most common. Um I don't have anything interesting to say about april but regular attempts to have a slightly different pattern of growth than usual melanoma, so usually instead of spreading sideways and, and it goes upwards, so it uh elevates and fun gates. Really again, I'm not gonna touch on that may be. The only thing here is that patient's who have benign mathematic navy tend to be at higher risk than other people now. I did say when we first started that there are, there tend to be slight differences when it comes to examinations. It's not that this is a slight difference. You can use the style of examination for any lesion, but it's not as useful um in other skin cancer than it is in melanomas, uh so just the 80 assessment so is asymmetry. Uh bees border uh color. Usually, these lesions are multi pigmented um and the, the diameter is usually above six. Some people say about five millimeters and then that it's evolving over times is another thing um I did say that nodular melanoma has a slightly different way of evolving, so the e. F. G. Is more targeted to nodular melanoma, so if you're examining lesion that you suspect as a melanoma, but it doesn't really fit the 80 e. Um findings, then you can use the e. F. G. Which is it's elevated, it's growing pretty quickly and it's firm to pop patien. I do remember the first time I saw this and I had no idea e. F. G. Even existed. I think it was a ct one anyway um and uh don't forget to examine the lymph nodes and the liver and the spleen okay, So managing melanomas. In the first instance tends to be quite easy, so if you do happen to be F two s or cT ones or c. D two s and plastic surgery managing melanomas is fairly straightforward. When you first see them in clinic, you've got the lesion, we need the diagnosis to out with a narrow margin and send it off to the lab Now. The question is why why is it so easy to manage melanomas. In the first instance, because there is a there is a good answer for that. Basically, you don't want to be too aggressive in the first instance, because you want to come back and see if the patient possibly has micro metastases into their lymph nodes, so if you were to take a wide margin, then take all that healthy dermis around the lesion, and then disrupt the lymphatics and then come back and inject radioactive chemicals or uh or what what it's called the blue dye uh. To then find the sentinel lymph node biopsy or the first note that drains limb from that particular area. You're not gonna be able to do that, so that's why you do a two millimeter margin biopsy. You get a diagnosis, you get the breath brazil thickness. You you know you find out whether it's ulcerated or not. You see if there's any perineural invasion. Um We're vascular invasion and you want to know what the mitotic rates are as well um and then that helps you do the initial staging and then you do your definitive planning with discussion in a multidisciplinary team uh meeting, which in the skin cancer meeting usually has a pathologist to radiologist, an oncologist, the dermatologist, and obviously plastic surgeons and the cancer nurse specialists. I think they're running tuesdays and uh well. I don't think they do run on tuesdays and uh the n. H. S. Grampian, So you staged them, this is not about today staging. I just wanted to have something here, although it's a bit flimsy um The other one is really complicated, so I didn't want to put it in, but you just you staged them. Usually, stage one gets a 11 centimeter by one centimeter um weren't sending me to a wide local excision the stage ones uh I don't usually get offered slm, Bs or sentinel lymph node biopsies and then stage two's and above always get sentinel lymph node biopsies or at least the patient's get offered it um. And generally, there's been a move away from doing a full lymph node dissection, but I'll touch on that in a minute. Um There's also been an increased use of biological therapy in the form of adjuvant therapy to help maintain uh remission after surgical treatment, so what's the point of an m. B. T. Is to manage the patient holistically because just because the guidelines say do 123 that doesn't apply to every single patient, this is a person per place, person uh specific management, and what do guidelines in an m. D. T. Help you do helps you practice evidence based medicine, and it helps you utilize uh up to date evidence to make decisions in a um uh what's the word in a chance, just judicial way you know, can you tell that I've done an interview recently. I can um so, yeah you do a wide local excision, you decide on the reconstruction. You uh do an issue, offer an s. N. M. B. And the reason you do an s. N. M. B. And not a lymph node dissection or lymphadenectomy in the first instance is due to the increased morbidity with lymphadenectomy, seroma as infection, hemotomas, and just an overall poor quality of life and sometimes it doesn't add anything to the patient. Um it doesn't add anything to the patient's management so that's why we do s. N. M. B. S, that's why we do a small excision. In the first instance uh to be more specific in our biopsy, novel immigrants. I'm not gonna say much about juvon therapy. It's there, it's improving um although the side effects seem to be horrible, I did present, I did present um some findings about side effects and nhs grampian in the celtic Bad Press and it's actually um I question whether it's worth it for our patient's, but people are excited about it because of because people who who works on it works really well and the people that it causes side effects that really causes bad side effects. Uh There was a patient to have a cardiac arrest and then eh my um other patient's develop you know uh immunocompromised conditions, or autoimmune side, autoimmune conditions. Um uh colitis with admission's is quite prevalent under chronological disorders, in particular. Hypothyroidism is also um quite often, now oftenly seen uh This image these are just for you to see other other lesions and and how there can be similarities between uh skin cancers and benign lesion's, but the thing the thing that you can see with these ones is that they tend to be more or less a single pigment they're fairly regular uh. I know some of them are not but seborrhea keratosis. I did mention this earlier on the bottom left that's that can become um an sec, but it's it's been unreasonable um yeah ok next slight, so this is what I was a lovely picture okay. Uh The Fitzpatrick what did I call it earlier Fitzgerald know that strong Fitzpatrick scale um so yeah. Again, this is just for your own information more than anything we do mention it, but all in all, it says is that the light or your the more likely you can get a skin cancer and the darker you're the opposite is true, okay, fine. The next three slides are just questions. Hopefully, they'll be quick, just type in the chat. If you have an answer, no sorry, two questions type in the chat. The last one is if there is a volunteer that likes to would like to go through it, we can if there is an, is fine um So yeah let's go into the first question, so the first question is can you risk stratify by uh this patient, so you're in clinic you get a 50 year old male uh He works as a farmer uh he smokes, but he's otherwise fit in well. He has a nose lesion on a three millimeter nose lesion on his nose. Yeah whatever lesion on his, known that knows that it's three millimeters. He explains that it's you know it's uh let's say four months ago. Um It's been leading. He wakes up in the morning nose has blood on his pillow um It can be painful at times, it catches his um his glasses. Um It weeps and heals over um and on examination, the derma scopic findings show a vascular are, are your Ization leaf lack areas and blue grey avoid dusts, which is what you find on um uh be ccs, so the question is is this patient considered a low risk or a high risk and really there's one state route in there. That tells you definitively which one is and I've already kind of touched on it through the presentation. If you just say high risk or no risk in the chart come on. Yeah so, yeah I mean three of you have already answered, then it's correct, so I'm just gonna uh say it is it is high risk and it's the most important piece of information here is that it's on the nose and we already know that location or area area H is on the nose, I'm sure you've a heat map um and that means it's a high risk lesion, so I would offer this patient two options, I would say we could either do a punch biopsy and confirm that it's an easy see or if they would like we could go straight ahead and excise it, and I could tell them that we can proceed with a full thickness skin graft or do a local flap, and I tell them that the advantage of a full thickness skin graft is that it's a temporizing measure. We can always come back and excise further and then do the reconstruction that's definitive and has nicer cosmetic outcomes with the local flap, so um and also other things that I take from his history is that uh this patient's a smoker, he's a male, he's older, he's a farmer, which means he has higher some exposure, so a lot of risk factors in there for be CCS, so that's the first question and then the second question is just uh please label um so just you can see the letters in the top right of the images and you can see what the diagnoses are, but you can see that. I've only but I just showed you that there are different growth patterns and yeah anyway, you can label them and put them in the chart. Yeah I'll just wait for a bit, just another minute or two few people answer okay, I'm just gonna start answering it, so you're all wrong, I'm sorry one of your one of your one of them is right, so see three is correct yes. This is this is a bit of a trick one This is a trick melanoma to pick up and actually not this exact same one. I didn't get this exact same one of my interview, but uh it was it wasn't a it was a a melanotic melanoma, but the fungating lesion was white and there was a benign pigmented lesion at the bottom of it, so let's go from the top, a you can see that there's a bit of ulcerating you've got these rolled edges that are slightly pearly in appearance and this is a nodular bcc, so it's a one. Obviously, I don't have a dramatic scopic picture, so I can't really explain that very well looking at. B. B. Is an ulcerated invasive sec, and you can see that there is carotin depositions um circumferential e. Um it's raised and it's also it's raised circumferentially and it's also right in the middle, um. And then finally we've already contest on the melanoma okay the last one I don't know if anyone wants to do this to describe this lesion. You can describe it on the chart. If you want to I don't mind and then I can describe it and there's no right to answer By the way I mean after working in after working in plastic surgery for the past year and seven months, let's say people I mean some people don't even try the lesion's, but when you do describe the lesion's them to be very simple in the description mm that's it yeah. I mean you guys have you get what I'm trying to get across to you. If I were to describe this, I would say this is an ovoid patch, flat lesion with asymmetrical with an asymmetrical shape. It's uh I said its borders are irregular, it's multi pigmented, um it's larger than six millimeters. This that's probably two by one centimeter, and I can't really comment on the evolution, but I just kept that in there, so that's how I would describe it. Ovoid patchy, multi pigmented uh asymmetrical uh lesion with irregular borders and then and then mentioned the size and that it's flat so, yeah, I tell you guys uh Matthews had mono pigmented. It's not you can see that the you can see that the, the inferior aspect of the lesion is slightly darker than the superior aspect and then if you look at the left aspect of the lesion is hyper pigmented lesion, so there's actually at least three pigmented three different pigments uh There yeah okay, I hope that was useful. We've reached then. If you have any questions, I am here and if you could uh scan the barcode and uh fill out the feedback, I've I've been actually I, I do use the feedback. Um I didn't have questions in my first couple of sessions and that was a suggestion from you. Guys Thank you so much for that has. Um um If you guys have any questions, um you can either put them in the chat or ask like just turn on your mic and speak, I'm just going to stop the recording just now.