skill lab: skin cancer - sgaim...olivier gaide, md-phd, pd, ma. dermatologie et vénéréologie....
TRANSCRIPT
Olivier Gaide, MD-PhD, PD, MADermatologie et Vénéréologie
Skill lab:Skin cancer
SGAIM SSMIG SSGIM – Bern Sept 2017
Method
ZzzZzz
Zzz
Method
Plan
• Surgery: • Quick reminders• Hands on
• Suspect but benign• Non suspect but malignant• Red flags
• Dermatoscopy in between
Reminders
Punch biopsy
2 3 4 5 6 8
Biopsy trop petite Defect trop large
Scalpel is better than the punch
A key message before starting
Primum non nocere !
The five rules of surgery :
1. I can close what I open2. I favor excision over biopsy
3. I react to the diagnosis4. I bear responsibility (not the pathologist)
5. I give the diagnosis with care
O. Gaide
The five rules of surgery :Case 1
Help, I bit off more than I can sew
The five rules of surgery :Case 1
Suspect yet benign !
Case 2
Seborrheic keratosis
Dermoscopy
melanocytic lesion
Nevus vs. melanoma
angiomaangiokeratoma
basal cell carcinoma
seborrheic keratosis
dermatofibroma
Vascular structures in non-melanocytic tumors = Keratinizing tumor, SCC, Clear cell acanthoma, Sebaceous hyperplasia
Level 7
Pattern trumps structure
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
Level 3: Seborrheic keratosis
Aspect cérébriforme Pseudo-comédonsPseudo-kystes cornés
Fissures
Level 3: hairpin vessels
Attention: difficilement visible si la KS est (très) pigmentée
Hairpin avec halo clair !
Case 3
melanocytic lesion
Nevus vs. melanoma
angiomaangiokeratoma
basal cell carcinoma
seborrheic keratosis
dermatofibroma
Vascular structures in non-melanocytic tumors = Keratinizing tumor, SCC, Clear cell acanthoma, Sebaceous hyperplasia
Level 7
Pattern trumps structure
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
LacunesLacunes
Variee from black to red(periphery often not as dark)
Level 4: angio-(kérato-) mes lacunes
Sharp borders / polycyclic
Case 4
Not suspect yet malignant
Case 5
Lettre reçue à notre policlinique
A quoi pensez-vous?
Case 5
Délai avant l’envoi à notre consultation: 6 mois
A perfect letter !
… is better than a poor picture
Fax reçu à notre policlinique
Case 6
Délai avant l’envoi à notre consultation : >12 mois
Case 7
Délai avant l’envoi à notre consultation : 7 mois
Case 8
Délai avant l’envoi à notre consultation : 24 mois
Now some suspicious lesions that are malignant
Case 9
Case 10
Délai avant notre consultation: 0.1 semaines
The red flags !
Case 11(courtesy Dr Cherix):
CBC + CSC + MM = 50% of all cancer
Basal Cell Carcinoma
Squamous Cell CarcinomaProstate
Breast
Lung
Colon
Melanoma
Human Cancer Frequency in Europe
CTCLDFSPMerkel
Other giant CBCs we saw recently…
Other giant CBCs we saw recently…
Other giant CBCs we saw recently…
Other giant CBCs we saw recently…
Other giant CBCs we saw recently…
BCC
Aged patients Photo-exposed areas
Blue or brown pigmentation Telangiectasia « Papules perlées » Central erosion or crust
Local aggressivity
Supe
rfic
iel
Nod
ular
Scle
rode
rmifo
rm
Case 11b
What surgery for BCC ?
OCT allows comprehensive sampling
12
Do not blindly trust the pathologist
melanocytic lesion
Nevus vs. melanoma
angiomaangiokeratoma
basal cell carcinoma
seborrheic keratosis
dermatofibroma
Vascular structures in non-melanocytic tumors = Keratinizing tumor, SCC, Clear cell acanthoma, Sebaceous hyperplasia
Level 7
Pattern trumps structure
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
Level 1: all BCC
Erosions or crusts
Tree-like blood vessels
Featureless areas
Niveau 1: CBC pigmenté ou non
Spokewheels
Blue-gray dots
Ovoid nests
Maple leaf-like str.
Level 2: Pigmented BCC
Red flags !
Case 12
Courtesy: Dr P. Perrier, Epalinges
Sqamous cell carcinoma (SCC)
Aged patients Photo-exposed areas
Papules et nodules Squames or crusts
Local and distant aggressivity !
Case 13 and 14
Case 15 and 16
Quelle approche pour le CSC ?
RED flags for SCC
Cave ! Immuno-supprimés en général : HIV, LLC, OT Extrémités: Mains / pénis >2cm, croissance rapide Forme peu différentiée
Red flags !
Case 17-20
Malignant melanoma
1) Adults 2) UV co lentigo maligna > SSM > nodular
1) Pigmented macules to nodules 2) ABCD (only valid for late stages)
3) Very early metastasis!1) Immuno-suppression in general : HIV, LLC, OT2) Cave solarium / sunburns
Case 21
Case 22
Superficial spreading M
Case 23
Superficial spreading + nodular M
Case 24
MM nodulaire
What surgery for MM ?
Case 25
Case 26
Case 27
3 slides on screening …
The ABCD rule
Benign Malignant
1 Couleur
Symmetrical Asymmetrical
Assymetry
Colors
Diametre
< 6 mm ≥ 6 mm
BorderRegular bordes Irregular borders
1 color ≥ 2 colors
… becomes (ABCD) EF
E pour Evolution / F is for Funny looking
ça bouge, je me bougeABCD
Every digital rectal examination is an excuse to look
Peri-anal
Dermoscopy
melanocytic lesion
Nevus vs. melanoma
angiomaangiokeratoma
basal cell carcinoma
seborrheic keratosis
dermatofibroma
Vascular structures in non-melanocytic tumors = Keratinizing tumor, SCC, Clear cell acanthoma, Sebaceous hyperplasia
Level 7
Pattern trumps structure
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
Level 1: melanocytic origin
Network
Globules Dots Radial streaks
Level 1: melanocytic origin, particular areas
Face Acral
Pseudo-network Parralel furrow pattern
Level 1: melanocytic origin, blue naevus
Symmetry
Homogeneous blue-white vail
Examination: Dermoscopyperformance diagnostique
B
D
A
C
melanocytic lesion
Nevus vs. melanoma
angiomaangiokeratoma
basal cell carcinoma
seborrheic keratosis
dermatofibroma
Vascular structures in non-melanocytic tumors = Keratinizing tumor, SCC, Clear cell acanthoma, Sebaceous hyperplasia
Level 7
Pattern trumps structure
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
Blood vessels in melanocytic lesions
Coma shapedDermal Naevi
Dotted VxMelanoma
Irregular linear VxMelanoma
Crok-screw VxMelanoma (métastasis)
Irregular hairpin Vx.Melanoma
Diffuse pink colorMelanoma / BCC / SCC
Irregular hairpin Vx
Mélanocytic origin …
Irregular linear Vx
Dotted Vx
NPD Non-polarised (contact)
Polarised
Red flags !
Case 28
Case 29
Pink is usually not good !
Botryomycoma BCC
Amelanotic MM Merkel Cell Ca Lymphoma
Undiff SCC Poroma
Le repos