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Hi Doc, should I worry about this skin lump?

Parkway Cancer Centre’s new “Hi Doc” Continuing Medical Education (CME) Empowerment Series aims to provide a systematic patient-centric approach to our discussions, starting with a common complaint. We then review the various clinical approaches and consider the differential diagnoses, before finally leading us to the definitive treatment of the patient.

In the first webinar of the series, titled “Hi Doc, should I worry about this skin lump?”, Dr Mark Tang, Senior Consultant, Dermatology from The Skin Specialists & Laser Clinic, highlighted the common skin cancers in Asian patients, discussing practical tips and management pearls in dealing with various skin lumps and bumps in clinical practice. This was followed by a presentation by Dr Richard Quek, Senior Consultant, Medical Oncology from Parkway Cancer Centre, who provided a comprehensive update on the latest advances in the systemic treatment of various skin cancers.

An approach to skin lumps and bumps for the busy clinician

Dr Tang began the CME webinar by highlighting the key characteristics of various skin cancers, namely melanoma, basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). He also provided a practical approach to identifying signs and symptoms of skin cancer by classifying skin them based on colour – black or pigmented lesions (which can be a sign of melanoma and pigmented BCC), red or flesh coloured lesions (SCC, angiosarcoma) and lighter or hypopigmented lesions (hypopigmented mycosis fungoides).

His key ‘take home’ messages from his presentation included a reminder that melanoma in Asians tend to present in atypical sites such as the acral, subungal, mucosal or genital areas; the importance of repeat diagnostic workup for persistent or non-resolving lumps and rashes; and the advantages of using bedside diagnostic tools such as dermoscopy for increased accuracy.

He highlighted the important differential diagnosis of cutaneous cancers that can mimic persistent asymptomatic red patches (angiosarcoma), red lumps (cutaneous metastasis) and ‘eczema like’ rashes (extramammary Paget’s disease and cutaneous T cell lymphoma). He also reminded participants that you can identify whether a skin lump is cancerous using the ABCDE rule for skin growths: A for Asymmetry, B for uneven Borders, C for unusual Colors, D for a Diameter of more 6 millimeters, and E for an Evolving or changing skin lesion, with ‘E’ being the most crucial indicator for a malignant lesion.

He then ended his talk with case studies to showcase some further learning points.

The first case study of an amelanotic melanoma in a young patient highlighted the importance of doctors to do close follow-up of “featureless” skin growths that do not have a clear initial diagnosis.

The second case study of a delayed diagnosis of advanced melanoma highlighted the challenge of ‘by the way’ consultations – in which patients raise their problems at the end of their doctor’s visit – and the need for accurate and detailed documentation. This is especially relevant as teledermatology or virtual consultations become more common.

Finally, the case study of a delayed diagnosis of a dermatofibrosarcoma protuberans emphasised that atypical features of a case must prompt a diagnostic rethink, and that it is good practice to record the descriptive terms of skin lesions, such as size and site, rather than the diagnostic terms.

Fortunately, most lumps, bumps and rashes under the skin are usually benign and not deadly or cancerous. An increased awareness of the various diagnostic pearls and potential pitfalls in handling common scenarios allows clinicians to make an earlier diagnosis of the skin cancers, thus improving the outcome and prognosis for patients.

Managing patients with advanced skin cancer

Skin cancer is a diverse group of cancers, and the management of patients with advanced skin cancer is complex. In the modern era, we now have unique systemic treatment options for each type of skin cancer, says Dr Quek.

In general, skin cancers can be broadly classified into 5 main types including BCC, SCC, melanoma, sarcomas, and lymphomas. Each of these groups has a unique presentation, clinical course, and treatment paradigm.

In BCC, treatment involves surgery alone with good clinical outcomes. However, for patients with advanced or unresectable BCC, there is now an approved group of medication called Hedgehog inhibitors.

In advanced skin SCC, apart from chemotherapy, immunotherapy has proven to be effective and approved for use.

Cutaneous sarcomas are not common and varied. The 2 common types of cutaneous sarcomas include dermatofibrosarcoma protruberans (DFSP) and angiosarcoma. DFSP is managed with surgery with wide margins, while cutaneous angiosarcoma – more common in the elderly – is seldom completely resectable as they tend to be multi-focal and infiltrative. Angiosarcoma is sensitive to standard chemotherapies like liposomal doxorubicin and taxanes.

In cutaneous lymphoma, a rare subtype of non-Hodgkin lymphoma, there is a paradigm of care.

In the setting of limited disease, the cutaneous lymphomas can be treated with topical creams and localised radiation, while UV light therapy, oral chemotherapy, oral HDAC inhibitors and targeted therapy may be reserved for patients whose disease has recurred despite local treatment, or in those with more extensive disease who are deemed unsuitable for local treatment alone.

In those with extensive, refractory or recurrent disease, treatment may include chemotherapy either given as a single agent or in combination with other agents.

Advice for medical professionals

Risk stratification is key when it comes to detection of skin cancers. Dr Tang advises medical professionals to identify risk factors such as skin type, age, history of chronic sun damage, immunosuppression, smoking, and family history of skin cancers, and use photography and diagnostic tools such as dermoscopy to detect subtle differences and track changes.

He also advises to keep a high index of suspicion and consider a diagnostic work up, including a skin biopsy, for skin lesions that are persistent, changing or atypical, even in non-sun exposed sites. With skin cancer on the rise, it is most important to keep yourself updated.