Smilow Shares: Sun Safety

July 15, 2021

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July 13, 2021 | Presentations by Drs. Richard Connors, Bruce McGibbon, and Sajid Khan

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00:00Bruce Mcgibbon I'm a radiation
00:02oncologist for Yale.
00:03The smile of Greenwich site and
00:05very happy that we can join us
00:07tonight for these great talks on
00:09skin cancer or joined tonight by
00:11Doctor Connors and Doctor Khan and.
00:15Uh, everyone will introduce themselves
00:17and at the end will be able to do a Q&A.
00:20If you have any questions,
00:21feel free to type them into the chat
00:23and that will address in the PM.
00:25So first up is Doctor Connors.
00:31Hello hello I'm doctor Richard Connors.
00:33I'm a dermatologist in Greenwich.
00:35I did my training at my basic
00:38dermatology training at New York
00:40Hospital and Cornell and then I did.
00:43Did a years fellowship at the NYU
00:46Medical Center in Skin pathology.
00:48I am certified in both general
00:52dermatology and dermatopathology.
00:54I have practiced in this area for
00:56I'm amazed to say for 44 years I did
00:59two years with my one of my teachers
01:02from New York Hospital, Stanford,
01:04and I've been in Greenwich for 42 years.
01:08I'm not as old as you might think.
01:10I kid people and say it was a
01:12child prodigy and I I graduated
01:14from medical school at age 12 so,
01:16but I've been doing dermatology
01:18for a long time, here and.
01:20Uh, it's highly relevant that we should
01:23talk about skin cancer nationwide.
01:26It certainly is.
01:28Prevalent,
01:28it's more common.
01:30It's more numerous than
01:32all other cancers combined,
01:34but I think that's especially
01:36true for this particular area.
01:40I talk occasionally to the
01:42Greenwich Retired Men's Association.
01:44I lasted at about five years ago.
01:47I consulted the Connecticut Tumor
01:49registry to see what the incidents the
01:52year before Melanoma and Greenwich was,
01:54it was remarkably higher than it was
01:57that at that same time in Queensland,
02:00Australia, which has the highest
02:02incidence of Melanoma in the world.
02:05So most Melanoma, I mean most skin cancer,
02:08are not Melanoma.
02:10Most are easily treated.
02:12But there's important to find them
02:14and treat them early and prevent as
02:16much damage by them as you can't.
02:19The question becomes who gets skin cancer.
02:21While anyone can get skin cancer.
02:23But the most likely candidate is a fair
02:28skinned person who sunburns readily.
02:31OK, the more.
02:32Easily you sunburn,
02:34the more apt you are to develop skin cancer,
02:38so will will will run a series
02:40of slides here.
02:41This repeats what I've just said.
02:46And again, it's a very very common
02:49cancer that fair skinned individual,
02:51the blonde, the redhead people with lots
02:54of moles are more apt to develop Melanoma.
02:58People with unusual shaped or
03:00darker moles may develop Melanoma.
03:02In addition, people with a family history
03:05of skin cancer are certainly more at risk.
03:08Those people have had lots of sun,
03:11blistering, sunburns.
03:12People have been to tanning beds.
03:15Too much immunosuppressed people.
03:17Uh, people with blood malignancies or so,
03:20especially organ transplants,
03:21are very prone to skin cancer,
03:24so it's a wide ranging problem in
03:27a wide ranging population who are
03:30exposed to that likelihood. Ah.
03:34Again, when detected early as we say here,
03:36it's very, very treatable.
03:38The general advice is an old
03:41skin spot that's changing,
03:43particularly in size, color, shape.
03:47Or elevation or a new spot on the
03:49skin that's growing perceptibly.
03:51Those are the warning signs of skin cancer,
03:54or in a unique aspect of skin cancer,
03:57of course,
03:57is unlike any other cancer.
03:59It's readily available.
04:00It's on the skin that can be seen.
04:03It can be palpated,
04:04so people on their own do well as well.
04:07Touch on later to do their own skin exam.
04:11The ultimate diagnosis procedure
04:14for skin cancer is a skin biopsy.
04:19Now we call it skin cancer,
04:22but it's it's overwhelmingly
04:24epidermal cancer.
04:25The epidermis remember from high school
04:28biology is the outer layer of the skin,
04:32and that's the interface with the world
04:35and it's the epidermis that's hit,
04:38particularly by the ultraviolet
04:40segment of the the sun.
04:43And that's what dismantles or disrupts.
04:45Rather,
04:46the DNA of these rapidly
04:49producing epidermal cells.
04:50So the lowest layer of the epidermis
04:53is the basil layer.
04:54The middle layers of squamous melanocyte
04:56which resides in the basal layer is
04:59those are the main skin cancers.
05:01There's a much less common one called Burt
05:04Merkel cell which will touch on later.
05:08An aspect of skin cancer clinically
05:12is that there's no single,
05:15predictable presentation.
05:17Basal squamous Melanoma.
05:20Each has its own variety.
05:22Each could have a
05:25multiplicity of presentation.
05:26Basil cell in particular.
05:28Prototypically,
05:29it's an elevated spot on the skin
05:31that that cross or bleeds easily,
05:34but sometimes it's just a
05:36whitish spot on the skin.
05:38Sometimes it's simply an innocuous
05:39looking red spot on the skin.
05:42Sometimes Basil cell is even
05:44pigmented and looks like a mole, so.
05:48One has to understand the multiplicity
05:50of pleasant presentations, squamous cell,
05:53a second most common skin cancer.
05:56Often presents as just a skin colored
05:59thickening or nodule on the skin
06:02that may present and grow rapidly.
06:05It may seem almost like an inflamed cyst.
06:09Other times,
06:10it's independent girls slowly
06:11like basil cell.
06:13It may ulcerate and crust and scab.
06:18And but it does grow all
06:21of these things malignant,
06:23and their ascential feature is growth,
06:26uninhibited growth.
06:27So untreated they get bigger,
06:29they get deeper.
06:30Now the last of the most common skin cancers,
06:34of course, is the most worrisome.
06:37I see literally 100 basil and
06:39squamous for one Melanoma.
06:41I keep track of all my biopsy,
06:43and if arbitrarily I go through them,
06:46pick a hundred consecutive skin cancer
06:48positive biopsy 75 to 80 will be basil.
06:51That's how dominant and incidents
06:53basil is 20 to 25% will be squamous
06:56cell 1 to 2% will be Melanoma,
06:59so much less common.
07:01And certainly potentially.
07:04Very serious, however,
07:05even Melanoma is a from many of them.
07:08There's a period where they're just
07:10on the surface and very curable,
07:13and that's why you're looking
07:15at your own skin.
07:16Having a skin doctor look at you
07:20periodically is.
07:21It's desirable.
07:23With Melanoma,
07:24there's been a mnemonic we've used for years,
07:28ABC, DE to highlight the differences
07:31clinically between your typical
07:33mold and typical Melanoma,
07:35your typical mole is hardly as a
07:39regular border, pretty uniform color,
07:42pretty symmetrical.
07:43In its division 1/2 like the other half.
07:47Melanoma is up.
07:49Typically are often at least disorderly,
07:51and we have this ABCDE mnemonic.
07:54A is asymmetry 1/2 of the spot different,
07:58as here from the other half of this,
08:02but by its color by its shape I had
08:06size the border again, mole smooth,
08:09regular, often with Melanoma,
08:11a notched, the irregular.
08:13Uh, the colored ABC?
08:16The color in melanomas is often.
08:19Irregular, varied, I should say brown,
08:22grey, white, black.
08:24We're usually moles are pretty
08:26uniform in color. D.
08:28The next criterion is the diameter.
08:31It's it's not a very.
08:35It's not a universal one,
08:37but you usual Melanoma by the time
08:39it's diagnosable, at least is at
08:41least 6 millimeters in diameter,
08:42which is about the width of the
08:45eraser and the head of a pencil.
08:47Benign things can be with that wide.
08:49Some melanomas, of course,
08:51are smaller, but it's the bigger
08:53the brown pigmented lesion,
08:54the more you should pay heed to it.
08:56The last of the mnemonic is easy,
08:59meaning evolving or changing.
09:02Melanoma is at least 80% begin his Melanoma.
09:05Most don't begin from antecedent mold.
09:07Early on, they look like a mole is
09:10small there doc, but they slowly,
09:13steadily spread out like an oil
09:15spill and end up with a uh,
09:18with much more than they began with.
09:20So, ABC DERA good guide as to how
09:23to evaluate pigmented skin spots.
09:28The 4th. Skin cancer considerably less
09:32common than the other four are free,
09:35but getting more and more common as
09:38Merkel cell carcinoma which originates
09:40actually in the dermis of Merkel cell,
09:43is an oral endocrine cell involved
09:46in the transmission of light touch.
09:49In the typical Merkel cell,
09:51cancer is on the sun,
09:52damaged skin of a senior citizen,
09:55Caucasian, often a man.
09:56But women certainly could get it,
09:58but it grows rapidly.
10:00It's a typically a bright
10:01red or dark red nodule.
10:03It comes up quickly and is
10:05in a matter of days or weeks.
10:08It's getting bigger and that
10:09should get you right to either
10:11a doctor or dermatologist.
10:13Again, that's much less common
10:15than the other three,
10:16but important.
10:19What what can you do to limit
10:22damage that a skin cancer might do?
10:25Again, your own skin exam self exam will
10:28get to that more particularly after this,
10:31but I think going to a dermatologist
10:34once a year for a skin exam is an
10:37inexpensive bit of preventative medicine.
10:40But on your own, if you see something that
10:42seems different, growing itch bleeding.
10:44I have a sister-in-law giving an anecdote,
10:47but I was a first year resident at New
10:49York Hospital. It was Christmas time.
10:52She presented me with a mole on
10:54her right arm that was itchy.
10:56And I knew that wasn't good.
10:58I was still young in my career,
11:01but I said get that thing off and it
11:04turned out to be a Melanoma. So it's not.
11:07It's an uncommon presentation of skin cancer,
11:10but it it can be.
11:12So you should protect your skin.
11:14Try not to sunburn.
11:15Most of all, I never say no son, I say no.
11:19Sun Burns a little bit of sun,
11:21particularly if you're darker in color.
11:24I I I can't object to,
11:26there are good things about sun,
11:28particularly vitamin D.
11:29There are no good things about
11:31tanning booths.
11:32They are awful.
11:33They should be renamed wrinkle machines.
11:35They not only increase skin cancer,
11:38particularly young women,
11:39but they age the skin very quickly.
11:43So here's a guide to skin self exam from
11:46the American Academy of Dermatology.
11:48I think we have a skin cancer.
11:50It just on your own and will will be
11:53able to send you if you want these from
11:56the both the Academy of Dermatology
11:58and the Skin Champion Foundation.
12:00This sort of a guy but you
12:03can examine on your own.
12:04I urge people once a month
12:07do your own skin checks.
12:09Uh, and and this is a guide to doing it.
12:14Test. You don't have to be a
12:17professor of dermatology at Harvard
12:19to be able to recognize something
12:22new and different on your skin.
12:24It's helped, certainly if you have a
12:27partner to look particularly at your back.
12:30I don't do these exams once a month.
12:32I urge people a 15th of the month.
12:35Take two minutes and do a skin exam.
12:38Is there something new something
12:39changing something you don't recognize?
12:43So.
12:48OK, the most common place,
12:50for instance men get Melanoma is the
12:52upper back and they can't see it readily.
12:55For women the front of the lower
12:57legs is the most common place,
12:59although neither one Mitt
13:00represents 30% of their locations.
13:02But particularly with the back,
13:03the back for women is also an
13:05important place for Melanoma.
13:07So do check one another's backs at home.
13:12In terms of. Prevention in sun safety.
13:15Avoid the worst of the Suns.
13:1710:00 o'clock till talked in the
13:19morning till 2:00 in the afternoon. Uh.
13:22Clothing big hats like patients kidney.
13:25I'm always telling get a big head skin cancer
13:28on the ear is almost uniquely among men.
13:32Women inadvertently protect
13:33their ears with their long hair.
13:36But men should. Everyone should wear
13:38a big hat that protects ears and face.
13:41Uh sunglasses, of course.
13:44Sunscreens, they should be broad spectrum,
13:47water resistant and at least a 30 SPF.
13:51And don't forget, even on a cloudy day,
13:54you certainly can get sunburn and
13:56reapply it every couple of hours.
13:58Succinctly, in the realm of sunscreens,
14:00I think the evidence more and more
14:03favors for a variety of reasons using
14:06the inorganic sunscreens, which are
14:08the zinc and titanium dioxide sunscreens.
14:10But that's it's another topic for discussion,
14:13but I would favor that type of sunscreen
14:15and their work cosmetically acceptable.
14:18You're not as white when you use them,
14:21they've broken the particles down,
14:22so there that you're you're less white.
14:27Yeah, don't forget the reflection from the
14:29water from sand at the beach and from snow.
14:33The worst sunburns I've seen
14:35have been 17 year old skiing at
14:38Vail at 5 or 6000 feet with snow.
14:40Terrible amounts of ultraviolet.
14:43On their face now,
14:45the skiing goggles and the
14:46helmets protects a lot of that,
14:48but the worst sunburns can
14:49be out there skiing.
14:52And whatever you do,
14:54don't use tanning bed again.
14:56They should be renamed wrinkle machines.
14:58There has been an uptick over the
15:01last 20 years or so skin cancer,
15:03Melanoma, squamous cell,
15:04and young women in America,
15:06undoubtedly because of their their,
15:08their primary users of tanning beds.
15:12And these are two references.
15:15The first is from the American Academy
15:17of Dermatology spots incanter.org.
15:19They have excellent material,
15:21excellent pamphlets on all
15:23the different skin cancers.
15:24The same is true for the
15:27store dot skin cancer,
15:29or that's from the Skin Cancer Foundation.
15:32Wonderful material,
15:32very inexpensive and it details
15:34more of the clinical presentations
15:37of the various skin cancers.
15:39Thank you for your time.
15:50That's great Doctor Connors
15:52come I'm gonna come.
15:54I'm going to just, uh, uhm, talk, uh,
15:57next let me just pull up my slides.
16:02OK, so my name is I'm for I'm
16:05here so my name is Sajjad Khan.
16:08One of these surgical oncologists at Yale,
16:11one of three surgical resurgens at Yale
16:14that take care of Melanoma patients.
16:16There's myself, there's doctor
16:18Alina and there's doctor Clune,
16:20and we see patients currently in the
16:23shoreline in New Haven and Trumbull in
16:26our clinics and provided care of patients
16:29throughout the state of Connecticut we.
16:32We're also working closely with
16:33some of the excellent surgeons that
16:35you have at Greenwich Hospital,
16:36such as Doctor Petrotest,
16:38and we're and we hope to have a
16:40bit of more of a presence for our
16:42surgical oncology group at that
16:44time in that location as well, too.
16:48So what I'm going to talk to you about
16:50for our March from my perspective,
16:52is from a surgical oncologist.
16:54So Doctor Connors believe an excellent
16:56talk about from a dermatology
16:57perspective on skin cancer.
16:59Mine is going to be a little bit more
17:01focused on Melanoma because, you know,
17:03many patients with skin cancers.
17:05Don't see us, they see.
17:08Dermatologist Doctor Connors who can
17:10handle things uh within their office.
17:12And oftentimes dermatologists,
17:13Doctor Connors,
17:14mother dermatologist throughout
17:15the region when they see a patient
17:17with Melanoma diagnosis,
17:19still have the patient see one of us.
17:22So this is just going to be a
17:25very basic talk going over some
17:28of that from our perspective.
17:30So this is a general slide that shows that
17:34cancer is obviously a big problem in America.
17:37So in 2020,
17:38nearly 2 million people were
17:40diagnosed with cancer altogether.
17:41I'm sure just that everyone in this audience
17:44has been affected somewhat with cancer.
17:46Whether it's personally
17:47worth a friend or a family.
17:50And unfortunately we still have a lot
17:52to do with our battle against cancer.
17:55Over half a million people
17:56died in 2020 due to cancer,
17:59and cancer is not just a problem nationally
18:01to problem locally here in Connecticut,
18:04just in our small state here,
18:0620,000 /, 20,000.
18:07People were diagnosed with cancer and
18:106300 people died of cancer specifically.
18:15This is a slide that you may
18:16see another talks.
18:17If you haven't seen this already
18:19and this is a slide that shows the
18:21top ten cancers diagnosed in the
18:22United States in men and in women.
18:24You could see that the leading
18:26cause of cancer,
18:27the leading diagnosed cancer
18:28in America for men,
18:30is prostate cancer and in
18:32women's breast cancer.
18:33The purpose of this talk
18:35is Melanoma and you see,
18:36Melanoma does make the top ten
18:38list for both males and females,
18:40accounting for 60,000 patients
18:42in men and 40,000 patients,
18:4340,000 cases in women.
18:47And and this is some of this
18:49is a little bit of a recap of
18:52Doctor Connors and presentation.
18:53But 3.5 million Americans,
18:55probably even higher than that,
18:56were diagnosed with a non Melanoma
18:58skin cancer such as basal cell
19:00or squamous cell carcinoma.
19:01The Merkel cells,
19:02like Doctor Connor said is are quite
19:05rare and deaths related to these
19:07types of skin cancers are uncommon.
19:09And the number of individuals
19:11diagnosed with Melanoma is nearly
19:13100,000 and it depends on who
19:16who statistics you're looking at.
19:18But the American Cancer Society last
19:21year reported 100,000 individuals
19:23with diagnosed with Melanoma in 6800.
19:26Cancer related deaths from Melanoma.
19:27They also document for the NCCN and
19:29for the American Cancer Society,
19:31that the incidence is rising.
19:33There's some controversy to that,
19:34but the incidence is running rising
19:37according to these sources and
19:39the lifetime risk of developing
19:40Melanoma is 1 in 34 for females
19:42and one in 53 for males.
19:44So it's a it's not an uncommon problem.
19:49So so UV light exposure is
19:51a major ideological factor.
19:52And like again these are. These are not.
19:54This isn't even sum it up as well
19:57as Doctor Connor summed it up,
19:59but sunburned early in life.
20:00These are some questions that we
20:02asked for patients in the clinic
20:04in our surgical oncology clinic.
20:05I always ask him about sunburns,
20:07particularly blistering sunburns,
20:08which is a risk factor for
20:10development of Melanoma tanning beds,
20:11which are obviously very.
20:13They can be there.
20:14Very dangerous.
20:14Kind of like cigarettes is the analogy.
20:17I use them too.
20:18Oftentimes a personal history of
20:20Melanoma or other skin cancers.
20:22A family history of Melanoma.
20:24There are less common things such
20:26as dysplastic nevus syndrome,
20:27Xeroderma pigmentosum,
20:28some genetic mutations in
20:29radiation exposure as a child,
20:31but those latter ones are very
20:33uncommon or a much less common.
20:38So the key to a good outcome for
20:40Melanoma often is an early diagnosis,
20:42as is the deal with other types of cancers,
20:45solid tumor malignancies and prevention,
20:47and you know first thing is to
20:49avoid UV radiation exposure,
20:50and this is particularly important
20:52for fair skinned individuals.
20:53You know technically,
20:54just being in a building,
20:56being indoors is the way to avoid the sun.
20:58Obviously that's not practical in the
21:00United States, but uh, so you know.
21:03So if you are out and about,
21:05you know, use protective clothing.
21:07And then sunscreen SPF 30 or higher is
21:09what we cancel our patients as well too.
21:12And so prevention the best
21:14you can and screening.
21:15I couldn't have summarizes
21:16better than Doctor Connors,
21:18but he also just to reinforce
21:20talked about self examinations and
21:22after we see our patients in our
21:24surgical oncology clinic that we
21:26make sure that they should have
21:28long term surveillance with their
21:29local dermatologists for total
21:31body checks is what we counsel them
21:33are on and we also plug patients
21:35into our Melanoma oncology.
21:37Program and that can involve a
21:38medical oncologist or surgical
21:39oncologist that follows along,
21:41but they keep for a certain period of time.
21:43But the key thing we tell our patients
21:45is you need to see your dermatologist
21:48for life for total body checks.
21:50Uhm,
21:50and there are some particular scenarios
21:52where patients may need some screen
21:55a little bit sooner than that.
21:58So these are the, you know,
22:00the we look at the same things as
22:03the surgical oncologist and you
22:04know our eyes are not as good as
22:07the dermatologist size such as
22:08Doctor Connors and some of the other
22:11dermatologists because you know we all
22:13often times will see patients with a
22:15cancer diagnosis and we are working
22:17on patients taking care of patients.
22:19Once that diagnosis is made.
22:20But these are questions we ask
22:22our patients just during their
22:24visit to our surgical oncology.
22:25Clinically focused, we asked if they.
22:27Have any if they have any recollection
22:29of the tumor or the lesion with eight
22:32for asymmetry orders being irregular,
22:34the color or not being the same or
22:37uniform throughout the diameter
22:38larger than a pencil eraser and has
22:40the has the skin lesion evolved
22:43over the course of time and these
22:45are just some simple examples of
22:47a symbol of an asymmetric Melanoma
22:49with an irregular another one with
22:51an irregular border.
22:52You can see stitches there in the middle
22:54from a biopsy that was performed the color.
22:57Variation,
22:58meaning that color is not the same
23:00throughout the entire skin lesion
23:02diameter larger than a pencil eraser,
23:04so those are and then the evolution
23:06that I didn't show any pictures on.
23:09So now you know.
23:11So let's say someone that you
23:13know is diagnosed.
23:14Melanoma,
23:15they see the dermatologist dermatologist
23:17performs a biopsy and you know at
23:20that point that's that's such a
23:22critical point in the the work up in
23:24the whole management of this patient.
23:26So you know,
23:27we work very closely with the dermatologist.
23:30We have the Dermot dermatologist
23:31Office will fax us or send us over the
23:35biopsy results after they've performed
23:37the biopsy and we pay attention to this.
23:40This slide just sums up how are surgical
23:42management is the primary tumor.
23:43We have patients that present with
23:45Melanoma Insight 2 and that some
23:47Melanoma that has not invaded into
23:49the deeper layers of the skin,
23:50which is which is a favorable thing
23:52because there's no lymphatics in the
23:54in that superficial layer of the skin.
23:56Thus there's no risk for lymphatic spread.
23:58So for Melanoma insight two,
24:00we tend to excise margins of five to 8
24:02millimeters around the side of the tumor,
24:04and I have a court picture for you.
24:07I'll show you a little bit later
24:09about what that means.
24:10Uh,
24:11if melanomas are less than
24:12one millimeter in thickness,
24:14and this is a vertical thickness.
24:15So it's, uh, we, we, we.
24:17Patient has a Melanoma that's less
24:20than one millimeter in thick thickness.
24:22We performing exceptionally wide margin
24:24resection of 1 centimeter circumferentially.
24:26I'll show you it's not
24:28technically circumferential.
24:29I tend to take in the lips.
24:33If patients having Melanoma 1 to
24:352 millimeters in thickness uh,
24:36we perform a wide margin resection
24:38with one to two centimeter margins.
24:41If patients have a Melanoma that's two
24:43to four millimeters in Breslow thickness,
24:45we take margins of two centimeters.
24:48And if patients have greater than
24:494 millimeter, Breslow think there's
24:51not great data to support what
24:52the wet propriate margins are.
24:54But we tend to take a little
24:55bit more than two centimeters,
24:57and particularly if I see someone
24:58with some of their at some
25:00other adverse features such as
25:01ulceration or high mitotic rate,
25:03I tend to sometimes even get the three
25:05centimeters in those in those scenarios,
25:07if I did do a PET scan ahead of time,
25:09but this is basically the
25:11margins that we aim for.
25:12For these wide excisions and and
25:14you know the and I in our clinic,
25:16we draw a cartoon.
25:17We draw it on a piece of paper.
25:19Exactly what we do to scale,
25:21and you know,
25:22the patient's natural reaction is
25:23always a little bit of surprise
25:25over how wide the margin, how,
25:26how much skin needs to be excised,
25:28or provide a good Hanukkah logic
25:30margin in our goal is to provide a good
25:32cancer operation and to provide so
25:34the patients have a good immediate outcome.
25:36But just as importantly good
25:37long term outcome as well too.
25:39And of course, our decision,
25:40our scars look very nice too,
25:42but at the end of the day
25:44we never want to compromise.
25:47Uh,
25:47the cancer outcome.
25:50Another thing that comes up with central
25:52and so I'm not I wouldn't read all this,
25:54but I'll give you some of the highlights.
25:56So another natural question was sent
25:58with Melanoma is is there any lymph
26:00node involvement so when patients
26:01see us in our surgical oncology clinic,
26:03we asked them to come into a gallon
26:05so we can do a skin exam and make
26:08sure that there's no satellite
26:09lesions or any other lesions that are
26:11missed and that there's no evidence
26:14of any clinical lymph adenopathy or
26:16enlarged lymph nodes if there's not.
26:18Patients have various characteristics
26:19of Melanoma.
26:20We will often offer them a
26:22Sentinel lymph node biopsy,
26:23a Sentinel lymph node biopsy is the
26:25first lymph node where Melanoma
26:26can spread to doesn't mean that
26:28Melanoma is there.
26:29It simply means we have to biopsy
26:31those lymph nodes in order to make
26:33sure that there's not Melanoma there.
26:35So for patients with Melanoma that
26:37are 1 to 2 millimeters in thickness,
26:40basically everyone gets sent a lymph
26:41node biopsy unless they have some
26:43issues with their performance status.
26:45They might not be flat chanted
26:47for clinical trials.
26:48Some in some circumstances they don't,
26:50but it's a general rule for
26:51patient with one to four millimeter
26:53Breslow thick Melanoma.
26:54I offered them a widest wide excision
26:56and a Sentinel lymph node biopsy.
26:58Sometimes it gets a little bit more
27:00difficult for patients with thin melanomas,
27:02so patients with thin melanomas
27:04that are less than 8.
27:06Millimeters generally don't get
27:07us into lymph node biopsy,
27:08but if they have a .8 millimeters to
27:101 millimeter in Breslow thickness,
27:12we sometimes will offer them a
27:14settlement biopsy.
27:15If they have other characteristics
27:16that are adverse,
27:17such as a high mitotic rate or ulceration,
27:20or if there's some concern about the deep
27:22margin being thicker than .8 millimeters.
27:24So that's a group of patients.
27:26We will offer sentiment biopsy
27:27little bit more selectively.
27:28For patients with thick melanomas,
27:30you know this has become less controversial,
27:32but you know about 8:00 or
27:34nine years ago it was a little.
27:36Questionable about should patients with thick
27:38Melanoma is greater than 4 millimeters?
27:41Get us into lymph node biopsy.
27:43Would it provide prognostic
27:45information or not?
27:46But now we tend to offer sent by
27:48aspiration for 4 millimeters or
27:50greater than or greater thickness
27:53Melanoma because there is some utility
27:55in this patient cohort and the last
27:58important point that's important.
27:59Last last point that's important is
28:01the role of completion lymph node
28:04dissection so so sentimental biopsies are.
28:06You know, removing usually about
28:08one or two lymph nodes,
28:09sometimes a little bit more,
28:11sometimes one,
28:11but it's just removing a small select number
28:14of lymph nodes where Melanoma may spread to,
28:16and I have a cartoon for you to show
28:18you what that what that looks like.
28:21However,
28:21there was a time where patients that
28:23had positive Sentinel lymph nodes ended
28:25up getting completion lymphadenectomy's.
28:26Which means we removed the
28:29entire lymph node basin.
28:31Uh, within these patients as well too,
28:33but there was two major trials that
28:35happened in the last five years,
28:36one based out of North America,
28:38another one based out of Germany,
28:40where they randomized patients
28:41with positive central nodes to
28:43removing all the center,
28:44all the rest of the lymph nodes
28:45which AK completion lymphadenectomy
28:46or or just observing the group
28:48with the positive central nodes.
28:50And at the end of the day they
28:52found that there was no difference
28:54in the survival between both
28:55of those groups of patients.
28:57So that's pretty practice changing because
28:59there's been a lot of advances in Melanoma.
29:01The last 10 years.
29:02So a lot of which yell has contributed
29:04based on systemic treatment
29:06options such as immunotherapy,
29:07and some of these trials as well
29:09to where you know we are offering
29:12less surgery for patients.
29:13Because sometimes we we we want
29:15to help patients with surgery.
29:17If we're going to help them,
29:18but we wanna.
29:19We don't take patients through surgery
29:21if we put them into some unnecessary
29:23risk for unnecessary morbidity
29:24without providing much benefit.
29:26So these trials were very exciting
29:29in the surgical oncology community.
29:31So this is an example of what's
29:33called the lymphoscintigraphy,
29:34so if you see us in our surgical
29:36oncology clinic,
29:37I tend to get Olympus interior
29:38fee on most of my patients,
29:40which is basically an X ray of the
29:42lymph nodes where the patient goes
29:44to the nuclear medicine sweet and
29:46has an injection of what's called
29:48technetium and that travels to the
29:49Sentinel lymph nodes and we use
29:51that information in the operating
29:52room where we inject the blue dye
29:54called methylene blue and that
29:56methylene blue travels to the
29:57Sentinel lymph nodes in using the
29:59technetium study and the methylene blue.
30:01We were able to make a small
30:03incision directly over the
30:05Sentinel nodes and excise them.
30:06So that is what I sent to the lymph node.
30:10Biopsy is. And these are just some some
30:12examples of Sentinel lymph node biopsies
30:15in patients small incision produce.
30:17And the last few slides around this out,
30:20or just going to tell you a little bit
30:23more about, uh, about the survival.
30:24So the most important thing is
30:26the Breslow thickness and this.
30:28This is what's called a Captain Meier curve.
30:30And by the way,
30:31that what that means is on the Y axis.
30:34Here on the left is the Melanoma
30:36specific survival, and on the X axis.
30:38Here are the years after the
30:40patient is diagnosed with Melanoma,
30:42and as you see here in the in the purple,
30:45which is the top.
30:46These are patients with T1.
30:48Paid tumors is from a recent study from
30:50the MD Anderson Group where patients have
30:53that have less have a thin Melanoma,
30:55have an excellent long term survival,
30:57and as you advance and have
31:00a thicker Melanoma.
31:02Greater than 4 millimeters to survival
31:04is not as good, so that is a one.
31:06That's why the the tumor thickness is
31:09important and having a good dermatologist.
31:11Biopsy you such as Doctor Connors
31:13and his group go along way.
31:15The next important thing is if
31:17patients have positive Sentinel
31:18lymph nodes then you know the number
31:20of settling the number of nodes
31:22sometimes can play can play a big
31:24difference and what this shows is the
31:26more lymph nodes which are involved.
31:28You know the you know the outcome
31:30is not the Melanoma specifically.
31:33Old decreases,
31:33and that's basically what this a
31:36busy slide shows. So in summary.
31:38So for Melanoma it is the deadliest
31:41type of skin cancer which exists.
31:44Prevention early diagnosis
31:45improved clinical outcomes.
31:46So uh,
31:47so we do reinforced our patients to see the
31:50dermatologist to perform self body exams.
31:52Avoid UV exposure and remember the
31:55abcd's or ease because I think sometimes
31:57that will be important for you when you talk.
32:00But when you examine a skin lesion on
32:03yourself were in the family member,
32:06you know the surgical treatment
32:07is the backbone to the management.
32:10So we summarize the wide margin resection,
32:12a Sentinel lymph node biopsy
32:14very selectively.
32:15Completion lymphadenectomy's
32:15I didn't show you some of the
32:17circumstances where it's useful,
32:18but uh,
32:19there are some slight circumstances
32:21and you know.
32:21And then this metastasectomy what
32:23I mean by that is patients that
32:25have this metastasis of Melanoma.
32:26There is a selective role where
32:28sometimes surgery can play a role,
32:30but you know this talk was given by I'm.
32:32I'm speaking on behalf of
32:34surgical oncologists.
32:35If a medical oncologist,
32:36one of our medical colleagues gave you talk,
32:38they would tell you about how great the
32:40immune immune checkpoint inhibitors are.
32:42So they have revolutionized
32:43management for Melanoma in the last
32:4510 years. That that class of drugs
32:47is is is just really changed.
32:49The management is the most important group
32:51that cancer drugs have been developed and
32:53fortunately it works very well for Melanoma,
32:55so so there's less of a role for that for us.
33:00And finally, tumor thickness, ulceration,
33:01mitotic rate are the most important
33:03prognostic variables we tried to show you
33:06that toured in the last couple of slides,
33:08and if the sentiment is positive,
33:10the prognosis is determined by the
33:11number of positive nodes thickness,
33:13mitotic rate, and ulceration.
33:15Uh, and, uh, yeah.
33:16And that is it from my perspective here,
33:19and I'll hand it over to Doctor Mcgibbon.
33:24I was excellent. Thank you Doctor Cole.
33:30Transfer rank excellent. Let me
33:31see if I can share my screen here.
33:43OK, perfect. So again,
33:45I'm doctor Bruce Mcgibbon,
33:48radiation oncologist. Greenwich and.
33:51I'm going to talk through early advances
33:53in radiation therapy for skin cancer.
33:55Really particular to be non Melanoma cancers,
33:58especially the squamous and basal cell.
34:02I would say that the the main types
34:04of cancers that get referred to to
34:07our clinic are really basal cell,
34:09squamous cell and a kind of a lesser
34:11version or an earlier version of
34:14scandal called Bowen's Disease or
34:16Springfield Person inside too.
34:17We definitely do see Melanoma
34:20and Merkel cell.
34:22Carcinoma and also at the other end
34:24called Capozzi, sarcoma and radiation,
34:26can play potential role in all of those.
34:29But to keep this talk a little more concise,
34:33we're going to stick nonmelanoma versions.
34:36And of these ones actually
34:38basal cell and squamous cell,
34:39about 70% of them seem to occur on the face
34:43and other ones on the face of at least 1/4.
34:46Almost a third are on the nose.
34:49And.
34:51Just something you know.
34:52Certainly the the full skin
34:54exam is really full body,
34:55but you know certainly is an area that
34:58that we pay a lot of attention to.
35:00Mike now in terms of the the managing
35:03right now you've been you've had
35:05that buys you Doctor Connors timed
35:07out and confirm your baseless claim
35:09of house is going to be managed.
35:11There are a bunch of options
35:13that are possible from you know,
35:14burning it or freezing it or
35:16certain topical chemo therapies.
35:17But I would say most of them are
35:19managed by some type of surgical
35:21removal and one form that perhaps
35:23the most popular series is called
35:25Mohs surgery and we don't have
35:27a most surgeon here tonight.
35:28But it's very nifty technique
35:30where you go to one.
35:31One time visit for the procedure and,
35:34uh,
35:34that surgeon really removes the
35:35team were very close margins,
35:37then looks at in the microscope
35:39and tries determine if they've
35:41really cleared all the cans or not,
35:43and if not,
35:43they go right back and take a little
35:46bit more and keep looking the
35:48microphone going back and forth and really,
35:50really feel they have cleared it.
35:52And this is a really good option
35:54for for many of these early cancers,
35:56especially the small ones,
35:58especially in areas where you know
36:00the surgical defect would not be.
36:02Two cosmetic Lee, challenging from very nice.
36:06Obviously what I do is not.
36:07That is, radiation therapy is.
36:08I'll give you more detail on that.
36:11Radiation therapy is actually
36:12being used for skin cancers for
36:14well over a century now,
36:15but it's just not unnecessarily.
36:17It's widely known skin cancer
36:18is one of the very first things.
36:20The traditions even tried on to see
36:22if they could cure cancer and a lot
36:24of it is is done is what's called definitive,
36:27which is really we're being done
36:29instead of surgery when these
36:30options sometimes for more landscape
36:31to be called for post operative,
36:33where it certainly is not able to
36:35clear it or we feel like there's
36:37still a very high risk of coming back
36:39until we're giving doing the surgery.
36:41Handling radiation.
36:42Just get a sense of you know
36:45what the effectiveness is.
36:47That means treatments.
36:48There was a study of it was
36:50retrospective, meaning that no one
36:52is randomized was just going back and
36:55looking at massive numbers of people
36:57to what they got and how they did,
36:59and this was done and reported in 1989.
37:02That gives him some respect.
37:03If there this is on basal cell cancers
37:06that have not been previously treated.
37:09And you can see the the figures here,
37:11down below it at five years.
37:12The chance of keeping cancer
37:14coming back were very high,
37:15with really all the options and others.
37:17Of course selection bias here 'cause
37:18some of the one street with that they
37:20curettage would have been very very small,
37:22so it's a little hard to compare.
37:24Just get a general sense of the numbers.
37:26You can see that everything is
37:28kind of the 90% in most surgery is
37:31already with the highest year at 99.
37:33Uhm? When we look at,
37:36you know further at comparing and
37:37look a little more at radiation,
37:39we can see that in our world,
37:41how much dose you can put in,
37:43how much energy can put in,
37:45and how big the tumor is has a big
37:47impact on our chances of really
37:49getting rid of it and what the
37:51cosmetic result is going to be like.
37:53So in this trial by love it,
37:55for example, a little bit of a
37:56busy slide will talk it through.
37:58You can see in this top.
38:00So first of all,
38:01just looking at local control,
38:02if you had a small tumor less than.
38:05Centimeter chance with the basis of
38:07getting rid of it really long term is
38:0997% as it gets bigger, it gets down.
38:11In the 80s you can see if you go a
38:14little bit to the right and the FCC.
38:16That squamous cell cancer that size
38:18effect is even more prominent.
38:20You really want to catch those quotes
38:22about early early one more time.
38:2391% of this in the 70s and 60s
38:26to get really large one.
38:28Uh, and the same thing goes.
38:30I guess it stands to reason
38:31on the cosmetic hand.
38:33Most people at radiation here were
38:34very happy with their resulting
38:36in good or excellent,
38:37but it did relate to how big the tumor is.
38:40So you had people being thrown with
38:42their cosmic result when we're done
38:44with small tumor, but you know,
38:46still mostly happy but not as
38:48good with the bigger ones.
38:50And I couldn't stand to reason,
38:52bigger cancers and more aggressive treatment,
38:54but it's all of your choice really.
38:56Find these early and being treated fairly.
38:59There is one type of treatment at all.
39:02Show a bit more detail later,
39:04which is newer with skin, breakey,
39:06therapy and showed some pictures.
39:07But just to give a sense up to more more
39:10current data than the 1980s on this,
39:13here is a group that went back and
39:15looked at a couple 100 patients
39:17treat with Moze couple 100 done
39:19with this breaking therapy.
39:21And it is relatively short fall,
39:23but I think it's still interesting
39:26about 3 1/2 years
39:27though, is sale 99 to 100% in both groups.
39:30Had had control of this and and very
39:33high percent were thrilled with
39:36their customer consultants well.
39:38Uhm, just little bit about housework,
39:40so there are two basic styles of
39:42radiation therapy for skin cancer.
39:43You have X rays and then
39:45we called Reiki therapy.
39:46So for X rays you have a machine.
39:48This machine in the middle here is
39:50called a linear accelerator and the
39:51picture on the right shows someone
39:53who is actually a person being
39:55approved for a different type of camp
39:57or something in the head and neck.
39:59But sometimes we need a mask or
40:01some other way of holding a patient
40:03on the table so they're still and
40:05the X rays are going to spot that.
40:07We're directing them to.
40:08And this is going to be done with X rays.
40:12They're similar to what's in a chest
40:14X ray machine or cat scanner or
40:16another version called electrons.
40:17Electrons are cousin of X rays that
40:19can be shot directly at a person
40:22that just doesn't penetrate as far.
40:24So actually go right through.
40:25You have to be careful how we're
40:27shaving and angling them.
40:29Electrons will only go to a
40:31certain depth and then we'll stop.
40:32So it's especially effective
40:34for skin cancers.
40:35Were course,
40:35we're mainly looking to
40:37treatment through superficial.
40:38Breaky therapy is a different idea
40:40and break you therapy for skin.
40:42You have these bells,
40:43or these applicators here and they
40:45get placed directly on the spot.
40:47So and that's the picture on the lower right.
40:50This person is in the mass and
40:52said lesion on the scalp and this
40:54just rest gently on the skin and
40:56there's a radioactive piece of metal
40:58over idiom that is kind of snakes.
41:00Through Catherine goes into the bells.
41:02It's never touching the person,
41:03but it's in that balance is shining there.
41:06Radiation down on the skin
41:07as a different way.
41:09Of applying radiation if we're using X rays,
41:11we have a really a broad range of what we
41:15can do in terms of the shape and size,
41:18or really almost no limit on that.
41:21For Reiki therapy, we just have these
41:23three different applicator sizes.
41:25And they are totally round.
41:26So and they had to be placed
41:28flattening service.
41:29So we're treating someone.
41:29But then the tip of the nose where you
41:32can't quite put a flat applicator.
41:33It doesn't work out as well,
41:35but on the side of the nose or the
41:37chief or head or leg or shoulder
41:38can work quite well.
41:41Uh, in terms of number trains are
41:44talking bout Mosey for Moses,
41:45more of a you know one day procedures,
41:47something nice about it,
41:49but then you know is a surgery
41:50and sometimes the feeling from
41:52the wound and things like that.
41:54Radiations a different idea is
41:56usually multiple visits there
41:57short visits but multiple and for
41:59let's say a medium sized cancer.
42:00You can see there.
42:02This table shows a bunch of different
42:04options from 1:00 to 3:00 to 5:00
42:06to 8:00 all the way to 30 to 35.
42:08But the most common regimen is is usually 20.
42:11Sessions and those are 15 minutes
42:13per session, then Monday to Friday,
42:14so it's usually a four week course.
42:16For most things we do and our machines
42:18operate from about 8:00 to 5:00,
42:20and so we find a 15 minute time
42:22slot that works for people.
42:24Bring them and and just get
42:26that treatment and head home.
42:27And because their X rays can't
42:29feel anything on the table so
42:31it's kind of in and out.
42:33People go about their day using the
42:35same medications and everything
42:36and our main side effect for most
42:38scanner is is we call skin reaction
42:40which looks like a temporary sunburn.
42:42It's not a sunburn really,
42:43but it has that look to it and we apply
42:46ointments and that gets better in the cancer,
42:48shrinks down and get some healing
42:50in without having a a defect there.
42:53So about 20 trees would be the
42:55stand for X rays.
42:56Breakey therapy is very different.
42:57It's actually only six treatments and
42:58instead of being Monday to Friday,
43:00they get a little more spread out there.
43:02Usually two treatments for weeks on
43:03my clinic I usually do them on Mondays
43:05and Thursdays and so and they take
43:07I'd say closer to about 1/2 hour visit,
43:09although the actual time of each
43:11treatment going up four or five minutes.
43:12The rest I'm just going to set up.
43:15And sharing looks perfect.
43:18Just give us a couple quick
43:20examples of some outcomes here.
43:22Shows some pictures,
43:23so hopefully the pictures
43:24aren't too offputting here.
43:26Here's an example of a 9 year old lady
43:28with a squamous cell cancer quite
43:30large over her wrist and you think
43:33about treatment options as we very
43:35difficult to do surgery in a 9 year
43:38old lady for skin like any nine year 2010,
43:41this defect be hard to close and so I was
43:45called to treat this one and by the very.
43:48Last treatment you can see that the
43:51cancer has disappeared and you have
43:53this sunburn patch over her wrist.
43:55And I saw her back at three months.
43:57There's a slight discoloration
43:59of skin cancer still gone.
44:01And very very happy with him.
44:03It's all.
44:03Uh,
44:03we get called a bunch of other
44:05before and after examples here so
44:07we don't always get called for
44:09large things on the smaller things
44:10beyond the bridge of the nose,
44:12like the lady in the top left or an
44:15eyelid more advanced one like the tip
44:17of the nose to the top right or the lip.
44:20Patient denies a lot of facial ones here,
44:22but really these can be done all
44:25over the body and and because of
44:27where these things tend to pop up,
44:29then I've got more pictures from the face,
44:32but it's coming to treat on on the leg arm,
44:35shoulder really, really anywhere from.
44:39I'll give one other example of bones,
44:41diseases, squamous cell carcinoma insight,
44:42two so this is an earlier I guess a
44:44less deep version of squamous cancer.
44:47It's like can't see me with this area almost
44:49like a a buildup of plaque or scabbing,
44:52as it looked like on her foot.
44:54And you can see in this left side
44:56they really spread quite a bit.
44:59And she's a very tricky situation
45:00that to cut this out would have
45:02been a big defect on her foot.
45:04She had circulation issues to
45:06begin with and would have been a
45:08very long healing and I'm kind of
45:11uncertain to how to close that.
45:12And uhm, luckily for through this there is
45:16a radiation option which uses a lower dose.
45:19Radiation and the full full cancers
45:21and the middle picture is how we
45:24immobilized her foot and ankle.
45:25So we could make sure we're getting
45:27a consistent set up and at one
45:30month we see that the we had a great
45:32outcome and it disappeared.
45:34She had just a very modest sunburn
45:36feeling on her foot and was
45:38absolutely thrilled with.
45:39We will manage it without surgery.
45:43So thank you for your time and sit for my
45:47slides there and let me see if I can get.
45:51Back up to our questions.
45:55This is a good time if you haven't
45:57typed anything in another question,
45:59please, please do so.
46:01We have one. Question here maybe?
46:07For Doctor Khan,
46:08where the question was lost,
46:09the thing of it, but it basically someone
46:12who had a Melanoma some years ago.
46:14I think it said seven years
46:16ago what at this point,
46:18what's the chance that could
46:19still come back or risk of
46:21something popping up elsewhere?
46:23Or how should they follow this up?
46:29Repeat that again Bruce. Ah, OK,
46:32I was gonna direct this to Doctor Khan,
46:34but if this is a if you have a
46:36Melanoma about seven years ago,
46:38successfully treated.
46:38And doesn't seem to be back.
46:40What's the chance that it
46:42could still come back now?
46:43And what kind of fault should have
46:44there or for the rest of the body?
46:47Got it 'cause I thought you
46:49said Doctor Connor so so uh,
46:51so we sound similar, right?
46:52Connor Connor so so we.
46:55So you know. So what we tell our
46:58patients is that they should so,
47:00so I guess specifically,
47:01this question is so we tell our
47:03patients that for the first
47:05five years they should continue.
47:06You know, for early stage Melanoma they
47:09should see someone in our Melanoma program.
47:11They should continue to see the
47:13dermatologist for the rest of their life.
47:15So and the reason for that is you know once
47:18an individual has a diagnosis of Melanoma,
47:20we tell them there are eight to 10
47:22full risk higher than the general
47:24population to develop Melanoma again.
47:26In their lifetime that can be at
47:29the same location or could be a
47:31different tumor or a different site.
47:33So so the answer to the first question
47:36is it can come back seven years out,
47:39but for early stage Melanoma less common,
47:42more likely that something a new
47:44lesion might may develop.
47:45That's the reason for the
47:47dermatology follow up and if you
47:49have more advanced stage Melanoma,
47:51there is a chance that melanomas can
47:54return it distant sites depending on this.
47:56Initial stage of the tumor.
47:59I know Doctor Connors that consistent
48:01with what you tell your patients
48:03too because we always ask our
48:04patients to see you for forever.
48:06But we stick with our oncology follow up,
48:08you know basically 5 to 10 years
48:10depending on the stage of the tumor.
48:16Yes, it is consistent with what I recommend.
48:20Uh, the first couple of years after
48:23an invasive Melanoma is diagnosed,
48:25I I I generally see the patients every
48:29four months. And after two years,
48:32Will will frequently go to every six months.
48:37But I see them. Indefinitely and I
48:40have had considerable who many years
48:43later developed a second Melanoma.
48:46I mean, I, I early in my practice, I had a
48:50young man who was a student at Dartmouth.
48:53He was an undergraduate.
48:54He had a Melanoma on his anterior
48:57right shoulder. He moved away.
48:59He comes to see me now every
49:01six months and three years ago.
49:04This is 25 years.
49:05For here he had a second Melanoma
49:08on his mid back.
49:09So we look at them forever.
49:13And they are frequently people who
49:15have had non Melanoma skin cancers
49:18and you find plenty of them too.
49:20And that same patient group.
49:22So we we absolutely should
49:24follow them faithfully.
49:25Whether after the initial diagnosis
49:27follow up at three or four or six month,
49:30that's a debated issue,
49:31but I think four months is reasonable
49:34initially and then transitioning
49:36if things are going well to six
49:38months in a couple of years.
49:42And as a follow up for yes.
49:44Well we do 2 for our surveillance
49:46is every six months for the first
49:48two to three years and then annually
49:50thereafter up until year five,
49:52unless they have more advanced disease
49:54and if they have more advanced disease,
49:56will tighten it up to maybe
49:58four months or so.
49:59And that's usually our medical
50:00oncologists tend to follow those patients
50:02because sometimes those patients are
50:04patients were debating on should they
50:05get immune checkpoint inhibitors.
50:07Should they be getting?
50:08Are these qualifying for clinical trials
50:10so that our medical oncologists tend to.
50:12All the little bit more tightly than
50:13we do just because they tend to see
50:15more of the advanced stage disease.
50:17Yeah.
50:19As I've got another question
50:22for Doctor Connors here,
50:23do all skin cancers appear or do
50:27skin cancer sometimes appear on areas
50:29not exposed to the skin? Absolutely.
50:33So they certainly the preponderance our own
50:36at least relatively exposed skin as your
50:40slide demonstrated, there's a tremendous.
50:43Predilection for skin, non Melanoma skin,
50:46cancer from the neck up, but there's no
50:49area on the skin where I haven't found it.
50:53I'm talking the bottom of the foot,
50:56the covered genital areas and the
50:58hairy scalp where I haven't found both
51:01Melanoma and non Melanoma skin cancer.
51:04Melanoma is probably of the three
51:06major basels claimers in Melanoma,
51:08had the highest percentage that occur
51:11on at least relatively covered skin.
51:14And it engendered years ago debate
51:16about well, are they really sun induced?
51:19Well, the epidemiology is
51:21overwhelmingly in favor of the sun.
51:23Be the major factor I mentioned earlier,
51:26Australia in America, Phoenix,
51:28AZ has often led the country
51:30in the incidence of Melanoma.
51:32So for the preponderance of Melanoma,
51:35yes, it's sun. But there are exceptions.
51:38No question about it.
51:39I had a secretary for years,
51:42lovely lady, who's older brother.
51:44Died at a young age of a Melanoma
51:48on his scalp on a hairy scalp.
51:51No sun involved.
51:52So as you know,
51:54about 50% of melanomas have that CDKN
51:572A mutation and that can occur without
52:00any requirement for sun exposure.
52:03So undoubtedly the proper skin
52:05exam for skin cancer.
52:09Looks at all the skin.
52:11That's what it every.
52:12Every now I limit that some with
52:14women men know or you come to me
52:16as a man I'm gonna see everything
52:19with women we make sure there are
52:21areas that I don't see a check
52:23by the appropriate doctors but
52:25but there's no terrain on us
52:27that can't develop a skin cancer.
52:31Just like dumb one question I I'll
52:33answer dude basal cell and screaming
52:36cell cancers turn into melanos,
52:38especially not really.
52:39An answer is no that these
52:42are distinct entities.
52:44You know there may be some
52:45association between those who get
52:46based on some sort of get Melanoma,
52:48but the one doesn't turn into the other.
52:51Uhm? One of the good question here
52:53was if if Moses so successful?
52:56What are the scenarios when you would
52:58not offer Moe's for basal squamous?
53:01I'll give my quick answer.
53:02I'll let Doctor Connors expound
53:04born but I think the ones who come
53:06to us would say either it's because
53:09they've been through a bunch of
53:11surgical procedures like that and
53:13they they think I'm tired of being
53:15cut on or they had some cosmetic
53:18outcomes that they really didn't like
53:20and looking for a different option.
53:22Awards something where it's large
53:24enough for an area that we are can
53:26already anticipate that it's it's really
53:28gonna have an unfavorable cosmetic
53:30outcome or it's obviously going to
53:32need radiation anyway afterwards,
53:33and my eyes will just start with
53:35radiation and try to cure it without it.
53:37So that's why I see it from from
53:40my perspective with Doctor Connors.
53:41Any other kind of thoughts on
53:44on when Moses not as optimal?
53:46Well,
53:47I
53:47think we should give a
53:49little background for most,
53:51Frederick Mose was a Derma Doe,
53:54a dermatology surgeon at the
53:56University of Wisconsin 60 or
53:58so years ago and he saw lots of
54:01farmers who had lots of difficult
54:04skin can't and he developed
54:06the method of treating them by.
54:10Using frozen sections while the patient
54:13waits, he initially impregnated the
54:16lesion with the zinc chloride paste.
54:19And then brought them back the next
54:21day and it was akin to shaving a bad
54:24spot out of a banana and every little
54:27shaving was taken and looked at under
54:29the microscope using frozen section.
54:31They that evolved into the current most
54:33process with his nose in chloride paste
54:36and it's the fresh tissue technique.
54:40And it's a. It's an absolutely wonderful
54:43procedure for the right lesion.
54:45It's not meant for your
54:48routine basil or squamous cell.
54:50It's more complicated.
54:51It's more expensive.
54:53There is what I call Moe's Addiction
54:56syndrome, where people have had
54:59most insist on most for every.
55:03Basal or squamous, they have,
55:04and it's really inappropriate.
55:07But it's a wonderful technique for difficult,
55:11primary lesions,
55:12or many recurrent lesions.
55:16An interesting area is it's it's
55:18used for pigmented lesions and
55:21that pigmented lesions don't
55:23stain well with frozen sections,
55:26so that's been an obstacle
55:28to using it for melanomas,
55:31but it's a wonderful technique.
55:33I think. It's frequently,
55:35frankly overused.
55:38Sign one for Doctor Khan here the
55:41question is what is the mitotic
55:43rate and how is it determined?
55:46So the mitotic rate is basically how
55:49quickly the Melanoma is growing under
55:51a microscope to a dermatopathologist.
55:52So after the dermatologist does a biopsy,
55:54they send they put it on,
55:56they arrange for it to be sent to one
55:59of their dramatic pathology colleagues
56:00and they look to see how many,
56:03how quickly the microscope is,
56:05how quickly the Melanoma is
56:06growing under a microscope.
56:08And then that's a score that could
56:10be 0 and it can sometimes be in
56:12the double digits as well too.
56:14So it gives us a sense to snapshot.
56:17Picture that they're looking at,
56:18but they can get a sense of how
56:20quickly a Melanoma is growing just
56:22from looking at that mitotic rate so.
56:26Excellent UM and then a question I guess,
56:29for for either of you to this.
56:32So someone with three melanomas between
56:341994 and 2017 and different locations
56:36being follicles every six months
56:38still trying to get a sense to what?
56:40What are the odds of having
56:42yet another Melanoma?
56:47I.
56:50It's. You get it.
56:53It might be qualified by what
56:55type of skin the patient has?
56:57What kind of sun exposure,
56:59what kind of family history they have?
57:02Are they that dysplastic nevus syndrome,
57:05where they have scores and scores of eight?
57:08Typical moles?
57:09Obviously no one can say definitively.
57:12I have had patients with up to 7 melanomas,
57:15but they are Fasken people with lots of
57:19laws and lots of past sun exposure so.
57:24The answer is we can't say for sure.
57:27Certainly that someone that patient
57:29should be examined every four months.
57:31I think rather than every six months,
57:33but that's my preference,
57:35but not no one can answer definitively,
57:38but clearly close surveillance is indicated.
57:42Only people who are just
57:44more prone to Melanoma,
57:45both those with lots of moles.
57:47The point about the patient
57:49with lots of moles is, again,
57:51most melanomas begin de Novo.
57:53They don't begin from an antecedent mole.
57:56On the other hand,
57:57people who have scores and scores of malls,
58:00both typical and atypical,
58:02are in fact more prone to Melanoma.
58:04Dysplastic nevus is not
58:06a precursor of Melanoma,
58:07but it's an indicator of an
58:10individual or after get Melanoma.
58:12And so there's something about those
58:14people who make lots of mold both benign
58:17and malignant about their melanocytes.
58:19They just inclined to proliferate
58:21both in a benign and a malignant way.
58:25So it's it's I I have, I mean, my own,
58:29my wife's family or their sister or cousin.
58:33Her father all in their melanomas.
58:35Their fair skin there of Celtic background,
58:38and they spent summers on Martha's Vineyard.
58:41So whether it's primarily genetic or
58:43primarily environmental, I don't know.
58:45But that type of person certainly
58:48is needs close surveillance.
58:51If there aren't any more questions Bruce,
58:53I might ask you a couple.
58:56Interrupting some another question.
58:57Go ahead.
58:57There's a.
58:58There's a question I think
59:00we talked about this.
59:01The increased melanin racers.
59:03I think someone wanted to just repeat.
59:06Thoughts on what's the best
59:08sunscreen you might just?
59:09I guess I'm just normal sunscreen.
59:11That's a very good question.
59:13I I can't say this science that
59:16proves one is better than another.
59:18But as I said, the the division and
59:21sunscreens is between organic and inorganic.
59:24But you know organic RR, zinc and titanium.
59:28And they're the ones that make you white.
59:31But they they work right away.
59:33They're now much better.
59:35Cosmetic Lee. In other words,
59:37you put on the IT takes 20 or 30 minutes.
59:40As I said,
59:41for the organic sunscreens to work,
59:44they don't pollute the water,
59:45they don't get into your bloodstream. I,
59:48I would favor a zinc or titanium sunscreen.
59:51It should be again an SPF that's 30 or
59:54higher and it should say broad spectrum.
59:58The point about.
59:59SPF is that I guess I made the
01:00:02point that people don't use the
01:00:05sunscreens nearly to the extent
01:00:07that the testers of sunscreens do.
01:00:10They use 2 milligrams per centimeter squared.
01:00:13We use about 1/3 or 1/4 of that typically,
01:00:17so there's a downside to sunscreens
01:00:19in that people are imbued with
01:00:22a false sense of security.
01:00:24They spray the sunscreen around their
01:00:27child and they've done their job and.
01:00:30And they really aren't that protected.
01:00:32That's why clothing is so much better.
01:00:34So much better.
01:00:35I'm very delighted there's a trend
01:00:38towards people wearing swim shirts
01:00:40now it it's wonderful 'cause you
01:00:42can never get the sunscreen to
01:00:44your back the way you'd like.
01:00:46And the water clearly dilutes them.
01:00:48So so long, yeah,
01:00:49the swim shirts the the golf is a
01:00:52wearing these sleeves on their arms.
01:00:54The Big Hat Sunscreen is an additional thing,
01:00:57but it shouldn't be the central
01:00:59part of your son.
01:01:01Protection strategies actually.
01:01:04So don't I'm not saying don't use them,
01:01:07but understand they're imperfect
01:01:08and they don't give you the
01:01:10protection that clothing does.
01:01:15Questions for me. Yeah, couple.
01:01:19What is the youngest age at which
01:01:21you would irradiate a basil,
01:01:22a squamous cell we?
01:01:24We've thought in dermatology
01:01:2550 years of age after that.
01:01:27OK, used to be 60. It's out today.
01:01:30I mean there was always the concern that
01:01:33you're going to generate if you irradiate
01:01:35a 45 year old at 30 rather at 75,
01:01:38and we gotta a squamous cell
01:01:40because of your radiation.
01:01:41So yeah, you have such an arbitrarily.
01:01:44Age related schedule.
01:01:45I mean, it's we, it's it's a
01:01:48good question. No, not really.
01:01:49I think you know what we've seen is of,
01:01:52we think of all the cancers that we treat
01:01:55and all the I'd say incidental skin dose,
01:01:58which is substantial.
01:01:59You know, if you really sum it all up,
01:02:02we really see it's.
01:02:03It's not that radiation never causes cancer.
01:02:05Clearly it does once in a great while,
01:02:08but the skin cancer development years
01:02:10later has been very, very rare.
01:02:12The closest thing I've
01:02:13really seen in that is.
01:02:15It's only less than 1% chance of
01:02:17sarcoma after resting with his
01:02:19tremendous deficits in there.
01:02:20Yeah, even that is quite rare.
01:02:22So yeah, I don't know 'cause I
01:02:24don't really have an archery
01:02:26employee think it's just based
01:02:28on if you have a 40 year old or 40 year
01:02:30old attractive woman with the basil
01:02:33cylinder knows you consider radiation.
01:02:35I definitely would be interested.
01:02:38We've also been of the mind and
01:02:40you addressed it in your talk,
01:02:42but but the extremities,
01:02:43particularly the lower legs,
01:02:45haven't done well with that radiation.
01:02:46Is that less true now with your technology?
01:02:50So we we do have to be careful.
01:02:53I think that's something where I feel like
01:02:54surgeons and radiation caused struggle.
01:02:56But it's all about the blood supply.
01:02:58Yes yeah, a lesion or they
01:03:00say over the shin bone.
01:03:01Yes, everybody struggles there.
01:03:02'cause it just doesn't heal that well.
01:03:04Just takes a long time
01:03:05and I think you're right.
01:03:07I think there that the the key there
01:03:09couple things that number one is
01:03:11again it's you know the size you
01:03:12know where we're going to begin with.
01:03:14Is there an ulcer to start?
01:03:16'cause if someone's coming to me
01:03:18with an ulceration as a really
01:03:19long time to heal and then also
01:03:21asking about diabetes and other.
01:03:23More obvious, you know? Yes, yes.
01:03:25The blood vessel issues but.
01:03:27That said,
01:03:28I think you know having a bigger excision
01:03:30over shin and the flaps of racing
01:03:32that can be very challenging also,
01:03:34so I think mainly it is.
01:03:36I think there's still candidates,
01:03:38but the the counseling I do in
01:03:40terms of you know how long is
01:03:42this going to take to heal?
01:03:43And could you have participated in drafting?
01:03:46It is a different discussion and same thing.
01:03:48I showed the lady with the
01:03:50leash on the bottom of foot.
01:03:52If that had been a regular squamous
01:03:54cancer she would have many
01:03:55very difficult position because
01:03:56doses are proud that or or.
01:03:58Double what are needed for the
01:04:00for the inside too and you just
01:04:03really have tremendous issues on
01:04:04the foot in the area that we do
01:04:07really well in the footman cold.
01:04:09I've seen quite a few of
01:04:10perusing early Capozzi sarcoma.
01:04:12Whatever reason.
01:04:12Yeah, yeah, but Mankell and you know,
01:04:15they respond really well to low doses
01:04:17of radiation and versus the you know,
01:04:19the functional cosmetic surgery
01:04:20is is not so hot.
01:04:22So it depends on the dose or time location.
01:04:25But yes, I think you know, get close to the.
01:04:28The fingers and toes and over the shin
01:04:31is tricky, but I'm treating over a calf.
01:04:34For example.
01:04:35Yeah usually does pretty well.
01:04:37Yeah,
01:04:37yeah.
01:04:39I I would.
01:04:41Add to your presentation, boost it.
01:04:46Rate radiation therapy for
01:04:49basal cell squamous cells.
01:04:51Particularly on the nose.
01:04:54It's underutilized.
01:04:55Frankly, it's underutilized.
01:04:57I mean the the cosmetic result is superior.
01:05:02There's no surgery that approaches
01:05:04what what you can do on a tip of the
01:05:08nose basal cell, and it it it it,
01:05:11it's a it's it's an option that's you know,
01:05:14very valuable.
01:05:14Very valuable.
01:05:15As you know,
01:05:16we shared a number of patients
01:05:18and they're delighted with
01:05:20the final result.
01:05:21Delighted.
01:05:22I yeah, I'm I'm really pleased you.
01:05:24You mentioned that 'cause
01:05:25I I completely agree I.
01:05:26I think that there is a.
01:05:29For what I've seen of the
01:05:31certainly the centers that I've
01:05:32been to or the academic centers,
01:05:34I should say that I think the education,
01:05:36sometimes in some of the dermatology
01:05:38residencies and things is is just
01:05:40lacking a little bit on what they,
01:05:42what they talk about in terms of radiation.
01:05:44And I, you know, you all names aside I,
01:05:47I've I've visited.
01:05:47You know many dermatologists who really knew,
01:05:49you know you stand out as someone
01:05:51who's really quite knowledgeable
01:05:52about about radiation.
01:05:53A lot of retailers really don't
01:05:55know much of any know that it's
01:05:57maybe good for being so that they.
01:05:59They had no idea can use for squamous.
01:06:02Like literally no idea and said OK.
01:06:04Well yes it can be and and talking it
01:06:07through so there's a you know I love
01:06:09to to talk to dermatologists and to you
01:06:12know surgeon certain oncologists in
01:06:14the community to them know that it's
01:06:16it's not the answer for everything
01:06:19but it really doesn't realize for
01:06:21certain should good dermatologist
01:06:22should include it in the options
01:06:24of the good dermatologist should
01:06:26know the five six or seven relevant
01:06:28possibilities and for each patient.
01:06:30There's one or two that are a maximal
01:06:33that are appropriate in radiation.
01:06:35Often is in it's it's.
01:06:37It's a wonderful technique.
01:06:40The the, The the thought and dermatology.
01:06:43I'll admit used to be squamous cells
01:06:45don't do as well as basil cells.
01:06:48Is that no longer true in your
01:06:50experience? I think it's it's true,
01:06:52but with an asterisk it's really.
01:06:54It's more size related on those slides.
01:06:57It's bigger ones,
01:06:58but then everybody is struggling.
01:06:59That's right once you know
01:07:01so it's so somehow that then
01:07:03seeped into a more general idea.
01:07:05It's less than that,
01:07:07and that's not that's not true.
01:07:09And you know some of the squamous.
01:07:11And we know some of the sensitivity,
01:07:13and perhaps some it is,
01:07:15is an appreciation for what
01:07:16dose we should be using.
01:07:18Maybe some disclaimers that big
01:07:19Russian musical hired oaks and
01:07:21that's part of what's been underdone.
01:07:23I think it's certainly you know
01:07:24the squares cancers occur in the,
01:07:26you know,
01:07:27the console that on the service
01:07:28questions it's it's actually a
01:07:30fairly sensitive different type
01:07:31and not this skin is identical,
01:07:33but it's you know it's close enough.
01:07:35We do see a sensitivity there and
01:07:37and a lot of really good outcomes.
01:07:39Life got you lady with the the large lesion.
01:07:42Over her wrists,
01:07:43I show that was a large squamous cancer.
01:07:46You know, so it's it is still effective,
01:07:49but everyone struggles a little more
01:07:51of those bigger scale and I'm tired
01:07:53of my unoptimized discussion about.
01:07:55Before you irradiate,
01:07:56you consider the Histology as well.
01:07:58I mean, you know how varied basil cells
01:08:00are and that micronodular are invasive?
01:08:03Or are, you know we we used to
01:08:06call him or feel like basil cells?
01:08:08And yeah, those are those are
01:08:10more difficult also for everyone
01:08:11more difficult and I think that's
01:08:14it. That's where it's a great
01:08:15to have a nice collaboration.
01:08:17Between us parents. Observation.
01:08:18Because then he talked through, you know,
01:08:20the sense of of what the depth and
01:08:23the width of the problem logically.
01:08:24So you know, Doctor Khan was showing,
01:08:26you know some of the day of God.
01:08:28You know how wide to to creating margin
01:08:31depending on the size of the Melanoma.
01:08:33But there's a similar concept in radiation,
01:08:34whether it's Melanoma or screens or basal.
01:08:36About you know how?
01:08:37How, why? We should go on,
01:08:39how deep we should go,
01:08:41or even in certain cases it's on a
01:08:43single perineural invasion where it's
01:08:44tracking on nurse would be actually
01:08:46going back and picking inerview deeper.
01:08:48And so you know,
01:08:49this is really where that that
01:08:51collaboration is so important and you know,
01:08:53for example, that breakey therapy that I
01:08:56showed is wonderful for certain things,
01:08:58but it can't go that deep.
01:08:59It must be a thin lesion,
01:09:01but luckily we we can treat the whatever
01:09:04depth we want with electrons and X rays.
01:09:06So it's you know it's having the the
01:09:09various tools and the appreciation
01:09:11for how how there is the variation.
01:09:13It's really so so important and
01:09:15and having that connection with
01:09:16the dermatologist every pocket.
01:09:23Let me just double check to see if
01:09:25there any other questions here.
01:09:33Sorry, scrolling through.
01:09:36Those are those are the ones,
01:09:38so I really appreciate everyone tuning
01:09:40in and and thank you to Doctor Connors
01:09:43and Doctor Kahn for for joining us.
01:09:46You know, we're really proud of
01:09:47the of the skin cancer care that's
01:09:49available throughout the jail system
01:09:51and in the community in Greenwich
01:09:54more generally and specifically,
01:09:56doctor Doctor Connors and some of
01:09:58their great people we work with.
01:10:00And you know, certainly we're all.
01:10:02If you have further questions or evaluation,
01:10:04were all happy too.
01:10:06Help out and see people and I just
01:10:08thank you all again for your time
01:10:11and have a good rest evening.