Case Study on the Treatment of Various Skin Cancers: AHS301

This case study examines the treatment of various skin cancers, including non-melanocyte skin carcinoma (NMSC), squamous cell carcinoma (SCC), basal cell carcinoma (BCC), and melanoma. It highlights the prevalence of skin cancer in Australia, emphasizing the impact of geographical location and UV radiation exposure. The study delves into the differential diagnosis of skin cancers, discussing the characteristics, subtypes, and associated treatments for each type. It covers the ABCDE sign for melanoma diagnosis, and also touches upon benign skin tumors. The study further discusses various treatment methods like surgical excision, Mohs micrographic surgery, electrodessication, cryotherapy, and radiotherapy. The case study aims to provide an overview of skin cancer diagnosis and treatment, incorporating relevant research and highlighting key considerations in patient care.

Running head: CASE STUDY ON TREATMENT OF VARIOUS SKIN CANCER
CASE STUDY ON TREATMENT OF VARIOUS SKIN CANCER
Name of the Student:
Name of the University:
Author Note:

1CASE STUDY ON TREATMENT OF VARIOUS SKIN CANCER
Table of Contents
Introduction................................................................................................................................2
Discussion..................................................................................................................................3
Conclusion..................................................................................................................................9
References................................................................................................................................11

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Introduction
Skin Cancer rate has been found to be highest in Australia, with prevalence of non-
melanocyte skin carcinoma (NMSC), squamous cell carcinoma (SCC) basal cell carcinoma
(BCC) in older adults and younger people affected with melanoma. Two out of three
individuals in Australia are diagnosed with symptoms of skin cancer by age 70 (Perera et al.,
2015). Geographical location of the country has a major impact in developing skin
carcinoma. A higher intensity of UV (Ultraviolet) radiation is exposed on the Southern
hemisphere and could increase 15% or higher if clouds are fewer than normal. Australia is
located in southern hemisphere, relatively closer to the equator compared to North America
and Europe, which results in intense UV radiation faced by the country. Civilians residing
closer to this geographic patch (Queensland and Northern Territory) are prone to develop
skin cancer and a higher frequency of NMSC is observed in individuals who had significant
exposure to sunlight on a daily basis (Lucas, 2006; Bauer, Diepgen, & Schmitt, 2011; Schmitt
et al., 2011).
NMSC or non-melanocyte skin carcinoma is the most reported skin cancer reported
among patients in Australia, while basal cell carcinoma (BCC) and melanoma being the
second and third most frequently occurring skin cancer types. Differential diagnosis of
various skin cancers has become an important area of interest as it is growing rapidly in
numbers every year. Fair complexion is another important factor in skin cancer development.
People with darker complexion have higher amount of melanin in their skin cells, which
helps blocking of ultraviolet (UV) rays upto a limit. Fair or white people have much lesser
melanin at their disposal, facing a higher risk of UV irradiation from the sun. UV rays affect
cell nucleus, specifically the genome, by modifying adenine-thymine bonding (A=T) to
thymine-thymine dimer (T=T). Prolonged exposure to UV rays, introduces point mutation in

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the DNA structure, which leads to malfunction of proteins and abnormal proliferation of skin
cells or higher prurific response due to invasion of infectious agents. Several methods have
been developed to identify skin cancer types and propose treatment accordingly. This report
briefly discusses about various types of lesions formed in skin cancer and postulated
treatments in practice with associated effectiveness.
Discussion
Human skin is the largest organ of the body, which covers the entire skeletal structure,
protecting against UV rays, heat shock, allergens and infectious microorganisms. Older
individuals are highly affected by non-melanocyte skin carcinoma (NMSC), which is
independent of action of the melanin pigment. NMSC are found to be initiated at the basal or
squamous cells of the epidermis and hence is a typical condition of basal cell carcinoma
(BCC) and squamous cell carcinoma (SCC). Basal cells are circular cellular structures found
on the outer layer of epidermis. Basal cell carcinoma has significant characteristic lesion
formation on the head or neck, which enables distinguishing these from squamous or other
forms of skin carcinoma.
Four major subtypes of BCC are, nodular, superficial, morpheaform, infiltrative and
micronodular. Nodular BCC is the most frequently occurring subtype of basal cell carcinoma,
occurring primarily on the facial part that is exposed to direct sunlight. A red or pink colored
spherical wart or white lump of mass are found to be resulting symptoms of this disease.
Blood vessels are often seen on the surface of the swollen lesions. Superficial BCC forms
generally on the central part (trunk, legs, arms) of human body. Morpheaform BCC are found
primarily in head and neck area with a flatter, whitish or yellow aggregation of rash. In some
cases, morpheaform BCC could resemble a normal scar, which makes it harder to
differentiate during diagnosis. Additionally, morpheaform BCC spreads rapidly than nodular

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and superficial BCC and could develop fibrous cluster of cells affecting a wider skin area, if
not treated timely. Infiltrative and micronodular BCC are a special type of basal cell
carcinoma that crosses epidermis and develops in the dermis layer of the skin, forming
microscopic nodules similar to nodular BCC, but has the potential to spread out from the
region to the distant part of the body. Nodular BCC possess lesser threat for relapse due to
localized and slower proliferation rate of the ulceric skin cells.
Squamous cell carcinoma (SCC) is associated with squamous cells of the epidermis,
flat in shape and mostly cause due to irradiation from the sunlight. SCC can proliferate faster
than BCC and could infect other layers of the skin, thus invasive to other tissues. Initial stage
SCC is curable and relapse could be prevented. In this stage, it is also called in situ or
intraepidermal SCC. These type of lesions can also generate from a burn wound, or a scar or
local ulcer that shows delayed healing. Subtypes of SCC include desmoplastic SCC and
adenosquamous SCC. Desmoplastic SCC is highly rare, having higher chances of recurrence
and malignancy. These kinds of cells have atypical epithelial cyoskeletal structures with a
dense desmoplastic stroma and are affected by variety of factors including tumor size,
thickness, penetration of infectious cells and proliferation rate (Velazquez, Werchniack &
Granter, 2010). Adenosquamous SCC is also a very rare form of squamous and glandular
carcinoma, which are predominantly found on scalp, face or upper extremeties of male
patients. Radiotherapy could result in rapid recurrence of these tumor cells. In addition,
ASCC cells has dual characteristics, some of the tumor cells synthesize keratin like squamous
cells, and some of the cells produce mucin, similar to glandular cells (Kase et al., 2014).
Melanoma is the malignancy of the skin cells that occurs due to ultraviolet exposure,
which causes DNA damage and uncontrolled proliferation of melanocytes, leading to tumor
formation. Melanocytes consist of a pigment called melanin, located in the basal layer of
epidermis. One significant indicator of early melanoma is a developing mole, which can be in

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a varying size and color. Unlike other skin cancer types discussed above, melanoma has been
observed to affect younger individuals compared to older adults. Early melanoma (in situ
melanoma) is curable if diagnosed at an appropriate time. Preliminary stages of melanoma
are restrained in the epidermal layer, but it can potentially penetrate the dermal barrier and
metastasize different parts of the body, if diagnosed in the later stage of life. As stated earlier,
moles can be of different color for instance, brown and black are the most common types of
melanoma; though red, pink, white, blue/purple had also been documented. A globally
accepted technique to diagnose melanoma is termed ABCDE sign. Assymetrical pattern of a
skin ulcer is an indicator of malignant cancer cell formation; Borders are irregular and
uneven in case of lesions of melanoma; Variety of colors designate cancer cell progression,
as benign tumor cells are overall brown in color; Diameter of moles are another significant
indicator, as >6mm diameter of a mole infers cancerous growth; Malignant tumors are found
to be evolving in shape, size and color, compared to benign skin tumors which remains
almost same over longer time (Rigel et al., 2005).
Several types of melanoma have been discovered. Superficial spreading melanoma
develops rapidly on the horizontal surface of the skin layer, and then penetrates into the inner
layers. Almost 50-70% of all melanoma is of this type. Symptoms include irregular shape and
brown lesion formation on the surface of the skin, along with itchiness and bleeding in some
cases. Nodular melanoma is another type of melanoma accounting for around 15% of all
melanoma cases in Australia and New Zealand. It has a specific shape, like a nodule or a
raised lump of mass, and could have different colors like red, brown, pink or skin-colored.
Nodules can appear afresh on the skin, or can grow on an existing mole or pimple. These type
of tumor cells proliferate vertically downwards and invades the inner skin layers. Nodular
melanoma is highly proliferative and can relapse rapidly to other parts of the body. Acral
lentiginous melanoma is another type of rare melanoma that occurs under the nails and palms

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of the hand and under the feet. Almost 3% of all melanoma diagnosed are acral lentiginous
type. Lentigo maligna melanoma is a major subtype of melanocyte skin carcinoma, which
resides in the neck or cheek of the body and causes due to extended ultraviolet exposure from
the sun. This type of melanomas could remain dormant for 5-20 years, forming a large
freckle and often misdiagnosed as an in situ melanoma. These tumor cells differentiate
gradually and penetrate the epidermal layer, invading dermis. Almost 10% of all melanoma
cases reported in Australia are of this type. Lentigo maligna has a distinctive large size
(>6mm) and a smooth surface, unlike superficial spreading melanoma, and diagnosed mostly
in older adults.
However, there is also benign or non-cancerous skin tumor formation. These category
of tumors include Dermatofibroma, Lipoma, Keratinous and pilar cysts, Hemangioma,
Seborrheic keratosis, mole, wart-which donot metastasize into other tissues except the site of
infection. Abnormal growth is observed and these are not life-threatening. Surgical procedure
might be required for some cases (Scher & Lipner, 2017).
Dermatofibroma is the formation of hardened lump of mass, usually small in size.
These generally red in color, brown in some cases, which primarily occurs due to insect bite.
These are more frequent in females than males and predominantly occur in legs. Although,
manual excision might be applicable for selective cases. Cryosurgery could be performed in
extreme exceptions, using liquid nitrogen, to freeze and remove dermatofibroma structures.
Abnormal proliferation of adipocytes generates Lipoma, especially in the underlying
muscles and subcutaneous tissues. These are soft nodular structures that resembles warts.
Medicines are prescribed by health professionals, however, surgical excision might be
required in few cases.

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Keratin, a protein found in skin surface can aggregate and form keratinous and pilar
cysts in frequent places of the whole body, exhibiting a condition called keratosis pilaris.
These lumps can be operated by surgical excision or the internal fluid could be released via
incision.
Blood vessels can also form an unusual cluster to create a condition called
hemangioma. These are normally found in infants of 1 to 3 weeks of age and are non-
cancerous and harmless. However, if sustained for longer period of time, laser mediated
removal could be performed. Growth of these structures can be controlled through oral or
injectable streroid and ß-blocker drugs exempting surgical intervention.
A waxy non-malignant wart-like hardened structure can also occur in neck, face and
back, which are called seborrheic keratosis. These are black or brown in color and feature a
tanned lumpy growth affecting older adults. These abnormal structures look similar to skin
cancer formations and could be removed by surgical procedures if required.
Melanocytic nevus or a mole is a widely occurring small melanocyte cluster
comprised of a smooth surface and defined border. These structures can develop in multiple
locations within a body and could be elevated or flat. These are mostly harmless and remain
for entire life. Although, irregular border or frequent bleeding should be checked by a doctor
and biopsy could be performed to analyze the possibility of skin cancer.
Warts are one of the most common types of small benign tumor formation, often oval
or spherical in shape and could arise in hands, legs, genitalia. HPV or human papillomavirus
are the causative agents of these structures. Dermal ointments and medicines are generally
prescribed for this condition. Although, if warts become permanent, cryosurgery (freeze
removal of tumor cells) or electrosurgery (specific electrical current to abolish the abnormal
growth) can be applied.

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Basal cell carcinoma could be excised surgically if diagnosed early. Mohs
micrographic surgery could be performed to dislodge subsequent malignant tissue layers in
case of large tumors. Electrodessication (dehydrate the malignant tissue with electric current)
and cryotherapy (liquid nitrogen mediated freezing and removal of tumor cells) are possible
solutions along with radiotherapy (Firnhaber, 2012). Alternative superficial basal cell
carcinoma treatments include photodynamic therapy, fluorouracil treatment, imiquimod
treatment. Study suggests, tumor-free conditions were observed highest among imiquimod
treated patients (83.4%) compared to fluorouracil treatment (80.1%) and photodynamic
therapy (72.8%). However, these alternative approaches are less popular in practice (Arits et
al., 2013).
Chemotherapy combined with surgical procedure or radiation is widely practiced for
treatment of stage I and stage II squamous cell carcinoma (Pfister et al., 2013). Utilizing
cisplatin, taxane and 5-fluorouracil mediated induction chemotherapy prior radiotherapy, was
able to deliver 2.2% higher efficacy compared to radiotherapy only treatment with decreased
chances of SCC recurrence (Marur & Forastiere, 2016). Molecular docking of specific drugs
designed specifically to target receptors regulating cellular signaling cascades and
manipulation of immune cell mediated apoptotic pathways could be a potential treatment for
prevention and abolishment of squamous cell carcinoma in any stage cancer patients, without
receiving the harmful side effects of chemotherapy and radiotherapy (Akhter & Amin, 2017).
Classical treatment for melanoma consisted of chemotherapeutic agents like
dacarbazine and temozolomide. Temozolomide is an oral analog of dacarbazine. Both of
these compounds are DNA alkalylating agents, which gets converted into MTIC (methyl
triazen imidazole carboxamide) under physiological conditions and prevent cerebral
metastasis caused by melanoma (Velho, 2012). Due to lesser effectiveness of
chemotherapeutic agents, immunotherapy has been prescribed for treatment of melanoma in

9CASE STUDY ON TREATMENT OF VARIOUS SKIN CANCER
recent times. Immune stimulators like IL-2, Interferon-α and monoclonal antibodies like
ipilimumab are approved by FDA for treatment of melanoma patients. Interleukin-2 (IL-2) is
a cytokine that stimulates T-cell proliferation. Intravenous administration with high dose of
IL-2 delivered significant success, but also promoted IL-2 associated toxicity. Famotidine in
combination with IL-2, has been found to lower the toxic effects of IL-2 while retaining the
anti-cancerous activity against melanoma cells (Chen et al., 2013). Interferons are also a type
of cytokines that are produced when foreign particles invade cellular environment. IFN-α was
approved by FDA in 1996 as an adjuvant used in melanoma victims with higher chance of
recurrence. Higher doses of IFN-α produced greater risk free survival than IL-2 mediated
therapy (Di Franco, 2017). Ipilimumab is a monoclonal antibody which has been approved as
a second line of treatment by FDA in 2011. It is a CD152 blocker, which prevents
downregulation of T-cell mediated immune response (Franklin et al., 2017). Several other
monoclonal antibodies include Sorafenib, Dabrafenib, Vemurafenib (Braf inhibitors) and
Trametinib (MEK inhibitor) which facilitates programmed cell death via Ras-Raf-MAP
Kinase pathway (Mandalà & Voit, 2013; Menzies & Long, 2014). Recent developments in
nanoparticle research have demonstrated carbon nanotubes, copper and gold nanoparticles as
potential anti-melanoma agents or carriers of specific drugs against malignant melanocytes
(Mishra et al., 2018).
Conclusion
Skin-related tumors have higher prevalence in areas, which experience higher
intensity of sunlight like Australia and New Zealand. Effects of ultraviolet rays are the most
common causative agent of malignant and benign skin carcinoma. Non-melanocyte skin
carcinoma has the highest contribution in skin cancer growth. Basal cell carcinoma (BCC)

10CASE STUDY ON TREATMENT OF VARIOUS SKIN CANCER
and melanoma is the second and third most frequently occurring skin cancer types next to it.
People with fair complexion have greater chance of developing skin cancer, compared to
people with darker complexion. Different varieties of skin lesions are discussed in details
with focus on shape, color of lump formation, characteristics of moles, and patches of
infection with chances of recurrence. Treatment of BCC and SCC are elaborated along with
surgical excision, chemotherapy based approach, radiotherapy and succession rates were
compared with lesser implemented fluorouracil treatment and photodynamic therapy.
Melanoma or cancer of the melanocytes is also addressed in this report with various types of
lesion associated with the disease. Treatments ranging from classical chemotherapeutic
agents to widely used immunotherapy methods involving cytokines were also elucidated,
along with future usage of copper and gold nanoparticles as anti-melanoma medication.

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