105: Cancer of the Skin Flashcards
(94 cards)
1
Q
T or F: Cutaneous melanoma has no age predilection. It can occur in adults in all ages.
A
True
2
Q
T or F: Cutaneous melanoma is predominantly a malignancy of white-skinned people (98%)
A
True
3
Q
Sex predilection of cutaneous melanoma
A
Male
Diagnosis at late fifties
4
Q
Strongest risk factors for melanoma
A
- Presence of multiple, benign OR atypical nevi
2. Family or personal history of melanoma
5
Q
Marker of increased risk of melanoma
A
Presence of melanocytic nevi, common or dysplastic
6
Q
Congenital melanocytic nevi and classification accdg to diameter
A
Small: = 1.5cm
Medium: 1.5-2.0cm
Giant: >20cm
7
Q
Management for giant melanocytic nevus (bathing trunk nevus)
A
Prophylactic excision early in life
6% lifetime risk of melanoma
8
Q
T or F: The higher the number of total body nevi, the higher the risk of melanoma
A
True
9
Q
Surveillance for patients diagnosed with melanoma
A
Lifetime
Should be done by dermatologist and include total body photography and dermoscopy if appropriate
10
Q
Cell cycle regulatory gene responsible for 20-40% of cases of hereditary melanoma
A
cyclin-dependent kinase inhibitor 2A (CDKN2A)
Chromosome 9p21
Encodes for tumor suppressor proteins: p16 (cell cycle arrest) and ARF (defective apoptotic response to genotoxic damage)
11
Q
T or F: Red hair color (RHC) phenotype is associated with increased risk of melanoma.
A
True
12
Q
Primary prevention of melanoma and nonmelanoma skin cancer
A
Protection from the sun
Advise:
Regular use of broadspectrum sunscreens blocking UVA and UVB with SPF atleast 30
Avoidance of tanning beds and midday (10am-2pm) sun exposure
13
Q
Secondary prevention of melanoma and nonmelanoma skin cancer
A
- Education
- Screening
- Early detection
14
Q
Interval of self examination that enhance likelihood of detecting change
A
6-8 week intervals
15
Q
ABCDE for early detection of melanoma
A
Asymmetry Border irregularity Color Variegation Diameter >6mm Evolving (size, shape, color, elevation or new symptoms: bleeding, itching, crusting)
16
Q
Where do benign nevi usually appear?
A
Sun-exposed skin above the waist
Rarely: Scalp, Breasts, Buttocks
17
Q
Average number of benign nevi in adults
A
10-40 moles
18
Q
Who should be a candidate for biopsy?
A
- Any pigmented cutaneous lesion that has changed in size or shape
- Has other features suggestive of malignant melanoma
19
Q
Margins suggested for excisional biopsy?
A
1-3mm margins
Definitive treatment for benign nevi
20
Q
When is incisional biopsy opted rather than excisional biopsy?
A
If excisional biopsy is not feasible (face, hands, feet)
Through the most nodular or darkest area of lesion
21
Q
T or F: Cauterization is allowed in biopsy
A
False. It should be avoided.
Shave biopsies are acceptable
22
Q
What should we expect in the biopsy reading?
A
- Breslow thickness
- Mitoses per square millimeter for lesions =1mm
- Presence or absence of ulceration
- Peripheral and deep margin status
23
Q
Greatest thickness of a primary cutaneous melanoma measured on the slide from the top of the epidermal granular layer, or from the ulcer base, to the bottom of the tumor
A
Breslow thickness
24
Q
Four MAJOR types of cutaneous melanoma
Table 105-2
A
- Lentigo maligna melanoma
- Superficial spreading melanoma
- Nodular melanoma
- Acral lentiginous melanoma
25
Period at which the skin lesion increase in size but does not penetrate deeply; period most capable of being cured by surgical excision
Radial growth phase
Types: Lentigo maligna melanoma, superficial spreading melanoma, acral lentiginous melanoma
26
Type of melanoma with no radial growth phase which usually presents as deeply invasive lesion capable of early metastasis
Nodular melanoma
Brown-black to blue-black nodules
27
Period where tumors begin to penetrate deeply into the skin
Vertical growth phase
28
The most common variant of melanoma observed in the white population
Superficial spreading melanoma
29
Most common site for melanoma in men and women
Men: Back
Women: Back and Lower leg (knee to ankle)
30
Type of melanoma occurring on the palms, soles, nail beds, and mucous membranes
Acral lentiginous melanoma
31
Most common types of melanoma in blacks and East Asians
1. Acral lentiginous melanoma
| 2. Nodular melanoma
32
Other SITES where melanoma can arise
1. Mucosa of head and neck (nasal cavity, paranasal sinuses, oral cavity)
2. GI tract
3. CNS
4. Female genital tract (vulva, vagina)
5. Uveal tract of the eye
33
Fifth type of melanoma associated with fibrotic response, neural invasion, and greater tendency for local recurrence
Desmoplastic melanoma
34
Type of melanoma commonly seen on sun-exposed surfaces, particularly malar region of cheek and temple
Lentigo maligna melanoma
35
Effects of UV solar radiation on skin
1. Genetic changes in skin
2. Impairs cutaneous immune function
3. Increases the production of growth factors
4. Induces formation of DNA-damaging reactive oxygen species affecting keratinocytes and melanocytes
36
Mechanism of BRAF mutation found in most benign nevi
```
Point mutation (T-->A mucleotide change)
Valine-to-glutamate amino acid substitution
```
37
Best predictor of metastatic risk
Brelow thickness
38
Defines melanomas on the basis of the layer of skin to which melanoma has invaded and has minimal influence on the treatment decisions
Clark level
39
Anatomic site of the primary lesion is prognostic. What are the favorable and unfavorable sites?
Favorable: Forearm and leg (excluding feet)
Unfavorable: Scalp, Hands, Feet, Mucous membranes
40
Laboratories for diagnosis of melanoma
1. CBC
2. Complete metabolic panel
3. LDH
41
Staging criteria for melanoma
1. Pathologic and TNM stage
2. Thickness (mm)
3. Ulceration
4. No. of involved lymph nodes
5. Nodal involvement
6. 15-year survival estimate (%)
42
An elevated LDH signifies what staging for melanoma and the 15-year survival estimate?
Stage IV - 10%
43
Margins recommended for primary melanoma
In situ: 0.5 - 1 cm
Invasive up to 1mm thick: 1cm
>1.01 - 2 mm: 1 - 2 cm
>2 mm: 2cm
Include subcutaneous fat
Careful for lesions on face, hands and feet
44
Valuable staging tool that replaced elective regional nodal dissection for evaluation of regional nodal status
Sentinel lymph node biopsy (SLNB)
45
Provides prognostic information and helps identify patients at high risk for relapse who may be candidates for adjuvant therapy
Sentinel lymph node biopsy (SLNB)
46
Stains used in histopathology of melanoma
1. Hematoxylin and eosin stains
| 2. Immunohistochemical stains: s100, HMB45, MelanA
47
T or F: SLNB is required in all patients.
False.
In general: Tumors > 1mm thick
Not for patients whose melanomas are =0.75mm thick
For 0.76 - 1.0mm tumors: Depends on high risk features; wide excision alone is Definitive therapy
48
Patient with melanoma underwent SLNB and turned out positive. What is your next step?
Perform complete lymphadenectomy
49
Melanomas that recur at the edge of the scar or graft which are separate from but within 2cm of the scar
Satellite metastases
50
Melanomas that recur > 2cm from the primary lesion but not beyond the regional nodal basin
In-transit metastases
51
T or F: Radiotherapy can reduce risk of local recurrence after lymphadenectomy, but does not affect overall survival.
True
52
Who should undergo radiotherapy?
1. Large nodes ( >3-4cm)
2. Four or more involved lymph nodes
3. Extranodal spread on microscopic examination
53
Therapy indicated primarily for patients with stage III disease
Systemic adjuvant therapy
54
Adjuvant therapies for Stage III disease
1. Interferon a2b (IFN-a2b) 20 M units/m2 IV 5 days/wk for 4 weeks + 10M units/m2 SC 3x/wk for 11 months
2. Subcutaneous peginterferon a2b (6ug/kg/wk for 8 weeks) + 3ug/kg/wk for total of 5 years
55
Toxicities of treatment
1. Flu-like illness
2. Decline in performance status
3. Development of depression
56
Laboratories and imaging for recurrent melanoma
1. CBC
2. Complete metabolic panel (Na, K, crea, RBS, AST, ALT)
3. LDH
4. MRI brain and total-body PET/CT
5. CT scan of chest, abdomen, pelvis
57
Common distant metastases of melanoma
1. Skin
2. Lymph nodes
3. Viscera
4. Bone
5. Brain
58
Median survival range of metastatic melanoma
6 - 15 months
59
FDA approved therapeutic agents for melanoma
1. Anti-CTLA-4: Ipilimumab
2. BRAF inhibitor: Vemurafenib, Dabrafenib
3. MEK inhibitor: Trametinib
4. Interleukin 2 (IL-2 or aldesleukin)
60
Surgical option for metastatic melanoma
Metastasectomy
61
Most common immune-related adverse events using Ipilimumab
Skin rash
| Diarrhea
62
Immunotherapy treatment for melanoma with significant toxicity and high cost, but with increased survival benefit
Ipilimumab
63
Adverse reaction of this immunotherapy agent for metastatic melanoma is appearance of well-differentiated squamous cell skin cancers
BRAF inhibitors
64
T or F: No chemotherapy regimen has ever been shown to improve survival in metastatic melanoma and have relegated it only to palliation of symptoms.
True
65
Chemotherapeutic drugs considered in metastatic melanoma
1. Dacarbazine
2. Temozolomide
3. Cisplatin, Carboplatin
4. Paclitaxel, Docetaxel
5. Carmustine
66
You diagnosed your patient to have Melanoma stage IV by biopsy. Accdg to the initial approach to metastatic disease, what should be your next step?
Molecular testing (BRAF status)
67
Follow-up for patients with melanoma
ALL : Skin examination and surveillance at least one a year
Stage IA - IIA : Hx and PE every 6-12 mos for 5 years, then annually
Stage IIB-IV : Imaging (cxr, ct and pet/ct scan) every 4-12 months can be considered
*Perform scan only if indicated
68
Most common cancer in US
Nonmelanoma skin cancer (NMSC)
Basal cell CA (BCC) - 70-80%
Squamous cell CA (SCC) - 20%
Merkel cell CA
69
Most significant cause of BCC and SCC
UV exposure (sunlight or artificial)
70
Mechanism of DNA damage of UVA and UVB
UVA : free radical formation
| UVB : induction of pyrimidine dimers
71
What type of UV light is present in tanning bed equipments?
UVA 97%
UVB 3%
72
Genes damaged most commonly by UV in BCC and SCC
BCC: Hedghog pathway (Hh)
SCC: p53, N-RAS
73
Cells where BCC arise?
Epidermal basal cells
74
The least invasive type of BCC consisting of subtle, erythematous scaling plaques that slowly enlarge and most commonly seen on the trunk and proximal extremities
Superficial BCC
75
Type of BCC that presents as small, slowly growing pearly nodule, often with tortuous telangiectatic vessels on its surface, rolled borders, and central crust
Nodular BCC
76
Most invasive and potentially aggressive subtypes of BCC that manifest as solitary, flat, or slightly depressed, indurated whitish, yellowish, or pink scar-like plaques;
Morpheaform (fibrosing), infiltrative, and micronodular BCC
77
Cells where primary cutaneous SCC arise?
Keratinizing epidermal cells
78
Appears as an ulcerated erythematous nodule or superficial erosion on sun-exposed skin of head, neck, trunk and extremities; may appear banal, firm, dome-shaped papule or rough-textured plaque
SCC
79
Hallmark of SCC through dermatoscope
Dotted or coiled vessels
80
Very rapidly growing but low-grade form of SCC that typically appears as a large dome-shaped papule with a central keratotic crater
Keratoacanthoma
81
Premalignant forms of SCC that present as hyperkeratotic papules on sun-exposed areas
Actinic keratoses
| Cheilitis (actinic keratoses on the lip)
82
SCC in situ that is the intraepidermal form of SCC most commonly arising on sun-damaged skin
Bowen's disease
83
Type of NMSC that is slowly enlarging, locally invasive neoplasm with low metastatic potential
BCC
84
This type of NMSC metastasizes most frequently to regional lymph nodes
SCC
85
Treatment for BCC
1. Electrodesiccation and curettage (ED&C)
2. Excision
3. Cryosurgery
4. Radiation therapy
5. Laser therapy
6. Mohs micrographic surgery
7. Topical 5-FU
8. topical immunomodulators: Imiquimod
86
Most commonly employed method for superficial, minimally invasive nodular BCC and low risk tumors
ED&C
87
Surgical treatment for invasive, ill-defined and more aggressive subtypes of tumors or for cosmetic reasons
Wide local excision
88
Specialized type of surgical excision that provides the best method for tumor removal while preserving the uninvolved tissue with cure rate of >98%
Mohs micrographic surgery (MMS)
89
Standard treatment for SCC
1. Surgical excision
| 2. MMS
90
Treatment for lymph node metastasis in SCC
Surgical resection and/or
| Radiotherapy
91
Neural crest-derived highly aggressive malignancy with mortality rates approaching 33% in 3 years
Merkel cell carcinoma (MCC)
92
Uncommon apocrine malignancy arising from stem cells or epidermis characterized histologically by presence of Paget cells
Extramammary Paget's disease
93
Tumors presenting as moist erythematous patches on anogenital or axillary skin of the elderly
Extramammary Paget's disease
Treatment: Surgical excision with MMS
94
Soft tissue sarcoma of vascular origin that is induced by the human herpesvirus 8
Kaposi's sarcoma (KS)
