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DERMATOLOGY phase 1b > Skin Cancer > Flashcards

Skin Cancer Flashcards

1
Q

What is a melanoma?

A

Malignant tumour arising from melanocytes
Leads to >75% of skin cancer deaths
Can arise on mucosal surfaces (e.g. oral, conjunctival, vaginal) and within uveal tract of eye

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2
Q

What are some risk factors for melanoma? (genetic,environmental,phenotypic)

A

Genetic factors
Family history (CDKN2A mutations), MC1R variants
DNA repair defects (e.g. xeroderma pigmentosum)
Lightly pigmented skin
Red hair

Environmental factors
Sun exposure – intense intermittent or chronic
Sunbeds
Immunosuppression

Phenotypic
>100 Melanocytic nevi
Atypical melanocytic nevi

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3
Q

What role does the MAPK (RAS-RAF-MEK-ERK) pathway play in the pathogenesis of skin cancer?

A

It regulates cellular proliferation, growth and migration

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4
Q

What are the subtypes of melanoma?

A

Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Unclassifiable

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5
Q

How common is superficial spreading as a subtype of melanoma?

A

60-70% of all melanomas

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6
Q

Where is superficial spreading most typically found?

A

Trunk of men and legs of women

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7
Q

In superficial spreading how does growth occur?

A

Horizontal growth then vertical growth through the skin layers

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8
Q

What is the second most common type of melanoma?

A

Nodular
15-30% of all melanomas

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9
Q

Where does nodular melanoma typicaly present?

A

trunk, head and neck

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10
Q

What type of growth is shown in nodular melanoma?

A

Only vertical growth

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11
Q

What population is lentigo maligna most prevelent in?

A

> 60 years old
- Occurs in chronically sun-damaged skin
- Most common on face

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12
Q

What is lentigo maligna?

A

Slow growing, asymmetric brown / black macule with colour variation and an irregular indented border.
In situ – termed ‘Lentigo Maligna’
Invasive termed ‘Lentigo Maligna Melanoma’
5% of lentigo maligna progresses to invasive melanoma

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13
Q

Where is acral lentiginous typical presentation?

A

Typically palms and soles or in/around nail apparatus

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14
Q

What is the ABCDE for detection of melanoma?

A

Asymmetry
Border irregularity
Colour variation
Diameter greater than 5mm
Evolving

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15
Q

What is Garbe’s rule?

A

If a patient is worried about a single skin lesion, do not ignore their suspicion and have a low threshold for performing a biopsy

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16
Q

What are some poor prognostic features?

A

Increased Breslow thickness >1mm
Ulceration
Age
Male gender
Anatomical site – trunk, head, neck
Lymph node involvement

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17
Q

What is investigation for melanoma and what is to be noted about it?

A

Dermoscopy –can improve correct diagnosis of melanoma by nearly 50%

NB

Dermoscopic findings should not be considered n isolation

History and risk factor status are important

Excise lesion for histological assessment if in any doubt

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18
Q

What is the typical management for melanoma?

A

Primary excision down to subcutaneous fat
- 2mm peripheral margin

Wide excision
- Margin determined by Breslow depth
- 5mm for in situ
- 10mm for </=1mm
Prevents local recurrence or persistent disease

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19
Q

What is sentinel lymphoma node biopsy?

A

Lymphatic drainage of finite regions of skin drain specifically to an initial node within a given nodal basin - the ‘sentinel node’
Most likely nodes to contain metastatic disease
Currently offered for pT1b+
Extracapsular spread on lymph node biopsy – needs lymph node dissection

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20
Q

What imaging is done for melanoma?

A

Stage III, IV
And Stage IIc without SLNB

PET-CT
MRI Brain

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21
Q

What is a mojor prognostic indicator in melanoma?

A

LDH

22
Q

What are two methods used in unresectable or metastatic melanoma?

A

Immunotherapy and mutated oncogene targeted therapy

23
Q

What does immunotherapy involve?

A

CTLA-4 inhibition – unresectable or metastatic BRAF negative melanoma (Ipilimumab)
PD-L1 (Programmed cell death ligand) inhibitors (Nivolumab)

24
Q

What does mutated oncogene targeted therapy involve?

A
  • Combination of aBRAFinhibitor (e.g. encorafenib, vemurafenib, dabrafenib) andMEK inhibitor (e.g. trametinib)
25
Q

What are some examples of keratinocyte dysplasia?

A

Actinic keratoses
- Dysplastic keratinocytes
Bowen’s disease (Squamous cell carcinoma in situ)
Squamous cell carcinoma
- Potential for metastasis/ death
Basal cell carcinoma
- (Virtually) never metastasises
- Locally invasive

26
Q
A
26
Q

What is the pathogenesis for basal cell carcinoma?

A

Cross talk between tumour cells and mesenchymal cells of stroma
- Receptors for PDGF are upregulated in Stroma but PDGF is upregulated in tumour cells
BCC has proteolytic activity e.g. metalloproteinases and collagenases
– degrade pre-existing dermal tissue and facilitate spread of tumour cells
Loss of function in chromosome 8q (PTCH gene)
- p53 mutations are also important – majority are missense mutations that carry a UV signature

27
Q

What is the pathogenesis for squamous cell carcioma?

A

Develops through addition of genetic alterations – alterations in p53 are most common
- CDKN2A also
NOTCH1 or NOTCH2 (Wnt / β-catenin signalling) also plays role

28
Q

Which is more common between basal cell carcinoma na d squamous cell carcinoma?

A

BCC:SCC 4:1

Both commoner in pale skin types

Both more common in men vs women (2-3:1)

Median age at diagnosis of BCC is 68

29
Q

What are some risk factors for keratinocyte carcinomas?

A

UV exposure
- PUVA
Fair skin
Genetic syndromes
- Xeroderma pigmentosum
- Oculocutaneous albinism
- Muir Torre syndrome
- Nevoid basal cell carcinoma syndrome*
Nevus sebaceous
Porokeratosis
Organ transplantation (immunosuppressive drugs)
Chronic non-healing wounds
Ionising radiation
- Airline pilots
Occupational chemical exposures
- Tar, polycyclic aromatic hydrocarbons

30
Q

What are some characteristics of actinic keratoses?

A

Atypical keratinocytes confined to epidermis
Develop on sun-damaged skin - usually head, neck, upper trunk and extremities
Macules or papules
Red or pink
Usually some scale – may be thick scale
Distinction from squamous cell carcinoma sometimes difficult – requiring biopsy

31
Q

What is bowen’s disease?

A

Squamous cell carcinoma in situ
Erythematous scaly patch or slightly elevated plaque
May arise de novo or from pre-existing AK
May resemble actinic keratoses, psoriasis, chronic eczema

32
Q

what is the treatment for bowen’s disease and actinic keratoses?

A

5-fluorouracil cream
Cryotherapy
Imiquimod cream
Photodynamic therapy
Curettage and cautery
Excision

33
Q

What might squamous cell carcinoma look like?

A

Erythematous to skin coloured
- Papule
- Plaque-like
- Exophytic
- Hyperkeratotic
- Ulceration

34
Q

What are some clinical features of squamous cell carcinoma?

A

Localisation and size:
- Trunk and limbs > 2cm
- Head / neck > 1cm
- Periorificial zones
Margins: Ill-defined
Rapidly growing
Immunosuppressed patients
Previous radiotherapy or site of chronic inflammation

35
Q

What are keratoacanthoma (how they present, how they resolve, where they present, what are they similar to)?

A

Rapidly enlarging papule that evolves into a sharply circumscribed, crateriform nodule with keratotic core
Resolves slowly over months
Most occur on head or neck / sun exposed areas
Difficult to distinguish clinically and histologically from squamous cell carcinoma

36
Q

What are some diffrential diagnoses for squamous cell carcinoma?

A

Basal cell carcinoma
Viral wart
Merkel cell carcinoma

37
Q

What is the treatment for squamous cell carcinoma?

A

Examination of rest of skin and regional lymph nodes
Excision
Radiotherapy
- Unresectable
- High risk features e.g. perineural invasion
Cemiplimab for metastatic SCC
Secondary prevention
- Skin monitoring advice
- Sun protection advice

38
Q
A
38
Q

What are the main subtypes for basal cell carcinoma?

A

Nodular
Superficial
Morpheic
Infiltrative
Basisquamous
Micronodular

39
Q

Describe nodular basal cell carcinoma

A

Most common subtype
Accounts for approximately 50% of all Basal cell carcinomas
Typically presents as shiny, pearly papule or nodule

40
Q

Describe superficial basal cell carcinoma?

A

Well-circumscribed, erythematous, macule / patch or thin papule /plaque

41
Q

Describe morphoeic basal cell carcinoma?

A

Less common
Slightly elevated or depressed area of induration
Usually light-pink to white in colour
More aggressive behaviour
- Extensive local destruction

42
Q

Describe basisquamous basal cell carcinoma

A

Histological features of both basal cell carcinoma and squamous cell carcinoma

43
Q

Describe micronodular basal cell carcinoma?

A

Resembles nodular basal cell carcinoma clinically
More destructive behaviour – high rates of recurrence and subclinical spread

44
Q

What are soem diffrential diagnosis for basal cell carcinoma?

A

Squamous cell carcinoma
Adnexal (sebaceous) carcinoma
Merkel cell carcinoma

45
Q

What are the main teeatment options for basal cell carcinoma?

A

Standard surgical excision

Mohs micrographic surgery
- Recurrent basal cell carcinoma
- Aggressive subtype (morpheic / infiltrative / micronodular)
- Critical site

46
Q

What are some other options for treating basla cell carcinoma?

A

Topical therapy e.g. 5-Fluorouracil, Imiquimod
Photodynamic therapy
Curettage
Radiotherapy
Vismodegib - selectively inhibits abnormal signalling in Hedgehog (Hh) pathway

47
Q

What are origin cell for merkel cell carcinoma?

A

Origin cell not a Merkel cell – are highly anaplastic cells which share features with neuroectodermally derived cells (including Merkel cells)

48
Q

How does merkel cell carcinoma present?

A

Predilection for the head and neck region of older adults
Solitary, rapidly growing nodule- pink-red to violaceous, firm, dome shaped,
- Ulceration can occur

DERMATOLOGY phase 1b (6 decks)

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