1b// Skin cancer Flashcards
(105 cards)
1
Q
What do you have to consider to make a differential diagnosis with derm?
A
2
Q
What are the investigations you can do for derm?
A
and tissue culture
3
Q
What investigations are best for derm cancers?
A
imaging and skin biopsies
4
Q
What are the derm cancers you need to know?
A
melanoma
squamous cell carcinoma (SCC)
basal cell carcinoma (BCC)
Merkel cell carcinoma
5
Q
What is a melanoma?
A
a malignant tumour arising from melanocytes
leads to >75% of skin cancer deaths
Rising incidence rates observed worldwide
6
Q
Where can a melanoma arise?
A
Can arise on mucosal surfaces (e.g. oral, conjunctival, vaginal) and within uveal tract of eye
skin asw
these are just the ones that you wouldn’t expect
7
Q
What happens when a melanoma is found in weird places such as the GI tract?
A
abnormal migration of melanocyte precursors
8
Q
What is this?
A
An asymmetric, irregularly pigmented melanocytic lesion. The central depigmented zone is due to tumour regression.
9
Q
What are the categories of the risk factors for melanoma?
A
genetic factors
environmental factors
phenotypic
10
Q
What are the genetic risk factors for melanoma?
A
- Family history (CDKN2A mutations), MC1R variants
- DNA repair defects (e.g. xeroderma pigmentosum)
- Lightly pigmented skin
- Red hair
11
Q
What are the environmental risk factors for melanoma?
A
- Sun exposure – intense intermittent or chronic
- Sunbeds
- Immunosuppression
12
Q
What are the phenotypic risk factors for melanomas?
A
- > 100 Melanocytic nevi
- Atypical melanocytic nevi
nevi= mole
13
Q
What is the epidemiology of melanomas?
A
- Increasing worldwide
- Develops predominantly in Caucasian populations
- Incidence low amongst darkly pigmented populations
- 10-19/100,000 per year in Europe
- 60/100,000 per year in Australia / NZ
14
Q
What are the subtypes of melanomas? (5)
A
Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Unclassifiable
15
Q
How common are superficial spreading melanomas?
A
60-70% of all melanomas
- most common type in fair skin
16
Q
Where are superficial spreading melanomas most frequently on?
A
trunk of men
legs of women
17
Q
How can superficial spreading melanomas arise?
A
de novo or in pre-existing nevus
18
Q
What happens in roughly 2/3 of tumours of superficial spreading melanomas?
A
In ~2/3 of tumours, regression (visible as grey, hypo-or depigmentation visible (host immunity against tumour)
19
Q
What type of growth happens in superficial spreading melanomas?
A
horizontal growth and vertical growth
20
Q
What happens in horizontal growth?
A
asymmetry
border irregularity
colour variation
diameter greater than 5/6mm
21
Q
What happens in vertical growth?
A
grow downwards (and upwards)
nodule formed, raised
22
Q
What is the 2nd most common type of melanoma in fair skinned individuals?
A
nodular melanoma
15-30% of all melanomas
23
Q
What growth occurs with nodular melanoma?
A
no horizontal growth
just vertical
24
Q
Where are the most common places for nodular melanomas?
A
most commonly trunk, head and neck
25
Is nodular melanoma more common in women or men?
men
26
How does nodular melanoma usually present?
Usually present as blue to black, but sometimes pink to red, nodule – may be ulcerated, bleeding
27
Do nodular melanomas develop rapidly or slowly?
rapidly
28
What melanoma makes up 10% (minority) of cutaneous melanomas?
lentigo maligna
29
In who is lentigo maligna most common?
Elderly over 60 y/o
- chronically sun damaged skin
30
Where on the body is lentigo maligna most common?
on the face
31
How would you describe a lentigo maligna?
Slow growing, asymmetric brown / black macule with colour variation and an irregular indented border.
32
What are the 2 types of lentigo maligna melanomas?
in-situ=> lentigo maligna
invasive=> lentigo maligna melanoma
33
Is it common for lentigo maligna to progress to invasive melanoma?
* 5% of lentigo maligna progresses to invasive melanoma
34
Which melanoma is most frequent in 7th decade of life?
acral lentiginous
35
Where is acral lentiginous most frequently found?
Typically palms and soles OR in / around nail apparatus
36
What is the incidence like of acral lentiginous?
Incidence similar across all racial and ethnic groups
- Disproportionate percentage of melanomas diagnosed in Afro-Caribbean (up to 70%) or Asians (up to 45%)
37
What is pigmentation in the nail called?
melanonychia
con happen with acral lentiginous
but also common in afro-carribean after trauma
(not necessarily a term to describe melanoma)
38
What is an amelanotic melanoma?
no pigment so pink
39
What is the method for self-detection of melanomas?
40
What are differential diagnoses of melanomas?
basal cell carcinoma
seborrhoeic keratosis
dermatofibroma
41
What are poor prognostic features of melanomas?
Increased Breslow thickness >1mm (increased thickness means a worse prognosis)
Ulceration
Age
Male gender
Anatomical site – trunk, nhead, neck
Lymph node involvement
42
What is survival llke comparing a stage 1a melanoma and a pT4b?
Stage 1A melanoma have 10 year survival of >95% whereas thick melanomas >4mm and ulceration pT4b have a 10 year survival rate of 50%
43
Who gives you the measurements of the depth of a melanoma? And what is that thickness called
histologists
Breslow thickness
44
How do you investigate for melanomas?
Dermoscopy –can improve correct diagnosis of melanoma by nearly 50%
NB
Dermoscopic findings should not be considered in isolation
History and risk factor status are important
Excise lesion for histological assessment if in any doubt
“If in doubt, take it out”
45
What is the management for resectable melanomas?
Primary excision down to subcutaneous fat
- 2mm peripheral margin
Wide excision (go beyond lesion)
- Margin determined by
Breslow depth
- 5mm for in situ
- 10mm for
46
What is the staging for melanomas?
47
What is the imaging done for melanomas?
Imaging
- Stage III, IV
And Stage IIc without SLNB
PET-CT
MRI Brain
48
What is a major prognostic indicator in melanoma?
LDH
Lactate dehydrogenase
49
What is the management of unresectable melanomas or metastatic melanomas?
Immunotherapy
Mutated oncogene targeted therapy:
50
What is the immunotherapy for unresectable melanomas?
CTLA-4 inhibition–unresectable or metastatic BRAF negative melanoma (Ipilimumab)
PD-L1 (Programmed cell death ligand) inhibitors (Nivolumab)
51
What is the mutated oncogene targeted therapy for melanomas?
Combination of a BRAF inhibitor (e.g. encorafenib, vemurafenib, dabrafenib) and MEK inhibitor (e.g. trametinib)
52
In who are Keratinocyte Dysplasia / Carcinomas most common in? And what type of damage is it?
predominantly pale skin types
solar induced UV damage
53
What is a carcinoma?
cancer that forms in epithelial tissue
54
What are the types of Keratinocyte Dysplasia / Carcinoma?
Actinic keratoses
Bowen’ s disease
Squamous cell carcinoma
Basal cell carcinoma
55
What is actinic keratoses?
dysplastic keratinocytes
56
What is Bowen's disease?
squamous cell carcinoma in situ
57
what is does squamous cell carcinoma have the potential for?
metastasis/ death
58
What does basal cell carcinoma basically never do?
(virtually) never metastasises
locally invasive
59
What is a significant risk factor for basal cell carcinoma?
UV radiation
60
What is the pathogenesis of basal cell carcinoma?
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
61
What is a significant risk factor of squamous cell carcinoma?
UV radiation
62
What is the pathogenesis of SCC?
Develops through addition of genetic
alterations–
alterations in p53 are most common
- CDKN2A also
NOTCH1 or NOTCH2 (Wnt / β-catenin signalling) also plays role
63
What is epidemiology of keratinocyte carcinomas?
- Basal cell carcinoma is most common skin cancer
- BCC:SCC 4:1
- Both commoner in pale skin types
Systemic
- Both more common in men vs women (2-3:1)
disease
- Median age at diagnosis of BCC is 68
64
What are the risk factor for keratinocyte carcinomas? (9)
UV exposure - e.g., PUVA
Fair skin
Genetic syndromes
Nevus sebaceous
Porokeratosis
Organ transplantation (immunosuppressive drugs)
Chronic non-healing wounds
Ionising radiation
- Airline pilots
Occupational chemical exposures
- Tar, polycyclic aromatic hydrocarbons
65
What are the genetic syndromes that are risk factors for keratinocyte carcinomas?
- Xeroderma pigmentosum
- Oculocutaneous albinism
- Muir Torre syndrome
- Nevoid basal cell carcinoma syndrome
66
What are actinic keratoses?
Atypical keratinocytes confined to epidermis
67
Where do actinic keratoses develop?
Develop on sun-damaged skin - usually head, neck, upper trunk and extremities
68
What can actinic keratoses look like?
macules or papules
red or pink
Usually some scale – may be thick scale
69
What type of carcinoma is it hard to make a distinction between it and actinic keratoses? And how do you make that distinction?
Distinction from squamous cell carcinoma sometimes difficult – requiring biopsy
70
What can actinic keratoses progress to, and what are its chances of progressing?
Risk of progression to squamous cell carcinoma: 0.025–16% per year for any single lesion
71
What is Bowen's disease?
squamous cell carcinoma in situ
72
What does Bowen's disease look like?
Erythematous scaly patch or slightly elevated plaque
73
How may Bowen's disease arise?
de novo or from pre-existing Actinic keratosis
74
What can Bowen's disease resemble?
actinic keratoses, psoriasis, chronic eczema
75
What is the treatment for actinic keratosis and Bowen's disease?
5-fluorouracil cream
Cryotherapy (liquid nitrogen)
Imiquimod cream
Photodynamic therapy
Curettage and cautery
Excision
76
What does squamous cell carcinoma arise within the background of?
of sun damaged skin
77
What can squamous cell carcinoma look like?
- Erythematous to skin coloured
- Papule
- Plaque-like
- Exophytic
- Hyperkeratotic
- Ulceration
78
What are high risk features of squamous cell carcinoma?
don't need to know all of this esp the second box
but j in case
79
What tumour mimics SCC?
Keratoacanthoma
Difficult to distinguish clinically and histologically from squamous cell carcinoma
80
What is keratoacanthoma?
Rapidly enlarging papule that evolves into a sharply circumscribed, crateriform nodule with keratotic core
81
How are keratoacanthomas resolved?
resolves itself slowly over time
but excisions occur often
82
Where do most keratoacanthomas occur?
Most occur on head or neck / sun exposed areas
83
What are the investigations for SCC?
Often clinical diagnosis sufficient
Diagnostic biopsy may be taken if diagnostic
uncertainty
Ultrasound of regional lymph nodes ± FNA if concerns regarding regional lymph node metastasis
84
What are the differential diagnoses for SCC?
basal cell carcinoma
viral wart
merkel cell carcinoma
85
What is the treatment for non-metastatic SCC?
Examination of rest of skin and regional lymph nodes
Excision
Radiotherapy
- Unresectable
- High risk features e.g. perineural invasion
86
What is the secondary prevention for SCC?
- Skin monitoring advice
- Sun protection advice
87
What do you give for metastatic SCC?
cemiplimab
88
What are the main subtypes for basal cell carcinoma? (6)
- Nodular
- Superficial
- Morpheic
- Infiltrative
- Basisquamous
- Micronodular
89
What is the most common subtype of BCC?
nodular
90
How does nodular BCC present typically?
Typically presents as shiny, pearly papule or nodule
91
How would you describe superficial BCC?
Well-circumscribed, erythematous, macule / patch or thin papule /plaque
92
What does a morphoeic BCC look like?
(looks like a scar and grows rapidly)
- Less common
- Slightly elevated or depressed area of induration
- Usually light-pink to white in colour
- More aggressive behaviour
* Extensive local destruction
93
What histological features does basisquamous have?
Histological features of both basal cell carcinoma and squamous cell carcinoma
94
Describe micronodular BCC?
- Resembles nodular basal cell carcinoma clinically
- More destructive behaviour – high rates of recurrence and subclinical spread
95
What are the investigations of BCC?
Often clinical diagnosis sufficient
Diagnostic biopsy may be taken
96
What are the differential diagnoses for BCC?
SCC
adnexal (sebaceous) carcinoma
Merkel cell carcinoma
97
What is the difference between SCC and BCC (google)?
98
What is the treatment for BCC?
Standard surgical excision
Mohs micrographic surgery
- Recurrent basal cell carcinoma
- Aggressive subtype (morphoeic/ infiltrative / micronodular)
- Critical site
Other options:
- Topical therapy e.g. 5-Fluorouracil, Imiquimod
- Photodynamic therapy
- Curettage
- Radiotherapy
- Vismodegib
99
What does vismodegib do?
selectively inhibits abnormal signalling in Hedgehog (Hh) pathway
100
Types of surgery for BCC, which is better?
Bread loafing method
Mohs micrographic surgery
Mohs is better, but takes longer and you have to be very skilled
- 2nd image
101
Why is merkel cell carcinoma named after merkel cell?
Origin cell not a Merkel cell –
are highly anaplastic cells which share features with neuroectodermally derived cells (including Merkel cells) (I don't really get this part bu hey ho! its not a merkel cell cancer)
102
What are most MCC associated with?
80% are associated with polyomavirus
103
Where are MCC most common on the body?
head and neck region of older adults
104
What is the growth and appearance of MCC?
Solitary, rapidly growing nodule- pink-red to violaceous, firm, dome shaped,
- Ulceration can occur
105
What is the behaviour like of MCC?
Aggressive, malignant behaviour
>40% develop advanced disease/ metastasis
