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BRS DERMATOLOGY > 1b Skin Cancer > Flashcards

1b Skin Cancer Flashcards

1
Q

What are the 5 layers of skin?

Come Let’s get sun burnt!

A
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2
Q

What are 5 points of self detection for skin lesions that may turn cancerous?

ABCDE

A
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3
Q

What is a malignant 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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4
Q

Outline the epidemiology of malignant melanomas.

A
  • Rising incidence rates observed 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 (Sunny locations)
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5
Q

What are the risk factors of malignant melanomas (Genetic 3 / Environmental 3 / Phenotypic 2)?

A

Genetic factors:
* Family history (CNKN2A mutations), MC1R variants
* Lightly pigmented skin, red hair
* DNA repair defects (e.g. xeroderma pigmentosum)

Environmental factors:
* Intense intermittent sun exposure, chronic sun exposure, residence in equatorial latitudes
* Sunbeds
* Immunosuppression

Phenotypic:
* Patient who has more than 100 melanocytic nevi on the whole body
* Patient who has atypical melanocytic nevi

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6
Q

What are the main different subtypes of malignant melanoma (5)?

A
  • Superficial spreading (Horizontal growth then Vertical growth)
  • Nodular (Only vertical growth)
  • Lentigo maligna
  • Acral lentiginous
  • Unclassifiable
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7
Q

A patient present with the following symptoms:

What is the most likely diagnosis?

A
  • Superficially spreading malignant melanoma

Epidemiology:
* 60-70% of all melanomas
* Most common type in fair-skinned individuals
* Most frequently seen on trunk of men and legs of women

Pathogenesis:
* Can arise de novo or in pre-existing nevus
* In up to 2/3 of tumours, regression (visible as grey, hypo-or depigmentation), due to host immune system reacting to tumour

Pathophysiology:
* After a slow horizontal (radial) growth phase, limited to epidermis, a more rapid vertically oriented growth phase: development of nodule

Differential diagnosis:
* Dermatofibroma

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8
Q

A patient present with the following symptoms:

What is the most likely diagnosis?

A
  • Nodular malignant melanoma

Epidemiology:
* 2nd most common type of melanoma in fair skinned individuals
* 15-30% of all melanomas
* Most commonly trunk, head and neck, M>F

Pathogenesis:
* Usually dark nodule -but can be pink or red, may be ulcerated, bleeding
* Develops rapidly

Pathophysiology:
* De novo vertical growth phase without the horizontal growth phase. Present more advanced stage, with poorer prognosis.

Differential diagnosis:
* Basal cell carcinoma

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9
Q

A patient present with the following symptoms:

What is the most likely diagnosis?

A
  • Lentigo maligna (malignant melanoma)

Epidemiology:
* 5% progress to invasive melanoma
* > 60 yo chronically sun damaged skin

Pathophysiology:
* Slow growing macule
* It is an in-situ melanoma

Differential diagnosis:
* Seborrhoeic keratosis

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10
Q

A patient present with the following symptoms:

What is the most likely diagnosis?

A
  • Acral lentiginous (malignant melanoma)

Epidemiology:
* Uncommon: ~5% of all melanomas
* Most frequently 70yo
* Incidence similar across all age groups

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11
Q

What investigations are suggested in suspected malignant melanomas (2)?

A
  • Examination with a dermatoscope
  • Excision biopsy for histological assessment
    • Measure Breslow thickness: prognosis worse if >1mm
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12
Q

What is the management of malignant melanomas (Surgery 2 / Imaging 1 / Immunotherapy 2)?

A

Surgery:
* Wide local excision
* Margin depends on Breslow thickness
* Sentinel lymph node biopsy - lymph node dissection

Imaging:
* TNM staging

Immunotherapy:
* CTLA-4 inhibition (Ipilimumab)
* PD-L1 (Programmed cell death ligand) inhibitors
* (Nivolumab)

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13
Q

What are the 3 stages of keratinocyte dysplasia?

A

Actinic keratoses
* Dysplastic keratinocytes

Bowen’s disease
* Squamous cell carcinoma in situ

Squamous cell carcinoma
* Invasive cancer
* Potential for metastasis/ death

Predominantly pale skin types
Solar induced UV damage

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14
Q

A patient present with the following symptoms:

What is the most likely diagnosis?

A

Actinic keratoses
* Dysplastic keratinocytes

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15
Q

A patient present with the following symptoms:

What is the most likely diagnosis?

A

Bowen’s disease
* Squamous cell carcinoma in situ

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16
Q

What is the management of actinic keratosis and bowen’s disease (6)?

A
  • 5-fluorouracil cream
  • Cryotherapy
  • Imiquimod cream
  • Photodynamic therapy
  • Curettage and cautery
  • Excision
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17
Q

A patient present with the following symptoms:

What is the most likely diagnosis?

A
  • Squamous Cell Carcinoma (SCC)

Pathophysiology:
* Can have different appearances
* Erythematous to skin coloured
* Papule
* Plaque-like
* Exophytic
* Hyperkeratotic
* Ulceration
* Arises within background of sun-damaged skin
* Rapidly growing

Differential diagnosis:
* Basal cell carcinoma
* Viral wart
* Merkel cell carcinoma

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18
Q

What investigations are recommended for suspected squamous cell carcinoma (SCC) (2)?

Often clinical diagnosis sufficient

A
  • Diagnostic biopsy may be taken if diagnostic uncertainty
  • Ultrasound of regional lymph nodes ± FNA if concerns regarding regional lymph node metastasis
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19
Q

What is the management of squamous cell carcinoma (SCC) (5)?

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
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20
Q

A patient present with the following symptoms:

What is the most likely diagnosis?

A
  • Keratoacanthoma
    • Pseudo-malignancy VS Variant of SCC (still unclear)

  • Rapidly enlarging papule that evolves into a sharply circumscribed, crateriform nodule with keratotic core
  • Resolves slowly over months to leave atrophic scar
  • Most occur on head or neck / sun exposed areas
  • Difficult to distinguish clinically and histologically from squamous cell carcinoma, so often excision
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21
Q

A patient present with the following symptoms:

What is the most likely diagnosis?

A
  • Basal Cell Carcinoma (BCC)

Main subtypes: Nodular- Superficial
* Nodular:
* Most common subtype
* Approximately 50% of all BCCs
* Typically: shiny, pearly papule or nodule
* Superficial:
* Well-circumscribed, erythematous, macule/plaque

Differential diagnosis:
* Squamous cell carcinoma
* Adnexal (Sebaceous) carcinoma
* Merkel cell carcinoma

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22
Q

What investigations are recommended for suspected basal cell carcinoma (BCC) (1)?

Often clinical diagnosis sufficient

A
  • Diagnostic biopsy may be taken if diagnostic uncertainty
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23
Q

What is the management of basal cell carcinoma (BCC) (1)?

A
  • Standard surgical excision
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24
Q

A patient present with the following symptoms:

What is the most likely diagnosis?

A
  • Merkel Cell Carcinoma
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25
Q

What is melanoma

A

Malignant tumour arising from melanocytes

most common sc death (over 75%)

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26
Q

Where can melanoma arise besides regular skin

A

Can arise on mucosal surfaces (e.g. oral, conjunctival, vaginal) and within uveal tract of eye

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27
Q

genetic risk factors for skin cancer

A

Family history (CNKN2A mutations), MC1R variants
Lightly pigmented skin
Red hair
DNA repair defects (e.g. xeroderma pigmentosum)

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28
Q

environmental risk factors for melanoma

A

Intense intermittent sun exposure
Chronic sun exposure
Residence in equatorial latitudes
Sunbeds
Immunosuppression

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29
Q

phenotypic risk factors for melanoma

A

> 100 Melanocytic nevi

Atypical melanocytic nevi

30
Q

What does BRAF substitution result in

A

BRAF mutations substitution leads to activation of mitogen-activated protein kinase (MAPK) pathway
melanoma

31
Q

host response to melanoma

A

CD8+ T-cell recognise melanoma-specific antigens and if activated appropriately, are able to kill tumour cells.

CD4+ helper T-cells and antibodies also play a critical role

Cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) is natural inhibitor of T-cell activation by removing the costimulatory signal (B7 on APC to CD28 on T-Cell

32
Q

immunotherapy for melanoma based on

A

CTLA-4 blockade – ipilimumab

  • Also checkpoint inhibitors (PD-1, PDL1)
33
Q

subtypes of melanoma

A

Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous
Unclassifiable

34
Q

features of superficial spreading melanoma

A

Most frequently seen on trunk of men and legs of women
regression (visible as grey, hypo-or depigmentation), due to reaction of host immune system with tumour
After a slow horizontal (radial) growth phase, limited to epidermis, a more rapid vertically oriented growth phase, which presents clinically with development of nodule

35
Q

nodular melanoma epidemiology

A

2nd most common type of melanoma in fair skinned individuals
Most commonly trunk, head and neck
M>F

36
Q

presentation of nodular melanoma

A

Usually present as blue to black, but sometimes pink to red, nodule – may be ulcerated, bleeding
Develops rapidly
Nodular melanoma is believed to arise as a de novo vertical growth phase without the pre-existing horizontal growth phase
Tend to present more advanced stage, with poorer prognosis.

37
Q

lentigo maligna epidemiology

A

Occurs in chronically sun-damaged skin, most commonly on the face
>60 years old
rarer

38
Q

presentation of lentigo maligna

A

Slow growing, asymmetric brown to black macule with colour variation and an irregular indented border
sun exposed areas e.g neck

In situ- termed ‘Lentigo Maligna’
Invasive (5%)- termed ‘Lentigo Maligna Melanoma’

39
Q

acral lentiginous epidemiology

A

Typically occurs on palms and soles or in and around the nail apparatus
Incidence similar across all racial and ethnic groups

40
Q

why BAME groups get acral lentiginous melanomas?

A

As more darkly pigmented Africans and Asians do not typically develop sun-related melanomas, ALM represents disproportionate percentage of melanomas diagnosed in Afro- Caribbean (up to 70%) or Asians (up to 45%)

41
Q

public awareness of early detection of skin cancer

A

ABCDE
Asymmetry
Border irregularity
Colour variegation
Diameter greater than 5mm
Evolving

42
Q

poor prognosis indicators (melanoma)

A

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

43
Q

how to measure breslow thickness

A

From granular layer to bottom of tumor

44
Q

what is dermoscopy

A

Investigation that can improve correct diagnosis of melanoma by nearly 50%

45
Q

main features of general melanoma

A

Asymmetry
Presence of multiple colours
Reticular, globular, reticular-globular, homogenous
Starburst

46
Q

removal of melanomas

A

primary excision - 2mm peripheral margin

wide excision - margin determined by breslow depth - 5mm in situ, 10mm for 1mm invasion

47
Q

staging of melanomas

A

thickness
ulceration
TNM

48
Q

unresectable melanoma management or metastatic

A

Immunotherapy

Mutated oncogene targeted therapy

49
Q

mutated oncogene melanoma therapy

A

BRAF inhibitor and MEK inhibitor combined

50
Q

keratinocyte dysplasia/carcinoma epidemiology

A

Predominantly pale skin types

Solar induced UV damage

51
Q

types of skin carcinoma

A

Actinic keratoses
- Dysplastic keratinocytes

Bowen’s disease (Squamous cell carcinoma in situ)

Squamous cell carcinoma
- Potential for metastasis/death

Basal cell carcinoma (more common)

  • rarely metastasises
  • Locally invasive
52
Q

BCC pathogenesis

A

stroma produced by dermal fibroblasts
crosstalk between tumour cells and mesenchymal stroma cells
proteolytic activity (invasion) via metalloproteinases and collagenases

53
Q

UV radiation role in SCC

A

Develops through addition of genetic alterations – alterations in p53 are most common

54
Q

risk factors of all keratinotye carcinomas (SCC,BCC etc)

A
  • UV exposure
    -PUVA
  • Genetic syndromes
    -Xeroderma pigmentosum
    -Oculocutaneous albinism
    -Muir Torre syndrome
    -Nevoid BCC syndrome
  • Nevus sebaceous
  • Porokeratosis
  • Organ transplantation (immunosuppressive drugs)
  • Chronic non-healing wounds
  • Ionising radiation
    -Airline pilots
  • Occupational chemical exposures
    -Tar, polycyclic aromatic hydrocarbons
55
Q

what is actinic keratoses

A

Atypical keratinocytes confined to epidermis
Erythematous macule or scale or both-> thick papules or hyperkeratosis or both
Develop on sun-damaged skin - usually head, neck, upper trunk and extremities

56
Q

what is bowens disease

A

Squamous cell carcinoma in situ
Erythematous scaly patch or slightly elevated plaque
may arise from existing actinic keratinosis
can resemble AK, psoriasis, chronic eczema

57
Q

treatment of AK and bowens

A

5-fluorouracil cream
Cryotherapy

Imiquimod cream
Photodynamic therapy
Curettage and cautery
Excision

58
Q

SCC presentation

A

Arises within background of sun-damaged skin

  • Erythematous to skin coloured
  • Papule
  • Plaque-like
  • Exophytic
  • Hyperkeratotic
  • ulcerated
59
Q

red flags of SCC

A

rapid growth
immunosuppressed patient
inflammation
poorly differentiated
invasion beyond subcut fat

60
Q

what is keratoacanthoma

A

sharply circumscribed, crateriform nodule with keratotic core
Most occur on head or neck / sun exposed areas
hard to distinguish from SCC

61
Q

diagnosis of SCC

A

clinical sufficient

biposy maybe, ultrasound of lymph nodes if concerned

62
Q

treatment SCC

A

Examination of rest of skin and regional lymph nodes
Excision
Radiotherapy
- Unresectable
- High risk features e.g. perineural invasion
Cemiplimab for metastatic SCC

63
Q

types of basal cell carcinoma

A

Nodular
Superficial
Morpheic
Infiltrative
Basisquamous
Micronodular

64
Q

most common type of BCC

A

Nodular

Accounts for approximately 50% of all Basal cell carcinomas

65
Q

how does BCC often present

A

Typically presents as shiny, pearly papule or nodule

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

66
Q

diagnosis of BCC

A

clinical sufficient

biopsy maybe

67
Q

BCC treatment

A

Standard surgical excision

Mohs micrographic surgery

Other options

68
Q

when to use Mohs micrographic surgery

A
  • recurrent BCC
  • aggressive subtype - morpheic, infiltrative, micronodular
  • critical sites
69
Q

main features of merkel cell carcinoma

A
  • Origin cell not a Merkel cell
  • 80% associated with polyamovirus
  • Solitary, rapidly growing nodule- pink-red to violaceous, firm, dome shaped,
    - Ulceration can occur
70
Q

merkel cell carcinoma treatment

A

Treated with surgery, radiation therapy

anti-PD1 (Pembrolizumab) / anti-PDL1 (Avelumab)

BRS DERMATOLOGY (9 decks)

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