Skin lesions and Skin cancer

Question 1

How do you describe a skin lesion?

Answer 1

Site
Shape 
Size 
Colour 
Palpate - mobility, surface changes, temperature and consistency

Question 2

What are seborrhoea keratoses and how do they present and what is the treatment?

Answer 2

(turtle shells) 
Benign, commonly referred
Warty growths - "stuck on appearance" 
Patients often have multiple 
Generally left untreated, but if troublesome - cryotherapy and curettage.

Question 3

What is Cryotherapy?

Answer 3

Liquid nitrogen
+ cheap and easy to perform on the day
- Can scar, failure and reoccurrence

Question 4

How is seborrhoea linked to Leser-trelat?

Answer 4

Paraneoplastic phenomonenon
- abrupt onset of widespread seborrhoeic keratosis, particularly in young
Sis remain benign but may indicate underlying solid organ malignancy - GI adenocarcinoma

Question 5

What are viral warts and how are they treated?

Answer 5

Due to Human papilloma virus
Rough hyperkeratotic surface
Difficult to treat - will clear when immunity developed to virus.
Cryotherapy or wart paints can stimulate immune system slightly
Can curette in severe cases.

Question 6

What are cysts, how do they present and how do you treat them?

Answer 6

Encapsulated lesion containing fluid or semi-fluid material. Usually firm and fluctuant. Common.
Many different types:
Can rupture and cause inflammation of surrounded skin - may become secondary infected.
Treat with excision
If inflamed/infected - antibiotics, intralesional steroid, incision and drainage.

Question 7

What are Dermatofibroma?

Answer 7

Benign fibrous nodule, often on limbs.

Firm nodule, tethered to skin but mobile over fat. Pale pink/brown. often paler in centre.

Question 8

What is Lipoma?

Answer 8

Bening tumour consisting of fat cells
Common
smooth and rubbery subcutaneous mass

Question 9

What is an Angioma?

Answer 9

Vascular lesion
Overgrowth of blood vessels in the skin due to proliferating endothelial cells.
Pregnancy and liver disease.

Question 10

What is pyogenic Granuloma?

Answer 10

Vascular lesion 
rapidly enlarged red/raw growth, often at site of trauma. 
Common on head and hands
Bleed easily 
Removed by curettage and cautery.

Question 11

What are Actini Keratoses?

What is the treatment?

Answer 11

Pre-malignant lesion
Rough scaly patches on sun damaged skin
Low risk of transformation to SCC
Treatment = Cryotherapy, Curettage, Diclofenac gel, Imiquimod.

Question 12

What is Bowen’s disease?

What is the treatment?

Answer 12

Squamous cell carcinoma in situ.
Full thickness dysplasia, entire contained within the epidermis, no metastatic potential.
Potential to become malignant (5%)
Irregular, scaly erythematous plaque.
Treatment = Cryotherapy, Curettage, photo-dynamic therapy, and Imiquimod

Question 13

What is photo-dynamic therapy?

Answer 13

Photochemical reaction to selectively destroy cancer cells.
Topical photosensitising agent applied.
Red light applied.

Question 14

What is Imiquimod?

Answer 14

Immune response modifier - stimulates cytokine release - inflammation and destruction of lesion.
+ useful where surgery not wanted, good cosmetic result.
- treatment is 6 weeks, significant inflammation.

Question 15

What are the 2 non-melanoma skin cancers?

Answer 15

Basal cell cancer (70%) (146 to 788/100000)

Squamous cell cancer (38 to 250 / 100000)

Question 16

What are the risk factors of non-melanoma skin cancer?

Answer 16

UV radiation 
Photochemotherapy - PUVA  
Chemical carcinogens 
X-ray and thermal radiation 
Human Papilloma virus 
Familial cancer syndromes 
Immunosuppression

Question 17

What is Basal Cell carcinoma?

Answer 17

Slow growing 
Locally invasive 
Rarely metastasise 
Nodular:
- pearly rolled edge 
- telangiectasia (thread like)
- Central ulceration 
- absorbing vessels on dermoscopy 
- can be superficial, pigmented, or morphoeic

Question 18

Treatment of BCCs

Answer 18

Surgery

• Excision is gold standard
• Curettage in some circumstances
• Mohs surgery

Question 19

What is Mohs surgery?

Answer 19

Removal layer by layer. 
Indications:
site
size
subtype
poor clinical margin definition 
recurrent 
perineurial or perivascular involvement

Question 20

What is Vismodegib and when is it used?

What are the side affects?

Answer 20

drug for invasive BCC
Indications:
Locally advanced BCC not suitable for surgery or radiotherapy
metastatic BCC
Selectively inhibits abnormal signalling in the hedgehog pathway (molecular driver)
Can shrink tumour and heal visible lesions in some
Median progression free survival 9.5 months
- side affects = Hair loss, weight loss, altered taste, muscle spasm, nausea, fatigue.

Question 21

What is squamous cell carcinoma and how does it present?

Answer 21

Derived from keratinising squamous cells
Usually on sun exposed sites 
Can metastasise 
Faster growing, tender, scaly/crusted or fleshy growths 
Can ulcerate.

Question 22

Treatment for SCC

Answer 22

Excision +/- radiotherapy 
Follow up if high risk:
immunosuppressed 
>20 mm diameter 
>4mm depth 
Perineurial invasion 
ear, nose, lip, eyelid

Question 23

What is Keratoacanthoma?

Answer 23

Variant of SCC
Erupts from hair follicles in sun damaged skin
Grows rapidly, may shrink after a few months and resolve
Surgical excision.

Question 24

Risk factors for melanoma skin cancer?

Answer 24

UV radiation
Genetic susceptibility - fair skin, red hair, blue eyes and tendency to burn easily
Familial melanoma and melanoma susceptibility genes.

Question 25

What is the ABCDE rule of cancer lesions?

Answer 25

Asymmetry 
Border 
Colour 
Diameter 
Evolution

Question 26

What is the 7 point checklist for cancer lesions?

Answer 26

Major features:
Change in size
Change in shape 
Change in colour 
Minor features: 
Diameter more than 5 mm
Inflammation 
oozing or bleeding 
Mild itch or altered sensation.

Question 27

What are the different sub types of malignant melanomas?

Answer 27

Superficial spreading malignant melanoma
Lentigo maligna melanoma
Nodular melanoma
Aural lentiginous melanoma/ subungal melanoma
Ocular melanoma

Question 28

What is the treatment for malignant melanoma?

Answer 28

Urgent surgical excision 
- subtype 
- breslow thickness
Wide local excision 
sentinel lymph node biopsy 
Chemo/ immunotherapy 
Regular follow up 
Primary and secondary prevention

Question 29

Metastatic Melanoma drugs

Answer 29

Monoclonal antibodies
ipilimumab
Vemurafenib and Dabrafenib (only Braf)
Pembrolizumab

Question 30

What is cutaneous lymphoma?

Answer 30

Secondary cutaneous disease from systemic/nodal involvement
Primary cutaneous disease - abnormal neoplastic proliferation of lymphocytes in the skin.
- cutaneous T cell lymphoma (65%)
- cutaneous B cell lymphoma (20%)

Question 31

What is Mycosis fungicides?

What are the stages of MF?

Answer 31

Most common CTCL and accounts for around 50% of all primary cutaneous lymphommas.
Stages:
Patch - flat, red, dry oval lesions, usually covered sites, itch, difficult to differentiate between eczema and psoriasis.

Plaque - patches become thickened, generally itch

Question 32

What is sezary syndrome?

Answer 32

“red man syndrome”
CTCL affecting skin of entire body - skin thick and scaly and red and itchy.
Lymph node involvement

Question 33

Treatment of cutaneous lymphoma

Answer 33

Dependent on stage:

• topical steroids
• PUVA or UVB
• Localised radiotherapy
• Interferon
• Bexarotene
• low does methotrexate
• Chemotherapy
• Total skin electron beam therapy (type of radio)

Question 34

What is cutaneous Metastases?

How is it treated?

Answer 34

Can be secondary to primary skin malignancy such as melanoma or due to primary solid organ malignancy - most common in breast, colon and lung.
treat underlying malignancy, local excision, localised radiotherapy, symptomatic.