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BCC & SCC Flashcards

1
Q

What are skin derivatives of ectoderm

A
  • pilosebaceous units
  • apocrine
  • eccrine
  • nail unit
  • epidermis
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2
Q

What are skin derivatives of neuroectoderm

A
  • melanocytes
  • nerves
  • specialized sensory receptors
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3
Q

What are skin derivatives of mesoderm

A
  • adipocytes
  • fibroblasts
  • langerhans
  • macrophage
  • mast cells
  • merkel cells
  • blood vessels
  • lymph vessels
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4
Q

what is epidermis

A

stratified squamous epithelium

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5
Q

What cell types are in the epidermis

A
  • keratinocytes ++++
  • melanocytes +++
  • Langerhans ++
  • Merkel +
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6
Q

What is the fitzpatricks classification

A

To describe Sun-Reactive Skin types

  • I - White - always burn, never tan
  • 2- White - usually burn, tan with difficulty
  • 3- White - Sometimes mild burn, tan average
  • 4- Moderate brown - Rarely burn, tan with ease
  • 5- Dark Brown* - Very rarely burn, tan very easily
  • 6 - Black - Donot burn, tan very easily

* asian, hispanic oriental, light african descent

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7
Q

What UV exposure is damaging to skin and what is the pathophysiology

A

UVB 290-320nm is carcinogenic

UVA 320-400nm - is mildly carcinogenic, synergistic w UVB

sunlight is 5% UVB, 95% UVA

photochemical effect - electron excitability in absorbing atoms induces damaging induces chemical changes

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8
Q

How are melaosomes protective against UV exposure

A

Melanin protect against UVB damage by reducing the amount of UVB delivered to the dermis

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9
Q

What are etiologies for cutaneous malignancies

A
  • UV exposure
  • immunosuppresion
  • chemical carcinogenesis
  • ionizing radiation
  • inherited conditions
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10
Q

How do you prevent skin cancer exposure

A
  • sunscreen - chemical - contianing PABA, and physical - zinc oxide/clothing
  • education
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11
Q

What are etiologies of BCC development

A
  • UV exposure
  • Chemical exposure - arsenic
  • Ionizing radiation exposure (latency 10-20yrs)
  • Inherited conditions (Bazex, XP, Gorlin, Gardner, Albinism, Muir Torres)
  • Immunosuppresion (loss of NK cells, T cells)
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12
Q

What is the distribution of BCC

A

Mainly on H&N, where most pilosebaceous units are located

Nose> Cheek >periorbital

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13
Q

How do you classify BCCs

A

N - Nodular ulcerative

O - Other (Micronodular, Infiltrative, Cystic)

P - Pigmented (most common in africain and hispanic

M - Morpheaform (perineural invasion, high recurrance rates)

S - Superficial (on the shoulder, red macular patch)

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14
Q

What are mimickers of BCC

A
  • Merkel cell
    • aggressive, metastasize to LN, bone, viscera
    • Tx: WLE, SLNBx, radiation
  • Adnexal Carcinoma
    • uncommon, appear in elderly, high incidence of local recurrence
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15
Q

What is the histopathologic feature of BCC

A
  • basoloid cell collections with peripheral palisading and stromal reaction (fibroblast and T cell infiltrates)
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16
Q

What is the rate of BCC metastasis?

A

0.04%

More aggressive BCC - morpheaform, infiltrative, micronodular

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17
Q

What is the natural history of BCC growth

A

growth at 0.5cm/yr

direct invasion into adjacent structures, may grow along perineural/lymphovascular structures

Slow growing

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18
Q

What are features of a BCC which make it high risk??

?????????need answers

A
  • Location
    • H-zone
19
Q

What is Gorlin’s syndrome

A

Basal Cell Nevus Syndrome

  • AD, PTCH gene mutation

Clinical features

  • frontal bossing, pseudohypertelorism
  • odontogenic mandibular keratocysts
  • spina bifida, bifid ribs
  • palmar and plantar pits, syndactyly
  • falx cerebri, mental retardation
  • medulloblastoma, meningioma, fetal rhabdomyoma, ameoloblastoma

Degeneraiton occurs post puberty

Tx - close observation and aggressive tx

possibel VIsmodegib systemic therapy - Shh inhibitor

20
Q

WHat is XP

A
  • AR, genetic mutation in endonuclease, required for repair of DNA damage post- UV exposure

Clinical features

  • risk for BCC, SCC, melanoma
  • Skin: early lentigos
  • Ocular: corneal opacity, blindness
  • Neurologic - deficits???
21
Q

What is Bazex

A
  • X-linked

Clinical features

  • icepicks on hands - follicular atrophoderma
  • hypotrichosis, anhydrosis
  • BCC noted on face in teenage years
22
Q

Management options for BCC

A

Medical

  • Cryotherapy
    • cure rate 90%
    • BUT no tissue path, pigment loss in scar
  • Radiotherapy
    • single dose of 5-20Gy or multi sessions totaling to 35Gy
    • cure rate 90%
    • for elderly, large areas where surgical recon difficult/disfiguring
    • BUT higher recurrence, poor cosmetic outcome
  • Photodynamic Therapy
    • Less effective than surgery!!! anything else?????/
  • Chemotherapy
    • Imiquimod (Aldara) for superficial BCC and AK
    • TID for 6wks
    • Cure 75-80%. imiquimod > 5-FU >PDT
  • CO2 laser
    • for superficial BCC, especially with coagulation disorders

Surgical

  • Curettage & Dessication
    • <1cm nodular exophytic lesions
    • Cure rate 80-95% if <2cm
    • But - get scar, little tissue to examine for path
  • Dermabrasion and chemical peel
    • premalignant lesions only
  • Surgical Excision with Margins
    • margins recommended are 2-5mm - dpeends on type, location, age, medical state
    • 4mm margin to eradicate 95% tumors greater than 2cm
    • Mohs fresh frozen techniue
      • mass debulk w curette, thin area removed at 45’ w 2mm margin
      • map of tumor is done with H slices and all margins are examined
      • cure 99% 1’ BCC, 94-96% 2’ BCC
23
Q

What is the risk of recurrence with a possitve margin

A
  • 30% if deep margin +
  • 15% if peripheral margin +
24
Q

What are signs of BCC recurrence?

A
  • development of papule/nodule within scar
  • telangiectasia with enlarging scar
  • scar erythema, crusting
  • non-healnig wound
25
What are risk factors for BCC recurrence?
* young female * located in midface/ear * hx of radiation exposure * BCC morpheaform or perineural invasion * incompletely treated/recurrent disease * large tumor \>2cm
26
Wht is follow-up after diagnosis of BCC
q6mths for 5yrs Because 4/10 patient who develop 1' BCC will develop a second in next 5yrs
27
What is SCC?
Malignancy that develop in the malphigian layer o fthe pidermis (s. germinativum, s. basale)
28
How fast do SCC's grow
cellular doubling time 4days
29
What are etiologic factors leading to SCC
* Chronic sun exposure * Precursor lesions * AK, AK, L, E, EdQ, P, KA * Precursor condicitions * XP, Epidermodysplasia Verruciformis, albinism, muir torre, porokeratosis * Ionizing radiation * Previous chronic wounds/scar * EB, burn scar, pressure sore, venous stasis/arterial insufficiency, chronic draining OM sinus tract. * Average time from injury to SCC is 20yr * chemical carcinogens * arsenic, psoralen, , nitrogen mustard * Immunosuppression * NK cells, Tcells depleted * 50% of trasnplant pts will dveelop SCC in first 10yrs * Vial infection * due to chronic HPV 16.18 infections * most common penile shaft, external labia, periungal
30
What is the epidemiology of SCC?
2nd most common skin cancer M:F, 1:1000, Hx of NMSC
31
How is SCC classified
* SCC in situ * Invasive SCC * Verrucous Carcinoma * low grade SCC with locald estruciton but no mets, apepars like verruca vulgaris
32
What are clinical features that distinguish ISCC from SCC in situ?
Insitu SCC * scaly dull red plaque, sharply defined SCC * Initially: can be smooth, verrucous, papillomatous +/- ulceration * Then become nodular, infiltrative, inflamed
33
What are the histopathologic features of SCC
H - Hyperkeratosis (much of s. corneum) A - Acanthosis (much s.spinosum) D -Dyskeratosis (premature keratinization of cells prior ot reaching keratinizing layer P - Parakeratosis (retention of nuclei in s. corneum)
34
What are the histopathology features of insitu vs iSCC
In Situ * atypical keratinocytes in "windblown" appearnce throughout layers of epidermis * atypia may occur in hair follicles even in dermis but DO NOT invade the dermis Invasive SCC * as above but extend into dermis * see "keratin pearls" * degree of cellular differentiation determine grade of SCC
35
How do you grade SCC
Broder's Grading Classification * Well differentiated =\<25% undifferentiated * Moderately \<50% undiff * Poor \<75% undifferentiated * Anaplastic/pleomorphic \>75% undiff Degree of atypia relates to risk of recurrence
36
List histologic variants of SCC
Acantholytic (adenoid ) SCC Adenosquamous SCC Spindle cell SCC Clear cell SCC Verrucous SCC KA
37
What immunohistochemical stains/antibodies are used to stain SCC
Cytokeratin Epithelial membrane antigen Use to identify source of tumor when poorly differentiated
38
WHat is ther ate of metastasis of SCC
2-5% to LNs within first few yrs of diagnosis * SCC on upper half of face drain to parotid LN * SCC on lips/perioral drain to submental/upper Ij LN * Cure rate for met SCC is 50% w surgery/Rtx, multimodal Tx * 5yr survival 35%
39
What factors of SCC are associated with more aggressive tumor
* Location (lip & ear high recurrence) * Size (\<1cm, 1% met rate,\>2cm, 10% metastatic rate) * Histopathologic Grade (poorly diff 30% recur) * Depth of invasion (ass. w recurrence, met, death, \>6mm) * Perineural invasion * Lymphovascular invasion * Recurrent SCC * Immunosuppresion (frequent mets/recurrence) * Marjolins ulcer (25% mets)
40
What is your DDX other than SCC for lesion that appears inflamed, ulcerated, nodule
* BCC * AK * KA * Irrittaed SK * Adnexal tumor * Atypical fibroxanthoma * merkel cell * pyoderma granulosum * pagets
41
What is the TNM stagin for SCC and BCC
Tumor Tx, T0, Tis T1 _\<_2cm with \<2high RFeatures T2 \>2cm or ANY tumor with \>2Rfeatures T3 Tumor w invasion to adjacent strucutres T4 invasion to skeleton axial/sleketal/perineural to skull base high risk Features: * Depth : \>2mm, clarke\>IV, perineural inv. * Anatomic location ; ear, hair bearing lip * Differentiation; poorly/undiff N NxN0 N1 single ipsi LN \>3cm N2a single ipsi LN 3-6cm N2b multiple LN \<6cm N2c bilat or contra lat LN \<6cm N3 any LN\>6cm M0 M1 distant mets Staging 0 = Tis 1 = T1 2 = T2 3 = T3, N1 with T1-3 4= Any T4, N2/3, M1
42
What are the management options for SCC
Surgical Excision * Margin 5-15mm * SCC \<2cm with 4mm margins, 95% will be cured. * SCC \<2cm with high risk features, do 6mm * SCC 3cm, do 1.5 cm * SLNBX indicated if clinically palpable nodes EDC * if \<2cm and well defined border RTx * for eldely, medically unfirt, lips/ear/nose * \<2cm lesion, 85-95% cure rate Medical tx * Imiquimod for SCC in situ ONLY
43
What is f/u for SCC
q3mth for 3yrs then q6mth

Skin and soft tissue (13 decks)

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