Cancers

Question 1

Melanoma?

Answer 1

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
Rising incidence rates observed worldwide

Question 2

Melanoma risk factors?

Answer 2

Genetic - FHx, red hair, light skin
Environment - sun exposure, sunbeds, immunosuppression
Phenotypic - >100 melanocytic nevi, atypical melanocytic mevi

Question 3

Melanoma subtypes?

Answer 3

Superficial spreading
Nodular
Lentigo maligna
Acral lentiginous

Question 4

Superficial spreading melanoma?

Answer 4

Most frequently on trunk of men, legs of women
In 2/3 - regression = hypo or depigmented area showing host immunity
Horizontal then vertical growth

Question 5

Nodular melanoma?

Answer 5

Usually blue to black, sometimes pink to red, nodule - may be ulcerated, bleeding
Develops rapidly
Only verticals growth

Question 6

Lentigo maligna melanoma

Answer 6

> 60, chronically sun-damaged skin, most common on face
Slow growing, asymmetric brown black machine with colour variation and an irregular indented border

Question 7

Acral Lentiginous melanoma?

Answer 7

Typically palms and soles OR around nail apparatus
Incidence similar across all racial and ethnic groups - disproportionate percentage in BAME

Question 8

Melanoma self-detection?

Answer 8

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

Question 9

Garbe’s rule?

Answer 9

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

Question 10

Melanoma poor prognostic factors?

Answer 10

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

Question 11

Breslow thickness?

Answer 11

Measurement from granular layer to bottom of tumour

Question 12

Dermoscopy?

Answer 12

Can improve correct diagnosis of melanoma by nearly 50%

Question 13

Melanoma management?

Answer 13

Primary excision down to subcutaneous fat - 2mm peripheral margin
Wide excision - 5mm for in situ, 10mm for </=1mm

Question 14

Sentinel lymphoma node biopsy?

Answer 14

Lymphatic drainage of finite regions of skin drain specifically to an initial node within a given nodal basin - the ‘sentinel node’
Currently offered for pT1b+

Question 15

LDH?

Answer 15

Major prognostic indicator in melanoma

Question 16

If melanoma unresectable or metastatic?

Answer 16

Immunotherapy or mutated oncogene targeted therapy

Question 17

Melanoma immunotherapy?

Answer 17

CTLA-4 inhibition
PD-L1 inhibitors

Question 18

Mutated oncogene targeted therapy for melanoma?

Answer 18

Combination of BRAF inhibitor and MEK inhibitor

Question 19

Keratinocyte dysplasia/carcinoma subtypes?

Answer 19

Actinic keratoses
Bowen’s disease
Squamous cell carcinoma
Basal cell carcinoma

Question 20

BCC pathogenesis

Answer 20

UV radiation
Has proteolytic activity
Loss of function in chromosome 8a, p53 mutations

Question 21

SCC pathogenesis?

Answer 21

UV radiation
p53 alteration
NOTCH1 or NOTCH2 plays role

Question 22

Actinic keratoses?

Answer 22

Atypical keratinocytes confined to epidermis
Develop on sundamaged skin
Macules or papules, red or pink, some scale

Question 23

Bowen’s disease?

Answer 23

SCC in situ
Erythematosus scaly patch or slightly elevated plaque

Question 24

Actinic keratoses and Bowen’s disease treatment?

Answer 24

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

Question 25

SCC may be?

Answer 25

Erythematous to skin Papule Plaque-like Exophytic Hyperkeratotic Ulceration

Question 26

SCC clinical features - high risk?

Answer 26

Localisation and size - trunk and limbs >2cm, head and neck >1cm Ill-defined margins Rapidly growing Immunosuppressed Previous radiotherapy or chronic inflammation

Question 27

Keratoacanthoma?

Answer 27

Rapidly enlarging papule that evolves into sharply circumscribed, crateriform nodule with keratotic core Resolves slowly over months Most on head or neck/sun exposed areas

Question 28

SCC treatment?

Answer 28

Excision Radiotherapy Cemiplimab for metastatic Secondary prevention - skin monitoring advice, sun protection

Question 29

BCC subtypes?

Answer 29

Nodular Superficial Morpheic Infiltrators Basisquamous Micronodular

Question 30

Nodular BCC?

Answer 30

Most common, typically presents as shiny, pearly papule or nodule

Question 31

Superficial BCC?

Answer 31

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

Question 32

Morpheic BCC?

Answer 32

Slightly elevated or depressed area of induration, usually light-pink to white in colour More aggressive behaviour

Question 33

Basisquamous BCC?

Answer 33

Histological features of both BCC + SCC

Question 34

Micronodular BCC?

Answer 34

Resembles nodular BCC More destructive - high rates of recurrence and sub clinical spread

Question 35

BCC treatment?

Answer 35

Surgical excision Mohs micrographic surgery Topical therapy, photodynamic therapy, radiotherapy, vismodegib *Breadloaf method*

Question 36

Merkel cell carcinoma?

Answer 36

Highly anaplastic cells which share features with neuroectodermally derived cells Solitary, rapidly growing nodule - pink-red to violaceous, firm, dome shaped Ulceration can occur *AGGRESSIVE, MALIGNANT BEHAVIOUR*

Question 37

Melanoma common mutations and pathway dysregulation?

Answer 37

Commonest mutation is BRAF, KIT and NRAS.  MAPK pathway is dysregulated in most melanomas

Question 38

Melanoma risk factors?

Answer 38

Intense intermittent sun exposure Immunosupression Family history 

Question 39

Melanoma thicker than 1mm investigation?

Answer 39

Sentinel lymphoma node biopsy

Question 40

Breslow's depth with stage?

Answer 40

I - 0.75mm or less II - 0.76-1.5mm III - 1.51-4mm IV - >4mm

Question 41

Non-metastatic vs metastatic melanoma treatment?

Answer 41

Non-metastatic - excision: primary or wide excision, depending on extension Metastatic - oncogene targeted therapy (kills cancer cells as stops them to grow and survive) or Immunotherapy (boosts immune response)