Cutaneous Neoplasms

Question 1

WHat are the relevant epithelial (epidermal) tumors?

Answer 1

• Seborrheic keratoses
• actinic keratosis
• squamous cell carcinoma
• keratoacanthoma
• basal cell carcinoma

Question 2

What is seborrheic keratosis/what does it look like? who gets it? where is it most common?

Answer 2

• very common cutaneous neoplasm
• common in middle age or older patients
• brown or tan waxy papules and plaques with a “stuck on” or warty appearance
• most common on face, trunk, and upper extremeties
• Leser-Trelat sign

Question 3

What is the Leser-Trelat sign?

Answer 3

sudden onset of multiple seborrheic kertoses associated with internal malignancy (usually stomach cancer)

Question 4

what is visible on this histology slide?

Answer 4

seborrheic keratoses

Question 5

What is actinic keratoses? what is it also known as? what is it a result of?

who gets it? what d they look like?

Answer 5

• aka solar keratosis
• common lesiosn that develop as a result of chronic sundamage
• predilection for sun-exposed areas
• middle-age to elderly
• red tan-brown macules with “gritty” sandpaper like scale
• may regress or remain stable
• .1-10% become malignant

Question 6

what is seen on this histology slide?

Answer 6

Actinic Keratosis

retention of nuclei in the corneum and loss of granular layer. lower 1/3 of epidermis is very irregular.

Question 7

who gets squamous cell carinoma and what are predisposing factors?

Answer 7

• common neoplas in older individulas, 20% of all skin cancers
• UV radiation is most common cause (DNA damage)
• also chronic ulcers, old burn scars, HPV, radiation, arsenic, immunosuppression

Question 8

How does SCC in situ present? How does Invasice SCC present?

WHat is the risk of metastasis of insitu?

Answer 8

• SCC in situ presents as red scaly plaque
• Invasive SCC lesions are nodular and may ulcerate
• 5% of insitu become invasive, and risk of metastasis is 2-4%, but even higher if immunosuppressed
• likelihood of metastasis is related to location and degree of invasion

Question 9

What is this?

Answer 9

SCC in situ

full thikness (thicker) basal layer to top and you lose the granular layer

Question 10

what is this?

Answer 10

Invasive SCC

no longer is contained to the epidermis it is almost down to the fat in this image

Question 11

What is a Keratoacanthoma? How does it grow? what causes it?

Answer 11

• variant of squamous cell carcinoma with pink papule or nodule with a central keratin plug
• grows rapidly over 2-10 weeks
• usually occurs due to sun damage and may resolve spontaneously, but treatment is usually advocated bc can cause extensive local destruction
• in immunosuppresed patients, mulitple lesions may be present

Question 12

What is shown on this histology slide?

Answer 12

Keratoacanthoma

Question 13

WHat is the most comon human cancer?

Answer 13

Basal Cell Carcinoma

Question 14

What causes basal cell carcinoma? How does it grow? What is it associated with?

Answer 14

• secondary to chronic sun exposure/UV radiation
• can be locally destructive, and is slow growing/rarely metastasizes
• When it metastasizes, patient is often immunocompromised
• associated with dysregulation of sonic hedgehog or PTCH pathway (30-40%)

Question 15

What do basal cell carcinomas look like?

Answer 15

pink, pearly papules with prominent arborizing subepidermal blood vessels (telangiectasia). Ulceration and erosion are common

Question 16

What doe sit mean to say that a basal cell carcinoma has retracted?

Answer 16

it broke away from surrounding stroma

Question 17

What are the common melanocyti tumors?

Answer 17

• melanocytic nevi
• acquired melanocytic nevus
• congenital melanocytic nevus
• dysplastic nevi
• melanoma

Question 18

Where are melanocytes usually seen and what do they increase with? WHat are the 3 classifications melanocytic nevi can be histologically?

Answer 18

• melanocytes are normally seen in epidermis, and increase with sun exposure (acquired nevi), also present aat birth (congenital nevi)
• histologically melanocytic nevi can be:
  
  • junctional (dermal epidermal junction)
  • compound (epidermis and dermis)
  • intradermal (in dermis only)

Question 19

What do acquired melaocytic nevi usually look like?

Answer 19

• pink, tan or brown uniformly pigmented papules and macules
• small (usually < .5cm) well-defined, smooth borders

Question 20

what classification is this melanocytic nevi?

Answer 20

Junctional nevus: just in the epidermis, not in the dermis

Question 21

What classification is this acquired melanocytic nevus?

Answer 21

intradermal

Question 22

what classification is this nevus?

Answer 22

compound (epidermis and dermis)

Question 23

What does this lil babe have?

Answer 23

A very large congenital melanocytic nevus

Question 24

What are displastic nevi?

Answer 24

• clinically and histologically distinctive
• dysplastic nevi may occur sporadically or in a familial form
• ppl with mulitpile dysplastic nevi have increased risk of melanoma
• clinically, larger than acquired nevi (>.5cm), irregular in shpe and uneven color

Question 25

What is dysplastic nevus syndrome? What do they have an increased incidence of?

Answer 25

* familial or sporadic * large # of dysplastic nevi (80) or more * increased incidence of melanoma * familial variant is inherited as autosomal dominant (mutations CDKN2A gene 9p21-21 in 40% of cases) * patients can develop other malignancies (pancreatic carcinoma)

Question 26

Compare and contrast sporadic dysplastic nevi syndorme and familial dysplastic nevi syndrome

Answer 26

* sporadic * lower number of dysplasti nevi (usually 2-10) * lifetime risk of melanoma in the sporadic form is approximately 10% * Familial * hundreds of dysplastic nevi * lifetime risk of melanoma approaches 100% \*\*\*\*note, they have identical histological features\*\*\*\*

Question 27

What do dysplastic nevi often resemble

Answer 27

melanoma

Question 28

Dysplastic nevi may be ______ or \_\_\_\_\_\_

Answer 28

junctional or compound

Question 29

What are the histological features of Dysplastic nevi?

Answer 29

* lentiginous hyperplasia * irregular nests * briding of rete ridges * cytologic atyia * lamellar fibroplasia of capillary dermis * inflammatory response

Question 30

Who typically gets melanoma and where on the body is it most common?

Answer 30

more common in white population, affects men and women equally, typically a disease of adulthood and most common eon back in men and on legs in women

Question 31

What are the risk factos for melanoma?

Answer 31

* Multifactorial disease * UVexposure at early age (more important risk factor) * fair complexion and older age * dysplastic nevus syndrome * history of melanoma in the family * tanning bed use * xeroderma pigmentosum

Question 32

What are the clinical features of melanoma?

Answer 32

ABCDEs ## Footnote A=Assymetry B= Borders (notched, uneven or blurred) C= Color (uneven; shades of brown, tan, red, and black may be present. 3 or more colos) D= diameter (\>6mm) E=eveolving-change in color andn size of the lesion

Question 33

Why is it important to recognize melanoma ealy? and what ae the 2 growth phases?

Answer 33

* early/superficial melanomas are cured surgically * Radial growth phase: melanocytes will proliferate within the epidermis (in situ) NO metastatic potential * Vertical growth phase: dermal invasion and potential for metastasis * \*\*\*\*extent of vertical growth phase determines the biologic behavior of melanomas\*\*\*\*

Question 34

What is the most important prognostic indicator for melanoma?

Answer 34

depth of invasion (Breslow thickness) when \<1mm rarley metastasize when \>1.7mm have greater otential to metastasize

Question 35

How do we measure invasion?

Answer 35

Clark level I Intraepidermal II in papillary dermis III Fills papillary dermis IV Reticular dermis IV Enters fat

Question 36

Besides level of invsion (clarks level) what are some indicators of metastatic potential for melanoma?

Answer 36

ulceration, mitotic rate, angioinvasion

Question 37

What are the 4 type of melanoma?

Answer 37

* Supreficial spreading type * most common type (70%) located on trunk (men) legs (women) * Nodular type * NO radial growth phase, high vertical growth phase poor prognosis. men\>women * Lentigo maligna type * most commonly located on the head and neck (sun exposed areas) * Acral lentiginous type * located on palm, sole, or beneath nail * most common type in African Americans (and other non-whites)

Question 38

What kind of melanoa is this?

Answer 38

Lentigo type

Question 39

What kind of melanoma is this?

Answer 39

Supeficial spreading type

Question 40

What kind of melanoma is this?

Answer 40

Nodular type

Question 41

What kind of melanoma is this?

Answer 41

Acral lentiginous type

Question 42

What are the cutaneous lymphomas?

Answer 42

Mycosis fungoides Sezary syndrome

Question 43

How does mycosis fungoides present? What are the 3 stages? When does it usually occur?

Answer 43

* most common cutaneous lymphoma * occurs in late adulthood with male predominance * usually presents as red or pink scaly patches * stages of patch, plaque and nodules * usually hronic course although may become aggressive

Question 44

What is Sezary syndrome? how does it present and what is the prognosis?

Answer 44

* blood involvement of T cell lymphoma * erythrodermaskin is diffusely red and scaly * poor prognosis * survival 1-3 years

Question 45

What do you see histologically for mycosis fungoides?

Answer 45

infiltration of the epidermis and upper dermis b¥ neoplastic ˇ cells, which have often have a ceribriform nucleus characterized by marked infolding of the nuclear membrane \*\*cerebriform lymphocytes \*\*invasion of blood vessels

Question 46

besides CDKNA2 9p21 mutation what activatin gmutations are associated with melanoma?

Answer 46

NRAS and **BRAF**

Question 47

what 2 new drugs arebeing used for melanoma and what do they target?

Answer 47

**vemurafenib-inhibit mutant BRAF** trametinib- influence the MEK pathway