Dermatological Malignancies

Question 1

Risk factors for skin cancer (8)

Answer 1

Sun exposure
FHx
Fair skin
Actinic keratosis & Bowen's disease
radio/phototherapy
smoking
immunosuppression
long-standing leg ulcers
(other diseases e.g. atypical mole syndrome, Gorlin's syndrome)

Question 2

Features of actinic keratosis; premalignant condition (5)

Answer 2

crumbly yellow-white scales 
can be brown or skin coloured
MAY HAVE CUTANEOUS HORN
commonly found on scalp/forehead
occurs in sun-exposed skin due to dyplastic intra-epidermal proliferation of atypical keratinocytes

Question 3

Topical therapy for actinic keratosis

Answer 3

5-FU
diclofenac gel
imiquimod-induces IFN-alpha

Question 4

Destructive therapy for actinic keratosis (3)

Answer 4

cryotherapy-may cause blistering which can be burst
chemical peeling
Photodynamic therapy-topical sensitiser applied and light shone. reduces risk of progression to SCC.

Question 5

Features of solar lentigo/liver spots (4)

Answer 5

brown patches/macules
flat, irregular, variable pigment
due to collection of melanocytes (freckles due to excess melanin)
typically affects caucasians >40yrs with sun-damaged skin.

Question 6

Management options for solar lentigo (2)

Answer 6

excision is ideal

radiotherapy is an option

Question 7

In Situ Disease-Bowen’s disease (SCC in situ) features (3)

Answer 7

Well-circumscribed, scaly, erythematous plaque
solitary
symptomatic

Question 8

Histological features of Bowen’s disease (2)

Answer 8

full thickness dysplasia

carcinoma in situ (hasn’t invaded BM)

Question 9

DDx of Bowen’s disease (2)

Answer 9

eczema

psoriasis

Question 10

Management of Bowen’s disease (2)

Answer 10

cryotherapy

5-FU

Question 11

In situ disease-lentigo maligna: features (2)

Answer 11

melanoma in situ

precursor to invasive lentigo maligna melanoma

Question 12

Presentation of lentigo maligna (2)

Answer 12

macular

often on FACE of elderly people

Question 13

Management of lentigo maligna (2)

Answer 13

excision is 1st line

if not possible then topical imiquimod or cryotherapy

Question 14

Features of lentigo maligna melanoma (4)

Answer 14

invasive malignant melanoma
arises from lentigo maligna
darker nodule +/- ulceration
lentigo>lentigo maligna>lentigo maligna melanoma

Question 15

Subtypes of BCC (rodent ulcer) (4)

Answer 15

nodular
superficial
morpheic/infiltrative
pigmented

Question 16

Presentation of BCC (4)

Answer 16

Pearly nodule
Rolled telangiectasic border
usually on face
usually smooth and clean but may become ulcerated

Question 17

Management of BCC (4)

Answer 17

Excision=cure; no further Rx needed
Mohs surgery-layers of skin removed and examined under microscope until normal skin remains
Radiotherapy-for large lesions, avoided in <65 since increased risk of further skin ca.
imiquimod/5-FU for superficial lesion/surgery inappropriate
(mets rare)

Question 18

Presentation of SCC (4)

Answer 18

Ulcerated, keratotic, firm, irregular lesion
grows rapidly
often sun-exposed area
may be painful

Question 19

RFs for SCC (4)

Answer 19

transplant/immunosuppression
smoking-lower lip
chronic inflammation e.g. venous ulcer
HPV

Question 20

Management of SCC (3)

Answer 20

SURGERY=GOLD STANDARD
radiotherapy is an alternative
topical imiquimod for superficial lesions
(mets rare but more common in certain areas e.g. ears)

Question 21

Genetic mutation seen in 66% of melanomas

Answer 21

B-RAF mutation

Question 22

Presentation of melanomas (6)

Answer 22

most arise from normal skin (few from dysplastic nevi)
nodular
scalloped border
grow rapidly
may ulcerate
skin markings lost
(EXCISE ALL NEW BLACK, IRREGULAR LESIONS)

Question 23

DDx for melanomas (2)

Answer 23

benign melanocytic lesion

non-melanocytic pigmented lesion e.g. seborrheic keratosis

Question 24

surgical management of melanomas

Answer 24

All lesions need narrow excision to assess BRESLOW THICKNESS
if <1mm: wide local excision
if >1mm: wide local excision(2cm margin)+sentinel node biopsy (if LN+ve then stage 3)

Question 25

Immunological agents for melanomas

Answer 25

match immunological agents to molecular analysis
ipilimumab: anti CTLA-4
vemurafenib: anti-BRAF
PD-1/PDL-1

Question 26

Prognostic indicators in melanomas (4)

Answer 26

Breslow thickness
ulceration
sentinel node involvement
mitotic index