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Lecture 8: Pigmented, Precancerous lesions (Enochs) Flashcards

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1
Q

What is Actinic Keratosis?

A

Solar keratosis Neoplastic condition in which precancerous epithelial lesions are found on sun-exposed areas of the body.

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2
Q

What skin type is actinic keratosis MC in?

A

Lighter skin

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3
Q

Where is Actinic Keratosis MC?

A

Any sun exposed skin

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4
Q

What does actinic keratosis look like?

A
  • 2-6 mm plaques
  • Yellowish
  • Hypertrophic
  • Rough
  • Ill-defined border with some scale
  • Underlying red base
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5
Q

Who is MC for actinic keratosis?

A

Immunosuppressed

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6
Q

What cancer can actinic keratosis evolve into?

A

squamous cell carcinoma

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7
Q

What can help and/or resolve actinic keratosis?

A

Protection from UV light

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8
Q

How do you find actinic keratoses?

A

Palpation

“gritty”

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9
Q

How is actinic keratosis dx?

A

Clinically, but refer to derm if unsure.

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10
Q

What is the lower lip involvement version of actinic keratosis called?

A

Actinic cheilitis

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11
Q

If you choose to do dermoscopy, what will show up for actinic keratosis?

A
  • White to yellow surface scale
  • Erythema with pseudo-network around hair follicles
  • linear-wavy vessels
  • follicle openings with yellowish keratotic plugs

Classic gritty feel

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12
Q

What causes actinic keratosis to be pigmented?

A

Collision of solar lentigo and actinic keratosis

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13
Q

When would a biopsy be indicated for actinic keratosis?

A
  • Recurrent, hyperkeratotic
  • Large > 6mm
  • Indurated
  • Painful

R/u invasive carcinoma

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14
Q

What is the MC type of tx for actinic keratosis that is lesion-targeted?

A

Cryosurgery

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15
Q

What meds can treat actinic keratosis?

A
  • 5-FU
  • Imiquimod cream
  • Ingenol mebutate
  • Diclofenac gel
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16
Q

What is the MOA of 5-FU?

A

Blocks DNA synthesis and leading to selective cell death.

you say “FU!” and then you block them and they die of embarassment

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17
Q

How often is 5-FU dosed?

A

BID to affected area for x 2-4w

QD for micronized to face/scalp

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18
Q

What is the main pt education for using 5-FU for actinic keratosis?

A

Success is parallel to pt compliance.

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19
Q

MOA of imiquimod

A

Immunomodulator that stimulates local cytokine induction.

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20
Q

When is imiquimod used?

A

ImmunoCOMPETENT people with non-hypertrophic AK on their face or scalp

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21
Q

How is imiquimod given?

A

Cream nightly, wash after 8 hrs. 2x/wk for 16 wks.

Start at 5%

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22
Q

Main SE of both 5-FU and imiquimod?

A

Local skin rxn

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23
Q

Main pt education for imiquimod

A
  • SE = getting better
  • Wash hands before and after
  • Wash area before
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24
Q

What is the MOA of ingenol mebutate (Picato)?

A
  1. Disruption of the cell membrane and DNA => necrosis
  2. Neutrophil-mediated cytotoxicity that eliminates remaining tumor cells

PLANT DERIVATIVE

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25
When is ingenol mebutate (Picato) used?
Actinic Keratosis
26
How is ingenol mebutate (Picato) administered?
* 0.015% gel for the face/scalp. * 0.05% gel for trunk/extremities | Cover affected area for 3d for face, 2d for trunk.
27
What is the risk of ingenol mebutate (Picato)?
Invasive SCC
28
What is the MOA of diclofenac 3% gel?
COX-2 inhibitor | PGE production makes non-melanoma skin CA ## Footnote Dic(k) = cox
29
How long do you apply diclofenac 3% gel?
BID for **60-90 days**
30
Why might diclofenac 3% gel be preferred over other agents for Actinic Keratosis?
Mild skin reaction compared to others.
31
What are the 5 procedural field therapies for actinic keratosis?
* Cryopeeling * Dermabrasion * Chemical Peels * Laser Resurfacing * Photodynamic therapy
32
A patient is being seen for their **first derm visit** regarding a **few** suspicious actinic keratosis. What is the first-line tx?
**Lesion targeted therapy** * Cryosurgery * Curettage * Shave excision * Patient education on sunscreen * **3 mo f/u**
33
What would be the first two drugs you would choose for a 2nd visit of multiple AKs?
* 5-FU * Imiquimod
34
A patient **compliant with topical field therapy and having multiple AKs** does not like 5-FU or imiquimod. What can you give them?
Diclofenac gel
35
What is Squamous Cell Carcinoma?
**Malignant** cutaneous epithelial cells, MC on **sun-exposed** areas. | AK often is a precursor.
36
What area, if found, is SCC highest risk for metastasis?
Oral mucosa and lip
37
How does differentiated SCC present?
* **Hard/firm** papule/plaque/nodule * Thick, adherent keratotic scale * Erythematous, yellow, or skin colored. * **Found on sun-exposed areas** * Can cause regional LAN with metastasis
38
What does undifferentiated SCC look like?
* **Soft, fleshy**, erosive papule/nodule * Papillomatous, like a cauliflower. * Bleeds easily * **Found on less on sun-exposed areas (genitalia, trunk, LE, face)**
39
Top RFs for SCC
* Chronic sun exposure * **Fair skin, blue eyes** * FHx * Old * Scarring * HPV * **Tattoos if traumatic**
40
What is the MC skin cancer in AA?
SCC | Even though it is 80x less likely to occur in dark skin.
41
Why do dark skin ppl rarely get dxd with SCC?
* Doesn't occur often in darker skinned * Occurs in scars and non-sun-exposed areas for darker skin, so its not caught.
42
What is SCC in situ?
Confined to epidermis | Includes Bowen dz and erythroplasia or Queyrat (on testes)
43
Who is SCC in situ more frequent and aggressive in?
Immunosuppressed
44
What will you often see on the skin of patients with SCC? (besides SCC)
* Solar elastosis * AKs * Solar lentigines
45
Most important predisposing factors/locations for SCC
* Old burn scar * Chronic cutaneous ulcers * Inflammation * Irradiation * Chronic lymphedema * Venous stasis
46
What is the classic presentation of SCC on dermoscopy?
Red vessels as dots, scale/crust, and shiny white structures (**Crystalline Structures** ## Footnote SCC - "shiny crusty crystals"
47
What does pigmented SCC look like?
Red vessels + Shiny white structures + brown/gray dots in a linear arrangment.
48
Besides looking at the actual lesion in SCC, what else is essential to examine?
Regional lymph nodes
49
What is the most effective means of detecting SCC?
A thorough H&P
50
What is the characteristic histopathology of SCC biopsy?
* Pleomorphic/hyperchromatic squamous cells with variable nuclear size * Loss of full-thickness epidermal maturation * Overlying parakeratosis * Dyskeratosis * Squamous peals * Adjacent solar/actinic keratosis
51
What are the subtypes of SCC?
* Bowen dz (SCCIS variant) * Acantholytic/adenoid/pseudoglandular * Well differentiated * Poorly differentiated
52
TOC for SCC
Excision with **narrow margins (3-5 mm)** | Does not apply to oral mucosa, head and neck, or immunocomped pts? ## Footnote Wider margins are needed if its well-differentiated
53
In high-risk SCC, what is the main TOC?
Excision with **6 mm** margins if Mohs cannot be done.
54
If we suspect/know SCC with nodal metastases, what secondary procedure is indicated beside excision?
Lymph node dissection.
55
For **superficial SCCs**, whats a less invasive procedure/non surgical option?
Electrodessication and curettage x 3 with margins of 3-4 mm
56
For non-surgical candidates with SCC, what can we do? (2nd/3rd line)
* Topical imiquimod * Topical/intralesional 5-FU * Electrochemo * Interferon * Photodynamic therapy
57
Pt Ed for SCC
* Check any sus lesions (open sore, pink-reddish growth, irritated or shiny) * 30 SPF minimum * Seek shade outdoors * **NO TO TANNING BEDS**
58
What characterizes a keratoacanthoma?
* A variant of SCC that **grows rapidly** * Solitary or multiple * Involutes over time
59
Histology of keratoacanthoma
* Craterioform * Endophytic nodule * Well differentiated keratinocytes * **CENTRAL KERATIN PLUG**
60
Tx for keratoacanthoma
Mohs or Excision
61
MC skin cancer
Basal cell carcinoma
62
MC subtype of basal cell carcinoma?
Nodular variant
63
What 3 ethnicities have pigmented BCC as the most common variant?
* African * Hispanic * Asians
64
What are the 4 types of BCC?
* Nodular (MC overall) * Infiltrating * Pigmented (MC in african/hispanic/asian) * Superficial
65
What happens if BCC is not treated?
Local destruction | rarely metastasizes
66
Describe nodular BCC
* Translucent **pearly** papule/nodule * **well defined borders** * Smooth, firm surface with telangiectasias. * +/- erosions, sporadic pigmentation
67
Describe ulcerating BCC
* Translucent and pearly * Smooth and firm * **CENTRAL ULCER** * +/- elevated borders = rodent border
68
Describe sclerosing BCC
* Plaque, scar like lesion * Pink/white * Telangiectasias * **ill defined borders**
69
Describe superficial multicentric BCC
* Thin plaque/patch * Pink/red * +/- scaling
70
Describe pigmented BCC
* Firm papule/nodule * +/- umbilication * Smooth pearly surface * Pigmented/stippled globules of pigment
71
Hereditary conditions associated with BCC
* Albinism * Xeroderma pigmentosum * Nevoid BCC syndrome * Rasmussen syndrome * Rombo syndrome * Darier dz
72
Prognosis for BCC
If properly identified and treated, very good! Make sure to keep f/u since 2nd BCC is common.
73
If 2 or more BCC appears in a patient **younger than 30**, what underlying condition may they have?
Nevoid BCC syndrome | Or exposure to ionizing radiation ## Footnote BCCs will often be bigger
74
Best test for BCC dx
Skin biopsy with shave/punch | Biopsy Basal, See Squamous
75
Pt ed for BCC
General sun protection
76
What is the tx for BCC?
* Electrodessication and curettage (ED&C) * Excision * Cryosurgery * Radiation * Mohs * Oral smoothened inhibitors (suppresses hedgehog pathway) | Individualized per pt
77
Mohs criteria for BCC
* Recurrent * Aggressive subtype * > 2 cm * Head/neck location
78
Best tx for BCCs that are recurrent, primary BCCs in the nasolabial folds, or morpheoform histopathology?
Mohs
79
What are the pharm options for non-surgical BCC or metastatic BCC patients?
Vismodegib (metastatic BCC) or Sonidegib (locally advanced BCC) | (**hedgehog pathway inhibitors**) ## Footnote Sonic is a Very fast Hedgehog
80
What is a common melanocytic nevi?
Benign overgrowth of skin cells
81
What are the two types of common melanocytic nevi and what is the more sus one?
* Congenital MN (CMN) is a developmental defect in melanoblasts. Big ones = **increased risk for melanoma** * Acquired (MN) = develops in early childhood **but regresses after 60**
82
What are the clinical features of a common melanocytic nevi? (4)
* Asymptomatic without change * Symmetric * Sharp borders * Uniform color
83
How do you dx a common acquired nevomelanocytic nevi?
Dermoscopy
84
Indications for excision of **unconfirmed** common acquired nevomelanocytic nevi? (5) | Confirmed = no tx
* Located on scalp, anogenital, mucosa * Rapid change * Irregular borders * Erosions * Persistent itching/pain/bleeding
85
What is dysplastic melanocytic nevi? (DN)
Pigmented lesion resulting from proliferation of **Atypical melanocytes**
86
When does dysplastic melanocytic nevi (DN) occur?
Late onset childhood to middle adulthood
87
Why is dysplastic melanocytic nevi scary? (DN)
Precursor to superficial spreading melanoma | Increases risk for melanoma
88
Clinical features of dysplastic melanocytic nevi (DN) (5)
* Asymptomatic * Irregular shape * Sharp and ill-defined borders * Variegated color * Maculopapular
89
Dx of dysplastic melanocytic nevi (DN)
Clinical | If confirmation needed, via histopatho
90
Tx of dysplastic melanocytic nevi (DN)
* Obs with dermoscopy * Excision with biopsy if necessary to r/o melanoma | Indications: changing or can't closely observe. ## Footnote Shave, laser, cryo, and electro are all contraindicated.
91
How do you f/u or monitor dysplastic melanocytic nevi? (DN)
* Routine skin exams **every 3 months if FHx of DN or melanoma** * Otherwise 6-12 months. | Tell family members to check too
92
Table of MN vs DN
* MN = several or many * MN = symmetrical * MN = smaller, around < 5 mm * MN = stops in adolescence
93
4 subtypes of melanoma
1. Superficial Spreading Melanoma (SSM) **MC** 2. Nodular Melanoma 3. Lentigo maligna melanoma 4. Acral lentiginous melanoma (LEAST COMMON)
94
Top 2 RFs for Melanoma
* Genetics * Exposure to UVA/UVB with light skin
95
MC cancer in young women 25-29
Melanoma
96
Most deadly skin cancer
Melanoma | 80% of skin cancer deaths
97
How many nevi is a RF for melanoma?
more than 25
98
What are the two clinical classifications of melanoma development?
* De novo melanoma = brand new (**MC 70%**) * Precursor melanoma = developed from DN or CMN
99
What do radial/thin and vertical melanoma mean?
* Radial/thin = epidermis only * Vertical = extending down leading to metastasis
100
What is the primary prognostic feature of melanoma?
Depth of invasion, measured as the **Breslow thickness** | measured in mm
101
Who dies more from melanoma: men or women?
Men
102
MC melanoma metastases sites
* Skin/SC * Lymph nodes * Lungs * Liver * Brain | It can go anywhere tho
103
Common features of melanoma
* Asymmetry * Border irregularity * Color change/variegation * Diameter > 6 mm * Evolution | Ulceration/bleeding = late signs
104
What is a lightly pigmented melanoma called?
Amelanotic
105
Where is SSM MC in men and women?
* Men: trunk * Women: LE | Men go shirtless and women wear shorts
106
Which two melanoma subtypes are slow growing?
* Lentigo maligna * Acral lentiginous
107
Which melanoma subtype is most likely to ulcerate/bleed?
Nodular melanoma | 2nd MC after SSM
108
What is an ugly duckling lesion?
The weirdest looking pigmented lesion out of many
109
Best test for melanoma
Excision biopsy (shave/punch)
110
What are the 5 levels of Clark staging for melanoma?
1. in situ 2. Invade papillary dermis 3. Invade papillary dermis and reaches reticular dermis 4. Invade reticular dermis 5. Invade SQ fat | I,P,Pr, R, S
111
What are the 3 ways to stage melanoma?
* Clark * TNM * Breslow
112
When do you need a sentinel lymph node biopsy for Melanoma per breslow thickness?
**> 0.76 mm on breslow**
113
TOC for melanoma
Surgical excision
114
What are the guidelines regarding margins for melanoma excision?
* in situ = 0.5 cm (large for lentigo maligna) * Less than 1 mm = 1 cm margins * 1-2 mm = 1-2 cm margins * 2-4 mm = 2 cm margins * 4 mm = 2 cm magins | Melanoma uses LARGE margins
115
How often should someone with a FHx of BCC or SCC get a skin exam? Melanoma?
* BCC/SCC = Q6months * Melanoma = Q3months
116
In general, what cancers can Mohs be done for?
BCC and SCC | Not for melanoma! ## Footnote High cure rate, low recurrence, minimal tissue loss
117
Indications for simple excision with 5 mm margins
1. Well-defined nodular BCC 2. Low risk SCC in anatomical appropriate site
118
When is wide local excision with 2-5 **cm** margins indicated?
1. Well-differentiated SCC 2. Well-defined large nodular-ulcerative BCC
119
CIs to suturing after punch biopsy
* Active infection * Poorly healing skin
120
What do you stabilize skin perpendicular to in punch biopsies?
Langer lines
121
Longest wavelength UV
UVA
122
What kind of sunscreen do you need?
Broad spectrum (ZINC OXIDE) | Covers UVA and UVB

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