Pigmented, Precancerous and Cancerous Lesions Flashcards
(108 cards)
1
Q
Solar keratosis neoplastic condition in which precancerous epithelial lesions are found on sun-exposed areas of the body
A
Actinic Keratosis
1
Q
AKs are MC in who?
A
- lighter skin type
- older age - d/t lifetime sun exposure
- immunocomp - esp solid organ transplantation
2
Q
AKs are MC seen where on the body?
A
sun-exposed skin
- Face
- Scalp (balding or part)
- Neck
- Upper chest
- Forearms
- Dorsal hands
- Shins and feet
3
Q
These flat, scaly papules are of varying sizes and usually begin as “rough” localized skin lesions that the patient feels but are difficult to see
A
Actinic Keratosis
4
Q
AKs have a higher risk for developing what?
A
- non-melanoma skin cancer
- potential to evolve into SCC
5
Q
- Subtle, barely elevated to thicker, hypertrophic, rough papules with ill-defined borders on sun-damaged skin
- color variation from whites to yellows, pink and light, mid-brown, or uniformly brown; reddish-brown or gray-colored scale (rarely)
- underlying red base
- easily palpated than seen - “gritty,” “scaly”
dx?
w/u?
A
- AKs
- clinical; can refer to derm for bx
6
Q
When large in number, actinic keratoses may coalesce to form what?
A
plaque
7
Q
Whitish scaly flat papules or a confluent plaque on the lower lip are called?
A
actinic cheilitis
8
Q
Dermoscopy shows a white to yellow surface scale, erythema revealing a pseudo-network around hair follicles, linear-wavy vessels, follicle openings with yellowish keratotic plugs
what is this?
A
Actinic Keratosis
9
Q
how would a pigmented AK look like on dermoscopy?
A
similar to non-pigmented actinic keratosis with the addition of moth-eaten or sharp borders and gray dots / granules.
10
Q
MC AKs are pigmented, why?
A
due to the collision of a solar lentigo and actinic keratosis
11
Q
when would a bx be necessary for an AK vs invasive carcinoma?
A
recurrent, hyperkeratotic, large (>6 mm), indurated, and/or painful lesions to r/o invasive carcinoma
12
Q
general mgmt/protection against AK
A
- sun avoidance / sun-protective measures
- Sunscreen SPF +30
13
Q
Lesion-Targeted therapies options for AKs
A
- Cryosurgery - MC form of tx for AK
- Curettage & Electrosurgery
- Shave excision/biopsy
14
Q
Field therapies options for AKs
A
- 5- Fluorouracil (5-FU)
- imiquimod cream
- ingenol mebutate (Picato)
- diclofenac gel
15
Q
MOA of 5-Fluorouracil (5-FU)
A
Blocks DNA synthesis = apoptosis and selective cell death
16
Q
SE of 5-FU
A
- localized skin reaction - burning, pruritus, erythema, erosion, crusting, ulceration
- d/c once erythema, erosion, crusting and necrosis have occurred
17
Q
- immunomodulator - stimulates local cytokine induction
- used for non-hypertrophic AK- face OR scalp
- Avoid in immunocompromised individuals
what med?
A
Imiquimod
18
Q
SE & pt ed for imiquimod
A
- SE - localized skin reaction (as with 5-FU)
- Pt Ed - SE are associated with increased clearance rates; wash hands before and after application; wash tx area before application
19
Q
MOA of ingenol mebutate (Picato)
A
plant derivative - MOA - 2 step process
- disruption cell membrane and DNA –> necrosis
- neutrophil-mediated cytotoxicity that eliminates remaining tumor cells
20
Q
indication for ingenol mebutate?
A
AK only
21
Q
dosing of ingeol mebutate
A
- 0.015% gel - face/scalp - once daily x 3 days
- may repeat once after 8 wks if recurrence or full resolution isn’t achieved - 0.05% gel - trunk/extremities - once daily x 2 days
22
Q
SE & caution with ingenol mebutate
A
- SE: localized skin irritation - large erosions are possible
- Caution - risk of invasive SCC ????
23
Q
MOA of Diclofenac 3% gel
A
COX-2 inhibitor (inhibits prostaglandin synthesis)
Theory: production of prostaglandins contributes to non-melanoma skin CA
24
which AK tx uses cryotherapy over larger area?
Cryopeeling
25
whats Dermabrasion?
surgical scraping of the outermost layers of the skin
26
what are chemical peels?
use of acidic agent (5-10% trichloroacetic acid) to remove outer layer of skin
27
what is laser resurfacing?
use of laser to remove multiple AK’s
28
what is photodynamic therapy?
use of a photosensitizer and light source which induces cell death
29
disposition of AK
1. First visit- lesion targeted tx; extensive pt education
1. f/u 2-3 months - bx recurrent/persistent lesions; Lesion targeted tx for few new AK’s, f/u 6-12m
- Field therapy for numerous AK’s - Assess compliance and SE profile; f/u 3-6 m
30
malignancy of cutaneous epithelial cells occurring most frequently on sun-exposed areas of the skin, particularly the face and dorsal hands
SCC
31
which parts of the body carries a greater risk of metastases with SCC?
1. oral mucosa
1. lip
32
1. hard/firm papule/plaque/nodule with a thick adherent keratotic scale
1. +/- erosion, ulcerated, umbilicated
1. erythematous, yellow or skin colored
1. lesions found on sun-exposed areas - head, neck, dorsal hands, legs (women)
1. regional LAd with metastasis
SCC
33
RF for SCC
1. Chronic sun exposure
1. Fair skin and blue eyes
1. FHx skin cancer
1. Increased age
1. Scarring processes (chronic ulcers, burns, hidradenitis)
2. occupational trauma
3. chronic lymphedema
4. venous stasis
1. Ionizing radiation
1. Immunosuppression
1. HPV
1. **tattoos** (due to trauma)
34
In individuals with darker skin phototypes, SCC has been found to occur where?
1. scars
1. non-sun-exposed areas
35
MC skin cancer in african americans?
**SCC**
still 80x less likely to occur in dark skin < light skin
36
Confined to the epidermis and includes other specific clinical entities Bowen disease and erythroplasia of Queyrat (on the male genitalia)
Squamous cell carcinoma in situ (SCCIS)
37
what other findings are common with a pt with SCC?
other evidence of sun exposure (eg, solar elastosis, actinic keratoses, solar lentigines)
38
characteristics of SCC on dermoscopy?
1. Nonpigmented and pigmented lesions
1. red vessels as dots, scale / crust, and shiny white structures - crystalline structures
1. Vessels appearing more coiled or twisted-loop in appearance - Thickened stratum corneum
1. Orange / tan circular or ovoid structures with a white peripheral rim - keratin pearl
2. Pigmented SCCs - SCC features + brown/gray dots or brown circles, in a linear arrangement
39
Careful examination of _____ is essential when SCC is considered and especially after it is diagnosed
regional lymph nodes
40
w/u for SCC
* **H&P is the most effective**
* Bx
41
histopathology findings of SCC
1. Pleomorphic and hyperchromatic squamous cell with variable nuclear size
1. Loss of full-thickness epidermal maturation
1. Overlying parakeratosis
1. Keratinocyte mitoses
1. Dyskeratosis
1. Squamous pearls
1. Occasional features
1. Presence of an adjacent solar / actinic keratosis
42
tumor subtypes of SCC
1. Bowen disease (SCC in situ variant)
1. Acantholytic / adenoid / pseudoglandular
1. Well differentiated
1. Poorly differentiated
43
tx for SCC
Both **Mohs** (95%) micrographic surgery and **excision with narrow margins** (3-5 mm)
44
In high-risk SCC in which Mohs surgery is not performed, what margins are typically required?
6 mm
45
In cases of known or suspected nodal metastases, what mgmt is often indicated?
| SCC
sentinel or formal lymph node dissection
46
alt mgmt for superficial SCC not eligible for surgery?
* **electrodesiccation and curettage** 3x (3-4 mm margins)
* **Radiation**
* Topical imiquimod
* Topical or intralesional 5-fluorouracil
* Electrochemotherapy with intralesional bleomycin
* Intralesional interferon-alpha
* Photodynamic therapy
47
pt ed for SCC
1. watch for suspicious lesions - open sore, pink-reddish growth, irritated area, shiny papule/nodule, scar-like area
1. sunscreen +30 SPF, broad-spectrum, water resistant
1. wear protective clothing/hats when outdoors, seek shade
1. NO tanning beds
48
histology reveals craterioform, endophytic nodule with well differentiated keratinocytes
CENTRAL KERATIN PLUG
dx? mgmt?
* Keratoacanthoma (KA)
* Mohs vs excision
49
MC skin cancer?
BCC - a neoplasm of basal keratinocytes
50
MC places for BCC?
sun-exposed areas such as the head, neck, face and nose, upper chest, and back
51
types of BCC? which is MC?
**nodular**, infiltrating, _pigmented_ (MC in black hispanic, asian), superficial, micronodular, Sclerosing / morpheaform, Metaplastic / basosquamous
52
translucent “pearly” papule/nodule
well defined borders
smooth, firm surface with telangiectasias
+/- erosions, sporadic pigmentation
dx?
Nodular BCC (MC subtype)
53
translucent-pearly, smooth, firm, telangiectasias with a central ulcer
+/- elevated border (rodent ulcer)
dx?
Ulcerating BCC
54
plaque, scar like lesion
pink/white in color
telangiectasias
ill defined borders
dx?
Sclerosing BCC
55
thin plaque/patch
pink/red
+/- scaling
BCC dx?
Superficial multicentric BCC
56
firm papule/nodule
+/- umbilication
smooth pearly surface
generally pigmented or stippled globules of pigment
dx?
Pigmented BCC
57
RF for BCC
light skin phototype, sun exposure, radiation, advanced age, immunosuppression, and a personal history of non-melanoma skin cancer
58
Hereditary conditions associated with BCCs in general include ?
1. albinism
1. xeroderma pigmentosum
1. nevoid BCC syndrome
1. Rasmussen syndrome
1. Rombo syndrome
1. Darier disease
59
+1 BCC before age 30 may suggest what causes?
1. nevoid basal cell carcinoma syndrome
1. exposure to therapeutic ionizing irradiation
60
best w/u for any skin cancer?
skin bx
61
histopathology findings of BCC
1. Nests and cords of basaloid keratinocytes with peripheral palisading and a central haphazard arrangement
1. Tumor nests usually attach to the undersurface of the epidermis
1. Tumor cells have hyperchromatic nuclei and scant cytoplasm
1. Numerous mitotic figures, some atypical
1. Abundance of apoptotic neoplastic cells
1. Clefts between tumor nests and the surrounding stroma
1. Stroma is mucinous, loose and with increased vascularity
1. Keratin-derived amyloid is common in the stroma
1. Marked solar elastosis is present in the adjacent dermis
62
occasional features of BCC
1. Ulceration, especially in large lesions
1. Deep-dermal extension
1. Involvement of the subcutis, cartilage, and nerves
1. Variable inflammatory infiltrate
1. Calcification may be found in the center of cystic lobules
1. Metaplastic bone formation (ossification)
63
tx of choice for BCC
1. **mohs**
- Mohs micrographic surgery - recurrent, primary BCC on nasolabial fold
2. alt: radiation - used cautiously and with circumscription since BCCs have been induced after XR therapy for internal malignancy
64
characteristics of aggressive BCC
1. recurrent
2. >2 cm
3. on head/neck
65
alt mgmt for pts that cannot have surgery and radiation for BCC?
1. Vismodegib
1. Sonidegib
66
a hedgehog pathway inhibitor taken once a day in pill form
It is the first FDA-approved drug for metastatic BCC. Resistance to this agent has been reported
Vismodegib
67
another hedgehog pathway inhibitor taken once a day in pill form
It is FDA approved for treatment of locally advanced BCC in patients who are not candidates for surgery or radiation, or whose cancer has returned after such treatments
Sonidegib
68
a developmental defect in melanoblasts
a benign overgrowth of skin cells
congenital MN (CMN)
69
a benign overgrowth of skin cells
develops in early childhood
often regresses after age 60
acquired (MN)
70
lesion that is asymptomatic without change
symmetric
sharp borders
uniform color
is this benign?
yes - Common Melanocytic Nevi
71
indications for excision for Common Melanocytic Nevi
1. location - scalp, anogenital, mucosal lesions
1. rapid change
1. irregular borders
1. erosions
1. persistent itching, pain, bleeding
72
* a pigmented lesion resulting from proliferation of atypical melanocytes
* MC onset late childhood - middle adulthood
* precursor to superficial spreading melanoma (SSM)
Dysplastic Melanocytic Nevi (DN)
73
how does the numberof DN affect the risk of melanoma?
* one DN increases risk for melanoma by 2-fold
* ≥10 DN increases risk by 12-fold
74
characteristics of Dysplastic Melanocytic Nevi (DN)
1. asymptomatic
1. irregular shape
1. sharp and ill-defined borders
1. variegated color
1. maculopapular
75
mgmt for DN
1. Observation with dermoscopy (+/-) digital dermoscopy
1. Surgical excision with bx
- indications: changing lesions or those that can’t be closely observed
- **shave excision, laser, cryo-, electrotherapy all CI**
76
f/u and pt ed for DN
1. routine skin exam q 3-12m; 3m if FHx of DN or melanoma; 6-12m if sporadic DN
1. monthly self exams, sun protection, family should have regular skin exams
77
* aggressive malignancy of pigment-producing cells known as melanocytes
* can be seen on skin, mucous membranes, around the nail apparatus, and in the eye
Melanoma
78
subtypes of Melanoma? MC?
**superficial spreading melanoma (MC)**, _nodular melanoma (2nd MC)_, lentigo maligna melanoma, and acral lentiginous melanoma (least common)
79
what strong associations have been identified in melanoma? (2)
1. genetics
1. cumulative/prolonged exposure to UVA/UVB exposure in light skin types
80
melanoma MC in who?
how common is it?
* MC cancer in young women between 25-29
* 1 in 50 (2014) will be dx with invasive melanoma
* responsible for 80% of skin cancer deaths
81
theory of cause of melanoma?
ultraviolet radiation
82
RF for melanoma?
1. increasing age
1. Photo-skin type I-II
1. > 25 nevi
1. atypical nevi
1. immunosuppression
1. personal or family hx of melanoma
1. UV exposure - blistering sunburns before puberty; tanning beds increases risk by 75% - risk increases if use before 35 y/o
83
classifications of melanoma? which one is MC?
1. **De novo melanoma (70%)**: develop as a new pigmented papule, plaque or nodule
1. Precursor melanoma (30%): developing from precursor lesion (DN or CMN)
84
2 phases of melanoma growth
1. radial (thin melanoma) - remains in epidermis
1. vertical - extends to dermis/vessels leading to metastasis
85
The primary prognostic feature of melanoma is ?
what is this referred as?
1. **depth of invasion**
1. measured histologically in mm and referred to as the **Breslow thickness**
86
MC melanoma metastasis sites?
* skin / subcutaneous, lymph nodes, lungs, liver, and brain
* can still occur anywhere
87
An asymmetric macule with variegated pigmentation and notched or ragged borders
May occasionally be somewhat elevated
Usually seen on the trunk in men and the lower extremities in women
Superficial spreading melanoma (MC)
88
* A dark brown to bluish-black nodule that grows rapidly RAPID GROWTH
* This type of melanoma is most likely to ulcerate or bleed
* MC trunk, head, and neck (1-3 cm)
Nodular melanoma
89
* An asymmetric brown to black macule or patch with color variegation and irregular borders SLOW GROWING
* May have area(s) of dermal induration or nodularity
* 0.5 - 20 cm
* early well defined evolving to irregular geographic borders
* early tan, later variegated colors of brown/black
Lentigo maligna melanoma
90
Asymmetric brown to black macule with variegated pigmentation and irregular borders SLOW GROWING
Found on the palms, soles, or nail apparatus
Acral lentiginous melanoma
91
Individual pigmented lesions can be evaluated in the physical exam by applying the **ABCDEs** of melanoma and the "ugly duckling" rule:
* A – Asymmetry: One half of the lesion does not mirror the other half
* B – Border: The borders are irregular or indistinct
* C – Color: The color is variegated; the pigment is not uniform, and there may be varying shades and/or hue
* D – Diameter: Classically, any pigmented lesion greater than 5-6 mm in diameter is concerning, although melanomas may also be smaller
* E – Evolving: Notable change in a lesion over time raises suspicion for malignancy. Ulceration and bleeding should prompt biopsy
92
how to bx if pt has multiple pigmented lesions and are suspicious for melanoma?
look for and consider biopsy of any lesion that stands out from the rest of the patient's nevi or is unlike the others (the "**ugly duckling**" lesion)
93
what diagnostic aids may increase diagnostic accuracy and minimize unnecessary biopsies for melanoma?
1. serial photography
1. dermoscopy
94
3 ways to stage melanoma?
1. Clark
1. TNM
1. BRESLOW
95
Clark levels for melanoma?
* Level I: in situ (limited to within the epidermis)
* Level II: invades the papillary dermis
* Level III: fills the papillary dermis and reaches reticular dermis
* Level IV: invades the reticular dermis
* Level V: invades the subcutaneous fat
96
what is the American Joint Committee on Cancer (AJCC) primary tumor staging?
* Tumor
* Node
* metastatis
97
what measurement/thickness (Breslow) of melanoma would need a SLNB?
| Sentinel Lymph Node Biopsy
>0.76 MM Breslow
98
mgmt for melanoma
1. excision as initial tx
2. margins required depend on depth of invasion of the tumor
- In situ – 0.5 cm margins (larger in lentigo maligna form of melanoma in situ)
- < 1 mm – 1 cm margins
- 1-2 mm – 1-2 cm
- 2-4 mm – 2 cm
- >4 mm – 2 cm
99
f/u and pt ed for melanoma?
1. over the age of 18 - yearly skin exam
1. FHx = Increased risk
- BCC and SCC - q 6m
- Melanoma - q 3m
1. Pt ed: Never use tanning bed, always wear sunscreen, Perform self skin exams regularly
100
what is Mohs Micrographic Surgery
* Excision that evals tumor margins using inverted horizontal frozen sections w/ tumor mapping
* Indicated for BCC and SCC
* Benefits: spares greatest amount of healthy tissue while completely removing all cancer cells; cure rates >99%, lower recurrence rates < other tx options
101
elliptical removal of tissue sample with clear margins
excision
102
2 types of excisions, and what are their indications?
* simple excision (5 mm margins): well defined nodular BCC, low risk SCC in anatomical appropriate site
* wide local excision (2-5 cm margins): well differentiated SCC, well-defined large nodular-ulcerative BCCC
103
what is excisional bx?
* removal of tissue sample using excision surgical technique
* sent off for histopathology
* cure rates are inferior to Mohs
104
what are the 3 types of UV light?
* UVA - longest wavelength- passes through window glass
* UVB - most responsible for sunburns - unable to pass through glass
* UVC - absorbed by the ozone therefore doesn’t reach Earth
*All damage DNA and collagen which = skin CA and aging of skin*
105
what is SPF?
* a measure of protection against UVB
* the SPF is a ratio of the time it takes for sunscreened skin to burn compared to un-sunscreened skin
106
Only sunscreens labeled “broad spectrum” will protect against what UV lights?
wht ingredients are you looking for?
* **UVA** and **UVB**
* _mineral sunscreen is best_ - **zinc oxide**, titanium dioxide, octocrylene, octisalate, octinoxate
107
what active ingredient has only UVA protection?
avobenzone
