Premalignant/Malignant Lesions

Question 1

ACTINIC KERATOSIS

Answer 1

• common, persistent keratotic lesions
• pre malignant (SCC)
• usually asymptomatic, but may be tender if rubbed or while shaving

Question 2

ACTINIC KERATOSIS

Predisposing factors

Answer 2

• 50 yo+ (but can also occur younger!)

- chronically sun exposed areas (face, ears, balding scalp, dorsal hands, forearms)

Question 3

ACTINIC KERATOSIS

Clinical appearance

Answer 3

• multiple, discrete
• flat or elevated
• red, pigmented or skin colored
• may have adherent scale (palpation feels like rough sandpaper)
• most < 6mm

Question 4

ACTINIC KERATOSIS

Tx

Answer 4

• sun protection: sunscreen, hat, clothing
• topical therapy: cryotherapy, 5-fluorouracil, imiquimod, laser resurfacing, chemical peels
• warn of downtime for all treatments

Question 5

BASAL CELL CARCINOMA

Answer 5

• most common form of skin CA
• related to sun exposure (cumulative)
• most common on scalp, face, ears, neck
• rare on dorsal hands
• slow growing

Question 6

BASAL CELL CARCINOMA

Risk factors

Answer 6

• intermittent intense sun exposure (prior sunburns)
• radiation therapy
• family hx of BCC
• immunosuppression
• fair, esp w/ red hair
• Fitzpatrick type I or II (easy sunburning)
• blistering sunburns as a child

Question 7

BASAL CELL CARCINOMA

Variations

Answer 7

• nodular
• superficial
• pigmented
• micronodular
• morpheaform

Question 8

BASAL CELL CARCINOMA

Nodular BCC Characteristics

Answer 8

• pink, pearly, telangiectatic papule
• rolled border
• central depression that may have ulceration and crusting
• 50-80% BCC

Question 9

BASAL CELL CARCINOMA

Superficial BCC Characteristics

Answer 9

• MC on trunk
• scaly
• dry patch that doesn’t heal

Question 10

BASAL CELL CARCINOMA

General Characteristics

Answer 10

• persist, enlarging gradually
• can invade and destroy surrounding tissues
• rarely metastasize but can directly spread
• asymptomatic - bleed w/o pain

Question 11

BASAL CELL CARCINOMA

Tx

Answer 11

• biopsy
• goal: permanent cure w/ best cosmetic result
• determined by variant, size, location
• electrodessication, curetage
• elliptical excision
• Moh’s surgery
• topical chemotherapy
• F/U every 6 months then yearly

Question 12

SQUAMOUS CELL CARCINOMA

Answer 12

• second most common form of skin CA
• frequently develop on site of AK
• face, scalp, neck, dorsal hands

Question 13

SQUAMOUS CELL CARCINOMA

Risk factors

Answer 13

• fair complexion
• chronic, long term sun exposure (eg farmers)
• biologics and other immunosuppressives, HPV, chronic ulcer, HS, hx of radiation, PUVA, DLE, erosive lichen planus

Question 14

SQUAMOUS CELL CARCINOMA

Characteristics

Answer 14

• begins w/ sun damage changes (AK, actinic cheilitis)
• red base w/ hyperkeratotic white adherent scale
• becomes raised, larger
• over time, becomes nodular and ulcerated
• faster growing, can be invasive and metastasize

Question 15

SQUAMOUS CELL CARCINOMA

Course/Outlook

Answer 15

• have a low threshold for biopsy: degree of differentiation used to grade
• metastasis: 0.5-5% (greater risk on scars, lip, ear)
• poorer prognosis with immunocompromised patients

Question 16

SQUAMOUS CELL CARCINOMA

Tx

Answer 16

• excision with margins
• Moh’s surgery for head/neck, large lesions
• lymph node palpation, biopsy if enlarged
• adjunct therapy
• self exam education
• regular F/U 6 months then annual

Question 17

KERATOACANTHOMA

Answer 17

• controversial diagnosis: previously categorized as reactive or pseudomalignancy
• now considered malignant and managed like SCC

Question 18

KERATOACANTHOMA

Features

Answer 18

• solitary nodule
• central keratotic plug
• firm, often tender
• rapid growth to max size 3-6 weeks, stable for wks to months then resorbs leaving a pitted scar
• can progress to invasive or metastatic carcinoma
• often indistinguishable from SCC
• dermatopathology necessary for Dx

Question 19

KERATOACANTHOMA

Risk factors

Answer 19

• rare before 40, peak age 50-69
• fair skin
• most common on face, neck, dorsal arms/hands, legs

Question 20

KERATOACANTHOMA

Ddx

Answer 20

• SCC
• molluscum contagiosum
• wart

Question 21

KERATOACANTHOMA

Tx

Answer 21

• assume SCC
• excision biopsy best (need depth to evaluate dermis)
• surgical excision of partial biopsy
• Moh’s surgery for large or recurrent or cosmetically sensitive lesions

Question 22

MELANOMA

Answer 22

• rapidly increasing skin CA of melanocytes
• one person dies of MM hourly; 76100 new cases in 2014
• potentially curable with early detection
• affects young and old (rare in children)
• enviro and genetic components: 86% due to sun, risk double if 5+ sunburns or 1+ blistering sunburn

Question 23

MELANOMA

Risk factors

Answer 23

• fair skin
• 50-100 nevi
• hx of atypical nevi
• PMH of melanoma
• FH of melanoma, atypical nevi
• h/p 1 blistering or 5+ sunburns
• large congenital nevi
• immunosuppression
• tanning bed (one session increases risk by 20%)

Question 24

MELANOMA

Subtypes

Answer 24

• superficial spreading
• nodular
• acral lentiginous
• lentigo maligna
• melanoma in situ
• amelanotic melanoma
• subungual

Question 25

MELANOMA Warning signs/What to watch for

Answer 25

- huge variations - ABCDE - may have itching or tenderness - may have bleeding or ulceration - slow or abrupt change - examine all pigmented lesions regularly

Question 26

MELANOMA What to do w/ atypical lesion

Answer 26

- if MM suspected, complete excision with 1-3 mm margin - if lesion too large, perform punch biopsy - lentigo maligna tend to be large and on cosmetically sensitive area so do broad shave biopsy - send to dermatopathologist

Question 27

MELANOMA 1. Breslow thickness 2. Clark level

Answer 27

1. vertical mm from top of granular layer to deepest point of tumor involvement; thinner/localized is better 2. anatomic plane of invasion; deeper = greater risk metastasis

Question 28

MELANOMA Tx

Answer 28

- surgery referral, wide local excision - derm referral - consider lymph node biopsy - adjuvant therapy - frequent F/U - also need to be followed by ophthalm and dentist b/c can develop MM in iris or mouth

Question 29

MELANOMA What to do for a pt Dxed w/ MM lesion

Answer 29

- full skin exam: conjunctive, oral mucosa, genital, perianal; photography or mole mapping - palpate lymph nodes - check scars of previous MM for recurrence - consider labs: low yield, but may help with prognosis (work with derm and oncology) - patient education - 6 month F/U

Question 30

MELANOMA Prevention/Pt education

Answer 30

- avoid peak sunlight hours - broad spectrum sunscreen daily - sun protective clothing - lip balm SPF 15+ - minimize exposure in kids <18 months - avoid tanning beds

Question 31

Cryotherapy 1. Define 2. List preferred lesions

Answer 31

1. separates dermis from basal membrane | 2. AK, acrochordons, condyloma, molluscum, seborrheic keratosis, solar keratosis, verrucae

Question 32

Moh's Surgery 1. Define 2. List preferred lesions

Answer 32

1. staged (gradual downward) excision of pathologic lesion | 2. BCC, SCC, high risk locations, large or aggressive tumors