Skin Cancer

Question 1

What are risk factors for non-melanoma skin cancer?

Answer 1

UV radiation

Chemical carcinogens

Ionising radiation

HPV

Familial cancer syndromes (basal cell carcinoma when they are young suggests that they might have a familial cancer syndrome)

Immunosuppression

Question 2

What are the pathogenic features of basal cell carcinoma?

Answer 2

Slowly growing

Locally invasive

Rarely metastasise

Question 3

Describe the visual features of a basal cell carcinoma

(BCC is the most common type of cancer as well as the most common type of skin cancer)

Answer 3

Nodular:

–Pearly rolled edge

–Telangiectasia

–Central ulceration

–Arborising vessels on dermoscopy

Question 4

What are these?

Answer 4

Pigmented

Morphoeic basal cell carcinomas

Question 5

What is the treatment of BCC?

Answer 5

Excision

Courettage

Mohs surgery

Vismodegib (for locally advanced BCC that is not suitable for surgery or radiotherapy, metastatic basal cell carcinoma)

Side effects include hair loss, weight loss, altered taste, muscle spasms, nausea and fatigue

Question 6

Describe the pathogenicity of squamous cell carcioma

Answer 6

Can metastasise

Faster growing, tender, scaly/crusted or fleshy growths

Can ulcerate

Question 7

What do squamous cell carcinomas develop from?

Answer 7

Keratinising squamous cells

Usually on sun exposed sites

Question 8

What is the treatment of small cell carcinoma?

Answer 8

Excision

With or without radiotherapy

Follow up is recquired for those who are considered high risk:

• Immunosuppressed
• Greater than 20 mm diameter
• Greater than 4 mm depth
• Ear, nose, lip, eyelid
• Perineural invasion
• Poorly differentiated

Question 9

What skin cancer is a variant of squamous cell carinoma and erupts from hair follicles in sun damaged skin?

Answer 9

Keratocanthoma

Grows rapidly, may shrink after a few months and resolve

Surgical excision

Question 10

What are the genetic risk factors for UV radiation?

Answer 10

UV radiation

Genetic susceptibility - fair skin, red hair, blue eyes and tendency to burn easily

Familial melanoma and melanoma susceptibility genes

Question 11

What is the ABCDE rule for melanoma?

Answer 11

• Asymmetry
• Border - ill defined
• Colour - tends to vary
• Diameter - over 6mm is likely to be a melanoma
• Evolution - means the melanoma is changing

Question 12

What is the 7 point checklist for malignant melanoma?

Answer 12

Major features:

Change in size

Change in shape

Change in colour

Minor features:

Diameter more than 5 mm

Inflammation

Oozing or bleeding

Mild itch or altered sensation

Question 13

What visual aid can be used to help in the diagnosis of malignant melanoma?

Answer 13

Dermoscope

Question 14

What are the different types of malignant melanoma?

Answer 14

Superficial Spreading Malignant Melanoma - often at the site of a preexisting mole - most common type and confined to the epidermis

Lentigo maligna melanoma - confined to the epidermis

Nodular

Acral lentiginous Melanoma

Ocular

Question 15

What is the treatment for melanoma?

Answer 15

Urgent surgical incicsion

Sentinal lymph node biopsy

Chemotherapy/immnotherapy

Regualr follow up

Primary and secondary prevention

Question 16

What are the biological agents for metastatic melanoma?

Answer 16

•Ipilimumab

–Inhibits CTLA-4 molecule

–One year survival 47-51% (double those not on treatment)

•Pembrolizumab

–Targets PD-1 receptor on tumour cell

–One year survival 68-74%

•Vemurafenib and Dabrafenib

–Blocks B-RAF protein

–Only useful if B-RAF mutation

–Median survival 10.5 months (7.8 months with standard chemotherapy)

Question 17

Is cutaneous lymphoma primary or secondary?

Answer 17

Can be secondary (disease from systemic / nodal involvement)

Can also be primary - abnormal neoplastic proliferation of lymphocytes underneath the skin (cutaneous T cell lyphoma 65% and cutaneous B cell lymphoma 20%)

Question 18

What are types of cutanous T cell lymphoma (a primary cause of lymphoma)?

Answer 18

Mycosis fungiodes

Sezary syndrome

Question 19

What is the most common type of cytotoxic T cell lymphoma (accounts for around 50% of all primary cutaneous lymphomas)

Answer 19

Mycosis fungiodes

Question 20

What are the features of mycosis fungiodes?

Answer 20

Patch - flat, red oval lesions

May spontaneously enlarge or spontaneously resolve

may itch

Hard to differentiate from eczema and psoriasis

Plaque - Patches become thickened - generally itch

Tumour - large irregular lumps which arise from existing plaques or in normal skin - can ulcerate - more likely to have metastatic spread

Metastatic - neoplastic cells in lymph nodes, bloods and solid organs

Question 21

What is red man syndrome?

Answer 21

Sezary syndrome

Cytotoxic T cell lymphoma affecting the skin of the entire body

Skin thickened, scaly

ITCHY

Lymph nodes are involved and sezary cells are found are in the peripheral blood (atypical t cells)

Por prognosis - opportunistic infection

Question 22

What is the treatment of cutaneous lymphoma?

Answer 22

–Topical steroids

–PUVA or UVB

–Localised radiotherapy

–Interferon

–Bexarotene (this is a retinoid)

–Low dose Methotrexate

–Chemotherapy

–Total skin electron beam therapy

• Extracorporeal photophoresis
• Bone marrow transplantation

Question 23

What is total skin electron beam therapy?

Answer 23

•Type of radiotherapy consisting of very small electrically charged particles

• Delivers radiation primarily to superficial layers i.e. Epidermis and Dermis
• Spares deeper tissues and organs

Question 24

What is extracorporeal photophoresis?

Answer 24

•Step 1

–Patients blood is drawn and leucocytes collected

•Step 2

–Collected white cells mixed with psoralen which makes the T-Cells sensitive to UVA radiation

•Step 3

–Exposed to UVA radiation, damaging diseased cells

•Step 4

–Treated cells re-infused back to patient

Question 25

Where does cutaneous metastases arise from?

Answer 25

Can be secondary to primary skin malignancy such as melanoma or due to primary solid organ malignancy