Skin Cancer Flashcards
(207 cards)
1
Q
What is a Marjolin ulcer
A
Malignant transformation of scar with ulcer, mostly scc but can be BCC and Melanoma
2
Q
What is the metastatic rate of Marjolin ulcer
A
25-30%
3
Q
What percent of burn scars undergo malignant transformation
A
2%
4
Q
Average time for a malignant degeneration to occur in a Marjolin ulcer
A
20years
5
Q
Brigham and Women’s Hospital SCC staging
What is T1?
A
Zero high risk factors
6
Q
Brigham and Women’s Hospital SCC staging
What is T2a?
A
One high risk factor
7
Q
Brigham and Women’s Hospital SCC staging
What is 2b?
A
Two-Three High risk factors
8
Q
Brigham and Women’s Hospital SCC staging
What is T3?
A
4 or more high risk factors
9
Q
List the Brigham and Women’s Hospital SCC staging
high risk factors
A
1 diameter more that 2cm
2 poorly differentiated histology
3 Perineural invasion .1mm or more
4 Tumor invasion beyond the sub Q fat.
10
Q
AJCC Staging of SCC what is Tx?
A
Primary SCC not identified
11
Q
AJCC Staging of SCC what is Tis?
A
In situ
12
Q
AJCC Staging of SCC what is T1?
A
Less than 2 cm in diameter
13
Q
AJCC Staging of SCC what is T2?
A
More than 2 cm and less than 4 cm
14
Q
AJCC Staging of SCC what is T3?
A
Greater than 4cm or
Deep invasion (beyond subQ fat or more than 6mm)
Perineural invasion of nerve more than .1mm in dia.
15
Q
AJCC Staging of SCC what is T4?
A
Invasion of bone
16
Q
What % of Pagets disease of the nipple will have underlying ductal or invasive breast cancer?
A
95%
17
Q
Above 1mm in Breslow thickness what is the surgical margin for a melanoma
A
2cm
18
Q
What is the most common form of cell death by radiation.
A
Mitotic Catastrophe
19
Q
What is a Marjolin ulcer
A
aggressive cancer in old burn or poorly healing wound. usually SCC but can be BCC
20
Q
What margins should be used in an excision of a basal cell carcinoma without frozen sections planned.
A
4mm
21
Q
what tumor do you see the eyeliner sign.
A
SCC in in situ
22
Q
What is a keratin pearl
A
a swirl of parakeratosis
23
Q
naked nuclei are seen in what?
A
pagetoid spread in SCC
24
Q
where are there no atypical keratinocytes in the basal layer in an AK
A
In the follicular epithelium openings. orthokeratosis over the follicular opening.
25
if you see thick keratin corneal layer with underlying sun damaged skin what do you think of?
AK
26
what is the stain for DFSP
CD34
27
What two stains are negative in DFSP
Factor XIIIa .... + in dermatofibroma
| Stromelysin 3 ....+ in dermatofibroma
28
How to excise a DFSP if not mohs?
2cm margin down to fascia.
29
What is the recurrence rate of DFSP for excision and for Mohs?
excision >20% or more Mohs 1-2%
30
how many greys of radiation are used for radiation adjunct treatment of DFSP and margins.
50-60 gy and 3 to 5 cm beyond the surgical margin.
31
what is the best radiologic study for extensive DFSP
MRI with contrast.
32
What medicine and dosage is used for DFSP
Imatinib Mesylate (Gleevec) 400mg PO bid
33
What changes are seen in fibrosarcomatous changes in DFSP
Densely packed herring bone pattern.
CD34 may only be weakly +
Less haphazard more worrisome
34
What causes 90% of DFSPs
Chromasome translocation of a collagen 1 gene and a platelet derived growth factor gene to form an oncogenic fusion gene
35
What is a DFSP oncogenic fusion gene
t(17:22) q22 q13
36
what is the 10 year risk transformation for SCC in those that have AKs
17%
37
What percent of people treated for AK with cryo have complete clearing at 6mo?
<10%
38
What is tirbanibulin
klisyri inhibits tubulin polymerization and Src kinase signalling used in treatment of AKs
39
What is the treatment course for tirbanibulin
5 days.
40
With tirbanibulin what is the peak day of Localized Skin Reactions?
day 8
41
Name 5 Agents that may help prevent AK & SCC
1. Sunscreens
2. 5FU bid 30 days
3.Retinol (Vit A) 25,000 IU daily
4 Acitretin 25mg daily
5. Nicotinamide 500 bid
42
What % of DFSP metastasis?
5%
43
What is the most common site of DFSP to metastasize to?
lung
44
what drug treats DFSP
imatinib
45
What is the protein made by the oncogenic fusion gene.
COLA1 - PDGFB
46
What margins should you use with an excision of a bcc (non mohs)?
4mm
47
What margins should you use for an excision of a high risk SCC. and name 4 high risk features
1. >2cm
2. neurotropic
3. high risk sites
4 Invasion into fat
6mm
48
What is the cure rate with curettage alone?
96%
49
list 3 cancers you can ed&c
bcc, scc in situ, well diff scc <1cm
50
List two criteria for not doing an ed&c
hair follicle involvement and involvement of the deep dermis.
51
which field TX for AKs has the best non recurrence rate at 5 years.
5FU
52
what is the mnemonic for the Brigham & Women's Hospital staging system?
3 D's and large caliber perineural
53
what are the four risk factors in Brigham & Women's Hospital staging system for mets or death ?
Diameter >2cm
Deep penetration fat
Differentiation poor
Perineural involvement >.1mm
54
What are the four stages of Brigham & Women's Hospital staging system?
T1 0 risk factors
T2a 1 risk factor
T2b 2-3 risk factors
T3 4 risk factors or bone involvement
55
What are the four stages of the AJCC staging..
```
T1 <2cm and no other risk factors
T2 2-3.9 cm and no other risk factors
T3 - one of the following risk factors
*4cm diameter
*invasion >6mm or beyond fat
*perineural >.1mm or subdermal nerve involve
*minor bone erosion
T4- deep bone or base of skull
```
56
What is a risk factor in Brigham & women's staging that is not listed as a risk factor in AJCC?
Poor differentiation.
57
Is the NCCN (National Comprehensive Cancer Network) a staging system.
No. It is treatment recommendations only.
58
Does NCCN high risk predict recurrence or death?
No
59
With Brigham & Women's Hospital staging system what is the risk for recurrence mets or death in T2a SCC tumors Mohs vs excision.
Mohs 3.5 %
| Non Mohs 10%
60
With Brigham & Women's Hospital staging system what is the risk for recurrence mets or death in T2b-T3 with Mohs vs excision.
15 to 22%
61
What % of T2b cases that had sentinal node bx were positive.
30%
62
What % of nodal SCC mets are found in first 2 years?
80%
63
What studies should be done with patients high risk for mets (T2b-T3)
serial CTs or ultrasound.
64
What study is done if major nerve involvement with SCC
MRI
65
If a person has CLL with lymph node involvement what study can separate SCC nodes from CLL nodes?
PET scan
66
What was the first systemic treatment for approved for treatment of SCC.
Cemiplimab
67
what is the response rate to Cemiplimab
50%
68
If you do get response what % is durable over 1 year?
80%
69
Pembrolizumab is what?
anti -PD1 therapy like Cemiplimab 2nd to be released
70
What is the death rate of organ transplant patients with Anti-PD1 Treatments
50%
71
What other diseases will flare with Anti-PD1 tx
autoimmune
72
People who get more than 10 dermal invasive SCCs have either transplants or what.
CLL
73
What is the normal presentation of a merkel cell carcinoma
rapidly growing violaceous nodule 2-3 mo duration on sun exposed skin/
74
What is the aeiou mnemonic for merkel cell (MCC)
```
Asymptomatic
Expanding rapidly
Immune depressed
Older than 50
UV damaged skin
```
75
Which has a higher rate of metastasis Merkel Cell or Melanoma
Merkel Cell
76
Approximately what % have regional or distant mets in Merkel cell carcinoma MCC at time of presentation.
nodes 25%
distant mets 10%
Total 35%
77
What cell line is a merkel cell carcinoma considered.
neuroendocrine
78
What stain is used for Merkel Cell Carcinoma (MCC)?
CK20
79
what is the staining pattern of CK20 in MCC (merkel cell)
paranuclear dot like pattern
80
What is merkel cell carcinoma hard to tell apart from on H& E
metastatic small cell carcinoma (presumably from the lung)
81
what stain is positive in small cell lung cancer and negative in Merkel cell
TTF-1 (thyroid transcription Factor 1)
82
what are the two causes of Merkel cell carcinoma
1. merkel cell polyomavirus mutated
| 2. DNA mutations from UV
83
In those with polyomavirus and merkel cell what can you follow lab wise.
oncoprotein antibody levels. high at diagnosis may rise again with recurrence.
84
Will there be a oncoprotein antibody titer in merkel cell carcinoma without viral infection.
no
85
What are the surgical margins with merkel cell carcinoma (MCC)
1-2 cm or Mohs
86
In MCC (merkel cell carcinoma) how should nodes be evaluated?
If no clinically apparent nodes then a sentinel node bx should be done. If palpable nodes then a needle bx is done.
87
Which is better Cytotoxic Tx or Checkpoint immuno TX for Merkel cell carcinoma?
Cytotoxic therapies are only palliative. Check point immuno TX have longer durability.
88
Name two treatments for Merkel Cell Carcinoma
Avelumab 2017
| Pembrolizumab 2018
89
Show the staging AJCC of merkel cell carcinoma
Stage 0 In situ primary (? WTF)
Stage 1 < 2cm no nodes
Stage 2a >2cm no nodes
Stage 2b tumor invades muscle bone no nodes
Stage 3a node + no primary or + sentinel node
Stage 3b nodes involved
Stage 4 distant disease
90
What is the latency for exposure of ionizing radiation and development of BCC
20 years
91
what type of drugs have a lower risk for BCC in the immunosuppressed.
mTOR inhibitors
92
What are increased risk of BCC Melanoma and SCC with HIV infection
2.1 none reported 2.6
93
Which in order of risk are the skin cancer types with immunosuppression.
BCC about 6-16 Melanoma 1.4 8 SCC 20-250
94
What type of transplant immunosuppression does not increase risk of skin cancer as much as other types.
hematopoetic transplants
95
what does the hedgehog signaling pathway do?
regulates cell differentiation, proliferation and tissue polarity
96
hydrochlorothiazide increases incidence of BCC and SCC by how much?
BCC two fold SCC four fold
97
show the hedgehog signaling pathway
1. Extracellular signaling molecules (Shh sonic hedgehog protein)
2. attach to trans membrane receptors (PTCH 1 & 2)
3. PTCH suppresses signal transducer SMO (smoothened) in cell membrane.
4. SMO activates transcription factor Gli1, 2, 3)
5. if SuFu does not hibit then Gli enters nucleus
98
what chromosome is sonic hedgehog gene located?
chromosome 7
99
How does cancer come from the hedgehog signaling pathway.
Too much activation of the pathway.
100
In BCC what is the mutation that causes >50% of the bcc
TP53 mutation p53 in UV damaged cells stops replication and induces apoptosis
101
Beside inactivation of PTCH 1 what are two other mutations that can cause GLI to enter the nucleus to cause BCC?
activation of SMO or inactivation of SUFU
102
What is the staging system for BCC
There is no staging system for BCC
103
What is the risk for mets in BCC
.0028%
104
In the sonic hedgehog pathway activating or inactivating of each of these cause BCC which is it for each one PTCH1, Smoothened, SUFU, GiL
inactivating PTCH1
activating Smoothened (SMO)
inactivating SUFU
activating GIL
105
Does UV light from gel nail manicures increase risk for Nail SCC.
No
106
Name an immunosuppressive drug used in organ transplants and Crohn's disease that increases SCC risk by %56
Azathioprine
107
What is the primary cause of BCC?
Intermittent intense UVB & sunburns at any age.
108
What is the primary cause of SCC and AKs?
cumulative UV exposure & childhood sunburns
109
How much do tanning beds increase risk of SCC
2.5 x
110
How much do tanning beds increase risk of BCC
1.5
111
PUVA therapy is assoc with increased risk of SCC in what fashion.
dose related increase risk.
112
What is the increase risk from narrow band uvb 311-312nm
none
113
wavelengths below this number in phototherapy increase your risks for burning and cancer
300nm
114
With ionizing radiation what is increase of risk of BCC and SCC in 20 years based on in proportion to dosage?
3x the risk
115
What two co-carcinogens increase risk for SCC
HPV and UV
116
What percent of transplant patients have HPV in their SCC
90%
117
What is the increased risk for SCC and BCC in transplant patients?
SCC 40-250x
| BCC 5-10 x
118
What are the HPV types associated with SCC in transplant patients
1,2,5,6,11,16,18
119
what vaccination if injected into a SCC might clear it?
HPV
120
Name five classes of the immunosuppressive drugs that might increase risk for SCC
1. Biologics
2. steroids
3. Nibs (Braf inhibitors)
4. Calcineurin inhibitors (cyclosporin, tacrolimus, pimecrolimus
5. Mycophenolate Motetil Cellcept
121
What gene is most commonly mutated in SCC?
P53 the tumor suppressor gene
122
What % of BCCs have a mutated P53 gene
about 50%
123
What is the most frequently altered gene in all human cancers.
P53 mutated in over 50% of all human cancers
124
What are the three ways that p53 gene stops tumorigenesis.
1. Stops cell growth arrest by stimulating p21 which produces Cdk and stops mitosis in S phase.
2. Causes Apoptosis by stimulating BAX
3. Increases thrombospondin which decreases angiogenesis.
125
what is P63
a gene similar to P53 and found in many skin cancers.
126
In order what are the three most common mutations in BCC
PTCH
P53 (most common in SCC)
SMO
127
what do you call a gene that has the potential to turn into an oncogene?
Proto-oncogenes
128
HHV-8 is found in what percent of Kaposi's sarcoma patients?
Almost all.
129
What is the mechanism of action of HHV-8 in Kaposi's sarcoma.
Reactivation of a virus rather than primary infection.
130
Of the 4 clinical variants of Kaposi's how many are associated with HHV-8
all four
131
What are Bcl-2 and Bcl-xL proteins
promote cell survival and inhibit pro-apoptotic proteins.
132
What are BAD, BAX, BID, and BAK proteins
proteins that promote apoptosis
133
what percent of porokeratosis develops SCC
10%
134
What is the one porokeratosis that does not develop SCC
punctate porokeratosis on palms and soles around adolescence.
135
What is the cause of DSAP
Autosomal dominant disorder with a mevalonate mutation.
136
What is the hyperkeratotic layer of porokeratosis called?
cornoid lamella
137
In which merkel cell carcinomas should sentinel node biopsies be done?
all
138
Risk of progression of ak to scc is what?
.1 to1%
139
NCCN guidelines recommend a sentinel node bx in all patients with merkel cell carcinoma because clinically negative node patients have what percent of nodal involvement on sentinel node biopsy?
25-35%
140
In Merkel cell carcinoma what percent eventually get's node mets and what percent gets distant mets.
50% and 35%
141
What are the three types of verrucous carcinoma
Giant condyloma of Buchske-Lownstein
Oral florid papillomatosis
Epithelioma cuniculatum (on bottom of foot assoc with wart)
142
How likely is verrucous carcinoma likely to metastasize?
rarely. It is considered a well differentiated variant of SCC. Can penetrate deep.
143
Is UV exposure implicated in verrucous carcinoma?
Yes
144
Although excision and Mohs is considered the best treatment for verrucous carcinoma what treatment should be avoided.
Radiation. May induce anaplastic changes, risk is likely low.
145
HPV vaccination may be preventative for verrucous carcinoma because of its association with what viruses.
6 & 11 low risk
| 16 & 18 high risk
146
For merkel cell carcinoma if you have a positive sentinel node biopsy what are the next steps.
1. PET CT scan
2. referral for adjuvant therapy clinical trial
3. if above not available radiation or node dissection or both
147
which of the following cancers have been associated with arising out of Hailey Hailey disease , SCC BCC Melanoma
all
148
With SCC and regional node involvement what is the NCCN guideline for derm f/u
2-3 months for one year
2-4 for year two
4-6 for years three - five
6-12 afterward
149
What is the polyomavirus associated with merkel cell carcinoma?
MCPyV
150
what percent of the population has been exposed to the polyomavirus MCPyV
60 to 80%
151
What happens if you are seronegative for MCPyV with merkel cell carcinoma at baseline?
you are at high risk for recurrance.
152
What two antibodies for MCPyV are important in Merkel cell carcinoma?
```
Major capsid antibody (VP1) found in general population
oncoprotein antibody (T1) found in merkel cell cases
```
153
Which of the two MCPyV antibodies are found in the general population and low baseline with merkel cell carcinoma diagnosis portends more metastatic disease.
Major capsid antibody
154
Which of the two MCPyV antibodies can you track to follow for recurrance.
oncoprotein antibody. (not useful in people that are seronegative at baseline)
155
What is the most important feature in differentiating Atypical Fibroxanthoma from pleomorphic dermal sarcoma
depth of invasion. They look the same histologically.
156
What is the highest risk factor for death from SCC at time of treatment.
Tumor diameter. tumors over 2cm have a 20 risk of death for tumors under 2 cm.
157
Risk for death with perineural involvement that is clinical is what. And risk for death from PNI on histology only is what?
30% and 13%
158
Being able to determine perineural involvement on biopsies require a depth of how much?
3-4 mm
159
Is a sentinel node biopsy done before or after the malignancy is resected?
before the tumor is removed
160
What drug has been shown to reduce skin cancers by 63 % in patients with xeroderma pigmentosa
Isotretinoin
161
What type of leukemia has an increased risk for nonmelanoma skin cancer.
CLL
162
Is arsenic exposure a risk factor for BCC
Yes, chronic arsenic exposure is a risk factor.
163
what type of solid organ transplant has the least risk for development of SCC
Liver
164
Which has higher SCC assoc. Liver Kidney transplants or Lung Heart transplants
Heart and Lung transplants have the most risk for SCC
165
what is the increased risk of scc in organ transplant patients.
6-100 fold
166
Mucinous carcinoma can be primary or metastasize from cancers of what organs?
breast, GI, Lung, ovary, prostate
167
Why is mohs the treatment of choice for Mucinous carcinoma?
poor response to radiation and chemo. Recurrence rate of 13% with Mohs over double that with excision.
168
Is primary mucinous carcinoma a low or high grade malignancy?
Low grade with low rate of mets but high recurrence rate.
169
although mucinous carcinoma can be found in multiple locations which are the most common?
```
eyelid #1
scalp
Neck
axillae
trunk
```
170
Diets low in what have been shown to reduce AK risk
Fat
171
what are the subclinical spread numbers at 1cm 3cm and 5 cm for DFSP
1cm 75%
3cm 15%
5cm 5%
172
What is the cure rate for DFSP with Mohs
98%
173
Where are the most common areas for finding basosquamous cell carcinoma.
perinasal, periocular, preauricular skin
174
What sites are most common for microcystic adnexal carcinoma.
cutaneous upper and lower lips
175
What is the earliest sign of Gorlin's syndrome
Odontogenic keratocysts
176
what is the followup for merkel cell carcinoma with skin check and lymph node exam
3-6 months for 3 years
| 6-12 forever
177
In immunocompromised pts do they get more or less superficial BCC compared to normal pts.
more
178
Who has higher recurrence rates for treated BCCs immunocompromised or normal patients.
rate of recurrence is the same for BCC, but SCC is worse for immunocompromised.
179
Who gets more non head and neck BCCs immunocompromised or normal patients.
immunocompromised
180
Who gets BCCs at a younger age immunocompromised or immunocompetent.
immunocompromised
181
what is the number one skin cancer in the US and how many are diagnosed each year?
BCC 2million
182
what is your lifetime risk of getting a BCC
20%
183
how many cases of SCC are diagnosed in US a year
about 1 million
184
How many cases of melanoma are diagnosed in the US each year
80K+
185
What locations are KAs less likely to regress
mucosal and periungual (those arising in non-hairbearing areas.
186
in the asian/hispanic population what #1 feature of a pigmented basal would be expected to show more subclinical extension.
Ulceration
187
In the asian/hispanic population with a pigmented basal cell what features increase risk for subclinical extension and more layers.
Ulceration #1
under age 50
Location on nose
Size over 1 cm (unlike caucasion size over 2cm)
188
In a asian/hispanic population one sign of a BCC that makes it more likely to be cleared in one stage.
pigmentation
189
After the risk factor of size over 2cm for risk of disease specific death what is the second highest risk factor in SCC.
Depth
| as compared to non clinical perineural involvement..
190
acantholytic SCCs are not associated with what lesion that other SCCs are commonly associated with?
AKs
191
what is the most common skin cancer in african americans and what is the most common location
SCC lower extremities (associated with chronic inflammation and scarring)
192
What is considered the UV signature mutation
a Cytosine to Thymine mutation at a dipyrimidine site
| found in the PCTH gene in basal cell, the p53 gene in SCC and the CDKN2A gene in melanoma
193
what is opposite with gay men and women when it comes to skin cancer.
gay men use tanning beds more than non-gay men and have a higher incidence of skin cancer.
Gay women have less tanning bed use that Hetrosexual women and have fewer skin cancers.
194
Malignant peripheral nerve sheath tumor (a sarcoma) which can occur with neurofibromatosis type1 has what gene mutation
p53
195
What type of gene is p53
tumor suppressor gene - mutated by UV at the C to T transitions on the dipyrimidine sites
196
What is the risk for a Marjolin ulcer to metastasize?
30%
197
The leg is the most common site for a marjolin ulcer, but what location on the leg is the most common site.
Plantar surface of the foot.
198
in merkel cell carcinoma which patients have a better survival. Those with a known primary or those with an unknown primary.
unknown primary
199
what % of melanoma in situ is found to have invasive melanoma on excision
4-6%
200
of the three types of congenital nevi small <1.5cm medium <20 cm or large have a risk for melanoma compared to the general population.
Large only with a 6% risk
201
When is the risk for melanoma the highest in a giant congenital nevus
The first ten years.
202
although the overall incidence of melanoma is increasing what two age groups is it decreasing in.
```
adolescents (10-19)
Young adults (20=29)
```
203
Blueberry muffin syndrome is associated with what disease and what mutation that is shared by melanoma.
Langerhans cell histiocytosis (caused by cells from bone marrow)
BRAF V 600E +
204
what viruses are associated with organ transplant SCC 80% of the time.
HPV 5 & 8 Same as Epidermodysplasia Verruciformis
205
When if you see halo nevi would give the better prognosis for what factor in a melanoma.
Early new melanoma lesions.
206
when doing mohs on a toe vs amputation which has lower recurrence rates.
They both have the same recurrence rates.
207
why is the bar lower for taking another layer with a low grade melanoma on acral skin.
There are fewer melanocytes on acral skin so it is easier to miss subtle positive margins.
