Skin Cancer other than Melanoma FRCR CO2A Flashcards
(167 cards)
1
Q
Commonest cancer in the UK
A
Non melanoma skin cancer
2
Q
premalignant conditions of skin
A
- actinic keratosis
- Bowen’s diseasee
- Erythroplasia of Queyrat
- Paget’s disease
3
Q
Malignant tumors of skin
A
- BCC
- Sq CC
- Merckel Cell CArc
- Amelanocytic melanoma
- Cut T Cell Lymphoma
- Primary Cut B Cell Lymphoma
- Kaposi’s Sarcoma
- Angiosarcoma
4
Q
Incidence of Non melanoma skin cancer in UK
A
100,000 cases in UK in 2010
500 annual deaths
5% of people > 60 yrs develop this cancer
5
Q
RFs for skin cancer
A
Chronic Sun Exposure and UV radiation
Actinic keratosis and Bowen disease
Immnosuppression (AIDS, CLL, CML)
RT exposure
Chemicals like nitrates, arsenicals in tonics and pesticides
6
Q
Genetic Predisposition for skin cancer other than melanoma
A
- Gorlin’s syndrome
- Bazex’s syndrome
- Xeroderma Pigmentosa
- Ferguson Smith disease
- Muir Torre syndrome
7
Q
What is Gorlin’s syndrome?
A
Autosomal familial cancer
multiple BCCs at early age
gene: PTCH on Chr 9q22-31
8
Q
what other abnormalities are a/w gorlin syndrome
A
- bone cysts of mandible
- abnormalities of ribs, short 4th metacarapal
- Coloboma at birth or cataracts in later life
- increased risk of medulloblastoma and meningioma
Rember MC, Mandible: Cyst
Metacarpal,4th: short
Meningioma
Medulloplastoma
Chordoma and Cataract
9
Q
Defect in Xeroderma Pigmentosa
A
defective DNA repair (nucleotide excision repair)
10
Q
what is erythroplasia of queyrat a/w
A
sq cell carc of glans penis
11
Q
BCC among skin cancers
A
80 % of all non melanoma skin cancers
12
Q
Causes of BCC
A
- UV Radiation
- fair complexion, red or blonde hair
- light eye color
13
Q
common sites of BCC
A
Sung exposed region
1. Head n Neck
2. Trunk
14
Q
s/s of BCC
A
grow very slowly over years
itching, bleeding, discomfort
infiltrate locally and destroy local tissues
15
Q
Nodular BCC
A
pearly papule with rolled border, central crusting or ulceration
16
Q
superficial spreading BCC
Appearance
A
scaly erythematous patch or plaque, brown due to melanin pigmentation
17
Q
molecular pathogenesis of BCC
A
- Hedgehog (HH) signaling pathway
- mutations in TP53
18
Q
pathogenesis of Sq Cell Carc
A
progression thorough dysplasia, carcinoma in situ, or Bowen’s disease to frankly invasive sq cell carcinoma
19
Q
Hx of keratocanthoma
A
histologically similar to Sq cell carc but grows rapidly 4 to 6 weeks that subsequently under goes spont regression, leaving a small pitted scar on the surface
20
Q
what are the poor prognostic factors for Sq cell carcinoma skin
A
- tumor size > 2cm
- poorly defined borders
- location on the central part of face and ears
- long standing duration
- incomplete excision
- recurrent cancer
- prev site of RT
- immunocompromised pts
21
Q
What should be asked in Hx with skin cancer pt?
A
- any past high sun exposure
- topical treatment used in past
- chemical exposure
- previous irradiation
- rate of growth
22
Q
How rate of growth helps to differentiate difft types of skin cancer
A
presents for years and slow growing: BCC
months: sq cell carc
weeks: keratoacanthoma
23
Q
palpation for skin tumors
A
margins and depth
24
Q
why depth Palpation?
A
to chose type of RT and energy to be used
25
skin cancer Dx
punch biopsy, excisional biopsy or scrapings
26
when is CT required for skin cancer
for deep involvment
27
when is MRI helpful for skin cancer?
PNI
28
Surgeries for skin cancer
1. Mohs micrographic surgery
2. Surgical excision
3. curettage and electro desiccation and cryosurgery
29
WHat is Mohs micrographic Surgery?
rapid examn of frozen section to examine peripheral and deep surgical margins
determine whether further excision required or not
cure rate at 5 yr: 99%
30
Advantage of surgical excision over RT
complete removal confirmed histopathological and long term f/u can be avoided
31
Indications for Sx over RT
1. younger than 60 yrs
2. recurrent tumors
3. uncertain or incomplete margins
4. involving cartilage, tendon, bone or joint
32
Non Surgical Rx for skin cancers except melanoma
1. Imiquimod 5%
2. PHotodynamic therapy
3. Topical 5 FU therapy
4. RT
33
Imiquimod 5% ?
topical immune modulator, OD 5 days per week for 6 weeks
34
RT uses in skin Cancer?
1. Older pts
2. multiple tumor or larger tumors
3. sites where surgery is difficult
4. refuse surgery or on anticoagulant
35
Cure rate of RT for skin cancer
95% at 5 yrs
36
C/I for RT
1. Xeroderma Pigmentosa
2. Basal Cell Naevus Syndrome
37
which sites poorly tolerate RT ?
1. sites of prev RT
2. areas of vascular insuffy
3. skin overlying the shin
4. malleoli of the lower leg
5. middle 3rd of upper eyelid
6. dorsum of hand
38
acute side effects of radiotherapy for skin cancer
dry inflamed red skin
Scabing
ulceration
39
Intermediate side effects of radiotherapy for skin cancer
slow healing over 4 to 8 weeks
tiredness
watery eyes
40
How can watering eyes be treated?
if d/t Nasolacrimal duct stenosis, Recanalisation
41
Late RT S/Es for skin cancers
radiation dermatitis
telangiectasia,
fibrosis
permanent hair loss on scalp
dry eye due to lacrimal gland damage
2ndary malignancies
42
why is wax bolus added for electron therapy?
to increase the surface dose to 90 % isodose, to cover the PTV
43
Why wider margin (1.5 cm ) for electron therapy?
Bowing of the isodoses
44
Eye Shield
inner surface coated with liquid paraffin to reduce friction with cornea
45
for how long eye pad has to worn on by pts post LA to eye
2 hrs, till corneal reflex is back to normal
46
Choice of RT for tumors < 4 cm and thickness < 5 mm
Superficial X Ray (90 to 150 kV)
47
Choice of RT for tumors > 4 cm and thickness 5> mm
Electron therapy
48
at which sites should e therapy be avoided
1. near the eyes, bcoz wide margins are required, more scatter dose, difficult to shield
2. nasal cavities
3. sinuese, mastoid air cells
Bcoz of uncertain dose distribution
49
what energy of electron should be used
depth x 3 (MeV)
50
RT dose Schedules for skin cancers
1. small BCC (< 3 cm): 35 GY/ 5# over 5 days to the 100 % isodose
2. For large BCC and sq cell carcinoma: 45 Gy/ 10# or 55 Gy/ 20 # to 100 % isodose
3. for very large: 64 Gy/ 32# to the 100 % isodose
51
Adj RT Dose
50 Gy/ 20#
or 60 Gy/ 30# to 100% isodose
52
Interstitial BT dose for skin cancers
45 Gy/ 10#
53
Precautions during skin RT
1. wash area with plain running water in a shower or bath every day and pat it dry
2. avoid shaving and deodorants and soaps
3. Avoid sun exposure
54
why should deodorants and soaps be avoided during RT
sensitize skin to radiation (heavy metals increase PE effect)
55
mBCC Rx (NCCN 2025)
* Vismodegib
* Cemiplimab
56
mSq Cell CArc skin Rx
Cemiplimab
* Pembrolizumab
* Nivolumab
57
what if * If ineligible for or progressed on immune
checkpoint inhibitors
Carboplatin + paclitaxel ± cetuximab
EGFR inhibitors (eg, cetuximab)
58
Merkel Cell Carcinoma Pecularities
1. highly malignant
2. develops satellite tumors and LN mets
3. elderly
4. Neuroendocrine origin (APUD) system
59
Presentation of Merkel cell carcinoma
painless, red, indurated nodule or an ulcer in H & N region
60
Rx of Merkel Cell carcinoma
WLE and SLNB with IHC analysis
61
what if SLNB + in MCC
Nodal dissection f/b RT
62
mMCC Rx
Carboplatin and Etoposide
63
malignant porocarcinoma and eccrine carcinoma Rx
WLE
64
Types of Kaposi Sarcoma
1. HIV related Kaposi Sarcoma
2. Classical Kaposi sarcoma
3. Endemic Kaposi sarcoma
4. Kaposi sarcoma in immunocompromised state
65
where is endemic kaposi saroma?
sub saharan Africa
66
Presentation of Kaposi Sarcoma
small, painful, reddish or purple papules on face, hard palate, gums, shins, lower legs, soles of the feet
ulceration, H'ge and dental instability
67
HIV Rx in Kaposi sarcoma
immediately start HAART, many lesions disappear
68
RT dose for nodular localized Kaposi sarcoma
8 Gy SF with SXR or electrons
69
mucosal tumors kaposi sarcoma RT dose
20 Gy / 10 # over 2 weeks
70
Classic non HIV kaposi sarcoma RT dose
16 Gy/ 4 # over 8 days
71
chemotherapy for kaposi sarcoma
PLD and Paclitaxel
72
keloid Scar RT
post Sx (excision) to avoid recurrence
6 Gy Single exposure with SXR if less than 2 cm
12 Gy/ 3# with electron if > 2 cm
72
How effective is RT for keloid scar
effective in 80% cases
73
Dermatofibrosarcoma Protuberans Rx
WLE with Mohs micrographic surgery
74
What is basal cell carcinoma (BCC)?
A slow growing, locally invasive malignant epidermal skin tumour
## Footnote
Also known as rodent ulcer
75
What are the most significant aetiological factors for BCC?
UV exposure and genetic predisposition
## Footnote
Increasing incidence worldwide is noted
76
What is a common feature of Gorlin’s syndrome related to BCC?
Multiple BCC occurrences
## Footnote
Gorlin's syndrome is a genetic condition that increases the risk of BCC
77
What are other risk factors for developing BCC?
* Increasing age
* Male gender
* Fair skin
* Immunosuppression
* Vaccination scars
* Arsenic exposure
## Footnote
Sunscreen use and low fat diet are thought to be protective
78
What are the common histologic subtypes of BCC?
* Superficial
* Nodular
* Morphoeic (sclerosing)
## Footnote
Other aggressive variants include micronodular, infiltrative, and basosquamous BCC
79
What is the typical growth pattern of superficial BCC?
Well-defined, erythematous, scaling or slightly shiny macular lesion
## Footnote
Can enlarge to 5–10 cm in diameter
80
Where are the common sites affected by BCC?
* Head and neck (52%)
* Trunk (27%)
* Upper limb (13%)
* Lower limb (8%)
## Footnote
Superficial BCC is common on the trunk or limbs of young people
81
How does nodular BCC typically present?
Shiny, pearly, telangiectatic papule or nodule
## Footnote
Central umbilication of the lesion may occur with ongoing growth
82
What is the clinical examination process for BCC?
Should be done in a well-lit area with the aid of a magnifier
## Footnote
Whole skin examination and regional nodal examination is necessary
83
What is the primary method for diagnosing BCC?
Often clinical; biopsy is indicated when there is clinical suspicion of an alternative diagnosis
## Footnote
Punch or shave biopsy may be appropriate
84
What is the goal of BCC treatment?
Eradication of tumour with acceptable cosmetic and functional outcome
## Footnote
Various treatment options are available depending on the specific case
85
When is radiotherapy indicated for BCC treatment?
When cosmetic and/or functional outcome is better with radiotherapy compared to surgery
## Footnote
Also when complex plastic surgery needs to be avoided
86
What is the first treatment modality listed for BCC?
Surgical excision
## Footnote
This includes methods such as wide excision and Mohs' micrographic surgery.
87
What are the two types of surgical destruction methods for BCC?
* Curettage and cautery
* Cryosurgery
* Carbon dioxide laser
## Footnote
These methods involve physically destroying the cancerous tissue.
88
What is a non-surgical destruction method for BCC?
Topical immunotherapy with imiquimod
## Footnote
This method stimulates the immune system to fight the cancer.
89
List two non-surgical treatment modalities for BCC.
* Photodynamic therapy
* Radiotherapy
## Footnote
These methods utilize light or radiation to treat the cancer without surgery.
90
What is Mohs' micrographic surgery?
A surgical excision technique that removes skin cancer with minimal surrounding tissue
## Footnote
It allows for immediate microscopic examination of cancer margins.
91
Fill in the blank: _______ is a type of cryosurgery used to treat BCC.
Carbon dioxide laser
## Footnote
This laser method freezes the cancerous cells to destroy them.
92
True or False: Radiotherapy is a surgical method for treating BCC.
False
## Footnote
Radiotherapy is a non-surgical treatment method.
93
What is the purpose of curettage and cautery in BCC treatment?
To surgically destroy cancerous tissue
## Footnote
This method involves scraping away the cancer and applying heat to stop bleeding.
94
What is the treatment of choice for small and less invasive BCC tumors?
Surgery and radiotherapy (RT) are effective treatments.
95
How are large and deeply invasive BCC lesions typically treated?
With surgery with or without postoperative radiotherapy.
96
In which situations is radiotherapy favored for BCC treatment?
* Mid-face, nasal, inner canthus, lower eye lid, lip commissures (better function)
* Multiple superficial lesions difficult to excise (better cosmesis)
* Patients >70 years (long-term toxicity is less of an issue)
* Patients who wish to avoid surgery
* Patients prone to keloid formation
97
When is surgery the preferred choice for BCC treatment?
* Readily excisable lesions in those <70 years
* Lesions in hair-bearing areas or overlying lacrimal gland
* Recurrence after radiotherapy
* Multifocal disease especially with dysplastic skin
* Upper eyelid tumours (better function)
* Dorsum of the hand (better function)
* Below knee and other sites of poor vascularity
* Invasion to bones and joints
98
What is a notable exception regarding cartilage invasion and radiotherapy?
Cartilage invasion is not an absolute contraindication to radiotherapy.
99
In which specific cases is radiotherapy avoided?
In large pinna lesions with extensive, inflamed or painful cartilage invasion.
100
Fill in the blank: Patients who are prone to _______ may prefer radiotherapy over surgery.
keloid formation
101
True or False: Surgery is preferred for patients over 70 years old with BCC.
False
102
Fill in the blank: Surgery is the choice for lesions in _______ areas.
hair-bearing
103
What is a key consideration for treating upper eyelid tumors?
Surgery is preferred for better function.
104
What is a concern when treating BCC lesions below the knee?
Poor vascularity can lead to problems with healing and function.
105
What is the margin required for wide excision of simple lesions?
2–3 mm
## Footnote
Complex lesions or poorly defined lesions require a margin of 3–5 mm.
106
What is the adequate microscopic margin for wide excision?
0.5 mm
107
What are the treatment options after incomplete excision?
* Re-excision
* Radiotherapy
* Observation
108
How much does adjuvant radiotherapy improve 5-year survival?
From 61% to 91%
109
Why might observation be chosen as a treatment option?
For elderly patients where further surgery and radiotherapy may not be appropriate
110
What is Mohs’ micrographic surgery?
A procedure where the tumour is excised and peripheral and deep margins are examined for residual tumour
111
What is the control rate of radiotherapy for BCC of ≤2 cm?
93–95% 10-year control rate
112
What factors contribute to recurrence of tumours?
* Location (mid face and pre-auricular lesions)
* Tumour size (>2 cm)
* Aggressive subtypes
113
When do two-thirds of recurrences occur after primary treatment?
Within 2 years
114
What is the general treatment for recurrences after non-surgical treatment?
Surgical resection followed by plastic surgical repair
115
What is the overall 10-year control rate?
>90%
116
What are important prognostic factors for skin lesions?
* Size
* Depth of invasion
* Histological subtype
* Completion of excision
* Site of disease
* Presence of perineural spread
117
Fill in the blank: Incomplete excisions have a _______ recurrence rate.
30%
118
True or False: Tumours around the nose, eyes, and ears have lower recurrence rates.
False
119
What is Squamous cell carcinoma (SCC)?
SCC is the second most common skin cancer, constituting 20% of skin malignancies.
120
What factors increase the risk of developing SCC?
* Exposure to ionizing or ultraviolet radiation
* Immunosuppression
* Scars
* Chronic wounds
* Smoking
* Arsenic exposure
* Congenital conditions such as oculocutaneous albinism and xeroderma pigmentosum
121
What is the typical appearance of in situ SCC (Bowen’s disease)?
A flat scaling pink lesion with irregular borders.
122
What is the risk of metastasis for in situ SCC of the glans penis (erythroplasia of Queyrat)?
20% risk of metastasis.
123
What are the histologic variants of invasive SCC?
* Adenoid SCC
* Adenosquamous SCC
* Spindle cell SCC
* Verrucous SCC
* Keratoacanthoma
124
What characterizes Adenoid SCC?
Can metastasize in 3–19% and is associated with rapid local growth.
125
Describe Spindle cell SCC.
Appears as ulcerated nodules or exophytic tumours and may be difficult to distinguish from sarcoma histologically.
126
What is the typical clinical presentation of SCC?
A raised pink papule or plaque with erosion or ulceration.
127
Where is SCC most commonly located in males?
Head and neck region.
128
What is the significance of a tissue biopsy in SCC diagnosis?
Essential for diagnosis.
129
What are the T staging criteria for SCC?
* T1 – ≤2 cm
* T2 – >2 to 5 cm
* T3 – >5 cm
* T4 – tumour invades deep extradermal structures
130
What are the treatment options for SCC?
* Cryotherapy
* Curettage and electrodessication
* Radiotherapy
* Surgical excision
* Mohs’ micrographic surgery
131
What is the minimum margin for excision of low-risk tumours of <2 cm?
4 mm.
132
What is the role of postoperative radiotherapy for high-risk SCC?
Considered after complete excision.
133
What chemotherapy is most effective for distant metastasis from SCC?
Cisplatin-based chemotherapy.
134
What is the overall response rate for the combination of cisplatin with adriamycin?
>80%.
135
What is the typical timeline for most recurrences of SCC?
Within 2–3 years.
136
Fill in the blank: The incidence of SCC appears to be ______.
increasing.
137
True or False: Verrucous SCC metastasizes.
False.
138
What is the accepted minimal microscopic margin for SCC excision?
>1 mm.
139
List some indications for postoperative radiotherapy after surgical management of metastatic lymph nodes.
* ≥3 cm node
* ≥2 positive nodes in neck
* Extranodal extension
* Close or positive margin
* Skin involvement
* Major nerve involvement
* Parotid node metastases
140
What is the role of elective lymph node dissection in SCC?
Not routinely advised, but may have a role in tumours of >8 mm in depth.
141
Digital Squamous cell carcinoma
142
What are acute reactions to radiotherapy for skin cancer?
Dermatitis and mucositis which resolve by 6 weeks following treatment.
143
What are late effects of radiotherapy for skin cancer?
Thinning of skin, alopecia, loss of sweating, change in colour, telangiectasis and fibrosis.
144
What does the choice of position and immobilization for radiotherapy depend on?
The site of the lesion.
145
What factors determine the type of radiation used in skin cancer treatment?
Depth of penetration needed and type of underlying tissue.
146
What type of radiation is used for a lesion ≤5 mm deep?
Superficial X-ray.
147
What type of radiation is used for a lesion >5 mm and ≤2 cm deep?
Deep X-ray or low energy electrons (6 MeV).
148
What type of radiation is used for a tumour >2 cm?
High energy electrons or photons.
149
Why are electrons preferable for treating lesions near bone?
To avoid increased absorbed dose from deep X-rays.
150
What type of radiation is preferred near air cavities?
X-rays or photons, as dosimetry is difficult with electrons.
151
What is the treatment volume margin for a well-defined BCC?
5 mm margin around macroscopic tumour.
152
What is the treatment volume margin for ill-defined BCC and SCC?
10 mm margin.
153
What is beam shaping in radiotherapy?
Custom made lead cut out for X-rays and end frame cut-out for electron.
154
What does crenallation of the margin of a round cut out achieve?
Better cosmesis by blurring the edge of radiation reaction.
155
Which type of skin cancer is thought to be more radiosensitive?
BCC is thought to be more radiosensitive than SCC.
156
What is the equivalent dose for BCC using 30 fractions over 6 weeks?
60 Gy.
157
What is the equivalent dose for SCC using 30–32 fractions?
60–66 Gy.
158
What fractionation is used for patients aged <70 years with tumour >3–4 cm?
60 Gy/30 fractions/6 weeks.
159
What is the purpose of electron beam field definition?
Defined by 50% isodose; 90% isodose is 3–5 mm inside the field.
160
How much larger should the electron applicator be than the defined PTV?
5 mm larger to enclose the PTV within 90% isodose.
161
What is the stand off effect in electron therapy?
Filling the area with bolus/calculate correction.
162
What is needed for lower energy electrons to bring up the 90% isodose to the skin surface?
A bolus.
163
What type of shielding is needed for lower eyelid and canthi tumours?
Corneal shielding.
164
What shielding is required for lip tumours?
Buccal shields.
165
What is the purpose of coating shields with wax?
To absorb scattered radiation.
166
What is needed for tumours in the pinna and nasal regions treated with electrons?
Wax coated lead plugs in the external auditory canal and nose.
