Skin Lesions

Question 0

How are pigmented lesions evaluated?

Answer 0

ABCDE: asymmetry, Border irregularity, colors variable, diameter of more than 6 mm, erythema.

Question 1

Differential diagnosis for skin lesions?

Answer 1

Benign lesions – keratoses or pigmented lesions. Malignant lesions – BCC, SCC, adnexal tumors, cutaneous melanoma

Question 2

Name the types of keratoses

Answer 2

“SACKS” Seborrheic keratoses, actinic keratoses, cutaneous horns, keratocanthomas

Question 3

Describe some characteristics of seborrheic keratoses?

Answer 3

Common benign lesions, trunks of elderly patients, multiple rounds tan to black well demarcated plaque like, biopsy not necessary

Question 4

Describe general characteristics of actinic keratoses

Answer 4

Common, sun exposed areas, 20% progress to squamous cell carcinoma within one year if not treated, raised, red, gritty, scaley

Question 5

Treatment for actinic keratoses?

Answer 5

Removal by excision, topical 5– fluorouracil, cryotherapy and electrodesiccation.

Question 6

Describe characteristics of Keratoacanthomas

Answer 6

Solitary usually benign, sun exposed skin and adults older than 40, rapidly enlarge over 6–8 weeks, painless firm well circumscribed and raised nodules with shiny unpigmented rim and scaly cratered Center. Should excise.

Question 7

Cutaneous horns

Answer 7

Hard scaly conical projections up to several centimeters in length. Most common on face or scalp of elderly, 25% arise from premalignant bases of actinic keratoses and bowens disease, 15% from SCC

Question 8

Bowen’s disease

Answer 8

SCC in situ

• ill-defined, scaly red plaques
• head and neck
• biopsy necessary to differentiate from superficial basal cell carcinoma or actinic keratosis

Question 9

Rx for bowen’s disease

Answer 9

Treat with superficial removal curettage, electrodesiccation, cryotherapy, shave excision

Question 10

What are the four types of nevi?

Answer 10

Melanocytic, compound, junctional, architectural disorder

Question 11

Melanocytic Nevus

Answer 11

• benign proliferation of melanocytes in the dermis

- no need for excision unless suspicious

Question 12

Compound melanocytic nevus

Answer 12

• Melanocytes at dermoepidermal junction and dermis

- raised, flesh colored to Brown

Question 13

Junctional melanocytic nevus

Answer 13

• melanocytes at the dermoepidermal junction
• m/c in children
• transforms to compound nevus by adulthood
• small, flat, brown, regular borders with no distortion of surrounding skin

Question 14

Nevus with architectural disorder

Answer 14

• acquired lesion
• appeared similar to malignant melanoma, large-size 5 to 10 mm
• often seen in familial disorders

Question 15

Basal Cell Carcinoma

• incidence?
• Cause?
• Where on body?

Answer 15

• m/c skin malignancy, 800,000 cases per year
• Chronic UV A or B exposure, immunosupppresion
• sun exposed parts of body
• pigmented or black

Question 16

Types of BCC

Answer 16

Superficial BCC
Nodular BCC
Morpheaform or sclerosing BCC

Question 17

Superficial BCC

Answer 17

least aggressive
red scaly patch grows to peripheral extension
usually on trunk/extremities

Question 18

Nodular BCC

Answer 18

• M/C
• more aggressive
• pink, elevated, firm and shiny with rolled borders and pearly appearance, usually overlying telangietasia

Question 19

Morpheaform or sclerosing BCC

Answer 19

• more aggressive
• yellowish or pale plaquelike lesion
• ill defined borders blend into surrounding skin

Question 20

Treatment for BCC?

Answer 20

• surgical excision with negative histologic margins (2-4 mm normal appearing skin)
• small well defined lesions with radiation or cryotherapy but rate of recurrence higher and cosmetic results poorer

Question 21

What is the cure rate for BCC?

Answer 21

with treatment, >90%

Question 22

Incidence of SCC?

Answer 22

2nd m/c skin malignancy

200,000 cases/year

Question 23

Risk factors for SCC

Answer 23

sun-exposure, fair skin, hydrocarbons and arsenic, immunosuppression, chronic inflammation

Question 24

Appearance of SCC?

Answer 24

Hyperkeratotic, flesh colored, raised, may have ulceration or surrounding erythema

Question 25

Rx for SCC?

Answer 25

Surgical excision with negative margins (2-4mm normal appearing skin)

Question 26

What are adnexal tumors?

Answer 26

Tumors arising from skin appendages (hair follicles, eccrine, apocrine, and sebaceous glands, fibrous tissue and neural tissue) -examples: pilomatricoma, merkel cell carcinoma, cylindroma

Question 27

Rx adnexal tumors. Prognosis?

Answer 27

Surgical excision, depends on origin of tumor.

Question 28

Incidence of cutaneous melanoma?

Answer 28

54,200/year, incidence increased significantly over last 40 years 5th m/c cause cancer in men 7th m/c cause cancer in women

Question 29

Diagnosis of skin lesions?

Answer 29

``` Asymmetry Border irregularity Color variation Diameter > 6mm Evolution or elevation ```

Question 30

Types of biopsies?

Answer 30

Excisional biopsy preferred. Punch biopsy acceptable for larger. - Thickness of tumor most important prognostic indicator, full thickness biopsy. - AVOID SHAVE BIOPSY

Question 31

When should sentinel node biopsy be considered?

Answer 31

patients without clinical evidence of nodal involvement (palpable nodes) but with reasonable possibility of occult nodal involvement, absence of widely metastatic disease. -intermediate thickness (1-4mm) most likely to benefit from SNB

Question 32

Is SNB offered for lesions <1mm?

Answer 32

if lesion <6% risk of nodal metastasis so SNB not routinely offered. If other risk factors for mets including ulceration, regression, male gender, or axial location.

Question 33

Prognosis for thick melanomas?

Answer 33

70% risk of occult systemic mets and 60-70% risk of occult nodal mets.

Question 34

Indications for radical lymphadenectomy?

Answer 34

Standard treatment for all patients with REGIONAL NODAL METS (clinically palpable disease proven to be mets by FNA or excisional biopsy of palpable node or SNB+)

Question 35

Indication for adjuvant therapy?

Answer 35

interferon alfa-2b improves survival in patients with high risk melanoma (>4mm thickness or nodal mets)

Question 36

What determines risk of recurrence for melanoma?

Answer 36

Thickness and +/- nodal mets

Question 37

Where will recurrence of melanoma occur?

Answer 37

Wide local excision site and regional nodal basin. Distant mets possible: nods, lung, liver, brain, bone, GIT

Question 38

F/u for patients with thin melanoma?

Answer 38

node negative followed q6mo for 2-3 years, then annually 2-3 years

Question 39

F/u for patients with intermediate or thick melanoma?

Answer 39

q3-6 months for 3 years, q4-12 months for 2 years, then annually

Question 40

Which factors lead to a poor prognosis and melanoma?

Answer 40

Lesions > 0.75mm lesions on the back, arms, neck, and scalp; and female gender

Question 41

Tumor stage Tis | Description and what are the surgical margins?

Answer 41

Tumor confined to epidermis. | Surgical margins 5 mm

Question 42

T1 melanoma | Description and surgical margins?

Answer 42

Tumor depth < or = 1mm | Surgical margins 1 cm

Question 43

T2 melanoma | Description and surgical margins?

Answer 43

Tumor depth of 1.01-2 mm | Surgical margins 1-2 cm

Question 44

T3 melanoma | Description and surgical margins?

Answer 44

Tumor depth 2.01 - 4mm | Surgical margins 2 cm

Question 45

T4 melanoma | Description and surgical margins?

Answer 45

Tumor depth > 4 mm | Surgical margins > 2 cm