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Surgery M4 part 1 > Skin tumors > Flashcards

Skin tumors Flashcards

1
Q

What is the 2nd most common skin cancer?

A

SQUAMOUS CELL CARCINOMA (epithelioma)

  • in old men
  • occurs in pre-existing lesion (venous ulcer or burn)
  • grossly proliferative/ulcerative/red plaque like
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2
Q

What are the predisposing factors for SSC?

A
  • prolonged exposure to UVR or tar
  • previous irradiation
  • long standing irradiation (marjolin ulcer)
  • PREMALIGNANT LESIONS
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3
Q

What are the premalignant lesions that predispose to SSC?

A
  • senile keratosis
  • Bowen’s disease
  • Paget’s disease
  • leukoplakia
  • chronic scars
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4
Q

What is the clinical picture of a SSC?

A
  • ulcero-proliferative lesion
  • raised & everted edge, fixed indurated base, necrotic floor with bloody discharge
  • induration extends beyond the margin
  • regional lymph nodes are hard, nodular, initially mobile eventually fixed

histo -> malignant epithelial cells with central Keratin pearls surrounded by prickle cells

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5
Q

What other variants of SSC are present?

A

MARJOLIN’S ULCER -> no lymph node involvement

VERRUCOUS CARCINOMA -> no lymph node involvement

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6
Q

What is the TNM staging of for skin cancer (other than melanoma)?

A 
T0: no tumor 
T1: <2cm
T2: 2-5cm
T3: >5cm
T4: spread to cartilage, muscle or bone

N0: no nodes
N1: regional nodes ++

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7
Q

What is Broder’s classification of SSC?

A

I -> Well differentiated 75% or more Keratin pearls
II -> moderately differentiated 50-75% keratin pearls
III -> poorly differentiated 25 - 50% keratin pearls
IV -> <25% keratin pearls

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8
Q

What investigations should be done for suspected SSC?

A
  • edge biopsy

- take a whole lymph node

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9
Q

How should SSC be treated?

A
  • radiotherapy (BRACHYTHERAPY) -> doesnt effect nearby structures
  • wide excision with safety margin -> skin graft or flap
  • amputation 1 joint above
  • block dissection of regional lymph nodes
  • if LN + -> chemotherapy (methotrexate, vincristine, bleomycin)
  • cryo probe or topical fluorouracil or electrodessication -> field therapy
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10
Q

What is the treatment of a Verrucous carcinoma?

A

wide excision

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11
Q

What makes the prognosis of SCC worst?

A
  • tumor size >2cm
  • ill defined borders
  • associated immunosuppression
  • poorly differentiated
  • perineural involvement
  • invasion
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12
Q

What is the commonest skin tumor?

A

BASAL CELL CARCINOMA
- more common in whites, males, & middle aged or elderly
- high exposure to UV light
- only locally malignant -> erodes deeply into local tissues including cartilages & bone causing extensive local destruction
RODENT ULCER

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13
Q

What is the most common site for occurrence of a rodent ulcer?

A
  • face above the line drawn between angle of mouth & ear lobule
  • TEAR CANCER
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14
Q

What are the types of of BCC?

A
  • NODULOCYSTIC & NODULOULCERATIVE (commonest)
  • nodular
  • ulcerative
  • pigmented BCC (mimics melanoma)
  • field fire or forest fire BCC
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15
Q

What is forest fire BCC?

A

wide area involvement with central scabbing & peripheral active proliferating edge

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16
Q

What are the clinical features of a BCC?

A
  • nontender, dry, slowly growing, non mobile ulcer with RAISED & BEADED edge
  • central scab
  • beading area is active proliferating cells
  • DIRECT SPREAD ONLY (no LN involvement)
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17
Q

What is considered a high risk BCC lesion?

A
  • > 2cm
  • near eye/nose/ear
  • ill-defined margin
  • recurrent tumors
  • immunosuppressed
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18
Q

How should a BCC be treated?

A
  • radiosensitive
  • radiotherapy if its FAR from eyes
  • no radiotherapy if it erodes bones
  • wide excision with skin graft or flap
  • laser surgery, cryosurgery
  • local 5FU ointment
19
Q

What are the indications for surgery in BCC?

A
  • rodent ulcer eroding cartilage or bone
  • close to the eye
  • recurrent
  • radio-resistant
  • small lesion
20
Q

A hemartomata of melanocytes due to excessive stimulation is called?

A

NAEVI

- presents during birth of later on

21
Q

What are the types of NAEVI?

A
  • hairy mole
  • lentigo (flat black spot replace basal epidermis)
  • intradermal naevus (cluster of dermal melanocytes in face)
  • junctional naevus (immature unstable & PREMALIGNANT)
  • compound naevus (intradermal + junctional) potentially malignant
22
Q

What is a malignant tumor arising from the epidermal melanocytes? MOST AGGRESSIVE MALIGNANT TUMOR

A

MELANOMA

+ dopa test

23
Q

What are the risk factors for developing a malignant melanoma?

A
  • exposure to UV light
  • Albinism & Xeroderma pigmentosa
  • Junctional Naevus
  • Large congenital naevi (larger than 20cm)
  • family history
  • immunosuppression or post renal transplant or NHL
24
Q

How do we know a benign naevi is turning malignant?

A

MAJOR SIGNS -> change in size (more than 6mm), shape, & color

  • inflammation, crusting, bleeding, itching
  • nodularity, ulceration, halo around mole
  • satellite lesions
  • doppler positive pigmented lesions (>0.9mm thick have blood supply)
25
Q

What is the most common site in females for development of melanoma?

A

leg

26
Q

What is the most common site in males for development of melanoma?

A

front or back of trunk

27
Q

What classification is based on the thickness of the tumor in melanoma?

A 
BRESLOW'S CLASSIFICATION 
I -> less than 0.75mm
II -> between 0.76 to 1.5mm
III -> 1.51 to 4mm
IV -> more than 4mm
28
Q

What classification of melanoma is based on the depth of invasion?

A 
CLARK'S LEVELS
level 1 -> epidermis 
level 2 -> papillary dermis
level 3 -> fill papillary dermis completely 
level 4 -> reticular dermis 
level 5 -> subcutaneous tissue
29
Q

what is the common site for an extra cutaneous melanoma?

A

ocular

30
Q

What is the most common clinical type of a melanoma?

A

SUPERFICIAL SPREADING 64%

  • in middle age
  • more radial growth
  • from pre existing naevus
  • better prognosis
31
Q

What type of melanoma occurs in a younger age group of men on their trunk or head & neck, and has more vertical growth?

A

NODULAR MELANOMA 12-25%

  • more aggressive
  • poor prognosis
32
Q

which melanoma is the least malignant, is common in old age & face, is slow growing, variegated, brown macule/lentigo?

A

LENTIGO MALIGNA MELANOMA (Hutchinson’s melanotic freckle) 7-15%

  • in elderly women
  • common in face neck & hands
33
Q

What type of melanoma occurs in palms, soles & subungual region (under nail)?

A

ACRAL LINTIGINOUS MELANOMA 5%

  • least common
  • poor prognosis
  • more vertical growth phase
  • mimics fungal infection/pyogenic granuloma
34
Q

What is the WORST type of melanoma that is S100 & HMB45 +ve?

A

AMELANOTIC MELANOMA

  • tumor cells loose their capacity to synthesize melanin
  • pinkish FLESHY growth of rapidly progressive tumour
  • mimics soft tissue sarcoma
35
Q

Which melanoma has high affinity for perineural invasion?

A

DESMOPLASTIC MELANOMA

- common in head & neck with higher recurrence rate

36
Q

What are the clinical features of melanoma?

A
  • can start from pre-existing naevus (JUNCTIONAL) or as de novo in normal skin
  • no induration
  • pigmentation with irregular surface margin
  • rapid growth
  • ulceration, bleeding, itching, change in color
37
Q

How does the spread of melanoma occur?

A
  • spreads to regional lymphatics
  • in-transit nodules or satellite nodules (retrograde spread to lymphatics)
  • blood to lungs, liver, brain, skin, or bones (BLACK SECONDARIES)
38
Q

What is the TNM staging for melanoma?

A

T0: no tumor N0: no nodes
T: in situ N1a: 1 node micrometastasis
T1a: <1mm no ulceration N1b: 1 node macrometastasis
T1b: <1mm with ulceration N2a: 2 or 3 nodes micrometastasis
T2a: 1-2mm no ulceration N2b: 2 or 3 nodes macrometastasis
T2b: 1-2mm with ulceration N2c: satellite of in transit lesions
T3a: 2-4mm no ulcerations N3: 4 or more nodes; nodes with satellite or in transits
T3b: 2-4mm with ulcerations
T4a: >4mm no ulcerations M0: no blood spread
T4b: >4mm with ulcerations M1a: skin, subcutaneous tissue, distant node
M1b: lung spread
M1c: other viscera or distant spread & increase in LDH

39
Q

what are the 5 most important features of melanoma?

A
  • asymmetry
  • border irregularity
  • color variation
  • diameter >6mm
  • elevation
40
Q

what are the tumor markers for melanoma?

A
  • MELAN-A
  • S100
  • HMB45
  • LDH
41
Q

What investigations should be done for melanoma?

A
  • excision biopsy of primary
  • lymph node excision
  • US & chest X-ray to see metastasis
  • CT scan of head chest abdomen pelvis
  • urine for MELANURIA -> advanced disease
  • sentinel lymph node biopsy
42
Q

What is the treatment for primary melanoma?

A
  • wide excision with clearance margin 2cm
  • in fingers & toes -> disarticulation
  • if area is wide -> amputate 1 joint above
  • in anal canal -> abdominoperineal resection
  • in eye -> enucleation of eye
  • immunotherapy using tumour antibodies BCG, levamisole in advamced melanomas
  • radiotherapy on beneficial in secondaries in brain & bones
43
Q

When should chemotherapy be used in case of melanoma?

A
  • secondaries in liver, lungs, or bone

- after surgery IV (melphalan & carboplatin)

Surgery M4 part 1 (47 decks)

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