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HPIM Onco > 105: Cancer of the Skin > Flashcards

105: Cancer of the Skin Flashcards

1
Q

T or F: Cutaneous melanoma has no age predilection. It can occur in adults in all ages.

A

True

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2
Q

T or F: Cutaneous melanoma is predominantly a malignancy of white-skinned people (98%)

A

True

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3
Q

Sex predilection of cutaneous melanoma

A

Male

Diagnosis at late fifties

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4
Q

Strongest risk factors for melanoma

A
  1. Presence of multiple, benign OR atypical nevi

2. Family or personal history of melanoma

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5
Q

Marker of increased risk of melanoma

A

Presence of melanocytic nevi, common or dysplastic

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6
Q

Congenital melanocytic nevi and classification accdg to diameter

A

Small: = 1.5cm
Medium: 1.5-2.0cm
Giant: >20cm

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7
Q

Management for giant melanocytic nevus (bathing trunk nevus)

A

Prophylactic excision early in life

6% lifetime risk of melanoma

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8
Q

T or F: The higher the number of total body nevi, the higher the risk of melanoma

A

True

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9
Q

Surveillance for patients diagnosed with melanoma

A

Lifetime

Should be done by dermatologist and include total body photography and dermoscopy if appropriate

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10
Q

Cell cycle regulatory gene responsible for 20-40% of cases of hereditary melanoma

A

cyclin-dependent kinase inhibitor 2A (CDKN2A)

Chromosome 9p21
Encodes for tumor suppressor proteins: p16 (cell cycle arrest) and ARF (defective apoptotic response to genotoxic damage)

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11
Q

T or F: Red hair color (RHC) phenotype is associated with increased risk of melanoma.

A

True

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12
Q

Primary prevention of melanoma and nonmelanoma skin cancer

A

Protection from the sun

Advise:
Regular use of broadspectrum sunscreens blocking UVA and UVB with SPF atleast 30

Avoidance of tanning beds and midday (10am-2pm) sun exposure

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13
Q

Secondary prevention of melanoma and nonmelanoma skin cancer

A
  1. Education
  2. Screening
  3. Early detection
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14
Q

Interval of self examination that enhance likelihood of detecting change

A

6-8 week intervals

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15
Q

ABCDE for early detection of melanoma

A 
Asymmetry
Border irregularity
Color Variegation
Diameter >6mm
Evolving (size, shape, color, elevation or new symptoms: bleeding, itching, crusting)
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16
Q

Where do benign nevi usually appear?

A

Sun-exposed skin above the waist

Rarely: Scalp, Breasts, Buttocks

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17
Q

Average number of benign nevi in adults

A

10-40 moles

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18
Q

Who should be a candidate for biopsy?

A
  1. Any pigmented cutaneous lesion that has changed in size or shape
  2. Has other features suggestive of malignant melanoma
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19
Q

Margins suggested for excisional biopsy?

A

1-3mm margins

Definitive treatment for benign nevi

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20
Q

When is incisional biopsy opted rather than excisional biopsy?

A

If excisional biopsy is not feasible (face, hands, feet)

Through the most nodular or darkest area of lesion

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21
Q

T or F: Cauterization is allowed in biopsy

A

False. It should be avoided.

Shave biopsies are acceptable

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22
Q

What should we expect in the biopsy reading?

A
  1. Breslow thickness
  2. Mitoses per square millimeter for lesions =1mm
  3. Presence or absence of ulceration
  4. Peripheral and deep margin status
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23
Q

Greatest thickness of a primary cutaneous melanoma measured on the slide from the top of the epidermal granular layer, or from the ulcer base, to the bottom of the tumor

A

Breslow thickness

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24
Q

Four MAJOR types of cutaneous melanoma

Table 105-2

A
  1. Lentigo maligna melanoma
  2. Superficial spreading melanoma
  3. Nodular melanoma
  4. Acral lentiginous melanoma
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25
Q

Period at which the skin lesion increase in size but does not penetrate deeply; period most capable of being cured by surgical excision

A

Radial growth phase

Types: Lentigo maligna melanoma, superficial spreading melanoma, acral lentiginous melanoma

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26
Q

Type of melanoma with no radial growth phase which usually presents as deeply invasive lesion capable of early metastasis

A

Nodular melanoma

Brown-black to blue-black nodules

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27
Q

Period where tumors begin to penetrate deeply into the skin

A

Vertical growth phase

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28
Q

The most common variant of melanoma observed in the white population

A

Superficial spreading melanoma

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29
Q

Most common site for melanoma in men and women

A

Men: Back
Women: Back and Lower leg (knee to ankle)

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30
Q

Type of melanoma occurring on the palms, soles, nail beds, and mucous membranes

A

Acral lentiginous melanoma

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31
Q

Most common types of melanoma in blacks and East Asians

A
  1. Acral lentiginous melanoma

2. Nodular melanoma

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32
Q

Other SITES where melanoma can arise

A
  1. Mucosa of head and neck (nasal cavity, paranasal sinuses, oral cavity)
  2. GI tract
  3. CNS
  4. Female genital tract (vulva, vagina)
  5. Uveal tract of the eye
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33
Q

Fifth type of melanoma associated with fibrotic response, neural invasion, and greater tendency for local recurrence

A

Desmoplastic melanoma

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34
Q

Type of melanoma commonly seen on sun-exposed surfaces, particularly malar region of cheek and temple

A

Lentigo maligna melanoma

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35
Q

Effects of UV solar radiation on skin

A
  1. Genetic changes in skin
  2. Impairs cutaneous immune function
  3. Increases the production of growth factors
  4. Induces formation of DNA-damaging reactive oxygen species affecting keratinocytes and melanocytes
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36
Q

Mechanism of BRAF mutation found in most benign nevi

A 
Point mutation (T-->A mucleotide change)
Valine-to-glutamate amino acid substitution
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37
Q

Best predictor of metastatic risk

A

Brelow thickness

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38
Q

Defines melanomas on the basis of the layer of skin to which melanoma has invaded and has minimal influence on the treatment decisions

A

Clark level

39
Q

Anatomic site of the primary lesion is prognostic. What are the favorable and unfavorable sites?

A

Favorable: Forearm and leg (excluding feet)
Unfavorable: Scalp, Hands, Feet, Mucous membranes

40
Q

Laboratories for diagnosis of melanoma

A
  1. CBC
  2. Complete metabolic panel
  3. LDH
41
Q

Staging criteria for melanoma

A
  1. Pathologic and TNM stage
  2. Thickness (mm)
  3. Ulceration
  4. No. of involved lymph nodes
  5. Nodal involvement
  6. 15-year survival estimate (%)
42
Q

An elevated LDH signifies what staging for melanoma and the 15-year survival estimate?

A

Stage IV - 10%

43
Q

Margins recommended for primary melanoma

A

In situ: 0.5 - 1 cm
Invasive up to 1mm thick: 1cm
>1.01 - 2 mm: 1 - 2 cm
>2 mm: 2cm

Include subcutaneous fat
Careful for lesions on face, hands and feet

44
Q

Valuable staging tool that replaced elective regional nodal dissection for evaluation of regional nodal status

A

Sentinel lymph node biopsy (SLNB)

45
Q

Provides prognostic information and helps identify patients at high risk for relapse who may be candidates for adjuvant therapy

A

Sentinel lymph node biopsy (SLNB)

46
Q

Stains used in histopathology of melanoma

A
  1. Hematoxylin and eosin stains

2. Immunohistochemical stains: s100, HMB45, MelanA

47
Q

T or F: SLNB is required in all patients.

A

False.

In general: Tumors > 1mm thick
Not for patients whose melanomas are =0.75mm thick
For 0.76 - 1.0mm tumors: Depends on high risk features; wide excision alone is Definitive therapy

48
Q

Patient with melanoma underwent SLNB and turned out positive. What is your next step?

A

Perform complete lymphadenectomy

49
Q

Melanomas that recur at the edge of the scar or graft which are separate from but within 2cm of the scar

A

Satellite metastases

50
Q

Melanomas that recur > 2cm from the primary lesion but not beyond the regional nodal basin

A

In-transit metastases

51
Q

T or F: Radiotherapy can reduce risk of local recurrence after lymphadenectomy, but does not affect overall survival.

52
Q

Who should undergo radiotherapy?

A
  1. Large nodes ( >3-4cm)
  2. Four or more involved lymph nodes
  3. Extranodal spread on microscopic examination
53
Q

Therapy indicated primarily for patients with stage III disease

A

Systemic adjuvant therapy

54
Q

Adjuvant therapies for Stage III disease

A
  1. Interferon a2b (IFN-a2b) 20 M units/m2 IV 5 days/wk for 4 weeks + 10M units/m2 SC 3x/wk for 11 months
  2. Subcutaneous peginterferon a2b (6ug/kg/wk for 8 weeks) + 3ug/kg/wk for total of 5 years
55
Q

Toxicities of treatment

A
  1. Flu-like illness
  2. Decline in performance status
  3. Development of depression
56
Q

Laboratories and imaging for recurrent melanoma

A
  1. CBC
  2. Complete metabolic panel (Na, K, crea, RBS, AST, ALT)
  3. LDH
  4. MRI brain and total-body PET/CT
  5. CT scan of chest, abdomen, pelvis
57
Q

Common distant metastases of melanoma

A
  1. Skin
  2. Lymph nodes
  3. Viscera
  4. Bone
  5. Brain
58
Q

Median survival range of metastatic melanoma

A

6 - 15 months

59
Q

FDA approved therapeutic agents for melanoma

A
  1. Anti-CTLA-4: Ipilimumab
  2. BRAF inhibitor: Vemurafenib, Dabrafenib
  3. MEK inhibitor: Trametinib
  4. Interleukin 2 (IL-2 or aldesleukin)
60
Q

Surgical option for metastatic melanoma

A

Metastasectomy

61
Q

Most common immune-related adverse events using Ipilimumab

A

Skin rash

Diarrhea

62
Q

Immunotherapy treatment for melanoma with significant toxicity and high cost, but with increased survival benefit

A

Ipilimumab

63
Q

Adverse reaction of this immunotherapy agent for metastatic melanoma is appearance of well-differentiated squamous cell skin cancers

A

BRAF inhibitors

64
Q

T or F: No chemotherapy regimen has ever been shown to improve survival in metastatic melanoma and have relegated it only to palliation of symptoms.

65
Q

Chemotherapeutic drugs considered in metastatic melanoma

A
  1. Dacarbazine
  2. Temozolomide
  3. Cisplatin, Carboplatin
  4. Paclitaxel, Docetaxel
  5. Carmustine
66
Q

You diagnosed your patient to have Melanoma stage IV by biopsy. Accdg to the initial approach to metastatic disease, what should be your next step?

A

Molecular testing (BRAF status)

67
Q

Follow-up for patients with melanoma

A

ALL : Skin examination and surveillance at least one a year
Stage IA - IIA : Hx and PE every 6-12 mos for 5 years, then annually
Stage IIB-IV : Imaging (cxr, ct and pet/ct scan) every 4-12 months can be considered

*Perform scan only if indicated

68
Q

Most common cancer in US

A

Nonmelanoma skin cancer (NMSC)

Basal cell CA (BCC) - 70-80%
Squamous cell CA (SCC) - 20%
Merkel cell CA

69
Q

Most significant cause of BCC and SCC

A

UV exposure (sunlight or artificial)

70
Q

Mechanism of DNA damage of UVA and UVB

A

UVA : free radical formation

UVB : induction of pyrimidine dimers

71
Q

What type of UV light is present in tanning bed equipments?

A

UVA 97%

UVB 3%

72
Q

Genes damaged most commonly by UV in BCC and SCC

A

BCC: Hedghog pathway (Hh)
SCC: p53, N-RAS

73
Q

Cells where BCC arise?

A

Epidermal basal cells

74
Q

The least invasive type of BCC consisting of subtle, erythematous scaling plaques that slowly enlarge and most commonly seen on the trunk and proximal extremities

A

Superficial BCC

75
Q

Type of BCC that presents as small, slowly growing pearly nodule, often with tortuous telangiectatic vessels on its surface, rolled borders, and central crust

A

Nodular BCC

76
Q

Most invasive and potentially aggressive subtypes of BCC that manifest as solitary, flat, or slightly depressed, indurated whitish, yellowish, or pink scar-like plaques;

A

Morpheaform (fibrosing), infiltrative, and micronodular BCC

77
Q

Cells where primary cutaneous SCC arise?

A

Keratinizing epidermal cells

78
Q

Appears as an ulcerated erythematous nodule or superficial erosion on sun-exposed skin of head, neck, trunk and extremities; may appear banal, firm, dome-shaped papule or rough-textured plaque

79
Q

Hallmark of SCC through dermatoscope

A

Dotted or coiled vessels

80
Q

Very rapidly growing but low-grade form of SCC that typically appears as a large dome-shaped papule with a central keratotic crater

A

Keratoacanthoma

81
Q

Premalignant forms of SCC that present as hyperkeratotic papules on sun-exposed areas

A

Actinic keratoses

Cheilitis (actinic keratoses on the lip)

82
Q

SCC in situ that is the intraepidermal form of SCC most commonly arising on sun-damaged skin

A

Bowen’s disease

83
Q

Type of NMSC that is slowly enlarging, locally invasive neoplasm with low metastatic potential

84
Q

This type of NMSC metastasizes most frequently to regional lymph nodes

85
Q

Treatment for BCC

A
  1. Electrodesiccation and curettage (ED&C)
  2. Excision
  3. Cryosurgery
  4. Radiation therapy
  5. Laser therapy
  6. Mohs micrographic surgery
  7. Topical 5-FU
  8. topical immunomodulators: Imiquimod
86
Q

Most commonly employed method for superficial, minimally invasive nodular BCC and low risk tumors

87
Q

Surgical treatment for invasive, ill-defined and more aggressive subtypes of tumors or for cosmetic reasons

A

Wide local excision

88
Q

Specialized type of surgical excision that provides the best method for tumor removal while preserving the uninvolved tissue with cure rate of >98%

A

Mohs micrographic surgery (MMS)

89
Q

Standard treatment for SCC

A
  1. Surgical excision

2. MMS

90
Q

Treatment for lymph node metastasis in SCC

A

Surgical resection and/or

Radiotherapy

91
Q

Neural crest-derived highly aggressive malignancy with mortality rates approaching 33% in 3 years

A

Merkel cell carcinoma (MCC)

92
Q

Uncommon apocrine malignancy arising from stem cells or epidermis characterized histologically by presence of Paget cells

A

Extramammary Paget’s disease

93
Q

Tumors presenting as moist erythematous patches on anogenital or axillary skin of the elderly

A

Extramammary Paget’s disease

Treatment: Surgical excision with MMS

94
Q

Soft tissue sarcoma of vascular origin that is induced by the human herpesvirus 8

A

Kaposi’s sarcoma (KS)

HPIM Onco (4 decks)

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