19: Malignant and Pre-Malignant Lesions of Skin - Halverson Flashcards
only way to definitively diagnose malignancy
biopsy
ABCD and other indications of malignancy
asymmetry
irregular border
color change
diameter
changing/growing, bleeding, itching
firm, red papule, small, smooth, shiny, pale or waxy papule with telangiectasia
Stages of Skin Cancer
0 = carcinoma in situ I = less than 2 cm wide II = greater than 2 cm wide III = cancer has spread into subcutaneous tissue, such as cartilage, m, bone or to nearby lymph odes. not spread to other places in body IV = cancer has spread to other places in body METASTATIC Recurrent = cancer comes back in same area of body
most common malignant cutaneous neoplasm (among caucasians)
basal cell carcinoma
describe basal cell carcinoma
- sun exposed areas
- often multiple
slow-growing destructive - locally invasive, rarely metastasize
origin of basal cell carcinoma
basal layer of epidermal keratinocytes
histology indications
peripheral palisading
mucinous stroma
nodular form or morpheaform
basal cell carcinoma
Peripheral Palisading: Forms an orderly line around the periphery of tumor nests
Mucinous stroma
Nodular Form: Large nests of tumor cells
Morpheaform: Infiltrative nests and cords within a fibromyxoid stroma
most common form of basal cell carcinoma
nodular basal cell carcinoma
- often flesh-colored, dome-shaped nodule or papule
“rolled borders”
nodular basal cell carcinoma
worst type of basal cell carcinoma
morpheaform basal cell carcinoma
can be deeply invasive - high recurrence rate
look indurated, often flesh colored plaque
least aggressive form of basal cell carcinoma
superficial basal cell carcinoma
most comm basal cell carcinoma of LE and feet
superficial basal cell carcinoma
resembles eczema or psoriasis
gorlin’s syndrome
nevoid basal cell epithelioma syndrome
multiple BCC b/w puberty and 35 yo
assoc w/ palmar and plantar pits, skeletral abnormalities, jaw cysts, ectopic calcifications,
second most prevalent malignant tumor of skin
squamous cell carcinoma
most common among african americans and asian indians
metastasizes to lymph nodes and can be fatal
presents as non-healing ulcer or nodules. chronic ulcers, injury and burn scars are more aggressive and likely metastasize
squamous cell carcinoma
“keratin pearls”
squamous cell carcinoma
tx of choice squamous cell carcinoma
surgical excision
but oncology consult should take place for every pt with confirmed malignant neoplasm
multiple, erythematous to yellow-brown dry scaly lesions
actinic keratosis
SCC often develop in background of AK
keratinocytic atypia limited to lower portion of epidermis, often with epidermal budding
actinic keratosis histology
etiology of kaposi sarcoma
viral HHV8
violaveous macules and papules wwith slow progression to plaques
kaposi sarcoma (color due to vascular nature of tumor)
margin
rim of normal skin around the neoplasm
size of margin depends on the type of neoplasm
mohs surgery
each layer is immediately examined under a microscope. continue to shave away until no cancer cells can be seen under microscope
should you do electrodesiccation and curettage or cryosurgery for colored lesions?
no
most lethal type of skin malignancy
melanoma
ABCDEs of malignant melanoma
asymmety border irregularity color variation diameter enlargement evolving/elevated
malignant melanoma staging - Clark staging indicates level of invasion
I - all tumors above BM (in situ)
II - extends to papillary dermis
III - extends to interface b/w papillary and reticular dermis
IV - extends b/w bundles of collagen of reticular dermis
V - invasion of subq tisssue (87% metastases)
breslows depth (malignant melanoma)
Tumors are classified into four categories based on the depth:
pT1: Less than or equal to 1.00 mm (equivalent to Clark’s Level II)
pT2: 1.01-2.00 mm (equivalent to Clark’s Level III)
pT3: 2.01- 3.99 mm(equivalent to Clark’s Level IV)
pT4: Greater than or equal to 4 mm (equivalent to Clark’s Level V)
More accurate than Clarks Staging
4mm: 5-year survival is 37-50%
TNM
tumor, nodes(lymph), metastasized
T – Tumor - Based on the tumor thickness, a number (from 0 to 4) is assigned, and based on the ulceration, a letter (a or b) is assigned. The staging definition of metastatic melanoma when the primary site is unknown is to be categorized as stage III and not stage IV.
N –Nodes (Lymph)– Based on whether or not the melanoma has spread to lymph nodes, a number (from 0 to 3) is assigned. Nodal tumor deposits of any size are to be included in staging nodal disease.
M – Metastasized – Based on whether or not the melanoma has spread to other organs.The M category is primarily defined by the site or sites of distant metastases:M1a - skin/soft tissue/distant nodalM1b - lungM1c - all visceral metastitic sites; patients with an an increased serum lactic dehydrogenase level are all categorized as M1c regardless of the site or sites of distant disease.
T categories
Stage Tis. The tumor is in situ and remains non-invasive in the epidermis.
Stage T1a. The tumor is invasive but less than or equal to 1.0 mm in Breslow’s thickness, without ulceration and with a mitotic rate of less than 1/mm2.
Stage T1b. The tumor is less than or equal to 1 mm thick. It is ulcerated and/or the mitotic rate is equal to or greater than 1/mm2.
Stage T2a. The tumor is 1.01-2.0 mm thick without ulceration.
Stage T2b. The tumor is 1.01-2.0 mm thick with ulceration.
Stage T3a. The melanoma is 2.01-4.0 mm thick without ulceration.
Stage T3b. The melanoma is 2.01-4.0 mm thick with ulceration.
Stage T4a. The tumor is thicker than than 4.0 mm without ulceration
Stage T4b. The tumor is thicker than 4.0 mm with ulceration
when do you automatically get lymph node biopsy?
T1b and above
The two main factors in determining how advanced the melanoma is into Stage IV
the site of the distant metastases (nonvisceral, lung, or any other visceral metastatic sites) and elevated serum lactate dehydrogenase (LDH) level.
should you cauterize a pigmented lesion?
NEVER
melanoma on plams, soles, nails
acral lentiginous
worst prognosis of melanomas
nodular melanoma
hutchinsons sign
sudden appearance of subungual pigmented and at proximal nail fold
misdiagnosed as pyogenic granuloma
acral lentiginous melanoma
sentinel lymph node biopsy
Performed after the biopsy of the melanoma but before the wider excision of the tumor.
A radioactive substance is injected near the melanoma and movement of the substance is viewed on a computer screen.
The first lymph node(s) to take up the substance is called the sentinel lymph node(s). (The imaging study is called lymphoscintigraphy.)
The procedure to identify the sentinel node(s) is called sentinel lymph node mapping. The sentinel node(s) are removed to check for cancer cells.
If a sentinel node contains cancer cells, the rest of the lymph nodes in the area are removed (lymph node dissection). However, if a sentinel node does not contain cancer cells, no additional lymph nodes are removed.
cutaneous horn appears as funnel-shaped growth that extends from a red base on the skin
cutaneous horns - premalignant lesion
composed of compacted keratin
melanoma tx by stage
Stage 0
People with Stage 0 melanoma may have minor surgery to remove the tumor and some of the surrounding tissue.
Stage I
People with Stage I melanoma may have surgery to remove the tumor. The surgeon may also remove as much as 2 centimeters (3/4 inch) of tissue around the tumor. To cover the wound, the patient may have skin grafting.
Stage II or Stage III
People with Stage II or Stage III melanoma may have surgery to remove the tumor. The surgeon may also remove as much as 3 centimeters (1 1/4 inches) of nearby tissue. Skin grafting may be done to cover the wound. Sometimes the surgeon removes nearby lymph nodes.
Stage IV
People with Stage IV melanoma often receive palliative care. The goal of palliative care is to help the patient feel better—physically and emotionally. This type of treatment is intended to control pain and other symptoms and to relieve the side effects of therapy (such as nausea), rather than to extend life.
The patient may have one of the following:
Surgery to remove lymph nodes that contain cancer cells or to remove tumors that have spread to other areas of the body
Radiation therapy, biological therapy, or chemotherapy to relieve symptoms
describe superficial spreading malignant melanoma
- any body part
- raised irregular border, uneven pigment
- slow growing
- detected early, excellent prognosis
describe lentigo maligna
- sun-exposed areas
- flat, irregular border, tan, black, areas of red, white, blue and gray
- very slow growing
- detected early prognosis good
describe nodular
- any body part
- nodule blue, brown or black, or amelanotic
- grows very rapidly
- grave prognosis
describe acral lentiginous
- palms, soles nail beds
- flat, sometimes no pigment
- may remain latent for years
- greater than 3 mm is poor prognosis
describe basal cell carcinoma
- most common malignant skin lesion
- face, lower legs and feet
- slow growing
- good if caught early
describe squamous cell carcinoma
- 2nd most common malignant skin lesion
- sun-exposed wounds, scars
- may metastasize
- grade IV worse prognosis
describe kaposi sarcoma
- older males, european/mediterranean/jewish, AIDS
- ankles and feet
- slow progression
- good prognosis
describe malignant melanoma
- most common malignancy seen by podiatrists
- any body part
- metastasize
- nodular and acral lentiginous worse prognosis
