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#2 derm > 19 - Pre-malignant and Malignant Neoplasms > Flashcards

19 - Pre-malignant and Malignant Neoplasms Flashcards

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Dermatology Board Prep flashcards
1
Q

Skin malignancy clinical presentation

A

Varied clinical presentation

o Painful, painless, ulcerated, pruritic, asymptomatic, etc.

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2
Q

The only way to definitively diagnose malignancy

A

A biopsy is the only way to definitively diagnose malignancy

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3
Q

Prognosis once malignancy is diagnosed

A

Prognosis varies depending on type (basal cell carcinoma (BCC) vs melanoma)
o BCC – malignant but will never actually metastasize (low risk)
o Melanoma – malignant and will metastasize (high risk)

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4
Q

Indications of malignancy

A
  • Changing/growing
  • Bleeding
  • Itching
  • ABCDs
  • Patients are often the first to notice changes…history is important!
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5
Q

ABCDs

A

o Asymmetry
o Irregular Border
o Color Change—often variable depending on skin type
o Diameter

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6
Q

Examples of lesions

slides 4-6

A

o Small, smooth, shiny, pale, or waxy papule with telangiectasia
o Firm, red papule
o Nonhealing ulcer that bleeds, scales, or crusts
o Erythematous macule that is rough, dry, or scaly and may become itchy or tender
o Red or brown patch that is rough and scaly

NOTE – better to do a biopsy around the edge where you can see some normal skin and some abnormal skin

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7
Q

Stages of skin cancer

A
  • Stage 0: Carcinoma in situ
  • Stage I: 2 cm wide
  • Stage III: The cancer has spread into subcutaneous tissue , such as cartilage, muscle, bone, or to nearby lymph nodes. It has not spread to other places in the body.
  • Stage IV: The cancer has spread to other places in the body.
  • Recurrent: Cancer comes back in same area of the body
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8
Q

What do you NEED to know about basal cell carcinoma?

A
  • MOST COMMON MALIGNANT CUTANEOUS NEOPLASM (among Caucasians)
    o 4-5x more frequent than SCC
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9
Q

Characteristics of basal cell carcinoma

A
  • Sun exposed areas
  • Commonly seen on the face, back/shoulders, also lower legs and feet
  • Tumors often multiple (46% of patients had more than one lesion over a 10 year period)
  • Slow-growing destructive lesion
  • Locally invasive, rarely metastasizes
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10
Q

Basal cell carcinoma histology

A
  • Basal layer of epidermal keratinocytes
  • 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
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11
Q

Clinical forms of basal cell carcinoma

A
  • Nodular
  • Superficial
  • Cystic
  • Pigmented
  • Morpheaform/Infiltrative
  • Nevoid
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12
Q

Most common form of basal cell carcinoma

A

Nodular basal cell carcinoma

MOST COMMON FORM OF BCC

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13
Q

Characteristics of nodular basal cell carcinoma

A
  • Often flesh-colored, dome-shaped nodule or papule, can have “rolled boarder”
  • Slow growing
  • Telangiectatic vessels make appearance “erythematous”
  • Melanin pigment gives brown, black or blue-black discoloration
  • Can be elevated, multilobular
  • Center may ulcerate, bleed, never seems to heal
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14
Q

Cystic basal cell carcinoma

A
  • Smooth, round, cystic mass – can be misdiagnosed as a cyst
  • Lobulated, pearl-like in color, telangiectasia
  • Clear fluid if opened
  • Does not ulcerate much until late stages
  • Usually gets very large before treatment is sought
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15
Q

Pigmented basal cell carcinoma

A
  • Similar appearance to malignant melanoma
  • Can have erosive center
  • Pigmented border
  • Brown, black or blue
  • Elevated, pearly white with translucent border
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16
Q

Morpheaform basal cell carcinoma

A
  • Indurated, often flesh colored plaque
  • Frequently misdiagnosed
  • Pearly white, telangiectasia
  • Can be deeply invasive – the WORSE type of BCC
  • High recurrence rate
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17
Q

What is the least aggressive basal cell carcinoma?

A

Superficial basal cell carcinoma

LEAST AGGRESSIVE OF BCC

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18
Q

What type of basal cell carcinoma is most common in the lower extremity and feet?

A

Superficial basal cell carcinoma

MOST COMMON BCC OF LOWER EXTREMITY AND FEET

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19
Q

Superficial basal cell carcinoma characteristics

A
  • Red plaque with adherent scale
  • Borders slightly raised, telangiectatic and pearly white
  • Resembles eczema or psoriasis (BCC will never go away with a steroid treatment unlike eczema or psoriasis)
  • Spreads by peripheral spread along dermoepidermal junction (does not extend deeper)
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20
Q

Characteristics of nevoid basal cell carcinoma

A
  • Gorlin’s syndrome: nevoid basal cell epithelioma syndrome
  • Multiple BCC between puberty and 35 yo
  • Rare metastasis, but can cause death by brain or vital organ invasion

Constellation of symptoms:
o Palmar and plantar pits, skeletal abnormalities (rib), jaw cysts
o Ectopic calcifications of cerebri
o Milia formation, epidermal and sebaceous cysts, lipomas and fibromas

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21
Q

Treatment of basal cell carcinoma

A

Depends on size, number, location, nature of lesion, physical health

Goals:

  1. Complete tumor removal
  2. Preservation of normal tissue
  3. Preservation of function
  4. Optimal cosmesis
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22
Q

What do you NEED to know about squamous cell carcinoma?

A
  • SECOND MOST PREVALENT MALIGNANT TUMOR OF THE SKIN (Most common among African Americans and Asian Indians)
  • DANGEROUS TUMOR, METASTASIZES TO LYMPH NODES AND CAN BE FATAL
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23
Q

What causes primary SSC?

A

Primary SCC: Skin damage from UV radiation

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24
Q

What causes secondary SSC?

A

Radiation exposure, carcinogen, chronic skin wound, scar, genetic disorder, HPV

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25
Q

Characteristics of squamous cell carcinoma

A
  • Presents as ulcer or nodule
  • Sun-exposed etiology less aggressive, less likely to metastasize
  • Chronic ulcers, injury, and burn scars are more aggressive and likely metastasize
  • Non- specific clinical presentation
  • Lesions can be pink, red, red-brown, or tan and can be plaques or nodules
  • Not pearly like basal cell carcinoma
  • May be erosive, scaling, crusting or ulcerative
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26
Q

Approach to treatment of SSC

A
  • Management by surgeon, oncologist and radiotherapist
  • Surgical excision is treatment of choice
  • Radiation therapy is effective for lesions non-responsive to surgery and lesions with perineural invasion
  • ONCOLOGY CONSULT SHOULD TAKE PLACE FOR EVERY PATIENT WITH CONFIRMED MALIGNANT NEOPLASM
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27
Q

Is actinic keratosis malignant or premalignant?

A

PREMALIGNANT

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28
Q

Characteristics of actinic keratosis

A
  • Multiple, erythematous to yellow-brown, dry, scaly lesion
  • Associated with sun damage
  • Face, neck, hands, forearms, legs, feet
  • SCC often develop in background of AK
  • You can often FEEL these lesions before you can see them – they feel scaly and rough before you can see the red or brown coloration
  • Can progress to a malignancy, so they are something to pay attention to and treat
  • Histology: Keratinocytic atypia limited to lower epidermis, often w/ epidermal budding
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29
Q

Kaposi’s sarcoma

A

Indolent skin tumor of lower extremities, especially ankles and feet**

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30
Q

Virus associated with Kaposi’s sarcoma

A

Viral-HHV8

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31
Q

Characteristics of Kaposi’s sarcoma

A
  • Initially appears as red to brown flat macules, papules, nodules, or tumors
  • A tumor/neoplasm of mesenchymal cells involving the skin and other organs at times
  • Usually transmitted through saliva (also possible by organ transplantation, blood transfusion)
32
Q

4 subtypes of Kaposi’s sarcoma

A

o Classic KS (middle aged men of Mediterranean descent)
o African KS
o KS in iatrogenically immunosuppressed
o AIDS-related KS (most common in the US)

33
Q

Appearance of Kaposi’s sarcoma

A
  • Violaceous macules and papules
  • Slow progression to plaques
  • Multiple red-purple nodules
  • Ulcerate or diffusely infiltrate
34
Q

Histopathology of Kaposi’s sarcoma

A
  • Vascular proliferation
  • Hemorrhage
  • Hemosiderin deposition
  • Proliferation of dilated, thin-walled, irregular shaped vessels, perivascular inflammatory cell infiltrate in papillary and reticular dermis
35
Q

Treatment of Kapsi’s sarcoma

A

Treatment is geared towards controlling symptoms, disease may go into remission/be palliated, but not cured.

Cutaneous lesions:
- Cryotherapy (liquid nitrogen), injections, radiation, excision, topical immunotherapy

Severe cutaneous lesions/systemic lesions:

  • IV chemo or immunotherapy
  • Symptomatic
  • May need to d/c immuosuppressive therapy
  • Treat underlying HIV
36
Q

General treatment of skin malignancy

A
  • Excisional skin surgery (BEST)
  • Mohs surgery (shave by layer)
  • Electrodessication and curettage (not pathology preferred)
  • Cryosurgery (NOT FOR PIGMENTED)
  • Laser surgery
37
Q

Excisional skin surgery

A

o Removal of neoplasm and a rim of normal skin around the neoplasm.
o This skin is the margin.
o The margin is examined under a microscope to be certain that all the neoplastic cells have been removed.
o The size of the margin depends on the type of neoplasm.

38
Q

Mohs surgery

A

o Specially trained dermatologist shaves away thin layers of the neoplasm.
o Each layer is immediately examined under a microscope. The surgeon continues to shave away tissue until no cancer cells can be seen under the microscope.
o In this way, the surgeon can remove all the cancer and only a small bit of healthy tissue to achieve maximal cosmesis.

39
Q

Electrodesiccation and curettage

A

NOT preferred by pathology – hard to make diagnosis
o Often used to remove small basal cell skin cancers.
o The cancer is removed with a curette.
o An electric current is sent into the treated area to control bleeding and kill any cancer cells that may be left.
o Electrodesiccation and curettage is usually a fast and simple procedure.

40
Q

Cryosurgery

A

: NEVER DO THIS FOR A PIGMENTED LESION
o It uses extreme cold to treat early stage or very thin skin cancer.
o Liquid nitrogen creates the cold.
o The doctor applies liquid nitrogen directly to the skin growth.
o This treatment may cause swelling. It also may damage nerves, which can cause a loss of feeling in the damaged area.

41
Q

Laser surgery

A

o Uses a narrow beam of light to remove or destroy cancer cells.
o It is most often used for growths that are on the outer layer of skin only.
o Used in lesions that look flat and scaly (not a papule).

42
Q

Topical chemotherapy

A
  • Chemotherapy is most often used when the skin cancer is too large for surgery.
  • It is also used when new cancers keep appearing.
  • Most often, the drug comes in a cream or lotion.
  • It is usually applied to the skin one or two times a day for several weeks.
  • Fluorouracil (5-FU) is used to treat basal cell and squamous cell cancers that are in the top layer of the skin only (Superficial basal cell carcinoma, Squamous cell carcinoma in situ, Actinic keratosis)
  • Imaquimad also is used to treat basal cell cancer only in the top layer of skin (superficial basal cell carcinoma).
43
Q

Photodynamic therapy

A
  • Photodynamic therapy (PDT) uses a chemical along with a special light source, such as a laser light, to kill cancer cells.
  • The chemical is a photosensitizing agent.
  • A cream is applied to the skin or the chemical is injected. It stays in cancer cells longer than in normal cells.
  • Several hours or days later, the special light is focused on the growth. The chemical becomes active and destroys nearby cancer cells.
  • PDT is used to treat cancer on or very near the surface of the skin (multiple actinic keratoses).
44
Q

Radiation therapy

A
  • Radiation is not a common treatment for skin cancer.
  • May be used for skin cancer in areas where surgery could be difficult or leave a bad scar.
  • Example: when a skin cancer grows along a nerve (can’t remove entire nerve)
  • Treatment for growth on an eyelid, ear, or nose.
  • May be used if the cancer comes back after surgery to remove it.
  • Can be used with extensive perineural invasion for local control.
45
Q

Future treatment with biologics

A

o Treatment to boost or restore the ability of the immune system to fight cancer, infections, and other diseases.
o Also used to lessen certain side effects that may be caused by some cancer treatments.
o Agents used in biological therapy (monoclonal antibodies, growth factors, vaccines).
o These agents may also have a direct anti-tumor effect.
o Also called immunotherapy, biotherapy, biological response modifier therapy, and BRM therapy.

46
Q

What do you NEED to know about melanoma?

A

Melanoma is the most lethal type of skin malignancy

47
Q

Statistics of melanoma

A

o An estimated 76,690 people in US diagnosed in 2013
o One person dies of melanoma every hour
o 1 in 50 men and women will be diagnosed with melanoma of the skin during their lifetime
o Melanoma accounts for less than five percent of skin cancer cases, but the vast majority of skin cancer deaths.
o An estimated 6,280 men and 3,200 women in the US will die from melanoma in 2013.

48
Q

Melanoma facts

A
  • The chance of developing melanoma increases with age, but this disease affects people of all ages.
  • It can occur on any skin surface.
  • In men, melanoma is often found on the trunk or the head and neck.
  • In women, it often develops on the trunk or lower legs.
  • Melanomas in African Americans, Asians, Filipinos, Indonesians, and native Hawaiians most often occur on non-exposed skin with less pigment, with up to 60-75 percent of tumors arising on the palms, soles, mucous membranes and nail regions.
49
Q

Risk factors for developing melanoma

A
  • Dysplastic nevi
  • Many ordinary moles (more than 50)
  • Fair skin
  • Personal history of melanoma or skin cancer
  • Family history of melanoma
  • Weakened immune system
  • Severe blistering sunburn
  • UV radiation
50
Q

What do you NEED to know about malignant melanoma?

A
  • MOST DANGEROUS CUTANEOUS NEOPLASM OF LOWER EXTREMITY
  • METASTASIS TO ANY ORGAN; BRAIN AND HEART
  • UV exposure most common cause
51
Q

Signs of melanoma

A
  • Often, the first sign of melanoma is a change in the size, shape, color, or feel of existing nevus.
  • Most melanomas have a black or blue-black area.
  • Melanoma also may appear as a new lesion. It may be black, abnormal, or “ugly looking.”
52
Q

Symptoms of melanoma

A

NO PAIN

  • Melanomas in an early stage may be found when an existing mole changes slightly, for example, when a new black area forms.
  • Newly formed fine scales and itching in a mole also are common symptoms of early melanoma.
  • In more advanced melanoma, the texture of the mole may change. For example, it may become hard or lumpy. More advanced tumors may itch, ooze, or bleed.
  • Melanomas usually do not cause pain.
53
Q

ABCDE’s of malignant melanoma

A
  • Asymmetry (The shape of one half does not match the other)
  • Border irregularity (The edges are often ragged, notched, blurred, irregular in outline, The pigment may spread into the surrounding skin)
  • Color variation (Often uneven – shades of black, brown, tan, white, gray, red, pink, blue)
  • Diameter enlargement (Change in size, usually an increase (larger than a pencil eraser))
  • Evolving/Elevated
54
Q

Staging of malignant melanoma

A

Clark staging: Level of invasion

  • Level I: All tumor cells above basement membrane (in situ)
  • Level II: Tumor extends to papillary dermis
  • Level III: Tumor extends to interface between papillary and reticular dermis
  • Level IV: Tumor extends between bundles of collagen of reticular dermis
  • Level V: Tumor invasion of subcutaneous tissue (87% metastases)
55
Q

Breslow’s depth

A

Tumors are classified into four categories based on the depth:
o pT1: Less than or equal to 1.00 mm (equivalent to Clark’s Level II)
o pT2: 1.01-2.00 mm (equivalent to Clark’s Level III)
o pT3: 2.01- 3.99 mm(equivalent to Clark’s Level IV)
o pT4: Greater than or equal to 4 mm (equivalent to Clark’s Level V)

More accurate than Clarks Staging

56
Q

Breslow’s thickness survivial rate

A
  • 4mm: 5-year survival is 37-50%
57
Q

Cancer staging recommendation

A
  • T = tumor (describes the primary site)
  • N = nodes (based on whether or not it has spread to lymph nodes)
  • M = metastasized (based on whether or not it has spread to other organs)
58
Q

Prognosis of malignant melanoma

A
  • Melanoma can be cured if it is diagnosed and treated when the tumor is thin and has not deeply invaded the skin (Tis, T1a).
  • If melanoma is not removed at early stages, neoplastic melanocytes invade deeply into dermis.
59
Q

How do you diagnose melanoma?

A
  • Excisional biopsy
  • If the growth is too large to be removed entirely, a portion of the lesion is removed (broad, deep shave preferred).
  • Never cauterize a pigmented lesion – ALWAYS get a biopsy
  • If you can’t biopsy the whole lesion, you want to do a portion of the lesion (do a broad deep shave instead of a punch) – If you’re doing a partial sample, indicate how large it is
60
Q

Types of malignant melanoma

A
  • Superficial Spreading
  • Lentigo Maligna (insidious or slow growing)
  • Nodular
  • Acral Lentiginous
  • Amelanotic (doesn’t make melanin - not black or brown)
  • These classifications are important for determining survival rate and potential metastasis
61
Q

Neoplastic melanocyte growth

A
  • Radial: horizontal growth, confined to epidermis, slow progression and spread
  • Vertical: penetrates dermis producing a mass or palpable nodular lesion, aggressive
62
Q

Superficial spreading melanoma characteristics

A
  • Peak age is 4th to 5th decade
  • Radial spread
  • Early detection gives excellent prognosis
  • Lower extremities, more common in women
  • Raised, irregular border, uneven pigmentation
  • Once develop vertical growth, palpable nodule and metastasize
63
Q

Lentigo maligna melinoma characteristics

A
  • Sun-exposed areas (usually head and neck)
  • Begins in situ, after years becomes invasive
  • Usually in elderly on the face (possible in other areas)
  • Flat pigmented lesions that enlarge, irregular borders
  • Radial growth proceeds vertical growth by several decades
  • Misdiagnosed as pyogenic granuloma
  • May erode nail plate
  • Partial or decreased pigmentation
  • Sole of the heel or foot may appear as an ulceration, >3mm poor prognosis
64
Q

Nodular melanoma

NEED TO KNOW **

A
  • MOST MALIGNANT – Poor prognosis
  • 2:1 ratio, men
  • 5th or 6th decade
  • Distinct blue, brown or black nodularity
  • No apparent radial growth
  • Speedy and penetrating growth
  • Frequently misdiagnosed, resembles blood blister, hemangioma, dermal nevus or polyp
65
Q

Acral letinginous melanoma

A

MOST COMMON ONE WE WILL SEE

  • Palms, soles and nail beds
  • Sudden appearance of subungual pigmented band at proximal nail foldHutchinson’s sign
66
Q

More characteristics of acral letiginous melanoma

A
  • More prominent in African-Americans and Asians
  • 6th and 7th decade
  • Flat lesions - of subungual lesions, 92% are of thumb or hallux
67
Q

Amelanotic melanoma

A
  • Do not present as typical melanoma. May be red without melanin or “hypomelanotic” with minimal melanin.
  • Differential Dx: Nevus, basal cell carcinoma, hemangioma, dermatofribroma
  • Can come in any form, but most commonly nodular
  • Most are metastatic, but can be primary
68
Q

Methods of treatment for melanoma

A

Mainstay treatment is surgery

  • People w/ melanoma may have surgery, chemotherapy, biological therapy, or radiation therapy.
  • Patients may have a combination of treatments.
69
Q

Surgery for melanoma

A
  • Surgery is the usual treatment for melanoma. The surgeon removes the tumor and a broad margin of normal skin around it.
  • If the melanoma was not completely removed during the biopsy, the remaining tumor is removed. In most cases, additional surgery is performed to get a “clean margin”. This is often necessary, even for thin melanomas.
70
Q

Sentinel lymph node biopsy

A

o Performed after the biopsy of the melanoma but before the wider excision of tumor.
o A radioactive substance is injected near the melanoma and movement of the substance is viewed on a computer screen.
o The first lymph node(s) to take up the substance is called the sentinel lymph node(s). (The imaging study is called lymphoscintigraphy.)
o 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.
o 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.

71
Q

Chemotherapy for melanoma

A
  • By mouth or injection (bloodstream)

- Isolated limb perfusion (arm or leg only)

72
Q

Biologic therapy for melanoma

A
  • Biological therapy for melanoma uses cytokines.
  • The body normally produces cytokines in small amounts in response to infections and other diseases. Scientists can produce cytokines in large amounts. In some cases, biological therapy given after surgery can help prevent melanoma from recurring.
  • For patients with metastatic melanoma or a high risk of recurrence, interferon alpha and interleukin-2 (also called IL-2 or aldesleukin) may be recommended after surgery.
73
Q

Radiation therapy for melanoma

A
  • Radiation therapy may be used to help control melanoma that has spread to the brain, bones, and other parts of the body. It may shrink the tumor and relieve symptoms.
74
Q

Cutaneous horns

A
  • The cutaneous horn appears as a funnel-shaped growth, extends from a red base on the skin.
  • It is composed of compacted keratin (the same protein in nails). It can be a specialized type of actinic keratosis.
  • The size/shape of the growth can vary considerably, but most are a few millimeters in length.
  • Squamous cell carcinoma can be found at the base. It usually occurs in fair-skinned elderly adults with a history of significant sun exposure.
75
Q

When is a mole a problem?

A

Pigmented lesions acquired during adulthood on sun damaged skin NEED to be biopsied!!!

76
Q

Dysplastic nevi

A
  • Atypical moles are not cancer, but they can become cancer. They can be found in sun-exposed or sun-protected areas of the body.
  • Atypical moles may be larger (one-quarter inch across or larger) and more irregular in shape, with notched or fading borders.

#2 derm (13 decks)

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