2 - Topical and Intralesional Chemotherapeutic Agents

Question 1

5-FU is an antimetabolite and structural analog of uracil

Answer 1

True

Question 2

5-FU and its metabolites are misincorporated into RNA and disrupt RNA synthesis

Answer 2

True

Question 3

5-FU metabolites also block the function of thymidylate synthetase, interfering with DNA synthesis as well

Answer 3

True

Question 4

Topical 5-FU is not significantly systemically absorbed

Answer 4

True

Question 5

The selective effect allows the use of topical 5-FU over a broad area of skin without concern for damaging normal skin

Answer 5

True

Question 6

5-FU is converted to 3 active metabolites:

(1) fluorodeoxyuridine monophosphate
(2) fluorodeoxyuridine triphosphate
(3) fluorouridine triphosphate

Answer 6

True

Question 7

The key enzyme which converts 5-FU to dihydrofluorouracil is dihydropyrimidine dehydrogenase (DPD)

Answer 7

True

Question 8

80% of 5-FU is catabolised in the liver

Answer 8

True

Question 9

Topical 5-FU is used in the field treatment of AKs in that it is more selective for AK than for normal skin

Answer 9

True

Question 10

Topical 5-FU is useful in the treatment of SCC in situ or superficial BCC

Answer 10

True

Question 11

Topical 5-FU is not more effective than other treatments in the treatment of warts

Answer 11

True

Question 12

Topical 5-FU may be useful in the treatment of multiple disseminated porokeratosis

Answer 12

True

Question 13

Topical 5-FU is contraindicated in patients with known dihydropyrimidine dehydrogenase (DPD) deficiency, the key enzyme in metabolism of 5-FU

Answer 13

True (should not be used due to a case of life threatening toxicity from topical 5-FU in a patient who had deficiency of DPD)

Question 14

Topical 5-FU is contraindicated in pregnancy

Answer 14

True (pregnancy category X)

Question 15

Allergic contact dermatitis has been reported in topical 5-FU use

Answer 15

True

Question 16

Systemic adverse effects are rare in topical 5-FU use

Answer 16

True

Question 17

The most common adverse effects from topical 5-FU use are localised to areas of treatment I.e. Erythema, irritation, burning, pain, pruritus, hypopigmentation, hyperpigmentation

Answer 17

True

Question 18

Topical corticosteroids used concurrently with topical 5-FU and for 1-2 weeks beyond cessation of topical 5-FU application to relieve the inflammatory reaction does not impact on topical 5-FU efficacy

Answer 18

True

Question 19

Mechlorethamine (Nitrogen Mustard) is an alkylating agent highly reactive with DNA as donation of alkyl groups to DNA disrupts normal cell function

Answer 19

True

Question 20

The ultimate cause of cell death from Mechlorethamine (Nitrogen Mustard) is unknown

Answer 20

True

Question 21

Topical Mechlorethamine (Nitrogen Mustard) is not systemically absorbed

Answer 21

True (no known significant systemic absorption of topical Nitrogen Mustard and no systemic toxicities from cutaneous absorption have been observed in long term use in Mycosis Fungoides)

Question 22

The mechanism of action of topical Mechlorethamine (Nitrogen Mustard) is unknown

Answer 22

True

Question 23

The primary indication for topical Mechlorethamine (Nitrogen Mustard) is the treatment of Mycosis Fungoides

Answer 23

True

Question 24

Topical Mechlorethamine (Nitrogen Mustard) is not contraindicated in a previous history of multiple cutaneous SCCs

Answer 24

True (but need to use with caution if patients have had other skin damaging therapies such as radiation)

Question 25

Irritant or allergic (delayed type hypersensitivity) contact dermatitis is the most common effect of topical Mechlorethamine (Nitrogen Mustard)

Answer 25

True (irritant contact dermatitis more common than allergic contact dermatitis)

Question 26

Urticaria and anaphylactic reactions are rare in topical Mechlorethamine (Nitrogen Mustard)

Answer 26

True

Question 27

Irritant contact dermatitis from topical Mechlorethamine (Nitrogen Mustard) is most common and particularly if used on the face or in skin folds

Answer 27

True

Question 28

Allergic contact dermatitis is more common in topical Mechlorethamine (Nitrogen Mustard) aqueous formulation than ointment formulation

Answer 28

True

Question 29

Irritant or contact dermatitis from topical Mechlorethamine (Nitrogen Mustard) can be managed by reducing the frequency of applications

Answer 29

True

Question 30

Irritant or contact dermatitis from topical Mechlorethamine (Nitrogen Mustard) can be managed by reducing the strength of the application

Answer 30

True

Question 31

Topical corticosteroids can be helpful in the management of Irritant or contact dermatitis from topical Mechlorethamine (Nitrogen Mustard)

Answer 31

True (Topical Mechlorethamine/Nitrogen Mustard can be discontinued briefly and topical corticosteroids applied to reduce the inflammation, after which the topical Mechlorethamine/Nitrogen Mustard can be restarted at a lower concentration)

Question 32

Patients with allergic contact dermatitis to topical Mechlorethamine (Nitrogen Mustard) can undergo a formal desensitisation protocol

Answer 32

True

Question 33

Non-melanoma skin cancers have been reported in patients treated with topical Mechlorethamine (Nitrogen Mustard)

Answer 33

True (although most of these patients were also treated with multiple skin damaging therapy i.e. Phototherapy or radiation, or used topical Mechlorethamine/Nitrogen Mustard in the genital areas)

Question 34

There is no evidence of increased risk for secondary cutaneous malignancy in non-genital skin with long term use of topical Mechlorethamine (Nitrogen Mustard) as monotherapy

Answer 34

True

Question 35

Post inflammatory hyperpigmentation or hypopigmentation from topical Mechlorethamine (Nitrogen Mustard) gradually improves with time

Answer 35

True

Question 36

Patients should not apply topical Mechlorethamine (Nitrogen Mustard) to genital skin

Answer 36

True (risk of secondary cutaneous malignancy)

Question 37

There are no large randomised trials comparing the efficacy of total skin topical Mechlorethamine (Nitrogen Mustard) application versus treatment of affected areas only

Answer 37

True

Question 38

Topical carmustine is a nitrosurea compound used in the treatment of Mycosis Fungoides

Answer 38

True

Question 39

Nitrosureas (I.e. carmustine @ BCNU) are DNA alkylating agents leading to interstrand or intrastrand cross-linking of DNA

Answer 39

True

Question 40

Topical carmustine (BCNU) is available in solution or ointment form

Answer 40

True (although experience with the ointment is considerably less than the solution and there are no published series of patients treated with this modality)

Question 41

Class I topical corticosteroids had less adverse reactions than topical carmustine (BCNU) ointment

Answer 41

True

Question 42

Erythema simulating a sunburn mainly in body folds is a common side effect from topical carmustine (BCNU) especially in the solution form

Answer 42

True (severe reactions are often followed by benign telengiectasias)

Question 43

Telengiectasias from topical carmustine (BCNU) solution are benign but may rarely persist for years

Answer 43

True (usually resolves within months)

Question 44

Irritant or allergic contact dermatitis may occur with topical carmustine (BCNU)

Answer 44

True (treatment must be stopped if moderate-severe erythema, pruritus develop during treatment)

Question 45

There is higher risk of systemic absorption from topical carmustine (BCNU) when used in children

Answer 45

True (higher body surface area in children -use with caution)

Question 46

Systemic absorption of topical carmustine (BCNU) may cause Bone marrow suppression including mild leukopenia and mild anaemia

Answer 46

True (thrombocytopenia has not been noted)

Question 47

Thrombocytopenia has not been noted from bone marrow suppression of systemic absorption of topical carmustine (BCNU)

Answer 47

True (only leukopenia and anaemia have been noted)

Question 48

The face, genitals and intertriginous areas are not treated with topical carmustine (BCNU) unless involved

Answer 48

True

Question 49

Intralesional chemotherapeutic agents used in Dermatology include Vinblastine, Vincristine and Bleomycin

Answer 49

True

Question 50

Vinblastine and vincristine are vinca alkaloids that disrupt microtubular function leading to arrest of cell division in metaphase and cell death

Answer 50

True

Question 51

Vinblastine and vincristine are vinca alkaloids used intralesionally for treatment of Kaposi's sarcoma lesions

Answer 51

True

Question 52

Intralesional Vinblastine injections are painful

Answer 52

True (Lignocaine is added in an attempt to reduce injection pain although this did not reduce the pain of the injection)

Question 53

Lignocaine added to intralesional Vinblastine (to reduce pain of injection) did not reduce the efficacy of Vinblastine

Answer 53

True

Question 54

The therapeutic effect of intralesional Vinblastine is enhanced by injection of hyaluronidase before Vinblastine

Answer 54

True

Question 55

Intralesional Vinblastine adverse effects include pain, inflammation, blistering and post inflammatory hyperpigmentation

Answer 55

True

Question 56

Severe pain and ulceration is rare in intralesional Vincristine

Answer 56

True (erythema, burning pruritus more common)

Question 57

The overall response rate of classic Kaposi's sarcoma nodular lesions to intralesional Vincristine was 99%

Answer 57

True

Question 58

Bleomycin is a fermentation product of the bacterium Streptococcus verticillus

Answer 58

True

Question 59

Intralesional Bleomycin may be used off label in viral warts, vascular anomalies keloids and hypertrophic scars

Answer 59

True

Question 60

Intralesional Bleomycin's cytotoxic effect results from its ability to cause oxidative damage to the deoxyribose backbone of the DNA chain which lead to single and double stranded breaks in DNA

Answer 60

True

Question 61

Intralesional Bleomycin is not the first line agent in treatment of viral warts

Answer 61

True (used for treatment of viral warts refractory to standard therapies)

Question 62

Intralesional Bleomycin has demonstrated a slightly higher cure rate for MOSAIC plantar warts than other conventional therapies

Answer 62

True

Question 63

Intralesional Bleomycin resulted in complete resolution of infantile maxillofacial haemangiomas with no serious adverse effects

Answer 63

True

Question 64

Intralesional Bleomycin is a safe and effective treatment for macrocystic lymphatic malformations, superficial oral mucosal lymphatic malformations, and localised depot macrocystic lesions

Answer 64

True

Question 65

Pain is the most frequent adverse effect of intralesional Bleomycin

Answer 65

True (erythema with swelling, and burning sensation also may occur)

Question 66

Intralesional Bleomycin can cause blistering and tissue necrosis at the site of injection

Answer 66

True

Question 67

Intralesional Bleomycin has led to nail dystrophy or nail loss when used for periungual warts

Answer 67

True (care should be taken to avoid injecting into the nail matrix)

Question 68

Persistent Raynaud's phenomenon, anaphylaxis, and flagellate hyperpigmentation are uncommon in intralesional Bleomycin

Answer 68

True (more common in intravenous administration)

Question 69

Intralesional Bleomycin should be injected directly into a wart in such a way so as to try to blanch it

Answer 69

True

Question 70

Topical chemotherapeutic agents include: | 1) 5-Fluorouracil (2) Mechlorethamine (nitrogen mustard (3) Carmustine (BCNU)

Answer 70

True

Question 71

Intralesional chemotherapeutic agents include: (1) Vinblastine (2) Vincristine (3) Bleomycin

Answer 71

True