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Neurology and special senses (Y4) > 6- Dermatology (skin cancer) > Flashcards

6- Dermatology (skin cancer) Flashcards

1
Q

main skin cancers

A

Skin cancers (from best to worse)
- Basal cell carcinoma
- Squamous cell carcinoma
- Malignant melanoma

(best -> worse : BBC -> SCC -> Melanoma)

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2
Q

Basal cell carcinoma

Background

A
  • Most common skin cancer
  • Best prognosis
    - Slow growing, locally invasive -> arise from hair follicle
  • Subtypes include nodular, morphoeic, superficial and pigmented
  • Slow growing with low metastatic potential
  • Types >20
    o Nodular basal cell carcinoma
    o Superficial BBC
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3
Q

BCC RF

A

Risk factors
- Caucasian (type I and II)- fair
- Sun exposure (UV)/ sun burn
- Older age
- Previous skin cancer
- Immunosuppression
- Albinism
- Inherited syndrome e.g. Gorlin syndrome

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4
Q

BCC presentation

A
  • Slow growing plaques or nodules
  • Early lesions are small, translucent or pearly and have raised areas with telangiectasia
  • Varies in size
  • Spontaneous bleeding
  • Occurs in sun exposed sites apart from the ear
  • Indurated edge and ulcerated centre
  • Slow growing but can spread deeply to cause considerable destruction
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5
Q

investigations for BCC

A
  • Visual inspection
  • Punch biopsy if treatment other than standard surgical excision is planned
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6
Q

BCC management

A

Depends on size, type and location.
- Can be managed in primary care as long as GP trained to perform skin surgery

Surgical excision is the mainstay of treatment
1) Normal surgical excision of cancer

2) Mohs micrographic surgery (4mm margins) Best treatment: gold standard but not used that often
–> Involves examining carefully marked excised tissue under microscope later by layer to ensure complete excision
->Very high cure rates

Non-surgical
e.g. superficial BBC or if they decline or unfit for surgery
- Curettage and cautery
- Cryotherapy (liquid nitrogen)
- Imiquimod cream
- 5-Fluorouracil
- Radiotherapy if margins incomplete

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7
Q

management of advanced or metastatic BCC

A
  • Surgery
  • Radiotherapy
  • Target therapy
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8
Q

Prevention of BCC

A
  • Avoid sunburn esp in fair skinned
  • Oral nicotinamide (vitamin B3)
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9
Q

Prognosis for BCCs

A
  • Most BCCs cured by treatment
  • 50% develop second one within 3 years of first
    o At increased risk of melanoma
  • Advanced BCC very rare- often neglected tumours
  • Metastaic BCC very rare
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10
Q

squamous cell carcinoma

A

Squamous cell carcinoma

Background
- Malignant tumour arising from keratinising cells of the epidermis
- Locally invasive (passes basement membrane) and has the potential to metastasise
- Types e.g.
o Cutaneous horn
o Keratoacanthoma

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11
Q

SCC causes

A
  • Older patients
  • Previous skin cancer
  • Smoking
  • Inherited syndromes e.g. xeroderma pigmentosum
  • Related to sun exposure (UVR)
  • Fair skin
  • Chemical carcinogens- arsenic
  • HPV
  • Chronic inflammation
  • May arise in pre-existing solar keratoses
  • Immunosuppression after transplant
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12
Q

SCC presentation

A

- Grow quickly over weeks to months (much faster than BBC)
- Indurated nodular keratinising or crusted tumour that may ulcerate without evidence of keratinisation
- Non healing ulcer or growth in one of the highest risk sun exposed area
- Centre becomes necrotic and becomes an ulcer
- Ulcer with hard, raised edges
- Bleeding
- Size varies from a few mm to several CM

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13
Q

Investigations for SCC

A
  • Visual inspection
  • Biopsy for histology
  • If high risk: imaging using US, Xray, CT, MRI, lymph node biopsy
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14
Q

Classification of SCC

A

Based on low-risk or high-risk, depending on the chance of the tumour recurrening or metastasing

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15
Q

High-risk SCC

A
  • Diameter greater than or equal to 2 cm
  • Location on the ear, vermilion of the lip, central face, hands, feet, genitalia
  • Arising in elderly or immune suppressed patient
  • Histological thickness greater than 2 mm, poorly differentiated histology, or with the invasion of the subcutaneous tissue, nerves and blood vessels.
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16
Q

SCC staging

A

Staging: TNM

17
Q

management of SCC

A

1) Nearly always treated surgically
- Wide local excision – repeat surgery to gain adequate margins may eb required
- Mohs’ micrographic surgery- precise technique in which excision of skin lesion is carried out in stages and checked histologically

Other non-surgical procedures
- Curettage and cautery
- Crytotherapy
- Imiquimod cream
- Photodynamic therapy (PDT)
- Electrochemotherapy
- Radiotherapy

18
Q

Prevention of SCC

A
  • Avoid sunburn esp in fair skinned
  • Oral nicotinamide (vitamin B3)
  • Patients with multiple SCC may be prescribed oral retinoid (acitretin or isotretinoin)
  • Self examination important
19
Q

Prognosis
of SCC

A
  • Most SCCs cured by treatment
  • 50% develop a second within 5 years
  • Increased risk of melanomas
20
Q

melanoma

A
  • In situ- tumour confined to epidermis
  • Invasive- tumour spread into dermis
  • Metastatic- tumour spread to other tissues
21
Q

pathophysiology of melanoma

A

Pathophysiology
- Melanocytes are found in equal numbers in black and in white skin; however, the melanocytes in black skin produce much more melanin. People with dark brown or black skin are very much less likely to be damaged by ultraviolet (UV) radiation than those with white skin.
- Non-cancerous growth of melanocytes results in moles (benign melanocytic naevi) and freckles (ephelides and lentigines).
- Most skin melanomas spread out within the epidermis. If all the melanoma cells are confined to the epidermis then the lesion is a melanoma in situ, which can be cured by excision because it has no potential to spread around the body.
- When the cancer has grown through the dermis it is known as invasive melanoma  malignant melanoma

22
Q

metastasis sites for melanoma

A

Metastasis everywhere
- Lymph nodes
- Lungs
- Liver
- Bone
- brain

23
Q

Risk factors of melanoma

A
  • Previous primary invasive melanoma
  • Fair – highest incidence in Australia and new Zealand
  • Increasing age
  • Many melanocytic naevi – moles
  • Sun exposure
  • Family history
  • Immunosuppressed
24
Q

Presentation of melanoma

A
  • Can occur anywhere on the body e.g. the back or legs
  • Usually start as skin lesions- can also grow on mucus membranes e.g. lips or genitals
  • Bleeding
  • > 6mm
  • Key features- ABCDE
25
Q

ABCDE of melanoma

A
  • Asymmetry.
  • Border irregular.
  • Colour irregular.
    o Tan, dark borwn, black, blue, red
  • Diameter greater than 7 mm.
  • Evolving.
26
Q

investigations for melanoma

A
  • Visual inspection
  • Dermatoscopy
  • Removal for histology
  • Imaging to look for metastasis e.g. PET CT
27
Q

Staging of melanoma

A

TNM or AJCC

28
Q

management of stage 0 to 2 melanoma

A

Surgery: Wide local excision (look for margins)- Mohs

29
Q

management of stage 3 to 4 melanoma

A
  • Surgery
  • Chemotherapy e.g. dacarbazine
  • Immunotherapy e.g. ipilimumab
  • Radiotherapy
  • Vitamin D should be optimal
  • Palliative care treatment
30
Q

follow up for melanoma

A

Follow up
- Detect recurrence and metastasise early
- Skin self examination

31
Q

Prognosis of melanoma

A
  • Melanoma in situ cured by excision because no potential to spread around the body
  • Metastasis
    o Depends on Breslow thickness of melanoma at time of surgery
32
Q

Premalignant lesions

A
  • Actinic keratosis
  • Bowens disease
33
Q

Actinic keratosis
Background

A
  • Also known as Solar Keratosis (skin areas exposed to lots of sun)
  • Premalignant skin condition which can precede the development of cutaneous Squamous Cell Carcinoma (SCC)
  • The risk of development into SCC is small, but increases with increasing numbers of Actinic Keratoses.
34
Q

actinic keratosis risk factors

A

Risk factors/ causes
- Sun exposure causing DNA damage
- Type I or II skin (fair, burns easily)
- History of sunburn
- Outdoor occupation or hobbies
- Immunosuppression

35
Q

presentation of actinic keratosis

A
  • Generally, they are asymptomatic but can cause mild pruritis.
  • Thickened papules or plaques with surrounding erythematous skin and a keratotic, rough, warty surface.
  • They are commonly found on sun exposed areas of skin, such as the backs of hands or the face.
36
Q

management of actinic keratosis

A

Management
- Managed to prevent development into an SCC.
- Localised lesions are managed using cryotherapy, curettage or surgical excision.
- Larger lesions are managed with topical therapies such as 5-Fluorouracil (a cytotoxic agent), a non-steroidal anti-inflammatory (NSAID) or Imiquimod (which modifies immune response).

37
Q

Bowens disease
Background

A
  • Intraepidermal SCC or SCC in Situ
  • Very early form of a slow-growing skin cancer
  • Can develop into** SCC**
    **- Larger patches than actinic keratosis **
38
Q

Risk factors of Bowens disease

A
  • Women
  • 60s to 70s
  • Long term sun exposure with fair skin
  • Linked with HPV
39
Q

Presentation of Bownes disease

A
  • Usually found: face, scalp, neck, hands, lower legs
  • Red, scaly patch of skin
  • Can look like a spot or wart
  • May be itchy or sore
  • May bleed
  • Can look like eczema

Neurology and special senses (Y4) (52 decks)

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