8 - Premalignant And Malignant Tumors

Question 1

What is actinic keratosis?

Answer 1

SCC confined to the epidermis

Caused by chronic UVB exposure in fair skinned people

Question 2

Morphology of actinic keratosis?

Answer 2

Starts as area of increased vascularity

Rough feeling to skin

Erythema with scale

Hyperkeratotic lesion on ears and dorsum of hand

Sharp, adherent, yellow scale as lesion progresses

May present as subcutaneous horn with underlying AK, SCC, or wart

Question 3

What is actinic keratosis on the lower lip called?

Answer 3

Actinic cheilitis

Question 4

If you see a lesion of actinic keratosis on the superior aspect of the pinna, think:

Answer 4

Chondrodermatitis Nodularis Helicis (CDNH)

A degeneration of underlying collagen

Excise it

Special pillow for sleeping

Question 5

Management of actinic keratosis?

Answer 5

Photoprotection (discuss with patient)

Complete skin exam - risk factors for BCC and SCC

Liquid nitrogen for small lesions (TOC)

5-FU for multiple lesions (Imiquimod as alternative)

Thicker crust or indurated lesions - excision (shave)

Question 6

Prognosis for actinic keratosis?

Answer 6

10-20% will develop SCC over 10-20 yrs (aren’t those numbers convenient)

AK is a PRE-malignancy - it’s SCC of the epidermis only - once it invades the dermis, oh shit we got real cancer now boyyyyyy

Question 7

What is Bowen’s Disease?

Answer 7

AKA “SCC in situ”

Later in life, sun-exposed skin

Unlike AK, it can extend down into follicles

Question 8

Morphology and location of Bowen’s disease (SCC in situ)

Answer 8

Well-defined borders

Slightly elevated, red, scaly plaques

Very slow lateral growth

Women - lower extremities
Men - scalp and ears

Question 9

What is Erythroplasia of Queyrat?

Answer 9

Squamous cell carcinoma in situ of the glans of uncircumcised male, labia or female, or oral mucosa

A sub-type (?) of Bowen’s disease

Elderly folks

Moist, smooth, red, slightly raised plaque

Associated with HPV-8

Txt - 5-FU or Imiquimod or LASERS

Question 10

Management of Bowen’s Disease?

Answer 10

Small lesions? Elecrodessication and curettage (ED and C)
OR
Cryosurgery (LN2)

Larger lesions? Excisional surgery, 5-FU cream

Question 11

Prognosis of Bowen’s Disease?

Answer 11

Low-grade malignancy, follow-up Q 6 mos

Slow growth, recurrences common, can degenerate into SCC

Question 12

What is the second most common skin CA?

Answer 12

Squamous cell carcinoma

Question 13

What is the MC precursor to SCC?

Answer 13

Actinic keratosis

Question 14

Risk factors for SCC

Answer 14

UVA and UVB
AK
Bowen’s
Thermal or radiation burns
Chronic irritation
HPV
Inflammation 
Arsenic exposure
Immunosuppression

Question 15

Morphology of SCC?

Answer 15

Red, scaly, persistent

Usually with deeper involvement

With or without ulceration

Hypertrophic lesion with ulcer or hyperkeratosis (cutaneous horn)

Lip: ulcer with induration

Question 16

Typical SCC patient

Answer 16

Sun exposed areas on an older, asymptomatic dude

Can occur younger in smokers

Question 17

Management of SCC?

Answer 17

Small lesions arising from AK? ED and C

Larger lesions and those on lip? Excision with margins

Examine lymph nodes

F/U Q 12 mos FOR LIFE

Emphasize photo-protection

Question 18

Prognosis for SCC?

Answer 18

It’s malignant - must treat adequately

Aggressiveness varies with cell differentiation

The longer the hx of unprotected sun exposure, the higher the likelihood of mets

Overall, tho, SCC carries low potential for mets

Question 19

What is the most common invasive skin CA?

Answer 19

BCC

Question 20

Origin of BCC?

Answer 20

Malignant proliferation in basal layer of epidermis

Most important risk factor is inability to tan (just workin’ on my base, bro)

Question 21

Morphology and location of BCC?

Answer 21

Nodular BCC (most common form) - head/neck/NOSE (MC site)

Superficial BCC - trunk

Slow-growing, asxs, pearly, firm, dome-shaped papule

Evolved, becomes telangiectatic, ulcerates and has rolled borders (“rodent ulcer”)

Question 22

Typical BCC pt:

Answer 22

Over 40

Complaining of bleeding or scabbing sore that heals and then recurs

Looseness and friability

Question 23

Malignancy potential for BCC?

Answer 23

Advances by direct extension and destroys normal tissue

Untreated, it can destroy whole side of face, even subcutaneous tissue, bone, and invade brain

Question 24

Management of BCC?

Answer 24

If detected early - excise

If detected late - excise, but refer to derm and plastics (possible Mohs Micrographic surgery)

Question 25

Prognosis for BCC?

Answer 25

Will produce other lesions once dx’d

Rarely metastasizes

Question 26

Slide 49

Answer 26

Mohs Micrographic Surgery illustrations (BCC txt)

Question 27

Which has a stronger relationship with UV radiation: BCC or SCC?

Answer 27

SCC

Question 28

1/3 of BCC’s occur where?

Answer 28

Areas WITHOUT UV exposure

Question 29

A patient with increased wrinkling actually has a reduced risk of:

Answer 29

BCC

Question 30

I just watched a program about beavers

Answer 30

It was the best dam program i’ve ever watched