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Skin and soft tissue > BCC & SCC > Flashcards

BCC & SCC Flashcards

1
Q

What are skin derivatives of ectoderm

A
  • pilosebaceous units
  • apocrine
  • eccrine
  • nail unit
  • epidermis
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2
Q

What are skin derivatives of neuroectoderm

A
  • melanocytes
  • nerves
  • specialized sensory receptors
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3
Q

What are skin derivatives of mesoderm

A
  • adipocytes
  • fibroblasts
  • langerhans
  • macrophage
  • mast cells
  • merkel cells
  • blood vessels
  • lymph vessels
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4
Q

what is epidermis

A

stratified squamous epithelium

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5
Q

What cell types are in the epidermis

A
  • keratinocytes ++++
  • melanocytes +++
  • Langerhans ++
  • Merkel +
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6
Q

What is the fitzpatricks classification

A

To describe Sun-Reactive Skin types

  • I - White - always burn, never tan
  • 2- White - usually burn, tan with difficulty
  • 3- White - Sometimes mild burn, tan average
  • 4- Moderate brown - Rarely burn, tan with ease
  • 5- Dark Brown* - Very rarely burn, tan very easily
  • 6 - Black - Donot burn, tan very easily

* asian, hispanic oriental, light african descent

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7
Q

What UV exposure is damaging to skin and what is the pathophysiology

A

UVB 290-320nm is carcinogenic

UVA 320-400nm - is mildly carcinogenic, synergistic w UVB

sunlight is 5% UVB, 95% UVA

photochemical effect - electron excitability in absorbing atoms induces damaging induces chemical changes

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8
Q

How are melaosomes protective against UV exposure

A

Melanin protect against UVB damage by reducing the amount of UVB delivered to the dermis

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9
Q

What are etiologies for cutaneous malignancies

A
  • UV exposure
  • immunosuppresion
  • chemical carcinogenesis
  • ionizing radiation
  • inherited conditions
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10
Q

How do you prevent skin cancer exposure

A
  • sunscreen - chemical - contianing PABA, and physical - zinc oxide/clothing
  • education
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11
Q

What are etiologies of BCC development

A
  • UV exposure
  • Chemical exposure - arsenic
  • Ionizing radiation exposure (latency 10-20yrs)
  • Inherited conditions (Bazex, XP, Gorlin, Gardner, Albinism, Muir Torres)
  • Immunosuppresion (loss of NK cells, T cells)
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12
Q

What is the distribution of BCC

A

Mainly on H&N, where most pilosebaceous units are located

Nose> Cheek >periorbital

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13
Q

How do you classify BCCs

A

N - Nodular ulcerative

O - Other (Micronodular, Infiltrative, Cystic)

P - Pigmented (most common in africain and hispanic

M - Morpheaform (perineural invasion, high recurrance rates)

S - Superficial (on the shoulder, red macular patch)

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14
Q

What are mimickers of BCC

A
  • Merkel cell
    • aggressive, metastasize to LN, bone, viscera
    • Tx: WLE, SLNBx, radiation
  • Adnexal Carcinoma
    • uncommon, appear in elderly, high incidence of local recurrence
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15
Q

What is the histopathologic feature of BCC

A
  • basoloid cell collections with peripheral palisading and stromal reaction (fibroblast and T cell infiltrates)
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16
Q

What is the rate of BCC metastasis?

A

0.04%

More aggressive BCC - morpheaform, infiltrative, micronodular

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17
Q

What is the natural history of BCC growth

A

growth at 0.5cm/yr

direct invasion into adjacent structures, may grow along perineural/lymphovascular structures

Slow growing

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18
Q

What are features of a BCC which make it high risk??

?????????need answers

A
  • Location
    • H-zone
19
Q

What is Gorlin’s syndrome

A

Basal Cell Nevus Syndrome

  • AD, PTCH gene mutation

Clinical features

  • frontal bossing, pseudohypertelorism
  • odontogenic mandibular keratocysts
  • spina bifida, bifid ribs
  • palmar and plantar pits, syndactyly
  • falx cerebri, mental retardation
  • medulloblastoma, meningioma, fetal rhabdomyoma, ameoloblastoma

Degeneraiton occurs post puberty

Tx - close observation and aggressive tx

possibel VIsmodegib systemic therapy - Shh inhibitor

20
Q

WHat is XP

A
  • AR, genetic mutation in endonuclease, required for repair of DNA damage post- UV exposure

Clinical features

  • risk for BCC, SCC, melanoma
  • Skin: early lentigos
  • Ocular: corneal opacity, blindness
  • Neurologic - deficits???
21
Q

What is Bazex

A
  • X-linked

Clinical features

  • icepicks on hands - follicular atrophoderma
  • hypotrichosis, anhydrosis
  • BCC noted on face in teenage years
22
Q

Management options for BCC

A

Medical

  • Cryotherapy
    • cure rate 90%
    • BUT no tissue path, pigment loss in scar
  • Radiotherapy
    • single dose of 5-20Gy or multi sessions totaling to 35Gy
    • cure rate 90%
    • for elderly, large areas where surgical recon difficult/disfiguring
    • BUT higher recurrence, poor cosmetic outcome
  • Photodynamic Therapy
    • Less effective than surgery!!! anything else?????/
  • Chemotherapy
    • Imiquimod (Aldara) for superficial BCC and AK
    • TID for 6wks
    • Cure 75-80%. imiquimod > 5-FU >PDT
  • CO2 laser
    • for superficial BCC, especially with coagulation disorders

Surgical

  • Curettage & Dessication
    • <1cm nodular exophytic lesions
    • Cure rate 80-95% if <2cm
    • But - get scar, little tissue to examine for path
  • Dermabrasion and chemical peel
    • premalignant lesions only
  • Surgical Excision with Margins
    • margins recommended are 2-5mm - dpeends on type, location, age, medical state
    • 4mm margin to eradicate 95% tumors greater than 2cm
    • Mohs fresh frozen techniue
      • mass debulk w curette, thin area removed at 45’ w 2mm margin
      • map of tumor is done with H slices and all margins are examined
      • cure 99% 1’ BCC, 94-96% 2’ BCC
23
Q

What is the risk of recurrence with a possitve margin

A
  • 30% if deep margin +
  • 15% if peripheral margin +
24
Q

What are signs of BCC recurrence?

A
  • development of papule/nodule within scar
  • telangiectasia with enlarging scar
  • scar erythema, crusting
  • non-healnig wound
25
Q

What are risk factors for BCC recurrence?

A
  • young female
  • located in midface/ear
  • hx of radiation exposure
  • BCC morpheaform or perineural invasion
  • incompletely treated/recurrent disease
  • large tumor >2cm
26
Q

Wht is follow-up after diagnosis of BCC

A

q6mths for 5yrs

Because 4/10 patient who develop 1’ BCC will develop a second in next 5yrs

27
Q

What is SCC?

A

Malignancy that develop in the malphigian layer o fthe pidermis (s. germinativum, s. basale)

28
Q

How fast do SCC’s grow

A

cellular doubling time 4days

29
Q

What are etiologic factors leading to SCC

A
  • Chronic sun exposure
  • Precursor lesions
    • AK, AK, L, E, EdQ, P, KA
  • Precursor condicitions
    • XP, Epidermodysplasia Verruciformis, albinism, muir torre, porokeratosis
  • Ionizing radiation
  • Previous chronic wounds/scar
    • EB, burn scar, pressure sore, venous stasis/arterial insufficiency, chronic draining OM sinus tract.
    • Average time from injury to SCC is 20yr
  • chemical carcinogens
    • arsenic, psoralen, , nitrogen mustard
  • Immunosuppression
    • NK cells, Tcells depleted
    • 50% of trasnplant pts will dveelop SCC in first 10yrs
  • Vial infection
    • due to chronic HPV 16.18 infections
    • most common penile shaft, external labia, periungal
30
Q

What is the epidemiology of SCC?

A

2nd most common skin cancer

M:F, 1:1000, Hx of NMSC

31
Q

How is SCC classified

A
  • SCC in situ
  • Invasive SCC
  • Verrucous Carcinoma
    • low grade SCC with locald estruciton but no mets, apepars like verruca vulgaris
32
Q

What are clinical features that distinguish ISCC from SCC in situ?

A

Insitu SCC

  • scaly dull red plaque, sharply defined

SCC

  • Initially: can be smooth, verrucous, papillomatous +/- ulceration
  • Then become nodular, infiltrative, inflamed
33
Q

What are the histopathologic features of SCC

A

H - Hyperkeratosis (much of s. corneum)

A - Acanthosis (much s.spinosum)

D -Dyskeratosis (premature keratinization of cells prior ot reaching keratinizing layer

P - Parakeratosis (retention of nuclei in s. corneum)

34
Q

What are the histopathology features of insitu vs iSCC

A

In Situ

  • atypical keratinocytes in “windblown” appearnce throughout layers of epidermis
  • atypia may occur in hair follicles even in dermis but DO NOT invade the dermis

Invasive SCC

  • as above but extend into dermis
  • see “keratin pearls”
  • degree of cellular differentiation determine grade of SCC
35
Q

How do you grade SCC

A

Broder’s Grading Classification

  • Well differentiated =<25% undifferentiated
  • Moderately <50% undiff
  • Poor <75% undifferentiated
  • Anaplastic/pleomorphic >75% undiff

Degree of atypia relates to risk of recurrence

36
Q

List histologic variants of SCC

A

Acantholytic (adenoid ) SCC

Adenosquamous SCC

Spindle cell SCC

Clear cell SCC

Verrucous SCC

KA

37
Q

What immunohistochemical stains/antibodies are used to stain SCC

A

Cytokeratin

Epithelial membrane antigen

Use to identify source of tumor when poorly differentiated

38
Q

WHat is ther ate of metastasis of SCC

A

2-5%

to LNs within first few yrs of diagnosis

  • SCC on upper half of face drain to parotid LN
  • SCC on lips/perioral drain to submental/upper Ij LN
  • Cure rate for met SCC is 50% w surgery/Rtx, multimodal Tx
  • 5yr survival 35%
39
Q

What factors of SCC are associated with more aggressive tumor

A
  • Location (lip & ear high recurrence)
    • Size (<1cm, 1% met rate,>2cm, 10% metastatic rate)
  • Histopathologic Grade (poorly diff 30% recur)
  • Depth of invasion (ass. w recurrence, met, death, >6mm)
  • Perineural invasion
  • Lymphovascular invasion
  • Recurrent SCC
  • Immunosuppresion (frequent mets/recurrence)
  • Marjolins ulcer (25% mets)
40
Q

What is your DDX other than SCC for lesion that appears inflamed, ulcerated, nodule

A
  • BCC
  • AK
  • KA
  • Irrittaed SK
  • Adnexal tumor
  • Atypical fibroxanthoma
  • merkel cell
  • pyoderma granulosum
  • pagets
41
Q

What is the TNM stagin for SCC and BCC

A

Tumor

Tx, T0, Tis

T1 _<_2cm with <2high RFeatures

T2 >2cm or ANY tumor with >2Rfeatures

T3 Tumor w invasion to adjacent strucutres

T4 invasion to skeleton axial/sleketal/perineural to skull base

high risk Features:

  • Depth : >2mm, clarke>IV, perineural inv.
  • Anatomic location ; ear, hair bearing lip
  • Differentiation; poorly/undiff

N

NxN0

N1 single ipsi LN >3cm

N2a single ipsi LN 3-6cm

N2b multiple LN <6cm

N2c bilat or contra lat LN <6cm

N3 any LN>6cm

M0

M1 distant mets

Staging

0 = Tis

1 = T1

2 = T2

3 = T3, N1 with T1-3

4= Any T4, N2/3, M1

42
Q

What are the management options for SCC

A

Surgical Excision

  • Margin 5-15mm
  • SCC <2cm with 4mm margins, 95% will be cured.
  • SCC <2cm with high risk features, do 6mm
  • SCC 3cm, do 1.5 cm
  • SLNBX indicated if clinically palpable nodes

EDC

  • if <2cm and well defined border

RTx

  • for eldely, medically unfirt, lips/ear/nose
  • <2cm lesion, 85-95% cure rate

Medical tx

  • Imiquimod for SCC in situ ONLY
43
Q

What is f/u for SCC

A

q3mth for 3yrs then q6mth

Skin and soft tissue (13 decks)

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