Benign and Malignant Neoplasms Flashcards
1- An elderly patient with no prior history of skin cancer points out a hyperpigmented skin lesion on the trunk that clinically looks like the most common, non-melanocytic growth found mostly in older individuals. For further evaluation and confirmation, you pull out your dermatoscope as a diagnostic tool. Which of the following features would point away from a seborrheic keratosis?
A- Fissures
B- Fingerprinting
C- Telangiectasias arranged in regular loops
D- Pigment Network
E- Milia-like cysts
Correct choice: D. Pigment Network
Explanation: Seborrheic keratosis are the most common benign epidermal tumor which frequently occur in individuals older than 30. Dermoscopic features are comedo-like openings, milia-like cysts, fissures (brain-like cerebriform appearance), fingerprinting, lack of true pigment network, and telangiectasias arranged in regular loops (hair-pin like vessels). The absence of pigment network, branched streaks, and pigment globules are the key features that differentiate SKs from melanocytic neoplasms.
2- Clinically, this lesion often has a blue hue and usually occurs on the face: A- Apocrine hidrocystoma
B-Epidermoid inclusion cyst
C- Bronchogenic cyst
D- Eccrine hidradenoma
E- Myxoid cyst
Correct choice: A. Apocrine hidrocystoma
Explanation: Apocrine hidrocystoma are usually solitary, tranlucent nodules which may have a bluish hue due to the Tyndall effect. Histologically, they have one or several large cystic spaces with decapitation secretion. The other listed tumors are less likely to fit this clinical description.
3- The most likely diagnosis is?
A- CTCL
B - B-cell lymphoma
C- Angiosarcoma
D- Hemangioma
E- Merkel cell carcinoma
Correct choice: B. B-cell lymphoma
Explanation: These red juicy papules are characteristic for B-cell lymphoma. CTCL presents as erythematous scaly patches and plaques. Angiosarcoma is typically a violaceous nodule on the scalp. Merkel cell carcinoma is often a pink-skin colored solitary nodule on the head and neck.
4- An elderly native Floridian with a fair complexion and evident photodamage due to a history of chronic sun exposure presents for a skin check. He has numerous erythematous, flat, rough macules that are easily felt thorough his head, neck, forearms and dorsal hands. He usually presents to your office every 6 months for treatment of these lesions with cryotherapy. The etiologies responsible for the development of these skin lesions include which of the following?
A- UVA from sunlight
B- Formation of pyrimidine dimers in DNA
C- Mutations in patched within keratinocytes
D- Increasing apoptosis
E- Increased host immune response
Correct choice: B. Formation of pyrimidine dimers in DNA
Explanation: The etiology of actinic keratoses involves UVB from sunlight which is responsible for the development of AKs. This triggers the formation of thymidine dimers in DNA & RNA, resulting in mutated keratinocytes. The mutations occur on the tumor suppressor gene p53 within keratinocytes resulting in impaired apoptosis. Clonal expansion of mutated keratinocytes occurs, which may lead to formation of AKs.
5- All of the following accurately describe properties and mechanism of action of Denileukin diftitox (ONTAK®) EXCEPT:
A- Is a systemic treatment option for CTCL
B- Is a diphtheria fusion toxin
C - Targets the interleukin-2 receptor
D- May cause capillary leak syndrome as an adverse reaction
E- Targets the CD28 protein on T cells
Correct choice: E. targets the CD28 protein on T cells
Explanation: Denileukin diftitox is a diphtheria fusion protein chemotherapeutic agent used for the treatment of persistent or recurrent CTCL. It binds selectively to the high- and intermediateaffinity IL-2 receptor (CD25+) on lymphocytes and is internalized by these cells. Inside the cells, the toxin portion of the fusion protein is cleaved by proteolytic enzymes, causing cell death. It produces durable responses and may forestall disease progression. The most frequent and clinically significant adverse events include infusion reactions, capillary leak syndrome, hypoalbuminemia, visual changes, consititutional symptoms, rash, and hepatobiliary disorders - many of these can be managed without dose reduction. Deniluekin diftitox does not target the CD28 expression protein on T cells.
6- A patient presents for treatment of a melanoma on the cheek with Breslow depth of 0.7 mm and ulceration on pathology. There is no evidence of nodal metastasis. Based on the 8th edition AJCC, what is the correct staging for this patient?
A- Stage 0
B Stage IA
C -Stage IB
D- Stage IIA
E- Stage IIB
Correct choice: C. Stage IB
Explanation: Tumors less than 0.8 mm WITH ulceration OR tumors 0.8 - 1mm (regardless of ulceration) are a T stage of T1b. If there is no nodal or distant metstasis then the patient is a cancer StageIB. Patients with tumors 1.01 - 2mm without ulceration are T2a, and if there is no nodal metastasis they are also considered StageIB.
Stage 0 is melanoma in situ (T stage is referred to as Tis).
Stage 1A includes melanomas that are Breslow depth 0.01-0.7 WITHOUT ulceration. Note that tumors should be reported with a single digit after the decimal, and rounded up or down accordingly. Therefore a Breslow of 0.74 mm would be rounded down and reported as 0.7 mm, and a Breslow of 0.75 would be rounded up and reported as 0.8 mm).
Stage IIA would be T2b or T3a and no nodal metastasis. Stage IIB T3b or T4a and no nodal metastasis.
7- What is true about this tumor?
A- It is the second most common type of skin cancer
B- Telangiectasias are not commonly seen
C- Rombo syndrome has these tumors
D- Seen in Cowden syndrome
E- Mohs micrographic surgery is not an effective treatment
Correct choice: C. Rombo syndrome has these tumors
Explanation: This is a classic nodular basal cell. Mohs is often the most effective treatment. Rombo syndrome presents with atrophoderma vermiculatum, basal cell carcinoma, milia, telangiectasias, and acral erythema. The following syndromes can have multiple BCCs: Gorlin, Bazex-Dupre- Christol, Rombo, Brooke-Spiegler, xeroderma pigmentosum, and Schöpf-Schulz-Passarge.
8- What will the histology of this lesion look like?
A- Small round blue cells with salt and pepper chromatin
B- Basaloid proliferations budding off the epidermis and in the dermis
C- Atypical keratinocytes invading the dermis
D- Lentiginous proliferation of atypical melanocytes
E- Clonal keratinocytes within the epidermis
Correct choice: D. Lentiginous proliferation of atypical melanocytes.
Explanation: This is a lentigo maligna melanoma on dermoscopy which will show a lentiginous proliferation of atypical melanocytes along the DEJ and invading into the dermis. It is not a basal cell carcinoma which would be basaloid islands within the dermis, clonal keratinocytes within the epidermis would be a seborrheic keratosis. Merkel cell carcinoma is characterized by salt and pepper chromatin. SCC would be atypical keratinocytes invading the dermis.
9- Epithelioma cuniculatum is an HPV-associated verrucous carcinoma involving the:
A- Oral mucosa
B- Scalp
C- Sole
D- Penis
E- Trunk
Correct choice: C. Sole
Explanation: Verrucous carcinoma is a subtype of SCC that presents with well-defined exophytic growths that can resemble large warts. Lesions are subclassified according to site. Epithelioma cuniculatum is a form of verrucous carcinoma involving the sole. Verrucous carcinoma of the oral mucosa is called oral florid papillomatosis. Verrucous carcinoma of the anogenital area is called giant condyloma acumintum of Buschke-Lowenstein. Verrucous carcinoma of the scalp does not have a unique name.
10- This is considered to be the juvenile counterpart of DFSP:
A- Juvenile hyaline fibromatosis
B- Giant cell fibroblastoma
C- Myxofibrosarcoma
D- Myofibromatosis
E- Plexiform fibrous histiocytoma
Correct choice: B. Giant cell fibroblastoma
Explanation: Giant cell fibroblastoma is CD34-positive, is mostly seen in male children on the neck/trunk, and is thought to be a juvenile counterpart of DFSP. The other listed tumors are not as closely related to DFSP.
11- This has what finding on dermoscopy?
A- Brown globules
B- Arborizing vessels
C- Blue-grey veil
D- Starburst pattern
E- Red lagoons
Correct choice: D. Starburst pattern
Explanation: This is a Spitz nevus. A starburst pattern suggests a Spitz nevus. A basal cell carcinoma which would show arborizing vessels on dermoscopy. A blue-grey veil is associated with melanoma. Brown globules is indicative of pigmented nests in the papillary dermis. Red lagoons indicate a hemangioma.
12- A 65 year-old woman is referred to your office for evaluation of a skin lesion that has been increasing in size over the past 5 years. You perform a skin biopsy that results as poorly differentiated squamous cell carcinoma (SCC). Risk factors for cutaneous squamous cell carcinoma (cSCC) include all of the following EXCEPT:
A- Kidney disease
B- Fitzpatrick skin types I and II
C- Chronic ulcers
D- Immunosuppression
E- Chronic sun exposure
Correct choice: A. Kidney disease
Explanation: Kidney disease in and of itself is not a risk factor for cSCC, however a patient who has had a kidney transplant is at higher risk for the development of cSCC, 65x increased risk over the general population due to the use of immunosuppressive agents to prevent organ rejection. Other risk factors for SCC include: chronic sun exposure, skin types I and II, chemical carcinogens (arsenic, tobacco, coal, tar), immunosuppression, chronic ulcers, burn scars, genetic syndrome (e.g. xeroderma pigmentosa), male gender, and older age. The remaining answer choices are risk factors for SCC.
13- Dermoscopic features suggestive of malignant melanoma include:
A- Lacunar pattern
B- Arborizing blood vessels
C- Maple leaf structures
D- D Glomeruloid vessels
E- Blue-white veil
Correct choice: E. Blue-white veil
Explanation: Asymmetry, multicomponent pattern, blue-whitish veil, parallel-ridge pattern, atypical pigment network, uneven radial streaming, localized irregular and diffuse pigmentation, irregularly distributed globules, and regression structures are all dermoscopic features suggestive of malignant melanoma. Lacunar pattern is seen with cherry angiomas. Arborizing blood vessesl are seen with basal cell carcinomas. Glomeruloid vessels are seen with squamous cell carcinoma in situ. Maple leaf structures are seen with basal cell carcinoma.
14- Excisional biopsy was performed on this lesion and revealed melanoma in situ. In the photo shown, what is the recommended margin for surgical excision?
A- 0.5-1.0cm
B- 1.0-1.5cm
C- 1.5-2cm
D- 2-2.5cm
E- 3cm
Correct choice: A. 0.5-1.0cm
Explanation: Lentigo maligna or melanoma in-situ requires a surgical margin of 0.5-1cm.
15- Which of the following markers do not stain melanocytic lesions:
A. CK7
B. Vimentin
C. S-100
D. HMB-45
E. All of these answers are correct
Correct choice: A. CK7
Explanation: CK7 will stain keratinocytes. Vimentin, S-100 and HMB-45 stains melanocytic lesions.
16- The treatment for Merkel cell carcinoma is all of the following except:
A. Wide local excision 2-3 cm
B. Mohs
C. Radiation sensitive therapy
D. Chemotherapy
E. Local excision of 1-2 cm
Correct choice: A. Wide local excision 2-3 cm
Explanation: Merkel cell carcinoma is a type of aggressive cancer with a high rate of recurrence. It is a neuroendocine carcinoma that is most commonly on sun exposed areas like the head and neck in the elderly. Treatment includes wide local excision of 1-2 cm (per the NCCN guidelines), Mohs, radiation, and chemotherapy.
17- When performing a biopsy of a suspected keratoacanthoma, which of the following is incorrect?
A- Fusiform incision through the entire KA may be performed
B- It is necessary to biopsy down to subcutaneous fat
C- A full-thickness shave biopsy is acceptable
D- A complete excisional biopsy may be performed
E- It is important to biopsy the lesion, even if it is less than 1cm
Correct choice: B. It is necessary to biopsy down to subcutaneous fat
Explanation: When considering a keratoacanthoma, it is not required to obtain a biopsy of the specimen down to the subcutaneous fat. It is important to biopsy all lesions concerning for keratoacanthoma, even those sized less than 1cm. Biopsy can be achieved either by complete excisional biopsy, full-thickness shave biopsy, or fusiform incision through the entire KA including its center and sides.
19- Your patient with extensive actinic damage and many of the lesions seen here is interested in field therapy with a lightbased modality. On a cellular level, how does photodynamic therapy kill cells that make up this lesion?
A- Heat shock proteins
B- Inhibition of pyrimidine nucleotide synthesis
C- Neutrophil-mediated, antibody-dependent cellular cytotoxicity
D- Reactive singlet oxygen
E- Proteosome inhibition
Correct choice: D. Reactive singlet oxygen
Explanation: The lesions seen here is an example of Bowen’s disease (superficial squamous cell carcinoma). Photodynamic therapy is a photochemical reaction in which a photosensitizing molecule, under an activating wavelength, reacts with oxygen in the tissue to create reactive singlet oxygen species. This leads to local necrosis. The other options do not explain how photodynamic therapy works.
20- What pathway is involved with this tumors growth?
A- Hedgehog pathway
B- RAS pathway
C- WNTpathway
D- ERK pathway
E- MAPK pathway
Correct choice: A. Hedgehog pathway
Explanation: Basal cell carcinomas are associated with PTCH mutations which are in the sonic hedgehog pathway.
21- A patient requests removal of a hyperpigmented plaque with a stuck-on appearance that is eczematous and erythematous in appearance due to trauma. Under the microscope, the hallmark histopathologic findings that you are most likely to see that help distinguish this lesion from other neoplasms include:
A- Papillomatosis, acanthosis, hyperkeratosis
B- Hypogranulosis, hyperkeratosis, pseudoepitheliomatous hyperplasia
C- Hypergranulosis, parakeratosis, acanthosis
D- Parakeratosis, hyperkeratosis, vacuolated keratinocytes
E- Vacuolated keratinocytes, acanthosis, hyperkeratosis
Correct choice: A. Papillomatosis, acanthosis, hyperkeratosis
Explanation: Hallmark histopathologic findings of seborrheic keratoses include: acanthosis, papillomatosis, hyperkeratosis, horn cysts and pseudohorn cysts. In contrast to a common wart, vacuolated keratinocytes are not present in stucco keratoses, a clinicopathologic variant of seborrheic keratoses.
22- Which of the following is true regarding digital HPV associated squamous cell cancers?
A- The rate of metastasis approaches 15%.
B- HPV18 is the most common associated sybtype.
C- Mohs micrographic surgery yields a 20% recurrence rate.
D- Women outnumber men 2:1.
E- These lesions only occur in association with immunosuppression.
Correct choice: C. Mohs micrographic surgery yields a 20% recurrence rate.
Explanation: According to Riddel et al (JAAD 2011;64(6):1147- 1153), Mohs micrographic surgery, although the treatment of choice, results in a 20% recurrence rate, which is significantly higher than cutaneous SCC. HPV16 is most often implicated. Men outnumber women 2:1. The rate of metastasis averages between 2-3%. Although common in transplant patients, HPV associated digital SCCs can occur secondary to trauma and in immunocompetent patients.
23- What is the original function of the gene mutated in this tumor?
A- Inhibit p53
B- Inhibit c-KIT
C- Inhibit smoothened
D- Activate smoothened
E- Inhibit hedgehog
Correct choice: C. Inhibit smoothened
Explanation: PTCH is the most common gene mutated in basal cell carcinomas. The normal function of PTCH is to inhibit smoothened. When PTCH is inactivated smoothened is free to activate the sonic hedgehog pathway and stimulate the cell-cycle resulting in tumor cell proliferation.
24- UVB induced mutations on the PTCH gene is associated with the development of:
A- BCC
B- Merkel cell carcinoma
C- Angiosarcoma
D- BCC and Merkel cell carcinoma
E- Merkel cell carcinoma and Angiosarcoma
Correct choice: A. BCC
Explanation: The p53 and PTCH genes are the major targets of UVB for the development of BCC. Other genes involved include the Smoothened-activating mutations, and PTCH2 mutations. The other listed tumors are not due to mutations in the PTCH gene.
25- Which form of BCC is the most common form in patients with HIV infection?
A- Superficial BCC
B- Nodular BCC
C- Morpheaform BCC
D- Infiltrative BCC
E- Micronodular BCC
Correct choice: A. Superficial BCC
Explanation: Superficial BCC is the most common form of BCC seen in patients with HIV.
26- A 56-year-old marathon runner presents with a superficial BCC On the left lower leg. He prefers to avoid excision or dessication and curettage and presents 4 weeks later with the findings seen here. Which of the following is the best statement regarding counseling for the patient?
A- Treatment with topical creams for superficial cancers has a lower cure rate than surgery but has an excellent cosmetic outcome. The findings here are consistent with a robust response and suggests a better clearance of the tumor at completion of therapy
B- The tumor here has grown significantly and the patient must now undergo Mohs surgery for therapy given the size and location of the lesion
C- Desiccation and curettage has a similar cosmetic outcome to topical therapies (5FU or imiquimod) as well as similar cure rate to excision
D- Mohs surgery is never appropriate for superficial basal cell or squamous cell carcinoma in situ malignancies as they are minimally invasive
E- It is best to monitor the superficial basal cell cancer annually because it is not an aggressive malignancy
Correct choice: A. Treatment with topical creams for superficial cancers has a lower cure rate than surgery but has an excellent cosmetic outcome. The findings here are consistent with a robust response and suggests a better clearance of the tumor at completion of therapy.
Explanation: Imiquimod can be a reasonable treatment for superficial basal cell cancers. It has an excellent cosmetic outcome but can be very inflammatory, as seen in the image. The tumor has not grown significantly, this is a reaction to the imiquimod. Dessication and curettage often has a worse cosmetic outcome than topical chemotherapeutics and has a lower cure rate than excision. Based on location and size, Mohs surgery is sometimes an appropriate option for superficial keratinocyte cancers. It is not unreasonable to monitor a superficial BCC as they are slow growing tumors, however it is not the best answer and annual follow-up may not be enough treatment.
27- Where is the classic location of this lesion?
A- Scalp
B- Chest
C- Back
D- Nose
E- Ear
Correct choice: A. Scalp
Explanation: This is an angiosarcoma as evident by the numerous atypical vessels, hemorrhage and atypical endothelial cells within the atypical vessels. These tumors most commonly occur on the scalp as violaceous nodules in elderly men.
28- The application of what topical medication has been shown to decrease the risk of developing squamous cell carcinomas in the first year after treatment?
A- Ingenol mebutate
B- Imiquimod
C- Tacrolimus
D- Diclofenac
E- Fluorouracil 5%
Correct choice: E. fluorouracil 5%
Explanation: Fluorouracil 5%. A standard course of fluorouracil treatment (application twice daily for 2 to 4 weeks) to the face and ears were shown to decrease the risk of SCC by 75% in the first year after treatment, although it was not shown to decrease the risk of keratinocyte carcinomas over a 4-year period. The remaining medications are FDA-approved for the treatment of actinic keratosis, but have not yet been studied for chemoprevention of basal or squamous cell carcinomas.
29- Where is the classic location of this lesion?
A- Forehead
B- Dorsal nose
C- Upper cutaneous lip at the base of the nasal ala
D- Ear
E- Chin
Correct choice: C. Upper cutaneous lip at the base of the nasal ala
Explanation: This is a microcystic adnexal carcinoma. These typically occur on the upper cutaneous lip at the base of the nasal ala in young adult females. It is imperative the base of the tumor be seen to ensure it is completely removed as the tumor is aggressive.
30- What will this show on dermoscopy?
A- Arborizing vessels
B- Red lagoons
C- Blue-grey veil
D- Brown globules
E- Starburst pattern
Correct choice: A. Arborizing vessels
Explanation: This is a basal cell carcinoma which will show arborizing vessels. A hemangioma will show red lagoons on dermoscopy. A spitz nevus has a starburst pattern. A blue-grey veil is associated with melanoma. Brown globules is indicative of pigmented nests in the papillary dermis.
31- All of the following statements are true regarding the ‘MCW Melanoma Cocktail’ except:
A- it is a mixture of monoclonal antibodies that include MART-1
B- it is performed intraoperatively
C- it is a mixture of monoclonal antibodies that include Melan-A
D- it demonstrates micrometastases in sentinel lymph nodes
E- it is a mixture of polyclonal antibodies to tyrosinase
Correct choice: E. it is a mixture of polyclonal antibodies to tyrosinase
Explanation: The ‘MCW Melanoma Cocktail’ is an immunostain made up of monoclonal antibodies to MART-1, Melan-A and tryrosine. It is used intraoperatively during sentinel lymph node biopsy and allows for rapid and accurate determination of micrometastases. The mixture of stains are monoclonal antibodies; not polyclonal.
32- What is the mechanism of action of vorinostat, a therapy for refractory cutaneous T cell lymphoma?
A- Histone deacetylase inhibitor
B- IL-2 receptor inhibitor
C- Antibody against CTLA-4
D- JAK 1/3 inhibitor
E- Alkylating agent
Correct choice: A. Histone deacetylase inhibitor
Explanation: Vorinostat and romidepsin are histone deacetylase (HDAC) inhibitors. The most common side effects are fatigue, gastrointestinal symptoms and reversible thrombocytopenia. Denileukin difitox is an IL-2 receptor inhibitor, and is associated with capillary leak syndrome. Ipilimumab is an antibody to CTLA-4. Tofacitinib is a JAK 1/3 inhibitor.
33- Spindle cell lipoma is most commonly found on the:
A- Head
B- Lower extremities
C- Buttocks
D- Breast
E- Posterior shoulder
Correct choice: E. Posterior shoulder
Explanation: Spindle cell lipoma is a solitary benign tumor seen in adult male patients, and is most often located on the posterior shoulder or neck regions. The tumor histologically consists of mature collagen, adipose tissue, spindle cells, and mast cells. Treatment is with local excision. None of the remaining answer choices represent the most common location for spindle cell lipoma.
34- This tumor commonly results from mutations in p53. Which of the following is correct?
A- It is the most common type of skin cancer in Caucasians
B- Oral variants most commonly present on the dorsal tongue
C- It is typically less aggressive in patients with CLL
D- Organ transplant patients have a 10-fold increased risk of developing this tumor
E- Tumors arising within scars/chronic ulcers have the highest risk of metastasis
Correct choice: E. Tumors arising within scars/chronic ulcers have the highest risk of metastasis Explanation: This is SCC of the ear. SCCs arising within scars/chronic ulcers metastasize in
~30-40% of cases, whereas those arising on the lip or ear have a 10-20% risk of metastasis. Recurrent SCCs have a metastasis risk of up to 30%. SCC is the 2nd most common skin cancer in Caucasians (BCC is most common). Oral SCC most commonly presents on the lateral tongue. SCC
is typically more aggressive in patient with CLL. Organ transplant patients have a 65-fold increased risk for developing cutaneous SCC.
35- Which of the following is true about this neoplasm?
A- A sentinel lymph node biopsy is standard of care for tumors thicker than 1 mm
B- Locally advanced or metastatic variants may respond to sonic hedgehog inhibitors
C- Grows very rapidly over several weeks/months before stabilizing
D- Associated with a polyomavirus infection
E- Occurs at sites of chronic burns or fistulae
Correct choice: B. Locally advanced or metastatic variants may respond to sonic hedgehog inhibitors
Explanation: The dermoscopic picture is of a pigmented BCC.
Answer choice 1 refers to melanomas; choice 3 refers to keratoacanthoma; choice 4 refers to merkel cell carcinoma; choice 5 refers to squamous cell carcinoma.
36- The green color in chloroma is secondary to:
A- Stromelysin
B- Chloracetate
C- Fumarase
D- Myeloperoxidase
E- Alkaline phosphatase
Correct choice: D. Myeloperoxidase
Explanation: Chloromas are greenish tumor grossly secondary to involvement of the skin in acute granulocytic leukemia. The green color is secondary to myeloperoxidase. The other listed answers do not contribute to the green color of chloroma.
37- Which of the following is FALSE?
A- These lesions are often mistaken for basal cell carcinomas.
B- In the absence of ulceration, sentinel lymph node biopsy should be considered if tumor thickness is 0.8mm or greater.
C- These lesions are not treated differently than their pigmented variants.
D- These lesions often have a better prognosis than their pigmented variants.
E- Increased tumor thickness is associated with a worse prognosis.
Correct choice: D. These lesions often have a better prognosis than their pigmented variants.
Explanation: The correct answer is D (D is false). Amelanotic melanomas are often diagnosed later (i.e. thicker Breshlow depth) than their pigmented counterparts, which is the reason for their poorer prognosis. Amelanotic melanomas are often mistaken for basal cell carcinomas as both can appear clinically similar. The recently published AJCC 8th Edition Melanoma Staging System revised the definitions of T1a and T1b so that T1a melanomas include those <0.8 mm without ulceration while T1b melanomas include those 0.8-1 mm with or without ulceration and those <0.8 mm with ulceration. Mitotic rate is no longer a T1 category criterion but should be documented for all invasive primary melanomas. Thus, in the absence of ulceration, sentinel lymph node biopsy should be considered if tumor thickness is 0.8mm or greater. Amelanotic melanomas are treated identically
to their pigmented counterparts, and increased tumor thickness is associated with a worse prognosis (irrespective of the clinical subtype of melanoma).
38- This lesion may be associated with which of the following?
A. Cowden disease
B. Rombo syndrome
C. Reed’s syndrome
D. Brooke-Spiegler syndrome
E. Gorlin syndrome
Correct choice: D. Brooke-Spiegler syndrome
Explanation: This is a biopsy of a cylindroma. Multiple cylindromas seen with CYLD mutation either in cylindromatosis or in conjunction with other adnexal neoplasms in Brooke-Spiegler syndrome.
39- A 40 year-old man presents with a slow-growing, large, firm, nodular tumor on the back. Immunohistochemical staining of the biopsy specimen from this tumor is positive for CD34 and negative for Factor XIIIa. The patient subsequently undergoes wide excision with adjuvant chemotherapy. Which of the following chemotherapeutic agents was most likely used?
A. Imatinib
B. Vismodegib
C. Avelumab
D. Ipilimumab
E. Nivolumab
Correct choice: A. Imatinib
Explanation: Imatinib has been used in the treatment of primary or locally recurrent dermatofibrosarcoma protuberans. Even with wide excision, the 5 year recurrence rate for this tumor can be 20-25%. This neoplasm commonly possesses a reciprocal translocation t(17;22) resulting in fusion of collagen 1alpha1 and platelet derived growth factor B (a fusion oncogene). Activation of the platelet derived growth factor receptor associated with overexpression of platelet derived growth factor is central to the development of DFSP. Imatinib is a protein tyrosine kinase inhibitor used primarily to treat chronic myelogenous leukemia with the Philadelphia chromosome defect. Imatinib also inhibits the tyrosine kinases associated with platelet derived growth factor and stem cell factor. Therefore, it directly inhibits the platelet derived growth factor receptor signaling cascade, which plays a critical role in the pathogenesis and growth of DFSPs. While Imatinib has been successful in clinical trials, it is not yet FDA-approved for the treatment of DFSP. DFSP stains positive for CD34 and negative for Factor XIIIa, which differentiates it from a dermatofibroma (stains positive for Factor XIIIa and negative for CD34).
Vismodegib is a smoothened-inhibitor that is FDA-approved for the treatment of basal cell carcinoma. Avelumab is an anti-PD-L1 monoclonal antibody that was recently FDA-approved for the treatment of merkel cell carcinoma. Ipilimumab is an anti-CTLA-4 monoclonal antibody that is FDA-approved for the treatment of melanoma. Nivolumab is an anti-PD-1 monoclonal antibody that is FDA-approved for the treatment of melanoma.
40- Typical dermoscopic features of this common benign lesion that typically begins to appear during the fourth decade of life include all of the following except:
A. Fat fingers
B. Reticulated pigment network
C. Milia-like cysts
D. Cerebriform surface
E. Light brown parallel structures
Correct choice: B. Reticulated pigment network
Explanation: Typical dermoscopic features of seborrheic keratoses include: milia-like cysts, irregular crypts, fissures/ridges, blue-gray lobules, light brown fingerprint-like parallel structures, fat fingers (the gyri of a cerebriform surface). A reticulated pigment network is not a common feature of seborrheic keratoses.
41- Which of the following would you expect to find on dermoscopy of this lesion?
A. Blue-grey ovoid nests
B. Milky red globules
C. Orange crust
D. Maple leaf structures
E. Spoke wheel vasculature
Correct choice: B. Milky red globules
Explanation: This is an image of melanoma, which is associated with milky red globules on dermoscopy.
42- Which of the following is TRUE regarding this lesion?
A. Ulceration is the most important prognostic factor
B. Immunosuppression is not a risk factor
C. Female gender is a poor prognostic factor
D. It is the most common type seen in darker-skinned patients
E. Anti-PD-1 antibodies are not helpful in treatment
Correct choice: D. It is the most common type seen in darker-skinned patients
Explanation: The associated image depicts an acral lentiginous melanoma (ALM), which is the most common type of melanoma in darker-skinned individuals. Notably, and very sadly, the famous musician Bob Marley was diagnosed with ALM in 1977 and succumbed to this malignancy in 1981 as it had metastasized to his lungs and brain.
Breslow depth, not ulceration, is the most important prognostic factor for melanoma. Immunosuppression increases one’s risk of melanoma by a factor of 3-4. Male gender is a poor prognostic factor. Anti-PD-1 antibodies (e.g. nivolumab, pembrolizumab) are proven to prolong survival in patients with metastatic melanoma.
43- This lesion is most likely to possess a mutation in which of the following?
A. NRAS
B. BAP-1
C. CDKN2A
D. BRAF
E. C-kit
Correct choice: D. BRAF
Explanation: The pictured lesion is a melanoma. The most common mutation in a melanoma is in the BRAF gene (~50% of advanced or unresectable melanomas). NRAS mutations are the next most commonly found mutation (~30% of melanomas). BAP-1 (BAP-1 tumor predisposition syndrome), CDKN2A (melanoma pancreatic cancer syndrome), and C-kit may also be mutated in cases of melanoma.
44- This syndrome presents with multiple keratoacanthomas appearing suddenly during childhood or adolescence and inherited in an autosomal dominant pattern:
A. Ferguson-Smith
B. Grzybowski
C. Gorlin
D. KA centrifugum
E. Buschke-Lowenstein
Correct choice: A. Ferguson-Smith
Explanation: Patients that have a sudden appearance during childhood of multiple keratoacanthomas have Ferguson-Smith type of KA. This is autosomal dominant and are the KAs are typically self-healing.
Grzybowski is typically diagnosed in adulthood with the sudden appearance of hundreds to thousands of lesions in a disseminated fashion.
Gorlin syndrome is characterized by the appearance of multiple BCCs (not KAs) during childhood. It is also characterized by odontogenic keratocysts of the jaw and skeletal defects (e.g., macrocephaly, hypertelorism, frontoparietal bossing, spina bifida, or rib abnormality, among others). Tumors associated with this disease include medulloblastoma, meningioma, ovarian fibromas (bilateral), and cardiac fibromas. It is inherited in an autosomal dominant pattern, and due to a mutation in PTCH gene.
KA centrifugum is a subtype of solitary KA that may reach a size of up to 20 cm in diameter. Buschke-Lowenstein tumor is a verrucous carcinoma caused by HPV 6 and 11 that is locally invasive and destructive but rarely metastatic.
45- Biopsy of one of the lesions pictured reveals spindle cells forming slit-like vascular channels. Which of the following is also associated with the cause of these lesions?
A. Bacillary angiomatosis
B. Merkel cell carcinoma
C. Angiosarcoma
D. Multicentric Castleman disease
E. Nasopharyngeal carcinoma
Correct choice: D. Multicentric Castleman disease
Explanation: The clinico-pathologic correlation is best for Kaposi sarcoma, which is caused by HHV-8 (KSHV). Multicentric Castleman disease and primary effusion lymphoma are also associated with HHV-8. The other remaining answer choices are not associated with HHV-8.
46- What is the likely etiology of the pictured lesion?
A. PTCH mutation
B. CDKN2A mutation
C. Lichenoid infiltrate
D. HPV 5
E. p53 mutation
Correct choice: E. p53 mutation
Explanation: This is a SCC of the tongue. SCCs most commonly have mutations in p53.
PTCH mutations are in basal cell carcinomas. CDKN2A mutations are in familial melanomas. A lichenoid infiltrate would be seen with lichen planus which is usually on the buccal mucosa. Heck’s disease is due to HPV 13 and 32.
47- You perform a biopsy of a pink, soft, dome-shaped papule and the histology reveals a predominantly intradermal melanocytic proliferation composed of nests and sheets of epithelioid melanocytes with large pleomorphic nuclei and light eosinophilic cytoplasm. Immunohistochemical staining is positive for BRCA1 associated protein-1. Which of the following malignancies is this patient most at risk of developing?
A. Breast cancer
B. Ovarian cancer
C. Hodgkin’s lymphoma
D. Mesothelioma
E. Pancreatic cancer
Correct choice: D. Mesothelioma
Explanation: This clinico-pathologic picture is most consistent with the BRCA1 associated protein-1 (BAP1) cancer syndrome. BAP1 is a nuclear deubiquitinating enzyme that functions as a tumor suppressor via its role in DNA damage repair. The BAP1 cancer syndrome is a rare autosomal dominant genetic syndrome typified by the development of mesotheliomas and uveal melanomas. Patients with BAP1 cancer syndrome develop several, distinct, melanocytic neoplasms. These are raised, pink or tan, dome-shaped, benign lesions that have been referred to in the literature as “melanocytic BAP1-mutated atypical intradermal tumors/MBAITs” or “BAPomas.”
Less commonly, cutaneous melanomas, various types of carcinomas (mostly from the kidney and gallbladder), sarcomas, and brain tumors can arise in the BAP1 cancer syndrome. Thus, this patient is less likely to develop one of the other listed answer choices compared to mesothelioma.
48- The clear-cell variant of this neoplasm is associated with which of the following?
A. Brooke-Spiegler syndrome
B. Cowden disease
C. Rombo syndrome
D. Diabetes mellitus
E. Hypothyroidism
Correct choice: D. Diabetes mellitus
Explanation: This is a syringoma. The clear-cell variant (a rare histological variant of syringoma that is clinically indistinguishable from an ordinary syringoma) has been associated with diabetes mellitus.
49- What is the most common gene mutated in this type of lesion?
A. PMS
B. c-KIT
C. p53
D. MSH
E. PTCH
Correct choice: E. PTCH
Explanation: This is a basal cell carcinoma. The most common gene mutation is PTCH.
p53 is mutated in SCCs, PMS2 and MSH6 are lost in sebaceous neoplasms of Muir-Torre. c-KIT is mutated in acral melanoma, mucosal melanoma, and mast cell disorders.
50- Which of the following treatments carries the lowest risk of recurrence in the condition pictured?
A. Pembrolizumab
B. Imatinib mesylate
C. Radiation therapy
D. Mohs micrographic surgery
E. Wide local excision
Correct choice: D. Mohs micrographic surgery
Explanation: Standard treatment of dermatofibrosarcoma protuberans (DFSP) consists of complete surgical extirpation. The rate of recurrence is lower following Mohs micrographic surgery compared to wide local excision.
This question asks the examinee to identify DFSP presenting as a characteristic firm red-brown tumor on the shoulder, and know the treatment that will impart lowest recurrence risk. Initial treatment of this tumor is complete surgical removal, with studies demonstrating lower risk of recurrence with Mohs micrographic surgery (choice 4) versus wide local excision (choice 5). The programmed cell death-1 inhibitor pembrolizumab (choice 1) has not been used to treat DFSP. Imatinib mesylate (choice 2), which interferes with the activity of the COL1A1-PDGFB fusion protein found in DFSP, is FDA-approved for unresectable, recurrent, and metastatic cases. Radiation (choice 3) has been utilized for unresectable or recurrent DFSP, and would not be an appropriate choice for initial therapy.
51- Merkel cell carcinoma should be treated with what size surgical margins?
A. 2mm
B. 5mm
C. 1-2cm to subcutaneous
D. 1-2cm to fascia
E. 5cm
Correct choice: D. 1-2cm to fascia
Explanation: Merkel cell carcinoma is an aggressive rare tumor of the skin accounting for less than 1% of cutaneous malignancies. Also known as neuroendocrine cancer of the skin, this tumor presents as a painless red to violaceous, firm, solitary, nodule that usually presents on sun exposed areas such as the head, neck and upper extremities. These tumors present usually during the 6th and 7th decades, and have a 2 year survival rate of 50-70%. Because of this tumor’s high potential for regional and distal metastasis, this tumor should be excised with wide local excision with 1-2cm surgical margins to the depth of fascia or pericranium, or treated with Mohs Surgery.
52- On dermoscopy, which of the following findings most strongly supports the correct diagnosis?
A. Starburst pattern
B. Blue-whitish veil
C. Maple leaf structures
D. Regression structures
E. Irregular streaks
Correct choice: C. Maple leaf structures
Explanation: Maple leaf structures on dermoscopy support the diagnosis of basal cell carcinoma.
This question asks the examinee to identify a pigmented BCC and select the most closely associated dermoscopic finding. In the case of this dark blue-black irregular papule at the alar crease, initial concern for melanoma is quite reasonable. However, on close inspection, there is a subtly rolled border, suggesting the correct diagnosis, pigmented BCC. Dermoscopy can assist in distinguishing between pigmented BCCs and other pigmented lesions. Among the answer choices, maple leaf structures (choice 3) are most closely associated with BCC. The starburst pattern (choice 1) is classically seen in pigmented spindle cell nevus of Reed. Blue-whitish veil (choice 2), regression structures (choice 4), and irregular streaks (choice 5) are features of melanoma, not routinely observed in pigmented BCC.
53- The keratoacanthoma variant characterized by the sudden appearance during childhood or adolescence of multiple KAs is called:
A. Gorlin syndrome
B. Xeroderma pigmentosa
C. Ferguson-Smith
D. Grzybowski
E. None of these answers are correct
►C
The Ferguson-Smith is a keratoacanthoma variant characterized by the sudden appearance during childhood or adolescence of multiple KAs that may resolve and later-on reappear. This condition is inherited in an autosomal dominant pattern
54- The treatment of choice for this lesion shown is:
A. Radiation therapy
B. Imiquimod
C. 5 Flourouracil
D. Wide excision with 2cm margins
E. Mohs surgery
►E
The treatment of choice for Dermaotfibrosarcoma protuberans is Mohs surgery. Radiation therapy has been used, however has limited value as solitary therapy for thsi tumor. Radiation therapy can be used as an adjunct to wide surgical excision. Classically, these tumors should be excised with 3cm margins. The recurrence rate associated with these tumors can be 10 -20 percent with wide excision with 3 cm margins. With Mohs surgery, the recurrence rate ranges from 0% to 6%. 5FU and Imiquimod are not effective modalitites in treating DFSPs, as it infiltrates deep into the subcutaneous tissue.
55- Mutations in which gene would likely be found in the neoplastic cells of this lesion?
A. PATCH
B. p53
C. Fumarate hydratase
D. CREBBP
E. p63
►B
Squamous cell carcinoma is the second most common cancer of the skin. Mutations in the tumor suppressor p16 and p53 are commonly found in SCC’s. Normally, UV damage upregulates p53 thereby delaying cell cycle progression. DNA damage can then be repaired or the cell could undergo apoptosis. In squamous cell carcinoma, p53 exhibits loss of heterozygosity due to C to T or CC to TT mutations.
56 -A patient with a innumerable disseminated keratoacanthomas, including lesions on the larynx and oral mucosa:
A. Is unlikely to have palmoplantar involvement
B. Likely has an underlying immune deficiency
C. Is at high risk for myelodysplasia
D. Likely inherited their condition in an autosomal dominant manner
E. Likely developed them during adulthood
►E
This patient has the Grzybowski type of keratoacanthomas. Typically diagnosed in adulthood, these patients have the sudden appearance of hundreds of small lesions in a disseminated
fashion. The lesions can be found anywhere on the body including palms, soles, larynx, and oral mucosa.
57 -The patient is a 45 year old male complaining of red, chapped lower lip. Which of the following lasers is the most appropriate to treat this condition?
A. Pulsed Dye Laser
B. Nd:YAG laser
C. CO2 laser
D. Diode laser
E. Laser treatment is not an option
►C
The patient has actinic cheilitis. Notice the red, scaly lower lip, with erosions and fissures. The CO2 laser is currently a common treatment alternative for this condition.
Which of the following ethnic groups are commonly diagnosed with dermatosis papulosa nigra:
A. Asians
B. Hispanics
C. African-Americans & Hispanic patients
D. Caucasians
E. No difference between ethnic groups
►C
Characterized by the presence of multiple, small, hyperpigmented, sessile SKs on the face, DPN is typically diagnosed on the African-American and Hispanic population.
59- Intermittent sun exposure with painful sunburns is a predisposing factor for the development of:
A. Atypical nevi
B. Seborrheic keratosis
C. Malignant melanoma
D. Atypical nevi and Malignant melanoma
E. All of these answers are correct
►D
It has been reported that the risk for the development of atypical nevi and melanoma is higher than twofold with a history of five or more episodes of painful sunburn during adolescence.
60- The following lesion is the classic presentation of:
A. BCC
B. Merkel cell carcinoma
C. Melanoma
D. CTCL
E. Keratoacanthoma
►E
Keratoacanthomas present as a solitary, firm, dome-shaped papule with a cratiform center.
61 -A patient having Mohs surgery for a squamous cell carcinoma on the ear has tumor invading the cartilage and perineural invasion. What stage disease does the patient have?
A. T0
B. T1
C. T2
D. T3
E. T4
►C
TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in s itu T1 Tumor ≤2 cm in greatest dimension with <2 high-risk features∗ T2 Tumor >2 cm in greatest dimension with or without one additional high-risk feature, or tumor any size with ≥2 high-risk features∗ T3 Tumor with invasion of maxilla, mandible, orbit, or temporal bone T4 Tumor with invasion of skeleton (axial or appendicular) or perineural invasion of skull base. *High risk
features: Depth/invasion >2 mm thickness or Clark level ≥IV,Perineural invasion, Primary site ear, Primary site hair-bearing lip, Poorly differentiated or undifferentiated.
62- What would you expect to see under dermoscopy of this vascular neoplasm?
A. Red sacculae
B. Arborizing blood vessels
C. Hair pin telangectasia
D. Milky red globules
E. Blue-grey ovoid nests
►A
Hemangioma have a characteristic appearance under dermoscopy. Typically, they have a maroon lagoon or red sacculae appearance.
63- The most important mutated gene associated with a predisposition to develop malignant melanoma is:
A. PTCH
B. CDKN2A
C. PTCH2
D. None of these answers are correct
E. All of these answers are correct
►B
The CDKN2A gene located on chromosome 9p21 is the most important mutated gene associated with MM of the listed choices. BRAF is another important mutation.
64 -A patient is diagnosed with squamous cell carcinoma. As a doctor you explain to the patient that the metastatic rate is:
A. 0.3-16%
B. 15%-20%
C. 18%-25%
D. 25%-30%
E. 30%-45%
►A
Patients that have SCC have a 0.3-16% of chance of metastasis. The location, size and type of SCC can determine the possibility of metastasis.
- Which of the following is the most common initial site of metastasis from a primary BCC?
A. Lungs
B. Regional lymph nodes
C. Bone
D. Liver
E. Pleura
►B
The metastatic potential of BCC is very low with rates ranging from 0.0028 to 0.1%. The head and neck region is the most frequent location of the primary tumor with regional lymph nodes being the most common site of metastasis. The lungs, bone, liver, and pleural are also potential sites of metastasis.
66 -Chloroma is a characteristic cutaneous manifestation of:
A. Tuberous sclerosis
B. Sweetǁs syndrome
C. Neurofibromatosis
D. Leukemia
E. Pseudomonas sepsis
►D
Chloromas, also termed granulocytic sarcomas, are a localized tumor composed of immature granulocytic cells. They frequently have a greenish coloration due to the presence of myeloperoxidase and most commonly affect the bone. The condition most often occurs in patients with acute leukemia of the myeloid type.
67- Which phase of the cell cycle does p53 regulate?
A. G1
B. G2
C. S phase
D. Mitosis
E. Meiosis
►A
p53 is a tumor suppressor gene which arrests cell cycle in G1 as it controls the transition from G1 to
S. It also downregulates BCL-2. Mutations in p53 are associated with Li-Fraumeni syndrome as well as the development of squamous cell carcinomas.
68- A 65 year-old female with multiple actinic keratosis on the face under treatment with 5-FU. According to the image and aforementioned information, you may conclude that:
A. The patient must immediately stop treatment since unexpected side effects have developed
B. The patient has been compliant with 5-FU treatment and the appearance of inflammation, erythema and erosions are expected
C. The image is not relevant to 5-FU treatment
D. None of these answers are correct
E. All of these answers are correct
►B
Compliance is a key feature in treatment with 5-FU. Erythema, inflammation and erosion must develop and is considered a sign of successful treatment.
69- Which of the following would you not expect to see under dermoscopy?
A. Maple leaf pattern
B. Arborizing blood vessels
C. Blue-grey ovoid nests
D. Orange crust
E. Milky red globules
►E
Dermoscopy is a useful tool in differentiating a pigmented basal cell carcinoma from melanoma. Basal cell carcinomas may have arborizing blood vessels, maple leaf pattern, blue-grey ovoid nests, and orange crust or ulcer. Milky red globules are sometimes seen in melanoma.
70- Which of the following melanoma subtypes is more consistently seen in dark-skinned individuals?
A. Acral lentiginous melanoma
B. Superficial spreading melanoma
C. Lentigo maligna melanoma
D. Nodular melanoma
E. Superficial spreading melanoma and Lentigo maligna melanoma
►A
Acral lentiginous melanoma is the predominant type of melanoma in dark-skinned individuals. It is usually located on the soles, palms, and subungeal region of patients in their fifth to sixth decade of life.
71- Which of the following is an immunhistochemical marker for Merkel Cell Carcinoma?:
A. S-100
B. Vimentin
C. HMB-45
D. Neuron specific enolase
E. All of these answers are correct
►D
Neuron specific enolase stains merkel cells. Vimentin stains melanocytic lesions, sarcomas and lymphomas. S-100 and HMB-45 stains melanocytic lesions, such as melanoma.
72- Which one of the following malignancies is associated with HPV infection?
A. Verrucous carcinoma
B. Metastatic melanoma
C. Basal cell carcinoma
D. Sebaceous carcinoma
E. Atypical fibroxanthoma
►A
Verrucous carcinomas are low-grade carcinomas which are slow-growing and metastasize very late in the course. The presence of HPV has been demonstrated in cases both by electron microscopy and DNA hybridization.
73- Dermatofibrosarcoma protuberans is:
A. Cytogenetically characterized by reciprocal translocation t(17;22)(q22;q13)
B. Factor XIIIa positive
C. CEA positive
D. CD 34 positive
E. Cytogenetically characterized by reciprocal translocation t(17;22)(q22;q13) and CD 34 positive
►E
A chromosomal reciprocal translocation t(17;22)(q22;q13), and supernumerary ring chromosome have been reported as cytogenetic characteristics of DFSP. Typically DFSP is CD34 positive and factor XIIIa negative, allowing its differentiation from dermatofibroma.
74- Amplification of which of the following genes is associated with Merkel cell carcinoma?
A. L-Myc
B. C-Myc
C. GLI1
D. CDKN2A
E. PTEN
►A
The L-Myc gene has been found to be amplified in Merkel cell carcinoma but not in normal skin. C-Myc has been found to be amplified in neuroblastoma. GLI1 is a transcription factor involved in hedgehog signaling and a potential target in basal cell carcinomas. CDKN2A is implicated in familial forms of melanoma that are associated with pancreatic cancer. PTEN is a tumor suppressor gene that is mutated in Cowden Disease, Bannayan-Riley-Ruvalcaba Syndrome, and Proteus Syndrome.
75- The most common location for a basal cell carcinoma is:
A. Lower eyelid
B. Forehead
C. Ears
D. Back
E. Shoulders
►A
The most common location for a BCC is the lower eyelid. It is the most common epithelial tumor of the eyelid.
76- If left untreated, which of the following is not at risk for malignant transformation?
A. Bowenoid papulosis
B. Cutaneous horn
C. Actinic cheilitis
D. Leukoplakia
E. Stucco keratosis
►E
Cutaneous horn can overlie an AK or SCC or a benign lesion and it presents as a conical protuberance arising from an erythematous base. Actinic cheilitis results from the confluence of multiple AKs on the lips. Leukoplakia is a clinical diagnosis and is defined as a white patch in the oral cavity. It is the most common premalignant condition of the oral cavity. Bowenoid papulosis manifests clinially as multiple red-brown warty papules that histologically represent high grade squamous intraepithelial lesions.
77- Currently, the surgical margin for melanomas that measure less than 2 mm in thickness is:
A. 1 mm
B. 0.5 cm
C. 1 cm
D. 2 cms
E. 3 cms
►C
The current surgical margins are 0.5 cms for melanoma in situ, 1 cm for melanomas that measure less than 2mm in thickness and 2cm for melanomas >2mm.
78- Denileukin diftitox (ONTAK®):
A. is a systemic treatment option for CTCL
B. is a diphtheria fusion toxin
C. targets the interleukin-2 receptor
D. None of these answers are correct
E. All of these answers are correct
►E
Denileukin diftitox is as diphtheria fusion toxin that targets the IL-2 receptor. It is a systemic treatment alternative for recalcitrant or advance CTCL.
79- Maple leaf-like structures seen on dermoscopy are characteristic of which lesion?
A. Seborrheic keratoses
B. Pigmented basal cell carcinoma
C. Dermal nevi
D. Melanoma
E. Hemangioma
►B
Maple leaf-like structures seen on dermoscopy are an important diagnostic criterion for pigmented basal cell carcinomas. They correspond to the heavily pigmented cells in the bas aloid cells.
80- Which one of the following agents has demonstrated potential benefit as a chemopreventive to UV-induced skin cancer?
A. Prostaglandin E2
B. Vitamin D
C. Arachidonic acid
D. Celecoxib
E. Vitamin E
►D
Cyclooxygenase-1 and -2 and enzymes that catalyze the conversion of arachidonic acid to prostaglandins. It is believed the prostaglandin E2 (PGE2), whose levels are increased by ultraviolet irradiation, is pro-inflammatory and may contribute to skin carcinogenesis. In a study by Orengo et.al., hairless mice who were given celecoxib were found to have a significantly longer latency period between exposure to ultraviolet light and the development of skin carcinomas.
81- UVB induced mutations on the PTCH gene is associated with the development of:
A. BCC
B. Merkel cell carcinoma
C. Angiosarcoma
D. BCC and Merkel cell carcinoma
E. Merkel cell carcinoma and Angiosarcoma
►A
The p53 and PTCH genes are the major targets of UVB for the development of BCC. Other genes involved include the Smoothened-activating mutations, and PTCH2 mutations.
82- Periungual Squamous cell carcinoma has been linked to which HPV type(s)?
A. 6, 11
B. 2, 4
C. 16
D. 13
E. 8
►C
Infections associated with Human Papilloma Virus can produce growths on the epithelial or mucosal surfaces. There are over 100 strains of these viruses, and some of these strains can predispose to intraepithelial carcinomas, particularly when involving the anal or g enital mucosa. In general, HPV strains 16 and 18 are classified as his risk virus types and can be associated with cervical cancer , oral cancer, anal cancer and periungual cancers. HPV 6 and 11 are associated with condyloma acuminata; HPV types 2, 4 are associated with common warts; HPV type 13 has been associated with Heck’s disease and HPV type 8 has been associated with epidermal dysplasia verruciformis.
83- Which of the following features of thin melanomas (<1 mm thick) has not been associated with an increased risk of metastasis?
A. Regression
B. Location
C. Age
D. Gender
E. P53 expression
►E
Regression in malignant melanoma appears histologically as a focal area of fibrosis with lymphocytes and melanophages in the papillary dermis. The presence of regression precludes accurate measurement of true thickness of the melanoma. Extensive regression in thin melanomas has a significant association for the risk of metastases.
84- What is the most common site of metastasis for this dermal tumor?
A. Lung
B. Brain
C. Kidney
D. Liver
E. Bone
►A
Dermatofibrosarcoma protuberans is a rare, low-grade dermal sarcoma. Typically, the lesion occurs as a painless subcutaneous mass that grows slowly. This malignancy typically has lateral spread but invade deep. Metastasis is rare but has been reported to the lung.
85- Which substance does p53 normally activate to promote apoptosis via inhibition of bcl-2?
A. p21
B. p16
C. Puma
D. Mdm2
E. Akt
►C
p53 is the most commonly mutated tumor suppressor gene involved in human cancer and is often mutated in SCC and BCC. p53 acts via two main pathways, 1) activation of p21 (Cdk inhibitor) which leads to cell cycle arrest, and 2) activation of Puma which inhibits Bcl-2 (apoptosis inhibitor) thereby leading to cell death. CKDN2A, a gene that when mutated leads to a risk of melanoma, acts via 1) activation of p16 (another Cdk inhibitor) and 2) activation of p14ARF which inhibits Mdm2 (which normally degrades p53). Akt is involved in the PI3K-Akt signaling pathway and inhibits cell cycle arrest and apoptosis.
86- The most common location for primary mucinous carcinoma is:
A. neck
B. eyelid
C. areola
D. scrotum
E. nose
►B
Mucinous carcinoma presents as a slowly growing, asymptomatic, round, erythematous nodule on the head and neck. Forty percent of cases occur on the eyelid. Histologically it is characterized by the presence of large areas of mucin (―sea of mucousǁ) with small islands of basophilic epithelial cells. Primary mucinous carcinoma of the skin has an indolent course. Local recurrence occurs in 1/3 of patients following excision. The rate of metastasis is low (9.6%).
87- All of the following disorders may manifest as exfoliative dermatitis except
A. Behcet’s disease
B. Psoriasis
C. Pemphigus foliaceus
D. Drug reaction
E. Sezary syndrome
►A
The image shows erythrodermic patient with generalized desquamation of skin. Skin biopsy and blood tests the diagnosis of Sezary syndrome. Sezary syndrome is a leukemic variant of mycosis fungoides, is characterized by the triad of pruritic erythroderma, g eneralized lymphadenopathy, and the presence of Sezary cells more than 1,000 cell/mm3 (abnormal, large hyperconvoluted lymphocytes) in peripheral blood . Other manifestations include scaling and fissuring of palms and soles, alopecia, pruritus, peripheral edema, and nail dystrophy. Exfoliative dermatits can be manifested in many conditions other than Sezary syndrome inculude pemphigus foliaceus, psoriasis and drug reaction.
102- What would be the characteristic histopathologic findings of this lesion?
A. Full thickness keratinocytic atypia
B. Cornoid lamella
C. Pale staining cells
D. Horn pseudocysts
E. Wedge shaped granular layer with lichenoid infiltrate
►B
Five clinical variants of porokeratosis are recognized. They are the classic porokeratosis of Mibelli, disseminated superficial actinic porokeratosis, prokeratosis palmaris et plantaris disseminata, linear porokeratosis, and punctate porokeratosis. On histopathology they have varying degrees of a cornoid lamella. This appears as a column of parakeratosis.
104- Knowing that the patient in this picture has a biopsy confirmed BCC, which of the following would be the treatment of choice:
A. Conventional excision
B. Imiquimod
C. Radiation
D. Mohs micrographic surgery
E. Cryosurgery
►D
Providing the highest cure rates, Mohs micrographic surgery is the treatment of choice for large BCCs (1cm on the face or 2 cms on the trunk), located on high-risk anatomic areas (ear, eyelids, lips, genitals, nose, temples). , Morpheaform BCCs, tumors with positive margins after conventional excision, and recurrent BCCs, are also an indication for Mohs surgery.
121- What is the eponym for this metastasis to the umbilicus?
A. Tripe palm
B. Sign of Leser-Trelat
C. Pityriasis rotunda
D. Trousseau syndrome
E. Sister Mary Joseph Nodule
►E
Sister Mary Joseph nodule is a cutaneous metastasis that is most commonly associat ed with stomach, large bowel, ovary, and pancreatic cancer. Tripe palms are most commonly associated with lung, Leser-Trelat with adenocarcinomas of the stomach, colon and breast, Trousseau Sign with carcinoma of the pancreas and pityriasis rotunda with hepatocellular carcinoma and gastric cancer.
134- What is the most likely diagnosis?
A. Acquired digital fibrokeratoma
B. Supernumery digit
C. Verruca
D. Infantile digital fibroma
E. Acrochordon
►A
The condition shown is an acquired digital fibrokeratoma. It is a pedunculated, acral lesion with collarette which is defined by the lack of nerve twigs and bone on pathologic exam.
137- A 40 year-old female patient presents with the following lesion (see image). The biopsy report shows duct like structures, tadpole structures within a fibrotic stroma. According to the aforementioned information, the most likely diagnosis is:
A. Microcystic adnexal carcinoma
B. Seborrheic keratosis
C. Dermatofibrosarcoma protuberans
D. Merkel cell carcinoma
E. None of these answers are correct
►A
One of the most common locations for MAC includes the perioral area. Histologically it presents with poorly demarcated tumor cells invading the dermal and subcutaneous tissue. Islands of basaloid keratinocytes, horn cysts and duct structures are also seen within a desmoplastic stroma.
What is the most common location for this rapidly growing tumor?
A. Head and neck
B. Chest
C. Back
D. Arms
E. Legs
►A
Merkel cell carcinoma a cutaneous neuroendocrine carcinoma that usually occurs on the head and neck. It is a high grade malignant tumor with a 5-year mortality rate of 30-64%. On histopathology, there are trabecular strands of basophilic cells that stain with a characteristic paranuclear dot pattern with cytokeratin 20.
142 -This lesion is associated with which of the following:
A. HPV 5
B. HPV 11
C. HPV 4
D. HPV 7
E. HPV 1
►B
HPV 6 and 11 are most often associated with anogenital warts or condyloma acuminata. They can present as sessile lesions on the skin or peducnulated cauliflower lesions. HPV type 5 is associated with epidermodysplasia verruciformis, HPV 4 is assoicatd with common warts, HPV type 7 is associated with Butcher warts, and HPV type 1 is associated with common warts.
150- The mucin found in this lesion is produced by:
A. Fibroblasts
B. Keratinocyte
C. Merkel cells
D. Nail matrix
E. Osteoblast
►A
Digital mucous cysts are pseudocysts found on the dorsal digits between the distal interphalangeal joint and the nail fold. The fibroblasts in digital mucous cysts produce large quantities of hyaluronic acid.
152- What is the most common location for this lesion which lacks phosphorylase in the epidermal cells?
A. Back
B. Buttock
C. Leg
D. Neck
E. Sacrum
►C
Clear cell acanthomas are slow growing, benign growths which typically occur on the leg. They have a striking histologic appearance in the epidermis with sharp demaracation and enlarged, pale cells. Excess glycogen in the cells accounts for their clear appearance and is due to a defect in phosphorylase.
176 -Which neoplasm is associated with the Stewart-Treves syndrome?
A. Renal leiomyomas
B. Basal cell carcinoma
C. Angiosarcoma
D. Keratoacanthoma
E. T cell lymphoma
►C
Stewart-Treves syndrome is the development of angiosarcoma in the setting of chronic lymphedema. Originally, named after radical mastectomy for the treatment of breast cancer. The term applies to the development of angiosarcoma in any chronic lymphedematous condition.
181- This tumor, also called a Shagreen patch, is characteristic of which of the following genodermatoses?
A. Neurofibromatosis-1
B. Neurofibromatosis-2
C. Tuberous sclerosis
D. NAME syndrome
E. Buschke-Ollendorf
►C
Tuberous sclerosis a rare genodermatosis characterized by adenoma sebaceum, seizures and mental retardation. Other cutaneous features include hypopigmented macules, periungual fibromas, fibrous plaque of the face, cafe-au-lait macules and connective tissue nevus.
183- At what location is this tumor LEAST likely to recur after surgical excision?
A. Nasolabial fold
B. Lateral canthus
C. Chin
D. Preauricular
E. Scalp
►E
Basal cell carcinomas are slow-growing, epithelial tumors. Highest area of recurrences after surgical excision is in the “H-zone” of the face which include nose, nasolabial folds, periocular, periauricular. The scalp is a M-zone.
193- Which syndrome is characterized by multiple keratoacanthomas beginning in childhood?
A. Muir-Torre
B. Ferguson Smith
C. Rombo
D. Grybowski
E. Keratoacanthoma centrifugum marginatum
►B
Ferguson Smith is familial (AD), and is characterized by regressing keratoacanthomas beginning in childhood. Grybowski is a non-familial disorder in which patients develop generalized eruptive
keratoacanthomas beginning between age 40 to 60. Keratoacanthoma centrifugum marginatum is most commonly a solitary lesion occurring later in life. Muir Torre is a syndrome characterized by gastrointestinal or genitourinary neoplasms which precede development of sebaceous neoplasms and keratoacanthomas by one to two decades. Rombo is not associated with keratoacanthomas, but is associated with multiple basal cell carcinomas, atrophoderma vermiculatum, hypotrichosis, and milia.
199- All of the followings can be used for treatemt of this condition except
A. Cryotherapy
B. Topical Imiquimod 5% cream
C. Topical 5-flurouracil
D. Topical retinoids
E. Surgical excision
►E
Attached picture is disseminated superficial actinic porokeratosis (DSAP) which is the most common type of all porokeratosis, with multiple thin papules appearing most commonly on the legs of adult women. Many treatments have been used for this condition which include: cryotherapy, topical 5-fluorouracil (5-FU), topical retinoids, CO2 laser, and dermabrasion. Although surgical excision might be used for treatment of other forms of porokeratosis, it is not advised in this case because of number of lesions and increase risk of scarring. Other forms of porokeratosis are: porokeratosis of Mibelli, punctate porokeratosis, linear, and Porokeratosis palmaris et plantaris disseminata.
208- Mohs micrographic surgery the treatment of choice for all of the following, except:
A. 1 cm SCC located on the chest
B. 2 cms BCC on lower extremities
C. 1 cm BCC on the eyelid
D. Morpheaform BCC on the cheek
E. Recurrent BCC on the chest
►A
SCCs that measure 1cm on the chest are not an indication for Mohs micrographic surgery. Lesions must measure 2cms on the chest and extremities, or 1cm for those located on the face to be considered for Mohs surgery. Due to the aggressive growth patter and subclinical spread of morpheaform and recurrent BCCs are always and indication for Mohs surgery.
