Benign and Malignant Skin Lesions Flashcards
1
Q
What are the risk factors for skin cancer?
A
- Fair skin
- Occupational sun exposure
- Burning
- Artificial tanning
- Immunosuppressive medication (e.g. transplant)
- ?Genetics
2
Q
Clinical case:
- 76 year old man attending cardiology clinic.
- Longstanding crusty area on chest.
- Intermittently bleeding and slowly enlarging.
Describe the lesion and formulate a management plan.
A
- Basal cell carcinoma
- Superficial and nodular components
- Large incisional biopsy to confirm histology
- Planned 2nd stage incision
3
Q
Clinical case:
- Acute sunburn
- ‘Rash’ on the back
Describe the lesion and formulate a management plan.
A
- Basal cell carcinoma with infiltrative pattern.
- Full excision via plastic surgeons.
4
Q
Describe basal cell carcinoma.
A
- Commonest type of skin cancer.
- Nodulocystic / infiltrative / superficial.
- Related to UV exposure.
- Slow growing with minimal chance of metastasis.
- Can erode deeper under surface of skin.
- Surgical vs medical therapies.
5
Q
What are the treatments for BCC?
A
- Surgery, including Mohs micrographic surgery.
- Cryotherapy
- Imiquimod
- Photodynamic therapy
- Vismodegib - systemic treatment for metastatic or inoperable BCC.
6
Q
What are the differential diagnoses if you are considering BCC?
A
- Fibrous papule of the nose.
- Sebaceous hyperplasia.
- Intradermal naevus.
- Haemangioma.
7
Q
Clinical case:
- 88 year old lady
- Fleshy nodules over dorsal hand
- Spent many years in Malta
- Fair-skinned
Describe the lesion and formulate a management plan.
A
- Squamous cell carcinomas
- Wider excision +/- grafting by plastics.
8
Q
Clinical case:
- 76 year old man.
- Previous merkel cell cancer left arm.
- 12 week hx of enlargin nodule.
- Tender and bleeding.
- Patient on Warfarin.
Describe the lesion and state what you would do with it.
A
- Another Merkel cell carcinoma.
- Remove under local anaesthetic.
9
Q
Describe squamous cell carcinoma.
A
- Also driven by UV exposure.
- Less common than BCC.
- Small risk of metastases - mainly lymph nodes.
-
High risk SCC should be discussed at MDT.
- Site and size
- Immunosuppression
- Poorly differentiated
- Perineural / lymphovascular invasion
- Consideration of excision margin
- Radiotherapy
10
Q
Describe the managemen of SCC in the immunosuppressed.
A
- Azathioprine / cyclosporin
- Increased risk of SCC
- Reversal of BCC / SCC ratio
- Automatically classified as ‘high risk’
- Liasion with other clinicians ? Reduce immunosuppression
- ?Acitretin
11
Q
What is the primary aim of treating Actinic Keratosis (AK)?
What are the treatment options?
A
- The primary aim of treating AK is to reduce the total number of lesions that the patient has at any one time; the fewer lesions a patient has, the less risk they have for developing a SCC.
- Can be treated with lesion-directed therapy, field-directed therapy or a combination of the 2.
12
Q
With respect to Actinic Keratosis (AK), what is ‘the field’?
A
- The field is the skin surrounding the AK lesion, which may also have been damaged by UV exposure.
- Often the surrounding skin is red, with tiny, thread-like blood vessels (telangiectasias) indicating sun damage.
- Sometimes the surrounding skin does not have visible changes but is highly likely to have been exposed to the same amount of UV as the visible AK lesion and its cells may also be genetically damaged.
13
Q
What are the options for topical therapy in AK?
A
- Solaraze gel (diclofenac)
- Efudix (5-fluorouracil) cream
- Picanto gel (ingenol mebutate)
- Actikerall ointment (fluorouracil + salicylic acid)
- Cryotherapy remains useful for single lesions
- Curettage and cautery if recalcitrant to treatment-obtains histology
14
Q
Clinical case:
- 48 year old male
- Sunburnt back in youth
- Shirt sticking to back
Describe the lesions and formulate a management plan.
A
- 2 primary malignant melanomas
- Nodular (amelanotic)
- Superficial spreading
- Wide local excision and sentinel lymph node biopsy (clear)
- Sun protection advice
- Long-term follow up for 5 years
15
Q
What is an ink spot lentigo?
A
- AKA ‘sunburn’ lentigo
- Dark brown macule with reticular pigment network
- Often on shoulders / upper back
16
Q
What is the ugly duckling sign?
A
- A lesion which stands out as different to patient’s other lesions.
- A worrying sign.
- A marker for possible melanoma.
17
Q
Describe atypical naevus syndrome.
A
- Familial
- Unusual naevi
- Inherited melanomas
- ?2 or more clinically atypical naevi
- >100 naevi
- >1 naevus on buttocks / instep
- Pigmented lesions in iris
- CDKN2A mutation
- Increased incidence of melanoma and also pancreatic cancer
- Screening essential
18
Q
Describe atypical naevi.
A
- Pathologists report cytological and architectural atypia.
- Mild is thought to be insignificant.
- Severely atypical naevi need to be excised with at least 2mm margins.
- Consider pigmented lesions on a spectrum, rather than ‘black and white’.
19
Q
What are the subtypes of melanoma?
A
- Superficial spreading malignant melanoma (most common)
- Lentigo malignant melanoma
- Nodular / amelanotic malignant melanoma
- Acral lentiginous malignant melanoma
- Spitzoid malignant melanoma
- Desmoplastic malignant melanoma
- Animal type malignant melanoma
20
Q
Describe nodular / amelanotic melanoma.
A
- Often most aggressive
- Harder to diagnose
- May look like pyogenic granuloma
- Beware a red nodule in an older patient
21
Q
What is a sentinel node biopsy and what does it involve?
When is it indicated?
A
- Consider in patients with Breslow thickness of 1mm or more.
- Involves GA, and overnight stay.
- If positive, consider proceeding to clearance of lymph node basin.
- Significant morbidity.
22
Q
Describe the drug treatment for advanced melanoma.
A
- Melanoma is not very chemosensitive
- Targeted therapies showing promise
- Specimen tested for presence of BRAF gene mutation
- ?clinical trials
- Targeted therapies
-
BRAF mutant
- Vemurafenib
- Delays growth of advanced melanoma
- Oral administration
- Photosensitivity
- Dabrafenib
- Slows / stops growth of BRAF gene
- Limited availability in NHS
- Oral administration
- GI side effects
- Vemurafenib
- BRAF wild-type
- Ipilimumab
- Monoclonal antibody
- Triggers immune system to attack cancer cells
- IV infusion
- Fatigue
- Ipilimumab
23
Q
What are the different types of benign naevi?
A
- Junctional naevus
- Intradermal naevus
- Found on head and neck
- Compound naevus
- Can look similar to seborrheic keratosis
- Warty feel
- Halo naevus
- Pale area around naevus
Benign naevi = immunological phenomenon.
24
Q
What would you think if you saw a patient with these longstanding asymptomatic patches in the flanks?
A
- Patch stage mycosis fungoides
- (Cutaneous T cell lymphoma)
- Generaally runs an indolent course
- Follow-up to ensure does not transform or develop tumours
- UVB and PUVA helpful
25
Q
Describe primary cutaneous B cell lymphoma.
A
- Marginal zone lymphoma
- Associated with tick bites (borrelia)
- Excellent prognosis
- Need to exclude spread from nodal lymphoma - staging CT scanning
- Can be treated with radiotherapy, surgery, intralesional steroid injection
26
Q
What is a myxoid cyst? Describe.
A
- AKA mucous cyst.
- Caused by degeneration of connective tissue; association with osteoarthritis.
- Characteristically produces a sticky clear liquid if aspirated.
- May lead to a longitudinal groove in the nail.
- Can be treated with cryotherapy, infrared coagulation, excision.
27
Q
Describe this lesion.
A
- Talon noir / calcaneal petichiae
- Post-traumatic intraepidermal haemorrhage.
- Occurs in younger active patients.
- Grouped, punctate, linear, black or blue / black macules and horizontally arranged petichiae.
- Paring the superficial stratum corneum which will reveal puncta of black pigment of extravasated red cells from dermal papilla.
28
Q
Describe pilomatrixoma.
A
- Derived from hair cell matrix
- Commonest in young children
- Calcification within the lesion
- Rare risk of malignant transformation
- Picture = hard enlarging nodule on forearm.
