Ch. 108-BCC, AK, SCC Flashcards
What is the lifetime prevalence of SCC? BCC? melanoma? Overall risk skin cancer?
BCC: 1:4
SCC: 1:20
Melanoma: 1:75
Overall risk 1:4 (some say 1:5)
What is another name of NMSCs
Keratinocytes carcinomas
What % skin cancer is NMSC?
95%
What % of NMSC are BCC vs. SCC?
20% (or 25%) SCC
80 (or 75%) BCC
What is ratio of BCC: SCC in light-skinned? dark skinned?
Light skinned: 4:1→ increasing to 2.5:1
Dark skinned: 1:1.1
What is incidence of NMSC in lightly pigmented per 100 000? darkly pigmented?
230 per 100 000
3.4 in darkly pigmented
Most common location AKs and SCC in light skinned
head/neck, shins
Most common location SCC in dark skinned ?
HEad/nec also but ⅓ in non sun exposed areas
What is the percent of SCC arising in scars in light skinned? dark skinned?
<2% light skinned
30-40% in dark skinned
Risk factors for SCC
Environmental:
- UVR (tanning beds) and ionizing radiation
- HPV
- Chemicals: Arsenic, coal tar, soot, polychlorinated biphenyls, mineral oil, psoralen, nitrogen mustard
- cigarette smoking
Personal factors:
- caucasian/type I-II skin
- freckles and red hair
- older age
Immunosuppression (transplant, CLL, AIDS particularly, medications)
Genetic syndromes
Predisposing clinical scenarios:
- Chronic non healing wounds, scars, oral erosive LP, marjolin ulcer, DLE, lichen sclerosis, thermal burns
- Nevus sebaceous
- Linear porokeratosis
- Medications: BRAF, immunosupressants, HCTZ
Latitude
Risk factors for BCC
Environmental:
- UVR (tanning beds and PUVA too) and ionizing radiation
- Chemicals: Arsenic, coal tar, soot, polychlorinated biphenyls, mineral oil, psoralen, nitrogen mustard → MUCH LESS
Personal factors:
- caucasian/type I-II skin
- freckles and red hair
- older age
Immunosuppression (transplant especially*, CLL, AIDS particularly)
Genetic syndromes
Nevus sebaceous→ but more trichoblastomas
RF for SCC and NOT BCC
- SCC only:
- HPV
- Cigarette smoking
- Chronic non-healing wounds
- erosive LP
- genital LS
- discoid lupus
- Porokeratosis (linear esp.)
- Nevus sebaceous
- Genetic conditions:
- Ferguson-Smith
- Dystrophic EBA
- MOST of the chemical exposures, BCC has been reported from Tar
Genetic conditions predisposing to BCC
- Basal cell nevus syndrome (Gorlins)
- Bazex Dupre Christal and Rombo syndromes
- Xeroderma pigmentosum*
- Oculocutaneous albinism*
- Muir torre syndrome*
*= both SCC and BCC
MOX BB
Genetic conditions predisposing to SCC
WEBR DODX→ Werner, epideromodysplasia verruciformis, bloom, rothmund thomphon, dystrophic EBA, OCA, dyskeratosis congenita, XP
Whats more predictive of skin cancer, early or late life sun exposure
Early life
Is there gender difference in SCC?
More common in males 3:1
IS there gender difference in BCC?
Slightly more common in men 1.5-2:1
What features increase risk death from SCC?
Men, older,
Lips/genitals/ears
White skin
Most common skin cancer to cause death in light skinned? Dark skinned?
Melanoma before age 50
SCC after age 85
In dark skinned? SCC MOST COMMON AT ALL AGES
What is the increased risk of skin cancer with PUVA?
relative risk ratio 8.5 for SCC if PUVA >100 treatments
slight bcc risk if prolonged
What is the increased risk for ionizing radiation? What is latency ?
3x risk for BCC and SCC
Latency around 20 yrs later
Where is most common location for chemical exposure related SCC to develop?
Arms
Latency after chemical exposure
20-40 yrs
What condition is particularly predisposed to HPV infections and subsequent SCC?
Epidermodysplasia verruciformis
Which types of HPV are associated with EV and SCC development?
5, 8
Which HPV subtypes most responsible for SCC (digital and anogenital)
16 and 18
Which HPV subtypes with verrucous carcinoma/bushke Lowenstein?
6, 11
(same as condyloma acuminta)
Increased risk of SCC with solid organ tx? BCC?
SCC 250x
BCC 10x
Risk factors in immunsupression for NMSC
Skin phototype
Degree of UV exposure
Age at tx
Length/time immunosupression
Which solid organ tx have highest incidence skin cancer?
Heart + lung>kidney>liver
What % SCC tutors in tx recipients have HPV in them?
MAJORITY 70-90%
What immunosuppressant can be used in tx patients that has lower risk SCC?
Sirolimus
What immunosuppressants increase risk of SCC the most
Cyclosporine >tacro
Steroids do increase too, SCC>BCC (OR 2.3)
Imuran photosensitivity
Thiopurine
Pigmented AKs
“SPAKS”: superficial pigmented AKs
Lack erythema and scale, have reticulated and hyper pigmented appearance
Ddx: reticulated seb K, lentigo maligna melanoma, lentigines
Do hematopoetic transplant patients have increased risk NMSC
Not as significant, unless received long term voriconazole (increases photosensitivity)
Likely due to shorter duration immunosupression
Which cancer is particularly increased in HIV patients
anogenital HPV-SCC
Which medications can increase risk NMSC
Immunosupressants (see previous)
Imuran and voriconazole photosensitizing
HCTZ
BRAF inhibitors (vemurafenib, dabrafenib)
What can reduce incidence SCC and AK with BRAF inhibitors?
Combination with MEK inhibitor (routinely done)
What is a key gene controlling pigmentation?
MC1R gene codes human melanocortin-1 receptor (displayed on melanocytes)
9 variant alleles of this associated with red hair/light skin/freckling appearance
risk NSMC in XP vs. gen pop
4800x
Is SCC more common in dominant or recessive dystrophic EBA
Recessive
MOST COMMON CAUSE DEATH IS SCC
Diagnostic criteria BCNS
2 major OR 1 major + 2 minor
Major:
- 2+ BCC or 1 prior age 20
- Odontogenic cysts (histo proven)
- Palmar or plantar pits 3 or more
- Calcification falx cerebra
- Relative with BCNS
- Bifid, splayed or fused ribs
Minor:
- Congenital abnormalities: cleft palate, frontal bossing, coarse face, hypertelorism
- Skeletal abnormalities : Sprengel deformity, syndactylyl, pacts deformity
- Radiographic abnormalities:
- bridging of the sella turcica;
- vertebral anomalies such as hemivertebrae and fusion or elongation of the vertebral bodies;
- modeling defects of the hands and feet;
- flame-shaped lucencies of the hands or feet
- Macrocephaly
- Bilateral ovarian fibromas
- Medulloblastoma
What are two other cutaneous features BCNS
Facial milia
epidermoid cysts
Where do nodular BCCS appear on body vs. superficial
Superficial on torso
Nodular on face
What are the features of Basex-Dupre-christol syndrome
- follicular atrophoderma (dorsal hands and feet)
- hypotrichosis
- localized hypohidrosis
- BCCs-mostly facial,
- Milia
- Epidermoid cysts
What is interesting about BCCs in Basex-Dupre-christol
Often have trichoepithelioma like histology
Rombo syndrome
Atrophoderma vermiculatum on cheeks
hypotrichosis
BCC
Milia
Trichoepithelioma
blepharitis
peripheral (facial/acral) telangiectatic erythema
Clinical presentation AKs-describe
- rough erythematous papule with white to yellow scale on sun exposed sites such as head, neck, upper trunk, and extremities including dorsal arms/hands and shins
- few mm to confluent patches
- can begin as minimal erythema with minimal scale
- background solar elastosis, telengeiectasias, dyspigementation
- can spontaneously regress
What does dermoscopy of AKs show?
Face:
- Strawberry pattern: red-pink psuedonetwork around hair follicle
- skin coloured or white circles around a yellowish clod (this is a keratotic plug)
Non face
- surface scale, dotted vessels
Name 8 AK variants
Classic
Pigmented
Hypertrophic
Lichenoid
Actinic cheilitis
Atrophic
Bowenoid
Proliferative
Conjunctival
Hypertrophic AK
Erythematous papules or plaques with yellow or yellow brown scale or scale-crust
Sometimes hard to distinguish from SCC
Includes cutaneous horn
What % of cutaneous horns have SCC at their base?
15%
Need too biopsy
Lichenoid AK
Upper chest, red, papule or plaque, often mistaken for a BCC
Bx will show dense band-like inflammatory infiltrate
What is this?
Pigmented AK
(superficial pigmented)
Resembles MIS/Lentigo or LMM
Sometimes need to feel for scale
most common site actinic cheilitis?
risk x malignant transformation rate?
vermilion border of lower lip, 2.5x Higher malig transformation rate
Leukoplakia on lower lip canc occur - one or more white patches
Atrophic AK
usually have minimal/no scale
pink to red, slightly scaly macules or patches
histopathologic examination show atrophic epidermis.
Describe pathology for AKI, AKII, AKII and SCC
- AK I mild (basal or suprabasal layer atypia only)
- AK II moderate (budding or inv’t of hair follicles)
- AK III severe (full thickness atypia = SCC is)
- SCC
What percent AKs will resolve
25%
How many AKs to SCC annually?
1: 1000
What is SCC in situ? What are the variants?
Full thickness epidermal atypia
-Bowen’s disease, Bowenoid papulosis , Erythroplasia of queyrat, -Arsenic in situ, mucosal, pigmented
Where does SCC in situ occur
Mostly head and neck, torso and extremities
Can occur sun protected (anogenital region, periungual)
How does Bowens disease present?
Solitary, fiery red, scaly plaques on sun-exposed areas,
Can have arcuate, round or annular
How can you tell Bowens vs. superficial BCC
Superficial BCCs often have a more translucent quality with slight elevation of the leading edge
What is erythroplasia of Queyrat?
SCC in situ on glans penis of male in un-circumcised, often erosions
Related to HPV 16, 18