Chapter 11 - Skin Cancer

Question 1

Skin Cancer highest incidence transplant pop

Answer 1

SCC

Question 2

RF non-melanoma skin cancer

Answer 2

Fair skin light eyes
Blistering sunburns, sun exposure 
FHx
Prior skin cancer 
Chemical exposure (arsenic)
Genetic Syndrome 
Male, Old
Immunosuppressed 
Ionizing radiation (BCC, SCC)
Smoking, HPV (SCC)

Question 3

Skin cancer incidence

Answer 3

Melanoma 5% of skin cancer but 90% of Mortality pts < 50

20% will develop skin cancer in lifetime

Question 4

4 rare skin cancers

Answer 4

Merkel cell
Dermatofibrosarcoma Protuberans
Sebaceous carcinoma
Cutaneous T cell lymphoma

Question 5

BCC: classic appearance, worst recurrence types

Answer 5

75% of non-Mel skin Ca
Skin-pink pearly papule/plaque, rolled border, poss central ulcer

Desmoplastic (look like scar) and basosquamous

Question 6

Bowen’s disease

Answer 6

SCC In situ

Confined to epidermis

Thin pink scaly papule/plaque

Question 7

Location of HPV SCC

Answer 7

Hands, feet, genitals

Question 8

Classic SCC appearance

Answer 8

Pink crusted papule /nodule

Question 9

Metastasis risk of SCC

Answer 9

Less than 5% unless high risk:

Ear/Lip/Genitalia
HPV, site of chronic inflammation, rad/chemical
Poorly Diff, >2cm, >4mm depth, recurrence, perineural invasion
Immunosuppressed, xerod pigment

Question 10

Risk of SCC In transplant

Answer 10

100x more likely
10x more likely to get BCC
0-17x more likely melanoma

Question 11

Merkel cell CA

Answer 11

Rapidly enlarge violaceous/pink nodule 
Polyomavirus
30% Mets @ Pres 
Excise, LN, Rads
30% 5-yr Mortality

Question 12

Keratoacanthoma

Answer 12

Nodule enlarges over 2wk, treat as well-Diff SCC

Dome shaped, central crater

Question 13

Actinic Keratosis

Answer 13

Pink scaly papule

1/10-1000 turn into SCC per year

Tx: liq nitrogen
If multiple (field Tx): 5FU, imiquimod, 415nm blue light, peels

Question 14

Actinic cheilitits

Answer 14

Lower lip, pre-SCC, more risk than keratosis

Blur verm border, papules/scale

Tx like keratosis
If SCC develops: vermillionectomy, advancement flap

Question 15

Mohs cure rates

Answer 15

99% primary BCC/SCC

Less for high risk or recurrent

Question 16

IHC stains for melanoma in situ and Pagets (extramammary), and SCC

Answer 16

MART-1, Mel-5

Cytokeratin 7

AE1-3

Question 17

Locations treatable by Mohs

Answer 17

Hand, feet, genitalia
Face, neck, scalp
Other spots if recurrent, large, aggressive

Question 18

Non-Mohs Tx for BCC/SCC

Answer 18

Excision (4-5mm margins)

Electrodessication (low risk)

If superficial: 5FU, imiquimod, photo

Rads: inoperable, adjuvant

Question 19

Vismodegib

Answer 19

Inhibits pathway of PTCH gene mutations (majority of sporadic BCC, basal cell Nevus syndrome)
Prevents new BCC and kills existing ones

For advanced or metastatic
AE: non-scar alopecia, dysguesia, cramps, teratogenic

Question 20

Melanoma: Biology, RF, 4 types

Answer 20

Melanocytes present in basal layer and nevi

Fair skin, intense intermittent UV exposure (most common Ca in F 25-29)

Only 25% arise from moles

Sup Spread (70%), Nodular (15-30%), Lentigo Maligna (15%), Acral Lentiginous (5-10%)

Question 21

Typical melanoma diameter

Answer 21

> 6mm (pencil eraser)

Still Bx smaller suspicious lesions

Question 22

Which moles to be sure to evaluate

Answer 22

Any new pigmented lesion in patient > 35 yo

Question 23

Lentigo Maligna

Answer 23

Melanoma in Situ
Slow grow, irregular hyperpigmented patch, sun-exposed skin

Called melanoma if invade dermis. Elderly. Cumulative sun exposure

Question 24

RF Melanoma

Answer 24

CDKN2A mutations
> 50 benign nevi
Large congenital nevi (>20cm)
Dysplastic Nevus Synd (atypical moles plus FH melanoma)

Question 25

In-transit Met vs Satellite

Answer 25

1: >2cm from primary, not beyond regional LN
2: >2cm from primary

Question 26

Melanoma T Stage

Answer 26

<1mm (90-97)

1. 01-2mm (78-90)
2. 01-4mm (65-78) (4: 45-65)

a without ulceration, mitosis <1/mm2
b with ulceration or mitosis > 1/mm2
For all stages besides 1, just ulceration

Question 27

Mel N Stage

Answer 27

2 node a micro b macro

2-3 nodes c in-transit/sat no met

4+, matted, or intransit/satellite plus metastatic

Question 28

Mel M Stage

Answer 28

1a skin/SQ/modal distant Mets

1b Lung

1c other visceral or any distant plus elevated LDH

Question 29

Margins for melanoma excision

Answer 29

In situ: 0.5 cm

Depth 0-1mm: 1cm
Depth 1.01-2mm: 1-2cm
Depth >2mm: 2cm

Question 30

Treatment Metastatic Melanoma

Answer 30

Traditional chemo rad not very effective

Target gene therapies:
Vemurafenib (BRAF)
Trametinib (MEK)
Ipilumab (CTLA-4)

Question 31

Stage Group Melanoma and 5 yr survival

Answer 31

1A- T1A (97)
1B- T2a (93)
2A- T2b (82), 3a (79)
2B- 3b, 4a (68-71)
2C- 4b (53)
3 - Nodes, no Mets (40-78)
4- M1, (9-27)

Question 32

UV Light

Answer 32

C- blocked by atm, B somewhat blocked. C shortest wavelength

95% what reaches us is A
DNA mutations, immunosuppression in skin (decreases DNA repair)
Tan Beds - UVA

Question 33

Photo protection

Answer 33

Avoid sun 10am-2pm
Clothing, wise hat

Screen: absorb/scatter UV light, want broad spectrum, reapply a 2-4hr
SPF based on 2mg/cm2

Question 34

T stage SCC

Answer 34

1: <2cm is 0-1 high risk features
2: >2cm or 2/3+ high risk features
3: maxilla, mandible, orbit, T Bone
4: invade skeleton or perineural skull base invasion

High risk: breakdown >2mm, ear/lip, poor diff