Chapter 11 - Skin Cancer Flashcards by Ben Walters

Skin Cancer highest incidence transplant pop

SCC

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RF non-melanoma skin cancer

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)

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Skin cancer incidence

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

20% will develop skin cancer in lifetime

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4 rare skin cancers

Merkel cell
Dermatofibrosarcoma Protuberans
Sebaceous carcinoma
Cutaneous T cell lymphoma

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BCC: classic appearance, worst recurrence types

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

Desmoplastic (look like scar) and basosquamous

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Bowen’s disease

SCC In situ

Confined to epidermis

Thin pink scaly papule/plaque

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Location of HPV SCC

Hands, feet, genitals

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Classic SCC appearance

Pink crusted papule /nodule

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Metastasis risk of SCC

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

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Risk of SCC In transplant

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

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Merkel cell CA

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

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Keratoacanthoma

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

Dome shaped, central crater

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Actinic Keratosis

Pink scaly papule

1/10-1000 turn into SCC per year

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

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Actinic cheilitits

Lower lip, pre-SCC, more risk than keratosis

Blur verm border, papules/scale

Tx like keratosis
If SCC develops: vermillionectomy, advancement flap

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Mohs cure rates

99% primary BCC/SCC

Less for high risk or recurrent

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

MART-1, Mel-5

Cytokeratin 7

AE1-3

Locations treatable by Mohs

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

Non-Mohs Tx for BCC/SCC

Excision (4-5mm margins)

Electrodessication (low risk)

If superficial: 5FU, imiquimod, photo

Rads: inoperable, adjuvant

Vismodegib

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

Melanoma: Biology, RF, 4 types

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%)

Typical melanoma diameter

> 6mm (pencil eraser)

Still Bx smaller suspicious lesions

Which moles to be sure to evaluate

Any new pigmented lesion in patient > 35 yo

Lentigo Maligna

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

Called melanoma if invade dermis. Elderly. Cumulative sun exposure

RF Melanoma

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

In-transit Met vs Satellite

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

Melanoma T Stage

<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

Mel N Stage

2 node a micro b macro 2-3 nodes c in-transit/sat no met 4+, matted, or intransit/satellite plus metastatic

Mel M Stage

1a skin/SQ/modal distant Mets 1b Lung 1c other visceral or any distant plus elevated LDH

Margins for melanoma excision

In situ: 0.5 cm Depth 0-1mm: 1cm Depth 1.01-2mm: 1-2cm Depth >2mm: 2cm

Treatment Metastatic Melanoma

Traditional chemo rad not very effective Target gene therapies: Vemurafenib (BRAF) Trametinib (MEK) Ipilumab (CTLA-4)

Stage Group Melanoma and 5 yr survival

``` 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) ```

UV Light

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

Photo protection

Avoid sun 10am-2pm Clothing, wise hat Screen: absorb/scatter UV light, want broad spectrum, reapply a 2-4hr SPF based on 2mg/cm2

T stage SCC

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