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In Service Exam > Cutaneous Malignancies > Flashcards

Cutaneous Malignancies Flashcards

1
Q

What are the layers of the epidermis from superficial to deep?

A
  • Stratum corneum
  • Stratum licidum
  • Stratum granulosum
  • Stratum spinosum
  • Stratum basale (dermis is immediately deep to this)

Mneumonic: Come Lets Get Sun Burnt

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2
Q

Four cell types of the epidermis

A
  • Keratinocytes (80%)
  • Merkel cells (mechanoreceptors)
  • Langerhans cells (antigen processing and presenting cells)
  • Melanocytes (pigmented dendritic cells
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3
Q

What is the H zone of the head and neck?

A

This area extends vertically from the angle of the mandible through the ear and preauricular region to the temple and is connected horizontally through the periorbital skin, nasal skin and upper lip.

  • Denotes where SCC and BCC of the face potentially demonstrate a more aggressive course.
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4
Q

Which skin cancer is most common on the lower lip

A

SCC

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5
Q

Risk factors associated with lymphatic metastasis of cutaneous SCC?

A
  • Area greater than 20mm
  • Recurrent tumors
  • Site of prior radiation or scar
  • Rapidly growing tumor
  • Perineural invasion
  • Poorly differentiated tumors or high grade
  • Depth >5mm
  • Lymphovascular invasion
  • Immunosuppression
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6
Q

Metastasis from cutaneous head and neck SCC commonly occur in which lymphatics

A
  • 75% in the parotid bed

- 40% in level II

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7
Q

Risk factors for cutaneous SCC of the head and neck

A
  • UV radiation
  • Light skin pigmentation
  • Ionizing radiation
  • Immunosuppression
  • Exposure to coal tar, asphalt, arsenic consumption
  • Xeroderma pigmentosa, basal cell nevus syndrome
  • Tendency to burn or freckle
  • Male sex
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8
Q

Fitzpatrick scale

A

Classification of the color of skin and associated with decreasing risk of cutaneous malignancy

Type 1: pale white, blond or red hair, blue eyes, always burns never tans, freckles
Type 2: white, fair, blond or red, blue, green or hazel eyes, tans minimally, often burns
Type 3: fair skin, any hair and eye color, tans evenly, sometimes burns
Type 4: Mediterranean skin, rarely burns, tans easily
Type 5: dark brown skin, rarely burns, tans easily
Type 6: dark brown to black skin, never burns, tans very easily

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9
Q

Actinic keratosis

A

Also called a solar keratosis is a rough patch on the skin caused by years of sun exposure. Immunosuppressed individuals can also develop these. Fewer than 1/1000 will go on to become SCC but 60% of SCC can be traced back to an AK

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10
Q

Marjolin ulcer

A

A term used to describe an ulcerative SCC at the site of prior trauma, inflammation or scarring such as radiation or a burn

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11
Q

What % of nonmelanoa cutaneous malignancies are made up of SCC

A

20%

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12
Q

What pathologic finding in SCC is associated with the highest recurrence rate and regional metastasis?

A

Perineural invasion. This is associated with metastasis in 47% of patients.

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13
Q

Bowen disease

A

An intraepidermal SCC that manifests as enlarging, well demarcated erythematous plaque with surface crusting. Histologically it resembles SCC with atypical keratinocytes replacing epidermis. More common in women in the 6th and 7th decades of life. Can appear anywhere but more common in lower legs. Risks include sun exposure, arsenic, immunosuppression, viral infection. Tx with cryotherapy, curettage, excision, laser, PDT, 5-FU

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14
Q

What type of skin cancer is known for rapid progression of a swelling, dome shaped lesion that eventually resolves by sloughing off and scarring. It can have a central crater containing keratinous debris.

A

Keratoacanthoma

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15
Q

Symptoms to be elicited in an HPI for a newly diagnosed cutaneous SCC

A

Symptoms of advanced disease: numbness, pain, weakness, other perineural symptoms; weight loss, bone pain, shortness of breath, rapid growth, bleeding, fixation, neck mass to suggest locally advanced disease

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16
Q

What features of cutaneous SCC merit radiologic workup?

A
  • Locally advanced disease (>2cm, fixation, numbness, perineural or lymphovascular invasion)
  • Regionally advanced disease (palpable lymphadenopathy)
  • Distant metastasis risk
  • High risk patients (recurrent lesions, immunosuppression, history of radiation)
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17
Q

What is the most appropriate biopsy technique for deep ulcerated lesions of the skin of the head and neck?

A

Punch biopsy at the thickest portion of the lesion

- Full thickness biopsy should be attempted and should involve the reticular dermis or subcutaneous fat when possible.

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18
Q

T staging of head and neck nonmelanoma skin cancer

A

T1: smaller or equal to 2cm in greatest dimension
T2: 2-4cm or 2+ high risk features (>2mm invasion, clark level >IV, perineural invasion, primary site of the ear, primary site of non hair bearing lip, poorly or undifferentiated tumor)
T3: 4+ with minor bone erosion or perineural invasion
T4: gross cortical bone/marrow, skull base invasion

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19
Q

What locations of the head and neck are more likely to exhibit recurrence of cutaneous SCC

A

H zone due to these sites being the location of embryologic fusion affording tumor planes that provide avenues for spread.

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20
Q

What are appropriate margins for low risk cutaneous SCC?

A

4-6mm

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21
Q

Imiquimod

A

A local immune response modifier that induces activity or interferon alpha and other cytokines. Commonly used as a cream (brand name Aldara)

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22
Q

When is Mohs surgery indicated for cutaneous SCC of the head and neck?

A

Anatomically or aesthetically sensitive areas, where wide margins are not achievable (periorbital, nasal, periauricular, auricular, oral) or positive margins after WLE and potential extension into an area fulfilling the first criteria

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23
Q

When is radiation indicated for cutaneous SCC?

A
  • Nonoperative candidates
  • Positive margins or incomplete excision
  • Solitary node >3cm or with extracapsular extension
  • Multiple positive nodes
  • Multiple recurrent disease despite appropriate treatment
  • Perineural invasion
  • T4 disease
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24
Q

Appropriate treatment of keratoacanthoma?

A

WLE can also use intralesional methotrexate and 5-FU for nonoperative cases

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25
Q

What proportion of BCC occur on the head and neck?

A

4 of 5 cutaneous BCC

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26
Q

Is upper lip cancer more common in men or women?

A

Women - 21% of lip cancers on the upper lip vs 3% of lip cancer in men

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27
Q

What % of cutaneous malignancies occur on the lower lip?

A

90%

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28
Q

Is basal cell carcinoma more likely on the upper lip or lower lip?

A

Upper lip (13% vs 1% of lower lip cancers)

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29
Q

What is the significance of BCC found in the folds of the face?

A

More likely recurrence and higher risk of spread due to embryonic fusion plates. Need close follow up.

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30
Q

Likelihood of regional nodal metastasis in BCC?

A

Rare. Occurs in less than 0.5% of patients

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31
Q

What is the mechanism by which UV B light damages skin?

A

Causes direct damage to DNA by exciting DNA molecules resulting in covalent bonds between adjacent cytosine bases. These dimers are read as AA by DNA polymerase and therefore corresponding TT is added to the growing strand.

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32
Q

Risk factors for BCC

A

Sun exposure, lightly pigmented skin, blue or green eyes, genetic conditions, tanning beds, arsenic, prior trauma, ionizing radiation, immunosuppression

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33
Q

High risk features for staging BCC

A
  • Poor differentiation
  • Perineural spread
  • Origination of the ear or hair bearing lip
  • Depth >2mm
  • Clark level IV or V invasion
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34
Q

Clark levels

A

Clark levels of skin cancer. In Clark Level I, the cancer is in the epidermis only. In Clark Level II, the cancer has begun to spread into the papillary dermis (upper layer of the dermis). In Clark Level III, the cancer has spread through the papillary dermis into the papillary-reticular dermal interface but not into the reticular dermis (lower layer of the dermis). In Clark Level IV, the cancer has spread into the reticular dermis. In Clark Level V, the cancer has spread into the subcutaneous tissue.

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35
Q

What % of nonmelanocytic cutaneous neoplasms are BCC?

A

80%

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36
Q

Common types of BCC

A

There are 26 subtypes. The most common -

  • Nodular: most common form, described as pearly with rolled borders and occasional central ulceration and peripheral telangectasias
  • Morpheaform: (or sclerosis or fibrosing), irregular borders on yellow plaques, most aggressive type, high recurrence and worse prognosis
  • Fibroepithelial: often a pink papule on the trunk
  • Superficial: most common type on the trunk, irregularly shaped, waxy
  • Other: commonly described as pigmented or micronodular
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37
Q

What % of BCC are nodular type?

A

56-78%

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38
Q

What subtype of BCC has the youngest average age at initial diagnosis?

A

Superficial

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39
Q

What aspect of morpheaform or sclerosing BCC type make them more aggressive?

A

They secrete collagenases enabling movement between anatomic subsites

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40
Q

What subtype of BCC is more common in Asian and African patients compared to Caucasians?

A

Pigmented BCC

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41
Q

Clinical constellation of basal cell nevus syndrome

A

Aka Gorlin syndrome - patients diagnosed at an early age with multifocal BCC, odontogenic keratocytes, bifid ribs, scoliosis, developmental delay and frontal bossing

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42
Q

Features associated with arsenic exposure

A

Truncal BCC
Keratoses of the palms and soles
Nail changes (Mees lines)

43
Q

What type of biopsy should be performed for a suspected BCC?

A

Shave biopsy. When lesions are pigmented a punch biopsy should be performed as assess the depth of the lesion

44
Q

When is imaging required for BCC?

A

Rarely. Done in large tumors, suspicion of invasion of deeper structures, symptoms of perineural invasion, palpable lymphadenopathy

45
Q

When can cryotherapy be considered for management of BCC?

A

Small <1cm nonaggressive tumors

46
Q

Advantages of Mogs surgery over simple excision?

A

Maximal preservation of normal tissue. Optimization of functional/cosmetic outcomes, assessment and clearing of entire margin, lower recurrence rates, immediate reconstruction (usually)

47
Q

Nonsurgical management options for BCC

A
  • Radiation therapy
  • PDT
  • Immunotherapy
  • Chemotherapy
  • Vismodegib : an agent that targets the hedgehog signaling pathway
48
Q

In patients with cutaneous BCC when should neck dissection be considered?

A

Only in instances when there is clinical evidence of nodal metastasis

49
Q

Why is best to defer reconstruction in morpheaform type of BCC

A

Classically exhibits subdermal spread resulting in more common recurrence than other variants

50
Q

What % of mucosal melanomas present in the head and neck?

A

5%

51
Q

Most common site of head and neck mucosal melanoma?

A

Nasal cavity

52
Q

Incidence of lymphatic spread in malignant melanoma

A

Depends on subtype, depth and location

  • < .75mm: <5%
  • 0.75-4mm: 15-20%
  • 4.0mm: 34%
  • Incidence increases with ulceration, nodular type, Clark level IV or V and elevated mitotic rate
53
Q

Where do most melanomas arise?

A

On the trunk and extremities

- Nodular melanoma and lentigo maligna melanoma more commonly occur in the head and neck than other subtypes

54
Q

Metastatic rate of desmoplastic melanoma?

A

0-2.2% of cases of pure desmoplastic melanoma. It is more in mixed desmoplastic cases

55
Q

How has melanoma changes in the US in the last 30 years?

A

It has seen a 3 fold increase in Caucasian population and been stable in black population

56
Q

Risk factors for cutaneous mealnoma?

A

Family history, light skin, tendence to burn, red hair, DNA repair defects, sun exposure, equatorial residence, tanning bed use, immunosuppresion, >100 melanocytic nevi, more than 5 atypical melanocytic nevi, multiple solar lentigines, personal history of melanoma

57
Q

What familial AD disorder greatly increases risk of melanoma?

A

Atypical mole syndrome

58
Q

Common subtypes of cutaneous melanoma?

A
  • Superficial spreading (57%)
  • Nodular melanoma (21%) - most aggressive subtype
  • Lentigo maligna (9%) - the least aggressive with a long radial growth phase
  • Acral lentiginous (4%) - found on the soles of feet and palms of hands
  • Unclassifiable (4%)
  • Other (5%)
59
Q

What sizes of congenital nevus have an increased risk of developing into melanoma?

A

Giant congenital nevus 2cm or larger

60
Q

What differentiates lentigo maligna and lentigo maligna melanoma?

A

Lentigo maligna melanoma has invasion into the dermis

61
Q

Most common genetic aberrations found in melanoma?

A
  • Chronic sun damaged skin: KIT>KIT+NRAS=BRAF=NRAS
  • Nonchronic sun damaged skin: BRAF&raquo_space; NRAS
  • Mucosal: KIT&raquo_space; NRAS
62
Q

ABCDEs of melanoma

A 
Asymmetry
Border irregularity
Color variability
Diameter greater than 6mm
Evolving over time
63
Q

What clinical evaluation should patients with newly diagnosed melanoma receive?

A

Full body skin exam

64
Q

When should imaging be performed in malignant melanoma?

A

Extensive primary (fixation, perineural spread)
Abnormal or equivocal adenopathy
Stage III disease +
Specific signs to suggest metastatic spread

65
Q

Most ideal method to obtain a biopsy of a lesion suspicious for mealnoma?

A

Narrow margin excisional biopsy with adequate depth to determine breslow depth

66
Q

Histologic markers commonly used to identify melanoma

A
  • HMB-45
  • S-100 protein
  • MART-1
67
Q

Potential sites for occult primaries in patients with metastatic melanoma of the head and neck?

A

Ocular, mucosal, external auditory canal, hair bearing areas, tumor regression

68
Q

T staging of cutaneous melanoma

A

T1a: thickness <0.88mm without ulceration
T1b: thickness0.8-1mm with or without ulceration
T2: thickness >1-2mm
T3: thickness >2-4mm
T4: thickness >4mm

a: without ulceration
b: with ulceration

69
Q

M staging of cutaneous melanoma

A

M1a: metastasis to the dermis, soft tissue, nonregional lymph node
M1b: metastasis to the lung
M1c: metastasis to other visceral organs

(0) : LDH not elevated
(1) : LDH elevated

70
Q

N staging for cutaneous melanoma

A

N1: one node
N2: 2-3 nodes
N3: 4+ nodes

a: occult
b: clinically detected
c: presence of in transit, satellite and or microsatellite metastasis

71
Q

What is the most common site of melanoma metastasis?

A

regional lymph nodes

72
Q

Lifetime risk of developing a second primary melanoma?

A

4-8%

73
Q

In localized melanoma what is the most important prognostic factor?

A

tumor thickness

74
Q

Respective 5 year survival rates for melanoma patients with positive and negative sentinel lymph nodes?

A

56% vs 90%

75
Q

5 year survival for patients with metastatic melanoma?

A

10-20%

76
Q

What serum factor is an independent predictor of survival in stage IV metastatic melanoma?

A

LDH

77
Q

Treatment of choice for superficial thickness melanomas (1mm)

A

WLE with 1cm margins

78
Q

When should SLNB be considered in melanoma measuring 0.75-1.0mm thickness?

A

Tumors with ulceration or one or more mitosis/mm2

79
Q

Treatment of choice for intermediate thickness and deep melanomas (1-4+mm)

A

WLE with 2cm margins and SLNB

80
Q

Which chemotherapeutic agent is approved for treatment of stage IV melanoma?

A

Dacarbazine

81
Q

What adjuvant therapy is approved for use after surgery for stage III melanoma?

A

Interferon alpha2b

82
Q

What is the recommended treatment for Spitz nevus?

A

Complete excision

83
Q

Contraindications to methylene blue die injection

A

Previous hypersensitivity
Pregnancy
Concurrent use of SSRIs
Glucose 6 phosphate dehydrogenase deficiency

84
Q

Most common complications associated with Mohs surgery?

A

Complications are rare. Hematoma and graft necrosis are most common.

85
Q

Merkel cell carcinoma

A

A neuroendocrine tumor. Arises from Merkel cells which are specialized touch receptors found in the basal layer of the epidermis. Very aggressive. About 80% of tumors have cells that exhibit merkel cell polyoma virus

86
Q

What immunohistochemical stains are used for Merkel cell carcinoma?

A

Cytokeratin 20 (CK20), chromogranin, Cam5.2

87
Q

Syringomata

A

Benign sweat gland tumors that commonly occur in multiples. More common in women and occur predominantly on the face at the eyelids, upper cheeks and neck

88
Q

Pilomatrixoma

A

Benign appendageal tumors that commonly affect the head and neck and contain differentiation toward hair cells, rarely associated with carcinoma. Typically presents as a single firm, skin colored or slightly bluish nodule

89
Q

What is the appropriate management of a 1cm skin only central cheek defect?

A

Primary closure

90
Q

What is the appropriate management of a 2-4cm skin only central cheek defect?

A

Local flap

91
Q

What is the appropriate management of a >4cm skin only central cheek defect?

A

Facial or cervicofacial rotation flap

92
Q

What is the appropriate closure of a skin only defect of less than half of the lip (orbicularis oris intact)

A

Primary closure

93
Q

What is the appropriate closure of a full thickness defect of half to two thirds of the lip (commissure intact)

A

Abbe-Estlander flap

94
Q

What is the appropriate closure of a full thickness defect of half to two thirds of the lip involving the commissure?

A

Karapandzic flap

95
Q

What is the appropriate closure of a full thickness defect involving greater than 2/3 of the lip?

A

Radial forearm free flap or ALT

96
Q

What is the vascular supply for paramedian forehead flap

A

Supratrochlear artery and vein

97
Q

What components of the nose must be considered during reconstruction?

A

Skin, cartilage, bone, mucosal lining. Failure to reconstruct each of these will lead to poor cosmetic and functional outcome

98
Q

What is the aesthetic subunit principle of nasal reconstruction?

A

Reconstruct each of the 9 subunits separately. When greater than half of a subunit is resected, resection of the remainder of the subunit is desirable for cosmesis

99
Q

What local flap is most commonly used for nasal sidewall defects when primary closure is not achievable?

A

Bilobed flap

100
Q

General reconstruction ladder for full thickness lower eyelid defects?

A

<30% - primary closure with or without lateral cantholysis for larger defects
30-50%: semicircular flap with or without periosteum
>50%: transconjunctival flap with flap or graft closure of the skin

101
Q

Tenzel flap

A

Periorbital semicircular advancement flap for eyelid reconstruction

102
Q

Hughes flap

A

A pedicled tarsoconjunctival flap used in reconstruction of large >50-60% full thickness eyelid defects

103
Q

Limiting factors in using split thickness skin grafts in scalp reconstruction

A
  • Require a vascular bed; is periosteum is absent must drill to bleeding bone or rotate vascular tissue into defect
  • Poor color, texture, thickness and hair match
  • If postop radiation required a split thickness graft on bone will likely die
104
Q

What is the flap of choice for large scalp defects?

A

Latissimus dorsi myocutaneous free flap with split thickness skin graft

In Service Exam (16 decks)

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