Cutaneous Malignancies

Question 1

Most common invasive malignant cutaneous neoplasm

Answer 1

Basal cell carcinoma

Question 2

Most common presenting complaint with BCC

Answer 2

Bleeding or scabbing sore that heals and recurs

Question 3

BCC advances by ______ ______ and destroys normal tissue

Answer 3

Direct extension

Question 4

The average lifetime risk for Caucasians to develop BCC is 30%. It most commonly occurs in adults, especially in the _____ population

Answer 4

Elderly

Question 5

Risk factors for BCC

Answer 5

Main risk factor is UVB radiation exposure

Fair skin, blonde or red hair, light eye color, poor tanning ability, and sun-damaged skin

Question 6

Pathogenesis of BCC

Answer 6

Arise from epidermal basal keratinocytes and adnexal structures (e.g., hair follicles, eccrine sweat glands)

UVB radiation damages DNA and its repair system and alters the immune system

Grows by direct extension, appears to require the surrounding stroma to support its growth

Question 7

85% of BCC appear in head and neck region, with the most common site being the _____

Answer 7

Nose

Question 8

Most common form of BCC

Answer 8

Nodular BCC

Question 9

What type of skin lesion begins as a pearly white or pink, dome-shaped papule that then extends peripherally, may remain flat, have prominent telangiectatic vessels, irregular growth pattern that may become multilobular, and frequently shows ulceration at the center?

Answer 9

BCC (nodular)

Question 10

If you see a lesion that seems like it might be squamous, but has more ulceration, umbilication, or multinodularity to it, what is it more likely to be?

Answer 10

Basal cell carcinoma

Question 11

Which is more likely to metastasize — BCC or SCC?

Answer 11

SCC!

Unlike BCCs, cutaneous SCCs are associated with a substantial risk of metastasis

Question 12

SCCs are often separated into 2 major groups based on their malignant potential — what are the 2 groups?

Answer 12

High frequency of metastasis = SCC arising in areas of prior radiation or thermal injury, in chronic draining sinuses, and in chronic ulcers

Less likely to metastasize = SCC originating in actinically damaged skin

Question 13

Like BCC, SCCs are most common in sun-exposed areas. However, distribution of SCC is different, as these are found in areas where BCC is rarely found — where are these areas?

Answer 13

Scalp

Backs of the hands

Superior surface of the pinna

Question 14

When comparing SCC and BCC in terms of sun-exposure as a risk factor, _______ is more dose dependent (thus it may be found in younger patients) while _________ is more based on cumulative exposure (thus it is found in older patients)

Answer 14

BCC; SCC

Question 15

Is a flat, scaly lesion more likely to be BCC or SCC?

Answer 15

SCC

Question 16

Describe clinical presentation of SCC

Answer 16

SCCs arising from actinic keratosis may have thick, adherent scale that is often red and inflamed

Tumor is soft and freely moveable

Cutaneous horns may begin as actinic keratosis and degenerate into SCC

Question 17

Which of the following is the most common type of melanoma, which begins with initial radial growth phase before invasion?

A. Superficial spreading
B. Lentigo maligna
C. Acral lentiginous
D. Nodular

Answer 17

A. Superficial spreading

Question 18

Which of the following types of melanoma has a generally poor prognosis because of invasive growth from onset?

A. Superficial spreading
B. Lentigo maligna
C. Acral lentiginous
D. Nodular

Answer 18

D. Nodular

Question 19

Which of the following types of melanoma has a long growth phase before invasion and is most common in elderly and in sun-exposed areas?

A. Superficial spreading
B. Lentigo maligna
C. Acral lentiginous
D. Nodular

Answer 19

B. Lentigo maligna

Question 20

Which of the following types of melanoma is the most common form in darkly pigmented patients, occurs on palms and soles, mucosal surfaces, nail beds, etc., and has aggressive biologic behavior?

A. Superficial spreading
B. Lentigo maligna
C. Acral lentiginous
D. Nodular

Answer 20

C. Acral lentiginous

Question 21

Suspicion for melanoma should be raised by a pigmented skin lesion that is _____ in diameter, asymmetric, has an irregular surface or border, or has variation in color

Answer 21

> 6 mm

Question 22

ABCDs of malignant melanoma recognition

Answer 22

Asymmetry
Border irregularity
Color variation
Diameter enlargement

Question 23

In terms of the ABCDs of malignant melanoma recognition, changes in _____ and ______ are important early signs and shoul always increase suspicion, while _____ and ______ are late signs

Answer 23

Shape; color; ulceration; bleeding

Question 24

What change in color of a melanoma indicates pigment deep in dermis and is a sign of increasing depth of tumor?

Answer 24

Blue

Question 25

What change in color of melanoma indicates areas of regression or inflammation?

Answer 25

White

Question 26

Growth phases of melanoma

Answer 26

Initial phase = months to years (flat, not palpable, slight color variation, indistinguishable from other early melanomas)

Radial growth phase = months to 10 years (irregular border, areas of regression with angular notching)

Vertical growth phase = months to years (numerous patterns, tumors palpable, plaque-like elevation with nodules in center, areas of ulceration and scaling)

Question 27

T/F: Melanoma diagnosis, biopsy, or excision MUST BE REFERRED

Answer 27

True

Question 28

Diagnosis of melanoma is made by excisional biopsy. What is the most important prognostic factor?

Answer 28

Depth of invasion (thickness)

[note that diagnostic excisional biopsy of suspected cutaneous melanoma must include 1-2 mm margin of normal skin and some subcutaneous fat]

Question 29

What are some skin procedures for removing lesions?

Answer 29

Shave biopsy - most common

Punch biopsy

Excision and incision/wedge biopsy

Electrosurgery devices

Destructive techniques — cryotherapy, curettage, electrodessication

Question 30

Many cancers can present with skin manifestations that are not due to metastases.

________ may be a presenting feature of lymphoma, leukemia, and CNS tumors

Answer 30

Pruritis

Question 31

Many cancers can present with skin manifestations that are not due to metastases.

________ may precede cancers by many years and is particularly associated with gastric cancer

Answer 31

Acanthosis nigricans

Question 32

Many cancers can present with skin manifestations that are not due to metastases.

________ may be associated with malignant melanoma and is possibly due to an immune response to melanocytes

Answer 32

Vitiligo

Question 33

Many cancers can present with skin manifestations that are not due to metastases.

________ may occur in lymphoma, Kaposi’s sarcoma, and thymic tumors

Answer 33

Pemphigus

Question 34

Many cancers can present with skin manifestations that are not due to metastases.

________ associated with celiac disease may precede tumor development by many years, and is associated with GI lymphoma

Answer 34

Dermatitis herpetiformis

Question 35

Skin lesion with malignant potential that is characterized by scaly, erythematous macule or patch of skin that develops in sun-exposed areas of elderly and fair skinned individuals, and can expand slowly, becoming raised and crusty and may form hyperkeratotic horns or ulcers

Answer 35

Actinic (solar) keratosis

Question 36

Localized patch of neoplastic cells that are confined to epidermis; appear as flat, erythematous and scaly plaque that is well demarcated but irregularly shaped. Can occur anywhere on the skin but typically sun-exposed areas, especially the legs. Slow growing only 3-5% progress to invasive disease more characteristic of an SCC

Answer 36

In situ or intra-epidermal SCC (Bowen’s disease)

Question 37

In situ SCC affecting the glans penis or vulva is known as ___________________ and is associated with _______ infection

Answer 37

Erythroplasia of Queyrat; HPV