Cutaneous malignancy

Question 1

Classification of skin cancer

Answer 1

1. Primary skin cancers
   Arising from the skin and is appendages
   melanotic(MSCs) and Non melanotic skin cancers (NMSCS)
2. Secondary skin cancers
   Metastasis or secondary deposits

Question 2

What is an example of a Non melanotic skin cancer?

Answer 2

Basal cell carcinoma( Rodent ulcer)

Question 2

What is a Basal cell carcinoma (Rodent ulcer)?

Answer 2

BCC is by far the most common cutaneous malignancy worldwide and accounts for nearly 80% of all skin cancers.
There is marked worldwide geographic variability, most often affecting light-skinned populations in locations with the highest UV exposure.
Although mortality is rare, locally aggressive BCC can result in significant patient morbidity.

Question 3

What are the risk factors for Basal cell carcinoma?

Answer 3

1-UV LIGHT- the predominant risk factor both nmscs AND mscs and benign skin problem
UVA (95%) UVB more dangerous
2: SKIN TYPE -fitzpatrick skin( types I–IV)
FITZPATRICK CLASSIFY SKIN ACCORDING TO THE amount of melanocyte, the inherent skin pigmentation and the propensity to burn,
3- LATITUDE- the lower the latitude the higher the incidence of both NMSC and MSC
4-PHENOTYPES- the caucacian skin
5-inadequate dna repair – e.G xerodermal pigmentosa
6 lack of melanin –albinism and fitzpatrick i-iv
7- immuno deficiency

Question 4

What are the clinical types of BCC?

Answer 4

Two types- circumscribed and diffused type
A- nodular bcc (example of circumscribed)
MOST COMMON 50% 0f BCC
B- diffused subtype
A- superficial bcc
C- morpheaform bcc or sclerosing type (most aggressive)

Question 4

What are syndromes associated with Basal cell carcinoma?

Answer 4

While most arise sporadically,
BCC is also associated with several clinical syndromes,
Bazex syndrome: a rare psoriasis like dermatosis occurring on the feet and hands
Gorlin syndrome (basal cell nevus syndrome)-rare genetic condition associated with development of BCC in adolescence and in other organs
xeroderma pigmentosum. Inherited disorder marked by extreme sensitivity to UV light, because of inability to repair damaged DNA
ALBINISM-a recessive genetic disorder, has a defect in one of the genes that produce and distribute melanin.

Question 5

What is the treatment for BCC?

Answer 5

Diagnosis
History, examination and biopsy
Cure rate is over 90% but recurrence is common
Treatment
Surgical
Destructive
Medical
Surgical : primary excision or moh micrographic surgery
Destructive: radiotherapy, cryotherapy, electrodesication,shave
Medical : 5 florouracil and imiquimod

Question 5

What is the diagnosis for BCC?

Answer 5

• Indolent ulcer usually seen in sun exposed areas, the head and neck, presternal area and hands and forearm
• Above a line extending from the angle of the mouth to the ear lobe
• Well circumscribe ulcer with raised and rolled edges the ulcer occur as a crater at the summit (nodular type)
• It rarely metastasize , no lymph node involvement
• It slowly penetrate deeply (rodent ulcer)
  Common among albinos

Question 6

Investigations of squamous cell cancers

Answer 6

Fbc
E,u,cr
Biopsy for histology diagnosis
Lymph node sampling/ sentinel lymph node biopsy

Question 6

What are squamous cell cancers?

Answer 6

Commoner in africans than bcc. It constitue 5% percent of all cancer in africans

Can occur in all parts of the body but commonest in the lower limbs, volvovaginal area, penis(uncircumcised),scrotum and anus.
It spreads by local infiltration and lymphatic metastasis

Question 6

CF of squamous cell cancers

Answer 6

Chronic ulcer, non healing and progressively expanding
Raised and everted edges

Question 6

Risk Factors of squamous cell cancers

Answer 6

Chronic cumulative sun exposure, both uva and uvb are implicated
age,
Likely reflecting an increased cumulative exposure to sunlight.
Environmental risk factors for cscc
History of radiation,
Chronic inflammation (as in marjolin’s ulcer)
Exposure to arsenic and hydrocarbons.

Chronic immunosuppression:
Secondary to organ transplantation the risk of cscc up to 250 times
correlated to the type of transplant,
Immunosuppressive drug burden, and
Time since transplantation

Question 6

Premalignant lesion- actinic keratosis

Answer 6

Up to 80% of cscc tumors arise in association with a preexisting actinic keratosis, although overall only 1% of actinic keratosis transforms to cutaneous scc
Features of actinic keratosis that are associated with malignant transformation include
Inflammation,
Diameter >1 cm,
Rapid growth,
Ulceration,
Bleeding, and erythema.
A cutaneous horn

Is a clinical variant of actinic keratosis that presents as a hyperkeratotic protuberance shaped like a cone extending above the plane of the skin.

Approximately 15% of cutaneous horns actually contain cscc,
Excision is therefore indicated

Question 6

Host risk factors for CUTANEOUS SCC

Answer 6

Fitzpatrick I–II skin types, fair hair,
previous history of non-melanoma skin cancer,
infection with HPV.
certain inherited disorders such as
xeroderma pigmentosum,
epidermolysis bullosa, and
albinism

Question 6

Other forms of cutaneous scc

Answer 6

Bowen’s disease

Kerato achantoma

Marjolin”s ulcer

Question 7

Bowen’s disease

Answer 7

This is an intra epithelia squamous cell cancer
Seen in sun burn areas, perianal area
When cscc in situ occurs on the mucocutaneous epithelium of the glans of the penis or labia majora, it is referred to as erythroplasia of queyrat.
When cscc in situ occurs in the oral or genital mucosa, it presents as adherent white patches clinically referred to as leukoplakia.
Treament is curretage, wide excison, cryotherapy
5% 5fu given topically

Question 8

Keratoacanthoma

Answer 8

Keratoacanthoma is a rapidly growing nodule (over weeks to months) with a central ulceration or keratin. Keratoacanthoma is felt to be a low-grade variant of cSCC

Question 8

Treatment scc

Answer 8

Wide local excision with block dissection of involved lymph nodes
Curretage and dessication
Cryotherapy
Radiation
Amputation
Chemotherapy

Question 9

Malignant melanoma

Answer 9

This is the most deadly of all skin cancer.
It accouts for 75% of deaths from skin cancers

Incidence is on the rise world wide linked to decreasing stratospheric ozone layer

Commonest among caucasins living near the equator

It arises from the melanocytes of the skin or the uveal tract.

Question 10

Clinical types

Answer 10

Nodular melanoma (55%)
It grows vertically down so it has the worst prognosis, thick and often raised or ulcerated
Superficial spreading melanoma(25%)
Lentigo maligna (10%)
Common among elderly, slow growing, occur in long standing pigmented lesion, hypo pigmented lesion is also possible
Acral lentigenious melanoma
Seen in negros ,occuring in the soles,palms,nail bed and mucosa, commonest among blacks
Subgungal- occuring in the nail bed, hutchinson sign
Desmoplatic melanoma- invades fascial planes and perineural spread.

Question 10

Environmental Risk Factors

Answer 10

Exposure to uva and uvb sunlights

Question 10

Clinical/histological growth types

Answer 10

Melanoma can be classified into five clinical and histologic growth patterns, each of which has unique clinical characteristics:
Superficial spreading,
Nodular,
Lentigo maligna,
Acral lentiginous,
Desmoplastic melanoma.

Question 10

Host Risk factors

Answer 10

Host factors
Skin type- fitzpatrick type i and ii
Congenital nevi,
Atypical nevi,
giant nevi
Familiar melanoma

Question 11

Diagnosis

Answer 11

Five simple criteria for identifying pigmented lesions that are suspicious for melanoma: [abcde]

Asymmetry,
Border irregularity,
Color variegation,
Diameter > 6 mm,
Evolution or change in the appearance of lesion over time
(Except for the amelanotic type)

Question 11

Other diagnostic techniques

Answer 11

Excision biopsy with 2mm margin
Sentinel lymph node assessment

Further screening workup for newly diagnosed patients with invasive melanoma includes chest x-ray, complete blood count, liver function tests, and serum lactate dehydrogenase (ldh).
Ct scan
Pet, mri, lft,

Question 12

Treatment and staging

Answer 12

Stage i -only skin lesion i present

Stage ii- satellites and intransite metastasis

Stage iib -regional lymph node involvement

Stae iii disease has spread further than the lymph node

Question 13

Treatment

Answer 13

Wide and deep excision with 1-3 cm margin

Emblock excision of positive sentinel lymph nodes

Amputation of at the mid phallanx proximal to the fingers and toes melanoma

Chemotherapy for advance diseases:melphalan, actinomycin ,cisplatin

Immunotherapy with levimasole ,bcg,

Question 13

Prognostic guide lines

Answer 13

Tumor thickness,
Mitotic rate,
Ulceration
Mitotic rate is the second most powerful predictor of survival after tumor thickness,

Stage 1 survival 97% at 5 years
Stage iv survuval at 15% at 5years

Question 13

Dermatofibrosarcoma

Answer 13

Skin tumour with low grade malignancy

Characterised with reccurence after excision( has a false capsule)

Commonly found arround the abdomen, groin and limbs

Dermis fibroblast

It hardly ever metastasize

Question 13

Prognosis

Answer 13

Tumour thickness
Brestlow scale (.075->3.5) survival is inversely proportional
The status of the lymph node( number of metatatic ln, uoceration and tumour burden)
Sex: females survive better
Age: young have better prognosis
Site of tumour, type of tumour (lentigo maligna best prognosis)
Preexiting naevous
Ulcerated lesions

Question 14

Treatment

Answer 14

Excision with a margin of 3cm

Radiotherapy

Targeted molecular therapy e.G tyrosine kinase inhibitor imatinib mesylate( glevec

Question 14

Merkel cell tumour

Answer 14

Also called neuroendocrine tumour of the skin, arised from the merkel cells
Rare but aggressive skin tumour
Predilection to metastasize to the regional lymph nodes
It is fast growing - few weeks to months
Commonest in head and neck
But in africans it develop on the legs
Treatment is wide local excision