Cutaneous Neoplasms Flashcards

1
Q

What are seborrheic keratoses?

A
  • one of the most common cutaneous neoplasms
  • develop in middle age or older patients
  • brown/tan waxy papules and plaques with a “stuck on” warty appearance most commonly on face/trunk/upper extremities
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2
Q

What is the Leser-Trelat sign?

A

Sudden onset of multiple seborrheic keratoses associated with internal malignancy (most commonly stomach cancer)

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3
Q

What do seborrheic keratoses look like on histology?

A
  • Hyperkeratotic, papillomatous and verrucous epidermis
  • Horn and pseudo horn cysts (invaginations of keratin)
  • Variable melanin pigmentation is present, accounting for the brown coloration seen clinically
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4
Q

What is actinic keratosis?

A
  • also known as solar keratosis; common lesions that develop as a result of chronic sun damage
  • middle aged to elderly onset (esp with fair complexion)
  • red or tan/brown macues with “gritty” sandpaper like scales
    • some lesions regress or may remain stable
  • 0.1-10% become malignant squamous cell carcinoma
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5
Q

What does actinic keratosis look like on histology?

A
  • Atypia of the basal layer of the epidermis
  • Corneal layer is thickened with retained nuclei (parakeratosis)
  • Loss of granular layer in some places
  • Dermis contains thickened, blue-gray elastic fibers (solar elastosis), the result of chronic sun damage
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6
Q

Describe the etiology/prevalence of squamous cell carcinoma

A
  • common neoplasm in older individuals (40+); 20% of all skin cancers
  • UV radiation is the most common cause (DNA damage)
  • Other predisposing factors include;
    • chronic ulcers
    • old burn scars
    • HPV (esp in head and neck)
    • toxic exposure (radiation, arsenic)
    • immunosuppression (esp in solid organ transplant)
  • 1-5% risk of metastasis in low risk area (~20% in high risk area such as lip/mucosa)
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7
Q

What are the clinical symptoms of squamous cell carcinoma?

A
  • red scaly plaque
  • risk of metastasis is related to the location and degree of invasion
    • ~2-4% higher risk in immunosuppressed patients
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8
Q

How does SCC differ when it becomes invasive?

A
  • invasive lesions (5% of SCCs) tend to be nodular and may ulcerate
  • roughly 30% of invasive SCCs have metastatic potential
  • classified as invasive when the neoplastic cells break through the basement membrane
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9
Q

What does SCC look like on histology?

A
  • full-thickness dysplasia (characteristically involves the entire epidermis)
  • disorganization of the epidermal architecture
  • loss of maturation
  • lack of polarity of cells
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10
Q

What is keratoacanthoma?

A
  • variant of squamous cell carcinoma
  • pink papule/nodule with a central keratin plug that grows rapidly (period of 2-10 weeks)
    • can cause extensive local destruction
  • occurs mainly on sun damaged skin
  • some lesions will resolve spontaneously (or can become very aggressive)
  • multiple lesions may be present in immunocompromised patients
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11
Q

What do keratoacanthomas look like on histology?

A
  • exophytic lesions with an invaginating mass of keratinizing, well-differentiated squamous epithelium at the sides and bottom
  • central keratin-filled crater that enlarges with the maturation and evolution of the lesion
  • epidermis on either side of the lesion is thrown up into a well-formed collarette
  • epithelium is typically characterized by well-differentiated, often pale-staining, eosinophilic, glassy cytoplasm showing a striking tendency towards keratinization
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12
Q

Describe basal cell carcinoma

A
  • most common human cancer
  • secondary to chronic sun exposure/UV radiation
  • slow growing tumor that rarely metastasizes (unless immunocompromised)
    • can be locally destructive
  • associated with dysregulation of the sonic hedgehog or PTCH pathway (30-40%)
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13
Q

What does basal cell carcinoma look like on histology?

A
  • several histologic variants
    • multifocal growths originating from the epidermis (superficial type)
    • nodular lesions growing downward into the dermis (nodular type) of variably basophilic cells with peripheral palisading.
  • tumor cells are small and uniform with round, darkly staining nuclei and minimal cytoplasm
  • characteristic clefting artifact between the tumor nodules and the stroma
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14
Q

What are melanocytic nevi?

A
  • An above normal amount of melanocyte in the epidermis
    • acquired from sun exposure
    • congenital at birth (can be severe/widespread and increase risk of melanoma)
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15
Q

What are the histological classifications of nevi?

A
  • junctional (epidermis only)
  • compound (epidermis and dermis)
  • intradermal (dermis only)
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16
Q

What are dysplastic nevi?

A
  • clinically and histologically distinctive
    • clincially larger than acquired nevi (>0.5 cm), irregular shape and uneven color
  • may occur sporadically or in a familial form
  • patients with multiple dysplastic nevi have increased risk of melanoma
17
Q

What is dysplastic nevus syndrome?

A
  • familial or sporadic
    • familial variant is autosomal dominant (mutations in CDKN2A gene in 40% of cases)
  • large number of dysplastic nevi (80+)
  • increased incidence of melanoma
    • patients can also develop other malignancies (e.g. pancreatic carcinoma)
18
Q

Contrast familial and sporadic dysplastic nevus syndrome

A
  • sporadic
    • lower number of nevi (2-10)
    • lifetime risk of melanoma ~10%
  • familial
    • hundreds of nevi
    • lifetime risk of melanoma approaches 100%

**both show identical histological features (may be junctional of compound)

19
Q

What is the prevalence of melanoma?

A
  • represents 3% of all cutaneous malignancies
    • 6th most common cancer in the US
  • more common in white population… affects men and women equally
    • most common on back in men
    • most common on legs in women
  • typically a disease of adulthood
20
Q

What are the risk factors for melanoma?

A
  • UV exposure at early age (most important risk factor)
  • fair complexion and older age
  • dysplastic nevus syndrome
  • xeroderma pigmentosum (autosomal recessive disease)
  • history of melanoma in the family
  • tanning bed use
21
Q

What are the clinical features of melanoma? (ABCDE)

A
  • Asymmetry
  • Borders (notched, uneven, or blurred)
  • Color (uneven; shades of brown, tan, red, and black may be present… 3+ is concerning)
  • Diameter (>6 mm)
  • Evolving (change in color/size of the lesion)
22
Q

What are the growth phases of melanoma?

A
  • Radial growth phase
    • melanocytes will proliferate within the epidermis (in situ… NO metastatic potential at this stage)
  • Vertical growth phase
    • dermal invasion and potential for metastasis
    • extent of this phase determines the biological behavior (Breslow thickness/depth of invasion is the most important prognostic indicator)
    • lesions >1.7 mm have greater potential for metastasis, <1 mm rarely metastasize
23
Q

What factors determine a melanoma’s metastatic potential?

A
  • Breslow thickness/depth of invasion is the most important prognostic indicator
  • ulceration
  • mitotic rate
  • angioinvasion

**sentinel lymph node biopsy is considered if a lesion is deep

24
Q

What are some types of melanoma?

A
  • superficial spreading type (most common, 70%, located on back and extremities)
  • nodular type (NO radial growth phase, poor prognosis)
  • lentigo maligna type (most commonly located on the head and neck in sun exposed areas)
  • acral lentignous type (located on the palm, sole, or beneath nail… most common in african americans)
25
Q

What does a melanoma look like on histology?

A
  • radial growth phase= asymmetric population of melanocytes within the epidermis (located along the dermal epidermal junction)
  • melanoma cells are large with abundant cytoplasm, often showing dusty melanin pigmentation… often show pleomorphic vesicular nuclei with prominent eosinophilic nucleoli
  • vertical growth phase= cells in dermis that grow in poorly formed nests or individual cells as an expansile nodules. There is lack of melanocytic maturation at the base of the lesion
26
Q

What is mycosis fungoides?

A
  • most common cutaneous lymphoma
  • occurs in late adulthood with a male predominance
  • usually presents as red or pink scaly patches
    • stages of patch, plaque, and nodules
  • usually chronic course although may become aggressive
27
Q

What are the stages of mycosis fungoides?

A
  • Patch stage: nonspecific dermatitis (patches often found on the lower trunk and buttocks… ill-defined patches of varying hue, often with a fine scale, irregular in size and shape) This stage may persist for many years before progression occurs
  • Plaque stage: well-demarcated lesions which are often annular in shape, violaceous in appearance and occasionally scaly (may develop de novo or from patches)
  • Tumor stage: usually develops in association with pre-existing lesions. The tumors are red in color, with a tense shiny surface. Ulceration may occur. The lesions usually measure 1 cm in diameter or more.
28
Q

What is sezary syndrome?

A
  • blood involvement of T cell lymphoma
  • erythroderma (skin is diffusely red and scaly; sometimes misdiagnosed as chronic eczema)
  • poor prognosis (survival 1-3 years)
29
Q

What does mycosis fungoides look like on histology?

A
  • mature T-cells show a tendency to colonize the epidermis (epidermotropism), although this is more evident in the patch and plaque forms than in tumor-stage disease.
  • infiltrate contains large cells with highly irregular, convoluted or cerebriform nuclei, known as Sézary or mycosis cells.
  • presence of atypical lymphoid cells in an intraepidermal vesicle (the Pautrier microabscess) is typical