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Unit 3 D&D > DD 03-07-14 09-10am Skin Cancer slides - Dunnick > Flashcards

DD 03-07-14 09-10am Skin Cancer slides - Dunnick Flashcards

1
Q

Skin cancer - prevalence

A

= most common form of cancer in US
Each year…
- >3.5 million skin cancers Dxed in >2 million ppl
- More new cases of skin cancer than combined incidence of breast, prostate, lung & colon cancers

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2
Q

Common Skin Cancer Types

A

Basal cell
Squamous cell
Melanoma

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3
Q

Non-melanoma Skin Cancer - Risk Factors

A
  • Fair skin + geographic areas w/ high UV exposure
  • UV radiation is most common cause of BCC
  • Ionizing radiation, arsenic or polycyclic hydrocarbon exposure
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4
Q

Basal Cell Carcinoma - prevalence, morbidity/mortality

A

= Most common malignancy in the US

  • ~2.8 million are Dxed annually in US
  • rarely fatal, but can be highly disfiguring if allowed to grow
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5
Q

Basal Cell Carcinoma - Subtypes & prevalence

A

Superficial (15%)

Nodular (75%)

  • Micronodular
  • Pigmented (6%)

Infiltrative (5%)

Sclerosing / Morpheaform / Desmoplastic (3%)

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6
Q

Superficial BCC

A

?

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7
Q

Nodular BCC

A

?

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8
Q

Desmoplastic/Sclerosing/Morpheaform BCC

A

?

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9
Q

Pigmented BCC

A

?

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10
Q

Hedgehog Alterations in BCC & Treatment

A

Most BCCs have loss of function of PTCH1
= normally acts to block smoothened (SMO), a transmembrane protein

Vismodegib
= inhibitor of smoothened
= approved in 2012 for treatment of advanced BCC

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11
Q

Actinic Keratosis (AK) - defn., prevalence, lead to…

A

= Intraepidermal neoplasia
= most common pre-cancer affecting >58 million Americans
- ~65% of all squamous cell carcinomas & ~36% of all basal cell carcinomas arise in lesions previously Dxed as AKs

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12
Q

Actinic Keratosis - Treatment

A

Cryosurgery
- Liquid nitrogen (boiling point of -196 C)

Topical…

  • 5-fluoruracil
  • Imiquimod
  • Diclofenac

Photodynamic therapy

Sun protection

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13
Q

Squamous cell carcinoma - prevalence

A
  • 2nd most common cutaneous malignancy

- More common in immunosuppressed, esp. organ transplant pts

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14
Q

Squamous cell carcinoma - Risk factors

A
  • UV damage
  • Thermal injury
  • Radiation
  • HPV
  • Burn scars (Marjolin’s ulcer)
  • Chronic injury (i.e. EB)
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15
Q

Squamous cell carcinoma - Subtypes

A
  • SCC in situ (Bowen’s disease)
  • Keratoacanthoma
  • Invasive SCC
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16
Q

Keratoacanthoma - distribution, time of growth, appearance

A

= subtype of squamous cell carcinoma

Distribution- primarily sun-exposed skin

Rapid growth over 6-8 weeks

Size- 1-3 cm

Crateriform endophytic & exophytic nodule w/ central keratin plug

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17
Q

Keratoacanthoma - Complications

A

Deep invasion w/out regression in 10-20%

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18
Q

Squamous Cell Carcinoma - appearance & distribution

A

Hyperkeratotic papule w/ variable size & thickness

Typically found on chronically sun-damaged skin

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19
Q

Squamous Cell Carcinoma - complications

A

Metastasis occurs in 0.3-5%

= more common in SCC of the lip (10-30%)

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20
Q

Types of Skin Cancer & Transplant Pts Risks

A

Kaposi’s sarcoma = 84 fold risk
SCC = 65 fold risk
BCC = 10 fold risk
Melanoma = 3.4 fold risk

21
Q

Skin Cancer & Transplant Pts - Risk factors

A

Age, Skin type, UV radiation

Genetic Factors

HPV (in 65-90% of SCC)

Level of immunosuppression:

  • CD4 count
  • Medications
  • Heart > Kidney > Liver
22
Q

Skin Cancer & Transplant Pts - Statistics

A

Non-transplant pts SCC:BCC = 1:4
Transplant pts SCC:BCC = 4:1

Incidence of skin cancer increases w/ # of years post-transplant:

  • 0.2-7% after 1 yr
  • 47-82% after 20 yrs
23
Q

Non-melanoma Skin Cancer - Treatment

A

Topical…

  • 5-fluoruracil
  • Imiquimod

Cryosurgery

Electrodessication & Curettage

Excision

Mohs micrographic surgery

Radiation

24
Q

Malignant Melanoma - ABCD(E) & Ugly Duckling Guidelines

A 
A = Asymmetry
B = Border irregularity 
C = Color variegation 
D = Diameter greater 	than 6 mm
(E = Evolution or change)

Ugly Duckling = if it looks different than other moles on the pt’s body

25
Q

Stages of the Progression of Melanoma

A
  1. Benign Nevus
  2. Dysplastic Nevus
  3. Radial-Growth Phase
  4. Vertical-Growth Phase
  5. Metastatic Melanoma
26
Q

Biologic Events & Molecular Changes in Progression of Melanoma - Benign Nevus Stage

A
  • Benign limited growth

- BRAF mutation & Activation of mitogen-activated protein-kinase (MAPK) pathway

27
Q

Biologic Events & Molecular Changes in Progression of Melanoma - Dysplastic Nevus Stage

A
  • Premalignant
  • Lesions may egress
  • Random atypia
  • CDKN2A loss (cyclin-dependent kinase inhibitor 2A)
  • PTEN loss (phosphatase & tensin homologue)
28
Q

Biologic Events & Molecular Changes in Progression of Melanoma - Radial Growth Phase

A
  • Decrased differentiation
  • Unlimited hyperplasia
  • Cannot grown in soft agar
  • Clonal proliferation
  • Increased CD1
29
Q

Biologic Events & Molecular Changes in Progression of Melanoma - Vertical Growth Phase

A
  • Continued decreased differentiation
  • Crosses basement membrane
  • Grows in soft agar
  • Forms tumor

Loss of E-cadherin

Reduction of Reduced TRPM1 (melastatin 1)
= melanocyte specific gene

Expression of:

  • N-cadherin
  • alphaVbeta3 integrin
  • MMP-2
  • Survivin
30
Q

Biologic Events & Molecular Changes in Progression of Melanoma - Metastatic Melanoma Stage

A
  • Continued decreased differentiation
  • Dissociation from primary tumor
  • Grows at distant sites
  • Absent TRPM1 —> associated w/ metastatic properties
31
Q

Malignant Melanoma - Relative risk

A 
Fair skin - 2-3
Excessive sun exposure - 3-5
Immunosuppression - 2-8
MM in 1st degree relative - 2-8
Whites - 12
Large congenital nevus - 17-21
Sporadic dysplastic nevus syndrome - 7-70
FAMMM - 148
32
Q

Melanoma - Epidemiology

A
  • ~76,100 new melanomas will be Dx
  • ~9,710 ppl expected to die of melanoma
    = most common form of cancer for young adults 25-29 years old
  • 2nd most common form of cancer for young people 15-29 years old
  • One person dies of melanoma every hour (every 57 minutes)
33
Q

Age-standardized death rates in Melanoma

34
Q

Malignant Melanoma - Statistics

A
  • Rapidity of increase exceeds all malignancies except for lung cancer in women
  • Of 7 most common cancers in US, melanoma is only one whose incidence is increasing (1.9% annually)
35
Q

Colorado Cancers Statistics (Cases estimated for 2014)

A 
All Cancer: 23,810
Female Breast: 3,780
Prostate: 3,680
Lung & Bronchus: 2,540
Colon & Rectum: 1,720
Melanoma: 1,400
36
Q

Malignant Melanoma - Demographics

A

Affects all age groups
- Median 53 yo

Distribution:

  • Blacks- acral and mucosa
  • Men- back
  • Women- legs (torso in females age 15-29, perhaps due to tanning)
37
Q

Malignant Melanoma - Clinical Variants

A

Superficial spreading - 70%
Nodular - 15-30%
Lentigo maligna melanoma - 5%
Acral lentiginous - 2-10%

38
Q

Breslow Depth

A

Tumor invasion in millimeters

39
Q

Clark Levels

A 
I Epidermis
II Papillary Dermis
III Mid Dermis
IV Reticular Dermis
V SubQ fat
40
Q

Malignant Melanoma - Treatment

A

Surgical excision

  • MM in-situ: 0.5 cm w/ SubQ tissue
  • MM 1 mm: 1-2 cm margins to fascia w/ sentinel node biopsy
41
Q

Mutations in Melanoma

A

Frequency of Mutations in Melanoma:

  • BRAF 50%
  • NRAS 20%
  • Kit 2%
  • GNAQ 2%

*Vemurafenib for BRAF V600E

42
Q

Vemurafenib

A
  • BRAF inhibitor
43
Q

Malignant Melanomaand Tanning

A
  • # of skin cancer cases due to tanning may be higher than # of lung cancer cases due to smoking
  • UV radiation (UVR) is a proven human carcinogen, put in Group 1 (includes plutonium & cigarettes)
  • Just one indoor tanning session increases risk of melanoma by 20%
  • Each additional session increases risk 2%

Of melanoma cases among 18-to-29-year-olds who had tanned indoors, 76% were attributable to tanning bed use.

HB1054 Calls for a ban on tanning in Colorado <18

44
Q

Skin Cancer Prevention

A
  • Sun avoidance (Avoid mid-day sun)
  • Sun protective clothing (Long-sleeved shirt)
  • Shade
  • Sunscreen
  • Sombrero (Wide-brimmed Hat)
  • Sunglasses
45
Q

What is SPF?

A

= “Sun Protection Factor”
= only reflects product’s screening ability for UVB rays

Sunscreen w/ SPF 15 prolongs burning time by a factor of 15.
- i.e., it would take 15x longer to develop sunburn than w/out sunscreen

46
Q

When should sunscreen be used?

A
  • should be applied every day to sun exposed skin, not just if you are going out into the sun.
  • Windows protect against UVB, but not UVA
  • Even on cloudy days up to 80% of sun’s UV rays pass through clouds.
  • Sand reflects 25% of the sun’s UV rays
  • Snow reflects 80% of the sun’s UV rays
47
Q

How much sunscreen should be used and how often should it be applied?

A
  • Apply to dry skin 15-30 mins before going outdoors.
  • 1 oz of sunscreen (shot glass) to cover exposed areas of body.
  • Reapply at least every 2 hours or after swimming or sweating heavily.
  • Even “water-resistant” sunscreens lose their effectiveness after 40 minutes in the water.
48
Q

Will sunscreens limit amount of vitamin D I get?

A
  • Individuals concerned about not getting enough vitamin D should discuss with their doctor the options for obtaining vitamin D through foods and/or a vitamin supplement.
49
Q

Skin Cancer Prevention

A

Get Vitamin D safely through healthy diet
- may include vitamin supplements

Check your birthday suit on your birthday

  • Self skin examinations
  • See dermatologist if notice anything changing, growing or bleeding

Unit 3 D&D (18 decks)

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