L4 SK, AK, and Skin Cancer Flashcards
What are 3 important indications for Mohs micrographic surgery?
- recurrent tumors
- tumors>0.6 cm on the face or >2.0 cm on the body and extremeties
- high-risk anatomic locations (eyelids, nose, ears, lips, genitalia, fingers)
What is a solar lentigo?
-“age spot” “senile freckle”
-local proliferation of melanocytes
-uv damage in sun exposed areas
-very common
-well circumscribed
-small brown macule, often found in groups
No treatment required and cosmetic considerations only
What are Seborrheic Keratosis (SK)?
- common benign epidermal lesion
- proliferation of immune keratinocyte
- Develop typically after age 50
- “barnacles of aging”
- genetic link to excess multiple Sks
Clinical presentation
* tan to black with WARTY, WAXY, “STUCK ON” appearance
-well demarcated, oval/round/irregular shape
- may have single SK or hundreds
-commonly found on chest, back, head, or neck
-Christmas tree appearance on back due to Blaschko Lines
ISK= irritated SK caused by rubbing/friction
may have pruritus, pain, or bleeding
What is Leser-Trelat sign of SK?
-sudden onset of multiple SKs with inflammatory base
+ skin tags
+ acanthosis nigricans (with diabetics around the neck)
= possible association with GI and lung cancers
-Spontaneity should be a concern
How do you treat SK?
- reassurance: consider removing for cosmetic reasons or some ISKs
- Treatment options: cryotherapy, shave biopsy with 15 blade, curettage elctrodessication
What is a Keratoacanthoma?
*hallmark: RAPID GROWTH over 6-8 weeks
-round, flesh colored nodule with CENTRAL KERATIN PLUG
-more commonly found in sun exposed areas +/- hair distribution
-Risk factors:
-middle-age to elderly with fair skin
-increased UV radiation or chemical carcinogens
Management
-majrity resolve spontaneously in 6-9m
-due to difficult dx, REQUIRES BIOPSY AND TREATMENT
May be considered less aggressive squamous cell carcinomas with rare metastatic potential
-your body is able to fight it off
What is acitinic keratosis(AK)?
-aka solar keratosis
-originates from keratinocyte
-CONSIDERED PRE-CANCEROUS
-may progress to SCC (8% risk per year)
Risk factors
-increasing age
-M>F
-light skin complexion
-history of sunburns
-immunosuppression
-genetic syndromes
What is the clinical presentation of AK?
- THINK SANDPAPER
- erythematous, scaly/gritty macule or papule
- may be tender
Subtypes:
- hypertropic: thickened
- Atropic: scale absent
- Ak with cutaneous horn
- pigmented: normally skin colored
- actinic cheilitis (lip) patch of dryness
How do you diagnose AK?
- Typically by visualization and touch
- shave or punch biopsy if unable to differentiate from SCC
- lesion > 1 cm
- rapid growth
- ulceration or pain associated
*caution if lesion is > 6 mm: consider SCC in situ
How do you manage acitinic keratosis?
- may spontaneously resolve (20-30%) but could reoccur
- isolated lesions: cryotherapy or surgical intervention
- multiple lesions: field treatment
- topical fluorouracil cream: preferred
- Photodynamic therapy (PDT): topical photosesitizer selectively destroys target cells
- Imiquimod (i.e. aldara)
What are the clinical presentations of Basal cell carcinoma(BCC)?
- Nodular BCC is most common subtype
- flesh-colored or pinkish
- PEARLY
- TELANGIECTASIAS
- may have central ulceration with ROLLED BORDER
- most common on head and neck
*may also present superficial as pink patch similar to AK or SCC in situ. Pigmentation may also be present
How do you treat BCC?
Surgical: PREFERRED
- curettage and desiccation
- excision with 4mm margins
- Mohs for high-risk or cosmetic reasons
Nonsurgical
-radiation for poor surgical candidates
Superficall BCC
- Imiquimod cream
- 5% fluorouracil cream
- photodynamic therapy
What is BCC prognosis?
- locally invasive
- may recur requiring routine follow-up for surveillance
- 6-12m x 2y then annual follow -up
- metastasis is rare
- higher risk for developing other non-melanoma skin cancers
- appropriate patient education is key
What is squamous cell carcinoma (SCC)?
- second most common skin cancer
- originates from keritinocytes
- Males 50-70
Risk Factors: UV exposure including tanning beds, genetic alterations, chemical carcinogen exposure
-may arise in area of previous skin injury: burns, scars, etc
What is the clinical presentation of Squamous cell carcinoma?
- papule, plaque, or nodule
- pink, red, or skin colored
- often asyptomatic, may be pruritic or tender
- Lesion appears SCALY, EXOPHYTIC(grows outward), INDURATED(hard deep thickening), and or FRIABLE
- commonly appears warty
How to you treat SCC?
Surgical: preferred
- wide excision: margins based on risk
- Mohs: recommended for high risk and cosmetic considerations
Non-surgical
- radiation: for poor surgical candidates, residual tumor
- curettage and desiccation or cryotherapy
- select low-risk or SCC in situ
- less effective options include: 5-fluorouracil therapy, imiquimod cream, photodynamic therapy
What is SCC prognosis?
-rate of metastasis 5%
rate increases if lesion is > 2 cm in diameter >4 mm deep, or recurrent
Surveillance every 3-6m x 2y, then 6-12m x 3y, then annually for life
Malignant Melanoma and risk factors
3% of all skin cancers
- high morbidity and mortality if not treat early
- average age of Dx is 40 and rare in children
Risk factors
- fair skin, blue eyes, red/blonde hair, freckling
- > 5 atypical nevi, > 25 nevi
- immunosuppression
- personal or family history of melanoma: genetic predisposition in small percentage
- prolong UV exposure: blistering sunburns and UVA exposure in tanning beds
What are the clinical manifestations of melanoma?
-usually asymptomatic
-most de novo with some arising from pre-existing nevus
-pigmented papule, plague or nodule
-ABCDEs
A-asymmetry (shape or color)
B-border (irregular)
C-color (dark or variations)
D-diameter (>6mm - pencil eraser)
E-evolving (changes in above)
What is superficial spreading melanoma?
-most common subtype 70%
-confined to epidermis
-often younger population
-radial spread > vertical growth
men backs
women back and legs
What is nodular melanoma?
- rapid vertical growht
- minimal radial growth
- AGGRESSIVE!
- nodule is inflamed and friable
What is lentigo maligna?
- Elderly with chronic sun exposure
- Slow progression radially with rapid vertical growth
- Typically remains more superficial
What is acral lentiginous?
- darker skin (african/asian ancestry)
- spreads superficial then verticle
- M>F
- larger lesions due to delay in dx
- palmar, plantar or subungal
What are two melanoma considerations?
Subungual
- great toe or thumb
- history of trauma
- dark streak and involves proximal nail fold
Amelanotic
- minimal or absent pigment
- extensive ddx
- maybe changing or evolving
Biopsy
- photograph lesion prior to biopsy
- document size and landmark
- dermatologist can also triage images
- biopsy entire lesion + 1-2 mm and margin
Melanoma prognosis
- greatest risk for lethal melanoma: males over 50 living alone
- screen high risk patients in pcp
- screening every 6 months x 2 years then annually
- depth = worse prognosis
Breslow thickness and 5 year survivial <1 mm 95-100 T1 1-2 mm 80-96% T2 2.1-4 mm 60-75% T3 > 4 mm 37-50% T4
Node and metastasis
Node
- N0: no reginal metastasis
- N1: one tumore-involved node
- N2: 2-3 tumore-involved nodes
- N3: 4+ tumor-involved nodes
Metastasis
M0: no distant metastasis
M1: distant metastasis
a-d subsections based on location of metastasis
How do you treat melanoma?
WIDE SURGICAL EXCLUSION is the gold standard with 2 CM clear margins
- regional lymph node dissection/sentinel node biopsy
- advanced metastatic disease
- radiation
- chemotherapy: may be used alone or in combo with other agents
- immunotherapy/ targeted therapy: adjunct therapy
- follow up every 3 months
How to prevent melnanoma?
- avoid getting burned and tanning
- daily moisturizers with sunscreen (15+)
- Sunscreen SPF 30+ with planned sun exposure
- apply 30 min prior to activity and reapply every 2 hrs
- keep infants out of the sun, sunscreen only > 6 months of age
- sun protective clothing when in the sun (including hats and sunglasses)
- if possible, avoid the sun 10 am -4 pm or find shade
- avoid tanning beds
- routine skin exams
