Lecture 9: Skin Cancers

Question 1

What are the main types of NMSCs?

Answer 1

70% - Basal Cell Carcinoma (BCC)

30% - Squamous Cell Carcinoma (SCC)

Question 2

Compare the growth and spread of BCC/SCC?

Answer 2

BCC - slow growing, locally invasive and rarely metastasise

SCC - Fast Growing and frequently metastasise

Question 3

What are the risk factors for NMSCs?

Answer 3

UV radiation
Photochemotherapy (e.g. Guttate Psoriasis)
Chemical Carcinogens
X-ray/thermal radiation
HPV
Familial cancer Syndromes
Immunosuppression

Smoking is also associated with SCCs

Question 4

How do basal cell carcinomas look?

Answer 4

Nodular with a pearly rolled edge
Telangiectasia (visible vessels)
Central ulceration
Branching vessels on dermoscopy

Question 5

What would an unusual Basal cell carcinoma look like?

Answer 5

BCCs can be pigmented
then can also be morpheic (Firm, pallor, white area. A bit scar like), these have mostly grown down and through the skin so much less visible

Question 6

What are the treatments for BCCs?

Answer 6

Gold standard is surgical excision
- Best way is Moh’s Surgery

Curretage

Vismodegib

Question 7

Explain moh’s surgery?

Answer 7

tumour scooped out bit by bit with the pathologist checking between cuts whether you’ve reached the margin yet

so its used when the cancer is morpheic making it harder to determine the margins
And when the tumour is nearing imporant stuff like nerves. vessels or the eye and you want to minimise the excised tissue

Question 8

When is curettage indicated for BCC?

Answer 8

If the patient is too old or frail for surgery

Question 9

How does Vismodegib work?

Answer 9

It inhibits abnormal signalling in the hedgehog pathway, which is the molecular driver for BCCs

Question 10

When do you use vismodegib, and what can it cause?

Answer 10

For BCCs unsuitable for surgery such as advanced or metastatic tumours

It can cause hair loss, weight loss, taste abnormalities, fatigue, nausea and muscle spasms

Question 11

How do SCCs appear?

Answer 11

Fast growing
Tender growths either scaly/crusted or fleshy
They may ulcerate

Question 12

How do you treat SCCs?

Answer 12

Excision +/- radiotherapy

Question 13

What is a keratoacanthoma?

Answer 13

A variant of SCC

erupts from follicles in sun damaged skin and grows rapidly. It may shrink after a few months

Requires Surgical excision

Question 14

Differentiating BCCs & SCCs?

Answer 14

BCCs take a long time to grow
They have a pearly rolled edge, frequent central ulceration and telangiectasia

SCCs take a matter of months to grow
They are scaly/crusted or fleshy and feel tender

Question 15

Older patients often present with rough scaly patches, particularly on sun-damaged areas e.g. ears or hands. what are they?

Answer 15

Actinic Keratoses

They are extremely common pre-malignant lesions that may develop into SCC

Question 16

How would you manage actinic keratoses?

Answer 16

They need to be treated to pre-empt SCC.

Cryotherapy
Curretage
Diclofenoc Gel
Imiquimod

Question 17

A patient comes in with irregular scaly erythematous plaque. This is?

Answer 17

Bowen’s Disease

An intraepidermal SCC, example of a pre-malignant lesion

Question 18

How would you treat Bowen’s Disease?

Answer 18

Pre-empt SCC

Cryotherapy
Curretage + thermal ablation

Photodynamic therapy

Imiquimod

Question 19

How does photodynamic therapy wokr

Answer 19

Apply a photosensitizing agent to the cancer then apply a red light

Question 20

What is imiquimod

Answer 20

An immune response modifier that stimulates cytokine release.

It’s used on pre-malignant lesions like Bowen’s Disease & Actinic Keratoses.

Takes up to 6 wks to work and can cause significant inflammation

Question 21

Finally what is a melanoma in situ?

Answer 21

A small melanoma confined to the epidermis and so unable to metastasise
Its a pre-malignant lesion and must be excised before it gains the ability to metastasise

Question 22

A cancer arising from melanocytes in the epidermis

Answer 22

Define a melanoma?

Question 23

• H/o skin cancer- FH- Fair skin (Type 1 & 2 skin)- Living in tropical country >1yr- Working outdoors- Immunosuppression

Answer 23

What are the risk factors for Melanoma?

Question 24

ABCDE. Check For:- Asymmetry- Variable border (irregular, hard to define)- Variable Colour-Uneven diameter- Evolution (colour/size changes in moles)Look with a dermatoscopeIf you suspect, biopsy it

Answer 24

What approach do you take to diagnosing a melanoma?

Question 25

Surgical Excision followed with a sentinal lymph node biopsy to assess for spreadChemoImmunotherapyRegular follow up and 2* prevention i.e. suncream, no tanning beds etc

Answer 25

How would you treat a melanoma?

Question 26

Ipilimumab - inhibits CTLA-4 moleculesPembrolizumab - Blocks PD-1Vemurafenic - Blocks B-Raf Protein (requires B-raf mutation in the cancer)

Answer 26

What kinds of therapies are there for metastatic melanoma?

Question 27

Superficial spreading - Common (typical image of a melanoma)Lentigo Maligna melanoma - Slow growing melanomas usually on the faces of older people whove had a lot of sun exposure over the years, look like stains on the skinNodular Melanoma - Faster growing, nodular and ulcerate easilyAcral Lentiginous Melanoma - unrelated to sun, they appear more in darker skin types. On the palms, soles and nails.Ocular Melanoma

Answer 27

What are the main morphological types of melanoma?

Question 28

Cutaneous lymphomas:- Mycosis Fungoides- Sezary SyndromeCutaneous metastases

Answer 28

this covers

Question 29

65% are T cell Lymphomas e.g. mycosis fungoides (MF) or Sezary syndrome20% are B cell lymphomasThey may be 1* cutaneous cancersOr 2* to systemic/nodal malignancys

Answer 29

What are the types of cutaneous lymphoma?

Question 30

Rash - Flat/red/dry/oval patches much like psoriasis or eczemaThey eventually thicken and itch forming plaques.Large irregular lumps (tumours) form and ulcerate

Answer 30

How does Mycosis Fungoides look?

Question 31

A scaly thickned red itchy rash over the entire body (think end-stage MF) + Lymph node involvement

Answer 31

What does Sezary Syndrome look like?

Question 32

Bloods - Abnormal “Sezary” T cellsCT imagingSkin/tumour lesion biopsy

Answer 32

How do we test for cutaneous lymphomas?

Question 33

Topical steroids for the rashRadiotherapy/ChemotherapyMethotrexateInterferonPhototherapies

Answer 33

How is cutaneous lymphoma treated?

Question 34

Total Skin Electron Beam Therapy;- Irradiating epidermis/dermis while sparing deep tissuesExtracorporeal Photophoresis:- T cells are filtered out- Sensitized to UVA using Psoralen- Exposed to UVA (damaging the diseased cells)- Re-infused

Answer 34

What phototherapies are used for cutaneous lymphoma

Question 35

Primary skin cancers e.g. BCC/SCC/Cutaneous lymphomaBreastColonLung

Answer 35

What cancers cause cutaneous metastases?

Question 36

Do a biopsy which will show where the tumour came fromthen excision and radiotherapyIf its too advanced there are palliative and symptomatic treatments

Answer 36

How do you investigate and treat cutaneous metastases?