Malignant skin tumours

Question 1

What are the types of BCC(5)?

Answer 1

1. nodular
2. basosquamous
3. pigmented
4. superficial
5. morphoeic

Question 2

How does a nodular BCC present(4)?

Answer 2

• Commonly on the face
• Cystic, pearly, telangiectasia
• May be ulcerated
• Micronodular and microcystic types may infiltrate deeply

Question 3

How does a superficial BCC present(4)?

Answer 3

1. Often multiple
2. Usually on upper trunk and shoulders
3. Erythematous well-demarcated scaly plaques, often larger than 20 mm at presentation
4. Slow growth over months or years

Question 4

How does morphoeic BCC present?

Answer 4

• Also known as sclerosing or infiltrative BCC
• Usually found in mid-facial sites
• Skin-coloured, waxy, scar-like
• May infiltrate cutaneous nerves (perineural spread)

Question 5

How does pigmented BCC present?

Answer 5

• Brown, blue or greyish lesion
• Nodular or superficial histology
• May resemble malignant melanoma

Question 6

How does basosquamous BCC present?

Answer 6

• Mixed basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)

Question 7

Is BCC liable to metastasise?

Answer 7

No

Question 8

What are the 5 treatment options for BCC?

Answer 8

• monitoring – observation rather than immediate treatment
• surgical excision
• curettage and cautery/electrodessication
• cryotherapy/cryosurgery
• topical treatment (for example, imiquimod)

Question 9

How does SCC typically present?

Answer 9

Squamous cell carcinoma usually presents as an indurated nodular keratinising or crusted tumour that may ulcerate, or it may present as an ulcer without evidence of keratinisation. Squamous cell carcinoma usually appears on the head and neck.

Question 10

What are the treatment options for SCC?

Answer 10

• Surgery is usually the recommended treatment. This involves removing the SCC with a margin of normal skin around it, using a local anaesthetic. The skin is then closed with stitches or sometimes a skin graft is needed. Sometimes other surgical methods are used such as curettage and cautery. This involves scraping the SCC away using local anaesthetic.
• Radiotherapy can also be used to treat SCC. This involves shining a beam of X-rays onto the skin. Usually several sessions are required.
• For advanced SCC, a combination of treatments may be used. For SCC that has spread to other parts of the body a combination of surgery, radiotherapy and/or chemotherapy may be used.

Question 11

What group of patients are at particular risk of developing SCC?

Answer 11

Immunocompromised

Question 12

Melanoma can be classified in 3 ways depending on how far it has invaded tissue. What are these?

Answer 12

1. In situ, if a tumour is confined to the epidermis
2. Invasive, if a tumour has spread into the dermis
3. Metastatic, if a tumour has spread to other tissues.

Question 13

What is the 7 point checklist with regards to melanoma?

What is the cut off for referral?

Answer 13

Major features of the lesions (scoring 2 points each):

Change in size

Irregular shape

Irregular colour.

Minor features of the lesions (scoring 1 point each):

Largest diameter 7 mm or more

Inflammation

Oozing

Change in sensation

Cutoff=3

Question 14

What are the 5 types of melanoma?

Answer 14

1. Superficial spreading is the commonest type, mostly lower limbs. They have a relatively slow growth phase and typically present early and \ can often be cured
   
   1. This can be recognised as a progressively changing, irregularly coloured and shaped lesion
2. Nodular melanoma is the 2^nd commonest, most on trunk, this appears raised above the skin and can often be friable, variably pigmented (amelanotic melanoma), and have a vascular appearance
3. Acral lentiginous melanoma are found in unusual sites, such as the soles of the feet. These tend to start with a freckle-like appearance and will grow slowly over a period of years
   
   1. In situ disease is not commonly recognised as it appears as flat pigmented skin. It develops to become more nodular and pigmented through time, at which point it is invasive
4. Spitzoid melanomas tend to be more symmetrical, but appear inflamed and can have irregular colours
5. Sub-ungual melanoma forms under the nails, and typically presents with pigmentation or swelling and destruction of the nail. These typically appear vascular and may or may not be pigmented

Question 15

What two eponymous scores can be used to grade melanoma thickness?

Answer 15

• Breslow thickness = the depth of tumour invasion is good for predicting prognosis
  
  • A tumour <1mm has a 5-year survival of 98% compared to 65% for >4mm
• Clark levels can also be used
  
  • I (in situ), II/III (papillary dermis), IV (reticular dermis), V (subcutaneous tissue)

Question 16

What is the management of melanoma?

Answer 16

The initial treatment for melanoma is excision biopsy, followed by WLE with 10mm margins to lower risk of metastasis and local recurrence, this is usually under LA. The extent of surgery depends on the thickness of the melanoma and its site.

Question 17

What are Clarks 5 levels?

Answer 17

Level 1: Melanoma confined to the epidermis (melanoma in situ)

Level 2: Invasion into the papillary dermis

Level 3: Invasion to the junction of the papillary and reticular dermis

Level 4: Invasion into the reticular dermis

Level 5: Invasion into the subcutaneous fat

Question 18

Following excision of the lesion suspected to be melanoma, a pathologist report will be provided. What 6 features will it contain?

Answer 18

1. Diagnosis of primary melanoma
2. Breslow thickness to the nearest 0.1 mm
3. Clark level of invasion
4. Margins of excision (the normal tissue around a tumour)
5. Mitotic rate – a measure of how fast the cells are proliferating
6. Whether or not there is ulceration

Question 19

What are the 5 stages of the AJCC cutaneous melanoma staging guidelines?

Answer 19

Stage 0-In situ melanoma

Stage 1-Thin melanoma < 2 mm in thickness

Stage 2-Thick melanoma > 2 mm in thickness, or > 1mm thickness with ulceration

Stage 3-Melanoma spread to involve local lymph nodes

Stage 4-Distant metastases have been detected

Question 20

Should the lymph nodes be removed in malignant melanoma?

Answer 20

If the local lymph nodes are enlarged due to metastatic melanoma, they should be completely removed. This requires a surgical procedure, usually under general anaesthetic. If they are not enlarged, they may be tested to see if there is any microscopic spread of melanoma. The test is known as a sentinel node biopsy.