Neoplasms Flashcards
Actinic keratosis
- precancerous to SCC
- 10% risk malignant transformation
- very common
Actinic keratosis
- RF
- caucasion
- chronic sun exposure
- immunocompromised
- Fitz-Patrick I and II
Actinic keratosis
- common location
- sun-exposed areas
- scalp, head, face, dorsal forearms, hands, shins
Actinic keratosis
- epidemiology
- middle aged and older
- M>F 2:1
Actinic keratosis
- pathophys
atypical keratinocytes confined to lower portion of epidermis
Actinic keratosis
- S&S
- sometimes easier felt than seen
- gritty papule, erythematous base
- white to yellow scale
- rough like sandpaper
Actinic keratosis
- Dx
- History and PE
- Bx gen not needed
- Fluorescence with Woods lamp
Actinic keratosis
- progression
- persist
- spontaneously regress
- progress to SCC
Actinic keratosis
- what presentation is most likely to progress to SCC
- tender
- thick
- inflamed
- failure to respond to therapy
Actinic keratosis
- Treatment
- Cryotherapy #1
- F-fluorouracil 5% cream X 1 month
- Aldara 5% cream X 16 weeks
- Picato 0.015% gel X 3 days
Seborrheic keratosis
- overview
- superficial, often pigmented, benign lesions
- show up around 40s, increase as age
- trunk and temple MC
Seborrheic keratosis
- presentation
- vary in size
- grow slowly
- macular, papular, verrucous
- round or oval
- flesh colored, black, brown
- spares palms, soles, mucosal surfaces
What is concern if large, multiple, rapidly appearing Seborrheic keratosis?
Leser-Trelat sign
- associated with internal malignancy
Seborrheic keratosis
- dx
- tx
- clinical history and PE
- cryotherapy to remove if bothersome
Basal cell carcinoma
- overview
- MC type skin cancer
- rarely metastasize
- cause local destruction
- from basal cells in skin
Basal cell carcinoma
- appearance
- location
- superficial
- slow growing papule or nodule
- lesion that doesn’t heal and bleeds when traumatized
- sun exposed: hands, face, head, and neck region (85%)
- Periocular: MC lower eyelid
Basal cell carcinoma
- epidemiology
- elderly
- fair skinned (caucasian has 30% lifetime risk)
- M>F 2:1
Basal cell carcinoma
- RF
- Long term sun exposure
- Fitzpatrick type 1
- immunocompromised
- prior BCC
- trauma
- xeroderma pigmentosum
Basal cell carcinoma
- pathophys
- Basal keratinocytes of epidermis and adnexal structures
- grows as direct extension
- unpredictable growth and progression
Basal cell carcinoma
- 4 main patterns
- Nodular (60%)
- superficial (30%)
- infiltrative
- morpheaform
Basal cell carcinoma
- Nodular
- MC form **
- Pearly white/pink **
- Dome shaped
- Rolled border
- Telangiectasias **
- Can have central ulceration and crusting
Basal cell carcinoma
- Superficial
- epidermis
- younger, female
- trunk and extremities **
- slow growing, expands peripherally
- circumscribed, round-to-oval, red, scaling plaque **
- may resemble eczema or psoriasis **
Basal cell carcinoma
- Morpheaform
- Yellow/waxy *
- sclertoic
- no ulcerations usu
- Firm, flat, slightly raised **
- resembles scleroderma
- indistinct borders
Basal cell carcinoma
- Infiltrating
- slow growing
- sun exposed areas
- mostly males
- Irregular, poorly demarcated plaque **
- can be red and ulcer **
- infiltrate deeper, involve lymph nodes
- can grow large, infiltrate nerves, nearby tissue
- children: assoc. with basal cell nevus syndrome
Basal cell carcinoma
- Pigmented
- melanin
- usually people with darker skin and eyes
Basal cell carcinoma
- cystic
- cystic mass, smooth and round
- similar to nodular BCC
- less firm than nodular
Basal cell carcinoma
- Nevoid basal cell carcinoma syndrome
- rare, autosomal dominant
- multiple BCCs at birth or early childhood
*more on slide but this is what she said to know
Basal cell carcinoma
- Dx
- Bx: shave or punch **
- imaging (CT) only if need or for sx prep
Basal cell carcinoma
- Histology
two categories
- Undifferentiated: solid BCC
- Differentiated: contain other cell lines also
Basal cell carcinoma
- Treatment
- Surgical excision**
- MOHS**
- electrodessication and curettage
- radiation
- imiquimod
- 5-fluorouracil
- F/U observe 5+ years
- risk of second BCC within 5 years: 36-50%
Squamous Cell In Situ
- aka
- describe
- Bowen’s disease
- very early form skin cancer
- superficial SCC
- sun exposed MC but can be anywhere
Squamous Cell In Situ
- presentation
- solitary or multiple
- scaly patch doesn’t heal
- slow growth
- can itch
- not painful
Squamous Cell In Situ
- PE
- red-brown
- scaly or crusted
- resembles thin psoriasis plaques, dermatitis, dermatophyte infection
Squamous Cell In Situ
- dx
bx
Squamous Cell In Situ
- tx
- Aldara 5% cream
- 5-FU 5% cream
- cyrotherapy
- excision
- Sun care practices
Erythroplasia of Queyrat
- overview
- Bowen’s dz of the glans penis
- almost always uncircumsized
- can progress to invasive SCC
Erythroplasia of Queyrat
- signs and sx and PE
- solitary or multiple non healing lesions
- redness, crusting, scaling, ulceration
- itching, pain, bleeding
- phimosis, dysuria, penile discharge
- can affect adjacent mucosal epithelium/inner surface foreskin
Erythroplasia of Queyrat
- dx
- bx
Erythroplasia of Queyrat
- tx
- Aldara
- 5-FU
- MOHS
- surgical excision
- cryotherapy
- radiation
- laser treatment
Squamous Cell Carcinoma
- overview
- 2nd MC skin cancer
- substantial risk of metastasis **
Squamous Cell Carcinoma
- RF
- UVB radiation, esp in childhood
- light hair and eyes
- ionizing radiation
- outdoor occupation
- immunosuppression
Squamous Cell Carcinoma
- MC locations
- sun-exposed
- scalp
- back of hands
- superior pinna
Squamous Cell Carcinoma
- epidemiology
- elderly
- M>F 2:1
Squamous Cell Carcinoma
- precursors
- Actinic keratosis**
- cutaneous horns
Squamous Cell Carcinoma
- pathophys
- atypical squamous cells in epidermis
- from proliferating keratinocytes
Squamous Cell Carcinoma
- presentation
- Non healing lesion**
- sun exposed surface
- shallow ulcer with elevated margins, often covered by plaque
- red, soft, freely moveable tumor
- may have thick and adherent scale
Squamous Cell Carcinoma
- Metastatic potential
- depends on location, size, degree differentiation, immunologic status, histology, depth
- Highest risk: scalp, ears, lips, nose, forehead, areas of chronic inflammation
Squamous Cell Carcinoma
- Dx
- Bx: incisional or excisional **
- Imaging (CT/MRI): surrey prep or look for invasion or metastasis
Squamous Cell Carcinoma
- Staging
- Important to determine treatment
- TNM staging used **
- highest risk >2 mm thickness, invasion to lower dermis/subcut, skin nerves, ear or hair-bearing lip
Squamous Cell Carcinoma
- Tx
- Surgical excision with clear margins
- MOHS if in face
- radiation adjuvant to sx
- 5-FU
- systemic chemo for metastatic SCC
Kaposi Sarcoma
- overview
- develops from cells that line lymph or blood vessels
- usu tumors on skin or mucosal surfaces
- aka “multiple idiopathic hemorrhagic sarcomas”
- rare prior to AIDS era
AIDS-Associated Kaposi Sarcoma
- pathogenesis
- epidemiology
- caused by HHV-8
- MC type of KS in US
- HIV pts
AIDS-Associated Kaposi Sarcoma
- presentation
- violaceus macules, plaques, nodules
- head, neck, upper trunk
- node involvement common **
- fulminant onset, “AIDS defining”
- treatment response is poor
Karposi Sarcoma
- Dx
- Hx, PE
- bunch biopsy
- CXR/bronchoscopy
- EGD/Colonoscopy
Melanoma
- overview
- malignant transformation of melanocytes
- most serious skin cancer
- skin, mucous membranes, ocular, GI, GU, lymph nodes, CNS
- Metastatic correlated with depth of invasion
Melanoma
- incidence
- > 50% 20-40 yo
- median age 62 men 54 women
- M>F 1.5:1
- MC in caucasian
Melanoma
- Etiology and pathophys
- DNA damage
- initially in epidermis with lateral growth, then growth into dermis with vertical growth
Melanoma
- genetics
- RF: dysplastic nevus syndrome
- 8-12% have fam hx
- Familial atypical mole malignant melanoma
- 1/10,000 dysplastic nevi become melanoma annually
Melanoma
- RF
- genetics
- UVA and UVB exposure
- Hx >5 sunburns doubles risk **
- Intense intermittent sun exposure **
- previous pigmented lesions
- fair complexion, freckles, blue eyes, blond/red hair
- highest predictor: increased number nevi (>100) **
- Tannign bed use 75% inc risk 1st exposure <35 yo
- changing nevus
- large congenital nevi (>5 cm)
- other skin ca
- blistering sunburns in childhood
- live high altitude
- exposure to ionizing radiation
ETC ETC
Melanoma
- 7 main types cutaneous melanoma
- superficial spreading (50-80%): sun exposed areas
- Nodular (20-30%): older pts, ulcerate and hemorrhage
- Lentigo maligna (melanoma IS): slowest growing, older pts, sun-exposed
- Amelanotic melanoma (<5%): can mimic benign conditions
- Acral-lentiginous (2-8%): MC in AA and Asian
- Subungual: (<5%) dark band in nail bed, Hutchinson sign
- Desmoplastic melanoma (1%): sarcoma-like tendencies, hematogenous spread
Melanoma
- presentation
- change in pigmented lesion: hypo- or hyper pigmentation, bleeding, scaling, ulceration, change in size or texture
- fam/personal hx melanoma and non-melanoma skin cancer
- Social hx: sunbathing, tanning, other sun
Melanoma
- PE
- any new/changing or bleeding/ulcerated nevus
- high risk: ocular exam (iris and retina)
- Caucasions MC: back and lower leg
- AA MC: hands, feet, nails
- may include mucosal surfaces
Superficial spreading melanoma
- MC type
- grow horizontally along top layer of skin
- can have purple hue
Nodular melanoma
- fast growing
- cause nearly 1/2 melanoma-related deaths
- Don’t fit ABCDE as well = harder to dx
- older men MC
Lentigo maligna melanoma
- can look like solar lentigo
- not very common
- usu >6mm
Amelanoic melanoma
- can be pink, red, purple, flesh colored
- often aggressive
Acral lentiginous melanoma
- MC asians and AA
- only shaped dot on foot, toe, etc.
Subungual melanoma
- MC AA
- Nail streak
- usually big toe and thumb
Desmoplastic melanoma
- look like scars
- usually involve nerve fibers
- “neurotropic melanoma”
- MC sun exposed areas
- usually > 6mm
Melanoma
- Dx
- Bx: standard of care. Bx ANY suspicious nevus
- Dermoscopy: giant microscope to see skin more closely
- Sentinel node biopsy to stage
- Lactate dehydrogenase (LDH) baseline
- CT/MRI/PET CT baseline
- imaging only helpful in detecting/eval progression fo metastatic disease
Melanoma
- Staging
- Breslow staging
- based on thickness of tumor (for staging)
- msr in mm
Melanoma
- Tx
- Full surgical excision (curative for most stage I-III)
- stage IV can add chemo
- oncologist for chemo
- plastic sx for final excision depending on location
- MOHS
- Radiotherapy - lentigo maligna, some head and neck lesions
Melanoma
- prognosis
- Strongest predictor is breslow depth
- highest survival <45 women
- metastatic has ave survival 6-9 months
- stage I and II have 20-year survival rats of 90% and 80%
Melanoma
- prevention
- avoid sunburn
- use SPF30+
- avoid tanning beds
- Screen high-risk pts
- Proper dx!!
- Bx all suspicious lesions
Melanoma
- PT education
- Teach those at risk how to monitor for change (ABCDE)
- perform monthly skin self-exams
- regular total body exams for those with hx of melanoma or dysplastic nevus syndrome
- Regular use of SPF15+
