neoplasms Flashcards
leser trelat syndrome
sudden SKs due to chemo drugs, gastric cancer, breast cancer, lymphoma
sk features
white yellow milia cysts, comedo openings, demarcated, hairpin vessels, sulci, gyri
peutz jeghers
lentiges on mucosa and genitalia, due to GI, breast and ovarian cancers
NF 1 Features
> 6 CALM, > 2 plexiform neurofibromas, lisch nodules (pigmented hamartomas of iris), glioma (optic tumor) crowes sign (axillary or inguinal freckling)
NF1 referrals
neuro, opthamology, developmental assessment, scoliosis monitoring
congenital melanocytic nevi sizes
S <1.5cm, M 1.5-19.9cm both after puberty, L >20cm BEFORE puberty
junctional nevi
flat to slightly raised, dermo-epidermal junction, palms, soles, genitalias, mucosa in children
compound nevi
macule with a central raised papule, dermo epidermal junction and dermis, increases in thickness during childhood and adolescence
intradermal nevi
dermis-SC, after adolescence
spitz nevi
spindle shaped melanocytes on scalp and face, legs, before adulthood, worrisome histology so remove them
ATN
clinical dx
dysplastic nevi
histological dx
mild dysplastic nevi
ovoid or ellipsoid shape, hyperchromatic, small nuclei
moderate dysplastic nevi
melanocyte with large, hyperchromatic, ellipsoid or rhomboid shaped with a small nucleus in center of nucleus (2-3mm margin)
severe dysplastic nevi
spidle or ellipsoid shape, hyperchromatic, large nuclei with distal nucleoli (5mm margin)
this gene linked with MM and panc cancer
BRAF
30% of MM patients have these secondary cancers
renal, NMSC, leukemia, prostate, breast, colon
lifetime risk of MM in general population
1.3%
lifetime risk of MM in those with ATN
6%
lifetime risk of MM in those with ATN and FMH MM
15%
risk of MM by age 70 in those with FAMMM
100%
FAMMM
> 50 nevi with FMH of MM
percentage of MM that are hereditary
5-12%
majority of MM have
unknown or no genetic utation, 40% with a genetic mutation have CDKN2A
percent of MM de novo
70%
MM mets to
brain, lung
superficial spreading MM
70% of MM, head, neck, trunk, extremities, flat, irregular, brown black blue patch or plaque
nodular MM
10-15%, on back and extremities, raised brown black nodule with focal hemorrhage, rapidly growing lesion
LM
face, neck, arms, 5-10%, flat irregular mottled, variated pigment
acral MM
7%, hands, feet, asian and black pts, flat slowly growing macule
hutchinson sign
longitudinal pigment extending to proximal nail fold or distal digit
amelanotic
2%, skin types 1-2, enlarging pink red macule, papule or nodule
dermoscopy MM
atypical pigment network with dots, globs, vascular structures, structureless areas, regression, neg pigment network, streaks, blue white veil
breslow
strongest predictor of mets, >1mm limits survival, vertically in mm from top of layer to deepest tumor involvement
clark level
useful in outcome of thin tumors, 1: in situ, 2: invaded pap dermis, 3: filled pap dermis, 4: reticular dermis 5: invaded SC tissue
histology gene mutations with MM
CDKN2A, BRAF
histochemical staining
HMB45, S-100, MIFF, MART1, K167
Margins with MM MMIS
0.5cm
margins MM breslow < 1mm
1cm margin
margin MM breslow 1-2mm
2cm margin
margin MM breslow 2-4mm
> 2cm margin
T
0-4 based on breslow depth, Tumor, a - ulcer, b- no ulcer
N
Nodes, 0-3, based on nodal invasion
M
mets
pt education for MM
baseline FBSE, then every 3/4/6 mo, with lymph node and liver palpation. a new MMIS is dx in >20% of MM patients, 1nd invasive melanoma occurs in 5-10%.
pyogenic granuloma
dome shaped papule comprised of capillaries, assoc w trauma, hormones. need a shave then electrodessication
glomus tumor
blue red papule, tender, cold sensitivity, need to excise or do co2 laser
salmon patch, nevus simplex
stork bite, benign capillary malformation, 30-40 percent newborns
sturge weber
v1 trigeminal nerve, assoc w seizures, glaucoma, send to neuro, optho, laser
klippel trenaunay
vascular malformation, venous varicosity, soft tissue hyperplasia, lymphatic disease, increase risk of clotting if increased leg girth, need cards referral,
things that make you immunocompromised
UVR, CLL, AIDs
drugs that increase risk of skin cancer
azathroprine and MMF
drugs that promote skin cancr
cyclosporine and tacrolimus
percent of organ transplants that develop a NMSC
40-70% virtually all kidney and cardiac transplant pts will develop another NMSC within 5 years of their first
drugs that may reduce number of NMSC
nicotinamide, acitretin
AK patho
intraepidermal precurser to SCC, UVR leads to cellular mutations which form atypical keratinocytes, leads to gene mutations and impaired apoptosis and cell proliferation –> SCC
Percent of AK –> SCC
15
imiquimod dose
nightly 2 weeks on, 2 weeks off, 2 weeks on
5fu duration
BID x 2-6 weeks
picato duration (ingenol mebutate)
3 days face or scalp, 2 days trunk or extremities
diclofenac sodium
voltaren, 3 month tx
blue light - topical aminolevulanic acid and blue light FDA approved for
AK, superficial BCC, low risk nodular BCC, 70-90 cure rate singlet oxygen radicals react and destroy tissue from porphyrins
met rate of SCC
3%
SCC presentation
dull red, firm, poorly defined, plaque or nodule with central keratin scale
mgmt low risk SCC
excision
mgmt high risk SCC
mohs
high risk scc lesions
scalp, eyes, ears, nose, lips, genitalia, digits, scar sites, prior radiation. >1cm head and neck, >2cm on trunk and extremities
scc histology for high risk
moderately poorly differentiated, peri-neural, peri-vascular, recurrent tumor
high stage SCC
2 or more: diameter >2cm, tumor beyond fat, poorly differentiated, nerve invasion >0.1 == elevated nodal mets and death
high risk scc risk of mets
greater than 20%
SCCIS tx
edc, excision with 4-6mm margins (4mm for sccis, small lesions, well diff. 6 for large, mod diff, poor diff, perineural) - topical tx and PDT are off label
mohs scc
for high risk tumors, adjuvant therapy with + margins, recurrent tumors
Acitretin (Soriatane)
10mg/day for 2 months then 25mg/day. oral retinoid. slows development of multiple SCC. s/e desquamation of hands and soles, musk symptoms, headache, epistaxis. can have rebound phenom.
BCC
grows slowly, rare mets, can be very destructive, risk if exposed to UVR and heavy metals, lead to DNA mutations which inactivate the PTCH tumor suppressive gene
subtypes of low risk bcc
superficial, nodular. pigmented
subtypes of high risk bcc
micronodular, morpheoform/sclerosing
5FU for BCC
antimetabolite interferes with DNA synthesis, good for sBCC and nBcc on trunk and extremities, 5FU BID X 6 weeks, cure rate 80-90
imiquimod for BCC
immune response modifier, makes t cells make interferon, for small superficial BCC on neck, trunk, extremities. Apply once daily for 5 days per week x 6 weeks
first line for primary superficial BCC tx is
ed&c not for hair bearing skin though – follicular extension – this cant determine how completely tumor was removed
bcc excision
4-5mm margins, low risk bccs, if not completely excised - mohs, has advantage of under microscope
locally advanced bcc
invasive into underlying tissue, cartilage, bone
met bcc
spead to nodes, lung, bone, liver, rare, poor prognosis - need surgery, radiation, target therapy
erivedge
for recurrent, locally advanced, and met BCC. blocks ptch hedgehog pathway. 150mg daily. complete response in 7.6 months
odomzo (sonidegib)
for recurrent, locally advanced bcc, not for met bcc, 200mg daily
merkel cell carcinoma
primary cutaneous neuro endocrine cancer, fast, aggressive, high rates of mets and recurrence, 80-90 percent recur in 2 years
merkel mgmt
bx with immunostaining, MRI, CT or PET, SLNB, adjunctive xrt post excision with 3mm margins.
CTCL
class of non hodgkins lymphoma, malignant helper T cells migrate to the skin. two subtypes: MF and sezary syndrome
early ctcl
local or widespread, ill defined, scaly pink red plaques
patch ctcl
sharp demarcated, mottled telangiectasic, red pink scaling patches
plaque ctcl
dusky red brown patches, plaques on butt, hip, thighs
tumor ctcl
red brown nodules which ulcerate
sezary syndrome
leukemic form of ctcl, erythroderma, hot, tender, extreme itch
dx sezary syndrome
need smear, cbc, lft, bun, cr, LDH, CD4 CD8, CXR. Need numerous bx
mgmt sezary
bexarotene, nitrogen mustard, extracorpeal photophoresis
