NMSC Dan Flashcards

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1
Q

What are high risk features of SCC?

A

AJCC 7;
Diameter >2cm
Breslow thickness >2mm (esp >6mm) OR goes to fat
PNI (in nerve >0.1mm diameter)
Site; ear or nonhair-bearing lip
Poorly differentiated or undifferentiated
Non-AJCC 7;
SCC arising in burn, XRT field or chronic dermatosis
Immunosuppression - esp solid organ Tx or CLL
Recurrent SCC
Lymphovascular invasion
Non-sun exposed site (e.g. sole of foot)
Aggressive subtypes (e.g. acantholytic, adenosquamous, spindle or especially desmoplastic)
Incomplete excision

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2
Q

What are the guidelines for treating SCC by C+C?

A

Can be used for low-risk tumours with three caveats:
- Not on terminal hair baring areas
- If subcutaneous layer is reached then surgical excision should be performed instead
- Histology of the C+C should be performed to determine if still low-risk and if not then should be excised
96% 5 year cure rate if these adhered to

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3
Q

What are the recommended excision argins for NMSC?

A

IEC - 3-5mm
BCC - 4mm; 5-10mm if morphoeic or recurrent but Mohs preferred for these
SCC - 4-6mm if low risk, 6-10mm or Mohs if high risk
KA - 3-5mm margin
Merkel Cell - 3cm (Robinson); others say 1-2cm
AFX - 1-2cm; Mohs if large or on head/neck
DFSP - 1.5-2cm if 2cm diameter (Rob/Rook); 2-4cm if >2cm diameter or Mohs
MAC - Mohs recommended, adjuvant XRT if exc incomplete
Sebaceous carcinoma- 1-2cm; Mohs if large or on head/neck
EMPD - Mohs first line, WLE with 5cm margin +/- mapping biopsies or preop efudix to delienate

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4
Q

When may SLNB be considered for SCC?

A

Not clear if of benefit or not
If AJCC-7 stage T2;
over 2cm diameter OR any size with ≥2 specific high risk features;
- Breslow thickness >2mm OR goes to fat (Clark ≥4)
- PNI (in nerve >0.1mm diameter)
- Site; ear or nonhair-bearing lip (vermillion)
- Poorly differentiated or undifferentiated

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5
Q

What is risk of skin cancer from PUVA?

A

14x increased risk of cutaneous SCC in patients who have received >200 PUVA treatments or >2000J /cm2
Also evidence of increased risk for melanoma in these PUVA patients
PUVA lentigines indicate higher risk of PUVA-related skin cancers
>200 phototherapy treatments (of any kind) is PBS contraindication for phototherapy in Biologics work up
No evidence that UVB phototherapy increases skin cancer but probably does

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6
Q

What are treatments for individual AKs?

A
Shave
C+C
LN2 cryo
spot treat peel e.g. TCA 35-50%
ablative laser
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7
Q

What are treatments for widespread AKs/field change?

A

5% fluorouracil cream (Efudix); max 23x23cm area or 5-FU chemowraps for legs (as per AJD, 2013)
5% Immiquimod cream (Aldara); max 5x5cm area
-3x/wk 4 wks on, 4 wks off +/- further 4 wks on Or;
-3x/wk for 4-16 wks
3% Diclofenac gel (Solaraze); 0.5g per 5x5cm area, max 8g per day
0.05% Treinoin cream (ReTrieve)
Ingenol Mebutate gel (Picato); max 5x5cm area
- Face and scalp: 0.015% gel once daily for 2-3 consecutive days
- Body: 0.05% gel once daily for 2 consecutive days
Superficial chemical peels (need a course)
Medium depth chemical peel
- TCA 35%-50%
- Jessner’s solution + 35% TCA
- 70% glycolic acid + 35% TCA
PDT - single session per region
Daylight PDT (not if hyperkeratotic; may rpt in 3 months)
Laser resurfacing
Dermabrasion

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8
Q

What methods are available for prevention of AKs and skin cancers?

A

Sun protection
0.05% Treinoin cream (ReTrieve) nocte
Acitretin at least 20-30mg daily or 0.2mg/kg
Nicotinamide 500mg BD

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9
Q

T/F

Nicotinamide 500mg BD reduces the incidence of new BCCs

A

T
reduced AK, SCC and BCC
see effect from 2 mnths, further increased effectiveness until at least 12 mnths

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10
Q

When do SCCs metastasize?

A

Highest risk is in first 2 years
For high risk SCCs;
- consider 6 monthly FSE for 1st 2 years
- annual FSE thereafter

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11
Q

T/F

palmoplantar and periungual SCC associated with HPV 5

A

F
HPV 16
HPV 5 is associated with SCC in Epidermodysplasia verruciformis

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12
Q

What is the risk of IEC progressing to SCC?

A

3-5% for normal skin IEC
10% for Erythroplasia of Queyrat
Very low risk for Bowenoid papulosis

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13
Q

T/F

It may be reasonable to not treat IEC

A

T
Elderly patients with slowly progressive thin lesions esp on lower legs
Use emollient containing LA/SA or urea to reduce scaling and make less obvious

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14
Q

How long do you use efudix cream for IECs?

A

OD-BD for 4 wks face, 6wks limbs

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15
Q

T/F

for IEC, efudix is less effective than PDT

A

T
also less than immiquimod which is similar to PDT for IEC
Efudix similar efficacy to cryo

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16
Q

T/F

for sfBCC efudix is less effective than PDT

A

F
the same
Immiquimod is non-surgical Rx of choice for sfBCC

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17
Q

T/F

for IEC, imiquimod is more effective than PDT

A

F
the same or slightly less than PDT
But for sfBCC, imiquimod is more effective than PDT

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18
Q

T/F

PDT is an effective and suitable choice for IEC anywhere

A

T

Limited by availability, cost and pain

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19
Q

T/F

excison of IEC should be avoided on the digits

A

F

good Rx choice on digits

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20
Q

How is IEC of nailbed treated?

A

Mohs is 1st line
PDT reasonable choice
Can try aldara, laser or XRT

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21
Q

T/F

arsenic exposure can cause a corn-like PPK

A
T
Arsenical keratoses
can turn into SCC
Rx with keratolytics and chemoprevention
monitor for skin Ca and visceral malignancy
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22
Q

T/F

DSAP is inherited in a recessive fasion

A

F
AD
DSAP1 gene on chr 12

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23
Q

What are treatments for DSAP?

A
Emollients, sun-protect
Topical
•	5-FU (also chemo wraps)
•	topical retinoids
•	Calcipotriol
•	Aldara
Oral
•	Oral retinoids
Physical
•	LN2
•	PDT
•	Ablative lasers
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24
Q

T/F

Keratoacathomas are less common in darker skin

A

T

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25
Q

Which syndromes get KAs?

A

Muir-Torre (KA w/ sebaceous apearance)
Multiple spontaneously regressing epitheliomas of Ferguson-Smith
Generalised eruptive keratoacanthomas of Grzybowski

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26
Q

What are the features of

Multiple spontaneously regressing epitheliomas of Ferguson-Smith?

A

AD
multiple KAs in sun exposed areas in 20s
regress over weeks to months

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27
Q

What are the features of

Generalised eruptive keratoacanthomas of Grzybowski?

A

Thousands of papules resembling milia or early eruptive xanthomas; develop rapidly and persist indefinitely
V rare
Lesions inside oral mucosa
Mask like facies from skin thickening described
Lesion benign but persist indefinitely

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28
Q

Whats the natural Hx of KA?

A

reaches full size

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29
Q

What are variants of KA?

A
Solitary/craterfiorm (normal type)
Giant 
Erruptive/Syndromic - Muir-Torre, F-S, Gryzbowski
locally destructive types;
- Mutilating KA
- Aggregated KA
- KA centrigugum marginatum
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30
Q

What are treatment options for KA?

A
Excision
C+C
Cryo - if small
Ablative laser - if small
Intralesional methotrexate
Acitretin if numerous
Low dose XRT
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31
Q

What are associations of Verrucous Carcinoma?

A

LS if genital (Giant condyloma of Buschke-Lowenstein)
leukoplakia, smoking if oral
strong assoc w HPV infection; 6 and 11

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32
Q

T/F

XRT should be used for verrucous carcinoma

A

F
Do not treat with XRT – triggers anaplastic change and rapid growth and invasion
Excise
Oral retinoids may be useful

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33
Q

What is Epithelioma cuniculatum?

A

Rare tumour on sole of foot – variant of SCC
Discharges foul smelling keratin debris
Comprised of sinus-like tracts
Often infiltrate bone and overlyng nailbed
Histo looks like pseudoepitheliomatous hyperplasia but lesion is progressive and destructive
Mohs surgery

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34
Q

Other than treating BCCs what is the management of Gorlin’s syndrome?

A

Strict sun protection
Multidisciplinary Mx;
Baseline MRI brain and repeat yearly till 8y for medualloblastoma (ave age to develop is 2yrs; Mx by neurologist)
6 monthly skin exams
digital panorex of jaw at 3-4y and repeat yearly till 21y (Mx by Maxfax surgeon)
pelvic USS of female at menarche (paeds)
scoliosis assessment (ortho)
developmental screening (paeds)
prenatal counselling (genetics)

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35
Q

How are BCCs maanged in Gorlin’s?

A

Strict sun protection + avoid XRT
Self examination
6 monthly skin exams
BCC ‘s on central face - excision best
use non surgical methods to Rx BCC’s elsewhere;
C+C’s/ Cryo/ PDT/ aldara/ 5 FU
role of retinoids unclear (isotretinoin)
Vismodegib;
Smoothened receptor inhibitor
Off label use for Gorlins; NEJM 2012 study
93% reduction in new BCCs over 8 months, but 50% had to discontinue due to AEs (muscle spasms, alopecia, dysgeusia (altered taste), decreased appetite, wt loss, fatigue, nausea/vomiting, diarrhoea, constipation)

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36
Q

T/F

chronic occupational sun exposure is the main environmental risk factor for BCCs

A

F

intermittent intense esxposure more important for BCCs

37
Q

What are the high risk subtypes of BCC?

A

Morphoeic/infiltrative/sclerosing
micronodular
basosquamous

38
Q

What is Basisquamous (or Basosquamous) BCC?

A

Features of both BCC and SCC on histo
aggressive subtype of BCC
5% risk of mets
must completely excise

39
Q

Which BCCs are not suitable for curretage (unless as palliative procedure)?

A

Large tumours (≥2 cm diameter)
Tumours at sites where curettage produces a poor cosmetic result, is technically
difficult or is associated with a high risk of recurrence (most of face and scalp off limits except mid cheek)
Morphoeic, infiltrating or basisquamous BCCs
Recurrent tumours
Ill-defined tumours
Tumours penetrating muscle, fat, bone, etc.
Tumours where an incisional biopsy has been performed

40
Q

What are the indications for Mohs surgery on BCCs?

A
high risk sites = mask area on face / scalp/ anatomic fusion planes/ periorbital or eyelid
tumour > 2cm
aggressive histological subtypes
recurrent tumour
incompletely exc BCC
Previously RXT Rx area
immunosuppressed patient
indistinct border
situations requiring conservation of normal tissue or highest probability of cure
41
Q

T/F

some SCCs can be treated by C+C

A

T
If well-differentiated, primary, slowgrowing SCC arising on sun-exposed sites and no high risk factors in tumour or patient
>95% cure rate
esp good for older patients

42
Q

How does tumour thickness impact on SCC risk?

A

less than 2mm virtually no risk of mets
2-4mm some risk
6mm thick or more = highest risk of mets

43
Q

Which dermatoses predispose to NMSC?

A

Congenital/Inherited;
Occulocutaneous albinism - SCC
XP - those SCC

Aquired;
Chronic non-healing wounds (Morjolin ulcer)
Burns
DLE
NLD
Lichen planus (erosive)
Lichen sclerosus
Skin fistulae or discharging sinuses
HS esp perianal
44
Q

What is the risk of SCC arising from AK?

A

less than 0.1% per lesion per year

45
Q

What are the drawbacks of treating BCC with LN2?

A

histology not possible
fibrous scar tissue may obscure recurrence
But 99% cure rate for DFTC

46
Q

T/F

BCCs with involved margins always need re-excision

A

F
If low rsik type in low risk site and involved lateral margin on direct side-to-side closure can observe
In other cases Mohs best

47
Q

T/F
Photodynamic therapy has a 14% better chance of complete lesion clearance at 3 months after treatment than cryotherapy for thin AKs on the face and scalp

A

T

JAMA Derm meta-analysis 2015

48
Q

T/F
HPV 16 is the most common type found in
patients with penile cancer, followed by HPV types 18,
6, and 11

A

T
HPV found in 50-63% of penile SCC
JAAD CME 2015

49
Q

T/F

75% of penile cancers are SCC

A

F
95%
JAAD CME 2015

50
Q

T/F

QLD has highest incidence of both SCC and BCC in Aus

A

T

and Aus has highest rates in the world

51
Q

T/F

Perineural invasion occurs is seen in 10% of NMSC

A

F

2-6%

52
Q

What is incidental PNI?

A

When there are no clinical signs or symptoms or radiological evidence of PNI or perineural spread

53
Q

What are the histological high risk factors in PNI?

A

Multifocal: >1 focus of PNI seen
Involves nerve of diameter >1mm (1mm and under is lower risk)
Extratumoral PNI (implies possible perineural spread)

54
Q

When can clinical perineural invasion be diagnosed?

A

defined as one of the following;
Dysaesthesia (formication) and positive imaging for PNI
Facial nerve palsy in setting of a cutaneous tumour w/ or w/out evidence of PNI on histo
Cranial or spinal nerve involved on histo

55
Q

T/F

Consider recurrence due to PNI if formication occurs at or near site of skin cancer excision

A

T

Can do MRNeurography to assess

56
Q

What are complications of SLNB?

A
Anaesthetic complications
allergic reactions to the blue dye used intraoperatively
lymphoedema
wound infection
hematoma
seroma
cutaneous lymphatic fistula
dehiscence
57
Q

What stain differentiates merkel cell carcinoma from metastatic deposit of small cell lung carcinoma?

A

CK20

- positive in MCC, negative if SSLC

58
Q

What IHC stains are posiitve in Merkel cell carcinoma?

A

CK20
CAM5.2
synaptophysin
chromogranin A

59
Q

T/F
Merkel Cell Carcinoma is a rare highly aggressive primary cutaneous carcinoma of skin with epithelial and endocrine features

A

T
derived from skin mechanorceptor Merkel cells
neuroendocrine in origin

60
Q

What are risk factors for Merkel Cell Carcinoma?

A

solar damage esp in fiar skin
Immunosuppression
Older age (>50)

61
Q

What are clues to the diagnosis of Merkel Cell Carcinoma?

A
AEIOU
Asymptomatic/lack of tenderness
Expanding rapidly
Immunosuppression
Over  50 years
Ultraviolet-exposed site on a person with fair skin
62
Q

T/F

Most Merkel Cell Carcinomas occur on the trunk

A

F
Most on head and neck - 53%
extremities - 35%
Trunk, oral and genital mucosa

63
Q

T/F

5-yr survival of Merkel Cell Carcinoma is approximately 50%

A

F

10-yr survival of Merkel Cell Carcinoma is approximately 50%

64
Q

What are poor prognostic histo features of Merkel Cell Carcinoma?

A

DDD
Dense mononuclear inflammatory cell infiltrate
Deep extension (esp into subcutis)
Diffuse growth pattern including lymphovascular invasion

65
Q

What are poor prognostic clinical features of Merkel Cell Carcinoma?

A
Male
Immunsuppressed
head and neck site
tumour Diameter over 5cm (stage T3)
Lymph node status is the most important independent predictor
66
Q

How are Merkel Cell Carcinomas staged?

A

AJCC system
should always stage tumour
5 yr survival 80% if stage 1A (tumour up to 2cm max diameter)

67
Q

How is Merkel Cell Carcinoma managed?

A

Diagnosis of MCC should prompt FSE and clinical palpation of regional LNs for nodal involvement
Usually referred to plastic/soft tissue surgeon
SLNB for all lesions at time of WLE
- margin recommendations vary; 3cm (Robinson); others say 1-2cm
- LN dissection if SLNB +ve
PET CT for staging
Offer Adjuvant XRT to tumour region – reduced local relapse but not improved mortality
Consider adjuvant chemo if LN +ve or metastatic – but no proven benefit and signif morbidity
Close folow up and consider PET-CT every year for 5yrs

68
Q

How is DFSP managed?

A

WLE - 1.5-2cm if 2cm diameter (Rob/Rook); 2-4cm if >2cm diameter or Mohs
Staged excision with margin control (Slow Moh’s) is an option
Post op radiotherapy may reduce recurrence
Can use imatinib (Gleevac) if unresectable/metastatic – some data to support use as adjuvant

69
Q

T/F

DFSP has local recurrence rate of 15-60%

A

T
Mets to LNs or organs rare
except for fibrosarcomatous variant (herring bone pattern); Presence and amount of fibrosarcomatous areas relates directly to recurrence rate and metastatic potential

70
Q

T/F

AFX only occurs in sun damaged skin of older people

A

T

71
Q

T/F

AFX is a diagnosis of exclusion

A
T
Stains should be done in all cases;
melanoma (S100)
sarcomatous SCC (pan-keratin; MNF116 or AE1/AE3)
leimyosarcoma (desmin, SMA)
CD10 and CD99 usually +ve in AFX
Also +ve for Vimentin, CD31, CD34, CD68
72
Q

T/F

Dermatofibroma is always negative for CD34

A

F

May be focally positive for CD34 esp at periphery

73
Q

Which subtypes of Dermatofibroma are classes as high risk?

A

Recurrence;
Cellular(25%), Atypical(14%) and Aneurysmal(19%)
Mets (rare);
Cellular and Atypical
NB;
the 4th main variant is Epitheloid fibrous histiocytoma

74
Q

What are treatment options for Kaposis Sarcoma?

A

If HIV/AIDS-related best treated with HAART
Organ transplant KS – Reduce immunosuppression, substitute sirolimus for CsA can lead to improvement
Small area:
EOL, XRT, LN cryo, CO2 or PDLaser, PDT, 5FU, aldara, topical alitretinoin
For individual lesions - intralesional vincristine, cisplatin or bleomycin +/- prior diathermy
XRT for multifocal disease
Chemotherapy (doxorubicin, vincristine, etoposide, bleomycin) or IFN alpha indicated if; Rapidly progressive/ pulmonary KS/ symptomatic visceral involvement/ lymphoedema
Systemic IL-2 or Bexarotene also reported
Angiogenesis inhibitors; thalidomide, COL3, antiVEGF

75
Q

T/F

Angiosarcoma can arise as a complication of lymphoedema

A

T - classical presentation
Known as Stewart-Treves syndrome esp if arises after radical mastectomy or XRT for Ca breast
4 types of Angiosarcoma - PILL;
- Post XRT
- Idiopathic (esp face of old men)
- Lymphoedema associated
- arising in Lymphatic or vascular malformation

76
Q

What is the management of Angiosarcoma?

A

WLE + adjuvant XRT
Poor prognosis
high risk of both recurrence and mets
Doxorubicin chemo for palliation if unresectable mets

77
Q

What is an AFX if it extends into fat?

A

Undifferentiated pleomorphic sarcoma

connective tissue lesion that needs to be dealt with by specialist surgeon/oncologist; worse prognosis

78
Q

What is Gryzbowski syndrome?

A

generalised eruptive keratoacanthomas
very rare
sudden onset acquired condition cause unknown
young-mid aged adults, M=F
small widespread KAs - benign behaviour
B/g widespread erythematous rash
scleroderma and ectropion of face
white papules in mouth and nodules on larynx causing hoarseness
Resolves in months if treated;Acitretin, isotretinoin
MTX

79
Q

what is the risk of mets from an SCC?

A

overall 0.5-3.3%

80
Q

what is the risk of recurrence of an SCC?

A

overall risk 3%

81
Q

T/F

Efudix has the best evidence of all topicals for field AK treatment

A

F
Immiquimod has
JAAD 2014

82
Q

T/F
Immiquimod has good long term clearance rates as thought to cause induction of specific memory T cells that maintain immune surveillance against AKs

A

T

83
Q

T/F

Efudix, immiquimod, picato and solaraze all have similar efficacy

A

T
Cochrane rw
But elsewhere JAAD rw states solaraze may have lower efficacy than other agents

84
Q

What non surgical options are available for sfBCC?

Which is best?

A

Imiquimod (best)
Efudix
PDT (worst)
XRT - good cure rates but risk of aggressive recurrence
Aldara has 80% CR confirmed in long term studies

85
Q

T/F

aldara and efudix are effective for erythroplasia of Queyrat

A

T
Both have shown some effect in case reports but complete excsion is treatment of choice
If topicals used need close follow up as high rates of recurrence

86
Q

What is the genetic aberration responsible for DFSP?

A

Chr 17;22 translocation
results in ring chromasome on FISH (can also identify on PCR)
Involved genes are collagen type 1 alpha 1 (COL1A1) gene on chromosome 17 and platelet derived growth factor B (PDGFB) gene on chr 22
Basis for Imatinib Rx (PDGF receptor inhibitor)

87
Q

T/F

AFX recurs in 25%

A

F

10%

88
Q

What pts are at risk of multiple DFSPs?

A

pts with SCID due to adenosine deaminase deficiency

89
Q

What are the 4 types of Kaposis sarcoma?

A
CHAI
Classic - mediterranean and jewish men
HIV/AIDS
African endemic
Immunosuppressed