NMSC Dan Flashcards
What are high risk features of SCC?
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
What are the guidelines for treating SCC by C+C?
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
What are the recommended excision argins for NMSC?
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
When may SLNB be considered for SCC?
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
What is risk of skin cancer from PUVA?
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
What are treatments for individual AKs?
Shave C+C LN2 cryo spot treat peel e.g. TCA 35-50% ablative laser
What are treatments for widespread AKs/field change?
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
What methods are available for prevention of AKs and skin cancers?
Sun protection
0.05% Treinoin cream (ReTrieve) nocte
Acitretin at least 20-30mg daily or 0.2mg/kg
Nicotinamide 500mg BD
T/F
Nicotinamide 500mg BD reduces the incidence of new BCCs
T
reduced AK, SCC and BCC
see effect from 2 mnths, further increased effectiveness until at least 12 mnths
When do SCCs metastasize?
Highest risk is in first 2 years
For high risk SCCs;
- consider 6 monthly FSE for 1st 2 years
- annual FSE thereafter
T/F
palmoplantar and periungual SCC associated with HPV 5
F
HPV 16
HPV 5 is associated with SCC in Epidermodysplasia verruciformis
What is the risk of IEC progressing to SCC?
3-5% for normal skin IEC
10% for Erythroplasia of Queyrat
Very low risk for Bowenoid papulosis
T/F
It may be reasonable to not treat IEC
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
How long do you use efudix cream for IECs?
OD-BD for 4 wks face, 6wks limbs
T/F
for IEC, efudix is less effective than PDT
T
also less than immiquimod which is similar to PDT for IEC
Efudix similar efficacy to cryo
T/F
for sfBCC efudix is less effective than PDT
F
the same
Immiquimod is non-surgical Rx of choice for sfBCC
T/F
for IEC, imiquimod is more effective than PDT
F
the same or slightly less than PDT
But for sfBCC, imiquimod is more effective than PDT
T/F
PDT is an effective and suitable choice for IEC anywhere
T
Limited by availability, cost and pain
T/F
excison of IEC should be avoided on the digits
F
good Rx choice on digits
How is IEC of nailbed treated?
Mohs is 1st line
PDT reasonable choice
Can try aldara, laser or XRT
T/F
arsenic exposure can cause a corn-like PPK
T Arsenical keratoses can turn into SCC Rx with keratolytics and chemoprevention monitor for skin Ca and visceral malignancy
T/F
DSAP is inherited in a recessive fasion
F
AD
DSAP1 gene on chr 12
What are treatments for DSAP?
Emollients, sun-protect Topical • 5-FU (also chemo wraps) • topical retinoids • Calcipotriol • Aldara Oral • Oral retinoids Physical • LN2 • PDT • Ablative lasers
T/F
Keratoacathomas are less common in darker skin
T
Which syndromes get KAs?
Muir-Torre (KA w/ sebaceous apearance)
Multiple spontaneously regressing epitheliomas of Ferguson-Smith
Generalised eruptive keratoacanthomas of Grzybowski
What are the features of
Multiple spontaneously regressing epitheliomas of Ferguson-Smith?
AD
multiple KAs in sun exposed areas in 20s
regress over weeks to months
What are the features of
Generalised eruptive keratoacanthomas of Grzybowski?
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
Whats the natural Hx of KA?
reaches full size
What are variants of KA?
Solitary/craterfiorm (normal type) Giant Erruptive/Syndromic - Muir-Torre, F-S, Gryzbowski locally destructive types; - Mutilating KA - Aggregated KA - KA centrigugum marginatum
What are treatment options for KA?
Excision C+C Cryo - if small Ablative laser - if small Intralesional methotrexate Acitretin if numerous Low dose XRT
What are associations of Verrucous Carcinoma?
LS if genital (Giant condyloma of Buschke-Lowenstein)
leukoplakia, smoking if oral
strong assoc w HPV infection; 6 and 11
T/F
XRT should be used for verrucous carcinoma
F
Do not treat with XRT – triggers anaplastic change and rapid growth and invasion
Excise
Oral retinoids may be useful
What is Epithelioma cuniculatum?
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
Other than treating BCCs what is the management of Gorlin’s syndrome?
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)
How are BCCs maanged in Gorlin’s?
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)
