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NMSC Dan Flashcards

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
Which syndromes get KAs?
Muir-Torre (KA w/ sebaceous apearance) Multiple spontaneously regressing epitheliomas of Ferguson-Smith Generalised eruptive keratoacanthomas of Grzybowski
26
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
27
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
28
Whats the natural Hx of KA?
reaches full size
29
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 ```
30
What are treatment options for KA?
``` Excision C+C Cryo - if small Ablative laser - if small Intralesional methotrexate Acitretin if numerous Low dose XRT ```
31
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
32
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
33
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
34
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)
35
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)
36
T/F | chronic occupational sun exposure is the main environmental risk factor for BCCs
F | intermittent intense esxposure more important for BCCs
37
What are the high risk subtypes of BCC?
Morphoeic/infiltrative/sclerosing micronodular basosquamous
38
What is Basisquamous (or Basosquamous) BCC?
Features of both BCC and SCC on histo aggressive subtype of BCC 5% risk of mets must completely excise
39
Which BCCs are not suitable for curretage (unless as palliative procedure)?
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
What are the indications for Mohs surgery on BCCs?
``` 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
T/F | some SCCs can be treated by C+C
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
How does tumour thickness impact on SCC risk?
less than 2mm virtually no risk of mets 2-4mm some risk 6mm thick or more = highest risk of mets
43
Which dermatoses predispose to NMSC?
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
What is the risk of SCC arising from AK?
less than 0.1% per lesion per year
45
What are the drawbacks of treating BCC with LN2?
histology not possible fibrous scar tissue may obscure recurrence But 99% cure rate for DFTC
46
T/F | BCCs with involved margins always need re-excision
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
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
T | JAMA Derm meta-analysis 2015
48
T/F HPV 16 is the most common type found in patients with penile cancer, followed by HPV types 18, 6, and 11
T HPV found in 50-63% of penile SCC JAAD CME 2015
49
T/F | 75% of penile cancers are SCC
F 95% JAAD CME 2015
50
T/F | QLD has highest incidence of both SCC and BCC in Aus
T | and Aus has highest rates in the world
51
T/F | Perineural invasion occurs is seen in 10% of NMSC
F | 2-6%
52
What is incidental PNI?
When there are no clinical signs or symptoms or radiological evidence of PNI or perineural spread
53
What are the histological high risk factors in PNI?
Multifocal: >1 focus of PNI seen Involves nerve of diameter >1mm (1mm and under is lower risk) Extratumoral PNI (implies possible perineural spread)
54
When can clinical perineural invasion be diagnosed?
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
T/F | Consider recurrence due to PNI if formication occurs at or near site of skin cancer excision
T | Can do MRNeurography to assess
56
What are complications of SLNB?
``` Anaesthetic complications allergic reactions to the blue dye used intraoperatively lymphoedema wound infection hematoma seroma cutaneous lymphatic fistula dehiscence ```
57
What stain differentiates merkel cell carcinoma from metastatic deposit of small cell lung carcinoma?
CK20 | - positive in MCC, negative if SSLC
58
What IHC stains are posiitve in Merkel cell carcinoma?
CK20 CAM5.2 synaptophysin chromogranin A
59
T/F Merkel Cell Carcinoma is a rare highly aggressive primary cutaneous carcinoma of skin with epithelial and endocrine features
T derived from skin mechanorceptor Merkel cells neuroendocrine in origin
60
What are risk factors for Merkel Cell Carcinoma?
solar damage esp in fiar skin Immunosuppression Older age (>50)
61
What are clues to the diagnosis of Merkel Cell Carcinoma?
``` AEIOU Asymptomatic/lack of tenderness Expanding rapidly Immunosuppression Over 50 years Ultraviolet-exposed site on a person with fair skin ```
62
T/F | Most Merkel Cell Carcinomas occur on the trunk
F Most on head and neck - 53% extremities - 35% Trunk, oral and genital mucosa
63
T/F | 5-yr survival of Merkel Cell Carcinoma is approximately 50%
F | 10-yr survival of Merkel Cell Carcinoma is approximately 50%
64
What are poor prognostic histo features of Merkel Cell Carcinoma?
DDD Dense mononuclear inflammatory cell infiltrate Deep extension (esp into subcutis) Diffuse growth pattern including lymphovascular invasion
65
What are poor prognostic clinical features of Merkel Cell Carcinoma?
``` Male Immunsuppressed head and neck site tumour Diameter over 5cm (stage T3) Lymph node status is the most important independent predictor ```
66
How are Merkel Cell Carcinomas staged?
AJCC system should always stage tumour 5 yr survival 80% if stage 1A (tumour up to 2cm max diameter)
67
How is Merkel Cell Carcinoma managed?
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
How is DFSP managed?
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
T/F | DFSP has local recurrence rate of 15-60%
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
T/F | AFX only occurs in sun damaged skin of older people
T
71
T/F | AFX is a diagnosis of exclusion
``` 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
T/F | Dermatofibroma is always negative for CD34
F | May be focally positive for CD34 esp at periphery
73
Which subtypes of Dermatofibroma are classes as high risk?
Recurrence; Cellular(25%), Atypical(14%) and Aneurysmal(19%) Mets (rare); Cellular and Atypical NB; the 4th main variant is Epitheloid fibrous histiocytoma
74
What are treatment options for Kaposis Sarcoma?
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
T/F | Angiosarcoma can arise as a complication of lymphoedema
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
What is the management of Angiosarcoma?
WLE + adjuvant XRT Poor prognosis high risk of both recurrence and mets Doxorubicin chemo for palliation if unresectable mets
77
What is an AFX if it extends into fat?
Undifferentiated pleomorphic sarcoma | connective tissue lesion that needs to be dealt with by specialist surgeon/oncologist; worse prognosis
78
What is Gryzbowski syndrome?
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
what is the risk of mets from an SCC?
overall 0.5-3.3%
80
what is the risk of recurrence of an SCC?
overall risk 3%
81
T/F | Efudix has the best evidence of all topicals for field AK treatment
F Immiquimod has JAAD 2014
82
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
T
83
T/F | Efudix, immiquimod, picato and solaraze all have similar efficacy
T Cochrane rw But elsewhere JAAD rw states solaraze may have lower efficacy than other agents
84
What non surgical options are available for sfBCC? | Which is best?
Imiquimod (best) Efudix PDT (worst) XRT - good cure rates but risk of aggressive recurrence Aldara has 80% CR confirmed in long term studies
85
T/F | aldara and efudix are effective for erythroplasia of Queyrat
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
What is the genetic aberration responsible for DFSP?
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
T/F | AFX recurs in 25%
F | 10%
88
What pts are at risk of multiple DFSPs?
pts with SCID due to adenosine deaminase deficiency
89
What are the 4 types of Kaposis sarcoma?
``` CHAI Classic - mediterranean and jewish men HIV/AIDS African endemic Immunosuppressed ```

Medical dermatology Dan (41 decks)

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