non-melancytic skin cancers and benign skin tumours

Question 1

-overview of all skin lesions. LEARN

ones in objectives highlighted

benign epidermal (4) five in objectives

benign dermal (3) three in objectives

premaligmant epidermal (2)

malignant epidermal (3) three in objectives

Answer 1

*keratoacanthomatous scc should be added under benign

it is in objectives as a benign scc.

Question 2

actinic keratosis are best classed as premalignant. technically the same as scc in situ but very rarely transform.

• risk factors(3)
• presentation. type of lesion (1). abcde(4)
• complications(2)

Answer 2

• cumulative sun exposure, fair skin, age.
• melanin is protective - not seen in black people, seen more in albino people*
• -*presentation> macules. abcde-pink or grey, usually <1cm diameter, scaling, rough surface
• complications > transformation to scc in <1%, a cutaneous horn is a large keratotic protrusion

Question 3

Mx of AK (4)

Answer 3

• freezing
• shaving or scraping
• 5-flurouracil cream chemotherapy
• monitoring and follow ups

Question 4

-bowens disease. aka sometimes called intra-epidermal scc, or premalignant scc

• presentation. configuration(1) course(1) type of lesion(1) morphology (3).
• complications(1)
• risk factors(2)
• some differentials(3)

Answer 4

• usually single lesions. slowly expanging. plaques. pink, scaly, welldefined border with notches and progections.
• 3% progress to scc
• presence indicative of prev exposure to carinogens - sunlight, arsenic in tonic when young
• discoid ecema, psoriasis, superficial bcc

Question 5

-Mx of bowens (6)

Answer 5

• freezing
• scraping
• 5-flurouracil
• left under observation in frail or eldery
• photodynamic therapy kill cells with light
• -*monitoring and follow ups

Question 6

• keratoacanthomatous scc is what (1)
• risks and distribution are same as scc
• course (3)
• types of lesion(3)
• morphology (4)

Answer 6

• keratoacanthomatous scc is a benign form of scc (1)
• course - enlarges rapidly. never invades or metastasises. if left may resolve spontaneously over 6-12 months leaving ugly scar.
• starts as papule, enlarges to plaque, nodule forms in centre after 5-6wks
• symmetrical. pink. may reach 1cm in 1-2 months. nodule has keratinous plug.
• mx is excision, shaving, scraping

Question 7

• squamous cell carcinoma. histology (1)
• risk factors (8)

Answer 7

• histology - malignant keratinocytes
• risk factors

>prolonged, cumulative uv exposure

>xrays

>pale skin

>scarred areas of skin

>tar, arsenic tonics

>genetic disorders - xeroderma pigmentosum

>chronic inflammation

>immunisurpressive drug use eg steroids

>hpv

Question 8

• presentation. distribution- can arise anywhere. some at risk areas (5)
• course and comp (2)
• morphology (2). type of lesion (1) severe may present how (2)

Answer 8

• sun exposed areas, lower lip, mouth, chronic ulcers, previous areas of xray damage, within a premaligmant tumour - ak or bowmens.
• grow in size, varying in how quickly. can metastisize.
• scaling, nodules. more severe may present as ulcers with indurated edged.

Question 9

-complication - metastasis

>sites most likely to metastasize(2). sites least likely to (2) unless what risk is added (1)

>indicators of metastasis risk. in who particularly(1) size(1) depth(1) histology(1)

Answer 9

-metastasis

>most likely to are those arising in - chronic ulcers, xray damage.

>least likely to are those arising in - sun exposed skin, premalignant tumour.

-metastasis risk - immunosupressed, size >2cm diameter, depth >4mm, poorly differentiated tumours

Question 10

Mx of scc (5)

Answer 10

-biopsy to confirm diagnosis

-excision

>low risk tumours - excision with 0.5cm border

>high risk tumours - with 6mm+

-lymph node - examination. biopsy if suspected spread usually not needed

-radiotherapy - reserve for frail and elderly

-monitoring and follow ups

Question 11

basal cell carcinoma - most common form of skin cancer

• histology (1)
• risk factors similar to scc (6)

Answer 11

-small basal cells, grow in aggregates, invade dermis

-risk factors

>prolonged, cumulative uv exposure

>xrays

>pale skin

>scarred areas of skin

>tar, arsenic tonics

>genetic disorder different one to scc - Gorlin’s syndrome - pt has many bccs

Question 12

-subtypes of bcc (5)

Answer 12

-nodulo-ulcerative, cystic, cicatrical, superficial, pigmented

Question 13

-presentation varies with subtypes. general course? compication?

Answer 13

• general course is slow but relentless, destroying local tissue.
• complication- invasion of underlying cartilage or bone, destruction of tear ducts.

Question 14

nodulo-ulcerative bcc

• presentation
• type of lesion (1). morphology (7)

Answer 14

• a papule that slowly enlarges to plaque.
• glistening, translucent, may have central necrosis leaving an ulcer, crust and rolled pearly edge. may have telangiectatic vessels on surface. may reach 1-2cm in 5-10yrs

Question 15

• cystic bcc
• type of lesion (2). morphology(2)

Answer 15

• nodular. later becomes cystic.
• transluscent. marked telangiectasia.

Question 16

cicatrical bcc

• presentation
• type of lesion(1)
• morphology (5)

Answer 16

• plaque slowly expanding
• yellow or white, waxy. ulceration, crusting followed by fibrosis common. may resemble an enlarging scar

Question 17

superficial bcc

• distribution (2)
• morphology (4)

Answer 17

• most often on the trunk. several lesions may be present.
• plaque. slowly expanding
• red, pink or brown. irregular scaling. fine raised ‘whipcord’ border. may expland to 10cm in diameter.

Question 18

pigmented bcc

-pigment may occur in all types bcc. added morphology (1)

Answer 18

-causes tumour to be brown or speckles with brown or black.

Question 19

-some differentials for bcc. malignant (2), premalignant (2). benign (2)

Answer 19

-malignant

>melanoma

>scc

-premalignant

> ak ,bowens

-benign

>melanocytic naevi

>sebborhoeic keratosis

>any traumatized benign lesion

Question 20

Mx of bcc - depends on type, location, age and health of pt

-some options (7)

Answer 20

• biopsy
• surgical excision

>nb healing, scarring

• >*in general 0.5cm around lesion
• radiotherapy if surgery contraindicated eg eldery, frail
• -*freezing

-shaving, scraping

-photodynamic

-regular follow up

there is a 5yr cure rate in 95% of bcc

Question 21

-non-melanocytic benign lesions

-epidermoid and pilar cysts. occur where (4). contain (1). difference (2)

-viral wart - cause (1) risk factor (1)

Answer 21

-epidermoid and pilar cysts - common. occur on scalp, face, behind ears, trunk. contain foul smelling cheesy material.

in epidermal - wall of cyst resembles normal epidermis. in pilar -wall of cyst resembles sheath of hair follicle.

Mx - excision or incision followed by expression of contents and removal of wall

-viral wart - cause is hpv. immunosupressed pts at increased risl.

Question 22

-sebborhoeic keratosis risk (1) distribution (2). type of lesion (2). morphology (3)

Answer 22

• common. cause unknown. risk increases with age. occur as single or multiple, commonest on trunk, face.
• may be macular or plaque or variable.
• may be white, yellow, brown, black. distinctive ‘stuck on’ appearance. may have kertatin plugs over surface.

Question 23

-hemangiomas- inc strawberry naevus, cherry angiomas + pyogenic granulomas

>strawberry naevus morphology(3) age of onset(1) course(1)

-neurofibromas - risk (1)

-dermatofibrosis. occur in who(1) distrubition(2) type of lesion (1) morphology(3)

Answer 23

-strawberry naevus - raised, compressible swelling with bright red surface. onset 2wks-3months after birth. spontaneous regression over years.

-neurofibromas. these lesions occur as a result of genetic condition neurofibromatosis. usually mutiple.

-dermatofibrosis. younger adults. often single, on extremities. nodules. firm, feel larger than they appear, overlying epidermis often pigmented.