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MRCS B pathology > Pathology: melanoma and skin lesions > Flashcards

Pathology: melanoma and skin lesions Flashcards

1
Q

What are the characteristic features of a lipoma? What is its management?

A

Always benign
Hemispherical shape
Normal overlying skin
Non tender
Lobulated edge

Mx
-Excision if cosmetically unacceptable to pt
-If >5cm, US or MRI to rule out liposarcoma

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2
Q

What are the characteristic features of a sebaceous cyst?

A

Closed sac under skin
Punctum due to attachment to overlying skin
May be inflamed
Can lead to recurrent infection
Can have cheese like discharge

Surgical excision–> up to 40-50% chance recurrence

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3
Q

What is a dermoid cyst and what are the types?

A

A dermoid cyst is a teratoma of a cystic nature
Nearly always benign
Acquired/congenital
Congenital: all layers developmental tissue : ectoderm, endoderm, mesoderm
Occur at sites of embryological fusion (e.g. canthus of eye)

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4
Q

What is a hamartoma?

A

Benign developmental malformation
Disorganised excessive growth of normal tissue in its native location

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5
Q

What is a desmoid tumour?

A

Fibrous neoplasm, arising from musculoaponeurotic structures
Linea alba is classical
Involves proliferation of myofibroblasts
Firm overgrowth of tissue with predisposition to local invasion
Feature of Gardener’s syndrome

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6
Q

Name some premalignant skin conditions. How are they treated?

A

Bowen’s disease: SCC in situ
Actinic keratosis

Treatment:
-Topical 5-fluorouracil

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7
Q

What are the characteristic features of keratoacanthoma?

A

Rapidly growing skin lesion
Grows for 4 months, plateu’s, then regresses
irregular crater shape and a characteristic central hyperkeratotic core
Resembles SCC

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8
Q

What are the characteristic features of a bcc? How would you manage a bcc in an anatomically difficult area?

A

Pearly rolled edges, telangiectasia, central crater
Anatomically difficult area: moh’s micrographic surgery

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9
Q

What are the types of BCC?

A

Nodular (most common)
Superficial
Infiltrative
Noduloinfiltrative
Cystic

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10
Q

What is the most common type of BCC?

A

Nodular

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11
Q

What are the characteristic features of SCC?

A

Exophytic (outward) growth
Everted edges, areas ulceration, haemorrhage, necrosis

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12
Q

How are BCCs and SCCs managed?

A

If large/unsure diagnosis: punch biopsy, otherwise excision
BCC: 3-5mm margin
SCC <2cm: 6mm margin, >2cm: 1cm margin
Early BCC: can be managed with photodynamic therapy
Radiotherapy if Pt not suitable for surgery

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13
Q

What surgical margins would you consider for biopsy proven BCC?

A

3-5mm

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14
Q

What surgical margins would you consider for biopsy proven SCC?

A

If <2cm 6mm
If > 2cm 1cm

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15
Q

What are the red flag features in a patient with a pigmented lesion that would appear to be suspicious or signify malignant change?

A

A: Asymmetry
B: Bleeding
C: Colour variegation
D: Diameter (increasing)
E: Evolution/elevation (irregular border/itchy)
F: further (satellite lesions)
G: greater than 6mm
H: Halo (light pigmentation around lesion)

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16
Q

What are the types of melanocytic naevi?

A

Junctional (brown or black, flat)
Compound (elevated, slightly lighter)
Intradermal (lighter, dome shaped)

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17
Q

Describe junctional melanocytic naevus

A

Brown or black, flat

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18
Q

Describe compound melanocytic naevus

A

Slightly lighter, elevated

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19
Q

Describe intradermal melanocytic naevus

A

Lighter, dome shaped

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20
Q

Name some risk factors for developing a melanoma

A

UV (intense, intermittent e.g. sunbed)
Fhx melanoma
Fair skin
Immunosuppression
Albinism

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21
Q

Name some conditions that predispose to the development of a melanoma

A

Xeroderma pigmentosum (autosomal dominant)
Giant congenital melanocytic naevus
Multiple dysplastic naevi

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22
Q

What genes are associated with increased risk of melanoma?

A

CDKN2A and 4 (cycline dependent kinase)
BRAF
XP gene a/b/c/d/e/f/g

23
Q

In which layer of skin does a melanoma arise?

A

Stratum granulosum (granular layer epidermis)

24
Q

In which layer of skin does a basal cell carcinoma arise?

A

Stratum basale

25
Q

What is the embryological origin of melanocytes?

A

Neural crest cells (same as phaeochromocytoma)

26
Q

What type of melanoma? how common?

A

Superficial spreading (60%)

27
Q

What type of melanoma?

A

Nodular (20%)

28
Q

What type of melanoma?

A

Amelanotic melanoma

29
Q

What type of melanoma?

A

Acral (under nail bed, sole of foot)–> more common in dark skin

30
Q

What type of melanoma?

A

Lentigo maligna (melanoma in situ)

31
Q

What type of melanoma?

A

Ocular melanoma (most common type of eye cancer)

32
Q

What types of melanoma are there?

A

Superficial spreading (most common, 60%)
Nodular (20%)
Amelanotic
Acral (under nail bed, sole of foot)–> more common in dark skin
Lentigo maligna (melanoma in situ)
Ocular (most common eye cancer)

33
Q

What is the most common type of melanoma?

A

Superficial spreading

34
Q

Which types of melanoma have the best and worst prognosis?

A

Superficial spreading: best
Nodular: worst

35
Q

What type of tumour markers are used in diagnosis of melanoma?

A

S100B
HMB45

36
Q

What would you do for mole suspicious for melanoma?

A

Excision biopsy with 2mm margins, histology

37
Q

What might be the concerning features in the melanoma histopathology report?

A

-High vertical thickness (most important)
-High mitotic index
-Perineural invasion
-Perivascular invasion
-Perilymphatic invasion

38
Q

What is the breslow thickness?

A

-Same as vertical thickness
-Granular layer of epidermis to nearest 0.1mm
-Determines excision margins

39
Q

What is clarke’s level?

A

-Anatomical rather than prognostic measure: denotes level of skin invaded by tumour

Level 1: Melanoma confined to the epidermis (melanoma in situ)
Level 2: Invasion into the papillary dermis
Level 3: Invasion to the junction of the papillary and reticular dermis
Level 4: Invasion into the reticular dermis
Level 5: Invasion into subcutaneous tissue

40
Q

What are the prognostic indicators for a melanoma and what features have the worst prognosis?

A

-Breslow thickness (same as vertical)
-Presence vs absence of lymph nodes
-Ulceration

Above worst prognostic indicators

-Type of melanoma (nodular worst, superficial spreading best)
-Site: head and neck bad as lymphatic spread wide
-Recurrent melanoma

41
Q

Excision margins for breslow thickness

A

In situ–> 0.5cm
<1mm –> 1cm
1-2mm –> 1-2cm
2-4mm –> 2-3cm
>4mm –> 3cm

Above values: margins around the scar

42
Q

How would you manage a 4.2mm breslow thickness melanoma in the arm of a 24 year old woman with positive sentinel lymph nodes but no evidence of systemic spread?

A

-management depends on micro vs macro metastasis
-Staging CT scan

MDT discussion
–> depending on size of spread: further management
–> options would include: chemotherapy, immunotherapy, axillary clearance

43
Q

How would you manage a pt with early stage melanoma? What are the options for managing positive lymph nodes?

A

Surgical excision: WLE +/- SNB (early stage): assess most likely node with lymphoscintigraphy

Lymph nodes:
-Lymph node clearance
-Chemotherapy
-Immunotherapy

44
Q

What treatment options are available for treating metastatic skin deposits?

A

-CO2 laser
-Isolated limb perfusion –> chemo into limb
-Topical imiquimod 5%

45
Q

What is the 5 year prognosis for a patient with stage 1-4 melanoma

A

1 –> 90%
2 –> 70%
3 –> 50%
4 –> 30-40%

46
Q

How would you follow up a patient with a melanoma

A

Stage 1-3b: 3 monthly for 3 years, 6 monthly for 2 years
Stage 4: life long

Examine nodes, previous scar sites, abdomen for liver metastases, may include imaging

47
Q

Which type of BCC is this?

A

Nodular BCC (most common)

48
Q

Which type of BCC is this?

A

Superficial BCC

49
Q

What type of bcc is this?

A

Infiltrative

50
Q

What type of bcc is this?

A

Nodular infiltrative

51
Q

What type of BCC is this?

A

Cystic

52
Q

What is the staging classification used in melanoma?

A

American joint committee on cancer (AJCC)–> depends on breslow thickness and ulceration

53
Q

How would you manage pt with biopsy proven melanoma?

A

-<0.8mm: can discharge
->0.8mm: further WLE as per thickness
-Assess lymph nodes: LL –> groin, UL–> axilla
-No palpable LN: WLE, sentinel node biopsy
-Palpable LN: FNA. If tumour cells, staging CT

MRCS B pathology (14 decks)

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