Pigmented Lesions & Skin Cancer Flashcards
1
Q
Nevus
A
- Circumscribed, stable malformation of
the skin or oral mucosa - May involve epidermal, connective
tissue, nervous, or vascular elements - Brown, black, or pink
- Vary in size, thickness
2
Q
Dysplastic (atypical) nevus
A
- Unusual-looking
- Acquired melanocytic lesions
- Benign
- May resemble melanoma
- Increased risk of developing
melanoma - These patients should avoid
excessive UV exposure
3
Q
Melanocytic Nevi
A
Acquired
* Benign neoplasm
* Composed of melanocytes
* Commonly form during childhood
* Genetic factors + UV exposure
* Develop and spread after
blistering
* 2nd degree burns
* Severe sunburn
* Almost every individual
* Fair skin
4
Q
Melanocytic Nevi presentation
A
- Examine all skin
- Uniform color, even pattern of
pigmentation - Round or oval
- Regular, smooth border
- Symmetry
- Generally <1 cm in diameter
- Can change
- 16%
- Photograph
5
Q
Congenital melanocytic nevi (CMN)
A
- Anomaly in embryogenesis
- Malformation
- Usually present at birth
- Hypertrichosis- hair
- Increased risk for melanoma
- 1-2% overall; higher for large
- Small < 1.5 cm
- Medium 1.5-10 cm
- Large >20 cm (neonate: >9 cm on the head
or >6 cm on the body)
https://dermnetnz.org/topics/melanocytic-naevus
6
Q
Spitz nevi
A
- 70% in < 20 yrs old
- Red or pink dome shaped, firm papules on the head
- Head, neck, extremities; spare soles, palms, mucous
membranes - Rapid growth over 3-6 months followed by
stabilization - “juvenile melanomas”
- Histology resembles melanoma
- Prepubertal pt and stable lesions:
- May monitor Q 3-6 months
- Any change or atypical features, new onset
after puberty: Excise
7
Q
Blue nevi
A
- Heavily pigmented
- Women 2x men, Asian 3x white
- 1% to 2% of white adults and in 3% to 5% of Japanese adults
- Onset late childhood, adolescence
- Bluish cast
- Tyndall phenomenon- refraction of light by overlying dermis
- Melanocytes deeper than those of brown lesions
- Solitary, bluish, smooth surfaced macule, papule or plaque
- Generally round or oval, symmetric
- Distal extremities (dorsum of hands and feet), buttocks,
scalp and face - Common: 0.5-1 cm- benign, don’t change
- Cellular: >1 cm, nodular- rarely change to malignant
melanoma– Excise
8
Q
Melanocytic Nevi
Diagnosis
A
9
Q
Melanocytic Nevi
Diagnosis
A
- Consider MRI for patients with
multiple congenital melanocytic
nevi - Excisional biopsy with
microscopic evaluation - Shave
- Punch
10
Q
Melanocytic Nevi
Treatment
A
- Observation
- Removal
- Histology or cosmetic reasons
- Prevention
- Limit UV exposure
11
Q
UV Prevention recommendations
A
- UVA/UVB sunscreen SPF 30 or
higher, broad spectrum, water
resistant - Infants?
- Ears, scalp, lips
- Apply 1 ounce = shot glass
- Apply sunscreen to dry skin 15
minutes BEFORE going outdoors - Reapply sunscreen approximately
every 2 hours, or after swimming or
sweating
12
Q
Basal Cell Carcinoma
A
- Nonmelanocytic
- Arises from small cells found in the
lower layer of the epidermis - Lifetime risk >20% for women,
>30% for men - 85% occur on the face, neck, and
head - Risk factors include alcoholism,
immunosuppression, radiation
exposure, gene mutations
13
Q
Basal Cell Carcinoma presentation
A
- Sore that does not heal
- Gradually enlarging
- Bleeds when irritated
- Often mistaken for acne
Nodular 80% of cases - Pearly, waxy papule with central depression
- Central ulceration
- Rolled borders
- Telangiectasias
- Metastasis is rare
- Superficial 15% of cases
- Slightly scaly, nonfirm macules,
patches, or thin plaques - light red to pink in color, fine
translucent papules on periphery - shiny
14
Q
Basal Cell Carcinoma diagnosis
A
- Shave biopsy
- Excisional or punch biopsy, if
question of melanoma - CT, if suspicion of spread to
deeper structures - Usually not staged
15
Q
Basal Cell Carcinoma treatment
A
- Surgery:
-Electrodesiccation and curettage
-Mohs
-Excisional surgery - 5-Fluorouracil (5-FU)
- Imiquimod
- Radiation
16
Q
Squamous Cell Carcinoma
A
- Cancer
- 700,000 per year in the US
- Incidence increasing
- Head and neck
- Malignant transformation of
normal epidermal keratinocytes - Risk factors include UV exposure,
immunosuppression, radiation
exposure, HPV
17
Q
Squamous Cell Carcinoma
Presentation
A
- Wound that will not heal
- Ulcer
- Plaques/nodules with scale, crust
- Area of skin with history of UV
exposure - Often preceded by actinic keratosis
- Lesions >2 cm or located on the
external ear or lip have a higher rate
of metastasis
18
Q
Squamous Cell Carcinoma
Diagnosis
A
- Full thickness biopsy
- Shave biopsy not recommended
- Excisional biopsy
- Punch
- Can present as a neck mass
- Parotid
- CT if needed to evaluate
deeper structures
19
Q
Squamous Cell Carcinoma
Treatment
A
- Electrodessication and curettage
- Trunk, extremities
- Mohs or surgical excision
- Radiation
- Chemo
- Prevention
-UV exposure
-Actinic keratosis
20
Q
Melanoma
A
- Cancer
- Neoplasm of melanocytes
- Affects young and middle-aged
adults - Mean age of diagnosis is 63 years,
with 15% being younger than 45
years - Most common malignancy in
women aged 25-29 years - One third of melanomas develop
from a pre-existing nevus
21
Q
Melanoma
Risk factors
A
- UV exposure
- history of sunburns and/or heavy sun exposure
- One blistering sunburn in childhood more than doubles a person’s
chances of developing melanoma later in life - dysplastic nevi (1 doubles risk, 10+ 12x risk)
- blue or green eyes, blonde or red hair, fair complexion
- prior personal or family history of melanoma
- genetic mutation- p16 mutation.
- More than 50 nevi, ≥2 mm in diameter increases risk
22
Q
Melanoma
Growth
A
- Radial
- Irregular plaque
- Epidermis
- Vertical
- Extends deeper
23
Q
Melanoma
Presentation
A
- A - Asymmetry
- B - Border irregularity
- C - Color that is dark black, blue,
or variable - D - Diameter ≥ 6 mm
- E - Evolving
- Head-to-toe skin examination
- Lymph nodes
24
Q
SUPERFICIAL SPREADING MELANOMA
(SSM)
A
- 70% of cutaneous melanomas
- Classic ABCDE irregularities: irregular
borders and irregular pigmentation,
discrete focal area of darkening
within a preexisting nevus; slowly
changing - Preexisting nevi
25
Nodular melanoma
* 2nd most common (15-30% of
melanomas)
* Trunks of males, legs of women
* More symmetrical
* Dark brown or black
* Short radial growth phase, quickly
grow vertically, aggressive
* More likely to form de novo
26
Lentigo maligna melanoma
* Slightly more in females; uncommon
<40 yo
* Sun-exposed areas-
cheek/nose/scalp/ears
* Initially flat, slowly enlarging, large,
brown, frecklelike macule with irregular
shape and differing shades of brown and
tan, usually arising in a background of
photodamage
27
Acral lentiginous melanoma
* Least common <5%; avg age 63 yo
* Racial differences
* However, equal incidence in whites vs other
ethnicities
* Hands and Feet: Palms, soles, and subungual
areas
* Very aggressive, rapid progression to vertical
phase
28
Melanoma
Diagnosis
* Biopsy, excisional preferred
* 1-3 mm margins
* Shave biopsy typically
contraindicated
* Chest x-ray
* CBC c diff, CMP, LDH
* CT/PET
* MRI
* Lymph node dissection
29
Melanoma
Treatment
* Wide local excision with sentinel
lymph node biopsy and/or
elective lymph node dissection
* Adjuvant radiation therapy:
* Cryotherapy
* Imiquimod
* Immunotherapy, targeted
therapy
30
Clark scale
Level 1: (melanoma in situ) – the melanoma cells are only
in the outer layer of the skin (the epidermis)
Level 2: melanoma cells in the papillary dermis (superficial
dermis)
Level 3: melanoma cells are touching the next layer down
known as the reticular dermis (deep dermis)
Level 4: melanoma has spread into the reticular dermis
Level 5: melanoma has grown into the layer of fat under
the skin (subcutaneous fat)
31
Breslow thickness
measurement
of the depth of the melanoma from the
surface of your skin down through to the
deepest point of the tumor
32
Kaposi Sarcoma (KS)
* Spindle-cell tumor
* purplish, reddish blue, or dark brown/black
patches, plaques, or nodules
* Cancer that develops from the cells that line
lymph or blood vessels
* Most often: distal extremities
* Ranges from minimal mucocutaneous disease
to extensive organ involvement
* GI tract- often asymptomatic
(bleeding/diarrhea)
* Rare prior to AIDS epidemic
* Caused by Human herpes virus 8 (HHV-8)
33
Who gets Classic (Sporadic) KS?
* Elderly men of Mediterranean
and Eastern European descent
* 30% develop a second
malignancy
* Non-Hodgkin lymphoma
* Risk factors include infrequent
bathing, a history of asthma,
and in men, a history of
allergies
34
Epidemic (AIDS-related) KS
* Most aggressive form
* Advanced disease
* Most common malignancy in
HIV-infected patients
* AIDS-defining cancer
35
Immunocompromised (Iatrogenic) KS
* Organ transplant patients or other
pts receiving immunosuppressive
therapy
* 15-30 months following transplant
* Withdrawal of immunosuppression
therapy may lead to regression
* Sirolimus (Rapamune) - prevents
transplant rejection, also seems to
have an anti-KS effect
36
Kaposi Sarcoma (KS)
Presentation
* Lesions may involve the skin, oral mucosa,
lymph nodes, visceral organs
* The brain is spared
* Typically appear in a linear, symmetric
distribution, following Langer lines
* Macular, papular, nodular, or plaquelike
* Palpable
* Nonpruritic
* Brown, pink, red, or violaceous
* Lymphedema
* GI involvement +/- sxs
* Pulmonary symptoms
37
Kaposi Sarcoma (KS)
Diagnosis
* HIV
* CD4 lymphocytes
* Viral load
* Chest x-ray
* Gallium scan
* Punch biopsy
* Bronchoscopy
* Cherry red lesions
* EGD or colonoscopy
38
Kaposi Sarcoma (KS)
Treatment
* Refer
* HAART- antiviral HIV tx
* First line
* Chemotherapy
* Radiation
* Surgical excision, cryotherapy,
topical imiquimod
