Pigmented, Precancerous and Cancerous Lesions - Exam 2 Flashcards
What are actinic keratosis? **What is the highlighted finding? What pt population is the MC?
Solar keratosis neoplastic condition in which precancerous epithelial lesions are found on sun-exposed areas of the body
**precancerous
very common in lighter skin people and virtually unseen in darker people
Actinic Keratosis
Actinic Keratosis
Where are the MC places to see actinic keratosis? Describe the in words. Will they be tender?
sun exposed skin
flat, scaly, papules, thicker. hypertrophic, ill defined borders, usually rough in texture. can have crust that pt can pick off. usually on an underlying RED base
e usually asymptomatic but may be tender
What am I?
What are the common sizes?
Actinic Keratosis
2-6 mm plaque
What are the 3 risk factors for AKs? **Which one is MC? They may resolve with ______
increasing age
cumulative lifetime sun exposure
IMMUNOSUPRESSED pts
protection from ultraviolet (UV) light
What do AKs put you at a higher risk for? specially _______. What percentage?
Higher risk for developing non-melanoma skin cancer
squamous cell carcinoma
actinic keratosis will evolve into a squamous cell carcinoma or skin cancer is approximately 5-10%
What is the best way to dx AK when doing your PE? How would you define the feeling?
Actinic keratoses are often more easily palpated (with light touch) than seen
“gritty”
What am I?
What is it called when the lower lip is involved?
Actinic Keratosis
Actinic cheilitis
Whitish scaly flat papules or a confluent plaque is seen, especially on the lower lip
What am I?
actinic cheilitis
What will AKs look like under dermoscopy?
can demonstrate a white to yellow surface scale, erythema revealing a pseudo-network around hair follicles, linear-wavy vessels, follicle openings with yellowish keratotic plugs
Describe pigmented actinic keratosis in words. **What is the major diagnostic clue?
Pigmented similar to non-pigmented actinic keratosis with the addition of moth-eaten or sharp borders and gray dots / granules.
The classic gritty feel is a diagnostic clue
What are pigmented actinic keratosis due to?
This is due to the collision of a solar lentigo and actinic keratosis
What am I?
pigmented actinic keratosis
How are AKs dx? How do you confirm?
clinical diagnosis
skin bx
What are the bx indications for actinic keratosis?
Biopsies should be performed on recurrent, hyperkeratotic, large (greater than 6 mm), indurated, and/or painful lesions to rule out invasive carcinoma
How does the tx plan change in AKs for an IC pt?
In the immunosuppressed population, one should maintain a low threshold to biopsy actinic keratoses that do not respond to appropriate treatment to rule out non-melanoma skin cancer
What are the 2 management pearls for AKs?
Aggressive sun avoidance / sun-protective measures should be instituted
Sunscreen with SPF 30 or higher when exposed to the sun
_______ is the MC form of AK tx. What are 2 additional lesion-targeted therapy options?
Cryosurgery
aka liquid nitrogen
Curettage & Electrosurgery
Shave excision/biopsy
What are the 4 field therapy tx options for AKs? Which one was pulled from the market?
5- Fluorouracil (5-FU)
imiquimod cream
ingenol mebutate (Picato) -> pulled from the market
diclofenac gel
______ MOA blocks DNA synthesis = apoptosis and selective cell death. How often is it applied? What is the pt education? When should the pt f/u?
5-Fluorouracil (5-FU)
BID to affected region x 2-4 wks
Success is parallel to pt compliance!
F/U : 2 wks
______ MOA is an immunomodulator - stimulates local cytokine induction. What type of AK and what part of the body?
Imiquimod
used for non-hypertrophic AK- face OR scalp
Imiquimod should not be used to treat AK in the _______ pt population. What is slightly unique about the dosing?
Avoid in immunocompromised individuals
start at 5% dosing, then 3.75% then 2.5%
What is the pt education for Imiquimod? When do you need to f/u?
SE are associated with increased clearance rates
wash hands before and after application
wash treatment area before application
F/U: 2-4 wks
_____ MOA disruption cell membrane and DNA leading to cell necrosis and neutrophil-mediated cytotoxicity that eliminates remaining tumor cells. What is the indication?
ingenol mebutate (Picato)
only used in AK tx
For ingenol mebutate (Picato), how does face/scalp dosing differ from trunk/extremities? **What is the super highlighted caution that caused it to be pulled from the market?
0.015% gel - face/scalp
0.05% gel - trunk/extremities
**Caution - risk of invasive SCC **
_______ MOA COX-2 inhibitor (inhibits prostaglandin synthesis). What is important to note about it’s SE?
Diclofenac 3% gel
all AK treatment options cause localized skin reaction but diclofenac 3% gel has LESS skin reaction and is a good choice for very sensitive areas
What are the procedural field therapy options for AK that require a specialist and are expensive?
cryopeeling
dermabrasion
chemical peels
laser resurfacing
photodynamic therapy
What is the AK treatment algorithm recommendation?
_______ is a malignancy of cutaneous epithelial cells occurring most frequently on sun-exposed areas of the skin, particularly the face and dorsal hands. ______ may be a precursor lesion
squamous cell carcinoma
Actinic keratoses
Squamous cell carcinoma can involve the _____ and ______ and, when it does, it carries a much greater risk of metastases
oral mucosa and lip
squamous cell carcinoma
squamous cell carcinoma
squamous cell carcinoma
hard/firm papule/plaque/nodule with a thick adherent keratotic scale
+/- erosion, ulcerated, umbilicated
erythematous, yellow or skin colored
What am I?
What areas of the body?
squamous cell carcinoma
sun-exposed areas
from lecture: these bleed very easily and are PAINFUL
______ will be present in SCC that has metastasized
regional lymphadenopathy
soft, fleshly, erosive papule/nodule
papillomatous, cauliflower like
bleeds easy
on sun exposed areas
What am I?
SCC- undifferentiated lesion
SCC - undifferentiated lesion
SCC - undifferentiated lesion
What are risk factors for developing SCC? **Where is one highlighted site for SCC to occur?
Chronic sun exposure
Fair skin and blue eyes
Family history of skin cancer
Increased age
Scarring processes (chronic ulcers, burns, hidradenitis)
Ionizing radiation
Immunosuppression
HPV
**due to trauma, may occur in tattoos
SCC in darker skin pts, where is it going to occur?
occur in scars and has been known to occur in non-sun-exposed areas
SCC is about _____ less likely to occur in individuals with dark skin phototypes than in those with light skin
80 times
______ is the MC skin cancer in African Americans
Squamous Cell Carcinoma
squamous cell carcinoma
What layer of skin is Squamous cell carcinoma in situ (SCCIS) confined to? What population is it more invasive in? What 2 populations are these malignant tumors more prevalent in?
epidermis
more aggressive in immunosuppressed individuals
organ transplant recipients and those with HIV / AIDS
What is Squamous cell carcinoma in situ (SCCIS) on the male genitalia called?
erythroplasia of Queyrat
What are some predisposing factors and locations of SCC?
old burn scars
chronic cutaneous ulcers
inflammation (especially those causing atrophic lesions)
previous sites of irradiation
occupational trauma
chronic lymphedema
areas of venous stasis
In darker skin pts, where can SCC occur?
non-sun-exposed areas; thus a higher index of suspicion for irregular lesions in those areas is warranted
What will SCC look like under dermoscopy? What is the classic presentation? What will the vessels look like?
Nonpigmented and pigmented lesions
The classic presentation includes red vessels as dots, scale / crust, and shiny white structures (also known as crystalline structures)
Vessels appearing more coiled or twisted-loop in appearance
In SCC the stratum corneum will be _______. What is a keratin pearl?
thickened
Orange / tan circular or ovoid structures with a white peripheral rim
What will a pigmented SCC look like?
normal features of SCC plus brown or gray dots or brown circles, in a linear arrangement
What do you need to examine next when SCC is considered?
Careful examination of regional lymph nodes is essential when SCC is considered and especially after it is diagnosed
What is the most effective means of detecting SCC?
thorough history and physical exam
then bx
Pleomorphic and hyperchromatic squamous cell with variable nuclear size
Loss of full-thickness epidermal maturation
Overlying parakeratosis
Keratinocyte mitoses
Dyskeratosis
Squamous pearls
Occasional features
Presence of an adjacent solar / actinic keratosis
Path reports of what type of lesion?
SCC
What are the SCC tumor subtypes?
Bowen disease (squamous cell carcinoma in situ variant)
Acantholytic / adenoid / pseudoglandular
Well differentiated
Poorly differentiated
What is another name for Bowen dz?
squamous cell carcinoma in situ variant
What is the treatment of choice for SCC?
Excision, with narrow margins (3-5 mm),
Mohs procedure
both are first line options
What parts of the body for SCC have higher rates of metastasis? What patient population?
SCC of the head and neck, including the oral mucosa
IC patients
**In high-risk SCC in which Mohs surgery is not performed, ___ margins are typically required
6 mm
In SCC with cases of known or suspected nodal metastases,______ or _____ lymph node dissection is often indicated
sentinel or formal
In pts with SCC who are poor surgical candidates, _____ or ______ are reasonable alternatives
For superficial SCCs, electrodesiccation and curettage (times 3) with margins of 3-4 mm may be used
Radiation therapy
What are the pt education for SCC?
watch for suspicious lesions
use SPF 30 sunscreen or higher
wear protective clothing/hats when outdoors, seek shade
JUST SAY NO…. to tanning beds
What characteristics would make a lesion suspicious?
open sore, pink-reddish growth, irritated area, shiny papule/nodule, scar-like area
What am I? What are key features to know?
Keratoacanthoma: variant of SCC
RAPID growth
solitary or multiple
involutes over time
craterioform, endophytic nodule with well differentiated keratinocytes
What am I?
**What is a super important physical feature?
Keratoacanthoma
central keratin plus
What am I? What are the tx options?
Keratoacanthoma
Mohs or excision
_______ is the most common skin cancer. What is the underlying cause?
Basal cell carcinoma
a neoplasm of basal keratinocytes
What are the 4 types of BCC?
nodular, infiltrating, pigmented, and superficial
Are BCC likely to metastasize? What parts of the body?
This is largely a NON-metastasizing form of cancer
It is typically limited to sun-exposed areas such as the head, neck, face and nose, upper chest, and back
**What is the MC subtype of BCC? What is the MC variant of African, Hispanic, and Asian descent?
**nodular variant
pigmented variant
nodular BCC
translucent “pearly” papule/nodule
well defined borders
smooth, firm surface with telangiectasias
+/- erosions, sporadic pigmentation
nodular BCC
ulcerating BCC
translucent-pearly, smooth, firm, telangiectasias with a ______
ulcerating BCC
CENTRAL ULCER
+/- elevated border (rodent ulcer) “rat eaten” ulcer
aka a “non-healing bleeding ulcer”
sclerosing BCC
plaque, scar like lesion
pink/white in color
telangiectasias
ill defined borders
sclerosing BCC
Superficial multicentric BCC
thin plaque/patch
pink/red
+/- scaling
Superficial multicentric BCC
ecemza or psoriasis that is not getting better with steroids, should think _______
Superficial multicentric BCC
firm papule/nodule
+/- umbilication
smooth pearly surface
generally pigmented or stippled globules of pigment
Pigmented BCC
pigmented BCC
What are risk factors for BCC?
light skin phototype
sun exposure
radiation
advanced age
immunosuppression
personal history of non-melanoma skin cancer
Once a BCC is identified, what are the chances of a second BCC?
3 out of 5
_____ have a pearly or lucent quality, with small telangiectasias and a rolled edge or border
Nodular BCCs
In BCC, as the growth enlarges, ____ usually appears over the _____ and ____ with minor trauma is frequent
crusting
central depression
bleeding
nodular BCC
What does more than one BCC before 30 suggest? What size are they typically?
nevoid basal cell carcinoma syndrome or exposure to radiation
Usually, these BCCs are LARGER than they appear clinically
______ is the best test for determining BCC
skin bx either shave or punch
Nests and cords of basaloid keratinocytes with peripheral palisading and a central haphazard arrangement
Tumor nests usually attach to the undersurface of the epidermis
Tumor cells have hyperchromatic nuclei and scant cytoplasm
Numerous mitotic figures, some atypical
Abundance of apoptotic neoplastic cells
Clefts between tumor nests and the surrounding stroma
Stroma is mucinous, loose and with increased vascularity
Keratin-derived amyloid is common in the stroma
Marked solar elastosis is present in the adjacent dermis
This is the path report of what type of lesion?
BCC
What are the treatment options for basal cell carcinoma?
Treatment options include:
electrodessication and curettage (ED&C)
excision
cryosurgery
radiation
Mohs surgery
oral smoothened inhibitors (suppresses hedgehog pathway)
What are the Mohs criteria in BCC?
recurrent BCC
aggressive subtype
> 2 cm in size
on the head/neck
For BCC, what area on the body and what histopathology should be referred to Mohs surgeon?
nasolabial fold
morpheaform histopathology
_____ is an accepted treatment modality for BCC for patients who are not good candidates for surgical removal
Radiation therapy
______ is FDA approved for treatment of adult patients with locally advanced BCC who are not candidates for surgery or radiation, and for patients with _____ BCC
Vismodegib (Erivedge)
metastatic
_______ is an hedgehog pathway inhibitor taken once a day in pill form. What does it tx?
Vismodegib or Sonidegib (Odomzo)
metastatic BCC
______ is a benign overgrowth of skin cells. What are the 2 types?
Common Melanocytic Nevi
congenital and acquired
Which type of melanocytic nevi have larger CMNs have increased risk for melanoma development?
congenital MN (Melanocytic Nevi)
Which type of melanocytic nevi often regress after age 60?
acquired (MN): develops in early childhood
asymptomatic without change
symmetric
sharp borders
uniform color
What am I?
Common Melanocytic Nevi
common melanocytic nevi
How do you dx common acquired nevomelanocytic Nevi? How can you differentiate between it and melanoma?
clinical dx with dermoscopy
unable to appreciate neoplastic changes as seen in melanoma
What is the tx for common acquired
nevomelanocytic nevi?
nothing!!
What are the indications for excision of Common Acquired Nevomelanocytic Nevi?
location - scalp, anogenital, mucosal lesions
rapid change
irregular borders
erosions
persistent itching, pain, bleeding
______ a pigmented lesion resulting from proliferation of atypical melanocytes. What is the MC timing?
Dysplastic Melanocytic Nevi (DN)
MC onset late childhood - middle adulthood
Dysplastic Melanocytic Nevi (DN) are precursors to _________. What does have 1 do to your risk? having 10+?
superficial spreading melanoma (SSM)
one DN increases risk for melanoma by 2-fold
≥10 DN increases risk by 12-fold
Dysplastic Melanocytic Nevi (DN)
asymptomatic
irregular shape
sharp and ill-defined borders
variegated color
maculopapular
Dysplastic Melanocytic Nevi (DN)
Dysplastic Melanocytic Nevi (DN)
How do you dx Dysplastic Melanocytic Nevi (DN)?
Diagnosis is made clinically and confirmed (if needed) by histopathology
When do you need a bx in Dysplastic Melanocytic Nevi (DN)?
lesion is changing or cannot be closely observed
What are the f/u recommendations for Dysplastic Melanocytic Nevi (DN)?
routine skin exam every 3-12 months
3 months if family hx of DN or melanoma
6-12 months if sporadic DN
What are the 3 pt education for Dysplastic Melanocytic Nevi (DN)?
monthly self exams
sun protection - shade, sunscreen, clothing
family members should have regular skin exams
Look at this chart again comparing common acquired vs dyplastic Melanocytic Nevi
_____ is an aggressive malignancy of pigment-producing cells known as ______
Melanoma
melanocytes
Where are common melanoma sites?
Melanoma may arise at sites of melanocytes including on the skin, mucous membranes, around the nail apparatus, and in the eye
What are the 4 main subtypes of melanoma? Which one is MC? least common?
superficial spreading melanoma (the most common type)
nodular melanoma
lentigo maligna melanoma
acral lentiginous melanoma (the least common type)
melanoma
melanoma
______ and ______ are strongly associated with melanoma
genetics
cumulative/prolonged exposure to UVA/UVB exposure in light skin types
________ is the MC cancer in women between 25-29. What percentage? It is responsible for ____ of skin cancer deaths
melanoma
1 in 50 (2014) will be dx with invasive melanoma
80%
Melanoma has been shown to have one of highest _____ rates of any cancer type, reflective of its clinical and pathologic diversity and ______ to treatment in advanced stages
mutation
resistance
melanoma
melanoma
What are the individual risk factors for melanoma?
increasing age
Photo-skin type I-II
> 25 nevi
atypical nevi
immunosuppression
personal or family hx of melanoma
UV exposure
Using tanning beds before 35 increases risk of ______ by ______
melanoma by 75%
What are the 2 classifications of melanoma? How common are each kind?
De novo melanoma (70%)
Precursor melanoma (30%)
______ develop as a new pigmented papule, plaque or nodule
De novo melanoma (70%)
_______ developing from precursor lesion (DN or CMN)
Precursor melanoma (30%)
What are the 2 phases of growth in melanoma? What is happening in each?
radial (thin melanoma) - remains in epidermis
vertical - extends to dermis/vessels leading to metastasis
**The primary prognostic feature of melanoma is the ______, which is measured histologically in _____ and referred to as the ______
depth of invasion
millimeters
Breslow thickness
Melanoma mortality rates are higher among ____ than among _____
men
women
Where are the most frequent sites of metastasis in melanoma?
skin / subcutaneous
lymph nodes
lungs
liver
brain
however, melanoma can metastasize to any organ of the body
T/F: All melanomas are pigmented
False! some may appear to lack or contain little pigment and are referred to as amelanotic.
_______ An asymmetric macule with variegated pigmentation and notched or ragged borders. Can be elevated. Where are they commonly seen on the body?
superficial spreading melanoma
Usually seen on the trunk in men and the lower extremities in women
_______ A dark brown to bluish-black nodule that grows rapidly RAPID GROWTH. likely to ulcerate or bleed. Where is it found on the body?
Nodular melanoma (2nd MC)
trunk, head, and neck usually 1-3 cm
_______ An asymmetric tan/brown to black macule or patch with color variegation and irregular borders SLOW GROWING. May have area(s) of dermal induration or nodularity. What size? How do the borders evolve?
lentigo meligna melanoma
0.5 - 20 cm
borders: early well defined evolving to irregular geographic borders
What are the MC and 2nd MC types of melanoma?
Superficial spreading melanoma (MC)
Nodular melanoma (2nd MC)
_______ Asymmetric brown to black macule with variegated pigmentation and irregular borders SLOW GROWING. Where are they found on the body?
Acral lentiginous melanoma
Found on the palms, soles, or nail apparatus
In patients with multiple pigmented lesions, what should you do when evaluating? _____ is a helpful diagnostic aid
consider biopsy of any lesion that stands out from the rest of the patient’s nevi or is unlike the others (the “ugly duckling” lesion)
serial photography and dermoscopy
What is the best dx test for melanoma?
excisional bx: either shave or punch
**_____ mm Breslow score and you need to do a sentinal lymph node bx
> 0.76 MM Breslow
What are the NCCN guidelines for melanoma bx margins based on the size of the lesion?
In situ – margins at least 0.5 cm (larger in the lentigo maligna form of melanoma in situ)
Less than 1 mm – margins 1 cm
1-2 mm – margins 1-2 cm
2-4 mm – margins 2 cm
Greater than 4 mm – margins 2 cm
What is the recommendation for skin exams?
over 18 needs a yearly skin exam
If there is a family hx of BCC and SCC, how often should you get a skin exam?
Skin exam every 6 months
If there is a family hx of melanoma, how often should you get a skin exam?
Skin exam every 3 months
What are the indication for Mohs sx? **What is the benefit?
Indicated for BCC and SCC
spares the greatest amount of healthy tissue while completely removing all cancer cells
What is happening during a Mohs procedure? What is the cure rate?
Excisional procedure that permits real-time evaluation of tumor margins using inverted horizontal frozen sections with tumor mapping
cure rates or 99 % or higher, recurrence rates are lower than other tx options
What are the indications for a simple excision? What are the margins?
indications: well defined nodular BCC, low risk SCC in anatomical appropriate site
5 mm margins
What are the indications for a wide local excision? What are the margins?
indications: well differentiated SCC, well-defined large nodular-ulcerative BCCC
6-10mm
What are the punch bx technique instructions?
What are the 3 types of UV light? Give a brief description of each
UVA - longest wavelength- passes through window glass
UVB - most responsible for sunburns - unable to pass through glass
UVC -absorbed by the ozone therefore doesn’t reach Earth
Which type does sunscreen protect against? What does the SPF mean?
measure of protection against UVB
the SPF is a ratio of the time it takes for sunscreened skin to burn compared to un-sunscreened skin
Unprotected skin burns after 10 minutes of UVB exposure, sunscreen protected skin burns after 150 minutes = an SPF of 15 times
What does sunscreen labeled “broad spectrum” mean? What active ingredient provides the most protection?
UVA and UVB
Zinc oxide protects the most against UVA and UVB, followed by titanium dioxide then Octocrylene
Avobenzone only protects against UVA
