Premalignant and Malignant Lesions

Question 1

Characteristics Of:

Answer 1

Actinic Keratosis

• Multiple, discrete
• Flat or elevated
• Red, pigmented, or skin colored
• +/- adherent scale
  
  • Palpate: may feel rough like sandpaper
• Most are <6mm

Question 2

Treatment Of:

Answer 2

Actinic Keratosis

• Sun protection
  
  • Sunscreen, hat, sun protective clothing
• Topical therapy – treatment indicated since some will become NMSC
  
  • Cryotherapy
  • 5-fluorouracil (5-FU) or imiquimod
  • Laser resurfacing
    
    • Actinic Cheilitis
  • Chemical peels
    
    • Glycolic/TCA
  • Photodynamic Therapy
• Warn of downtime for all treatments: varies and should be part of decision making process

Question 3

Discription Of:

Answer 3

Basal Cell Carcinoma

• Most common form of skin cancer
• Related to sun exposure (cumulative)
  
  • most common on face, scalp, ears, neck
  • Rare on dorsal hands (may indicate not solely related to UVR)
• Slow growing

Question 4

Risk Factors For:

Answer 4

Basal Cell Carcinoma

• RFs:
  
  • Intermittent intense sun exposure (prior sunburns)
  • Radiation therapy
  • FH of BCC
  • Immunosuppression
  • Fair (esp with red hair)
  • Fitzpatrick Type I or II (easy sunburning)
  • Blistering sunburns as a child

Question 5

Characteristics Of:

Answer 5

Basal Cell Carcinoma

• Nodular BCC
  
  • pink pearly telangiectatic papule
  • Rolled border
  • Central depression +/- ulceration, crusting
  • 50-80% of BCC
• Superficial BCC
  
  • MC on trunk
  • Scaly
  • “dry patch that doesn’t heal”
• persist, enlarging gradually
• can invade and destroy surrounding tissues
• rarely metastasize – can directly spread
• Asymptomatic – bleeding without pain

Question 6

Treatment Of:

Answer 6

Basal Cell Carcinoma

• Biopsy: Shave

Treatment

• Goal = Permanent cure with best cosmetic result
• Determined by variant, size, location
  
  • electrodessication/curettage
  • elliptical excision
  • Moh’s surgery
  • Topical chemotherapy (Imiquimod>5FU)
• F/U: Q 6 months x first year then annual

Question 7

Characteristics of

Answer 7

SCC
•Begins with sun-damage changes (AK, actinic cheilitis)
•Red base with hyperkeratotic white adherent scale
•Becomes raised, larger
•Over time, becomes nodular and ulcerated
•Faster growing, can be invasive and metastasize
–Be mindful of lower lip lesions! 10-15% mets.

Question 8

Treatment of

Answer 8

SCC
•Excision with margins
–Moh’s surgery for head/neck, large lesions
–Excision trunk, extremities
–Published guidelines to assist
¬Lymph node palpation, biopsy if enlarged
•Adjunct therapy?
•Regular follow-up
–Q 6 months; annually
•Self-examination education

Question 9

Warning Signs for

Answer 9

Malignant Melanoma
•Huge variation - NO RULES
•Watch for ABCDE
–Imperfect, but helpful
•Asymmetry
•Border Irregularity
•Color variation (*or change)
•Diameter > 6mm
•Evolving nevus
–+/- itching, tenderness
–+/- bleeding, ulceration
–slow or abrupt ∆
•Examine all pigmented lesions regularly – photos are helpful

Question 10

If lesion is suspected for MM…

Answer 10

• If MM suspected, complete excision with 1-3mm margin is preferred method of biopsy
• If lesion is too large, perform punch biopsy
• Lentigo maligna tend to be large and on cosmetically sensitive area àbroad shave biopsy (small biopsy can result in misdiagnosis)
• Send to dermatopathologist if possible – or path experienced with pigmented lesions

Question 11

Prevention of

Answer 11

Malignant Melanoma
•Avoid peak sunlight hours (10am-4pm)
•Apply broad-spectrum sunscreen daily
–UVA & UVB, SPF 15+
–Sunblock (titanium dioxide or zinc oxide)
–Reapply q2H + after swimming/sweating
•Sun protective clothing: hat, shirts, sunglasses
•Lip balm with SPF 15+
•Minimize exposure in children under 18mo
•AVOID TANNING BEDS (recent research & legislation in our favor)

Question 12

Tx of

Answer 12

Malignant Melanoma
•SURGERY REFERRAL
–Wide local excision
•Dermatology referral
•+/- Lymph node biopsy
•Adjuvant therapy
•Frequent follow-up
•Also need to be followed by: ophthalmology and dentist