Pressure sores and Squamous cell carcinoma

Question 1

What is the most common form of lung tumour (approx 40% of cases)

Answer 1

Squamous cell carcinoma
More common in males
Assosciated with cigarette smoking

Question 2

Where is the squamous cell carcinoma of the lung found?

Answer 2

• typically centrally located and often larger than 4 cm in diameter
• most affect the large, segmental, more central bronchi
• tumour may be silent initially, but causes progressive narrowing of the bronchi until obstruction ensues, leading to distal collapse, bronchiectasis and lung abscesses.
  cavitation is seen in up to 82%
• grey / white in colour, and may extend into the adjacent lung, pleura and hilar nodes

Question 3

Due to their central location what is common ?

Answer 3

due to their central location segmental or lobar collapse is common

Question 4

What are the microscopic features of Squamous cell carcinoma of the lung?

Answer 4

keratinisation and intercellular bridge formation - ‘prickles’. Squamous dysplasia, metaplasia, or carcinoma in situ may be observed in the vicinity of the tumour.

Question 5

How fast is local growth is SCC of lung?

Answer 5

Local growth is rapid.Metastasis occurs via lymphatic and haematogenous routes, but tends to be later than for other types of carcinoma.

Question 6

Prognosis for squamous cell carcinomas of the lung?

Answer 6

prognosis is better for squamous carcinoma than for other lung malignancies. Although in part this is because squamous carcinoma is typically localised to the chest at presentation most investigators have found a better stage-for-stage prognosis in squamous cell carcinoma, than adenocarcinoma or large cell carcinoma

Question 7

Spindle cell squamous carcinoma

Answer 7

variant which may be misdiagnosed as sarcoma. However, immunohistochemical staining and electron microscopy clearly differentiate the two.

Question 8

Is squamous cell carcinoma of the lung small cell or non small cell?

Answer 8

Non small cell lung cancer

Question 9

Features of squamous cell carcinoma of the lungs

Answer 9

• Location: central lesion
• columnarl into Squamous cells that produce keratin
• Paraneoplastic syndromes:
• Hypertrophic pulmonary osteoarthropathy: causes inflammation of the bones and joints in the wrists and ankles, and clubbing of the fingers and toes
• PTHrP→ hypercalcaemia
• history of haemoptysis and ALARM symptoms together with the cavitating lesion in the lung makes this the most likely diagnosis

Question 10

First line investigation for lung cancer

Answer 10

CXR

• Hilar enlargement
• Lung consolidation
• “Circular opacity” – a visible lesion in the lung field
• Pleural effusion – usually unilateral in cancer
• Collapse

Question 11

GS for lung tumours

Answer 11

CT chest with contrast:gold-standard imaging; requested if there is an abnormal CXRorpersistent symptoms with a normal CXR.

Question 12

Other than CT chest and CXR what other primary investigations are done?

Answer 12

PET-CT
Biopsy

Question 13

Other investigations to consider for lung tumours

Answer 13

Mediastinoscopy:perform prior to surgery forNSCLCas CT does not always show mediastinal lymph node involvement
- Sputum cytology: generally only for those with central lesions that do not tolerate bronchoscopy
- Lung function tests:it is important to assess fitness for surgery, if eligible
- Brain imaging for metastasis: 10% of patients with advanced NSCLC have brain metastases
- FBC: anaemia of chronic disease and thrombocytosis may be noted

Question 14

What staging is used for lung tumours?

Answer 14

TNM

Question 15

Treatment for NSCLC

Answer 15

• Non-metastatic disease (stage I-IIIa):surgery, usually with adjuvant chemotherapy
  
  • Typically involves lobectomy or pneumonectomy. Segmentectomy or wedge resection (taking a segment or wedge of lung to remove the tumour) is also an option.
  • Removal of lymph nodes, if affected
  • Curative radical radiotherapycan be used as an alternative to surgery
• Metastatic disease (stage IIIb and above):palliative treatment with immunotherapy, chemotherapy, and radiotherapy

Question 16

What is SCC of the skin?

Answer 16

Squamous cell carcinoma (SCC) is a malignant tumour of the epidermis in which the cells, if differentiated, show keratin formation.

Question 17

What is SCC of the skin associated with?

Answer 17

• excessive sunlight exposure,
• eposure to chemical carcinogens such as coal tar products,
• chronic irritation,
• immunosuppression.

There is an increased frequency in persons with non- pigmented skin. It is less common than basal cell carcinoma (BCC), with an incidence ratio of BCC:SCC of 4:1.

Question 18

What is histology required to to do in skin?

Answer 18

Histology is required to discriminate the lesions - usually nodular and kerotic - from basal cell carcinoma and solar keratosis.

Question 19

What is the aetiology of SCC of the skin?

Answer 19

exposure to ultraviolet light:
usually occurs in fair-skinned, elderly people
may develop from pre-existing solar keratosis

chronic exposure to industrial carcinogens
arsenic, chromium compounds
ionising radiation
soot (carcinoma of the scrotum in chimney sweeps),
also tar, pitch, oils

chronic inflammation (Marjolin’s ulcer):
margins of osteomyelitic sinuses
margins of long-standing ulcers
lupus vulgaris

genetic predisposition:
xeroderma pigmentosum
albinism

premalignant conditions:
Bowen’s disease
leukoplakia
erythroplasia of Queyrat

immunosuppression e.g. renal transplant patients

Question 20

Epidemiology of the SCC of skin

Answer 20

incidence is estimated at 9000 - 10,000 per annum in England and Wales

squamous cell carcinoma (SCC) is rare in patients under 60 years of age unless immunosuppressed

commonest locations for SCCs:
both sexes - back of hands, face
men - scalp and ears
women - lower legs

econd most common type of skin cancer in the UK, following basal cell carcinoma.1
more common in men

Question 21

Aetiology of SCC in skin

Answer 21

In SCC, cancerous mutations occur in squamous keratinocytes in the epidermis, the outermost layer of the skin.3 The squamous keratinocytes lie above the stratum basale in the stratum spinosum.

Ultraviolet exposure (specifically UVB rays) is the main cause of SCC.7 Chronic UV exposure will damage the DNA of the squamous keratinocytes, leading to tumour formation.8 Signature mutations include the p53 tumour suppressor gene

Question 22

RFs of SCC of the skin

Answer 22

lifetime excessive sun exposure
multiple actinic keratoses
Ultraviolet radiation
Immunosuppression
Fitzpatrick skin types I and II (fairer skin)
Solid organ transplant recipients
Increasing age
Male sex
Ionising radiation
Sites of chronic inflammation
SCC is the most common skin cancer in Fitzpatrick skin types V and VI (brown and black skin

Question 23

DDs of SCC of the skin

Answer 23

basal cell carcinoma
keratocanthoma
malignant melanoma
solar keratosis
pyogenic granuloma
infected seborrheic wart

Question 24

Clinical features of SSC of the skin

Answer 24

• Often lesions develop on sun-exposed skin.
• Characteristically a rapidly expanding painless, ulcerated nodule rolled indurated margin.
• Often the lesion may have a cauliflower-like appearance with areas of bleeding, ulceration or serous exudation.
• About 55% of lesions occur in the head and neck region. About 25% of lesions occur on the hands and arms.
• Metastatic spread may occur via local draining lymph nodes and beyond.
• Lymphadenopathy

Question 25

Areas to cover in history for SSC skin

Answer 25

Ultraviolet risk: sun exposure and use of sun protection
Systemic enquiry: red flags for cancer (e.g. malaise, weight loss)
Past medical history: skin cancer, immunosuppression, Bowen’s disease, actinic keratosis and solid organ transplant recipients
Family history: implies skin type, genetic tendency and sun exposure
Social history: outdoors occupation, hobbies and tanning/use of sunbeds
Travel history: chronic sun exposure

Question 26

Clinical examination of skin

Answer 26

• Characteristic features of SCC lesions include bleeding, itching and crusting and these lesions will typically appear in sun-exposed areas (e.g. the lips, back of the hands and upper part of the face or scalp).

Other features of sun damage may be present near the lesion including:
- Age spots (solar lentigines)
- Sunburn or sun tan
- Excessive wrinkling caused by solar elastosis (age-related UV damage)
- Actinic keratosis (pre-malignant lesions induced by UV damage)

Question 27

Typical features of SCC lesions in skin

Answer 27

Firm to palpate (may be nodular/plaque-like)
May ulcerate and bleed
May be tender/painful
May have a crusty (keratotic) top with a nodular base
Size is variable

Question 28

When is a dermatoscope used

Answer 28

A dermatoscope is a tool used to evaluate skin lesions by magnifying the lesion.13 In the context of SSCs it can be used to aid diagnosis and help distinguish between a SCC and a BCC

Question 29

DDs for SCC

Answer 29

Actinic keratosis
Basal cell carcinoma
Seborrhoeic keratosis

Question 30

Investigations for SCC

Answer 30

1st line - biopsy
This may comprise an excisional, punch or incisional biopsy so the lesion can be examined histologically.20

Excisional or shave biopsy to remove the whole lesion is used if the lesion is small, in an accessible area, not present in a cosmetically sensitive area and not near vital structures, so it can all be removed in one go.

Incisional/punch biopsy which samples only a small (usually 4mm) part of the lesion is used if the lesion is large, in an inaccessible area, present in a cosmetically sensitive area or near vital structures, to confirm the diagnosis and allow planning of further treatment if required.20

Other relevant investigations may include ultrasound of lymph nodes, CT and MRI for staging or if metastasis is suspected.8

Question 31

Classification systems for SCC of skin

Answer 31

Histopathological
Clinicopathological
Border’s classification

Question 32

Staging of SCC OF THE SKIN

Answer 32

The American Joint Commission on Cancer (AJCC) TNM system is commonly used to stage SCC.23 They are broadly categorised as either low risk or high risk, which helps to direct appropriate management.

High-risk features include:

Size: >2mm deep or >20mm wide
Site: face, ear, genitals, hands, feet
Recurrence
Immunosuppressed individual
Poor differentiation (histologically)
Perineural invasion (histologically)
High tumour budding

Question 33

Management of SCC of the skin

Answer 33

If the tumour is localised and well differentiated, e.g. producing keratin pearls, then there is an approximate 90% cure rate via excisional surgery. There is also an excellent prognosis for treatment of these lesions with radiotherapy.

Large, poorly differentiated lesions have a greater tendency to infiltrate extensively and to cause vascular invasion. Treatment of these lesions may be surgical removal of the primary lesion, or surgery combined with radiotherapy, or radiotherapy as the only treatment method.

Cytotoxic chemotherapy may be used for disseminated disease.

These patients are usually reviewed annually for about 5 years after successful management.

Question 34

Skin cancer and when to refer to NICE SCC of the Skin

Answer 34

consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with a skin lesion that raises the suspicion of squamous cell carcinoma

Question 35

Treatment of Bowen’s disease (SCC in situ)

Answer 35

For Bowen’s disease, destructive therapies such as cryotherapy or topical therapies like 5-fluorouracil are first-line management.8

Cryotherapy, a form of non-surgical destruction, commonly uses liquid nitrogen to freeze the skin lesion.25 Topical 5-fluorouracil, a chemotherapeutic agent, targets the cancerous cells and leads to the resolution of the skin lesion.8

Question 36

Invasive SCC of the skin treatment

Answer 36

For invasive SCC (i.e, SCC growing beyond the epidermis), first-line treatment consists of conventional surgical excision with a minimum of 4mm margins.8

If the SCC is present in a cosmetically sensitive location like the face, then Mohs micrographic surgery, also known as also margin-controlled excision, is the preferred treatment option

Question 37

Metastatic SCC treatment

Answer 37

For metastatic SCC, first-line treatment may consist of surgical excision, radiotherapy and chemotherapy.8 New immunotherapy drugs are also now available for certain cases, for example, immune checkpoint inhibitors.

Question 38

Prevention of SCC of skin

Answer 38

Primary and secondary prevention includes the usage of broad-spectrum sun creams with UV-A and UV-B coverage, physical sun protection, avoidance of the sun and discouraging the use of sunbeds

Question 39

Complications of surgical management of SCC in skin

Answer 39

Bleeding
Post-operative infection
Pain
Scarring (including keloid)
Nerve damage
Physical deformities

Question 40

SCC of salivary gland

Answer 40

Squamous cell carcinoma is one of the less common forms of malignancy in the salivary glands, accounting for 1% of salivary carcinomas

Question 41

What must SCC of the salivary gland be differentiated from?

Answer 41

It must be differentiated from mucoepidermoid carcinoma and metastatic squamous carcinoma in a parotid lymph node. Patients are usually elderly males.

Question 42

SCC of the salivary gland

Answer 42

It is a high grade tumour requiring radical excision and radiotherapy. There is a 30% ten year survival rate.

Question 43

What are some conditions that increase the risk of SCC in the mouth?

Answer 43

Leukoplakia
Erythroplakia

Question 44

What is leukoplakia?

Answer 44

Leukoplakia is characterised by white patches in the mouth, often on the tongue or insides of the cheeks (buccal mucosa). It is a precancerous condition, meaning it increases the risk of squamous cell carcinoma of the mouth.

The patches are asymptomatic, irregular and slightly raised. They are fixed in place, meaning they cannot be scraped off.

Question 45

Management of leukoplakia

Answer 45

They may require a biopsy to exclude abnormal cells (dysplasia) or cancer. Management involves stopping smoking, reducing alcohol intake, close monitoring and potentially laser removal or surgical excision.

Question 46

What is erythroplakia?

Answer 46

Erythroplakia is similar to leukoplakia, except the lesions are red. Erythroleukoplakia refers to lesions that are a mixture of red and white. Both erythroplakia and erythroleukoplakia are associated with a high risk of squamous cell carcinoma and should be referred urgently to exclude cancer.

Question 47

What are some points of consideration in the treatment of salivary gland malignancy?

Answer 47

tumours in the parotid region should be removed by complete local excision - superficial parotidectomy
tumours in the submandibular region require that the entire submandibular triangle be cleared
complete excision is usually sufficient for localised, low-grade malignancy
post-operative radiotherapy should be administered for high-grade malignancy and for incomplete excision
clinically involved lymph nodes should be removed by an appropriate neck dissection, but prophylactic neck dissection is unneccessary except possibly for submandibular cancers
radical surgery is not usually performed when distant metastases are present, except for adenoid cystic carcinoma
the facial nerve should be preserved unless it is paralysed or found to be invaded by tumour. If it must be divided, it can be reconstructed using a nerve graft, e.g. sural nerve. Such grafts are effective in about 60% of cases but complete recovery may take up to 2 years.

Question 48

Head and neck cancers are usually what?

Answer 48

usually squamous cell carcinomas arising from the squamous cells of the mucosa.

Question 49

Locations of head and neck cancers are?

Answer 49

Nasal cavity
Paranasal sinuses
Mouth
Salivary glands
Pharynx (throat)
Larynx (epiglottis, supraglottis, vocal cords, glottis and subglottis)

Question 50

Where do head and neck cancers usually spread to?

Answer 50

lymph nodes first. Squamous cell carcinoma cells may be found in an enlarged, abnormal lymph node (lymphadenopathy), and the original tumour cannot be found. This is called cancer of unknown primary.

Question 51

RFs of head and neck cancer

Answer 51

Smoking
Chewing tobacco
Chewing betel quid (a habit in south-east Asia)
Alcohol
Human papillomavirus (HPV), particularly strain 16
Epstein–Barr virus (EBV) infection

Question 52

Red flag symptoms of head and neck cancer

Answer 52

Lump in the mouth or on the lip
Unexplained ulceration in the mouth lasting more than 3 weeks
Erythroplakia or erythroleukoplakia
Persistent neck lump
Unexplained hoarseness of voice
Unexplained thyroid lump

Question 53

Management of head and neck cancder

Answer 53

Management will be guided by the multidisciplinary team (MDT). It will be dependent on the location, stage and individual patient factors.

Staging usually involves the TNM staging system, grading the tumour, node involvement and metastases.

Treatment may involve any combination of:

Chemotherapy
Radiotherapy
Surgery
Targeted cancer drugs (i.e., monoclonal antibodies)
Palliative care

Cetuximab is an example of a monoclonal antibody used in treating squamous cell carcinomas of the head and neck. It may also be used to treat bowel cancer. It targets epidermal growth factor receptor, blocking the activation of this receptor and inhibiting the growth and metastasis of the tumour.

Question 54

Classification of head and neck neoplasia

Answer 54

neoplasia of the larynx
neoplasia of the oral cavity
neoplasia of the oropharynx
neoplasia of the hypopharynx
neoplasia of the nasopharynx
neoplasia of the nose and paranasal sinuses
neoplasia of the salivary glands
neoplasia of the ear

Question 55

When do pressure ulcers typically occur in patients?

Answer 55

typically occur in patients with reduced mobility, where prolonged pressure on particular areas (e.g., the sacrum whilst sitting) lead to the skin breaking down.

Question 56

Why do pressure ulcers occur?

Answer 56

This happens due to a combination of reduced blood supply and localised ischaemia, reduced lymph drainage and an abnormal change in shape (deformation) of the tissues under pressure

Question 57

Why is it important to spot a pressure ulcer?

Answer 57

Pressure sores may develop rapidly in patients at risk. Once established, they are very difficult to treat so that preventive measures are of utmost importance.

Question 58

Where are pressure ulcers caused

Answer 58

when an area of skin and the tissues below are damaged as a result of being placed under pressure sufficient to impair its blood supply. Typically they occur in a person confined to bed or a chair by an illness and as a result they are sometimes referred to as ‘bedsores’, or ‘pressure sores’

Question 59

Where are pressure ulcers more likely to occur?

Answer 59

pressure ulcers are more likely to occur in people who are seriously ill, have a neurological condition, impaired mobility, impaired nutrition, or poor posture or a deformity
also, the use of equipment such as seating or beds which are not specifically designed to provide pressure relief, can cause pressure ulcers

Question 60

When are pressure ulcers to be expected?

Answer 60

Pressure ulcers are to be expected if erythema appears at a site of pressure which does not blanch on application of pressure by the clinician.
use finger palpation or diascopy to determine whether erythema or discolouration (identified by skin assessment) is blanchable (1)
start appropriate preventative action in adults who have non-blanching erythema and consider repeating the skin assessment at least every 2 hours until resolved

Question 61

Which score provides a means of assessing the likely risk of pressure sores?

Answer 61

Waterlow score

Question 62

Repositioning of patients and ulcers

Answer 62

encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every 6 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required
encourage adults who have been assessed as being at high risk of developing a pressure ulcer to change their position frequently and at least every 4 hours.If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required

Question 63

Pathogenesis of pressure ulcers

Answer 63

pressure:
over the sacrum, greater trochanter, shoulders, occiput and heels
deeper tissues are pressed against bone and experience pressures as much as five times greater than the superficial tissues
ischaemia occurs where the capillary pressures are exceeded for a long while (pressures of 12 to 32 mmHg)

shearing forces:
impair tissue circulation, and stretch and angulate deep tissues

friction:
can cause intraepithelial blistering and superficial erosions
damage is accelerated if the skin is wet

Question 64

What happens initially in a pressure sore?

Answer 64

Initially the tissues of the hypodermis become necrotic followed by the overlying skin. The skin eventually sloughs off leaving a base of necrotic subcutaneous tissue and fat on granulation tissue. Extensive and prolonged pressure may result in ulceration extending to tendons and bone.

Question 65

Waterlow score criteria

Answer 65

weight for height
continence
skin condition
mobility
sex and age
appetite
special risks:
tissue condition and perfusion
neurological dysfunction
major surgery or trauma
medication

0-9 - low risk
10-14 - at risk
15-19 - high risk
20+ - very high risk

Question 66

Risk assessment involved in Prevention of pressure ulcers

Answer 66

be aware that all patients are potentially at risk of developing a pressure ulcer

carry out and document an assessment of pressure ulcer risk for adults: being admitted to secondary care or care homes in which NHS care is provided or receiving NHS care in other settings (such as primary and community care and emergency departments) if they have a risk factor, for example:
significantly limited mobility (for example, people with a spinal cord injury)
significant loss of sensation
a previous or current pressure ulcer
nutritional deficiency
the inability to reposition themselves
significant cognitive impairment

Question 67

Repositioning of patients for pressure ulcers

Answer 67

encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every 6 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required
encourage adults who have been assessed as being at high risk of developing a pressure ulcer to change their position frequently and at least every 4 hours.If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required

Question 68

Daily skin hygiene measures for Pressure ulcers

Answer 68

wash, thorough drying of skin. Do not use talcum powder
consider using a barrier preparation to prevent skin damage in adults who are at high risk of developing a moisture lesion or incontinence-associated dermatitis, as identified by skin assessment (such as those with incontinence, oedema, dry or inflamed skin) (1)

Question 69

What are some pressure relieving devices which redistribute loads?

Answer 69

foam PVC blocks
‘sheepskin’- synthetic sheet with large amounts of air trapped by fibres causing redistribution of pressure over larger surface area
padding mattresses
alternating pressure air mattresses e.g. ‘ripple beds’
air flotation beds

Question 70

Nutritional supplements and hydration for pressure ulcers

Answer 70

do not offer nutritional supplements specifically to prevent a pressure ulcer in adults whose nutritional intake is adequate
do not offer subcutaneous or intravenous fluids specifically to prevent a pressure ulcer in adults whose hydration status is adequate

Question 71

RFs of pressure ulcers

Answer 71

immobility as a principal prerequisite
incontinence
other moisture at site e.g. sweat, pus
reduced sensation
hypotension
oedema
dehydration
septicaemia
inability to communicate discomfort e.g. coma
malnutrition
Age
Trauma

Question 72

Management of pressure ulcers

Answer 72

documentation of site, size and number
pressure relief is vital, be it with regular turning or adjuncts such as air beds
instigate preventative measures for other sites
investigate for other pressure sores risk factors and treat as appropriate
avoid maceration of skin by sweat, urine or pus
ensure patient has adequate nutrition: maintain haemoglobin at normal levels by transfusion of packed cells if necessary
surgical measures