Pressure sores and Squamous cell carcinoma Flashcards

Question

Areas to cover in history for SSC skin

Answer 1

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

Answer 2

- 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)

Answer 3

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

Answer 4

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

Answer 5

Actinic keratosis Basal cell carcinoma Seborrhoeic keratosis

Answer 6

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

Answer 7

Histopathological Clinicopathological Border’s classification

Answer 8

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

Answer 9

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.

Answer 10

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

Answer 11

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

Answer 12

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

Answer 13

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.

Answer 14

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

Answer 15

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

Answer 16

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

Answer 17

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

Answer 18

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

Answer 19

Leukoplakia Erythroplakia

Answer 20

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.

Answer 21

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.

Answer 22

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.

Answer 23

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.

Answer 24

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

Answer 25

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

Answer 26

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.

Answer 27

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

Answer 28

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

Answer 29

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.

Answer 30

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

Answer 31

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.

Answer 32

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

Answer 33

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.

Answer 34

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'

Answer 35

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

Answer 36

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

Answer 37

Waterlow score

Answer 38

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

Answer 39

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

Answer 40

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.

Answer 41

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

Answer 42

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

Answer 43

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

Answer 44

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)

Answer 45

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

Answer 46

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

Answer 47

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

Answer 48

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