short cases

Question 1

Tell me about BCC what is the appearance?

Answer 1

from the history- slow growing
examination- sun exposed areas, nodular
waxy appearance rolled pearly edges and central ulceration
variants can be superficial *flat red and scaly found on trunk
and pigmented (ddx melanoma)

Question 2

What are the risk factors for BCC

Answer 2

previous exposure to sunlight without sun protection
PMH or FH of BCC
exposure to arsenic

Question 3

so you think this is a BCC how are you going to confirm this?

Answer 3

biopsy and histology if large followed by surgical excision

look for histological analysis

Question 4

What is the treatment for the BCC

Answer 4

excision * MOH’s surgery topical chemotherapy radiotherapy and cryosurgery

Question 5

What is MOh’s surgery?

Answer 5

this involves surgical removal of the obvious tumour and a thin layer of underlying tissue. This layer that is removed is sent off for histological examination- if tumour cells are present than a further deeper layer of tissue is removed and sent for analysis. This process is then repeated until the area is tumour free. This procedure maximises cosmetic outcome while also ensuring entire tumour is removed.

Question 6

How common is BCC?

Answer 6

75% of skin cancer

Question 7

How common is squamous cell cancer?

Answer 7

20% of cancers

Question 8

What is the appearance of a SCC?

Answer 8

typically a fleshy plaque or papule arising on sun exposed skin (70% head and neck) often with bleeding, scaling, or ulceration other forms include a Marjolin ulcer (new area of induration at the edge of the ulcer) Keratoacanthoma rapidly growing nodule with central ulceration that usually spontaneously regresses and is considered by most a variant of SCC.

Question 9

What is the investigation for SCC

Answer 9

biopsy

Question 10

What is the treatment for SCC

Answer 10

surgical excision
topical chemotherapy
photodynamic therapy
immunomodulators used if unsuitable for surgery

Question 11

What is the prognosis for SCC?

Answer 11

localised 95% cure with excision

mets - poor outcome

Question 12

What is the appearance of a malignant melanoma?

Answer 12

When I am looking at a pigmented lesion and trying to determine the likelihood of whether or not it is malignant…

1. asymmetry
2. border irregularity
3. colour variation
4. diameter increasing or greater than 6
5. evolving over time

Question 13

What is the management of malignant melanoma?

Answer 13

surgical excision
lymph node removal (injection of radioactive dye into site- sentinel lymph node biopsy)
chemotherapy

Question 14

What is the prognosis of malignant melanoma?

Answer 14

this depends upon completeness of the excision 
lymph node involvement 
the breslow thickness
These areas are combined into staging 
stage 1 being 5 yr survival of 99% 
stage 4 being 10% 5 year survival

Question 15

What are the risk factors for melanoma?

Answer 15

pale skin, sun exposure sunburn, multiple or congenital naevi.

Question 16

What is a benign lesion that can look like SCC?

Answer 16

actinic keratosis scaly lesions seen on sun exposed skin (fair skinned) usually treated topically.

Question 17

When do you see erythema nodosum?

Answer 17

sarcoidosis, IBD, autoimmune disease

common causes: infections strep, mycoplasma pneumonia, TB and EBV

Question 18

What are the four types of melanoma?

Answer 18

superficial spreading
nodular
lentigo maligna
acral lentiginous

Question 19

investigation of the melanoma

Answer 19

excisional biopsy and 1-3 mm margin

Histological diagnosis: TNM staging

Question 20

treatment of melanoma

Answer 20

Breslow thickness 
0-1 mm 1 cm 
1-2 mm 1-2 cm
2-3 mm 2 cm as going greater than this has not been shown to decrease reoccurrence (clear margin)
3-4 mm 2 cm

Question 21

Is there any additional therapies that can be used in advanced cutaneous melanoma?

Answer 21

immunotherapy based upon genetic subtyping

for example BRAF nivolumab

Question 22

what is a monoclonal antibody?

Answer 22

It is an antibody produced by a single clone of cells. These in medical practice are produced in a lab to target a certain receptor or substance in the body.

Question 23

What are the margins for a BCC?

Answer 23

margin 3-4 mm if less than 6 mm

margin 4-5 mm if greater than 10 mm

Question 24

What is the name of the chemo topical treatment for BCC

Answer 24

imiquimod

Fluorouracil

Question 25

What are the signs of shock?

Answer 25

QSOFA