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Skin Flashcards

1
Q

What are the three main types of skin cancer?

A

Basal-cell skin cancer (basal cell carcinoma)
Squamous cell skin cancer (SCC)
Malignant melanoma

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2
Q

What is the commonest form of skin cancer?

A

Basal cell carcinoma

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3
Q

What are the characteristics of basal cell carcinoma?

A

Slow-growing, locally invasive, malignant epidermal basal layer skin tumour

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4
Q

What are the risk factors for BCC?

A

Exposure to UV light is main aetiological factor
Fitzpatrick skin types I & II: light skin, tans poorly
Male
Mutations in PTCH, p53, ras
Albinism
Gorlin’s syndrome
Xeroderma pigmentosum
Increasing age
Previous skin cancers
Immunosuppression e.g. AIDs, transplantation
Carcinogens - ionising radiation, arsenic, hydrocarbons

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5
Q

What is Gorlin-Goltz syndrome?

A

Nevoid basal cell carcinoma syndrome
Rare autosomal dominant condition, mutation of PTCH1 gene

Early onset BCCS
Broad nasal root
Palmar and plantar pits
Bifid ribs
Hypertelorism - wide spaced eyes
Calcification of faux cerebri
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6
Q

What are the clinical features of a typical nodular BCC?

A

TURP

Presence of irregular pink/skin coloured lesion
Commonly on face/neck

Telangiectasia
Ulceration
Rolled edges
Pearly edge

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7
Q

What are the clinical sub-types of BCC?

A 
Nodular
Superficial
Morphoeic
Pigmented
Basosquamous
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8
Q

What are the features of nodular BCC?

A 
Most cases of BCC
Occur mostly on head
Flesh/red coloured
Well defined borders
Overlying telangiectasias
Rodent ulcer - central ulceration
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9
Q

What are the features of superficial BCC?

A 
Erythematous plaque
Mostly on trunk/limbs
Slow-growing
May be dry/crusted
May have bluish tinge

Numerous of these may indicate arsenic exposure

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10
Q

What are the features of morphoeic infiltrative BCC?

A 
Scar-like lesion or indentation
Commonly occur on upper trunk or face
Whitish, compact
Poorly defined plaque/scar
Deeply invasive
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11
Q

What are the features of pigmented BCC?

A

Difficult to distinguish from melanoma
Pigmentation due to melanin production, why it is hard
Often excised with 2mm margin as a result

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12
Q

What are the features of basosquamous BCC?

A

Rare but agressive
Increased risk of recurrence and metastasis
Differentiation towards SCC
Has macro and histopathological features of both

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13
Q

What surgical management is available for BCC?

A

Excision - wide local or Moh’s micrographic surgery for high risk lesions
Destructive - curettage, cautery, cryotherapy, carbon dioxide laser (these don’t provide histological sample, so low risk lesions only)

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14
Q

What non-surgical management is available for BCC?

A

Radiotherapy -
Adjuvant
Prevent recurrence e.g. incompletely excised margins
Recurrent BCC
High risk BCCs; and surgery not appropriate

NB risk of radiation induced BCC in those with Gorlin’s

Topical immunotherapy e.g. Imiquimod
PDT

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15
Q

What are the features of a high risk BCC lesion?

A

Size > 2cm
Site - around eyes, lips, ears
Poorly defined margins
Histological sub-type - morpoeic, infiltrative, micro nodular, basosquamous
Histological features - perineural, perivascular inv
Previous tx failure
Immunosuppression

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16
Q

What are the surgical excision margins for BCC?

A

Lesions should be excised down to subcutaneous fat to ensure entirety of skin; epidermis and dermis is included in sample

Low risk lesions - (small <2cm, well defined) margin of 4-5mm = 95% clearance

High-risk lesions - (large >2cm poorly defined) 5mm provides 83% clearance

Recurrent lesions - referral to Skin MDT, re-excision of scar 5-10mm margins or Moh’s surgery and radiotherapy

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17
Q

What is Moh’s surgery?

A

Surgical removal of tissue
Free margin removed can be less
Mapping piece of tissue, freezing and cutting, staining
Interpretation of slides, determines if any more needs to be removed
Possible reconstruction of surgical defect

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18
Q

What is the system used to describe a skin lesion?

A 
A - asymmetry
B - border irregularity
C - colour (varies)
D - diameter (greater than 6mm)
E - evolving (change in shape, size or shade)
F - funny looking
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19
Q

Describe how BCC grow

A

Slow growing
Locally Invading
Very rarely metastasis

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20
Q

What cells do BCC’s arise from?

A

Epidermal tumours arising from hair follicles

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21
Q

Describe the appearance of solar (actinic) keratoses:

A

On sun-exposed skin

Crumbly, yellow-white crusts

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22
Q

What is the risk associated with actinic keratoses?

A

Malignant change to squamous cell carcinoma may occur after several years

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23
Q

How should actinic keratoses be managed?

A

Cryotherapy or fluorouracil/imiquimod cream

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24
Q

Describe the appearance of Bowen’s disease:

A

Slow growing red/brown scaly plaque

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25
How should Bowen's disease be managed?
Cryo, topical fluorouracil, photodynamic therapy
26
Describe the appearance of keratoacanthoma:
Dome-shaped erythematous lesions that grow rapidly and often contain a central pit of keratin
27
name 3 genetic conditions associated with increased risk skin ca
- gorlins syndrome (PTCH1 gene mutation leading to increased risk nevoid BCC) - xeroderma pigmentosa - albinism
28
How should a suspected BCC be referred?
- routine referral if suspect BCC | - 2WW if concern that delay would have impact either bc or site or feature of the lesion
29
How should BCC be investigated?
- excision biopsy - incision biopsy before non surgical treatment to confirm diagnosis - examine for lymphadenopathy - MRI or CT only when bony involvement suspected or tumour invaded major nerves, orbit or parotid gland
30
What is squamous cell carcinoma?
Malignant tumouR Keratinising cells of the basal layer of the epidermis Locally invasive Potential to metastasise
31
What are the risk factors for SCC?
UV light Fair skin Chemical carcinogens - arsenic, chromium, soot, tar and pitch oils HPV Ionising radiation exposure Immunodeficiency Chronic inflammation - near chronic ulcers, lupus vulgaris Genetic conditions e.g. albinism, xeroderma pigmentosum Pre-malignant conditions e.g. Bowen's disease
32
Where do most invasive SCCs originate from?
Actinic keratoses
33
What are the features of actinic keratosis?
Macule or patch On areas that receive large amounts of sunlight: head and neck, dorsum of hands, forearms Erythematous base Overlying scale Typically non tender
34
What is cutaneous squamous cell carcinoma in situ?
``` Bowen's disease Most common on lower limbs Erythematous, well defined borders, patches/plaques Round to oval shape Rough scale Grows very slowly ```
35
What are some differentials for Bowen's disease?
Psoriasis Invasive cSCC Superficial BCC
36
Where can invasive cutaneous SCC occur?
Arise from any cutaneous surface Most frequently head and neck Legs, hands, forearms, shoulder, back, chest, abdomen
37
What are the characteristics of a well differentiated invasive cSCC?
``` Papule, plaque or nodule 0.5-1.5cm or larger Erythematous base Rough scale, crusting May have ulceration Firm, indurated on palpation ```
38
What are the features of a poorly differentiated invasive cSCC lesion?
``` Papule or nodule Granulomatous Lack scale May have ulceration, haemorrhage, necrosis Fleshy and soft on palpation ```
39
How do invasive cutaneous cSCC lesions evolve?
Grows over period of months Becomes increasingly tender More likely to ulcer and bleed May present as a non-healing wound, asymptomatic
40
What are the differential diagnoses for invasive cSCC?
Actinic keratosis Superficial BCC Warts Pyogenic granuloma
41
What are the investigations fo SCC?
Visual inspection and removal for histology where necessary Excision biopsy - whole lesion excised Incisional or punch biopsy if lesion in large, in cosmetically sensitive areas, close to vital structures If advanced disease - imaging including CT scanning for bone or soft tissue spread, MRI scan Clinically enlarged nodes should be examined histologically e.g. by fine needle aspiration
42
At which sites can squamous cell carcinoma of the skin develop from (predisposing sites)?
Actinic keratoses, lips of smokers, or in long standing ulcers (Marjolin’s)
43
How should Bowen's disease be managed?
Cryo, topical fluorouracil, photodynamic therapy
44
Describe the appearance of keratoacanthoma:
Dome-shaped erythematous lesions that grow rapidly and often contain a central pit of keratin
45
What are the high risk features of cutaneous squamous cell carcinoma?
``` >2cm in size High risk locations - ear, lip, genitals Rapid growth Immunosuppressed patient Arisen from within trauma site Recurrent disease Incomplete excision ```
46
What management is available for SCC?
Complete surgical excision and all excised specimens sent for histological exam Curettage and cautery to remove soft material from tumour, base of tumour then destroyed Best in small lesions Cryotherapy for small in situ SCCs and pre-cancerous lesions Topical treatment with Imiquimod 5% for actinic keratosis Photodynamic therapy - light therapy and a topical photosensitising agent Radiotherapy Moh's micrographic surgery
47
What is a difference between BCC and SCC?
SCCs are less common than BCCs, but metastasise more frequently than BCCs
48
What are the features of suspicious of melanoma?
ABCDE ``` Asymmetry Border - irregular Colour - alterations Diameter >6mm Evolving lesions ```
49
What are risk factors for melanoma?
``` Exposure to UV light Severe sun burn Immunosuppression Skin types I and II Family history Genetic mutations ```
50
How does distribution between sexes differ in melanoma?
1.5x more common in men In men lesions on trunk In women, lesions on arms and legs
51
What is melanoma?
Originates from uncontrolled proliferation of melanocytes in the basal epidermis
52
Describe the typical tumour progression of melanoma?
Benign naevus - typical mole, controlled proliferation of melanocytes Dysplastic naevus - atypical mole, abnormal proliferation results in pre-malignant lesion Radical growth phase Vertical growth phase - invade basement membrane, proliferate vertically downwards Metastasis - malignant cells may spread to other areas
53
What are the clinical features of melanoma?
Mostly arise de novo Appear as pigmented lesion with irregular border Tendency to grow or change ABCDE
54
What biopsy is available for melanoma?
Excision biopsy of the suspicious lesions Completely excised with a margin of 1-2mm of healthy surrounding skin Includes portion of subcutaneous fat to ensure full-thickness of dermis sampled Orientation important - longitudinal lesions preferred on the limbs Incisional biopsy - punch or incision for small sample for large lesions or close to vital structures - eyes, ears, nose
55
What are the major subtypes of melanoma?
Superficial spreading - initial radial growth progresses to vertical growth Nodular - transition quickly to vertical growth Acral lentiginous - under nails, hands and feet, black line on nail = Hutchinson's sign Lentigo maligna - common in elderly, chronically sun-exposed sites Desmoplastic - very rare, due to abnormal deposits of collagen
56
What are the features of histological analysis of melanoma?
Clark level: I-V histological classification for depth of invasion ``` Breslow thickness (mm): Measured from stratum granulosum of epidermis or from bottom of ulceration to the point of maximum infiltration ``` Ulceration: Absence of intact epithelium overlying the lesion Correlates with poorer prognosis, suggestive of aggressive tumour phenotype Mitotic index Indicator of cell turnover Important histological finding Number of mitoses per mm2
57
What are the investigations for melanoma?
Careful skin and lymph node examination FNA and cytology if suspicious lymph node Total body CT or PET-CT for high-risk lesions - those with aggressive lesions, or presence of known lymph node spread LDH (lactate dehydrogenase blood marker of cell turnover) for risk stratifying
58
What is the staging of melanoma based on?
TNM system - Tumour - breslow thickness (mm) +- presence of ulceration Node - whether melanoma has spread to lymph nodes and how many Mets
59
What is the AJCC (American Joint Committee on Cancer) system of staging?
Stage 0 - melanoma in situ Abnormal cells only present in the top layer of skin - epidermis, not spread to dermis Stage I IA - <0.8mm thick, no ulceration IB - <0.8mm, ulceration or 1-2mm thick, no ulceration Stage II usually thicker but not spread IIC is >4mm with ulceration Stage III - lymph node involvement Stage IV metastatic spread
60
What is the surgical management of melanoma?
Wide local excision for primary melanoma, removal of biopsy scar, margin depends on Breslow thickness Senital lymph node biopsy under GA at same time as WLE - radio-labelled tracer and CT identifies hot spots, further shown in surgery with blue dye Positive SLNB results in subsequent lymphadenectomy Electro-chemotherapy For locally advanced melanoma Chemo agent given IV or injected into the tumour, then powerful pulses of electricity applied to the tumour Increases permeability of tumour cell membranes so chemo agent can pass through
61
What is the medical management of melanoma?
Adjuvant therapy e.g. interferon alpha | Chemo, radio, immuno
62
Describe the clinical features of melanoma
- lesion changed in size - irregularity of pigmentation (may need dermatoscope to appreciate) - irregularity of outline - size >6mm - inflammation - oozing or bleeding - itch or altered sensation - risk factors identified - not all melanomas are pigmented but most are
63
what are the criteria for melanoma 2WW
``` - 2WW if 3 or more points from: 2 points: - change in size - irregular shape - irregular colour 1 point: - >6mm - inflammation - oozing - change in sensation ```
64
how should melanoma be investigated?
- narrow margin excisional biopsy initally - dermoscopy - sentinel node biopsy - CXR, liver USS, CT CAP - FBC, LFT, LDH - bone scan
65
Describe the breslow scale
- about depth of invasion at biopsy, strongly correlated with survival - Tis= top layer of skin - T1= 1mm thick or less - T2= melanoma between 1 and 2mm thick - T3= 2-4mm thick
66
How can stage 0-2 melanoma be managed?
- PDT if insitu - excision (see margins) - imiquimod cream for stage 0 melanoma and surgery wants to be avoided
67
How should stage 3 (spread to nearest LN or blood vessel but no systemic spread) melanoma be managed?
- complete lymphadenectomy if node biopsy shows micromets - lymph node dissection: palpable stage 3b-c or nodal disease detected by imaging - adjuvant radiotherapy for stage 3b pr c unless reduction in risk of local reoccurrence outweighs side effect risk - excision of tumour
68
How should stage 4 melanoma be managed?
- surgery to excise - targeted treatments: dabrafenib for unresectable or metastatic BRAF V600+ve melanoma - immunotherapy: ipilimumab (CTLA-4 blocker) for unresectable or metaststic melanoma in those who have had prior therapy - cytotoxic chemo if immuno or targeted therapy not suitable - palliative care
69
Describe the Glasgow 7-point checklist for malignant melanoma and when you should refer:
Major (2pts): change in size, shape, colour Minor (1pt): inflammation, sensory change, diameter >6mm, crusting/bleeding Refer if 3+
70
What is a lentigo maligna?
It is an area of "sun damaged skin" that is a melanoma in situ
71
Where do malignant melanomas metastasise?
Bone, brain, lung, liver
72
What are some poor prognostic indicators for malignant melanoma?
High Breslow thickness Ulcerated Node involvement Location of head, neck, back of arms

Cancer Care (15 decks)

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