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Plastics ST3 > Skin > Flashcards

Skin Flashcards

1
Q

Layers of the skin

A

Epidermis: (CLGSB)
- Stratum Corneum
- Stratum Lucidum
- Stratum Granulosum
- Stratum Spinodum
- Stratum Basale

Dermis:
- Papillary Dermis
- Reticular Dermis

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2
Q

What is squamous cell carcinoma (SCC)?

A

Malignant tumor from squamous epithelial cells.
Commonly affects skin; can involve lungs, mouth, genitals.
2nd most common skin cancer.

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3
Q

Main risk factors for SCC?

A

UV radiation (sun/tanning beds).
Immunosuppression (HIV, transplants).
Carcinogens (arsenic, tobacco).
Chronic inflammation (scars, ulcers).
HPV infection, fair skin.

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4
Q

How does SCC develop?

A

DNA damage (e.g., UV, carcinogens) mutates squamous cells.
p53 gene mutations disrupt cell cycle, causing growth.
Progresses from actinic keratosis to invasive SCC.

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5
Q

How does skin SCC present?

A

Scaly, red patch or firm nodule.
Non-healing ulcer, bleeding/crusting.
Found on sun-exposed areas (face, hands).

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6
Q

SCC presentation in non-skin?

A

Mouth/Esophagus: Painful ulcer, difficulty swallowing.
Lungs: Persistent cough, hemoptysis, chest pain.

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7
Q

Key histopathological features of SCC?

A

Atypical squamous cells invade dermis.
Keratin pearls (well-differentiated SCC).
High mitotic activity in poorly differentiated SCC.

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8
Q

What is Bowen’s Disease

A

Intra-epidermal SCC/ in-situ SCC

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9
Q

How does SCC differ from BCC and melanoma?

A

BCC: Less metastatic, pearly nodules.
Melanoma: Aggressive, arises from melanocytes, changing mole

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10
Q

Questions in the history for skin cancer?

A

PC:
Onset, development
Ulcerating, itching, bleeding, pain
Systemic/constitutional symptoms: cough, WL, tiredness, night sweats, headache

RFs: , PMHx/FHx of skin cancer, Sun exposure, history of blistering sunburn, outdoor occupation, tanning beds

PMHx: FIT, Genetic cancer syndromes: Gorlin’s Syndrome for BCC

DHx: immunosuppressants, anticoagulants, allergies

SHx: Smoking, alcohol, Home situation, social support

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11
Q

What examination would you perform in skin cancer clinic?

A

General: Pale skin, freckles

Lesion
A: Asymmetry
B: Border (irregular or poorly defined border)
C: Colour (>3 colours)
D: Diameter (>6mm)
E Evolving (change in colour or shape)
F: Fixed to underlying structures

Locoregional examination: Satellite lesions, local metastasis, Lymph nodes

Full skin examination with chaperone
Clinical photography with consent

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12
Q

What are the specific body areas for site assessment in classification cSCC?

A
  1. Head, neck, trunk, and limbs
  2. Genital/perianal
  3. Eyelid
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13
Q

If the cSCC lesion is located on the genital or perianal area, what is the next step?

A

Refer to a site specialist team.

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14
Q

What are the clinical staging size thresholds for cSCC lesions on the head, neck, trunk, or limbs?

A

T1: ≤ 20 mm
T2: > 20 to ≤ 40 mm
T3: > 40 mm

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15
Q

What are the clinical staging size thresholds for cSCC lesions on the eyelid?

A

T1: ≤ 10 mm
T2: > 10 to ≤ 20 mm
T3: > 20 mm

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16
Q

What additional clinical features are included in staging for cSCC eyelid lesions (apart from diameter)?

A

Involving the tarsal plate or lid margin:
T1b, T2b, or T3b if involved
T1a, T2a, or T3a if not involved

Full thickness of eyelid:
T1c, T2c, or T3c

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17
Q

What is the next step when assessing cSCC, if there is clinically positive nodes?

A

USS/FNAC and/or FNAB

If no nodes: incision/excision biopsy

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18
Q

How can be cSCC lesions be classified in terms of risk?

A

Low risk
High risk
Very high risk

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19
Q

Features of low risk cSCC

A

Clinical:
Tumour diameter <20mm (T1)

Histological:
Tumour thickness <4mm
No invasion into Dermis
No perineural/lymphovascular invasion

Patient:
Immuno-competent

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20
Q

Features of high risk cSCC

A

Clinical:
Tumour diameter 20 - 40 mm (T2)
Ear/Lip
From scar/chronic inflammation

Histological:
Tumour thickness 4 - 6mm
Invasion into Subcut fat
Perineural (dermal only)
Lymphovascular invasion

Patient:
Iatrogenic/biological immunocompromised

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21
Q

Features of very high risk cSCC

A

Clinical:
Tumour diameter >40mm (T3)
In transit metastasis

Histological:
Tumour thickness >6mm
Invasion beyond Subcut fat/into bone
Perineural (nerve beyond dermis/named nerve)
Lymphovascular invasion

Patient:
Iatrogenic/biological immunocompromised. Solid organ transplant recipient. Haematological malignancy (CLL/myelofibrosis)

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22
Q

Excision margins for Low risk cSCC?

A

Peripheral: ≥ 4 mm
Deep: “For mobile lesions the deep margin should be within the next clear surgical plane, and on the scalp the excision should include the galea.”

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23
Q

Excision margins for high risk cSCC?

A

Peripheral: ≥ 6 mm
Deep: “For mobile lesions the deep margin should be within the next clear surgical plane, and on the scalp the excision should include the galea.”.

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24
Q

Excision margins for very high risk cSCC?

A

Peripheral: ≥ 10 mm
Deep: “For mobile lesions the deep margin should be within the next clear surgical plane, and on the scalp the excision should include the galea.”

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25
Q

Follow up for low risk cSCC?

A

Single post-treatment appointment

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26
Q

Risk of recurrence for low risk cSCC?

A

40%: further keratinocyte cancer within 5 years

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27
Q

Follow up for high risk cSCC

A

4monthly for 12 months
6 monthly for second year

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28
Q

Risk of recurrence for high/very high risk cSCC?

A

Patients with more than one proior keratinocyte cancer have 80% chance of further keratinocyte cancer within 5 years

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29
Q

Follow up for very high risk cSCC?

A

4monthly for 2 years
6 monthly for third year

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30
Q

What is the first step in the management pathway for cSCC?

A

Freely mobile: offer surgical excision/Mohs/C&C

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31
Q

What margins following cSCC would indicate clearance?

A

> 1mm (peripheral and deep)

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32
Q

How would you manage a patient with cSCC with positive margins

A

Positive margin or <1mm peripheral/deep.
SSMDT discussion
Offer: re-excision/Mohs/Radiotherapy

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33
Q

How do you classify nodal staging (TNM) in cSCC?

A

Non-head and neck
N1: single node ≤ 3 cm
N2: single ipsilateral node 3-6 cm, multiple nodes <6cm
N3: node > 6 cm

Head and neck region
N1 single ipsilateral node ≤ 3 cm without ENEa (extra nodal extension)
N2a: single ipsilateral node 3-6 cm without ENE
N2b: multiple ipsilateral nodes <6 cm without ENE
N2c: Bilateral or contralateral nodes <6cm without ENE
N3a: single or multiple nodes > 6 cm without ENE
N3b: nodes with ENE

34
Q

How do you classify metastasis staging (TNM) in cSCC?

A

M0: No distant metastasis
M1: Distant metastasis (including contralateral nodes in non-head and neck cSCC)

35
Q

How do you classify tumour staging (TNM) in cSCC?

A

T1: ≤ 2 cm
T2: > 2 to 4 cm
T3: > 4 cm or minor bone erosion or specified perineural invasion (≥ 0.1 mm diameter and/or deeper than the dermis and/or a named nerve) or deep invasion (thickness > 6 mm and/or beyond the subcutaneous fat)

T4a: Tumour with gross cortical bone/marrow invasion
T4b: Tumour with skull base or axial skeleton invasion including foraminal involvement and/or vertebral foramen involvement to the epidural space

36
Q

What is Basal Cell Carcinoma (BCC)?

A

Most common type of skin cancer.

A slow-growing, locally invasive skin cancer arising from basal cells in the epidermis.

37
Q

Types of BCC

A

27 Types
Nodular (most common): Pearly, dome-shaped papule with telangiectasia.

Superficial: Erythematous, scaly plaque with a thread-like border.

Morpheaform/Sclerosing: Waxy, scar-like lesion; more aggressive.

Pigmented: Brown/black pigmentation, mimicking melanoma.

38
Q

How can you classify BCC by risk?

A

Low risk
High risk

39
Q

Features of low risk BCC?

A

Area Lb < 20 mm
Trunk and extremities but excluding hands, nail units, genitals, pretibia, ankles and feet.

Area Mc < 10 mm
Cheeks, forehead, scalp, neck and pretibia

Well defined borders
Immuno-competent
Type: Nodular/superficial
Contained within subcut fat
<6mm depth
No perineurial/lymphovascular invasion

40
Q

Features of high risk BCC?

A

Area Lb > 20 mm
Trunk and extremities but excluding hands, nail units, genitals, pretibia, ankles and feet.

Area Mc > 10 mm
Cheeks, forehead, scalp, neck and pretibia

Area Hd
Periorbital, temple, ear, lips, mandibular margin

Poorly defined borders
Immunocompromised
Type: Infiltrative
Invading beyond subcut fat
>6mm depth
Perineurial/lymphovascular invasion

41
Q

Excision margins for BCC?

A

Low risk: >4mm
High risk: >5mm
“Excise BCC by ensuring adequate excision at the deep margin to a clear plane, including a fat layer where pre- sent, and other deeper structures if needed.”

42
Q

Treatment options for low risk BCC?

A

Standard surgical excision
Topical imiquimod/5-fluorouracil
Cryosurgery
Curette & cautery
Photodynamic therapy
Radiotherapy

43
Q

Treatment options for high risk BCC?

A

Standard excision
Mohs

44
Q

Treatment options for high risk BCC, if patient unsuitable or declines surgery?

A

Primary: Radiotherapy
Recurrent or advanced: Radiotherapy or Vismodegib

45
Q

Mechanism of action of Vismodegib

A

Vismodegib selectively binds to and inhibits the transmembrane protein smoothened homologue (SMO) to inhibit the Hedgehog signalling pathway.

46
Q

Mechanism of action of Imiquimod

A

Activate toll like receptor 7 (TLR7), which activates innate immune system

47
Q

Mechanism of action of 5-fluorouracil

A

Thymidylate synthesis inhibitor.
Blocks production of dTMP damaging and preventing DNA replication

48
Q

What is melanoma?

A

Malignant tumor of melanocytes, commonly occurring on the skin, but also in other melanocyte-containing sites like eyes (uveal melanoma) or mucosal surfaces.

49
Q

Types of melanoma?

A

Superficial Spreading (70% of cases): Common on sun-exposed skin. Irregular borders, color variation.

Nodular (15-20%):
Aggressive, vertical growth phase dominates. Dark, raised lesion.

Lentigo Maligna Melanoma (5-10%):
Found in older individuals with chronic sun damage. Slowly progressive; starts as lentigo maligna (in situ).

Acral Lentiginous Melanoma (<5%): palms, soles, or under nails. More common in darker-skinned individuals.

Desmoplastic Melanoma: Rare

50
Q

What will you look for in the histology report for melanoma?

A

Breslow thickness
Differentiation
Subtype
Ulceration
Lymphovascular invasion
Mitotic Rate

51
Q

What factors affect tumour staging (TNM) for melanoma?

A

Breslow thickness
Ulceration
Lymphovascular invasion
Mitotic index of 2 or more

52
Q

Melanoma: T1a

A

Breslow Thickness: <0.8mm
No Ulceration/Lymphovascular Invasion/
Mitotic rate <2

53
Q

Melanoma: T1b

A

Breslow Thickness: <0.8mm
Ulceration/Lymphovascular Invasion/ Mitotic rate>2

or
Breslow Thickness: 0.8-1mm

54
Q

Melanoma: T2a

A

Breslow Thickness: 1-2mm
No Ulceration/Lymphovascular Invasion/
Mitotic rate <2

55
Q

Melanoma: T2b

A

Breslow Thickness: 1-2mm
Ulceration/Lymphovascular Invasion/ Mitotic rate >2

56
Q

Melanoma: T3a

A

Breslow Thickness: 2-4mm
No Ulceration/Lymphovascular Invasion
Mitotic rate <2

57
Q

Melanoma: T3b

A

Breslow Thickness: 2-4mm
Ulceration/Lymphovascular Invasion/ Mitotic rate>2

58
Q

Melanoma: T4a

A

Breslow Thickness: >4mm
No Ulceration/Lymphovascular Invasion
Mitotic rate <2

59
Q

Melanoma: T4b

A

Breslow Thickness: >4mm
Ulceration/Lymphovascular Invasion/ Mitotic rate>2

60
Q

Excision margins for T1 MM

A

1cm

61
Q

Excision margins for T2 MM

A

2cm

62
Q

Excision margins for T3/T4 MM

A

> 2cm

63
Q

What is the next step in management for stages IB - IIB MM

A

WLE +/- SNLB

64
Q

What is the next step in management of IIB - IV MM

A

CT Scan

65
Q

What is the next step in management if SNLB is positive in MM

A

Lymph node dissection +/- Adjuvant SACT

66
Q

Differential Diagnosis for MM

A

Cherry angioma.
Angiokeratoma.
Dermatofibroma.
Freckles (ephelides).
Kaposi’s Sarcoma.
Lentigo.
Junctional naevus.
Compound Naevus.
Halo naevus.
Blue naevus.
Spitz naevus. E
Pigmented BCC.
Pyogenic granuloma.
Seborrhoeic keratosis.

67
Q

Cherry Angioma

A

Benign vascular lesions caused by proliferating endothelial cells. Small firm, popular angioma. Red, purple or blue inn colour. 1-10mm in diameter.

68
Q

Kaposi’s Sarcoma.

A

Malignant growth of blood vessels. Most commonly associated with HIV. Reddish/purplish macules which develop into modules or plaques. Usually, multiple lesions which may ulcerate or bleed.

69
Q

Angiokeratoma

A

Asymptomatic hyperkeratotic vascular skin lesion. Small (rarely >5mm) dark red to purple papules, nodules or plaques. Lesions are prone to thrombosis results in sudden colour change.

70
Q

Lentigo

A

Flat pigmented, well defined benign lesion. Doesn’t fade in winter. Types: Lentigo simplex, Solar lentigo, ink spot, lentigo, PUVA lentigo, mucosal. Can be associated with syndromes: Noonan with multiple lentigines (formerly LEOPARD), Peutz-Jeghers.

71
Q

Dermatofibroma

A

Benign fibrous nodule usually found in lower legs. Tethered to the surface, mobilse over subcutaneous tissue. Usually 5-15mm in diameter. Pink to light brown on white skin.

72
Q

Junctional naevus.

A

Groups or nests of naevus calls at the junction of epidermis and dermis. Flat, well defined, pigmented lesion.

73
Q

Compound Naevus

A

Nests of naevus cells at the epidermal-dermal junction as well as within the dermis. Raised central area surrounded by a flat patch.

74
Q

Freckles (ephelides)

A

Light to dark macules. More prominent in summer and fade in winter

75
Q

Halo naevus.

A

Naevus surrounded by a white patch and fade away after several years. Consider to be autoimmune process against melanoctyes.

76
Q

Blue naevus

A

Blue because of Tyndall effect in which shorter wavelengths of light are scattered by dermal melanocytes. Blue because deeper into tissues.

77
Q

Pyogenic granuloma

A

Acquired benign proliferation of capillary blood vessels of skin, which can develop in response to trauma, hormone changes, medication, infection. Painless, red, fleshy nodule, Typically 5-10mm that grows rapidly over a few weeks. Fingers and face most common sites. Smooth surface that is fragile and crust, ulcerate or bleed.

78
Q

Spitz naevus.

A

Epithelioid cell naevus. Pink (classic Spitz) or pigmented dome shaped mole that arises in children and young adults.

79
Q

Seborrhoeic keratosis

A

Caused by proliferation of epidermal keratinocytes. Raised plaques with “stuck on” appearance

80
Q
A

Plastics ST3 (11 decks)

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