Skin Flashcards by Mario Luna

Skin

Which of the following hereditary disorders is not associated with the development of skin cancer?

Xeroderma pigmentosum
Basal cell nevus syndrome
Neurofibromatosis type I
Albinism
Congenital epidermolysis bullosa

NF1

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Skin

What is the most common risk factor for the development of skin cancer?

sun exposure

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Skin

Skin cancer incidence increases with increasing Fitzpatrick skin type.

TRUE or FALSE?

False.

Increasing fitzpatrick type is associated with lesser burns and tans with sun exposure hence lesser incidence of skin cancer.

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Skin

Which of the following immune disorders is not associated with the development of skin cancer?

Myasthenia gravis
Chronic lymphocytic leukemia
Solid organ transplant patients
Discoid lupus erythematosus

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Skin

Enumerate the layers of the epidermis from superficial to deep.

Stratum corneum
Stratum lucidum
Stratum granulosum
Stratum spinosum
Stratum basale

(CLGSB)

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Skin

Which is/are true regarding the epidermis?

I. The epidermis is thinner in the face than in most portions of the body, measuring
approximately 1 mm.

II. The epidermis gets thinner with increasing age.

III. Men have thicker epidermis than women.

None

I. 0.04 mm
II. No change
III. No difference

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Skin

Which is/are true regarding the epidermis?

I. The dermis, which contains the blood and lymphatic vessels, adnexa, hair
follicles, sweat glands, and sebaceous glands, is 1 to 2 mm thick

II. the dermis of
the eyelid is thinner, ≤0.6 mm

III. No distinct transition occurs from
the dermis to the subcutaneous layer

All

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Skin

The density of the capillary lymphatics has been noted to be about the same in all areas, except the palms and soles, where it is denser.

TRUE or FALSE?

True.

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Skin

What is the most common histology of skin cancers?

BCC (>60%)

followed by SCC (≥30%)

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Skin

What histologic subtype of BCC shows little surface disease and a marked infiltrating pattern; it is an important subtype because of the higher risk for recurrence.?

morphea type (sclerosing)

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Skin

Most SCCs are well-differentated.

TRUE or FALSE?

True.

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Skin

Fill in the blanks.

_________ is a benign tumor of the skin that grossly resembles ________ and microscopically resembles _________.

Keratoacanthoma

cystic BCC

SCC or squamous papilloma

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Skin

“The diagnosis of keratoacanthoma can only be made with absolute certainty by biologic behavior in the form of __________.”

eventual involution

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Skin

What virus is associated with Merkel cell carcinoma?

This is associated with worse prognosis. TRUE or FALSE?

Polyomavirus

False.

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Skin

SCC vs. BCC

___ occurs more frequently around the central portion of the face, whereas ___ occurs more often on the ears, preauricular and temporal area,
scalp, and skin of the neck.

BCC

SCC

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Skin

SCC vs. BCC

Which is prone to enter the lymphatics?

SCC

Of note, BCCs rarely metastasize in the lymph nodes. When they do, it’s usually during a recurrence.

It is common for SCC and BCC to have a delayed lymphatic spread (>5 years) and is often missed.

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Skin

SCC vs. BCC

Which is prone to develop distant metastasis?

SCC

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Skin

What cranial nerves are most commonly affected by PNI?

V2 and VII

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Skin

Biopsy should be performed on the majority of lesions before deciding on treatment.

Based on Perez’ chapter on skin, the exception is:

for elderly patients who have a

typical skin carcinoma and are to be treated by RT.

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Skin

Small lesions occurring on the free skin areas usually can undergo biopsy and be treated
simultaneously with surgical excision.

When is simultaneous excision not advisable?

larger lesions

lesions involving areas of potential functional/cosmetic deficit might occur from excision.

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Skin

Shave biopsies are
also often used, except in pigmented lesions where a _____ is suspected.

melanoma

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Skin

What type of biopsy is usually advised/preferred for melanoma?

full-thickness skin biopsy (punch)

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Skin

What are the three stages of MCC based on the Yiengpruksawan system?

I - localized
II - regional nodes
III - distant metastasis

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Skin

AJCC TNM for head and neck SCC

Identify the T-stage and why?:

3 cm

Tumor 2 cm or larger, but smaller than 4 cm in greatest dimension

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Skin AJCC TNM for head and neck SCC Identify the T-stage and why?: 1 cm with PNI

T3 Tumor 4 cm or larger in maximum dimension of minor bone erosion or perineural invasion or deep invasion

Skin AJCC TNM for head and neck SCC Identify the T-stage and why?: 1 cm

T1 Tumor smaller than 2 cm in greatest dimension

Skin AJCC TNM for head and neck SCC Identify the T-stage: gross cortical bone invasion

T4a

Skin AJCC TNM for head and neck SCC Identify the T-stage: base of skull foramina involvement

T4b

Skin AJCC TNM for head and neck SCC Identify the T-stage: gross marrow involvement

T4a

Skin AJCC TNM for head and neck SCC Identify the T-stage: 1 cm but with 3 mm invasion beyond the subcutaneous fat (as measured from the granular layer of adjacent normal epidermis to the base of the tumor)

T1 | still not deep invasion deep invasion is >6 mm then this tumor will be staged as T3

Skin AJCC TNM for head and neck SCC Identify the N-stage: ENE+

N3b

Skin AJCC TNM for head and neck SCC Identify the N-stage: (assuming ENE-) 7 cm

N3a

Skin AJCC TNM for head and neck SCC Identify the N-stage: (assuming ENE-) 1 cm bilateral

N2c

Skin AJCC TNM for head and neck SCC Identify the N-stage: (assuming ENE-) <3 cm, multiple ipsilateral

N2b as long as ipsilateral and <6 cm

Skin AJCC TNM for head and neck SCC Identify the N-stage: (assuming ENE-) <3 cm, single ipsilateral

Skin AJCC TNM for head and neck SCC Identify the N-stage: (assuming ENE-) >3 and <6 cm, single ipsilateral

Skin AJCC TNM for head and neck SCC Identify the stage group. T4 N0 M0 (also identify other combinations that would be classified in the same stage as with this combination)

Stage IV T4 N0 M0 any N2 any M1

Skin AJCC TNM for head and neck SCC Identify the stage group. T3 N0 M0 (also identify other combinations that would be classified in the same stage as with this combination)

Stage III T3 N0 M0 T1-3 N1 M0

Skin AJCC TNM for melanoma. Identify the T stage based on size. (A is always without ulceration; B is with ulceration) >4mm

Skin AJCC TNM for melanoma. Identify the T stage based on size. (A is always without ulceration; B is with ulceration) >1 to 2 mm

Skin AJCC TNM for melanoma. Identify the T stage based on size. (A is always without ulceration; B is with ulceration) >2 to 4 mm

Skin AJCC TNM for melanoma. Identify the T stage based on size. (A is always without ulceration; B is with ulceration) <0.8 mm

Skin AJCC TNM for melanoma. Identify the T stage based on size. >0.8 to 1 mm

T1b with or without ulceration

Skin AJCC TNM for melanoma. Identify the T stage based on size. Diagnosis by curettage

Skin AJCC TNM for melanoma. What are included in the subset N_"a"?

clinically occult nodes (i.e., detected by biopsy) N1a - 1 N2a - 2-3 N3a - >4

Skin AJCC TNM for melanoma. What are included in the subset N_"b"?

clinically detected N1b - 1 N2b - 2-3 (at least one) N3b - >4 (at least one)

Skin AJCC TNM for melanoma. What are included in the subset N_"c"?

Presence of in-transit, satellite, and/or microsatellite metastases + tumor involved nodes N1c - 0 N2c - 1 N3c - >2

Skin AJCC TNM for melanoma. Identify the M stage. (0 for normal LDH; 1 for elevated LDH) distant metastasis to: non-regional nodes muscles skin

M1a

Skin AJCC TNM for melanoma. Identify the M stage. (0 for normal LDH; 1 for elevated LDH) distant metastasis to: lung

M1b

Skin AJCC TNM for melanoma. Identify the M stage. (0 for normal LDH; 1 for elevated LDH) distant metastasis to: CNS

M1b *** M1c is non-CNS visceral sites other than lung

Skin What is the initial treatment for small cancers located on free skin (forehead/cheek)

excision

Skin What is the initial treatment for small cancers located on eyelids, external ears, nose, especially in the elderly and growing children?

RT *** It is also desirable to avoid RT in young patients because the late effects of irradiation progress gradually with time and, with very long-term follow-up, may be associated with a suboptimal cosmetic result compared with resection and reconstruction. In contrast, resection of an early-stage skin cancer of the eyelid, external ear, or nose may result in a significant cosmetic deformity and necessitate complex reconstruction that compares unfavorably with RT. This is particularly relevant in the case of older patients who have a limited life expectancy and who are at higher risk for a perioperative complication if the lesion is large and general anesthesia is required

Skin What is the treatment preferred for patients with lesions associated with clinical PNI with gross tumor extending to sites that render complete resection unlikely or unfeasible, such as the cavernous sinus?

RT alone

Skin What are the the indications for PORT in SCC?

close or + margins invasion of nerve invasion of bone or cartilage.

Skin What are the situation when the patient may be observed/PORT may be withheld?

if the lesion is BCC primary site on free-skin patient is available for follow-up higher likelihood of salvage with good cosmetic and oncologic results * (also for the elderly with poor medical condition/short life expectancy) * BCC/SCC focal incidental PNI (

Skin In BCC, PORT/re-excision may be withheld except in what locations if the margins are positive because of higher risk of recurrences?

nose, ears, eyelid | locations that have immediate access to major nerve trunks

Skin What is the management for skin cancer with metastasis to the parotid gland nodes.

parotidectomy + PORT to the parotid and neck | treated as high-grade parotid neoplasm

Skin For skin cancer with metastasis to the parotid gland, the management is usually surgery and RT. When can RT be withheld?

if only one node is involved and without ECE | however, if this recurs, salvage is remot, hence, do not withhold

Skin For skin cancer with metastasis to the parotid gland, the management is usually surgery and RT. When can surgery be delayed and what is the RT dose?

of course if the lesion is unresectable/fixed lymph node 60 to 70 Gy followed by parotidectomy (if the patient is medically operable)

Skin What is the management for skin cancer with metastasis to the parotid gland nodes with one ipsilateral neck node.

parotidectomy + PORT +neck dissection alone. PORT to the neck is added if 2 or more cervical nodes are positive.

Skin MCC What is the preferred treatment for MCC?

resection with wide margins (2-3 cm) + SLNB + PORT to primary and neck.

Skin MCC When is adjuvant chemotherapy indicated? What drugs are often employed?

+ nodes EP (cis-etop)

Skin Melanoma What is the preferred treatment for Melanoma?

resection of primary +/- SLNB

Skin Melanoma When is SLNB indicated?

-T2 lesions (>1 mm) with clinically negative nodes

Skin Melanoma What are the indications for SLNB in 0.75 to 1 mm lesions?

- ulceration (T1b) - regression (T0) - invasion into Clark level IV or V - deep margin positive - young age

Skin Melanoma Indications for PORT to the primary site

PNI along a named nerve equivocal margins +in-transit nodes (Nxc) +regional nodes

Skin Melanoma Indications for ENI

high-risk for nodal metastases but are unable to undergo SLNB.

Skin Melanoma RT dose for ENI (both conventional & hypofractionated)

30Gy/5 fx with off-cord/CNS at 24 Gy 50 to 60/2/25-30

Skin All of the following are advantages of using orthovoltage RT except? A. maximum dose is just below the skin surface; bolus is not required. B. less beam constriction both at the surface and deapth so that smaller fields can be used. C. eye shielding is easier to accomplish D. less expensive E. higher likelihood of control due to higher RBE.

A. "at the skin surface" not below

Skin One of the disadvantage of this modality is that it delivers a higher dose to deeper tissues and to underlying bone and cartilage. A. Orthovoltage x-rays B. Electron beam

A. The disadvantages of orthovoltage x-rays, compared with electron beam, are that there is a higher dose to deeper tissues and to underlying bone and cartilage. The latter problem can be largely eliminated by using heavily filtered orthovoltage beams for tumors involving or overlying cartilage or bone. Another significant problem associated with orthovoltage RT is that most radiation oncology departments do not have an orthovoltage machine, and thus it is unavailable.

Skin Parotid RT: Total dose for negative and positive margins?

The final dose for patients treated at 200 cGy per fraction with negative margins is 6,000 cGy; with positive margins, 6,600 cGy; and with gross residual disease, 7,000 cGy. If the dose per fraction is reduced to 180 cGy, the total dose is increased by 500 cGy.

Skin Follow-up schedule

every 2-3 months for the first 2 years every 4 months for year 3 every 6 months for the years 4-5 then annually.

Skin Local control is better for BCC than SCCs in general. TRUE or FALSE?

True

Skin Local control is similar for previously untreated and recurrent BCCs. TRUE or FALSE?

False. Local control is better for previously untreated

Skin Local control is inversely-related to PNI. TRUE or FALSE?

True. | Balamucki et al.