Skin Flashcards
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
Skin
What is the most common risk factor for the development of skin cancer?
sun exposure
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.
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
MG
Skin
Enumerate the layers of the epidermis from superficial to deep.
Stratum corneum Stratum lucidum Stratum granulosum Stratum spinosum Stratum basale
(CLGSB)
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
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
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.
Skin
What is the most common histology of skin cancers?
BCC (>60%)
followed by SCC (≥30%)
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)
Skin
Most SCCs are well-differentated.
TRUE or FALSE?
True.
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
Skin
“The diagnosis of keratoacanthoma can only be made with absolute certainty by biologic behavior in the form of __________.”
eventual involution
Skin
What virus is associated with Merkel cell carcinoma?
This is associated with worse prognosis. TRUE or FALSE?
Polyomavirus
False.
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
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.
Skin
SCC vs. BCC
Which is prone to develop distant metastasis?
SCC
Skin
What cranial nerves are most commonly affected by PNI?
V2 and VII
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.
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.
Skin
Shave biopsies are
also often used, except in pigmented lesions where a _____ is suspected.
melanoma
Skin
What type of biopsy is usually advised/preferred for melanoma?
full-thickness skin biopsy (punch)
Skin
What are the three stages of MCC based on the Yiengpruksawan system?
I - localized
II - regional nodes
III - distant metastasis
Skin
AJCC TNM for head and neck SCC
Identify the T-stage and why?:
3 cm
T2
Tumor 2 cm or larger, but smaller than 4 cm in greatest dimension
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
N1
Skin
AJCC TNM for head and neck SCC
Identify the N-stage:
(assuming ENE-)
> 3 and <6 cm, single ipsilateral
N2
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
T4
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
T2
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
T3
Skin
AJCC TNM for melanoma.
Identify the T stage based on size.
(A is always without ulceration;
B is with ulceration)
<0.8 mm
T1
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
TX
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.
