Skin Cancer Flashcards
What are the 6 layers of skin?
Come Learn Good Skin Bitches
What are 5 points of self detection for skin lesions that may turn cancerous?
ABCDE
What is a malignant melanoma?
-
Malignant tumour arising from melanocytes
- Leads to > 75% of skin cancer deaths
Can arise on mucosal surfaces (e.g. oral, conjunctival, vaginal) and within uveal tract of eye
Outline the epidemiology of malignant melanomas.
- Rising incidence rates observed worldwide
- Develops predominantly in Caucasian populations
- Incidence low amongst darkly pigmented populations
- 10-19/100,000 per year in Europe, 60/100,000 per year in Australia / NZ (Sunny locations)
What are the risk factors of malignant melanomas (Genetic 3 / Environmental 3 / Phenotypic 2)?
Genetic factors:
* Family history (CNKN2A mutations), MC1R variants
* Lightly pigmented skin, red hair
* DNA repair defects (e.g. xeroderma pigmentosum)
Environmental factors:
* Intense intermittent sun exposure, chronic sun exposure, residence in equatorial latitudes
* Sunbeds
* Immunosuppression
Phenotypic:
* Patient who has more than 100 melanocytic nevi on the whole body
* Patient who has atypical melanocytic nevi
What are the main different subtypes of malignant melanoma (5)?
- Superficial spreading (Horizontal growth then Vertical growth)
- Nodular (Only vertical growth)
- Lentigo maligna
- Acral lentiginous
- Unclassifiable
A patient present with the following symptoms:
What is the most likely diagnosis?
- Superficially spreading malignant melanoma
Epidemiology:
* 60-70% of all melanomas
* Most common type in fair-skinned individuals
* Most frequently seen on trunk of men and legs of women
Pathogenesis:
* Can arise de novo or in pre-existing nevus
* In up to 2/3 of tumours, regression (visible as grey, hypo-or depigmentation), due to host immune system reacting to tumour
Pathophysiology:
* After a slow horizontal (radial) growth phase, limited to epidermis, a more rapid vertically oriented growth phase: development of nodule
Differential diagnosis:
* Dermatofibroma
A patient present with the following symptoms:
What is the most likely diagnosis?
- Nodular malignant melanoma
Epidemiology:
* 2nd most common type of melanoma in fair skinned individuals
* 15-30% of all melanomas
* Most commonly trunk, head and neck, M>F
Pathogenesis:
* Usually dark nodule -but can be pink or red, may be ulcerated, bleeding
* Develops rapidly
Pathophysiology:
* De novo vertical growth phase without the horizontal growth phase. Present more advanced stage, with poorer prognosis.
Differential diagnosis:
* Basal cell carcinoma
A patient present with the following symptoms:
What is the most likely diagnosis?
- Lentigo maligna (malignant melanoma)
Epidemiology:
* 5% progress to invasive melanoma
* > 60 yo chronically sun damaged skin
Pathophysiology:
* Slow growing macule
* It is an in-situ melanoma
Differential diagnosis:
* Seborrhoeic keratosis
A patient present with the following symptoms:
What is the most likely diagnosis?
- Acral lentiginous (malignant melanoma)
Epidemiology:
* Uncommon: ~5% of all melanomas
* Most frequently 70yo
* Incidence similar across all age groups
What investigations are suggested in suspected malignant melanomas (2)?
- Examination with a dermatoscope
- Excision biopsy for histological assessment
- Measure Breslow thickness: prognosis worse if >1mm
What is the management of malignant melanomas (Surgery 2 / Imaging 1 / Immunotherapy 2)?
Surgery:
* Wide local excision
* Margin depends on Breslow thickness
* Sentinel lymph node biopsy - lymph node dissection
Imaging:
* TNM staging
Immunotherapy:
* CTLA-4 inhibition (Ipilimumab)
* PD-L1 (Programmed cell death ligand) inhibitors
* (Nivolumab)
What are the 3 stages of keratinocyte dysplasia?
Actinic keratoses
* Dysplastic keratinocytes
Bowen’s disease
* Squamous cell carcinoma in situ
Squamous cell carcinoma
* Invasive cancer
* Potential for metastasis/ death
Predominantly pale skin types
Solar induced UV damage
A patient present with the following symptoms:
What is the most likely diagnosis?
Actinic keratoses
* Dysplastic keratinocytes
A patient present with the following symptoms:
What is the most likely diagnosis?
Bowen’s disease
* Squamous cell carcinoma in situ
What is the management of actinic keratosis and bowen’s disease (6)?
- 5-fluorouracil cream
- Cryotherapy
- Imiquimod cream
- Photodynamic therapy
- Curettage and cautery
- Excision
A patient present with the following symptoms:
What is the most likely diagnosis?
- Squamous Cell Carcinoma (SCC)
Pathophysiology:
* Can have different appearances
* Erythematous to skin coloured
* Papule
* Plaque-like
* Exophytic
* Hyperkeratotic
* Ulceration
* Arises within background of sun-damaged skin
* Rapidly growing
Differential diagnosis:
* Basal cell carcinoma
* Viral wart
* Merkel cell carcinoma
What investigations are recommended for suspected squamous cell carcinoma (SCC) (2)?
Often clinical diagnosis sufficient
- Diagnostic biopsy may be taken if diagnostic uncertainty
- Ultrasound of regional lymph nodes ± FNA if concerns regarding regional lymph node metastasis
What is the management of squamous cell carcinoma (SCC) (5)?
- Examination of rest of skin and regional lymph nodes
- Excision
-
Radiotherapy
- Unresectable
- High risk features e.g. perineural invasion
- Cemiplimab for metastatic SCC
- Secondary prevention
- Skin monitoring advice
- Sun protection advice
A patient present with the following symptoms:
What is the most likely diagnosis?
-
Keratoacanthoma
- Pseudo-malignancy VS Variant of SCC (still unclear)
- Rapidly enlarging papule that evolves into a sharply circumscribed, crateriform nodule with keratotic core
- Resolves slowly over months to leave atrophic scar
- Most occur on head or neck / sun exposed areas
- Difficult to distinguish clinically and histologically from squamous cell carcinoma, so often excision
A patient present with the following symptoms:
What is the most likely diagnosis?
- Basal Cell Carcinoma (BCC)
Main subtypes: Nodular- Superficial
* Nodular:
* Most common subtype
* Approximately 50% of all BCCs
* Typically: shiny, pearly papule or nodule
* Superficial:
* Well-circumscribed, erythematous, macule/plaque
Differential diagnosis:
* Squamous cell carcinoma
* Adnexal (Sebaceous) carcinoma
* Merkel cell carcinoma
What investigations are recommended for suspected basal cell carcinoma (BCC) (1)?
Often clinical diagnosis sufficient
- Diagnostic biopsy may be taken if diagnostic uncertainty
What is the management of basal cell carcinoma (BCC) (1)?
- Standard surgical excision
A patient present with the following symptoms:
What is the most likely diagnosis?
- Mycosis fungoides (sub-type of cutaneous T-cell lymphoma)
Epidemiology:
* 75% of cutaneous lymphomas are T-cell
* MF is most common variant of primary CTCL: 50% of all primary cutaneous lymphoma, 0.4/100,000 (so quite rare)
Pathogenesis:
* Heterogenous group of neoplasms! Considerable variation in clinical presentation, histological appearance, immunophenotype and prognosis
Pathophysiology:
* Patients progress from patch stage -> plaque stage -› (finally) tumour stage disease
Diagnosis:
* Diagnosis requires skin biopsy
* Diagnosis may take years as skin lesions may be present that are neither clinically nor histologically diagnostic for many years
Differential diagnosis:
* Psoriasis
* Eczema (discoid)
* Parapsoriasis
A patient present with the following symptoms:
What is the most likely diagnosis?
- Sézary syndrome (sub-type of cutaneous T-cell lymphoma)
- Triad of:
- Erythroderma
- Generalised lymphadenopathy
- Presence of neoplastic T-cells (Sézary cells) in the skin, lymph nodes and peripheral blood
Epidemiology:
* 75% of cutaneous lymphomas are T-cell
* Sézary syndrome is rare - < 5% of all CTCL
Pathogenesis:
* Heterogenous group of neoplasms! Considerable variation in clinical presentation, histological appearance, immunophenotype and prognosis
A patient present with the following symptoms:
What is the most likely diagnosis?
- Merkel Cell Carcinoma
A patient present with the following symptoms:
* PMx of HIV
What is the most likely diagnosis?
- Kaposi Sarcoma
