SKIN CANCER Flashcards
Most common type of malignant skin tumour ?
BCC
Typical features of a basal cell carcinoma?
An ulcer with a raised rolled edge - may leave a central crater
Prominent fine blood vessels around a lesion
Pearly or waxy nodule
Most common type of BCC?
Nodular BCC
How are BCCs characterised?
Slow growing and locals invasion
Where on the body are BCCs most commonly found?
Face, head, neck - most sun exposed
Management of BCCs?
Surgical excision
Curettage
Cryotherapy
Topical creams: imiquimod, fluorouracil
Radiotherapy
How does imiquimod work to Tx BCCs?
It’s an immune response modifier that works by stimulating the immune system = anti-tumour effects
Thought to act as a toll-like receptor-7 agonist
What layer of the skin do BCCs arise from?
The stratum basalt
Which skin cancer is least likely to metastasises?
BCC <0.05% risk
Subtypes of BCCs?
Nodular
Superficial
Morphoeic
Basosquamous
Investigtaions for BCC?
Dermatoscope examination
Diagnosed clinically
Confirmed through excision biopsy
What is Moh’s micrographic surgery?
A tissue preserving technique which removes the lesion whilst assessing thr entire excision margins
The tumour is initially debulked, and then saucer-shaped 1mm layers of tissue are excised at a time. Each layer is then immediately checked under a microscope by a trained technician, and the process is continued until the tumour has been fully removed.
Good for areas where it would be cosmetically better to remove as little skin as possible
Risk of developing another skin cancer after A BCC?
Patients who have had a BCC have a 35% risk of developing another non-melanoma skin cancer in 3 years and 50% risk in 5 years.
Risk factors for BCC?
Intense sun exposure e.g. prior sunburns
Positive FHx
Skin types 1 or 2
What is squamous cell carcinoma?
A malignant tumour of keratinocytes arising from the epidermal layer of the skin
How common are SCCs?
They are thr second most common form of skin cancer after BCCs
Risk factors for SCCs?
excessive exposure to sunlight / psoralen UVA therapy
actinic keratoses and Bowen’s disease
immunosuppression e.g. following renal transplant, HIV
smoking
long-standing leg ulcers (Marjolin’s ulcer)
genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism
Clinical features of SCCs?
Rapidly expanding, painless, raised, ulcerate nodules
May have a cauliflower-like appearance
May be areas of bleeding
Where on the body are SCCs most likely to appear?
Sun-exposed sites - head, neck, dorsum of hands and arms, lower limbs
Dermoscopy findings in SCC?
White circles or structureless areas
Looped blood vessels
Central keratin plug
Management of SCCs?
Surgical excision with 4mm if lesion <20mm diameter. 6mm if >20mm
Moh’s micrographic surgery may be used in high-risk pt or cosmetically-important sites
Radiotherapy may be considered if surgery is not feasible
Chemotherapy is third line
Features of SCC with good prognosis?
Well differentiated tumours
<20mm diameter
<2mm deep
No associated diseases
Features of SCC with poor prognosis?
Poorly differentiated tumours
>20mm diameter
>4mm deep
Pt has Immunosuppression for whatever reason
Prognosis of SCC?
Metastatic potential is 3%
10 year survival for those with metastasis is <10%
High and very high risk SCC have a 80% lifetime risk of further skin cancers
How do nodular BCCs typically present?
What proportion of BCCs do they make up?
commonly a pink pearly nodule with telangiectasia, and can become ulcerated or encrusted; subtypes include cystic, pigmented, or keratotic
50-60%
How do superficial BCCs present?
What % of BCCs do they make up?
erythematous scaly plaques with a thread-like border, and may bleed or ulcerate
10-15%
How do morphoeic BCCs present?
thickened and sclerosing plaques with poorly defined borders; highest risk of incomplete excision and often prone to recurrence after treatment
What is melanoma a cancer of?
It’s a malignant tumour of melanocytes
Commonly those in the stratum basale of the epidermis
ABCDE symptoms rule
Asymmetrical shape
Border irregularity
Colour irregularity
Diameter >6mm
Evolution of the lesion e.g. change in size/shape
Symptoms e.g. bleed or itch
Risk factors for melanoma?
PHx skin cancer, melanoma, atypical naevi
FHx of melanoma
Fitzpatrick skin type 1 + 2
Red/light coloured hair
High freckle density
Light coloured eyes
History of sunburn - particuarly blistering sunburn in childhood
Large number of moles
Intermittent sun exposure
Use of tanning/sun beds (esp if >10 sessions)
Older age
Outdoor occupation
Immunosuppression
Genetic syndromes e.g. xeroderma pigmentosum
Most common age of melanoma?
Peak incidence 85-89
25% of cases are diagnosed in people >75
Most important prognostic factors for melanoma?
Breslow’s thickness
Lymph node status
Prognosis of melanoma?
5 year survival of stage 1 melanoma is 100%
Stage 4 is 30%
Types of melanomas?
Superficial spreading
Nodular melanoma
Lentigo maligna melanoma
Acral lentiginous
Amelanotic melanoma
Most common type of melanoma?
Superficial spreading
60-70% of melanomas
Fitzpatrick type 1 skin?
Pale white skin
Blue/green eyes
Blonde/red hair
Always burns and does not tan
Fitzpatrick type 2 skin?
Fair skin
Blue eyes
Burns easily and tans poorly
Fitzpatrick type 3 skin?
Darker white skin
Tans after initial burn
Fitzpatrick type 4 skin?
Light brown skin
Burns minimally, tans easily
Fitzpatrick type 5 skin?
Brown skin
Rarely burns, tans dark easily
Fitzpatrick type 6 skin?
Dark brown or black skin
Always tans darkly and never burns
Where on the body do superficial spreading melanomas occur?
Most commonly on sun-exposed sites: torso on men and legs in women
Average age of incidence with superficial spreading melanoma?
Incidence increases with age, peaking in people aged 70-79
How do superficial spreading melanomas present? ?
A flat pigmented lesion with asymmetrical or irregular borders
Usually spreads horzontally
Where do nodular melanomas typically occur?
Sun exposed areas - co9mmon on the trunk
What age is nodular melanoma most common?
50-60 years old
How do nodular melanomas present?
Rapidly growing, atypical nodule that may ulcerate and bleed easily
May be pigmented
What age is lentigo maligna melanoma most common?
People aged >60
Where does lentigo maligna melanoma most commonly occur?
On sun-damaged skin - head and neck
How do lentigo maligna melanoma present?
Irregularly shaped brown macule that grows slowly and overtime may develop irregular colours
Usually grows horizontally initially
Who are acral lentiginous melanomas most common in?
Darker skin types and people aged >40
Where on the body are acral lentiginous melanomas most common?
Soles of feet, palms of hands and nail bed
How do acral lentiginous melanomas present?
A flat pigmented area, slowly increasing in size.
Smooth at first but later may become thicker with an irregular surface that may be dry/warty
Variable pigmentation- commonly brown, blue-grey, black and red
May be ulceration and bleeding
What is Hutchinson’s sign?
Periungal band of brown-black pigmentation
A sign of acral lentiginous melanoma
Which melanoma type has no clear link to UV exposure?
Acral lentiginous melanoma
What are amelanotic melanomas?
Forms of melanomas with little or no pigment
Any subtype can be amelanotic
What are lentigo maligna?
A precursor to lentigo maligna melanoma
Presents as a slow-growing or changing patch of discoloured skin - often resembles a freckle in the early stages
They are “in-situ”
Occurs on sun-damage skin particularly nose and cheek
Lesions grow slowly over 5-20 years
Most common in people >40, peaking at 60-80
Assessment for melanoma?
Med history - how long, changes in shape size + colour, ulceration, itchy, bleeding, cough, weight loss, fatigue, night sweats, PH or FHx, & risk factors
Examine with dermatoscope
Palpate lymph nodes
If suspected to be melanoma then refer urgently 2WW
What is the “Ugly Duckling Sign”?
When there is an atypical melanocytic lesion that is different from the person;s surrounding moles
Diagnostic features/criteria for melanoma?
Major criteria:
- change in size
- change in shape
- change in colour
Minor criteria:
- diameter >=7mm
- inflammation
- oozing or bleeding
- altered sensation
Diagnosis of melanoma?
Suspicious lesions should undergo excision biopsy
Breslow thickness of melanoma?
This is the distance between the stratum granulosum and the deepest point of the melanoma
Margins of excision-Related to Breslow thickness
Lesions 0-1mm thick - excise 1cm
Lesions 1-2mm thick - 1-2cm
Lesions 2-4mm thick - 2-3cm
Lesions >4mm thick - 3cm
Which patients with melanoma should be offered a sentinel lymph node biopsy?
Melanoma with a breslow thickness >1mm
What should be done if sentinel lymph node biopsy in a pt with melanoma shows a clinically or radiologically suspicious lymph node?
Fine need aspiration cytology
Breslow thickness and 5 year survival rates?
<0.75mm - 95-100%
0.76-1.5mm - 80-96%
1.51-4mm - 60-75%
>4mm - 50%
Investigtaions for staging of a ,drama?
CT chest-abdomen-pelvis
MRI brain
What staging system is used for melanoma?
TNM classification
Where does metastatic melanoma typically spread to?
Lymph nodes
Brain
Bones
Liver
Lungs
What is actinic keratoses?
Aka solar keratoses
A common pre malignant skin lesion that develops as a consequence of chronic sun exposure
Features of actinic keratoses?
small, crusty or scaly, lesions
may be pink, red, brown or the same colour as the skin
Multiple lesions may be present
Where are actinic keratoses most commonly found?
On sun-exposed areas e.g. temples of head
Management of actinic keratoses?
Prevention of further risk e.g. sun avoidance and sun cream
Fluorouracil cream - 2-3 week course
Topical imiquimod, topical diclofenac, cryotherapy, curettage and cautery
What is Bowen’s disease?
A type of precancerous dermatosis that is a precursor to SCC
What is the chance of bowen’s disease developing into skin cancer if left untreated?
5-10%
1 in 20
Features of bowen’s disease?
Red scaly patches 10-15mm in size
Slow growing
On sun-exposed areas - head, neck and lower limbs
Management of Bowen’s disease?
Topical fluorouracil TDS for 4 weeks
Cryotherapy
Excision
Topical fluorouracil common SE and how can we manage this?
Significant inflammation or erythema
Topical steroids can often be given to control this
Counsel pt on appropriate sun protection behaviours?
Spend 11am-3pm in the shade
Cover up with clothes, hat and UV protection sunglasses
Sunscreen at least SPF30 or star rating 4/5 - generously, regularly
Dont use sunbeds or sunlamps
MDT for skin cancer?
Dermatology
Plastic surgery
Clinical oncology
Medical oncology
Consultant radiologist
Skin cancer nurse specialist
Histopathology
Skin cancer pathway co-ordinator
Most common malignancy secondary to immunosuppression?
Skin cancer - particularly SCC
How often do melanomas arise from a pre-existing melanocytic naevi?
In about 1/3rd of cases
Types of skin biopsy
Punch biopsy - removes small core of skin
Shave biopsy - gathers cells from top dermis + epidermis
Curettage - electric needle
Incisional biopsy - removal of a piece of tissue
Excisional biopsy - removes entire area of irregular skin
When is a shave/sampling biopsy used instead of an excision/punch biopsy?
Superficial lesions e.g. BCC
What is a shave biopsy not appropriate for, and why?
For suspicious pigmented lesions
E.g. lesions suspicious of melanoma as the biopsy wont provide sufficient depth to accurately determine the stage
Most common skin lymphoma?
Cutaneous T cell lymphoma
Most common types of cutaneous T cell lymphomas?
Mycosis fungoides
Sezary syndrome
What does cutaneous T cell lymphoma look like?
Starts as flat, dry red patches on the skin which can sometimes be itchy
They may develop to become hypo/hyperpigmented, mottled, plaque-like, papules, ulcerations, erythroderma etc
Causes of cutaneous metastasis?
Melanoma
Breast cancer
Nasal sinus cancers
Larynx cancer
Oral cavity cancer
Management of any patients who have recieving organ transplants with new or growing skin lesions?
Urgent referral to dermatologist - SCCs are more common
