Skin Cancer Flashcards
What is the epidemiology of non-melanoma skin cancer?
Basal and squamous cell carcinoma
131000 cases every year in UK - underestimate
BBCs account for 70%
What are the risk factors for non-melanoma skin cancer?
UV radiation, photochemotherapy, chemical carcinogens, ionising radiation, human papilloma virus, familial cancer syndromes and immunosuppression
What are the characteristics of basal cell carcinoma?
Slow growing
Locally invasive
Rarely metastasise
Nodular
Can look pigmented or morphoeic (difficult to diagnosis as poorly defined)
Describe the nodular characteristic of BCC
Pearly rolled edge
Telangiectasia
Central ulceration
Arborizing vessels on dermoscopy
What is the surgery for BCCs?
Excision is gold standard - ellipse with rim of unaffected skin
Curettage is some circumstances
Imiquimod if superficial
What are the indications for Mohs surgery?
Site, size, subtype, poor clinical margin definition, recurrent, perineural or perivascular involvement
What is Mohs surgery?
Aim is to remove all cancer cells and preserve healthy tissue + prevent scarring
Thin layers are removed
What is the indications for Vismodegib?
Locally advanced BCC not suitable for surgery or RT
Metastatic BCC
How does Vismodegib work?
Selectively inhibits abnormal signalling in Hedgehog pathway
Shrinks tumour and heals visible lesions in some
Median progression free survival 9.5 months
What are the side effects of Visodegib?
Hair loss, weight loss, altered taste, muscle spasm, nausea and fatigue
Describe squamous cell carcinoma
Derived from keratinising squamous cells
Usually skin exposed areas
Can metastasise - 16%
Can ulcerate
What are the characteristics of squamous cell carcinomas?
Faster growing, tender, scaly/ crusted or fleshy growths
Well differentiated
What is the treatment for SCC?
Excision and maybe RT
Follow up if high risk
What is high risk for SCC and need follow up?
Immunosuppressed, >20mm diameter, >4mm depth, ear, nose, lip, eyelid, perineural invasion and poorly differentiated
What is keratoacanthoma?
Variant of SCC
Erupts from hair follicles in sun damaged skin
Grows rapidly and may shrink and resolve after a few months
What is the treatment for keratoacanthoma?
Surgical excision
What are the risk factors for melanoma skin cancer?
UV radiation
Genetic susceptibility - fair skin, red hair, blue eyes and tendency to burn easily
Familial melanoma and melanoma susceptibility genes
What is the ABCDE rule for melanoma skin cancer?
Asymmetry
Border - irregular
Colour - multiple colours
Diameter - >7mm
Evolution - is it changing
What is the 7 point checklist for melanoma skin cancer?
Major features - change in size, shape and colour
Minor features - diameter more than 5mm, inflammation, mild itch/ altered sensation and oozing or bleeding
What tool can be used to help investigate melanoma skin cancer?
Dermatoscope
Describe the biological progression of melanoma
Benign stage
Dysplastic stage
Rapid growth phase
Vertical growth phase - getting more into dermis
Metastatic melanoma
What are the different types of melanomas?
Superficial spreading malignant melanoma - more common
Lentigo Maligna melanoma
Nodular melanoma
Acral lentiginous melanoma/ subungal melanoma
Ocular melanoma
What is the treatment for melanomas?
Urgent surgical excision - subtype and Breslow thickness
Wide local excision
Sentinel lymph node biopsy
Chemotherapy - almost never
RT - rarely
Immunotherapy - metastasis or adjuvant therapy
What is used for metastatic melanoma and adjuvant therapy?
Ipilimumab
Pembrolizumab
Nivolumab
Vemurafenib and Dabrafenib
Trametinib
Describe Ipilimumab
Inhibits CTLA-4 molecule
One year survival 47-51%
Describe pembrolizumab
Targets PD-1 receptor on tumour cell
One year survival 68-74%
Adjuvant therapy in those with complete resection of lymph node/ metastatic disease
Describe Nivolumab
Single agent or in combination with Ipilimumab in metastatic disease
Adjuvant therapy in those with complete surgical resection of lymph node/ metastatic disease
Targets PD-1 antibody
Describe Vemurafenib and Dabrafenib
Blocks B-RAF protein - only useful if B-RAF mutation
Median survival 10.5 months
Describe Trametinib
Used in combination with Dabrafenib - reduced toxicity and increased response
MEK inhibitor
In those with B-RAF mutation in MEK pathway is hyperactive resulting in uncontrolled growth of melanocytes
What is cutaneous lymphoma?
Secondary cutaneous disease from systemic/ nodular involvement
Primary cutaneous disease - abnormal neoplastic proliferation of lymphocytes in skin ( T cell and B cell lymphoma)
What are the types of cutaneous T cell lymphoma (65%)?
Mycosis fungoides
Sezary syndrome
CD30+ lymphoproliferative disorders
Cutaneous CD4+ lymphoma
Extra-nodal NK/T cell lymphoma
Subcutaneous panniculitis like T cell lymphoma
What are some types of cutaneous B cell lymphoma (20%)?
Cutaneous follicle centre lymphoma
Cutaneous marginal zone lymphoma
Cutaneous diffuse large B cell lymphoma
Describe Mycosis Fungoides
Most common CTCL and 50% of all primary cutaneous lymphomas
Cause is unknown
Common in older patients and more men
Indolent course - no pain
What are the stages of mycosis fungoides?
Patch, plaque, tumour and metastatic
Describe the patch stage of mycosis fungoides
Flat, red, dry oval lesions
Usually covered sites
May itch, slowly enlarge or spontaneously resolve
Difficult to differentiate from eczema/ psoriasis
Describe the plaque stage of mycosis fungoides
Patches become thickened
Generally itch
Describe the tumour stage of mycosis fungoides
Large irregular lumps, can ulcerate
Arise from existing plaques or in normal skin
More likely to have metastatic spread
Describe the metastatic stage of mycosis fungoides
Infiltration of neoplastic cells in lymph nodes, blood and solid organs
What is the investigations for mycosis fungoides?
Work up includes bloods for sezary cells CT imaging for staging
Describe Sezary syndrome
Red man syndrome
CTCL affecting skin of entire body - thick skin, scaly, red and very itchy
Lymph node involvement
Sezary cells in peripheral blood - atypical T cells
What is the prognosis for red man syndrome?
Median survival 2-4 years
Opportunistic infection
What is used for treatment of cutaneous lymphoma?
Topical steroids, PUVA or UVB, localised RT, interferon, bexarotene, lose dose methotrexate, chemotherapy and total skin electron beam therapy
What is total skin electron beam therapy?
Type of RT consisting of very small electrically charged particles
Delivers radiation to superficial layers - epidermis and dermis
Spares deeper tissues and organs
What are the steps of extracorporeal phonophoresis?
1 - patients blood is drawn and leucocytes collected
2 - collected white cells mixed with psoralen which makes T cells sensitive to UVA radiation
3 - exposed to UVA radiation damaging diseased cells
4 - treated cells re-infused back to patients
What is used for extensive cutaneous lymphoma treatment?
Extracorporeal phonophoresis
Bone marrow transplantation
Describe cutaneous metastases
Can be secondary or primary such as melanoma or due to primary solid organ malignancy
Most common is breast, colon and lung
What is the management for cutaneous metastases?
Treat underlying malignancy
Local excision
Localised RT
Symptomatic
