Skin Cancer Flashcards by Sophie Pitcairn

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%

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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

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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)

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Describe the nodular characteristic of BCC

Pearly rolled edge
Telangiectasia
Central ulceration
Arborizing vessels on dermoscopy

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What is the surgery for BCCs?

Excision is gold standard - ellipse with rim of unaffected skin
Curettage is some circumstances
Imiquimod if superficial

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What are the indications for Mohs surgery?

Site, size, subtype, poor clinical margin definition, recurrent, perineural or perivascular involvement

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What is Mohs surgery?

Aim is to remove all cancer cells and preserve healthy tissue + prevent scarring
Thin layers are removed

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What is the indications for Vismodegib?

Locally advanced BCC not suitable for surgery or RT
Metastatic BCC

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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

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What are the side effects of Visodegib?

Hair loss, weight loss, altered taste, muscle spasm, nausea and fatigue

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Describe squamous cell carcinoma

Derived from keratinising squamous cells
Usually skin exposed areas
Can metastasise - 16%
Can ulcerate

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What are the characteristics of squamous cell carcinomas?

Faster growing, tender, scaly/ crusted or fleshy growths
Well differentiated

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What is the treatment for SCC?

Excision and maybe RT
Follow up if high risk

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What is high risk for SCC and need follow up?

Immunosuppressed, >20mm diameter, >4mm depth, ear, nose, lip, eyelid, perineural invasion and poorly differentiated

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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

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What is the treatment for keratoacanthoma?

Surgical excision

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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

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What is the ABCDE rule for melanoma skin cancer?

Asymmetry
Border - irregular
Colour - multiple colours
Diameter - >7mm
Evolution - is it changing

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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