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MD2 Dermatology > Skin Cancer > Flashcards

Skin Cancer Flashcards

1
Q

What % of skin cancers are melanomas vs non-melanomas?

A

Melanoma: 2%

Non-melanoma: 98%

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2
Q

What is the most common type of skin cancer?

A

BCC
SCC
Melanomas

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3
Q

What is the difference in prognosis between non-melanoma and melanoma skin cancers?

A

Non-melanoma usually not life-threatening (400 deaths per year, mainly from SCC)
Melanomas have the potential to spread internally to the LNs and internal organs (1500 deaths per year)

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4
Q

Describe the epidemiology of skin cancer

A

High cancer rates are directly related to UV exposure in a genetically susceptible population
The incidence of treated BCC and SCC is 5x the combined incidence of all other cancers
Deaths from skin cancers per year approximates the road toll

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5
Q

How does SCC arise?

A

From a group of disorders characterised by keratinocyte dysplasia (actinic keratosis, SCC in situ aka Bowen’s disease, SCC)

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6
Q

How do melanomas arise?

A

Melanomas arise from melanocytes

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7
Q

Describe the appearance of an SCC

A

Hyperkeratotic nodule growing over weeks (approx. 10mm in diameter)
Tender on palpation
Skin is freely movable over the underlying skull (not fixed)

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8
Q

Describe the prognosis of SCCs

A

Rapid rate of growth, over weeks or months

Greater potential to metastasise to regional LNs and distant sites when compared to BCC

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9
Q

What is the typical location for an SCC?

A

Found most commonly on chronically sun-exposed sites (hands, forearms, head and neck)

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10
Q

How do SCCs usually present?

A

Thickened scaly red patch or nodule, which may bleed easily or ulcerate and may be tender

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11
Q

List 2 risk factors for SCC

A

Sun damage

Smoking

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12
Q

What is the added risk with SCC of the lip?

A

Increased risk of metastatic disease

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13
Q

What is the definitive treatment for SCC?

A

Surgery: complete surgical excision with clear margins

High risk lesions may require additional adjunctive management (e.g. radiotherapy)

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14
Q

When may radiotherapy be used alone?

A

Clinically warranted in certain scenarios e.g. elderly, surgical risks, large size of defect

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15
Q

Describe the typical appearance of a nodular BCC

A

Pearly nodules with telangiectasia across the lesion, +/- central ulceration (bleeding is an important clue for diagnosis of BCC!)

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16
Q

How common is BCC?

A

2/3 of all skin cancers in Australia

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17
Q

What are typical sites for the development of a BCC?

A

Sites chronically exposed to sun (over half on head and neck, a quarter to a third on the trunk and smaller proportions on the limbs)

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18
Q

What is the typical natural Hx of a BCC?

A

Locally invasive, rarely metastasise (more indolent growth than SCC)

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19
Q

Name 3 subtypes of BCC

A

Nodular BCC
Superficial BCC (SBCC)
Infiltrative/morphoeic/sclerosing BCC

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20
Q

Describe the histology of a nodular BCC

A

Palisading (??)
Basaloid cells with a pushing border invading into stroma
IMAGE

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21
Q

Spot diagnosis

IMAGE (HISTO AND MACRO)

A

BCC

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22
Q

What is a “rodent ulcer”?

A

Ulcerated invasive nodular BCC

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23
Q

What skin lesion may mimic a melanoma and why?

A

Nodular BCC can be pigmented and for this reason can mimic a melanoma

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24
Q

How does SBCC present?

A

Slowly enlarging plaque

May develop superficial erosion

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25
What is the "red flag" for SCC?
Solitary red plaque not responding to topical treatment
26
Describe the histology of SBCC
Superficially budding basaloid cells | IMAGE
27
Spot diagnosis | IMAGE (HISTO AND MACRO)
SBCC
28
Describe the histology of infiltrative BCC
Infiltrative histological pattern
29
How does infiltrative BCC typically present?
Frequently asymptomatic; can present as a scar-like area of induration
30
How are nodular or infiltrative BCCs treated?
Surgical excision with clear margins
31
How may SBCCs be treated?
Surgical excision Serial curettage Topical imiquimod Photodynamic therapy (PDT)
32
How do actinic keratoses (solar keratoses) present?
Erythematous scaly lesions, often on dorsum of hands or other sun-exposed areas Not indurated or tender Can be pigmented Rough surface
33
Describe the epidemiology of AKs
Very common, increasing frequency with age
34
How frequently do AKs progress to invasive SCC?
Very rarely; rate is estimated at 1:1000 per year (however it is estimated that 70% of SCCs could have arisen from AKs)
35
Spot diagnosis | IMAGE (HISTO AND MACRO)
AK
36
What are the most common sites for AKs?
Sun-exposed skin (face, scalp, forearms, dorsum of hands)
37
Describe the histological appearance of AKs
Dysplastic keratinocytes confined to epidermis
38
What signs may indicate malignant transformation of an AK into an SCC?
Growing hyperkeratotic and tender nodule
39
Describe the options for AK treatment
Cryotherapy Topical Surgical excision
40
What topical therapies are recommended for AK?
``` 5-FU Imiquimod Ingenol mebutate Diclofenac in hyaluronic acid PDT ```
41
When is surgical excision indicated for AKs?
Lesions are resistant to treatment or suspicious for SCC
42
What is Bowen's disease?
In-situ SCC | Belongs in the continuum of keratinocyte dysplasia
43
How does Bowen's disease appear?
Scaly erythematous plaque with few surface erosions
44
What is the histological appearance of Bowen's disease?
Full thickness epidermal dysplasia, but non-invasive
45
What is the typical location for Bowen's disease?
On sun exposed areas but in particular on lower limbs
46
What is the risk of malignant transformation from Bowen's disease into SCC?
3-5%
47
What is the typical clinical presentation of Bowen's disease?
May be asymptomatic May be itchy or painful May bleed
48
What topical treatments are indicated for Bowen's disease?
5-FU Imiquimod PDT
49
When is surgical excision indicated for Bowen's disease?
Lesions which are: Resistant to treatment Suspicious for SCC In certain high-risk patient groups (??)
50
List 4 DDx for a pigmented lesions
Benign naevi Dysplastic naevi Melanoma Other brown lesions (e.g. freckles, lentigines, seborrhoeic keratoses, pigmented actinic/solar keratoses)
51
How do benign naevi and malignant melanomas arise?
From melanocytes
52
Are all lesions which look pigmented melanocytic in origin?
No; can have pigmented BCC, AK, seborrhoeic keratoses, solar lentigines due to melanin or keratin
53
Spot diagnosis
Seborrhoeic keratoses
54
Spot diagnosis
Solar lentigines
55
Distinguish between congenital and acquired naevi
Congenital: pigmented lesions present at birth or shortly after Acquired: mole pattern developing during childhood
56
When are naevi fully developed?
By 20s
57
Do naevi involute?
Yes, in old age
58
What are the 2 main concerns with a congenital naevus?
Cosmetic issues | Possibility of malignant transformation
59
Is malignant transformation of a congenital naevus rare or common? What characteristic of a naevus is most predictive of its capacity for malignant transformation?
Rare | Related to size of naevus
60
What are benign junctional naevi?
Naevi appearing during childhood, the cells of which are located at the epidermal side of the DEJ (dermal-epidermal junction)
61
Describe the typical appearance of a benign junctional naevus
Macular Slightly raised Uniform in colour (tan, brown, dark brown or black)
62
Describe the typical size of a benign junctional naevus
,
63
Distinguish between the histology of a benign junctional naevus, a benign compound naevus and a benign intradermal naevus
Junctional: naevus cells located at the epidermal side of the DEJ (dermal-epidermal junction) Compound: naevus cells located in the epidermis and dermis Intradermal: naevus cells are intradermal
64
Describe the typical appearance of a benign compound naevus
Papules or nodules Uniform in colour (brown, dark brown, black) Smooth or cobblestone border +/- hairs
65
Describe the typical size of a benign compound naevus
.
66
Describe the typical appearance of a benign intradermal naevus
Sharply define Papule or nodule Uniform in colour (paler; skin-coloured, tan, brown) Smooth surface
67
Describe the typical onset of a benign intradermal naevus
Later onset (cf junctional, compound)
68
What are the important characteristics of BENIGN moles?
``` Tend to be small Evenly coloured Regular edges 1 colour Symmetrical Does not stand out Does not change with time ```
69
What are freckles? When and why do they occur?
Sun-induced pigmentation Can occur from childhood; more prominent in summer and fade in winter Due to increase in melanin (not melanocytes)
70
What are lentigines? When and why do they occur?
Sun-induced pigmented macules which are static with time More common in middle-aged people Sunburn-induced or due to chronic sun exposure; due to few increased numbers of melanocytes
71
Where do lentigines occur?
Sun-exposed sites
72
In what demographic are seborrhoeic keratoses more common?
Older patients
73
Describe the typical appearance of a seborrhoeic keratoses
Warty, stuck on appearance Can get larger with time Can be pigmented (but not melanocytic!)
74
In what demographic are solar keratoses more common?
Middle-aged people (as for lentigines)
75
What is the definition of dysplastic naevi?
Naevi which show atypical features both clinically and histologically but are not a malignant melanoma
76
Describe some of the features which may suggest a dysplastic naevus
``` Larger (>5 mm) Atypical pigment net on dermoscopy 2 or more colours Smudgy borders Generally still symmetrical ```
77
What is the significance of a dysplastic naevus?
Independent risk factor for development of melanoma, especially if several However, risk of any one dysplastic naevus transforming into melanoma is very low (1 in 1000) 2/3 of melanomas arise out of normal skin rather than a pre-existing naevus
78
Is there a role for prophylactic excision of dyplastic naevi?
No; BUT if a dysplastic naevus is clinically suspicious for melanoma, it should be excised urgently
79
List 7 risk factors for melanoma
>5 dysplastic naevi >100 typical naevi PHx of melanoma or non-melanoma skin cancer Strong FHx (1 or more 1st degree relatives) Hx of blistering sunburns (especially in childhood) Physical appearance: type 1 skin (burns easily with no tanning), freckling, blue eyes, red hair Immunosuppression
80
What is the most common site for melanoma in men vs women?
Women: legs Men: trunk, head, neck
81
Signs of a melanoma
``` Asymmetry Border irregularity Colour variegation Diameter >5 mm Elevation and evolution (evolution trumps everything else) Plus symptoms - pain, itching, bleeding ```
82
What are the limitations of the ABCDE system for identifying possible melanomas?
Melanomas may have a diameter less than 5mm
83
What is the "ugly duckling sign" for identifying melanoma?
Naevi on the same individual tend to resemble one another; melanoma often deviates from this naevus pattern A new lesion or a history of change in an existing naevus is concerning
84
List 4 subtypes of melanoma
Superficial spreading melanoma (SSM) Lentigo maligna Acral lentiginous melanoma Nodular melanoma
85
What is the most common melanoma subtype?
SSM (80%)
86
What is the typical presentation of an SSM?
Usually follow the ABCDE rules | Usually evolves over weeks to months
87
What is the typical presentation of a lentigo maligna?
Presents as gradually enlarging pigmented lesion usually on the face Very slow evolution (may be present for years) into lentigo maligna melanoma
88
Spot diagnosis
Lentigo maligna
89
What is the typical presentation of an acral lentiginous melanoma?
Gradually growing pigmented lesion | ??
90
Spot diagnosis
Acral lentiginous melanoma
91
Why does the clinician need to be aware of the nodular subtype of melanoma?
Often do not fulfil the ABCDE criteria Grow rapidly and invade early Majority are amelanotic and do not look like a melanoma More common in older males, who are less likely to present for early review
92
Nodular melanomas represent a major challenge to melanoma screening campaigns. What should you look out for?
Lesion that is Elevated, Firm and Growing (EFG) | NB If in doubt, excise completely and urgently
93
What biopsy techniques can be used for a skin lesion?
Partial (punch or shave) | Excisional
94
What are the limitations of a partial biopsy?
Not recommended for pigmented lesions due to sampling error (only a small proportion of the lesion is sampled; may give a false negative)
95
When is an excisional biopsy indicated?
Pigmented lesions
96
How is a punch biopsy performed?
Under local anaesthetic, a 2-3 mm biopsy punch is made into the lesion to obtain a plug of skin 2-3 mm in diameter but deep enough to assess depth of the lesion
97
How is a shave biopsy performed?
Under local anaesthetic Scalpel or blade is used to shave across the lesion into the dermis and obtain a flat piece of tissue including epidermis and dermis
98
When is a punch biopsy indicated vs a shave biopsy?
Punch: good for assessing depth of lesion Shave: better for sampling across lesion, not good for assessing depth
99
Mrs MC, 57 year old housewife, presents with changing lesion on her arm Describes a 6/12 Hx of change in lesion Bled once after a shower, irritates her Does this patient require urgent assessment and, if so, what management is indicated?
Yes! Mx: full skin check (including LNs), complete excisional biopsy of lesion with a narrow margin, definitive wide local excision depending on the histology
100
For a 0.5 mm, level II lesion, what margin of excision is required?
1 cm
101
Describe the excision margins recommended for melanoma based on the Breslow thickness?
In-situ: 5mm 1mm-4mm: 1-2cm >4mm: 2cm
102
What is the role of sentinel LN biopsy in melanoma?
Indicated for prognosis in melanomas >1 mm thick For consideration of adjuvant therapy For trials, etc
103
What is the prognosis of melanoma?
In-situ: 100% | 4mm: 45-67%
104
What factors is melanoma prognosis dependent on?
Ulceration, mitotic rate Age, sex, other patient factors Location
105
Describe the principles of follow-up for skin cancer patients
Patients who have had skin cancer need regular follow-up, including full skin examination to look for suspicious lesions, recurrences of previous lesion(s), and to examine LNs, liver and spleen Frequency depends on the particular skin cancer and risk factors Patient needs to be told to seek urgent medical opinion if they have any concerns about new or changing skin lesions
106
Keratoacanthoma
``` Grows rapidly (4-6 weeks), elevated lesion with central crater filled with keratin Regresses spontaneously ```

MD2 Dermatology (3 decks)

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