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MD2 Dermatology > Skin Cancer > Flashcards

Skin Cancer Flashcards

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Dermatology Board Prep 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
Q

What is the “red flag” for SCC?

A

Solitary red plaque not responding to topical treatment

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26
Q

Describe the histology of SBCC

A

Superficially budding basaloid cells

IMAGE

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27
Q

Spot diagnosis

IMAGE (HISTO AND MACRO)

A

SBCC

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28
Q

Describe the histology of infiltrative BCC

A

Infiltrative histological pattern

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29
Q

How does infiltrative BCC typically present?

A

Frequently asymptomatic; can present as a scar-like area of induration

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30
Q

How are nodular or infiltrative BCCs treated?

A

Surgical excision with clear margins

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31
Q

How may SBCCs be treated?

A

Surgical excision
Serial curettage
Topical imiquimod
Photodynamic therapy (PDT)

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32
Q

How do actinic keratoses (solar keratoses) present?

A

Erythematous scaly lesions, often on dorsum of hands or other sun-exposed areas
Not indurated or tender
Can be pigmented
Rough surface

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33
Q

Describe the epidemiology of AKs

A

Very common, increasing frequency with age

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34
Q

How frequently do AKs progress to invasive SCC?

A

Very rarely; rate is estimated at 1:1000 per year (however it is estimated that 70% of SCCs could have arisen from AKs)

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35
Q

Spot diagnosis

IMAGE (HISTO AND MACRO)

A

AK

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36
Q

What are the most common sites for AKs?

A

Sun-exposed skin (face, scalp, forearms, dorsum of hands)

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37
Q

Describe the histological appearance of AKs

A

Dysplastic keratinocytes confined to epidermis

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38
Q

What signs may indicate malignant transformation of an AK into an SCC?

A

Growing hyperkeratotic and tender nodule

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39
Q

Describe the options for AK treatment

A

Cryotherapy
Topical
Surgical excision

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40
Q

What topical therapies are recommended for AK?

A 
5-FU
Imiquimod
Ingenol mebutate
Diclofenac in hyaluronic acid
PDT
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41
Q

When is surgical excision indicated for AKs?

A

Lesions are resistant to treatment or suspicious for SCC

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42
Q

What is Bowen’s disease?

A

In-situ SCC

Belongs in the continuum of keratinocyte dysplasia

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43
Q

How does Bowen’s disease appear?

A

Scaly erythematous plaque with few surface erosions

44
Q

What is the histological appearance of Bowen’s disease?

A

Full thickness epidermal dysplasia, but non-invasive

45
Q

What is the typical location for Bowen’s disease?

A

On sun exposed areas but in particular on lower limbs

46
Q

What is the risk of malignant transformation from Bowen’s disease into SCC?

A

3-5%

47
Q

What is the typical clinical presentation of Bowen’s disease?

A

May be asymptomatic
May be itchy or painful
May bleed

48
Q

What topical treatments are indicated for Bowen’s disease?

A

5-FU
Imiquimod
PDT

49
Q

When is surgical excision indicated for Bowen’s disease?

A

Lesions which are:
Resistant to treatment
Suspicious for SCC
In certain high-risk patient groups (??)

50
Q

List 4 DDx for a pigmented lesions

A

Benign naevi
Dysplastic naevi
Melanoma
Other brown lesions (e.g. freckles, lentigines, seborrhoeic keratoses, pigmented actinic/solar keratoses)

51
Q

How do benign naevi and malignant melanomas arise?

A

From melanocytes

52
Q

Are all lesions which look pigmented melanocytic in origin?

A

No; can have pigmented BCC, AK, seborrhoeic keratoses, solar lentigines due to melanin or keratin

53
Q

Spot diagnosis

A

Seborrhoeic keratoses

54
Q

Spot diagnosis

A

Solar lentigines

55
Q

Distinguish between congenital and acquired naevi

A

Congenital: pigmented lesions present at birth or shortly after
Acquired: mole pattern developing during childhood

56
Q

When are naevi fully developed?

A

By 20s

57
Q

Do naevi involute?

A

Yes, in old age

58
Q

What are the 2 main concerns with a congenital naevus?

A

Cosmetic issues

Possibility of malignant transformation

59
Q

Is malignant transformation of a congenital naevus rare or common? What characteristic of a naevus is most predictive of its capacity for malignant transformation?

A

Rare

Related to size of naevus

60
Q

What are benign junctional naevi?

A

Naevi appearing during childhood, the cells of which are located at the epidermal side of the DEJ (dermal-epidermal junction)

61
Q

Describe the typical appearance of a benign junctional naevus

A

Macular
Slightly raised
Uniform in colour (tan, brown, dark brown or black)

62
Q

Describe the typical size of a benign junctional naevus

A

,

63
Q

Distinguish between the histology of a benign junctional naevus, a benign compound naevus and a benign intradermal naevus

A

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
Q

Describe the typical appearance of a benign compound naevus

A

Papules or nodules
Uniform in colour (brown, dark brown, black)
Smooth or cobblestone border
+/- hairs

65
Q

Describe the typical size of a benign compound naevus

A

.

66
Q

Describe the typical appearance of a benign intradermal naevus

A

Sharply define
Papule or nodule
Uniform in colour (paler; skin-coloured, tan, brown)
Smooth surface

67
Q

Describe the typical onset of a benign intradermal naevus

A

Later onset (cf junctional, compound)

68
Q

What are the important characteristics of BENIGN moles?

A 
Tend to be small
Evenly coloured
Regular edges
1 colour
Symmetrical
Does not stand out
Does not change with time
69
Q

What are freckles? When and why do they occur?

A

Sun-induced pigmentation
Can occur from childhood; more prominent in summer and fade in winter
Due to increase in melanin (not melanocytes)

70
Q

What are lentigines? When and why do they occur?

A

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
Q

Where do lentigines occur?

A

Sun-exposed sites

72
Q

In what demographic are seborrhoeic keratoses more common?

A

Older patients

73
Q

Describe the typical appearance of a seborrhoeic keratoses

A

Warty, stuck on appearance
Can get larger with time
Can be pigmented (but not melanocytic!)

74
Q

In what demographic are solar keratoses more common?

A

Middle-aged people (as for lentigines)

75
Q

What is the definition of dysplastic naevi?

A

Naevi which show atypical features both clinically and histologically but are not a malignant melanoma

76
Q

Describe some of the features which may suggest a dysplastic naevus

A 
Larger (>5 mm)
Atypical pigment net on dermoscopy
2 or more colours
Smudgy borders
Generally still symmetrical
77
Q

What is the significance of a dysplastic naevus?

A

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
Q

Is there a role for prophylactic excision of dyplastic naevi?

A

No; BUT if a dysplastic naevus is clinically suspicious for melanoma, it should be excised urgently

79
Q

List 7 risk factors for melanoma

A

> 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
Q

What is the most common site for melanoma in men vs women?

A

Women: legs
Men: trunk, head, neck

81
Q

Signs of a melanoma

A 
Asymmetry
Border irregularity
Colour variegation
Diameter >5 mm
Elevation and evolution (evolution trumps everything else)
Plus symptoms - pain, itching, bleeding
82
Q

What are the limitations of the ABCDE system for identifying possible melanomas?

A

Melanomas may have a diameter less than 5mm

83
Q

What is the “ugly duckling sign” for identifying melanoma?

A

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
Q

List 4 subtypes of melanoma

A

Superficial spreading melanoma (SSM)
Lentigo maligna
Acral lentiginous melanoma
Nodular melanoma

85
Q

What is the most common melanoma subtype?

A

SSM (80%)

86
Q

What is the typical presentation of an SSM?

A

Usually follow the ABCDE rules

Usually evolves over weeks to months

87
Q

What is the typical presentation of a lentigo maligna?

A

Presents as gradually enlarging pigmented lesion usually on the face
Very slow evolution (may be present for years) into lentigo maligna melanoma

88
Q

Spot diagnosis

A

Lentigo maligna

89
Q

What is the typical presentation of an acral lentiginous melanoma?

A

Gradually growing pigmented lesion

??

90
Q

Spot diagnosis

A

Acral lentiginous melanoma

91
Q

Why does the clinician need to be aware of the nodular subtype of melanoma?

A

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
Q

Nodular melanomas represent a major challenge to melanoma screening campaigns. What should you look out for?

A

Lesion that is Elevated, Firm and Growing (EFG)

NB If in doubt, excise completely and urgently

93
Q

What biopsy techniques can be used for a skin lesion?

A

Partial (punch or shave)

Excisional

94
Q

What are the limitations of a partial biopsy?

A

Not recommended for pigmented lesions due to sampling error (only a small proportion of the lesion is sampled; may give a false negative)

95
Q

When is an excisional biopsy indicated?

A

Pigmented lesions

96
Q

How is a punch biopsy performed?

A

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
Q

How is a shave biopsy performed?

A

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
Q

When is a punch biopsy indicated vs a shave biopsy?

A

Punch: good for assessing depth of lesion
Shave: better for sampling across lesion, not good for assessing depth

99
Q

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?

A

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
Q

For a 0.5 mm, level II lesion, what margin of excision is required?

A

1 cm

101
Q

Describe the excision margins recommended for melanoma based on the Breslow thickness?

A

In-situ: 5mm
1mm-4mm: 1-2cm
>4mm: 2cm

102
Q

What is the role of sentinel LN biopsy in melanoma?

A

Indicated for prognosis in melanomas >1 mm thick
For consideration of adjuvant therapy
For trials, etc

103
Q

What is the prognosis of melanoma?

A

In-situ: 100%

4mm: 45-67%

104
Q

What factors is melanoma prognosis dependent on?

A

Ulceration, mitotic rate
Age, sex, other patient factors
Location

105
Q

Describe the principles of follow-up for skin cancer patients

A

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
Q

Keratoacanthoma

A 
Grows rapidly (4-6 weeks), elevated lesion with central crater filled with keratin
Regresses spontaneously

MD2 Dermatology (3 decks)

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