Skin Cancer Flashcards
What layer of the skin do melanocytes precide?
Stratum Basale
What are the layers of the epidermis from bottom to top?
Stratum basale Stratum spinosum Stratum granulosum Stratum lucidum Stratum corneum
Basal cell carcinoma effects what layer of the epidermis?
Stratum basale
What makes up Non-melanoma skin cancer?
Basal cell cancer Squamous cell cancer
What is the epidemiology of non-melanoma skin cancer?
Incidence has increased in the last 30-40 years Northern europe 3-4 times less than Australia BCCs account for 70% of NMSCs BBCs incidence from 146-788/100000 SCC 38-250/100000
What are the risk factors for non-melanoma skin cancer?
UV RADIATION Photochemotherapy Chemical carcinogens X-ray and thermal radiation Human papilloma virus Familial cancer syndromes Immunocuppression
How dangerous are Basal Cell Carcinomas?
Slow growing Rarely metastasise Removed because if left can form
Describe the appearance of Nodular Basal cell Carcinoma
Pearly rolled edge Telangiectasia Central Ulceration Arborising Vessels on dermoscopy
What is the most common BCC?
Nodular
Describe the appearacnce of superficial basal cell carcinoma
Larger diameter Flat Still a bit of a pearly look Eroded areas Telangiectasia
Descibe the appearance of pigmented BCC
Still pearly Very slow growing Telangiectasia Darker
Describe the appearance of morphoeic BCC
Much different to other BCCs
Look more like a scar
Very difficult to diagnose and treat, present late
What is the treatment for BCCs
Excision (GOLD STANDARD)
- Curative if fully excised
- Will scar
Curettage and Cautery
Moh’s Surgery
Photodynamic therapy
Cryotherapy
Imiquimod
What is curettage and cautery?
Lesion scrapped off and heat applied to sel vessels and destroy residual cancer cells
More likely for cancer to return as you cannot tell if you have removed it all
What are the indications for Moh’s Surgery?
Site (cannot remove alot of surrounding tissue)
Size (large)
Subtype
Poor clinical margin definition
Reccurrent
Perineural or perivascular involvement
What is Moh’s Surgery?
Thin layer of cancer removed
Put straight under microscope slide to see that there are clear margins all round
Next thin deeper layer removed
So on so that the whole cancer is gone with hopefully the minimum extra tissue
Where is Moh’s Surgery useful?
Places where alot of tissue cannot be spared like the nose
What is photo-dynamic tharapy?
Photochemical reaction to destroy cancer cells
Topical photsensitising agent applied which concentrates in cancerous cells
Red light applied
Photodynamic reaction occurs
What is photo-dynamic therapy good for?
Usually used for superficial BCC
Good for back aswell as it doesnt leave large scarring
What are the pros and cons of cryotherapy?
Pros:
- Cheap
- Easy to perform on the day
Cons
- Can scar
- Failure reccurence
What is Imiquimod?
Aldara
Immune response modifier
-Stimulates cytokine release (inflammation and destruction of lesion)
What are the pros and cons of Imiquimod?
Pros
- Useful where surgery is undesirable
- Usually good cosmetic result
Cons
- Treatment time is 6 weeks
- Significant inflammation
- Failure/ reccurence
What is squamous cell carcinoma?
Derived from keratinising squamous cells
Usually on sun exposed skin
Can metastasise
Faster growing (than BCC), tender, scaly crusted growths
Can ulcerate
What is the treatment of SCC?
Excision +/- radiotherapy
Usually you dont follow up patients who have had Squamous cell carcinoma excised.
When would you?
If high risk:
- Immunosuppressed
- >20mm diameter
- >4mm depth
- Ear, nose, lip, eyelid
- Perineural invasion
- Poorly differentiated
What is Bowen’s disease?
Squamous cell carcinoma in situ
Slow growing
Erythomatous scaly patch
What is the treatment for Bowen’s disease?
Cryotherapy
Imiquimod
Curettage and cautery
Photo-Dynamic Therapy
What is actinic keratosis?
Rough scaly patches on background of sun damaged skin
Completely result of UV damage
What is the treatment for actinic keratosis?
Diclofenac Gel
Cryotherapy
Curettage and Cautery
Imiquimod
What is keratoacanthoma?
Varient of squamous cell carcinoma
Erupts from hair follicles in sun damaged skin
Grows rapidly, may shrink after a few months and resolve
How is keratoacanthoma treated?
Excision
Very hard to differentiate from SCC even for pathology so excised to be safe
What is Sebhorroeic Keratosis?
BENIGN but commonly referred
Warty growths with a “stuck on appearance” (like you could just pick them off)
Can have variable appearance (different colours etc)
Patients often have multiple +/- cherry angiomas
How do you treat Sebhorroeic Keratoses?
Generally left untreated but if troublesome (getting caught on clothes etc)
- Cryotherapy
- Curettage
What is the epidemiology of melanoma?
Incidence increased from 60s to 90s
About 10 to 40 per 100000 per annum
Mortality is about 1.9 per 100000 per annum
What are the risk factors for melanoma?
UV radiation
Genetic susceptibility- fair skin, red hair, blue eyes and tendency to burn easily
Familial melanoma and melanoma susceptibility
What systems can you use to decide if a mole is worrying enough to consider melanoma?
ABCDE rule
7 point checklist
What is the ABCDE rule?
Asymmetry (worrying)
Border (loss of defined border)
Colour (new colours? 3 or more colours? dark areas?)
Diameter
Evolution (most important. Is it changing?)
What is the 7 point checklist?
Major features
- Change in size
- Change in shape
- Change in colour
Minor features
- Diameter more than 5mm
- Inflammation
- Oozing or bleeding
- Mild itch or altered sensation
How can dermoscopy be used?
“Dermascope” or “dermatoscope”
Improved clinical accuracy compared to unaided eye
How do melanomas grow?
2 growth phases
- Radial growth phase
- Vertical growth phase
What is the most common type of melanoma?
Superficial spreading malignant melanoma
What are lentigo malignant melanoma?
Generally found on the face
Have a pre cancer phase
Classical appearance of pigmentation around the hair follicles of the face
What is nodular melanoma?
Most dangerous melanoma
Dont really have a radial growth phase -> straight into vertical growth phase
More likely to metastasise
What is subungal melanoma?
Melanoma of nail
Looks like a bruised nail but doesnt grow out with nail
Bruise should be completely confined to nail. No involvement of skin (if not then melanoma: Hutchinson’s sign)
What is acral lentiginous melanoma?
Acral lentiginous melanoma is a form of melanoma characterised by its site of origin: palm, sole, or beneath the nail (subungual melanoma). It is more common on feet than on hands. It can arise de novo in normal-appearing skin, or it can develop within an existing melanocytic naevus (mole).
What is the treatment for melanoma?
Urgent surgical excision
- Wide local excision
- Subtype
- Breslow thickness
What is Breslow thickness?
Breslow depth in (mm) indicates the 10 year survival rate
Lower the breslow depth the better the survival
In addition to urgent surgical excision how do you tackle melanoma?
Offer sentinal lymph node biopsy
-Used for prognosis but no benefit in survival of removing lymph nodes
Chemotherapy
Regular follow up
Primary and secondary prevention
How do you protect yourself from sun?
Suncream
Cover up
Avoid sun at peak times (10am-4pm)
Dont burn at any time and try not to tan (tan just as damaging as burn!!)
Avoid sunbeds
How should suncream be used?
UVA and UVB protection
At least SPF 30/ 4 star
Need to apply 2 tablespoons every 2 hours
What does SPF mean?
SPF 30 means that if you burn in 1 min with this protection you should burn in 30 mins
When tested for SPF the participants are plastered so they are white. This means that IRL SPF 30 is more like 15 etc
Give some examples of new therapies
Vismodegib
Ipilimumab
Vemurafenib
Dabrafenib
What are the indications for vismodegib use?
Locally advanced BCC not suitable for surgery or radiotherapy
Metastatic BCC
How does Vismodegib work?
Selectively inhibits abnormal signalling in the Hedgehog pathway (molecular driver in BCC)
Can shrink tumour and heal visible lesions in some
What are the side effects of Vismodegib?
Hair loss, weight loss, altered taste
Muscle spasms, nausea, fatigue
What is ipilimumab?
Monoclonal antibody therapy
Inhibits CTLA-4 molecule
One year survival 47-51% (double those not on treatment)
How does Vemurafenib and Dabrafenib work?
Blocks B-RAF protein
Only useful if B-RAF mutation
Median suvival 10.5 months (7.8 months with standard chemotherapy)
