Skin Cancer Flashcards by Izzie Setford

What two distinct pathways converge to cause skin cancer?

Direct action of UV on target cells (kertatinocytes) for neoplastic transformation via DNA damage (e.g. p53 mutation)
Effects of UV on the host’s immune system

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What are the three main skin cancer types?

Basal cell carcinoma
Squamous cell carcinoma
Malignant melanoma

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From most superficial to the most deep, list the three skin cancer types.

Squamous cell carcinoma
Basal cell carcinoma
Malignant melanoma

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What is the most common type of skin cancer?

Basal cell carcinoma

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Describe the pathophysiology of basal-cell carcinoma.

Basal cells control the process of creating new skin cells
A mutation in the DNA of basal cells causes a basal cell to mutliply and grow rapidly when it would normally die.
Eventually the accumulating abnormal cells may form a tumour.

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Is there a genetic risk for basal cells carcinoma?

PTCH gene mutation may predispose a person to this

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Were are basal cell carcinomas most commonly found?

80% are found on the head and neck

- UV exposed sites

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How common is basal cell carcinoma?

30% of Caucasians will develop a basal cell carcinoma

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List the basal cell carcinoma subtypes.

Nodular - most common
Superficial
Pigmented
Morphoeic/sclerotic

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Describe the appearance of a nodular basal cell carcinoma.

Nodule (greater tha 0.5cm raised lesion)
Shiny - reflects light
Telangectasia - fine, broken blood vessels
Often central ulceration - the top layer of the dermis has come away
- more likely to bleed
Smooth edges

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Describe the appearance of a superficial basal cell carcinoma.

Doesn't have a nodular texture - smoother
Telangectasia on microscopy 
Shiny 
Small amount of ulceration 
Quite dry

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Describe the appearance of a pigmented basal cell carcinoma.

Ulceration
Telangectasia 
On a sun exposed site
Well demarcated, lumpy egde
Shiny

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What is the differential diagnosis of a pigmented basal cell carcinoma?

Pigmented lesion
Mole
Melanoma
- need to check with a biopsy

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Describe the appearance of a morphoeic/sclerotic basal cell carcinoma.

Very similar to normal skin
Shiny on flash
Well demarcated 
Telangectasia 
Central area of depression
Slightly raised edge

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List the available treatments for basal cell carcinomas.

Surgical excision - gold standard
- 3-4mm margin to account for infiltration
Curettage and cautery
Cryotherapy 
Photodynamic therapy 
Topical imiquimod/5-fluorouracil cream
Mohs micrographic surgery

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Describe curettage and cautery in skin cancer treatment.

Circular scalp instrument is used to scoop away the malignant skin. Cautery is used to burn away any remaining malignant cells

less accurate as you have to guess the penetration of the cancer
used in more elderly patients

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What is cryotherapy in skin cancer treatment?

Lquid nitrogen is sprayed onto the affected area, and the cancer is frozen off

no margin control
sore and causes blistering

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Describe topical imiquimod or 5-fluorouracil cream in skin cancer treatment?

These stimulate the immune reaction in tumour cells, which attracts the attention of the immune system
- works best in superficial BCC

Describe Mohs micrographic surgery in skin cancer treatment.

Frozen section technique

- can tell you immediatly whether you have excised all the malignant cells

When does squamous cell carcinoma occur?

Normal skin
Injured skin - burns
- most SCC occur on skin regularly exposed to UV radiation
Chronically inflamed

Which cells mutate to cause squamous cell carcinoma?

Keratinocytes

What is the second most common skin cancer?

Squamous cell carcinoma

What are the pre-malignant variants to squamous cell carcinoma?

Actinic keratoses

Bowens disease

What is the risk of metastasis of SCC?

From a high risk SCC (on ears, lips)

- 10-30%

Describe the appearance of a squamous cell carcinoma tumour.

``` Less shiny More ragged edges Hyperkeratinosis Crusty No/little ulceration ```

List the treatments for squamous cell carcinomas.

``` Surgical excision (larger margin than for BCC - 4mm) Curettage and cautery Topical imiquimod/5-fluorouracil cream Cryotherapy Photodynamic therapy Sun protection ```

Describe malignant melanoma.

Malignant tumour of melanocytes - most common in the skin, but can be found in the bowel and eye DNA damage caused by UV light (genetic mutations are rare) Radial growth phase followed by vertical growth phase

How is the prognosis of melanoma determined?

Depth of presentation and metastasis

What is the name of the pre-malignant form of melanoma?

Melanoma in situ

Where does melanoma commonly metastasise to?

To the local draining lymph nodes | - melanoma is spread via the lymphatics

List some of the risk factors for the development of melanoma.

``` Genetic markers (CDKN2A mutations) UV irradiation Sunburns during childhood Intermittent burning exposure in unacclimatised fair skin Number and size of melanocytic nevi Number of atypical nevi High socioeconomic status Skin types I or II DNA repair defects Immunosupression - no immune system to protect against cancer ```

What is the Clark's level?

Tells you what depth of the skin the melanoma has reached

What depths of the skin will the melanoma have reached in Clark's level 1-5?

``` 1 - epidermis 2 - superficial half of the papillary dermis 3 - deep half of the papillary dermis 4 - Reticular dermis 5 - Subcutaneous tissue ```

What is the 10 year survival for melanoma at all of the Clark's levels?

``` 1 - normal 2 - 93% 3 - 71% 4 - 59% 5 - 36% ```

List the melanoma subtypes.

``` Superficial spreading malignant melanoma - most common Nodular melanoma Acral melanoma (hands, feet and nails) Subungal melanoma (underneath nails) Amelanotic melanoma - looks like a BCC Lentigo maligna Lentigo maligna melanoma (invasive version) Melanoma-in-situ ```

Describe the appearance of an acral melanoma.

Late presenting - people don't look at their feet Irregular shape Irregular colour Callus formation Satellite tumours away from the original tumour

What feature of subungal melanoma indicates a high severity?

Hutichisons signs - pigment from the nail is spilling onto the skin - be aware of pseudo-hutichisons sign (reflection of pigment from the nail onto the skin)

How can you tell the difference between an amelanotic melanoma and granuloma tissue?

Amelanotic melanoma has a more chronic history | - has been kicking around for a long time

What is the treatment for melanoma?

Surgical excision - 1/2cm margin Chemotherapy (if metastatic) - isolated limb perfusion to prevent systemic effects of chemo Vaccine therapy Biologic antibodies to vascular growth factors (bevacizumab) or BRAF genetic defects (vemurafenib) Assessment for lymph node/organ spread

List the cutaneous tumour syndromes.

Gorlin's syndrome - multiple BCCs, jaw cysts and increased risk of breast cancer Brook Spiegler syndrome - multiple BCCs, trichoepitheliomas Gardner's syndrome - soft tissue tumours, polyps, bowel cancer Cowden's syndrome - multiple hamartomas, thyroid and breast cancer

Describe the appearance of superficial spreading melanoma.

``` Flat/smooth Dark brown patch of skin Superficial Irregular edge Often a precursor to malignancy ```

Describe the appearance and presentation of nodular melanoma.

``` Presents as a rapidly enlarging lump (weeks -> months) Larger size than moles (6mm - 10mm) Dome-shaped Symmetrical Firm Pigmented - red, black, brown Smooth, rough, crusted or warty surface Itchy ```

Describe the appearance of lentigo maligna and lentigo maligna melanoma.

``` Presents as a slowly growing or changing patch of discoloured skin - can grow to several cm in size over a few years Irregular shape Variable pigmentation Smooth surface Melanoma - thickening - increasing number of colours - ulceration - itching ```