Skin cancer Flashcards
What are the two forms of non-melanoma skin cancer?
• Basal cell cancer & Squamous cell cancer
What are some risk factors for non-melanoma skin cancer?
- UV radiation
- Photochemotherapy
- Chemical carcinogens
- X-ray and thermal radiation
- Human papilloma virus
- Familial cancer syndromes
- Immunosuppression
Describe morphoeic BCC
Morphoeic – infiltrative group of BCC; flat whitish plaque with pearly edge with central regression (pit)
Describe basal cell carcinoma
• Slow growing superficial lesions • Locally invasive • Rarely metastasise • Nodular – Pearly rolled edge – Telangiectasia – Central ulceration – Arborising vessels on dermoscopy
How is BCC treated?
Excision is gold standard – Ellipse, with rim of unaffected skin – Curative if fully excised – Will scar – Curettage in some circumstances
Describe Mohs surgery?
Microscopically controlled surgery used to treat common types of skin cancer – forms hole like wound which can be stitched up
When is Mohs surgery indicated?
– Site – Size – Subtype – Poor clinical margin definition – Recurrent – Perineural or perivascular involvement
When is Vismodegib indicated?
– Locally advanced BCC not suitable for surgery or radiotherapy
– Metastatic BCC
What is indicated if locally advanced BCC is not suitable for treatment or in metastatic BCC?
Vismodegib
What is Vismodegib?
- Selectively inhibits abnormal signalling in the Hedgehog pathway (molecular driver in BCC)
- Can shrink tumour and heal visible lesions in some
- Median progression free survival 9.5 months
What are the side effects of vismodegib?
• Side Effects
– Hair loss, weight loss, altered taste
– Muscle spasms, nausea, fatigue
From what do squamous cell carcinomas derive from?
- Derived from keratinising squamous cells
* Usually on sun exposed sites
Describe squamous cell carcinomas
- Derived from keratinising squamous cells
- Usually on sun exposed sites
- Can metastasise
- Faster growing, tender, scaly/crusted or fleshy growths
- Can ulcerate
Which non-melanoma skin cancer is associated with ulceration?
SCC
Which non-melanoma skin cancer is usually faster growing?
SCC
How is SCC treated?
• Excision +/- Radiotherapy
When is SCC high risk?
– Immunosuppressed – >20mm diameter – >4mm depth – Ear, nose, lip, eyelid – Perineural invasion – Poorly differentiated
Name a variant of SCC
Keratoacanthoma
Describe Keratoacanthoma
- Varient of squamous cell carcinoma
- Erupts from hair follicles in sun damaged skin
- Grows rapidly, may shrink after a few months and resolve
- Surgical excision
How is Keratocanthoma treated?
Surgical excision
What are some risk factors for melanoma?
UV Radiation
Genetic susceptibility- fair skin, red hair, blue eyes and tendency to burn easily
Familial melanoma and melanoma susceptibility genes
Describe the ABCDE approach in identifying melanoma
- Asymmetry – melanomas are asymmetrical
- Border – edges are uneven, crusty or notched in melanoma
- Colour – variety of colours, especially white or blue, are bad signs
- Diameter – melanomas are usually wider in diameter than a pencil eraser
- Evolution – danger if it has changed in size, colour or begins to bleed/scab
Describe the 7 point checklist in melanoma detection
Major features o Change in size/new lesion o Change in shape o Change in colour Minor features o Diameter more than 5 mm o Inflammation o Oozing or bleeding o Mild itch or altered sensation
Suspect melanoma if 1 or more major sign or if 3 or 4 minor signs alone
What 2 systems are used for melanoma identification
ABCDE approach
7 point checklist
What is used to examine the skin?
‘Dermoscope’ or ‘dermatoscope’
Describe the biologic progression of melanoma and the different types of melanoma associated with each stage
Benign then neoplastic
Rapid growth phase – superficial spreading melanoma
Vertical growth phase – nodular melanoma
Mestatsatic melanoma – has reached underlying blood stream
Describe superficial spreading melanoma
Superficial spreading melanoma is a form of melanoma in which the malignant cells tend to stay within the tissue of origin, the epidermis, in an ‘in-situ’ phase for a prolonged period (months to decades). At first, superficial spreading melanoma grows horizontally on the skin surface – this is known as the radial growth phase.
Describe lentigo maligna melanoma
Lentigo maligna is an early form of melanoma in which the malignant cells are confined to the tissue of origin, the epidermis, hence it is often reported as ‘in situ’ melanoma
Describe nodular melanoma
Nodular melanomas are a faster-developing type of melanoma that can quickly grow downwards into the deeper layers of skin if not removed. Nodular melanomas usually appear as a changing lump on the skin which might be black to red in colour.
Describe acral lentiginous melanoma
Acral lentiginous melanoma is a form of skin cancer that appears on the palms of the hands, the soles of the feet, or under the nails.
What two forms of melanoma can be found under the nails?
Acral Lentiginous Melanoma
Subungal Melanoma
Describe subungal melanoma
Subungual melanoma often starts as a brown or black streak under a toenail or fingernail
Describe ocular melanoma
Ocular melanoma (melanoma in or around the eye) is a type of cancer that develops in the cells that produce pigment and develops inside your eye or on your conjunctiva.
What is Breslow thickness?
To be exact, Breslow thickness measures in millimeters (1 mm equals 0.04 inch) the distance between the upper layer of the epidermis and the deepest point of tumor penetration. The thinner the melanoma, the better the chance of a cure.
Used in staging, determining prognosis and to determine diameter around tumour needed for excision
How is melanoma treated?
- Wide local excision - urgent surgery
- Sentinel lymph node biopsy
- Chemotherapy/immunotherapy
- Regular follow up
- Primary and Secondary Prevention
What biologics are used for metastatic melanoma
Ipilimumab
– Inhibits CTLA-4 molecule
Pembrolizumab
– Blocks activity of PD-1
Vemurafenib and Dabrafenib
– Blocks B-RAF protein
– Only useful if B-RAF mutation
What is the biologic targeted against CTLA-4 called used for metastatic melanoma?
Ipilimumab
What is the biologic targeted against PD-1 called used for metastatic melanoma?
Pembrolizumab
What are the biologics targeted against B-RAF called used for metastatic melanoma?
Vemurafenib and Dabrafenib
What is the one year survival of metastatic melanoma patients on ipilimumab?
One year survival 47-51% (double those not on treatment)
What is the one year survival of metastatic melanoma patients on pembrolizumab?
One year survival 68-74%
What is the median survival of metastatic melanoma patients on Vemurafenib and Dabrafenib compared with those on standard chemotherapy?
Median survival 10.5 months (7.8 months with standard chemotherapy)
What is cutaneous lymphoma?
Secondary cutaneous disease from systemic/nodal involvement
Primary cutaneous disease – abnormal neoplastic proliferation of lymphocytes in the skin
2 types:
– Cutaneous T Cell lymphoma (65%)
– Cutaneous B Cell lymphoma (20%)
What are the two types of cutaneous lymphoma and their relative frequencies?
2 types:
– Cutaneous T Cell lymphoma (65%)
– Cutaneous B Cell lymphoma (20%)
What are the different types of Cutaneous T Cell lymphoma?
- Mycosis fungoides
- Sezary syndrome
- CD30+ lymphoproliferative disorders
- Subcutaneous panniculitis like T cell lymphoma
- Cutaneous CD4+ lymphoma
- Extranodal NK/T cell lymphoma
What are the different types of Cutaneous B Cell lymphoma?
- Cutaneous follicle centre lymphoma
- Cutaneous marginal zone lymphoma
- Cutaneous diffuse large B Cell lymphoma
What is mycosis fungoides?
- Most common CTCL & accounts for around 50% of all primary cutaneous lymphomas
- Incidence 6 per 1 million population
- Cause unknown
- More common in older patients and more common in men than women
- Indolent course (causes little or no pain)
What is the most common cutaneous T cell lymphoma?
mycosis fungoides
What makes up 50% of all primary cutaneous lymphomas?
mycosis fungoides - most common cutaneous T cell lymphoma subtype
In what age group is mycosis fungoides most common?
Older patients
In what sex is mycosis fungoides most common in?
more common in men than women
What are the 4 stages of mycosis fungoides?
Patch - flat red dry oval lesions, can be itchy
Plaque - patches have thickened, itchy
Tumour - large irregular lumps, can ulcerate
Metastatic - infiltration of cells into blood, LNs etc
What is Sezary syndrome?
“Red Man Syndrome”
CTCL affecting skin of entire body
– Skin thickened, scaly and red – Itchy++ • Lymph node involvement • Sezary cells in peripheral blood – Atypical T cells • Poor prognosis – Median survival 2-4 years – Opportunistic infection
What is median survival for those with sezary syndrome?
2-4 years median survival
How is cutaneous lymphoma treated?
– Topical steroids
– PUVA or UVB
– Localised radiotherapy
– Interferon – increases targeted immune response
– Bexarotene – retinoid anticancer drug
– Low dose Methotrexate – immune suppressant
– Chemotherapy
– Total skin electron beam therapy
What is total skin electron beam therapy?
- Type of radiotherapy consisting of very small electrically charged particles
- Delivers radiation primarily to superficial layers i.e. Epidermis and Dermis
- Spares deeper tissues and organs
What is the benefit of total skin electron beam therapy when compared to normal radiotherapy?
Spares deeper tissues and organs
Describe Extracorporeal photophoresis for skin cancer treatment
Step 1
– Patients blood is drawn and leucocytes collected
Step 2
– Collected white cells mixed with psoralen which makes the T-Cells sensitive to UVA radiation
Step 3
– Exposed to UVA radiation, damaging diseased cells
Step 4
– Treated cells re-infused back to patient
What cancers often metastasise to the skin (cutaneous metastases)?
Most commonly breast, colon and lung cancer
What make up cutaneous metastases?
Can be secondary to primary skin malignancy such as melanoma or due to primary solid organ malignancy
How are cutaneous metastases treated?
- Treat the underlying malignancy
- Local excision
- Localised radiotherapy
- Symptomatic
