Skin Cancer

Question 1

dermoscopy

Answer 1

o	Provides intra- and sub-epidermal illumination
o	10x magnification 
o	With or without immersion oil
o	Easy to use
o	Low cost

Question 2

skin biopsy

Answer 2

o Excisional
o Shave
o Punch
o Indicated if pathologic confirmation is needed, gets tissue to send to lab for pathology

Question 3

actinic keratosis (solar keratosis)

Answer 3

o Proliferation of atypical epidermal keratinocytes
o May progress to squamous cell carcinoma
o Roughly 10% of Ak’s progress to invasive SCC – takes years to develop
o Solid organ transplant patients with AK’s must be closely followed. High occurrence of SCC, with higher than normal potential for metastasis
o Fair skin and sun exposure major risk factors
o Men > Women; incidence rises with age
o Most common reason pts go to dermatologist
o Most commonly found on sun-exposed areas or elderly patients with fair skin types who have had significant sun exposure in their lifetime

Question 4

presentation of AK

Answer 4

o Classic presentation is scaly, hyperkeratotic macules or papules with erythema
o Over time, lesions develop an increasing, thin yellowish scale
o Often easier to detect by palpation then visually
o Over time, retained scale may form an elongated structure called a cutaneous horn
o Typical locations are scalp, nose/face, lateral neck, dorsal forearms and hands
o Often found along with other signs of sun exposure – uneven pigmentation, atrophy, telangiectasias
o Advanced lesions with thick scale should be treated as a probable SCC and biopsied
o Clinical diagnosis; biopsy

Question 5

treatment of AK

Answer 5

o Prevention: sunblock, avoid sun exposure, monitor skin regularly once per month
 NO sun from 10-2 – UV rays are the most damaging here
 Wear sun protective clothing
 Any patient with multiple AK’s – skin exam at least yearly
 Patients with numerous AK’s have an increased risk of developing SCC’s
o Multiple options including destruction, topical medications, phototherapy
o Isolated, superficial AK: liquid nitrogen
o Field therapy with topical medications or light for multiple lesions
o Destructive therapies include cryotherapy, surgical curettage, excision or shave
o Topical medications include 5-FU, imiquimod, ingenol mebutate, diclofenac, retinoids
o 5-FU (Fluorouracil)
 Blocks DNA synthesis in fast growing dysplastic cells
 Apply topically x 2-4 weeks
 May use topical steroid for inflammation (Desonide)
o Imiquimod (Aldara)
 Topical immune response modifier, stimulates local cytokine induction
 5% cream twice weekly x 16 wks

Question 6

widespread AK’s of the face

Answer 6

o Visible or detectable lesions represent a fraction of the total number of atypical keratinocytes actually present
o Most of the atypical cells are scattered within sun damaged skin and below the level of clinical detection
o Treat with topical 5-fluorouracil BID x 6 days
o On day 7 patient is painted with Aminolevulinic Acid then suffers through 16 minutes of photodynamic therapy (Blue Light)
o Both 5 FU and ALA/PDT are indicated to treat Ak’s. When treated in the above manner, most of the non-detectable lesions are also treated
o This can be done once every 2-3 years to eliminate both surface and subclinical pre cancerous sun lesions

Question 7

SCC

Answer 7

o Common in sun exposed areas – face, head, neck or hands (Always check the ears)
o Lesions may develop from precursor Ak’s or may arise de novo
o Caucasian patients with fair skin are at the greatest risk
o SCC is the 2nd most common form of skin cancer in the US
o 2500 deaths/year from SCC arising in the skin
o Transplant/other immunocompromised patients develop SCC’s at a higher rate than the general population and these tumors are more aggressive
o Classic presentation is erythematous papules, plaques or nodules
 Pink to dull red, firm, poorly defined dome shaped nodule with a yellow-white scale
 As about non-healing ulcers or wounds
 Tender, painful lesions
o SCC of the oral mucosa is worrisome and prone to metastasis, especially of the lower lip
o Biopsy required for diagnosis
o Insitu means hasn’t gone down to lower levels

Question 8

Bowen’s disease

Answer 8

o Actinic Keratosis – partial epidermal cellular atypia
o Bowen’s Disease = SCC in-situ
 In-situ = An in-situ tumor is one that is confined to its site of origin and has not invaded neighboring tissue or gone elsewhere in the body
o Bowen’s Disease shows full thickness involvement of the epidermis
o Squamous Cell Carcinoma shows atypical keratinocytes with invasion into the dermis

•Ak  Bowen’s Dz  SCC

o Eczema or psoriasis that doesn’t respond to topical steroids is most likely Bowen’s dz

Question 9

risk of recurrence of SCC

Answer 9

o Approach to treatment should be determined based on the patient’s risk of local or regional recurrence and metastasis

Question 10

SCC: treatment

Answer 10

o 90% low risk lesions cured with local therapy
 Wide local excision with histologic confirmation of margins is the tx of choice
 Excision, Electrodessication & Curretage are the most common methods used
o Bowen’s Disease - Topical chemo with 5-FU or imiquimod, photodynamic therapy or 30 second cryosurgery
o High risk lesions treated with surgical excision
 Conventional or Mohs technique (98% cure rate with Mohs)
o More likely to recur or metastasize than BC
o Mohs micrographic surgery (MMS) is a specialized surgical technique for removing locally invasive, high-risk skin cancers. MMS provides high cure rates with maximal preservation of unaffected tissue. In contrast to standard excision in which only a small portion of the margins are evaluated, in MMS specimens are cut in horizontal sections that allow the evaluation of the entire peripheral and deep margins of the tumor.

Question 11

BCC

Answer 11

o Skin cancer arising from basal layer of epidermis
o Locally invasive, can be destructive of skin and surrounding tissue; low metastatic potential
o Most common malignancy of Caucasians
o Major risk factor is UV exposure, esp in childhood
o 70% present on face & head
o Shave or Punch biopsy to diagnose

Question 12

BCC presentation

Answer 12

o Most BCC’s are pink to PEARLY-white, sometimes translucent appearing papules or nodules
o May have a smooth surface with overlying telangiectasia
o Look for a raised, rolled border
o Tumors frequently bleed, become erosive, crusted and ulcerate in the center
o Several variants of BCC:
 Nodular, pigmented, superficial, micronodular
o Superficial BCC on trunk: peripheral pearly plaques with scale, hyperpigmentation
o Destructive BCC on the nose

Question 13

BCC treatment

Answer 13

o Electrodessication & curettage (ED&C), surgical excision most commonly used
 Consider location, depth/size, risk of recurrence
 Will leave patient with scar
o Topical chemo, photodynamic therapy, cryotherapy may be used for superficial BCC
 30 second cryo with a 2mm margin very effective for superficial
o Close monitoring for recurrence every 6 mos x 1 yr then yearly

Question 14

melanoma

Answer 14

o Most fatal type of skin cancer; Incidence rapidly increasing; strong family hx
o UV exposure major risk factor: intense sun damage, esp in childhood/adolescence
o Ask about personal/fam hx skin ca, sunburns, sun exposure, moles (esp atypical)
o Survival rates depend on stage at diagnosis
 Tumor thickness most important prognostic factor

Question 15

melanoma presentation

Answer 15

o Asymmetry, color variegation, irregular borders, diameter >6mm, recent changes or new pigmented lesion (“ugly duckling” sign)
 3+ colors, loss of borders, itching/bleeding, nail changes (pigmented line, plate damage, subungual)
o Discuss prevention and screening skin exams with high risk pts
o Excisional bx with 1-3mm borders for dx

Question 16

4 types of melanoma

Answer 16

o Superficial Spreading Melanoma
o Lentigo Maligna Melanoma
o Superficial spreading: asymmetry, color variegation
o Lentigo maligna: usually arises in areas of sun-damaged skin, particularly on the head and neck. It begins as a freckle-like, tan-brown macule and gradually enlarges and develops darker or lighter asymmetric foci and raised areas, which signify dermal invasion
o Acral Lentiginous Melanoma
o Nodular Melanoma
o An acral lentiginous melanoma shows the asymmetry and color variegation of typical melanomas. They are distinguished clinically by their location on the palms, soles, or nails.
o Nodular melanomas present a discrete nodule, usually with dark pigmentation, although they may be amelanotic, as depicted above.

Question 17

melanoma treatment

Answer 17

o This should be done by a specialist, ASAP
o Wide surgical excision is the rule
 How wide borders should be depend on thickness
o Lymphatic mapping, sentinel node biopsy may be required depending on thickness, high risk pts
o Adjunvant therapy may be indicated
 Immunotherapy, targeted therapy

Question 18

kaposi sarcoma

Answer 18

o Neoplastic angioproliferative disorder that requires infection with human herpes virus 8 (HHV-8) and other cofactors
o 4 types depending on clinical presentation
o Most common presentation is purplish, reddish blue, or dark brown/black skin lesions (macules, nodules, plaques) on the lower extremities, often with lymphedema
o Slow-growing, localized and indolent, but can become disseminated and/or grow rapidly; can cause significant morbidity and mortality
o Diagnosis confirmed by biopsy
o KS is the most common tumor arising in HIV-infected persons. AIDS-related KS is seen predominantly among homosexual men rather than in other HIV-infected groups (IV drug users, women, transfusion recipients).

Question 19

KS treatment

Answer 19

o No consensus on treatment guidelines
o Asymptomatic lesions may be monitored
o HIV+ patients should be treated with highly active antiretroviral therapy (ART). CD4 count <100 usually
o Topical treatments recommended over systemic chemotherapy
 Laser ablation, radiation, excision, cryotherapy, intralesional chemotherapy
 Systemic chemo may be indicated in progressive disease, visceral involvement

Question 20

when to refer to dermatology

Answer 20

o Glasgow 7 point checklist of melanoma
o A new mole appearing after the onset of puberty which is changing in shape, color, or size
o A longstanding mole which is changing in shape, color, or size
o Any mole which has three or more colors or has lost its symmetry
o A mole which is itching or bleeding
o Any new persistent skin lesion, especially if growing, pigmented, or vascular in appearance, and if the diagnosis is not clear
o A new pigmented line in a nail, especially where there is associated damage to the nail
o A lesion growing under a nail

Question 21

management of suspicious lesions

Answer 21

o Careful history including risk, FH, personal hx
o Two main drivers of melanoma – Sun exposure, FH
o Pt edu: sunscreen, avoid sunburn, complete skin exam q 6-12 mos if high risk
o Document PE carefully, pictures may be helpful
o Excisional biopsy when possible (1-3mm borders)
o Refer to Derm if unclear dx, melanoma, Mohs surgery recommended, extensive dz