Skin Cancer Flashcards
What classifies skin types
Fitzpatrick
What are the 6 skin types
1 - never tans, burns (red hair, blue eyes)
2 - tans but burns
1+2 have increased cancer risk
3 - always tans, sometimes burns (dark hair and eyes)
4 - always tans, rarly burn (olive skin)
5 - sunburn and tan after extreme UV (brown / Asian)
6 - black (never tans or burns)
What are the non-melanoma skin cancers and most common
Basal cell = 70%
Squamous cell
What are the RF for BCC / SCC
UV light exposure - SCC = chronic long term - BCC = sporadic burning Skin type 1 +2 Age Male FH skin cancer PMH skin cancer Photo chemotherpay Chemical carcinogens X-ray / radiation HPV Smoking
What are RF for SCC
Chronic inflammation Marjolins ulcer = excision Pre-malignant condition Organ transplant Immunosuppressoin
Where does BCC commonly affect
Head and neck
What is prognosis
Slow growing
Locally invasive causing destruction
Don’t tend to metastasis
Depends on tumour size, site, growth and histiological subtype
Failure of Rx / recurrent of immunosuppression = poorer prognosis
What is the presentation of BCC
Most common Pearly pink lesion Flesh coloured lesion Erythemtous keratotic papule or nodule Areas of sun exposure Irregular border May have central erosion o ulceration Telangiectasia around Rolled edge
What is BBC and types
Slow growing locally invasive malignant tumour of keratinocytes Superficial - plaque like Nodular = most common Ulcerative - rodent ulcer Pigmented Morphoeic = aggressive
How do superficial BCC present
Scaly and crusty Pigmented Pink to red brown Erosions / ulceration = less common Often resembles eczema or psoriasis
How do you manage superficial
Can be Rx conervatively
Cyrosurgery
Curettage and cautery
What do you do if high risk site or large
Excision
RT
Mohs procedure if high risk or cosmesis
What do nodular lesions tend to have
Smooth elevated surface
Telengiectasia’s
Arborizing vessel on dermoscopy
Central ulceration
How do you Rx
Excision
How does ulcerative present
Cycles of crusting and bleeding
May progress from nodular
What do you do if suspect BCC
Refer
Dermascope
Biopsy
What is gold standard Rx for BCC
Excision with margins
What are other options
Mohs = highly specalised
Curettage / cyroterhapy if unfit
RT
What can be used if not suitable for surgery / RT or metastatic
Vismodegib
Shrinks tumour and heals lesions
What are SE
Hair loss Weight loss Taste Muscle spasms Nausea
Where do SCC arise from
Keratinising squamous cells
Potential to metastasise
What are predisposing pre-malignancy conditions / RF
Bowen's - well defined Marjolins ulcer - chronic inflamation Acitinic keratitis - crust HPV Post transplant on immunosuppressants Chronic granuloma Chronic radiant heat - erythema ab igne Chronic UV Age Smoking
What are 1st signs of SCC and where does it affect
Induration of skin
Skin coloured papule
Head / ear / neck
How does it then go on to present
Plaque like Keratotic - scaly / crusty Ulceration Firm on palpation Irregular border Asymmetrical Hard to define Tender Scaly / crusting Common on sun exposed sites Grows more rapidly
Does SCC metastasis
Yes
3% at Dx have nodal mets
How do you Dx
Excision biopsy
Urgent referral if no response to 2 weeks topical Ax
How do you Rx SCC if insitu
5FU / imiquimod 2 week course with steroid
Excision
Mohs micrographic surgery may be needed for ill-defined large recurrent tumour
How do you Rx if +Ve nodes + what margins
Chemo / RT + block dissection
>4mm margin if low risk
>6mm if high risk
What is high risk requiring follow up
Immunosuppressed >20mm or 2cm >4mm depth On ear, nose, lip, perineurial invasion Poorly differentiated Recurrent 2 to chronic inflammation
What do you follow up for
Local recurrence
Nodal involvement
If in situ how do you follow up
No follow up - immediate Dx
If well differentiated + no other features
Discharge in 6 months
How do you follow up high risk
5 years
3/3/6 monthly
What factors affect malignant potential
Anatomical site Size >2cm or >4mm depth Rate of growth Aetiology Degree of differentiation - if poor = high risk Host immunosuppression
What sites are high and low risk
Radiation / thermal injury / chronic inflammation or Bowen = high risk
Sunexposed = low risk
What are pre-malignant conditions
Acitinic keratosis Bowen's Dysplastic naevi Sebaceous naevi Erythema ab igne Keratocanthoma Giant Congenital Hairy Naevus
What is actinic keratosis
Chronic pre-malignant condition to SCC
Low risk of progression
May referee
What are the features
Start as telanigiectasis capillary Rough, crusty, erythematous plaque White-yellow scale Flat, scaly, hyperkeratotic skin May be pink, brown or same colour Can form cutaneous horn On areas of chronic skin exposure
What are RF
Age
Proximity to equator
Fair skin
Outdoors
How do you Rx
Sun avoidance / cream Fluorouracil cream for 2-3 weeks then hydrocortisone to settle inflammation Topical diclofenac - mild Topical imiquimod - good result Cryotherapy or curettage to remove
If any doubt what do you do
Excision biopsy
What is Bowen’s disease
Intra-epidermal SCC in situ
Full thickness dysplasia contains within epidermis
Risk of becoming invasive
What are RF
Female Sun exposure UV Radiation Immunosuppression HPV Age Agricultural work
How does it present
3/4 of lesions on legs Irregular scaly erythematous persistent red plaque Non elevated Crust or scaling Clear border No bleeding Well demarcated Slower growing than SCC
What is 1st line Rx
Excision
What are other Rx options
Local 5-flouracicil cream + steroid if small
Imiquimod
Cryotherapy or curettage
Photodynamic therapy
What are sebaceous naevi
Circumscibed lesions / plaque Comprised of sebaceous glands Vary between yellow-ten Velevety Commonly present with bald patch Usually present from birth
What is risk
Small risk of malignancy change to BCC / SCC
How do you Rx
Excision due to malignant potential
What causes erythema ab igne
Overexposure to infrared e.g. sitting next to open fire
How does it present
Reticulated erythematous patches
Hyperpigmentation
Telangiectasia
What may develop
SCC
What is a keratocanthoma
Benign epithelial tumour of SCC in situ
How does it present
Erupt from hair follicles in sun damaged skin Rapid Initially a small domed pink papule Hyperkeratotic crater forms Most common on face
What is it related to
Sun exposure
Immunosuppression
Age
How does it progress
Can shrink and resolve in healthy skin
Small risk of SCC if >3 months so refer to exclude
How do you Rx
Excision
Topical 5-fu or RT if no surgery
How do you classify congenital hairy naves
Small <1.5cm
Medium 1.5-19.5
Large >20cm or >5% of BSA
What are features
Flat, round oval pigmented lesion
Covered in coarse hair
What is risk
Melanoma if multiple or large
How do you Rx
Surgical
Grafting
Laser to improve cosmoses but does not deal with malignancy risk
What are RF for melanoma
UV radiation Skin type 1 Hx of moles Sunburn Tropical country Outdoor work Previous history FH of melanoma Genetics- fair skin , red hair
What is melanoma and what are types
Invasive malignant tumour of melanocytes 70% related to BRAF mutation - role of Vemurafinib Potential to metastasise Superficial spreading = 70% Nodular Lentingo maligna Acral lentiginous Ocular Amelanotic
What are superficial spreading melanoma
Growing moles Affect young and middle aged adult Related to high intensity UV Commonly LL Common in arm, leg, back and chest
What s nodular
Sun exposed skin in middle age Commonly on trunk Red or black lump which bleeds and grows rapidly and invades deep Most aggressive with early mets Related to high intensity UV exposure
What is acral letiginous
Affects nails, palms or soles Subungual pigemntaiton Hutchinson's nail Very rare Common in elderly and black No clear relation with UV
What is amelanotic
Lack pigmentation
Dx more difficult
What is lentigno maligna
Melanoma in situ (confined to epidermis)
Does not invade into dermis
Common on face
Related to Lon term cumulative exposure
Common in chronic sun exposed skin in elderly
Can become invasive
More slowly growing than superficial spreading
What are features of letigno maligna
Flat
Two tone brown lesion
Irregular boder
What is ABCDE of suspicious melanoma
Asymmetrry Border irregular Colour irregular Diameter >6mm Evolution of size and shape Symptoms - bleeding or itching or change in sensation
How do you investigate
Refer 2WW if any suspicion
Dermoscopy
Biopsy
How do you Rx melanoma
can do topical 5FU or cryotherapy but high risk of recurrence
Urgent surgical excision with 2-5mm margin = definite
If lesion >1mm = SLNB
RT is sometimes useful
Chemotherapy for metastatic disease
Immunotherapy
- Targeted therapy against BRAF v 600 (Darbrafenib) has revolutionised Rx
Regular follow up
What does prognosis depend on
Breslow thickness = main determinant Depth of invasion <2mm = TNM1 >2m = TNM 2 N = 3 M = 4 Mets rare
How do you Rx metastatic
Immunotherapy revolutionised Rx
What can cutenaeous mets be from
Primary skin malignant - melanoma
Breast
Colon
Lung
How do you Rx
Treat malignancy
Excision
RT
How does sebaceous gland carcinoma present
Thick eyelid
Recurrent infection - Chalazion / unilateral blepharitis
Nodular, indurated lid
Yellow discolouration
How do you Rx
Excision
How can cutaneous lymphoma arise
Secondary from nodes
Primary disease from abnormal proliferation of lymphocytes in skin
What types do you get
T cell
B cell
What are T cell lymphomas
Mycosis fungiodes = most common
Sezary syndrome
How does mycosis fungiodes present
Flat,red dry oval patch
May itch
Can be difficult to differentiate from eczema/ psoriasis
Patch becomes thickened to form a plaque
Tumour can then cause large irregular lumps
Ulceration
Can it metastasis
Yes
How do you investigate
Blood - look for sezary cells
CT to stage
What is Sezary syndrome
Entire body affected
Thick scaly red skin
Very itch
LN involvement
What is seen on blood
Sezary cells
What else can cause
Vancomycin
How do you Rx cutaneous lymphoma
Steroid Photochemotherapy RT Total skin electron bean therapy Chemotherapy - low dose methotrexate Interferon Extracorporeal photophoresis Bone marrow transplant
What is extracorporeal photophoresis
Luekocytes collected Mixed which psoralen which makes T cells sensitive to UVA Exposed to UVA This damages diseased cells Reinfuse patient
What is Marjolin’s ulcer
SCC arising in chronically damaged skin Presents as non-healing sore of granulation tissue - Burns - Scar - Ulcer - venous - OM - RT - Vaccination Usually 30+ years after injury
How do you Ix
Biopsy = very important
Very aggressive form of SCC
