Skin Cancer Flashcards
1
Q
What % skin cancer is BCC, SCC
A
BCC 80%, SCC 20%
2
Q
Genetic conditions that cause BCC
A
Xerodermum pigmentosum and basal nevus syndrome
3
Q
Causes SCC
A
HPV, smoking cause SCC of the lip, scars or inflammatory conditions, thermal and electrical burns
4
Q
Most common cause of skin cancer
A
UVA and UVB rays
5
Q
What is congenital melanocytic nevi
A
nevus or mole present at birth, is a type of mole that can develop into melanoma
6
Q
Sizes of congenital melanocytic nevi
A
moles that can develop into melanoma
size small <1.5cm
Medium 1.5-20cm
Large >20cm large has 1% Chance of becoming melanoma
7
Q
Common acquired nevi
A
a mole that can develop into melanoma that develops later in life
8
Q
Types of common acquired nevi (3)
A
Junctional , compound and intradermal
9
Q
________ typically small (<6mm)are well circumscribed, flat lesions with smooth surfaces that are brown or black and circular, found above the basement layer
A
Junctional nevi (nevi that can become melanoma)
10
Q
………. contain melanocyte clusters in the dermis and epidermis. Small well-circumscribed slightly raised papules that often contain excess hair, surface is rough and colour is tan to brown throughout. These lesions may become nodular
A
Compound nevi (nevi that become melanoma)
11
Q
_______small well circumscribed dome shaped lesions that range from flesh to brown, they may contain excess hair. Rarely transform into melanoma
A
intradermal nevi (nevi that can become melanoma)
12
Q
skin cancer is most common in ages —–
A
50+
13
Q
dysplastic nevi
A
aka atypical moles have one off more clinical features of melanoma:
- Asymmetry
- Irregular borders
- colour variation
- diameter >6mm
14
Q
dysplastic nevus syndrome characteristics
what can it turn into and how commonly?
A
- Moles have distinct pathologic features
- pts have 50+ moles
- pts have 1, 1st degree or 2nd degree relative with melanoma
- dysplastic nevus syndrome has up to 100% chance of becoming melanoma
15
Q
4 functions of the skin
A
- Produces vitamin D which is absorbed by the GI tract
- Protects internal organs from outside pathogens
- Regulates temperature through perspiration
- Provides receptors for heat, cold, pain and sensation
16
Q
layers of the skin from most deep to superficial
A
basement membrane
subcutaneous
dermis
epidermis
17
Q
what layer of the skin contains nerves, blood vessels and fat tissue and areolar connective tissue that lies below the dermis layer
A
subcutaneous
18
Q
what layer of the skin onnective tissue layer contains blood and lymphatic vessels, nerves, nerve endings and hair follicles
A
dermis
19
Q
the 2 divisions of the dermis layer %
A
Upper layer 20% is called the papillary layer and contains dermal papillae, ridges that are responsible for fingerprints
The lower 80% is called the ticular layer containting hair follicles, sebaceous (oil) and subdiferour (sweat) glands and their ducts, nerve endings and blood vessels
20
Q
5 divisions of the epidermis layer
A
stratum basale, stratum granulosum, stratum corneum, stratum spinosum, stratum lucidum
21
Q
What layer of the epidermis is the following: contains stem cells able to produce karatinocytes and provides a barrier between the host and the environment and cells that give rise to hair follicles, it contains melanocytes, and merkel cells ( in the areas where hair doesnt grow),merkel cells are function in he sensation of touch, Merkel cell cancers are lethal even more lethal than melanoma
A
Stratum basale
22
Q
what layer of the skin is the following: contains rows of keratinocytes, that have a spiny appearance microscopically
A
stratum spinosum of the epidermis
23
Q
what layer of the skin is the following: this layer contains 3-5 rows of somewhat flattened cells, the keratinocytes produce keratinohyalin which is a precursor to keratin
A
stratum granulosum of the epidermis
24
Q
what layer of the skin is the following: only found in areas where thick skin is present (palms of hands and soles of feet) contain 3-5 rows of clear, flat cells that contain eleidin, another keratin precursor
A
Stratum lucidium of the epidermis
25
what layer of the skin is the following: forms skin surface and has thick rows of dead scaly (squamous cells) that are completely filled with keratin and lack internal organelles
stratum corneum of the epidermis
26
what connects the dermis and epidermis layers together?
the basement membrane
27
Melanoma is radio _______
resistant
28
most common sites of melanoma in men? women?
men: H&N and trunk
women: legs
29
4 types of melanoma
SSM- superficial spreading melanoma
NM-nodular melanoma
LMM- lentigo maligna melanoma
ALM-arcal lentigious melanoma
30
what type of melanoma is the following: most common subtype- 70% they arise on any part if the body and have a horizontal growth pattern, their periphery is notched or irregular, colours can be: brown, black, red, pink or white, after some time, the tumour tends to spreads more vertically, which results in irregular, notched surface
superficial spreading melanoma SSM
31
What type of melanoma is the following: 15% of all menlanomas, can occur on any anatomic site also, 2X miore common in M than F lesions can be dark, brown blue or amelanoitc- meaning no colour at all- when they are amelanotic they are more lethal as they are difficult to diagnose
nodular melanoma (NM)
32
What type of melanoma is the following:
aka Hutchinsons freckles 5% of all melanomas occur most often in chronically sun exposed spots most often in white elderly ladies, Radial growth phase for decades before it starts its vertical growth phase LMM is similar to SMM but lacks red hue and has minimal elevation
lentigo maligna melanoma (ALM)
33
What type of melanoma is the following: account for 10% of all lesions found on the palms and soles nail beds and mucous membranes. ALM is most common in blacks and asians has a tan or or brown flat stain on palms or soles. ALM can also appear as discoloration under nail bed and is mistaken for fungal infection
Arcal lentigious melanoma (ALM)
34
whats the growth phases of melanoma and how long does each stage take?
radial growth pattern takes 15 years in SSM, 5 years in LMM and has NO radial growth in NM and then grows vertically
35
T Staging melanoma
T1 melanoma <1mm in thickness
T2 melanoma 1.1-2mm in thickness
T3 melanoma 2-4mm in thickness
T4 melanoma >4mm in thickness
36
N staging melanoma
```
N1 mets in 1 Ln
N1a one nodal micromets mass
N1b one nodal macromets mass
N2 Mets in 2-3 nodes
N2a 2-3 micromets mass
N2b 2-3 macromets mass
N2c2-3 nodes in transit mets/ satellites without metastatic nodes
N3 4+ nodes or matted metastatic nodes or in transit mets / satellites with metastatic nodes
```
37
M staging melanoma
M1a mets to skin or distant LN
M1b mets to lung
M1c mets to other visceral sites or mets to any site associated with elevated serum lactic dehydrogenase
38
stage grouping melanoma
```
Stage 0 Tis N0 M0
Stage1A T1a N0 M0
Stage 1B T1b N0 M0
T2a N0 M0
Stage 2A T2b N0 M0
T3a N0 M0
Stage 2B T3b N0 M0
T4a N0 M0
Stage 2C T4b N0 M0
Stage 3 any T >N1 M0
Stage 4 anyT anyN M1
```
39
most common BCC subtype
nodular ulcerated BCC
40
4 subtypes BCC
1. nodular ulcerated BCC
2. superficial
3. Morphea
4. cystic
41
what BCC is as follows: most commonly found in the H&N, they appear mostly shiny, translucent and accompanied by telangiecatsis- an abnormal dilation of the capillaries and atrioles that may be visible at the skin surface
nodular ulcerated BCC
42
What BCC is the following: mostly on the trunk and appears as a red plaque which can appear in areas of translucent papules as it spreads over the skin surface, ulceration is common
superficial BCC
43
What BCC is the following: often appears like a scar, is very rare and is often found in the H&N has a high propensity for invasion and recurrence after treatment
Morphea or sclerosing BCC
44
What BCC is the following: uncommon type that undergoes central degradation to form a cystic lesion
cystic BCC
45
Where does SCC arise from ?
keratinocytes of the upper epidermis
46
Verrocouos SCC of the skin
grows slowly as a cauliflower like lesion and can be associated with HPV, ut is usually found in the genital area, orl cavity or sole of the foot
47
what SCC is associated with HPV
verrocouos SCC
48
Where is verrocouos SCC of the skin usually found ?
genital area, oral cavity or sole of the foot
49
high risk features of SCC and BCC
```
High risk features include:
Depth/ invasion >2mm
Clark level >4 perineural invasion
Anatomic location: primary site: ear, hair bearing lip
Poorly or undifferentiated
```
50
T stage of SCC and BCC
T1- tumour is <2cm with less than 2 high risk features
T2- tumour is >2cm with 2+ high risk features
T3- tumour with invasion of the maxilla, mandible, orbit or temporal bone
T4- tumour with skeletal invasion (axial or appendicular) or perineural invasion of the skull base
51
N stage SCC and BCC
N1-mets in one ipsilateral LN <3cm in greatest dimension
N2a- mets in 1 ipsilateral LN >3cm <6cm
N2b-mets in multiple ipsilateral LN none more than >6cm
N2c- mets in bilateral or contralateral LN no more than 6cm
N3- Mets in a LN >6cm in greatest dimension
52
Merkel cell carcinoma appearance
Similar in appearance to small cell carcinoma in that they are firm, nontender, pink-redish lesions with an intact epidermis
53
Treatment merkel cell carcinoma
chemorads or surgery
54
what type of uncommon skin cancer is most common in meditaranean people
Kaposi's sarcoma
55
Treatment kaposi's sarcoma
surgery and xrt can be used for localdisease and chemo will be added for widespread disease
56
what type of skin cancer is :Slow growing tumoir arising from vascular tissue, they are nodular purple lesions common in immunodeficient disease and meditaranean people
Kaposi's sarcoma
57
what skin cancer: esembles eczema, remains localized to the skin for long periods treated with tomotherapy, mustard and electrons, and chemotherapy
cutaneous lymphoma
58
T stage merkel cell carcinoma
T1- <2cm in maximum dimension
T2->2<5cm in maximum dimension
T3- >5cm in maximum dimension
T4 primary tumour invades bone, muscle fascia or cartilage
59
N stage merkel cell carcinoma
N1a- micromets
N1b-Macromets
N2- In transit mets
60
M stage merkel cell carcinoma
M1a- mets to skin, subcutaneous tissues or distant LN
M1b- Mets to lung
M2- mets to all other visceral sites
61
Precancerous conditions that develop into SCC
acetic keratoses, arsenical karatoses, bowen disease, kerathanocomas
62
BCC occur most commonly in what area, what %
H& N 80%
63
BCC appearance
smooth, red or milky lumps with a pearly border and multiple telangiectasia (tiny blood vessels visible on the skins surface) BCC can be shiny or pale.
64
SCC appearance
scaly, crusty, slightly elevated lesion that may have a cutaneous horn
65
Where do SCC mostly occur
H&N and arms
66
Treatment actinic keratoses
: surgery or 5FU, liquid nitrogen or electrodesication to destroy them and eliminate the possibility of developing into SCC
67
what precancerous condition is described as: Warty lesions or red scaly patches that occur in areas of sun exposure : occur more frequently on face or hands of older individuals.
actinic keratoses and is precancerous SCC
68
What precancerous condition is described as: multiple, hard corn like masses on the palms of hands or soles of feet that result from long term ingestion of arsenic
arsenical keratoses precancerous SCC
69
What precancerous condition is described as: precancerous dermatosis or carcinoma in situ characterized by red or brown papules covered with thickened horny layer
Bowen disease, a precancerous SCC
70
What precancerous condition is described as: rapid growing lesion can appear suddenly as dome shaped mass on a sun exposed area, difficult to distinguish from SCC and usually resolves themselves if not treated
Keratanthocoma a precancerous SCC
71
4 S&S of a BCC or SCC
Sore that takes longer than 3 weeks to heal
Recurrent tender red patch
Wart that bleeds or scabs
Any new growths or change in growths should be noted to the physician
72
70% of melanomas occur because....
of a change to a preexisting nevus
73
what are the ABCD'S of melanoma?
A-asymmetry melanomas are typically asymmetrical
B-borders, borders are typically irregular or notched
C-colour (black, blue, tan ,red) usually inconsistent throughout the lesion
D-diameter, melanoma is typically >6mm
74
changes of preexisting moles, indicative of melanoma
```
change in colour
change in surface: like flaky, peeling , oozing
change in texture: hard, lumpy
change in surrounding skin
change in sensation
```
75
Differential diagnoses of melanoma
simple lentigo, solar lentigo and sebhorric keratoses
76
differential diagnosis melanoma described as: 1-5mm brown macule with sharply defined edges, flat surface and is similar to a freckle, indistiguishable between junctional nevi
simple lentigo
77
differential diagnosis of melanoma described as: Small to medium, flat slightly pigmented macule is aka: liver spot especially common in elderly white people on areas of the skin chronically exposed to the sun
solar lentigo
78
differential diagnosis of melanoma described as: und or oval, wart-like papules are raised and composed of basal cells
sebhorric keratoses
79
what types of excisional biopsy are used? what types of skin cancer get these biopsies?
punch biopsy
saucerization
elliptic incision
used for suspected SCC and for melanoma
80
what types of biopsy is used for BCC of the skin
cutterage or shave, these types are not sufficient for biopsying a suspected SCC or melanoma
81
whats ELM ?
IN VIVO EPILUMINESCENT microscopy. Its a procedure in which an MD. differentiates between a benign lesion and early stages of skin cancer. Mineral oil is placed on the lesion and makes the stratum corneum almost invisible and helps to visualize the dermis/ epidermis junction
82
2 most important prognostic indicators in melanoma
Thickness and ulceration
83
most likely site of early mets in melanoma
sentinel node
84
Order of spread of melanoma
```
Direct extension of the primary including invasion to subcutaneous tissues
Regional LN
Distant skin and subcutaneous tissues
Lung
Liver, bone and brain
```
85
Melanoma LN in the H&N
Ipsilateral periacular, submandibular, cervical and supraclavicular LN
86
melanoma LN in the arm
ipsilateral epitrochlear and axillary LN
87
Melanoma LN in the trunk
ipsilateral axillary or inguinal LN
88
Melanoma LN in the legs
psilateral epitrochlear and axillary LN
| Leg: ipsilateral popiteal and inguinal LN
89
When is radiation therapy used in melanoma treatment?
for palliation
90
what is the treatment of choice for melanoma ?
wide en bloc excision
91
what treatment is used for treating metastatic melanoma?
biochemotherapy, immunotherapy and chemotherapy
92
what special treatment is used for melanomas of the extremity?
isolated limb perfusion
93
what is isolated limb perfusion? when is is used?
Isolated limb perfusion is used for melanoma of the limb.
The procedure is when blood flow in the limb is isolated by placing a tourniquet, then chemotherapy or hyperthermia is directly applied to the isolated blood stream so it'll be more directly applied to the tumour.
94
what chemotherapy agents are applied in the use of isolated limb perfusion?
melphalan and actinomycin-d
95
what is the single chemo agent of choice in the treat,int off melanoma
DTIC (Dacarazibine ) it is mostly used for palliation
96
whats interferon? what skin cancer is is used for?
activate and enhance tumour killing ability of monocytes and produce chemicals toxic to the cells in melanoma
97
whats interleukin? what skin cancer is this used for?
substances that act as costimulators and intensifiers of immune response
98
whats moh's surgery and when is it used?
tumour is mapped out during the surgery and each tissue is removed to determine the presence and extent of the tumour
Is surgery of choice for high grade SCC’s as it allows for intraoperational examination of the surgical margin
Treated on an outpatient basis with local anesthetic
Cons: timed consuming and expensive
Indications: areas of high recurrence, where the extent of cancer is unknown, or in aggressive rapidly growing tumours
99
whats cutter age and electrodessication? when is it used?
Used for BCC’s an early SCC’s
Cancer is scooped out with a curette an instrument in he shape of a loop or ring or scoop with sharpened edges
The destruction of remaining tumour cells and stopping the bleeding is done by electrodessication which uses a probe emitting high-frequency electric current to destroy tissue and cauterize blood vessels
100
what is cryosurgery? when is it used?
Liquid nitrogen or carbon dioxide is applied to the lesion, lowering the temperature to -50c, freezes and kills abnormal cells
101
whats laser surgery? when is it used?
Indications: for early BCC and SCC (in-situ) destroys areas of tumour while preserving healthy tissue
102
when is radiation therapy used in BCC and SCC ?
Is used in places of functional or cosmetic significance: eyelids, nose, lips, face, ears
Is used when surgery is not possible or in areas of recurrence
103
Topical therapies used in the treatment of BCC and SCC?
EX: topical 5FU and topical imiquimod (immunotherapy)
104
Photodynamic therapy in BCC and SCC
Photosensitizing agent is injected into the body and is absorbed by all cells, the agent is quickly discharged by healthy cells but stays longer in cancer cells
Light from the laser is directed on the tumour area and causes reaction within the cells that contain photosensitizing agent that destroys the cell
105
TYPES OF XRT used in BCC and SCC
Electrons and Kv are good especially for superficial lesions
IMRT may be used when close to critical structures or the need for retreatment
Brachytherapy may also be used, Ir-192, Cs137 or permanent Au seeds
106
when to use superficial X-rays vs orthovoltage vs electrons?
Rule of thumb, superficial Kv rays (50-150Kvp) is used for superficial lesions. For lesions with a few cm of depth, orthovoltage rays (150-400Kvp) and for lesions that are used to treat lesions that overlay critical organs or are between 8-10cm in greatest dimension, electrons (<12Mev) are best to use
107
max KV vs electrons
a surface dose <90-95% is unacceptable for skin cancer. Dmax for Kv is easy because is at the surface regardless of FS or collimation, for electrons Dmax is a function of FS, location of secondary collimation and surface contour and is found at a depth beneath the surface and therefore bolus may be required to bring the dose towards the skin
108
deep tissue dose Kv vs electrons
Electrons have a steep dose fall off they dissipate quickly leading to the sparing of healthy tissues, whereas in Kv the dose penetrates much deeper
109
cosmesis KV vs electrons
There is a slightly higher cosmesis rate in Kv than in electrons (95% to 80% respectively)
110
blocking electrons vs Kv
Electrons: used cerrobend cutouts that are inserted into the head of the machine
Kv: Blocks are made with lead, a thin metal alloy and are placed on the patients skin
111
whats the transmission factor for skin cancer blocks
should be <5%
112
Margins for small, superficial BCC <2cm
.5cm margin
113
Margins for BCC or SCC >6cm or advanced and high risk
>2cm
114
margins for BCC >2cm indistinct, morphea or recurrent disease
1cm
115
margins for an SCC must be at least ____
1cm
116
special considerations for :Pinna of the ear, or nasal caritlage
must be carefully planned to avoid chondritis which may require excision, bolus may be required in these cases
117
special considerations for the lip
has high likeliness of having LN involvement therefore prophylactic neck XRT may be used, they also require apariffin covered lead shield to protect the gums and teeth which decreases the dose to the buccal mucosa
118
special considerations of the nose
Should include coated lead strip in the nostril to protect the septum
119
special considerations of the eye
```
eye shields (internal and external)
Very important as eyes can develop cataracts at doses as low as 200cGy
```
120
special considerations of the ear
bolus may be used to flatten the surface of the ear to get rid if an air gap behind external ear
121
doses of BCC
3500/1
4500/15
5000/25
122
doses for SCC
5000/20
123
When is BCC given a SCC dosage
when the BCC is >5cm, that dose is 5000/20
124
when is radiation therapy used as the primary modality for melanoma?
when wide local excision can not be done without facial reconstruction for ex: large facial pre-melanoma (lentigo maligna)
125
Acute side effects of skin XRT
Erythema caused by swelling of the capillaries
Pigmentation changes caused by increased production of melanin
Dry desquamation affects the sensitive basal cells the basal layer has a hard time replacing the cells and the cells are naturally sloughed off
Moist desquamation cells of the basal layer are destroyed the dermis becomes exposed producing a serous oozing the epidermis is eventually repopulated from radioresistant cells that surround hair folicles and sweat glands
Temporary hair loss can occur at 3Gy >5Gy can result in permanent hair loss
Oil and sweat glands can produce less when subjected to curative doses
126
late side effects of skin XRT
Fibrosis
Telangiectasua
Epithelial layer is thinner and is more prone to damage
