Skin Cancer Flashcards
non-melanoma skin cancer
what is the peidemiology of non-melanoma skin cancer?
- Basal cell cancer & Squamous cell cancer
- Incidence has increased in the last 30-40 years
- 1 31,000 cases in the UK each year - Underestimate
- BCCs account for 70% of NMSCs
- BCCs incidence from 146 to 788/100000
- SCCs 38 to 250/100000
what are risk factors for non-melanoma skin cancers?
- UV radiation
- Photochemotherapy (PUVA)
- Chemical carcinogens
- Ionising radiation
- Human papilloma virus
- Familial cancer syndromes
- Immunosuppression
what is basal cell carcinoma?
Basal cell carcinoma begins in the basal cells - a type of cell within the skin that produces new skin cells as old ones die off
Slow growing
Locally invasive
Rarely metastasise
describe the properties of a nodular basal cell carcinoma?
Nodular:
- Pearly rolled edge
- Telangiectasia (widened venules (tiny blood vessels) cause threadlike red lines or patterns on the skin)
- Central ulceration
- Arborising vessels on dermoscopy
what does a basal cell carcinoma look like in histology?
Nests of basal cells that retract form surrounding stroma so this gap
pictures showing more nodular BCC
what are other types of BCCs?
pigmented (left)
morphoeic (right)
what is the treatment of BCCs?
surgery
• Excision is gold standard
- Ellipse, with rim of unaffected skin
- Curative if fully excised
- Will leave a scar
- Curettage in some circumstances
- Imiquimod if superficial
what is mohns surgery? and its indications
Take what they see with a bit of normal skin and the onsite pathologist looks around its rim and edge to see if all the cancer is out but if not then will remove more from residual edge where there is still some cancer left
• Indications:
- Site
- Size
- Subtype
- Poor clinical margin definition
- Recurrent
- Perineural or perivascular involvement
what is Vismodegib?
a drug for the treatment of basal-cell carcinoma
Selectively inhibits abnormal signalling in the Hedgehog pathway (molecular driver in BCC)
Can shrinks tumour and heal visible lesions in some
Median progression free survival 9.5 months
what are the indications for vismodegib?
Locally advanced BCC not suitable for surgery or radiotherapy
Metastatic BCC
what are the side effects of vesmodegib?
Hair loss, weight loss, altered taste
Muscle spasms, nausea, fatigue
what is squamous cell carcinoma?
a type of skin cancer that begins in the squamous cells. Squamous cells are the thin, flat cells that make up the epidermis, or the outermost layer of the skin
Derived from keratinising squamous cells
Usually on sun exposed sites
Can metastasise, up to 16% depending on study
Faster growing, tender, scaly/crusted or fleshy growths
Can ulcerate
Can get well differentiate carcinoma or poorly differentiated ones that are higher risk
what is the treatment of SCC?
- Excision
- +/- Radiotherapy
- Follow up if high risk
- Immunosuppressed
- >20mm diameter
- >4mm depth
- Ear, nose, lip, eyelid
- Perineural invasion
- Poorly differentiated
what is Keratoacanthoma?
- Varient of squamous cell carcinoma
- Erupts from hair follicles in sun damaged skin
- Grows rapidly, may shrink after a few months and resolve
what is the treatment of a keratoacanthoma?
• Surgical excision
melanoma skin cancer
what is the epidemiology of melanoma skin cancer?
- The incidence of malignant melanoma has increased by 360% since the 1970s in the UK
- About 10 to 40 per 100000 per annum
- Mortality is about 1.9 per 100000 per annum
what are the risk factors of melanoma skin cancer?
- UV Radiation
- Genetic susceptibility - fair skin, red hair, blue eyes and tendency to burn easily
- Familial melanoma and melanoma susceptibility genes
what is the ABCDE rule of melanoma skin cancer?
- Asymmetry
- Border
- Colour
- Diameter
- Evolution
what is the 7 point checklist for melanoma skin cancer?
• Major features:
- Change in size
- Change in shape
- Change in colour
• Minor features:
- Diameter more than 5 mm
- Inflammation
- Oozing or bleeding
- Mild itch or altered sensation
what is Dermoscopy?
- dermoscope’ or ‘dermatoscope’
- Improved clinical accuracy compared to unaided eye
what are different types of melanoma?
Superficial Spreading Malignant Melanoma (most common)
Lentigo Maligna Melanoma (mainly found on face and neck, particularly the nose and cheek)
Nodular Melanoma
Acral Lentiginous Melanoma/Subungal Melanoma (appears on palsm of hands, soles of feet and nails)
Ocular melanoma
pictures of melanomas:
Superficial Spreading Malignant Melanoma
Lentigo Maligna Melanoma
pictures of melanomas:
Nodular Melanoma
Acral Lentiginous Melanoma/Subungal Melanoma
pictures of melanomas:
Ocular Melanoma
what is the treatment of melanoma skin cancer?
• Urgent surgical excision
- Subtype
- Breslow thickness
Thicker it is – lower the 10 year survival rate
- Wide local excision
- Sentinel lymph node biopsy - First lymph node that it drains to and remove it and see if there is only melanoma deposit in that lymph node – optional and offered to the patient if they meet the criteria and helps give them the prognosis
- Chemotherapy – almost never
- Radiotherapy - rarely
- Immunotherapy – metastasis or adjuvent therapy
- Regular follow up
- Primary and Secondary Preventio
What is the treatment of Metastatic Melanoma and Adjuvent Therapy?
• Ipilimumab:
- Inhibits CTLA-4 molecule
- One year survival 47-51% (double those not on treatment)
• Pembrolizumab:
- Targets PD-1 receptor on tumour cell
- One year survival 68-74% in metastatic disease
- Adjuvent therapy in those with complete surgical resection of lymph node/metastatic disease
• Nivolumab (also PD-1 antibody):
- Single agent (one year survival 72.9%) or in combination with Ipilimumab in metastatic disease.
- Adjuvent therapy in those with complete surgical resection of lymph node/metastatic disease
• Vemurafenib and Dabrafenib:
- Blocks B-RAF protein
- Only useful if B-RAF mutation
- Median survival 10.5 months (7.8 months with standard chemotherapy)
• Trametinib:
- Used in combination with Dabrafenib
- Reduced toxicity
- Increased response
- MEK inhibitor
- In those with B-RAF mutation the MEK pathway is hyperactive resulting in uncontrolled growth of melanocytes
cutaneous lymphoma
What is cutaneous lymphoma?
- Secondary cutaneous disease from systemic/nodal involvement
- Primary cutaneous disease – abnormal neoplastic proliferation of lymphocytes in the skin
- Cutaneous T Cell lymphoma (65%)
- Cutaneous B Cell lymphoma (20%)
what are the types of Cutaneous T Cell lymphoma (65%)?
- Mycosis fungoides - MF varients
- Sezary syndrome
- CD30+ lymphoproliferative disorders
- Subcutaneous panniculitis like T cell lymphoma
- Cutaneous CD4+ lymphoma
- Extranodal NK/T cell lymphoma
what are the types of Cutaneous B Cell lymphoma (20%)?
- Cutaneous follicle centre lymphoma
- Cutaneous marginal zone lymphoma
- Cutaneous diffuse large B Cell lymphoma
what is Mycosis Fungoides?
most common form of cutaneous T-cell lymphoma
Most common CTCL & accounts for around 50% of all primary cutaneous lymphomas
Incidence 6 per 1 million population
what causes Mycosis Fungoides, who is it common in and is it painful?
- Cause unknown
- More common in older patients and more common in men than women
- Indolent course (causing little or no pain)
what are the stages of MF?
patch
plaque
tumour
metastatic
what happens in the patch stage of MF?
Flat, red, dry oval lesions
Usually covered sites
May slowly enlarge of spontaneously resolve
May itch
Difficult to differentiate from eczema/psoriasis
what is involved in the plaque stage of MF?
Patches become thickened
Generally itch
what is involved in the tumour stage of MF?
Large irregular lumps, can ulcerate
Arise from existing plaques or in normal skin
More likely to have metastatic spread
what is involved in the metastaic stage of MF?
Infiltration of neoplastic cells in lymph nodes, blood and solid organs
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
what is the prognosis of Sezary Syndrome?
Poor prognosis:
- Median survival 2-4 years
- Opportunistic infection
what is the treatment of cutaneous lymphoma?
• Dependant on stage:
- Topical steroids
- PUVA or UVB
- Localised radiotherapy
- Interferon
- Bexarotene
- Low dose Methotrexate
- Chemotherapy
- Total skin electron beam therapy
- Extracorporeal photophoresis
- Bone marrow transplantation
what is total skin electon 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
how is Extracorporeal photophoresis carried out?
- 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 can cutaneous metastases be due to?
Can be secondary to primary skin malignancy such as melanoma or due to primary solid organ malignancy
Most commonly breast, colon and lung
what is the managament of cutaneous metastases?
- Treat the underlying malignancy
- Local excision
- Localised radiotherapy
- Symptomatic
