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Skin Cancer Flashcards

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1
Q

What is a Marjolin ulcer

A

Malignant transformation of scar with ulcer, mostly scc but can be BCC and Melanoma

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2
Q

What is the metastatic rate of Marjolin ulcer

A

25-30%

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3
Q

What percent of burn scars undergo malignant transformation

A

2%

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4
Q

Average time for a malignant degeneration to occur in a Marjolin ulcer

A

20years

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5
Q

Brigham and Women’s Hospital SCC staging

What is T1?

A

Zero high risk factors

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6
Q

Brigham and Women’s Hospital SCC staging

What is T2a?

A

One high risk factor

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7
Q

Brigham and Women’s Hospital SCC staging

What is 2b?

A

Two-Three High risk factors

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8
Q

Brigham and Women’s Hospital SCC staging

What is T3?

A

4 or more high risk factors

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9
Q

List the Brigham and Women’s Hospital SCC staging

high risk factors

A

1 diameter more that 2cm
2 poorly differentiated histology
3 Perineural invasion .1mm or more
4 Tumor invasion beyond the sub Q fat.

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10
Q

AJCC Staging of SCC what is Tx?

A

Primary SCC not identified

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11
Q

AJCC Staging of SCC what is Tis?

A

In situ

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12
Q

AJCC Staging of SCC what is T1?

A

Less than 2 cm in diameter

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13
Q

AJCC Staging of SCC what is T2?

A

More than 2 cm and less than 4 cm

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14
Q

AJCC Staging of SCC what is T3?

A

Greater than 4cm or
Deep invasion (beyond subQ fat or more than 6mm)
Perineural invasion of nerve more than .1mm in dia.

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15
Q

AJCC Staging of SCC what is T4?

A

Invasion of bone

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16
Q

What % of Pagets disease of the nipple will have underlying ductal or invasive breast cancer?

A

95%

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17
Q

Above 1mm in Breslow thickness what is the surgical margin for a melanoma

A

2cm

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18
Q

What is the most common form of cell death by radiation.

A

Mitotic Catastrophe

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19
Q

What is a Marjolin ulcer

A

aggressive cancer in old burn or poorly healing wound. usually SCC but can be BCC

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20
Q

What margins should be used in an excision of a basal cell carcinoma without frozen sections planned.

A

4mm

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21
Q

what tumor do you see the eyeliner sign.

A

SCC in in situ

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22
Q

What is a keratin pearl

A

a swirl of parakeratosis

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23
Q

naked nuclei are seen in what?

A

pagetoid spread in SCC

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24
Q

where are there no atypical keratinocytes in the basal layer in an AK

A

In the follicular epithelium openings. orthokeratosis over the follicular opening.

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25
Q

if you see thick keratin corneal layer with underlying sun damaged skin what do you think of?

A

AK

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26
Q

what is the stain for DFSP

A

CD34

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27
Q

What two stains are negative in DFSP

A

Factor XIIIa …. + in dermatofibroma

Stromelysin 3 ….+ in dermatofibroma

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28
Q

How to excise a DFSP if not mohs?

A

2cm margin down to fascia.

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29
Q

What is the recurrence rate of DFSP for excision and for Mohs?

A

excision >20% or more Mohs 1-2%

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30
Q

how many greys of radiation are used for radiation adjunct treatment of DFSP and margins.

A

50-60 gy and 3 to 5 cm beyond the surgical margin.

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31
Q

what is the best radiologic study for extensive DFSP

A

MRI with contrast.

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32
Q

What medicine and dosage is used for DFSP

A

Imatinib Mesylate (Gleevec) 400mg PO bid

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33
Q

What changes are seen in fibrosarcomatous changes in DFSP

A

Densely packed herring bone pattern.
CD34 may only be weakly +
Less haphazard more worrisome

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34
Q

What causes 90% of DFSPs

A

Chromasome translocation of a collagen 1 gene and a platelet derived growth factor gene to form an oncogenic fusion gene

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35
Q

What is a DFSP oncogenic fusion gene

A

t(17:22) q22 q13

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36
Q

what is the 10 year risk transformation for SCC in those that have AKs

A

17%

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37
Q

What percent of people treated for AK with cryo have complete clearing at 6mo?

A

<10%

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38
Q

What is tirbanibulin

A

klisyri inhibits tubulin polymerization and Src kinase signalling used in treatment of AKs

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39
Q

What is the treatment course for tirbanibulin

A

5 days.

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40
Q

With tirbanibulin what is the peak day of Localized Skin Reactions?

A

day 8

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41
Q

Name 5 Agents that may help prevent AK & SCC

A
  1. Sunscreens
  2. 5FU bid 30 days
    3.Retinol (Vit A) 25,000 IU daily
    4 Acitretin 25mg daily
  3. Nicotinamide 500 bid
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42
Q

What % of DFSP metastasis?

A

5%

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43
Q

What is the most common site of DFSP to metastasize to?

A

lung

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44
Q

what drug treats DFSP

A

imatinib

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45
Q

What is the protein made by the oncogenic fusion gene.

A

COLA1 - PDGFB

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46
Q

What margins should you use with an excision of a bcc (non mohs)?

A

4mm

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47
Q

What margins should you use for an excision of a high risk SCC. and name 4 high risk features

A
  1. > 2cm
  2. neurotropic
  3. high risk sites
    4 Invasion into fat

6mm

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48
Q

What is the cure rate with curettage alone?

A

96%

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49
Q

list 3 cancers you can ed&c

A

bcc, scc in situ, well diff scc <1cm

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50
Q

List two criteria for not doing an ed&c

A

hair follicle involvement and involvement of the deep dermis.

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51
Q

which field TX for AKs has the best non recurrence rate at 5 years.

A

5FU

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52
Q

what is the mnemonic for the Brigham & Women’s Hospital staging system?

A

3 D’s and large caliber perineural

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53
Q

what are the four risk factors in Brigham & Women’s Hospital staging system for mets or death ?

A

Diameter >2cm
Deep penetration fat
Differentiation poor
Perineural involvement >.1mm

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54
Q

What are the four stages of Brigham & Women’s Hospital staging system?

A

T1 0 risk factors
T2a 1 risk factor
T2b 2-3 risk factors
T3 4 risk factors or bone involvement

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55
Q

What are the four stages of the AJCC staging..

A 
T1 <2cm and no other risk factors
T2 2-3.9 cm and no other risk factors
T3 - one of the following risk factors
             *4cm diameter
             *invasion >6mm or beyond fat
             *perineural >.1mm or subdermal nerve involve
             *minor bone erosion
T4- deep bone or base of skull
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56
Q

What is a risk factor in Brigham & women’s staging that is not listed as a risk factor in AJCC?

A

Poor differentiation.

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57
Q

Is the NCCN (National Comprehensive Cancer Network) a staging system.

A

No. It is treatment recommendations only.

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58
Q

Does NCCN high risk predict recurrence or death?

A

No

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59
Q

With Brigham & Women’s Hospital staging system what is the risk for recurrence mets or death in T2a SCC tumors Mohs vs excision.

A

Mohs 3.5 %

Non Mohs 10%

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60
Q

With Brigham & Women’s Hospital staging system what is the risk for recurrence mets or death in T2b-T3 with Mohs vs excision.

A

15 to 22%

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61
Q

What % of T2b cases that had sentinal node bx were positive.

A

30%

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62
Q

What % of nodal SCC mets are found in first 2 years?

A

80%

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63
Q

What studies should be done with patients high risk for mets (T2b-T3)

A

serial CTs or ultrasound.

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64
Q

What study is done if major nerve involvement with SCC

A

MRI

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65
Q

If a person has CLL with lymph node involvement what study can separate SCC nodes from CLL nodes?

A

PET scan

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66
Q

What was the first systemic treatment for approved for treatment of SCC.

A

Cemiplimab

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67
Q

what is the response rate to Cemiplimab

A

50%

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68
Q

If you do get response what % is durable over 1 year?

A

80%

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69
Q

Pembrolizumab is what?

A

anti -PD1 therapy like Cemiplimab 2nd to be released

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70
Q

What is the death rate of organ transplant patients with Anti-PD1 Treatments

A

50%

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71
Q

What other diseases will flare with Anti-PD1 tx

A

autoimmune

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72
Q

People who get more than 10 dermal invasive SCCs have either transplants or what.

A

CLL

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73
Q

What is the normal presentation of a merkel cell carcinoma

A

rapidly growing violaceous nodule 2-3 mo duration on sun exposed skin/

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74
Q

What is the aeiou mnemonic for merkel cell (MCC)

A 
Asymptomatic
Expanding rapidly
Immune depressed
Older than 50
UV damaged skin
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75
Q

Which has a higher rate of metastasis Merkel Cell or Melanoma

A

Merkel Cell

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76
Q

Approximately what % have regional or distant mets in Merkel cell carcinoma MCC at time of presentation.

A

nodes 25%
distant mets 10%
Total 35%

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77
Q

What cell line is a merkel cell carcinoma considered.

A

neuroendocrine

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78
Q

What stain is used for Merkel Cell Carcinoma (MCC)?

A

CK20

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79
Q

what is the staining pattern of CK20 in MCC (merkel cell)

A

paranuclear dot like pattern

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80
Q

What is merkel cell carcinoma hard to tell apart from on H& E

A

metastatic small cell carcinoma (presumably from the lung)

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81
Q

what stain is positive in small cell lung cancer and negative in Merkel cell

A

TTF-1 (thyroid transcription Factor 1)

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82
Q

what are the two causes of Merkel cell carcinoma

A
  1. merkel cell polyomavirus mutated

2. DNA mutations from UV

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83
Q

In those with polyomavirus and merkel cell what can you follow lab wise.

A

oncoprotein antibody levels. high at diagnosis may rise again with recurrence.

84
Q

Will there be a oncoprotein antibody titer in merkel cell carcinoma without viral infection.

A

no

85
Q

What are the surgical margins with merkel cell carcinoma (MCC)

A

1-2 cm or Mohs

86
Q

In MCC (merkel cell carcinoma) how should nodes be evaluated?

A

If no clinically apparent nodes then a sentinel node bx should be done. If palpable nodes then a needle bx is done.

87
Q

Which is better Cytotoxic Tx or Checkpoint immuno TX for Merkel cell carcinoma?

A

Cytotoxic therapies are only palliative. Check point immuno TX have longer durability.

88
Q

Name two treatments for Merkel Cell Carcinoma

A

Avelumab 2017

Pembrolizumab 2018

89
Q

Show the staging AJCC of merkel cell carcinoma

A

Stage 0 In situ primary (? WTF)
Stage 1 < 2cm no nodes
Stage 2a >2cm no nodes
Stage 2b tumor invades muscle bone no nodes
Stage 3a node + no primary or + sentinel node
Stage 3b nodes involved
Stage 4 distant disease

90
Q

What is the latency for exposure of ionizing radiation and development of BCC

A

20 years

91
Q

what type of drugs have a lower risk for BCC in the immunosuppressed.

A

mTOR inhibitors

92
Q

What are increased risk of BCC Melanoma and SCC with HIV infection

A

2.1 none reported 2.6

93
Q

Which in order of risk are the skin cancer types with immunosuppression.

A

BCC about 6-16 Melanoma 1.4 8 SCC 20-250

94
Q

What type of transplant immunosuppression does not increase risk of skin cancer as much as other types.

A

hematopoetic transplants

95
Q

what does the hedgehog signaling pathway do?

A

regulates cell differentiation, proliferation and tissue polarity

96
Q

hydrochlorothiazide increases incidence of BCC and SCC by how much?

A

BCC two fold SCC four fold

97
Q

show the hedgehog signaling pathway

A
  1. Extracellular signaling molecules (Shh sonic hedgehog protein)
  2. attach to trans membrane receptors (PTCH 1 & 2)
  3. PTCH suppresses signal transducer SMO (smoothened) in cell membrane.
  4. SMO activates transcription factor Gli1, 2, 3)
  5. if SuFu does not hibit then Gli enters nucleus
98
Q

what chromosome is sonic hedgehog gene located?

A

chromosome 7

99
Q

How does cancer come from the hedgehog signaling pathway.

A

Too much activation of the pathway.

100
Q

In BCC what is the mutation that causes >50% of the bcc

A

TP53 mutation p53 in UV damaged cells stops replication and induces apoptosis

101
Q

Beside inactivation of PTCH 1 what are two other mutations that can cause GLI to enter the nucleus to cause BCC?

A

activation of SMO or inactivation of SUFU

102
Q

What is the staging system for BCC

A

There is no staging system for BCC

103
Q

What is the risk for mets in BCC

A

.0028%

104
Q

In the sonic hedgehog pathway activating or inactivating of each of these cause BCC which is it for each one PTCH1, Smoothened, SUFU, GiL

A

inactivating PTCH1
activating Smoothened (SMO)
inactivating SUFU
activating GIL

105
Q

Does UV light from gel nail manicures increase risk for Nail SCC.

A

No

106
Q

Name an immunosuppressive drug used in organ transplants and Crohn’s disease that increases SCC risk by %56

A

Azathioprine

107
Q

What is the primary cause of BCC?

A

Intermittent intense UVB & sunburns at any age.

108
Q

What is the primary cause of SCC and AKs?

A

cumulative UV exposure & childhood sunburns

109
Q

How much do tanning beds increase risk of SCC

A

2.5 x

110
Q

How much do tanning beds increase risk of BCC

A

1.5

111
Q

PUVA therapy is assoc with increased risk of SCC in what fashion.

A

dose related increase risk.

112
Q

What is the increase risk from narrow band uvb 311-312nm

A

none

113
Q

wavelengths below this number in phototherapy increase your risks for burning and cancer

A

300nm

114
Q

With ionizing radiation what is increase of risk of BCC and SCC in 20 years based on in proportion to dosage?

A

3x the risk

115
Q

What two co-carcinogens increase risk for SCC

A

HPV and UV

116
Q

What percent of transplant patients have HPV in their SCC

A

90%

117
Q

What is the increased risk for SCC and BCC in transplant patients?

A

SCC 40-250x

BCC 5-10 x

118
Q

What are the HPV types associated with SCC in transplant patients

A

1,2,5,6,11,16,18

119
Q

what vaccination if injected into a SCC might clear it?

A

HPV

120
Q

Name five classes of the immunosuppressive drugs that might increase risk for SCC

A
  1. Biologics
  2. steroids
  3. Nibs (Braf inhibitors)
  4. Calcineurin inhibitors (cyclosporin, tacrolimus, pimecrolimus
  5. Mycophenolate Motetil Cellcept
121
Q

What gene is most commonly mutated in SCC?

A

P53 the tumor suppressor gene

122
Q

What % of BCCs have a mutated P53 gene

A

about 50%

123
Q

What is the most frequently altered gene in all human cancers.

A

P53 mutated in over 50% of all human cancers

124
Q

What are the three ways that p53 gene stops tumorigenesis.

A
  1. Stops cell growth arrest by stimulating p21 which produces Cdk and stops mitosis in S phase.
  2. Causes Apoptosis by stimulating BAX
  3. Increases thrombospondin which decreases angiogenesis.
125
Q

what is P63

A

a gene similar to P53 and found in many skin cancers.

126
Q

In order what are the three most common mutations in BCC

A

PTCH
P53 (most common in SCC)
SMO

127
Q

what do you call a gene that has the potential to turn into an oncogene?

A

Proto-oncogenes

128
Q

HHV-8 is found in what percent of Kaposi’s sarcoma patients?

A

Almost all.

129
Q

What is the mechanism of action of HHV-8 in Kaposi’s sarcoma.

A

Reactivation of a virus rather than primary infection.

130
Q

Of the 4 clinical variants of Kaposi’s how many are associated with HHV-8

A

all four

131
Q

What are Bcl-2 and Bcl-xL proteins

A

promote cell survival and inhibit pro-apoptotic proteins.

132
Q

What are BAD, BAX, BID, and BAK proteins

A

proteins that promote apoptosis

133
Q

what percent of porokeratosis develops SCC

A

10%

134
Q

What is the one porokeratosis that does not develop SCC

A

punctate porokeratosis on palms and soles around adolescence.

135
Q

What is the cause of DSAP

A

Autosomal dominant disorder with a mevalonate mutation.

136
Q

What is the hyperkeratotic layer of porokeratosis called?

A

cornoid lamella

137
Q

In which merkel cell carcinomas should sentinel node biopsies be done?

A

all

138
Q

Risk of progression of ak to scc is what?

A

.1 to1%

139
Q

NCCN guidelines recommend a sentinel node bx in all patients with merkel cell carcinoma because clinically negative node patients have what percent of nodal involvement on sentinel node biopsy?

A

25-35%

140
Q

In Merkel cell carcinoma what percent eventually get’s node mets and what percent gets distant mets.

A

50% and 35%

141
Q

What are the three types of verrucous carcinoma

A

Giant condyloma of Buchske-Lownstein
Oral florid papillomatosis
Epithelioma cuniculatum (on bottom of foot assoc with wart)

142
Q

How likely is verrucous carcinoma likely to metastasize?

A

rarely. It is considered a well differentiated variant of SCC. Can penetrate deep.

143
Q

Is UV exposure implicated in verrucous carcinoma?

A

Yes

144
Q

Although excision and Mohs is considered the best treatment for verrucous carcinoma what treatment should be avoided.

A

Radiation. May induce anaplastic changes, risk is likely low.

145
Q

HPV vaccination may be preventative for verrucous carcinoma because of its association with what viruses.

A

6 & 11 low risk

16 & 18 high risk

146
Q

For merkel cell carcinoma if you have a positive sentinel node biopsy what are the next steps.

A
  1. PET CT scan
  2. referral for adjuvant therapy clinical trial
  3. if above not available radiation or node dissection or both
147
Q

which of the following cancers have been associated with arising out of Hailey Hailey disease , SCC BCC Melanoma

A

all

148
Q

With SCC and regional node involvement what is the NCCN guideline for derm f/u

A

2-3 months for one year
2-4 for year two
4-6 for years three - five
6-12 afterward

149
Q

What is the polyomavirus associated with merkel cell carcinoma?

A

MCPyV

150
Q

what percent of the population has been exposed to the polyomavirus MCPyV

A

60 to 80%

151
Q

What happens if you are seronegative for MCPyV with merkel cell carcinoma at baseline?

A

you are at high risk for recurrance.

152
Q

What two antibodies for MCPyV are important in Merkel cell carcinoma?

A 
Major capsid antibody (VP1)  found in general population
oncoprotein antibody (T1) found in merkel cell cases
153
Q

Which of the two MCPyV antibodies are found in the general population and low baseline with merkel cell carcinoma diagnosis portends more metastatic disease.

A

Major capsid antibody

154
Q

Which of the two MCPyV antibodies can you track to follow for recurrance.

A

oncoprotein antibody. (not useful in people that are seronegative at baseline)

155
Q

What is the most important feature in differentiating Atypical Fibroxanthoma from pleomorphic dermal sarcoma

A

depth of invasion. They look the same histologically.

156
Q

What is the highest risk factor for death from SCC at time of treatment.

A

Tumor diameter. tumors over 2cm have a 20 risk of death for tumors under 2 cm.

157
Q

Risk for death with perineural involvement that is clinical is what. And risk for death from PNI on histology only is what?

A

30% and 13%

158
Q

Being able to determine perineural involvement on biopsies require a depth of how much?

A

3-4 mm

159
Q

Is a sentinel node biopsy done before or after the malignancy is resected?

A

before the tumor is removed

160
Q

What drug has been shown to reduce skin cancers by 63 % in patients with xeroderma pigmentosa

A

Isotretinoin

161
Q

What type of leukemia has an increased risk for nonmelanoma skin cancer.

A

CLL

162
Q

Is arsenic exposure a risk factor for BCC

A

Yes, chronic arsenic exposure is a risk factor.

163
Q

what type of solid organ transplant has the least risk for development of SCC

A

Liver

164
Q

Which has higher SCC assoc. Liver Kidney transplants or Lung Heart transplants

A

Heart and Lung transplants have the most risk for SCC

165
Q

what is the increased risk of scc in organ transplant patients.

A

6-100 fold

166
Q

Mucinous carcinoma can be primary or metastasize from cancers of what organs?

A

breast, GI, Lung, ovary, prostate

167
Q

Why is mohs the treatment of choice for Mucinous carcinoma?

A

poor response to radiation and chemo. Recurrence rate of 13% with Mohs over double that with excision.

168
Q

Is primary mucinous carcinoma a low or high grade malignancy?

A

Low grade with low rate of mets but high recurrence rate.

169
Q

although mucinous carcinoma can be found in multiple locations which are the most common?

A 
eyelid #1
scalp
Neck
axillae
trunk
170
Q

Diets low in what have been shown to reduce AK risk

A

Fat

171
Q

what are the subclinical spread numbers at 1cm 3cm and 5 cm for DFSP

A

1cm 75%
3cm 15%
5cm 5%

172
Q

What is the cure rate for DFSP with Mohs

A

98%

173
Q

Where are the most common areas for finding basosquamous cell carcinoma.

A

perinasal, periocular, preauricular skin

174
Q

What sites are most common for microcystic adnexal carcinoma.

A

cutaneous upper and lower lips

175
Q

What is the earliest sign of Gorlin’s syndrome

A

Odontogenic keratocysts

176
Q

what is the followup for merkel cell carcinoma with skin check and lymph node exam

A

3-6 months for 3 years

6-12 forever

177
Q

In immunocompromised pts do they get more or less superficial BCC compared to normal pts.

A

more

178
Q

Who has higher recurrence rates for treated BCCs immunocompromised or normal patients.

A

rate of recurrence is the same for BCC, but SCC is worse for immunocompromised.

179
Q

Who gets more non head and neck BCCs immunocompromised or normal patients.

A

immunocompromised

180
Q

Who gets BCCs at a younger age immunocompromised or immunocompetent.

A

immunocompromised

181
Q

what is the number one skin cancer in the US and how many are diagnosed each year?

A

BCC 2million

182
Q

what is your lifetime risk of getting a BCC

A

20%

183
Q

how many cases of SCC are diagnosed in US a year

A

about 1 million

184
Q

How many cases of melanoma are diagnosed in the US each year

A

80K+

185
Q

What locations are KAs less likely to regress

A

mucosal and periungual (those arising in non-hairbearing areas.

186
Q

in the asian/hispanic population what #1 feature of a pigmented basal would be expected to show more subclinical extension.

A

Ulceration

187
Q

In the asian/hispanic population with a pigmented basal cell what features increase risk for subclinical extension and more layers.

A

Ulceration #1
under age 50
Location on nose
Size over 1 cm (unlike caucasion size over 2cm)

188
Q

In a asian/hispanic population one sign of a BCC that makes it more likely to be cleared in one stage.

A

pigmentation

189
Q

After the risk factor of size over 2cm for risk of disease specific death what is the second highest risk factor in SCC.

A

Depth

as compared to non clinical perineural involvement..

190
Q

acantholytic SCCs are not associated with what lesion that other SCCs are commonly associated with?

A

AKs

191
Q

what is the most common skin cancer in african americans and what is the most common location

A

SCC lower extremities (associated with chronic inflammation and scarring)

192
Q

What is considered the UV signature mutation

A

a Cytosine to Thymine mutation at a dipyrimidine site

found in the PCTH gene in basal cell, the p53 gene in SCC and the CDKN2A gene in melanoma

193
Q

what is opposite with gay men and women when it comes to skin cancer.

A

gay men use tanning beds more than non-gay men and have a higher incidence of skin cancer.
Gay women have less tanning bed use that Hetrosexual women and have fewer skin cancers.

194
Q

Malignant peripheral nerve sheath tumor (a sarcoma) which can occur with neurofibromatosis type1 has what gene mutation

A

p53

195
Q

What type of gene is p53

A

tumor suppressor gene - mutated by UV at the C to T transitions on the dipyrimidine sites

196
Q

What is the risk for a Marjolin ulcer to metastasize?

A

30%

197
Q

The leg is the most common site for a marjolin ulcer, but what location on the leg is the most common site.

A

Plantar surface of the foot.

198
Q

in merkel cell carcinoma which patients have a better survival. Those with a known primary or those with an unknown primary.

A

unknown primary

199
Q

what % of melanoma in situ is found to have invasive melanoma on excision

A

4-6%

200
Q

of the three types of congenital nevi small <1.5cm medium <20 cm or large have a risk for melanoma compared to the general population.

A

Large only with a 6% risk

201
Q

When is the risk for melanoma the highest in a giant congenital nevus

A

The first ten years.

202
Q

although the overall incidence of melanoma is increasing what two age groups is it decreasing in.

A 
adolescents (10-19)
Young adults (20=29)
203
Q

Blueberry muffin syndrome is associated with what disease and what mutation that is shared by melanoma.

A

Langerhans cell histiocytosis (caused by cells from bone marrow)
BRAF V 600E +

204
Q

what viruses are associated with organ transplant SCC 80% of the time.

A

HPV 5 & 8 Same as Epidermodysplasia Verruciformis

205
Q

When if you see halo nevi would give the better prognosis for what factor in a melanoma.

A

Early new melanoma lesions.

206
Q

when doing mohs on a toe vs amputation which has lower recurrence rates.

A

They both have the same recurrence rates.

207
Q

why is the bar lower for taking another layer with a low grade melanoma on acral skin.

A

There are fewer melanocytes on acral skin so it is easier to miss subtle positive margins.

Derm Surg questions (26 decks)

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