Skin Cancer Flashcards
Describe the distribution of melanocytes in different races?
Melanocytes are found in equal numbers between black and white ethnicities but melanocytes in black races produce more protective melanin
Why might melanomas be found later in darker skinned ethnicities?
Reduced public/physician awareness
Lower index of suspicion
Challenging detection (more likely acral)
Name two non cancerous melanocyte growths
Moles
Freckles
Name the four types of Malignant Melanoma
Lentigo Maligna
Superficial Melanoma
Nodular Melanoma
Acral Lentiginous
How do Superficial Melanomas present?
Irregularly pigmented
Grow laterally before vertically
How do Nodular Melanomas present?
Most aggressive
Rapidly growing pigmented nodule that bleeds/ulcerates
How do Acral Lentiginous Lesions present?
Pigmented lesions on palm/sole/nail bed
Where are the common sites of metastases from Malignant Melanoma?
Lymph nodes
Liver
Lung
Bone
Brain
Give four risk factors for Malignant Melanoma
Naevi
Sun Exposure
Skin Pigmentation (Fitzpatrick 1 or 2)
Immunosupression
Describe the risk factor ‘Naevi’ in terms of Malignant Melanoma
Individual with >100 common naevi or >2 atypical naevi
What is Atypical Mole Syndrome?
> 100 common naevi
AND
2 atypical naevi
AND
Naevi on unusual sites
Describe the risk factor ‘Sun Exposure’ in terms of Malignant Melanoma
Sharp short bursts of acute exposure in childhood, or severe sunburn
Post Sunbed use
Cumulative moderate occupational exposure may be protective in some
Using the A to E mnemonic, how can Malignant Melanomas be described?
Asymmetry
Border (uneven, scalloped)
Colour (variety in shade/colour)
Diameter (>6mm)
Evolving
There is a point system for examining Malignant Melanomas, and if patients score >3 then they require a 2ww. State the major factors scoring 2 points
Change in size
Irregular Shape
Irregular Colour
There is a point system for examining Malignant Melanomas, and if patients score >3 then they require a 2ww. State the minor factors scoring 1 point
Largest diameter >7mm
Inflammation
Oozing
Change in sensation
What are excisional biopsies?
Suspicious lesions are completely excised with 1-2mm margin
Includes subcut fat to ensure full dermal sample
When are incisional biopsies used?
Reserved for large lesions
Cosmetically sensitive
Close to vital structures
Name three types of histological analysis carried out on Malignant Melanoma biopsies
Breslow Thickness
Ulceration
Mitotic Index
What is Breslow Thickness?
Based on vertical thickness of tumour in mm
From Stratum Granulosum to point of maximum infiltration
Correlates with mortality
What is Mitotic Index?
Indicator of cell turnover
Number of mitoses per mm2
If the Malignant Melanoma is high risk, what other investigations should be done?
PET CT
LDH (Risk Stratifying)
Name two different ways to stage Malignant Melanomas
TNM
AJCC (American Joint Committee on Cancer)
Are Malignant Melanomas radiosensitive?
No
What levels should be maximised before initiating management for Malignant Melanomas?
Vitamin D
How are Stage 0-2 Malignant Melanomas managed?
Stage 0 - Topical Imiquimod or Excision with 0.5cm margin
Stage 1 - Excision with 1cm margin
Stage 2 - Excision with 2cm margin
Describe some management options for more advanced Malignant Melanomas
Lymph node dissection
Adjuvant radiotherapy
Topical Imiquimod
Electrochemotherapy
Palliative surgery
Give two examples of Biological agents for Malignant Melanoma
Dabrafenib (BRAF V600 +ve)
Bevacizumab (VEGF)
Give an example of an Immunotherapy agent used to treat Malignant Melanoma
Ipilimumab (Targets T lymphocytes and stimulates their anti tumour effects)
How is stage 1A Malignant Melanoma followed up?
2-4 times in first year then discharge
How is stage 1B-2B Malignant Melanoma followed up?
3m for 3y
then
6m for 2y
How is Stage III Malignant Melanoma followed up?
3m for 3y
then
6m for 2y
and surveillance imaging
How is Stage IV Malignant Melanoma followed up?
Personalised follow up
What is a Mucosal Melanoma?
Rare and primarily affecting head and neck, vulvovagial and anorectal
Typically older patients
Worse prognosis
Name two common Non Melanoma Skin Cancers
Basal Cell Carcinoma
Squamous Cell Carcinoma
Name two rarer Non Melanoma Skin Cancers
Merkel Cell Carcinoma
Kaposi’s Sarcoma
Give four risk factors for Non Melanoma Skin Cancers
UV radiation
Chronic Inflammation
HPV
Hereditary Conditions
Define Basal Cell Carcinoma
Slow growing, locally invasive malignant epidermal skin tumours, commonly occuring on sun exposed regions of the body, rarely metastasising
Name four genetic predispositions to Basal Cell Carcinoma
p53 mutations
Albinism
Gorlins Syndrome
Xeroderma Pigmentosum
How does Gorlin Syndrome present?
Autosomal dominant condition increasing risk of BCC
Multiple early onset BCCs
Hyperteorism
Palmar and Plantar Pits
Falx Calcification
Name the five types of Basal Cell Carcinoma
Nodular (60-80%)
Superficial
Morpheic
Pigmented
Basosquamous
How does Nodular BCC present?
TURP
Telangiectasia, Ulceration, Rolled Edges, Pearly Edge
Central ulcer = rodent ulcer
How do Superficial BCC present?
Erythematous plaques (commonly on trunk and limbs)
Difficult to distinguish from dermatitis/SCC
How do Morpheic BCC present?
Presents as a scar like lesion
Commonly occurring on upper trunk/face
Deeply invasive
How do Pigmented BCC present?
Difficult to distinguish from Melanoma
How do Basosquamous BCC present?
Rare and aggressive form with increased risk of recurrence and metastases
Give four BCC features that would make it high risk
> 2cm
Poorly defined
Perineural/Perivascular incasion
Immunosupression
The definitive management for BCC is excision and histological analysis. What margins are required for low and high risk?
Low risk -> 4-5mm margin
High risk -> atleast 5mm margin, and referral for Mohs Micrographic surgery considered
What is Moh’s Micrographic surgery?
Tumour is excised at an oblique angle in a series of stages and examined microscopically
Further excision until all margins negative
If there is a low risk lesion, BCC may be treated by other treatments such as:
Cryotherapy
Electrosurgery
When is radiotherapy for BCC appropriate?
For recurrent disease
In cosmetically sensitive areas
What is Photodynamic Therapy?
Light + Topical Photosensitising Agent to produce tumour destruction
Good cosmetic results but lengthy process
Squamous Cell Carcinomas make up around 20% of non melanoma skin cancer. How do they present?
Rapidly growing red papule or non healing lesion
Ulceration
Bleeding
May have background of Actinic Keratoses
What makes a Squamous Cell Carcinoma more likely to metastasise?
Recurrent disease
Large Size
Certain sites (eg lip)
Name 5 management options for Squamous Cell Carcinoma
Surgical excision (+histological analysis)
Cryotherapy (small low risk lesions)
Radiotherapy (if small and well localised, or as adjuvant)
Chemotherapy (Cisplatin)
Cetuximab
What is Merkel Cell Carcinoma?
Rare malignant skin tumour arising in head/neck/limbs that has neuroendocrine features pathologically
How does Merkel Cell Carcinoma present?
Red/purple nodule with overlying shiny epithelium
How is Merkel Cell Carcinoma managed?
Ideally surgery (+/- adjuvant chemoradio)
Define Selective and Extended Neck Dissection
Selective : One or more lymphatic groups preserved based on pattern of metastases
Extended : Extra lymphatic or non lymphatic structures are removed
