Skin Cancers Flashcards
State the skin cancers you need to know
- Melanoma
- Basal cell carcinoma
- Squamous cell carcinoma
Order the following skin cancers from most common to least common:
- BCC
- Melanoma
- SCC
- BCC (80%)
- SCC
- Melanoma
What cells do basal cell carcinomas arise from?
Slow-growing, locally invasive epidermal skin tumour arising from the stratum basale (used to think originated from basal cell but recently discovered you can get it anywhere other than lip therefore has hair follicle origin)
***The lowest layer of the epidermis is called the basal layer. It contains rounder cells called basal cells.
State the 5 types of BCC; including which subtypes are low risk and which are high risk
Highlight the most common subtype?
Risk depends on many factors but generally nodular and superficial considered less risky
- Nodular (nBCC)
- Superficial (sBCC)
- Morpheic/sclerosing
- Basosquamous
- Pigmented
State some risk factors for BCC
- Fitzpatrick skin types I & II
- UV exposure
- Increasing age
- Smoking
- Immunosuppression
- Male
If someone has multiple BCCs presenting at a young age, what autosomal dominant condition might this be?
Basal cell naevus (Gorlin) syndrome
Describe the typical presentation of of nodular basal cell carcinoma
- Pearly (shiny) nodule with telangiectasia
- Rolled edge
- Tends to ulcerate with time
- Common on head & neck region
Describe the typical presentation of superficial basal cell carcinoma
- Erythematous irregular patch or plaque
- Slightly scaly
- Usually on trunk
Describe the typical presentation of morpheic/sclerosing basal cell carcinoma
- Shiny, scar-like plaque
- Ill-defined border
- Usually found in mid-facial sites
Basosquamous carcinoma is rare; what is it?
- Mixed basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)
- Infiltrative growth pattern
- Potentially more aggressive than other forms of BCC
Discuss the 2WW referral criteria for BCC
- Only consider urgent referral (2WW) if has skin lesion suggestive of BCC AND there’s concern that a delay may have unfavourable impact due to location or size of lesion
- In others, arrange a routine referral
Discuss what investigations are done for BCC
Diagnosis usually made clinically, biopsy only indicated if clinical doubt exists or when histological subtype may influence treatment & prognosis
Discuss the management of BCC (highlight the most common management/treatment of choice)
- Surgical excision with histological assessment of the margins (target excision depends on subtype)
- Moh’s surgery (for high risk facial BCCs)
- Destructive surgical techniques (small nodular or superficial)
- Curettage (scrape)
- Cryosurgery (extreme cold)
- Radiotherapy
- Destructive non-surgical techniques
- Topical imiquimod (sBCCs)
- Topical fluorouracil (sBCCs)
- Photodynamic therapy (sBCCs)
And of course skin protection advice (cover up, sun cream etc…)
Discuss the prognosis of BCC
- Very good prognosis (85-90% don’t get recurrence)
- Almost never a danger to life
What cells do squamous cell carcinoma arise from?
Cutaneous carcinoma arising from keratinocytes of the epidermis or it’s appendages
State some risk factors for squamous cell carcinoma
- Fitzpatrick skin types (I & II)
- Chronic UV radiation
- Smoking
- Immunosuppression
- Increasing age
- Male
- Genetic conditions (e.g. xeroderma pigmentosum, albinism)
- Chronic inflammation or chronic wounds (e.g. long standing leg ulcers [Marjolin’s ulcer])
- HPV (for genital or anal SCC)
- Actinic keratosis
- Bowen disease
What is actinic keratosis?
- Common premalignant skin condition that arises due to chronic sun exposure
- Presentation:
- Small, crusty or scaly lesions
- May be pink, red, brown or same colour as skin
- On sun exposed areas (e.g. face)
- May have multiple lesions
AK is an epidermal lesion characterized by aggregates of atypical, pleomorphic keratinocytes at the basal layer that may extend upwards to involve the granular and cornified layers. This presentation may resemble Bowen disease or carcinoma in situ, and the distinction between the two is a matter of degree (extent of the lesion) rather than differences in individual cells.**
What is Bowen disease/SCC in situ?
- Squamous cell carcinoma that is confined to the epidermis (with basement membrane intact)
- Presentation:
- Red or pink patch or plaque
- Scaly or crusty
- Might be intermittently itchy
- Common in sun-exposed areas
Compare:
- Actinic keratosis
- Bowen’s disease
- SCC
- AK: atypical keratinocytes that appear to crowd the basal layer and lower levels of the epidermis, but do not extend to full thickness
- Bowen’s: full-thickness atypia that is confined to the epidermis, with an intact basement membrane
- SCC: Extend beyond the basement membrane, penetrate into the dermis, and may invade deeper structures
Describe typical presentation of SCC
- Indurating (hard) keratinising or crusted plaque or nodule
- Commonly in sun exposed sites (e.g. face, forearms, dorsum of hands)
- Often symptomatic:
- Pain
- Discomfort
- Bleeding
- Ulcerating
- Sensory changes
*NOTE: SCCs have different morphologies:
- Well differentiated: scaly and grows slowly
- Poorly differentiated: non-scaly, appear rlike granulation tissue
Discuss the 2WW referral criteria for SCC
Refer via 2WW if person has lesion suspicious of SCC
What is Moh’s surgery?
Staged resection in which thin layers of skin are progressively removed. Once removed the layers are examined under a microscope. Keep removing layers until only cancer free tissue remains. Usually done under LA.(This differs from surgical excision in which they excise the lesion with a set margin e.g. 4mm or 6mm)
Discuss the prognosis of SCC
State some good and some poor prognostic factors
Prognosis generally very good
Describe the typical presentation of superficial spreading melanoma
-
Hyperpigmented patch or plaque (mole) growing radially following ABCDE rules:
- Asymmetry, irregular border, multi-coloured, diameter >0.6cm, evolution
- Commonly on arms, legs, back and & chest
- Can occur in young people
Describe the typical presentation of lentigo maligna melanoma
-
Hyperpigmented patch or plaque (mole) growing radially following ABCDE rules
- Asymmetry, irregular border, multi-coloured, diameter >0.6cm, evolution
- Occurs in sun exposed regions
- Older/elderly people
Describe the typical presentation of acral lentiginous melanoma
- Affects nails, palms or soles
- Hutchinson sign (extension of pigment into nailfold)
- More common in Afro-Caribbean & asian people
Describe the typical presentation of nodular melanoma
- Hyperpigmented or blue/black or amelanotic firm papule, nodule or plaque
- May bleed or ooze
- Occurs in sun exposed sites
- Middle-aged people
What checklist is used to determine likelihood of melanoma?
7 point weighted checklist:
**Suspicion is greater for lesions scoring 3 points or more. However, if there are strong concerns about cancer, any one feature is adequate to prompt urgent referral under the 2-week rule.
Discuss the 2WW referral criteria for melanoma
Refer via 2WW if person has:
- Suspicious pigmented skin lesion that has a weighted seven-point checklist score of three or more (but if strong concern one feature is enough to warrant referral)
- Or dermoscopy suggests malignant melanoma of the skin
Consider referral via 2WW if person has:
- A pigmented or non-pigmented skin lesion that suggests nodular melanoma
What is the difference between an excisional, incisional, shave & punch biopsy?
Why is excisional the gold standard for melanoma?
Excisional biopsy= entire tumour removed (along with small margin of normal skin around it). Do in elliptical shape to reduce risk of scarring as can design so that ellipse is in line with parallel with existing skin creases and can ensure edges of skin oppose nicely so can heal via primary intention
Incisional biopsy= part of tumour removed. Used if large lesion or if in sensitive region (e.g. eyelid, lip etc…)
Shave biopsy= samples a portion of the superficial layers of the skin and therefore is minimally invasive
Punch biopsy= a punch biopsy involves removing a small piece of skin using a circular blade called a punch (usually 6mm)
Excisional is gold standard as you are hopefully removing the whole lesion. incisional biopsy can make subsequent histopathological assessment difficult.
What staging is used for melanoma?
TNM
(Based on primary tumour Breslow thickness, lymph node involvement & metastases)
Discuss the management of melanoma
-
Suspicious lesions should have excision biopsy. Once diagnosis confirmed then a second surgery/wide local excision with following margins
- In situ= 5mm
- BT = 1mm= 1cm
- BT >1mm - =2mm= 1-2cm
- BT >2mm - =4mm= 2-3cm
- BT >4mm = 3cm
- Radical lymph node dissection if node metastasis
-
Adjuvant therapy:
- Normally immunotherapy (PD1 inhibitors e.g. Nivolumab)
- Targeted therapies (BRAF inhibitors (50% have BRAF mutation), MEK inhibitors)
- Radiotherapy (not often used. Mostly used for brain)
And of course skin protection advice (cover up, sun cream etc…)
Lecturer said doesn’t respond to chemotherapy
