Skin Cancers

Question 1

What are the broad different types of skin cancer?

Answer 1

Non-melanoma skin cancers (BCC, SCC)
Melanoma skin cancer
Cutaneous Lymphoma

Question 2

What are the different types of non-melanoma skin cancers and which is most common?

Answer 2

Basal cell carcinoma (70% of non-melanomas)

Squamous cell carcinoma

Question 3

What are the risk factors for non-melanoma cancers?

Answer 3

UV radiation
Photochemotherapy (PUVA)
Chemical carcinogens
Ionising radiation
HPV
Familial cancer syndromes
Immunosuppression

Question 4

What are the features/symptoms/signs of BCC?

Answer 4

Slow growing
Locally invasive
Rarely metastasise

Nodular

• pearly rolled edge
• telangiectasia
• central ulceration
• arborising vessels on dermoscopy
• pigmented or morphoeic

Question 5

How is BCC treated?

Answer 5

Surgery - excision is gold standard
Curative if fully excised
Mohs surgery

Vismodegib - indicated in locally advanced BCC not suitable for surgery/radiotherapy, or metastatic BCC
- median progression free survival 9.5months

Question 6

What are the features/symptoms/signs of SCC? Any particular variants?

Answer 6

Usually on sun-exposed sites
Faster growing, tender, scaly/crusted or fleshy growths
Can ulcerate
Can metastasise
Derived from keratinising squamous cells

Keratoacanthoma

• SCC variant
• erupts from hair follicles in sun-damaged skin
• grows rapidly, but may shrink after a few months and resolve

Question 7

How is SCC treated?

Answer 7

Excision +/- radiotherapy
Follow-up if high risk
Concern in immunosuppressed, if >20mm in diameter or 4mm in depth, on ear/nose/lip/eyelid, perineural invasion, poorly differentiated

Surgical excision for keratoacanthoma

Question 8

What are the risk factors for melanoma skin cancers?

Answer 8

UV radiation
Genetic susceptibility - fair skin, red hair, blue eyes, burn tendency
Familial melanoma and melanoma susceptibility genes

Question 9

How is melanoma assessed?

Answer 9

ABCDE
- asymmetry, border, colour, diameter, evolution

Major features - change in size, shape, colour
Minor features - diameter >5mm, inflammation, oozing/bleeding, mild itch, altered sensation

Dermoscopy can be used
Sentinel node biopsy

Question 10

What are the different types of melanoma?

Answer 10

Superficial spreading malignant melanoma
Lentigo maligna melanoma
Nodular melanoma
Acral lentiginous melanoma/subungal melanoma
Ocular melanoma

Question 11

How is melanoma treated?

Answer 11

Urgent surgical excision - depends on subtype, Breslow thickness
Wide local excision
Chemo/immunotherapy
Regular follow-up
Primary/secondary prevention

Question 12

What are the biologic treatments for metastatic melanoma?

Answer 12

Ipilimumab - CTLA-4
Pembrolizumab - PD-1 receptor
Vemufarenib/Dabrafenib - BRAF

Question 13

What is cutaneous lymphoma?

Answer 13

Secondary cutaneous disease from systemic/nodal involvement OR
Primary cutaneous disease of abnormal neoplastic proliferation of lymphocytes in cells

Question 14

What are the different types of primary cutaneous lymphoma and which is more common?

Answer 14

Cutaneous T Cell lymphoma - 65%

Cutaneous B Cell lymphoma - 20%

Question 15

What are the different subtypes of cutaneous T cell lymphoma and which are the most important?

Answer 15

Mycosis Fungoides + variants
Sezary syndrome
CD30+ immunoproliferative disorders
Subcutaneous panniculitis-like T cell lymphoma
Cutaneous CD4+ lymphoma
Extranodal NK/T cell lymphoma

Question 16

What is mycosis fungoides and its appearance?

Answer 16

Most common CTCL - accounts for 50% of primary lymphomas
Patch - flat, red, dry, oval lesions, usually on covered sites - may resolve or progress
Can become plaques - thickened, itchy patches

Can become tumour - large irregular lumps that may ulcerate - more likely to have metastatic spread

Question 17

What investigations are done for mycosis fungoides?

Answer 17

Bloods for sezary cells

CT for staging

Question 18

What are the signs/symptoms of sezary syndrome?

Answer 18

Red-man syndrome
CTCL affecting entire skin of body
- skin thickened, scaly, red, very itchy

Sezary cells in blood
Atypical T cells
Lymph node involvement

Question 19

What are the treatments for mycosis fungoides/sezary syndrome?

Answer 19

Topical steroids
PUVA/UVB
Localised radiotherapy
Interferon
Bexarotene
Low dose methotrexate
Chemotherapy
Total skin electron beam therapy
Extracorporeal photophoresis
Bone marrow transplant

Question 20

What is total skin electron beam therapy?

Answer 20

Type of radiotherapy

Delivers radiation primarily to superficial layers e.g. epidermis and dermis, sparing deeper organs/tissues

Question 21

How does extracorporeal photophoresis work?

Answer 21

1. Patients blood drawn and leucocytes collected
2. Collected white cells mixed with psoralen which makes the T cells sensitive to UVA
3. UVA exposure, damaging diseased cells
4. Treated cells re-infused back to patient

Question 22

How are cutaneous metastases managed? What are the common origins?

Answer 22

Treat underlying malignancy
Local excision
Localised radiotherapy
Symptomatic treatments

Can be secondary to primary skin malignancy such as melanoma, or due to primary solid organ malignany (commonly breast, colon, lung)