Skin cancers Flashcards
Learn about these nasty skin tumours
What is the epidemiology of non melanoma skin cancer?
- Basal cell cancer & Squamous cell cancer
- Incidence has increased in the last 30-40 years
- Northern europe 3-4 times less than Australia
- BCCs account for 70% of NMSCs.
- BCCs incidence from 146 to 788/100000
- SCCs 38 to 250/100000
What are the risk factors of non melanoma skin cancer?
- UV radiation
- Photochemotherapy (PUVA)
- Chemical carcinogens
- X-ray and thermal radiation
- Human papilloma virus
- Familial cancer syndromes
- Immunosuppression
Describe basal cell carcinoma (including the different types)
- Slow growing
- Locally invasive
- Rarely metastasise
Nodular
- Pearly rolled edge
- Telangiectasia
- Central ulceration
- Arborising vessels on dermoscopy
Superficial
Pigmented
Merphoeic
What is the treatment of basal cell carcinoma?
- Excision is gold standard
* Ellipse, with rim of unaffected skin
* Curative if fully excised
* Will scar - Curettage in some circumstances
- Mohs surgery
- Vismodegib
What are the indications of Mohs surgery?
- Site
- Size
- Subtype
- Poor clinical margin definition
- Recurrent
- Perineural or perivascular involvement
Explain Vismodegib
- Indications
* Locally advanced BCC not suitable for surgery or radiotherapy
* Metastatic BCC - Selectively inhibits abnormal signalling in the Hedgehog pathway (molecular driver in BCC)
- Can shrink tumors and heal visible lesions in some
- Median progression free survival 9.5 months
- Side Effects
* Hair loss, weight loss, altered taste
* Muscle spasms, nausea, fatigue
Explain squamous cell carcinoma
- Derived from keratinising squamous cells
- Usually on sun exposed sites
- Can metastasise
- Faster growing, tender, scaly/crusted or fleshy growths
- Can ulcerate
What is the treatment of squamous cell carcinoma?
- Excision
- +/- Radiotherapy
Follow up if high risk
- Immunosuppressed
- > 20mm diameter
- > 4mm depth
- Ear, nose, lip, eyelid
- Perineural invasion
- Poorly differentiated
Explain keratoacanthoma
- Variant of squamous cell carcinoma
- Erupts from hair follicles in sun damaged skin
- Grows rapidly, may shrink after a few months and resolve
- Surgical excision
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?
- Asymmetry
- Border
- Colour
- Diameter
- Evolution
What is the seven point checklist?
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 the treatment of melanoma skin cancer?
- Urgent surgical excision
* Subtype
* Breslow thickness - Wide local excision
- Sentinel lymph node biopsy
- Chemotherapy/immunotherapy
- Regular follow up
- Primary and Secondary Prevention
- drugs
What drugs are used to treat metastatic melanoma?
Ipilimumab - Inhibits CTLA-4 molecule - One year survival 47-51% (double those not on treatment) Pembrolizumab - Blocks activity of PD-1 - One year survival 68-74% Vemurafenib and Dabrafenib - Blocks B-RAF protein - Only useful if B-RAF mutation - Median survival 10.5 months (7.8 months with standard chemotherapy)
Describe secondary cutaneous lymphoma
Secondary cutaneous disease from systemic/nodal involvement
Describe primary cutaneous lymphoma
Primary cutaneous disease – abnormal neoplastic proliferation of lymphocytes in the skin
- Cutaneous T Cell lymphoma (65%)
* Mycosis fungoides
* MF variants
* Sezary syndrome
* CD30+ lymphoproliferative disorders
* Subcutaneous panniculitis like T cell lymphoma
* Cutaneous CD4+ lymphoma
* Extranodal NK/T cell lymphoma
Cutaneous B Cell lymphoma (20%)
* Cutaneous follicle centre lymphoma
* Cutaneous marginal zone lymphoma
* Cutaneous diffuse large B Cell lymphoma
Explain mycosis fungoides
- Most common CTCL & accounts for around 50% of all primary cutaneous lymphomas
- Incidence 6 per 1 million population
- Cause unknown
- More common in older patients and more common in men than women
- Indolent course
What are the stages of mycosis fungoides
- Tumour
* Large irregular lumps, can ulcerate
* Arise from existing plaques or in normal skin
* More likely to have metastatic spread - Metastatic
* Infiltration of neoplastic cells in lymph nodes, blood and solid organs - Work up includes bloods for sezary cells and CT imaging for staging
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 - 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 photopheresis
- Bone marrow transplantation
What is total skin electron 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
Explain extracorporeal photopheresis
- Step 1: patients blood is drawn and leukocytes 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
Explain cutaneous metastases
- Can be secondary to primary skin malignancy such as melanoma or due to primary solid organ malignancy
* Most commonly breast, colon and lung
