Skin Cancers

Question 1

What is actinic keratoses?

Answer 1

Pre-malignant crumbly yellow-white scaly crusts on sun-exposed skin from dysplastic intra-epidermal proliferation of atypical keratinocytes

Question 2

What are features of actinic keratoses?

Answer 2

Small crusty or scaly lesions
May be pink, red, brown or same colour as skin
Typically on sun-exposed areas e.g. temples
Multiple lesions may be present

Question 3

What are management options in actinic keratoses?

Answer 3

Prevention of further risk - hats, sunscreen, sun avoidance
Fluorouracil cream typically 2/3 week course. Skin will become red and inflamed - sometimes topical hydrocortisone is given following fluorouracil to help settle inflammation Works by causing erythema, vesiculation, erosion, ulcers, necrosis, healing epithelialisation

Topical diclofenac - well tolerated and cheap

Topical imiquimod - augments cell mediated immunity by inducing interferon alpha and causes a similar inflammatory reaction to fluorouracil

Cryotherpay

Photodynamic therapy - useful if located at sites of poor healing

Surgical excision and curettage - if atypical or unresponsive

Question 4

What is Bowen’s disease

Answer 4

Well-defined slowly-enlarging red scaly plaque with a flat edge
Type of intraepidermal squamous cell carcinoma

Red, scaly patches
Often occur on sun exposed areas such as lower limbs

UV exposure
Radiation
Immunosuppression
HPV infection

Question 5

What is management of Bowen’s disease?

Answer 5

Cryotherapy
Topical 5-fluorouracil or imiquimod
Excision

Question 6

What is the most common skin cancer?

Answer 6

Basal cell carcinoma

Then squamous cell carcinoma

Question 7

What are features of basal cell carcinoma?

Answer 7

Nodular: Pearly nodule with rolled telangiectasia edge on the face or a sun exposed site ± central ulcer
Central crater
Metastases are very rare
Slowly causes local destruction if left untreated

Superficial: lesions appear as red, scaly plaques with raised smooth edge often on the trunk or shoulders

Question 8

What is management of basal cell carcinoma?

Answer 8

Surgical excision
Cryotherapy
Curettage
Topical imiguimod or fluorouracil for low-risk superficial lesions

Question 9

What are risk factors for squamous cell carcinoma?

Answer 9

Excessive exposure to sunlight/psoralen UVA therapy
Actinic keratoses and Bowen’s disease
Immunosuppression
Smoking
Long stand-in leg ulcers (Marjolin’s ulcer)
genetic conditions (xeroderma pigmentosum

Question 10

Describe features of SCC

Answer 10

Persistently ulcerated or crusted firm irregular lesion often on sun-exposed sites
Locallu invasive and may metastasise
Increased risk if lip or ear or non-sun exposed site

Question 11

What is treatment of SCC?

Answer 11

Surgical excision with 4mm margins if lesion < 20mm

6mm margins if lesion > 20mm

Question 12

What are poor prognostic factors in SCC?

Answer 12

Increased risk if lip or ear or non-sun exposed site
>2cm diameter
Poor histological differentiation
Host immunosuppression
>4mm deep

Question 13

What cancers can cause cutaneous mets?

Answer 13

Breast - skin of chest and scalp
Stomach and colon - skin of abdominal wall
Lung - skin of chest and scalp
GU system 
Non-Hodgkins lymphoma
Leukaemia

Mets are usually firm, intradermal or subcutaneous nodules

Question 14

What is mycosis fungicides?

Answer 14

Cutaneous T-cell lymphoma which progresses from well-defined itchy red scaly patches and plaques to red-brown infiltrated plaques and ulcerating tumours

Lesions tend to be of different colours in contrast to eczema/psoriasis

Potent topical steroids
PUVA
Radiotherapy

Question 15

What is Paget’s disease of the nipple?

Answer 15

Itchy red scaly or crusted nipple from direct extension of intraductal adenocarcinoma

Different from eczema as involves the nipple primarily and only latterly spreads to the areola (opposite in eczema)

Dx: punch biopsy, mammography, US brease

Mx:
Mastectomy, lumpectomy, ± radiotherapy

Question 16

What are the types of BCC?

Answer 16

Nodular
Superficial
Mopheaform
Cystic
Basosquamous carcinoma

Question 17

Describe nodular BCC

Answer 17

Raised translucent papule

Usually affect face

Question 18

Describe superficial BCC

Answer 18

Usually appears as superficial erythematous macule affecting the trunk
Younger age at presentation (50s)
May show areas of spontaneous regression

Question 19

Describe morpheaform BCC

Answer 19

Macroscopically resembles flat, slightly atrophic lesion or plaque without well-defined border
Tumour has subclinical lateral spread which increases recurrence

Question 20

Describe cystic BCC

Answer 20

Often have clear or blue grey appearance

Question 21

What is keratocanthoma?

Answer 21

Dome shaped erythematous lesions that develop over a period of days and grow rapidly
Often contain a central pit of keratin
Begin to necroses and slough off
Generally benign
May be treated by curretage and cautery

Question 22

What is pyogenic granuloma?

Answer 22

Friable overgrowths of granulation at sites of minor trauma.
They may be ulcerated and bleeding on contact is common
Treated with curettage and cautery