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ROC 120 > Skin Cancers And Melanoma > Flashcards

Skin Cancers And Melanoma Flashcards

1
Q

Skin Cancer Broad Categories

A
  1. Non-melanoma: more than 80 types
    A: basal cell
    B: squamous cell
  2. Melanoma
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2
Q

Facts of Skin Cancer

A

-Most common cancer in the U.S.
-1 in 5 Americans develop skin cancer
- estimated at a higher incident rate than any other cancers combined in the U.S.

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3
Q

Carcinogens of Cancer

A
  1. Geographic Location: equator/more sun
  2. Skin type: fair complexion, burn easily- 10x more likely
  3. Multiplicity: prior skin camcer
  4. Gender: males are at a higher risk
  5. Age: 50% of all who live to be 65 will develop a skin cancer
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4
Q

Epidemiology

A

-Most arise form pre-existing lesions or damaged skin
-non-melanoma is more common
-melanoma is the most lethal

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5
Q

Greatest concern with skin cancer

A

Local recurrence

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6
Q

Sunburns

A

-ACS estimates that 90% of all skin cancers could be prevented if skin was protected form UV rays
- risk of melanoma increases after 5 or more blistering sunburns in adolescences
- time between sunburn and melanoma is 10 to 20 years

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7
Q

Melanocytes

A

-Produce melanin which gives pigment to the skin and protects the skin from damage of UV rays
——melanin is absorbed by keratinocytes in the stratum spinosum layer
-melanomas tend to develop from clusters of melanocytes (moles or nevus)

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8
Q

UV-B

A

-thought that cause cancer by damaging the DNA in its repair system resulting mutations/possible cancer
-not deep penetrating

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9
Q

UV-A

A

-UVA acts to promote tumors that are initiated by UVB
-deep penetrating

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10
Q

Skin

A

-Largest organ: 17sft to 20 sft
-example of an epithelial membrane

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11
Q

Skins function

A

-regulates temperature through perspiration
-acts as a barrier between the external environment and the body -participates in production of vitamin D
-provides receptors for external stimuli

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12
Q

Layers of skin

A
  1. Epidermis
  2. Dermis
  3. Subcutaneous layer
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13
Q

Epidermis

A

-avascular (gets its nutrients from the dermis and subcutaneous layer)
- epithelial layer
-composed of squamous and basal cells

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14
Q

Carcinomas

A

-originate from epithelium
(Tissues that cover a surface of line a cavity) Ex: lung cancers, skin cancers

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15
Q

Adenocarcinoma

A

-tumors that arise from epithelial cells that are glandular
(Prostate cancers, salivary glands)

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16
Q

Epidermis 5 layers

A
  1. Stratum corneum: 25-30 rows of flat dead cells
  2. Stratum lucidum: layer on found in thick skin areas
  3. Stratum granulosum: 3-5 rows of flattened cells
  4. Stratum spinosum: 8-10 rows of keratinocytes
  5. Stratum basale: stem cells, melanocytes, and merkel cells

—time it takes for travel form stratum basale to the surface is 2 to 4 weeks

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17
Q

Dermis

A

-deep connective tissue layer
-allows for strength and flexibility and cushions the body from stress and strain

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18
Q

Dermis contains:

A

-blood and lymphatic vessels
-nerves and nerve endings
-sweat glands
-hair follicles

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19
Q

Basement Membrane

A

holds the epidermis and dermis together

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20
Q

Subcutaneous Layer

A

—fatty layer beneath the dermis contains:
1.nerves
2.blood vessels
3. fat tissue

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21
Q

Clinical presentation of skin cancer

A

-A new growth on the skin
-irritation or sore that does not heal -persistent ulcer
-change in a wart or mole
—NOT all are malignant

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22
Q

Actinic Keratoses

A

-warty lesions or areas of red scaly patches on hands or face
-occurs in son Exposed Skin
-5% to 10% of degrading into squamous cell cancer

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23
Q

Bowen’s Disease

A

-development of pink or brown papules covered in a thick layer
-precancerous

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24
Q

Keratoacanthoma

A

-rapid growing lesion that can appear as a dome shape on a sun exposed area
-often considered to be less serious case of squamous cell carcinoma

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25
Q

Excisional biopsy

A
  • punch
  • saucerization
  • elliptical
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26
Q

Treatment techniques

A
  1. Surgical excision
  2. Mohs’ surgery-expensive, reserved for melanomas
  3. Curettage and electrodesication scooping out BCC
  4. Cryosurgery
  5. Laser: used for early BCC and in situ SCC
  6. Topical skin cream: 5fu to skin
  7. Epiluminescence microscopy (ELM) for melanoma
  8. Radiation therapy: BCC and SCC
  9. PDT: photodynamic therapy
  10. Immunotherapy
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27
Q

Approach to advanced lesions

A

-physical exam
-evaluation of motor skills
-chest x-ray
-liver function
-CBC
-bone scan
-biopsy of regional lymph nodes
-CT/MRI

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28
Q

Surgery preferred when:

A

-lesion is small
-located in hairy portions of scalp
- lesion located in scars or burns
- chronic dermatitis
- recurrent lesions post XRT
-infiltration of underlying bone or cartilage

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29
Q

Radiation preferred when:

A

-to treat lesions on nose lips eyelids face ears
-when surgical access is difficult
- in areas of reoccurrence
-when underlying structures must be protected
-for cosmetic purposes

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30
Q

Basal Cell Subtypes

A

-nodule ulcerated
(most common found on neck and head)
-superficial
(found on the trunk)
- morphea
(uncommon looks like a scar like lesion)
-cystic
(uncommon forms of cystic lesion)

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31
Q

Squamous Cell Subtypes

A
  • Veruccous
    (low-grade indolent well-differentiated cauliflower like lesions)

has a higher propensity to metastasize in BCC more aggressive than BCC

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32
Q

Grade

A

Tumor grading identifies how differentiated the tumor is or how will the tumor resembles normal tissue of origin
Grade 1-4

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33
Q

Basal Cell

A

—arises in the deepest layer of the skin (stratum basale)
-slow-growing
-unlikely to metastasize most (common form of skin cancer)

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34
Q

Squamous Cell

A

-arises in the superficial layers of the epidermis
-grows faster than BCC
-has an increased chance of metastasis
(can appear anywhere but most commonly in son exposed areas)

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35
Q

TNM Staging For Non-Melanoma

A

-TX-primary tumor cannot be assessed
-TO-no evidence of primary tumor
-Tis- in situ-“ in place” no invasion
T1-lesion 2cm or less with 1 cm or less depth
T2-lesion 2 to 5 cm with 1 to 2 cm depth without invasion of deep structures
T3-lesion greater than 5cm with 2cm or more depth Invasion
T4- tumor invading bone or cartilage or distant metastasis

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36
Q

Most important when staging skin cancer

A

Tumor depth

37
Q

TNM Staging

A

-TNM staging to fix the extent of the tumor using three subgroups
T-size of the primary tumor
N-involvement of the regional lymph nodes
M-presence of metastatic disease

(X is assigned if the information is unable to be determined)

38
Q

Two key staging systems

A
  1. American joint committee on cancer (AJCC)
  2. Union of international cancer control (UICC)
39
Q

Basal Cell Carcinoma (BCC)

A

-most common malignant tumor of the skin
-Usually non-inflammatory and painless but may become irritated and bleed
-constitute 75% of all skin cancers

40
Q

Presentation of BCC

A

-round or oval papule
- red to Pink in color
-pearly translucent shiny appearance
-often surrounded by Sun damaged skin

41
Q

BCC Facts

A

-usually occur in the T-Zone
- remain localized and they are slow-growing
-tend to spread by direct extension (growth into tissue and structures around it)
—also called rodent ulcer
-do not tend to metastasize (1- 4,000 cases)
—they are capable extensive destruction if left untreated
—late stage can have a rolled border around site

42
Q

Squamous Cell Carcinoma (SCC)

A

-2nd most common skin cancer
-develops in The Superficial layers of the epidermis
- occurs in sun damaged areas
- often seen on ears, temples, and lower lip

43
Q

Presentation of SCC

A

-plaque or nodule
-hyperkeratosis (thickening)
-crusty
-lack of luster

44
Q

SCC

A

-Somewhat more aggressive than BCC
-spreads quicker grows faster
-May spread through lymphatic, direct extension, or/and bloodstream (rare)
- when cartilage is involved it is hard to cure with radiation because cartilage is not well oxygenated

45
Q

SCC has been associated with:

A

-human papillomavitus Infection HPV
-immune suppression
-thermal or electrical burns
-scars or chronic inflammatory conditions
-hydrocarbons derived from coal and petroleum
-areas of chronic drainage (fistula or sinuses)
-smoking

46
Q

Brachytherapy for skin cancers

A

-implants or superficial molds (iridium 192, cesium 137, gold)
-same cure rates as external beam

47
Q

Disadvantages of Brachytherapy for skin cancers

A

-cost
-trauma
-Hospital stay
-exposure to Personnel
-uncertain dose distribution

48
Q

Adenocarcinoma

A

Arise from glands:
1. sebaceous (oil secreting)
2. Sudoriferous (sweat secreting)

49
Q

Cutaneous T-cell lymphoma

A

T lymphocytes become cancerous and affect the skin
—it can resemble eczema or other inflammatory conditions
-total skin Electron Beam radiation has been used to control early stages of the disease
—also called (mycosis fungoides)

50
Q

Kaposi’s sarcoma

A

-slow-growing cancer
-cancer cells form in the tissue lining the lymph vessels under the skin or in mucous membranes
-is associated with nodular purple lesions
-common individuals affected with AIDs

51
Q

Merkel’s cell carcinoma

A

-rare aggressive skin cancer
-forms on or just under the skin
—lethal

52
Q

Melanoma Facts

A

• Least common and most deadly form of skin cancer
• 5th most common cancer
• 20 times more common in whites than African Americans (1 in 38 for whites, 1 in 1,000 for blacks)
• ~ 2% of all skin cancers; ~ 2/3’s of all skin cancer deaths
• Begins in melanocytes found in basal layer of skin
• Strong tendency to spread-can spread to any organ
• Difficult to treat

53
Q

Melanoma Risk Factors

A

• Sun exposure
• Intensive sunburn during childhood or adolescence
• Heredity-family hx increases risk x 8 (chromosomal abnormalities)
• Congenital and dysplastic nevus syndrome
• Higher risk in fair skin/red hair individuals

54
Q

Melanoma Symptoms

A

• Mole or pigmented patch may have been present at birth or pre-existing
• May begin as a new mole that itches or bleeds

55
Q

Largest 2 concerns for melanoma symptoms

A

-tumor thickness and ulceration.

56
Q

Evaluating a Mole

A

A. This shows asymmetry – one half of the mole looks different than the other half
B. The border is irregular
C. The mole is more than one color
D. The diameter is greater than the size of a pencil eraser
E. Evolving

57
Q

Possible Signs of Melanoma

A

• Change in color-red, white, or blue in addition to black and tan
• Surface is scaly, flaky, bleeding or oozing moles or a sore that does not heal
• Change in texture-hard, lumpy, or elevated moles
• Change in surrounding skin-spread of pigmentation, swelling, or redness to surrounding skin
• Change in previously normal skin-pigmented areas that arise in previously normal skin

58
Q

After Biopsy

A

• The specimen is sent to a pathologist who examines it microscopically

59
Q

Biopsy Purpose

A

This provides information that is used to:
-diagnose
-stage
-develop a prognosis for the patient

60
Q

If Cancer is Diagnosed (Biopsy)

A
  1. Specific cancer subtype
  2. Depth of tumor penetration
  3. Degree of mitotic activity
  4. Growth pattern ( radial versus lateral)
  5. Level of host response (number of lymphocytes in or around the tumor)
  6. Determine the presence of tumor ulceration, tumor regression or lymphatic extensions of
    the tumor that result in small lesions adjacent to the primary
61
Q

Info determined form biopsy

A
  1. Diagnosis
  2. Thickness of the tumor
  3. Status of the margins-if the margins are not clear, the patient will most likely have a wider
    excision
62
Q

Melanoma Treatment options

A

-Surgery
• Considered Radio-resistent
• Poor prognosis
• Complication of surgery – must take a large volume of tissue
- Can be disfiguring
- Skin graft is often necessary

63
Q

Mohs treatment

A

-for melanoma
- exiscion will be done and examined
-if the edges still have cancer cells more biopsies/surgeries will be doen until it is completely removed
-after complete removal reconstruction will be done

64
Q

Epiluminescene Microscopy (ELM)

A

-another treatment for melanoma
—physician used a dermoscope to non-invasively differentiate between benign and malignant lesions by placing mineral oil on the surface of the lesion. This causes the stratum corneum to become invisible and helps to visualize the epidermis.
• Images from this exam can be digitized and exported to ELM experts for quick analysis.
• These images can also be evaluated by specially designed software based on shape, size, color and border to make an objective analysis.

65
Q

Ocular Melanoma

A

• Most Ocular melanomas form in the part of the eye you can’t see when looking in the mirror
• Typically, doesn’t cause early signs and symptoms

66
Q

Ocular Melanoma Treatment

A

Ocular melanomas are frequently treated by placing a radioactive plaque on the eye directly over the tumor in a brachytherapy procedure. The plaque is held in place with temporary stitches.

67
Q

Chemotherapy for Metastatic Melanoma

A

-typically palliative
• Dacarbazine is the chemotherapy of choice for melanomas
• Even with chemotherapy, the response rate is low and only lasts about 4 to 6 months

68
Q

Immune therapy for melanoma

A

—use of an immune checkpoint inhibiting antibody can prolong survival in patients and can produce a cure in a small number
• The common immune checkpoint inhibitors for melanoma are the drugs nivolumnab and ipilimumab
• Checkpoint Inhibitors

69
Q

Checkpoint inhibitors

A

— Type of immune therapy
—PD-L1 binds to PD-1 and inhibits the T-cell from killing the cancer
—with immune therapy blocking either PD-L1 or PD-1 will allow the T-cell to kill the cancer cell

70
Q

Adoptive cellular therapy

A
  • type of immune therapy
    -transfer of cells with antitumor properties into the tumor
71
Q

Therapeutic antibodies

A

-type of immune therapy
–antibodies produced in the lab designed to destroy cancer cells

72
Q

Vaccines

A

-type of immune therapy
—vaccines created from the patient’s own tumor cells that are designed to treat tumors by strengthen the body’s own natural defenses

73
Q

Immune System Modulators

A

—type of immune therapy
–uses proteins to regulate or modulate the body’s immune response

74
Q

Classification of Melanomas

A
  1. Superficial spreading melanomas(SSMs)
  2. Nodular melanomas (NMs)
  3. Lentigo malignant melanomas (LMMs)
  4. Acral Lentiginous melanomas (ALMs)
75
Q

Superficial spreading melanomas(SSMs)

A

most common ~70%, can appear brown, black, red, pink or white

76
Q

Nodular melanomas (NMs)

A

~15% , can appear dark brown, blue, blue-black-
—particularly lethal

77
Q

Lentigo malignant melanomas (LMMs)

A

-also called Hutchinson’s freckles ~5%

78
Q

Acral Lentiginous melanomas (ALMs)

A

-found on palms, soles, nail beds or mucous membranes
~10%

79
Q

Clark’s Melanoma Staging

A

• Clark’s-based on the invasion through layers
Level I: confined to the epidermis (insitu)
Level II: invasion through the bsmnt membrane
Level III: cells at papillary-reticular junction of dermis
Level IV: invades into reticular dermis
Level V: invades subcutaneous fat tissue

80
Q

Clark’s Staging is Based on

A

—based on the invasion through layers

81
Q

Breslow’s Staging System

A

—–based on tumor thickness:
-Level I: limited to epidermis
-Level II: .76-1.5 mm
-Level III: 1.55 mm-4 mm
-Level IV: More than 4 mm

82
Q

Breslow’s is based on

A

based on tumor thickness

83
Q

Prognosis Factors

A

• Tumor size and/or thickness
• Ulceration
• Gender – women have survival advantage
• Location-extremities ↑ Px
• Depth of Invasion
• Patient’s age
• Presence of metastatic disease

84
Q

Spread Patterns for Melanoma

A

1-Direct Extension-tends to penetrate deep
2-Regional Lymphatics
3-Distant Skin and Subcutaneous Tissues
4-Lung
5-Liver, Bone, Brain

85
Q

Fungating

A

(a lesion that breaks through the skin marked by ulcerations and necrosis and usually has a bad odor) ——malignant wound resulting from advanced cancer

86
Q

Radiation Side effects

A

• Stage I- Inflammation, erythema (1st sign of the effects of radiation)
• Stage II-Dry desquamation
• Stage III-Moist desquamation
• Stage IV-Epilation (hair loss) -can be temporary or permanent, depending on dose
—-permanent at 4500cGy and up

87
Q

Late Radiation effects

A

—6 months to 5 years post tx
1. Fibrosis – formation of scar tissue
2. Telangiectasia: dilation of blood vessels resulting from multiple pinpoint hemorrhages on skin
3. Hyperpigmentation/Hypopigmentation

88
Q

How to avoid fibrosis

A

-Numerous treatment ports
-Higher energies for skin sparing
- Avoid overlapping fields
- Do not exceed 4000cGy/4 weeks
- Any technique that is skin sparing

89
Q

Severe Late term radiation effects

A

• Ulceration
• Radiation induced carcinoma
• Necrosis-greater than 60 Gy to the skin

ROC 120 (2 decks)

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