SKIN ONCOLOGY Flashcards
Premalignant lesions for squamous cell cancer
Actinic keratoses is a premalignant lesion for squamous cell cancer (actinic is like acral - deadly)
Seborrheic - (water old age lesion) keratosis is a skin lesion that has no malignant potential.
A 43-year-old male comes to your office with a suspicious appearing lesion on his back. A full work up is initiated and the patient is found to have an ulcerated melanoma with a thickness of 1.5 mm and two positive lymph nodes. No distant metastases were found.
TNM staging for melanoma is based on depth of tumor and ulceration.
Primary Tumor (T)
T1 lesions are less than 1 mm. -a: without ulceration -b: with ulceration
T2 lesions are between 1.01-2 mm. -a: without ulceration -b: with ulceration
T3 lesions are 2.01-4 mm. -a: without ulceration -b: with ulceration
T4 lesions are greater than 4 mm. -a: without ulceration -b: with ulceration
The absence or presence of ulceration is noted by an “a” or “b” designation, respectively.
Regional lymph nodes (N)
N1 involves one lymph node.
N2 disease includes 2-3 regional lymph nodes.
N3 disease includes four or more regional nodes.
Distant metastasis (M)
M0: No detectable evidence of distant metastases
M1a: Metastases to skin, subcutaneous, or distant lymph node, normal serum LDH
M1b: Lung metastases, normal LDH
M1c: Metastasis to other visceral metastases with a normal LDH, or any distant metastases and an elevated LDH
Bottom Line: TNM staging factors in both depth of tumor and presence of ulceration.
MOST common tumors to spread to bone
Breast and prostate cancers are the two most common sources of cancer metastasis to the bone.
Answers C & E: Lung and kidney cancers metastasize frequently to the bone.
Hypersensitivity reactions four categories:
Type I, or an immediate hypersensitivity reaction, involves immediate release of IgE and vasoactive substances (choice A). This response is what leads to anaphylaxis.
Type II is an antibody mediated reaction, which involves IgG and IgM binding to target antigens and subsequent compliment activation (choice B).
Type II hypersensitivity is responsible for Goodpasture syndrome and autoimmune hemolytic anemia.
Type III reactions are due to deposition of antibody- antigen complexes and cause serum sickness (choice C).
Type IV are cell mediated reactions. They exhibit a peak response 24-72 hours after exposure and are responsible for contact dermatitis and reaction to PPD testing (choice D).
Bottom Line: PPD tests assess a cell mediated response or a type IV hypersensitivity reaction.
Soft tissue sarcomas most important predictors of prognosis are
mitotic index
and
amount of necrosis.
Chemotherapy is effective with what type of sarcoma
Ewing’s Sarcoma, that show survival benefits with neoadjuvant chemotherapy.
staging of sarcoma
High-grade histologic findings, deep location, and tumor > 5 cm are independent prognostic factors for survival.
Staging classifies lesions as:
-T1 - < 5 cm -T2 - > 5 cm
-N1 - regional node involvement
-G1 - well-differentiated -G2 - moderately differentiated -G3 - poorly differentiated -G4 - undifferentiated.
Staging is based on T, N, M and G classification.
Stage IV disease is classified as any G or T with regional nodal involvement (N1) OR evidence of metastatic disease (M1).
Primary therapy includes surgical resection with margin of normal tissue. Limb sparing is often possible. Local control pre-operatively may be achieved with radiation therapy.
Bottom Line: Stage IV soft tissue sarcoma involves regional nodal involvement (N1) or evidence of metastatic disease (M1).
Bladder tumors referred to as superficial disease
involve the mucosa (Ta)
and
the lamina propria (T1)
are referred to as superficial disease,
Bladder tumors invasive disease
extend beyond the lamina propria and invade muscle (T2a) or greater
Disease that extends through the muscle into the fat (T3), node- positive disease, or metastatic disease requires further treatment with neoadjuvant or adjuvant chemotherapy.
Answer A: Endoscopic resection is optimal treatment for patients with low risk, superficial disease.
Answer B: High-grade T1 lesions recur in more than 80% of cases and progress to muscle-invasive disease in 50% of patients within 3 years. Patients with high- risk superficial disease—defined as carcinoma in situ, stage T1 lesions, or large, high-grade, recurrent, or multifocal Ta lesions—should receive further treatment with intravesical bacillus Calmette-Guérin (BCG).
Answers C & D: Radical cystectomy alone or with lymoh nodes dissection is inadequate treatment for this patient as he has invasive disease that should be treated with either neoadjuvant therapy or radical resection, lymph nodes
Bladder tumors that requires further treatment with neoadjuvant or adjuvant chemotherapy.
Advanced features:
Disease that extends through the muscle into the fat (T3),
node- positive disease,
or
metastatic disease
** Radical cystectomy alone or with lymoh nodes dissection is inadequate treatment for this patient as he has invasive disease that should be treated with either neoadjuvant therapy or radical resection, lymph nodes
Bladder tumors optimal treatment for patients with low risk, superficial disease.
Endoscopic resection
Answer B: High-grade T1 lesions recur in more than 80% of cases and progress to muscle-invasive disease in 50% of patients within 3 years. Patients with high- risk superficial disease—defined as carcinoma in situ, stage T1 lesions, or large, high-grade, recurrent, or multifocal Ta lesions—should receive further treatment with intravesical bacillus Calmette-Guérin (BCG).
Myofibroblasts
responsible for wound contraction
Most squamous cell carcinomas of the tongue are
T2 or smaller at the time of identification and can be successfully managed by wide local excision with clear margins. Nearly ! of the tongue can be excised with preservation of oral function, although musculocutaneous free flaps are required with larger resections to prevent tongue tethering.
A sentinel lymph node biopsy (SLNB) is indicated in the case of invasive malignant melanoma with the following characteristics:
greater than 1 mm
or
tumor less than 1 mm in thickness with either ulceration, regression, Clark levels IV or V,
or
mitotic rate > 1 per 10 high powered fields.
A frozen section is not performed because special stains are needed including : S100, HMB 45, MART 1, Melan A, and Mitf.
A positive sentinel lymph node biopsy of melanoma management
mandate a completion lymphadenectomy of the draining basin,
level I, II, and III in the axilla,
Advanced stage cervical tumors are defined as what and how are they treated
IIB-IVA
treated aggressively with a multi-modal approach,
Primary radiotherapy (RT) with external beam and brachytherapy is the main stay of treatment for this disease!
including radiation therapy and cisplatin-based chemotherapy.
Clearing the lymph node basin may have some therapeutic advantage.
Presence of para-aortic lymph node spread has significant effect on
prognosis.
Cisplatin-based chemotherapy is also of some value in the treatemt.
NOT primary surgical approach - would not be appropriate in the setting of
advanced disease.
Any patient with a solid testicular mass, w
hich has been confirmed on ultrasound, is considered to have testicular cancer until proven otherwise, and should undergo a radical orchiectomy to make a definitive diagnosis.
When performing a radical orchiectomy, the surgery should be performed by an inguinal approach rather than a scrotal approach. If the scrotum is surgically violated by performing a scrotal orchiectomy, metastatic spread to both the retroperitoneal and the inguinal nodes becomes possible.
Bottom Line: Inguinal exploration with early vascular control of the spermatic cord structures is the initial intervention to exclude testicular neoplasm. If cancer cannot be excluded by examination of the testis, then radical orchiectomy is warranted. Scrotal approaches and open testicular biopsies should be avoided.
Testicular cancer is the most common cancer in men between the ages of
20 and 35 years
Ninety to 95% of all primary testicular tumors are
germ cell tumors
(seminoma and nonseminoma)
while the remainder are nongerminal neoplasms (Leydig cell, Sertoli cell, gonadoblastoma)
staging choice for testicular cancer
A CT scan is the study of choice for . CT scan allows you to evaluate retroperitoneal adenopathy and lung metastases.
The metastatic spread of testicular cancer is ordered and predictable.
primary metastatic landing site for left and right testicular cancers is the
para-aortic
and
interaortocaval nodes in the retroperitoneum, respectively.
The most common types of small bowel malignancies include
carcinoid,
adenocarcinoma,
and
stromal tumors.
lymphoma is rare
Stage ovarian cancer
Stage I ovarian cancer involves one or BILATERAL of the ovaries!
treated with resection alone.
Stage II is extended involvement of tumor, but limited to the pelvis.
Stage III tumor involvement into the abdomen.
Stage IV will have distant metastasis.
The most common clinical manifestation of a lip cancer is
an ulcerated lesion along the vermillion border.
predominant histologic variant and occurs primarily on the lower lip of Caucasian males between 50 and 70 years of age
Squamous cell!
CAREFUL - most common skin cancer over all is basal cell - but think head and neck is most associated with squamous
bigest risk factors for dvlp of squamous cell cancer of the lip
Sun exposure and tobacco use are the most significant risk factors.
Caucasian males between 50 and 70 years of age
Compare treatment of squamous cell cancer of the lip
Surgery and radiation therapy are equally effective for early stage tumors!
BUT PERFER - SURGERY - wide local excision with histologic confirmation of at least a 3mm margin is the preferred approach.
treatment of adjvanced squamous cell cancer of the lip
NO Sentinel lymph node biopsy - thus far not proved as effective in head and neck cancers as it has for melanoma and is therefore NOT considered to be standard of care.
Radiation therapy is a component of the POST operative ADJUVANT management for patients with clinically evident neck disease or advanced-stage primary tumors.
Neck metastases are an infrequent finding occurring in only 10% of cases thereby obviating the need for more extensive procedures including selective, modified, or radical neck dissections for most cases..
