Tumours & benign lesions

Question 1

Give examples of benign lesions

Answer 1

Acrochordons
Lipoma
Keratoacanthomas 
Seborrheic keratoses
Cherry angiomas

Question 2

What is Acrochordons? Incidence?

Answer 2

= skin tags

Increase incidence with age

Question 3

Characteristics of lipomas

Answer 3

Benign, asymptomatic

Question 4

Keratoacanthomas - Characteristics? Associated with? Advice?

Answer 4

• Rapidly growing resemble SCC. Start round firm reddish or skin coloured papules develop into a dome. Usually later in life and in sun exposed areas.
• Associated with sun, smoking , HPV, genetic factors, trauma and chemical carcinogens
• Pruritus and pain
• Some question over if a self-limiting SCC
• Histological cannot differentiate between SCC
• Advise excision- can disappear

Question 5

Seborrheic keratoses - What is it? Characteristics? When does it occur? Advice?

Answer 5

• Most common epithelial tumour
• Tend to be hereditary occur over 30
• Multiple well circumscribed yellow to brown raised lesions
• See GP- new growth, change in appearance, unusual colour, irritated or painful
• Abrupt eruption of multiple lesions sign for adenocarcinoma of for e.g. stomach
• Generally no treatment usually only cosmetic reasons

Question 6

Cherry angiomas - when is it common? Characteristics / S&S?

Answer 6

• Common increase with age.

* Asymptomatic small bright red. If damaged will bleed profusely

Question 7

Nevus - Mole - What is it? When do they appear?

Answer 7

• Non cancerous – melanocytic tumour

* Appear as children

Question 8

Nevus - Mole - Person with >50 at greater risk of what?

Answer 8

➤ Developing melanoma

Question 9

Melanoma - how do they appear?

Answer 9

• Change in size, shape or colour of existing nevus

* Or appear as new or abnormal looking mole

Question 10

Melanoma - When do you have skin checks?

Answer 10

Monthly

Question 11

Melanoma - due to what?

Answer 11

Sun and repeat sun burn

Question 12

Melanoma - Increased risk?

Answer 12

o	Close family hx melanoma
o	Pale skin that does not tan easily
o	Red or blonde hair
o	Blue eyes
o	Freckles
o	Radiotherapy
o	Immune compromised eg HIV, IBD
o	Previous diagnosis
o	Age 
o	May increase if you have had other cancers eg breast, renal, thyroid 
o	More common in females

Question 13

Distribution of melanoma in males?

Answer 13

head and neck 22%, trunk 41%, arm 19%, leg 13%

Question 14

Distribution of melanoma in females?

Answer 14

head and neck 14%, trunk 20%, arm 24%, leg 39%

Question 15

Different types of melanoma & characteristics

Answer 15

• Superficial spreading: -grows outwards rather than downwards most common form. Usually middle aged.
• Nodular melanoma: grows downwards and quickly- may not have arisen from a previous mole chest or back common areas
• Lentigo maligna melanoma: slow growing, elderly, areas lot of sun exposure and those outdoors a lot
• Acral lentiginous melanoma: palms and soles of feet and under nails. Rare, common type of melanoma in dark skinned people
• Amelanotic melanoma: no colour or little colour- rare

Question 16

Melanoma - Prognostic variables

Answer 16

The Breslow thickness is the single most important prognostic variable (distance in mm of the further tumour cell from the basal layer of the epidermis).

Question 17

Melanoma - Ix

Answer 17

o	Examination 
o	Skin biopsy and mapping 
o	Imaging: CT scan, MRI, PET scan, bone scan, chest xray 
o	Lymph node biopsy 
o	Blood tests- lactate dehydrogenase 
o	Vitamin D levels

Question 18

Melanoma - Tx

Answer 18

o Surgical
o If spread to other organs cure is difficult - chemotherapy and or radiotherapy to slow progression
o Other treatments immunotherapy e.g. interferon, IL-2; vaccine therapy- trials ongoing
o Metastasised to brain - proton therapy (restricted Tx in the UK)

Question 19

Melanoma - ABCDE rules

Answer 19

• Asymmetry – shape of one half does not match the other
• Border – edges ragged, notched or blurred
• Colour – uneven and cambered, brown, black etc
• Diameter – usually larger than 6mm but can be any size
• Evolving – changing in size, shape colour, appearance or growing in an area of normal skin
• Also itch, sore, crusty or bleeding

Question 20

Basal cell carcinoma - Due to what?

Answer 20

Exposure UV light from sun or sun beds

Question 21

Basal cell carcinoma - Where does it occur?

Answer 21

• Common on sun exposed areas eg head, neck, ears, but can occur anywhere
• Also occur in areas of scars, burns or ulcers

Question 22

Basal cell carcinoma - In who is it more common?

Answer 22

• More common in males than females, fair skinned, lot of sun exposure, previous BCC
• Most common in immuno compromised eg organ transplant

Question 23

What is a rare condition associated with basal cell carcinoma?

Answer 23

Gorlins syndrome

Question 24

Basal cell carcinoma - S&S?

Answer 24

o Painless 
o Superficial 
o Scab that bleeds and does not heal completely 
o >1cm 
o If left become rodent ulcers

Question 25

Basal cell carcinoma - Tx?

Answer 25

o Low risk BCC: NICE recommend Rx primary care ➤ low risk NOT head or neck, less than 1cm diameter with clearly defined margins, not a recurrence, not persistence after excision, not morphoeic, infiltrative or basosquamous in appearance, not located over important anatomical features, surgery closure is not a problem
o Other BCC ➤ surgery or radiotherapy in hospital
o Mohs micrographic surgery (surgeon take slices of the BCC and look at it under the microscope. They want a margin around the BCC clear of cancer but they left the healthy tissue so the wound can heal).
o Low risk: curettage and cautery ➤ cure rate 90%
o Imquimod 5% cream: small superficial lesions 70-100% effective
o Photo Dynamic Therapy: superficial BCC, 85% others lower, limited long term results
o Radiotherapy: incomplete excision

Question 26

Basal cell carcinoma - Prognosis

Answer 26

o Mortality low rarely metastasise
o Increased risk of SCC and melanoma and other BCC
o Recurrence have a worse cure rate

Question 27

Squamous cell carcinoma - caused by?

Answer 27

• Sun exposure: hobbies, occupational

* Skin damaged by x rays, scars, burns, persistent chronic wounds

Question 28

Squamous cell carcinoma - Incidence? Higher in?

Answer 28

• Incidence 10,000 per year

• Incidence higher:
o Caucasians 
o Rising incidence with age 
o HPV 
o Ionising radiation exposure 
o Chronic inflammation 
o Genetic conditions eg albinism, xeroderma pigmentosum 
o Pre malignant conditions- eg Bowens, actinic keratoses

Question 29

Squamous cell carcinoma - What does it present like?

Answer 29

A non healing ulcer

Question 30

Squamous cell carcinoma - Can it spread?

Answer 30

Yes ➤ other parts of the body

Question 31

Squamous cell carcinoma - Ix

Answer 31

o Excisional biopsy
o CT scan
o MRI
o Lymph node biopsy

Question 32

Squamous cell carcinoma - Tx

Answer 32

o	Refer to dermatologist 
o	Surgical excision 
o	Curettage and cautery  small lesions 
o	histology difficult to interpret 
o	Cryotherapy - histology not always possible 
o	Topical Rx  Imiquimod 5%, Fluorouracil, diclofenac 
o	PDT 
o	Radiotherapy

Question 33

Squamous cell carcinoma - Factors affecting the spread

Answer 33

o	Tumour location 
o	Diameter 
o	Depth 
o	Histological differentiation 
o	Previous treatment

Question 34

Squamous cell carcinoma - Prognosis

Answer 34

o Overall mortality low (<5%); distant mets 5 year survival poor 25-40%
o Up to 95% mets and local recurrence detected within 5 years of first treatment
o 70-90% occurring within first 2 years

Question 35

Skin protection - skin conditions reduced by?

Answer 35

Risk reduced by avoiding getting burnt, wearing protective clothing, avoiding midday sun, using high SPF products