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Flashcards in Skin cancer Deck (61):
1

What are the two forms of non-melanoma skin cancer?

• Basal cell cancer & Squamous cell cancer

2

What are some risk factors for non-melanoma skin cancer?

• UV radiation
• Photochemotherapy
• Chemical carcinogens
• X-ray and thermal radiation
• Human papilloma virus
• Familial cancer syndromes
• Immunosuppression

3

Describe morphoeic BCC

Morphoeic – infiltrative group of BCC; flat whitish plaque with pearly edge with central regression (pit)

4

Describe basal cell carcinoma

• Slow growing superficial lesions
• Locally invasive
• Rarely metastasise
• Nodular
– Pearly rolled edge
– Telangiectasia
– Central ulceration
– Arborising vessels on dermoscopy

5

How is BCC treated?

Excision is gold standard
– Ellipse, with rim of unaffected skin
– Curative if fully excised
– Will scar
– Curettage in some circumstances

6

Describe Mohs surgery?

Microscopically controlled surgery used to treat common types of skin cancer – forms hole like wound which can be stitched up

7

When is Mohs surgery indicated?

– Site
– Size
– Subtype
– Poor clinical margin definition
– Recurrent
– Perineural or perivascular involvement

8

When is Vismodegib indicated?

– Locally advanced BCC not suitable for surgery or radiotherapy
– Metastatic BCC

9

What is indicated if locally advanced BCC is not suitable for treatment or in metastatic BCC?

Vismodegib

10

What is Vismodegib?

• Selectively inhibits abnormal signalling in the Hedgehog pathway (molecular driver in BCC)
• Can shrink tumour and heal visible lesions in some
• Median progression free survival 9.5 months

11

What are the side effects of vismodegib?

• Side Effects
– Hair loss, weight loss, altered taste
– Muscle spasms, nausea, fatigue

12

From what do squamous cell carcinomas derive from?

• Derived from keratinising squamous cells
• Usually on sun exposed sites

13

Describe squamous cell carcinomas

• Derived from keratinising squamous cells
• Usually on sun exposed sites
• Can metastasise
• Faster growing, tender, scaly/crusted or fleshy growths
• Can ulcerate

14

Which non-melanoma skin cancer is associated with ulceration?

SCC

15

Which non-melanoma skin cancer is usually faster growing?

SCC

16

How is SCC treated?

• Excision +/- Radiotherapy

17

When is SCC high risk?

– Immunosuppressed
– >20mm diameter
– >4mm depth
– Ear, nose, lip, eyelid
– Perineural invasion
– Poorly differentiated

18

Name a variant of SCC

Keratoacanthoma

19

Describe Keratoacanthoma

• Varient of squamous cell carcinoma
• Erupts from hair follicles in sun damaged skin
• Grows rapidly, may shrink after a few months and resolve
• Surgical excision

20

How is Keratocanthoma treated?

Surgical excision

21

What are some risk factors for melanoma?

UV Radiation

Genetic susceptibility- fair skin, red hair, blue eyes and tendency to burn easily

Familial melanoma and melanoma susceptibility genes

22

Describe the ABCDE approach in identifying melanoma

• Asymmetry – melanomas are asymmetrical

• Border – edges are uneven, crusty or notched in melanoma

• Colour – variety of colours, especially white or blue, are bad signs

• Diameter – melanomas are usually wider in diameter than a pencil eraser

• Evolution – danger if it has changed in size, colour or begins to bleed/scab

23

Describe the 7 point checklist in melanoma detection

Major features
o Change in size/new lesion
o Change in shape
o Change in colour
Minor features
o Diameter more than 5 mm
o Inflammation
o Oozing or bleeding
o Mild itch or altered sensation

Suspect melanoma if 1 or more major sign or if 3 or 4 minor signs alone

24

What 2 systems are used for melanoma identification

ABCDE approach
7 point checklist

25

What is used to examine the skin?

'Dermoscope’ or ‘dermatoscope’

26

Describe the biologic progression of melanoma and the different types of melanoma associated with each stage

Benign then neoplastic

Rapid growth phase – superficial spreading melanoma

Vertical growth phase – nodular melanoma

Mestatsatic melanoma – has reached underlying blood stream

27

Describe superficial spreading melanoma

Superficial spreading melanoma is a form of melanoma in which the malignant cells tend to stay within the tissue of origin, the epidermis, in an 'in-situ' phase for a prolonged period (months to decades). At first, superficial spreading melanoma grows horizontally on the skin surface – this is known as the radial growth phase.

28

Describe lentigo maligna melanoma

Lentigo maligna is an early form of melanoma in which the malignant cells are confined to the tissue of origin, the epidermis, hence it is often reported as 'in situ' melanoma

29

Describe nodular melanoma

Nodular melanomas are a faster-developing type of melanoma that can quickly grow downwards into the deeper layers of skin if not removed. Nodular melanomas usually appear as a changing lump on the skin which might be black to red in colour.

30

Describe acral lentiginous melanoma

Acral lentiginous melanoma is a form of skin cancer that appears on the palms of the hands, the soles of the feet, or under the nails.

31

What two forms of melanoma can be found under the nails?

Acral Lentiginous Melanoma
Subungal Melanoma

32

Describe subungal melanoma

Subungual melanoma often starts as a brown or black streak under a toenail or fingernail

33

Describe ocular melanoma

Ocular melanoma (melanoma in or around the eye) is a type of cancer that develops in the cells that produce pigment and develops inside your eye or on your conjunctiva.

34

What is Breslow thickness?

To be exact, Breslow thickness measures in millimeters (1 mm equals 0.04 inch) the distance between the upper layer of the epidermis and the deepest point of tumor penetration. The thinner the melanoma, the better the chance of a cure.

Used in staging, determining prognosis and to determine diameter around tumour needed for excision

35

How is melanoma treated?

• Wide local excision - urgent surgery
• Sentinel lymph node biopsy
• Chemotherapy/immunotherapy
• Regular follow up
• Primary and Secondary Prevention

36

What biologics are used for metastatic melanoma

Ipilimumab
– Inhibits CTLA-4 molecule

Pembrolizumab
– Blocks activity of PD-1

Vemurafenib and Dabrafenib
– Blocks B-RAF protein
– Only useful if B-RAF mutation

37

What is the biologic targeted against CTLA-4 called used for metastatic melanoma?

Ipilimumab

38

What is the biologic targeted against PD-1 called used for metastatic melanoma?

Pembrolizumab

39

What are the biologics targeted against B-RAF called used for metastatic melanoma?

Vemurafenib and Dabrafenib

40

What is the one year survival of metastatic melanoma patients on ipilimumab?

One year survival 47-51% (double those not on treatment)

41

What is the one year survival of metastatic melanoma patients on pembrolizumab?

One year survival 68-74%

42

What is the median survival of metastatic melanoma patients on Vemurafenib and Dabrafenib compared with those on standard chemotherapy?

Median survival 10.5 months (7.8 months with standard chemotherapy)

43

What is cutaneous lymphoma?

Secondary cutaneous disease from systemic/nodal involvement
Primary cutaneous disease – abnormal neoplastic proliferation of lymphocytes in the skin

2 types:
– Cutaneous T Cell lymphoma (65%)
– Cutaneous B Cell lymphoma (20%)

44

What are the two types of cutaneous lymphoma and their relative frequencies?

2 types:
– Cutaneous T Cell lymphoma (65%)
– Cutaneous B Cell lymphoma (20%)

45

What are the different types of Cutaneous T Cell lymphoma?

• Mycosis fungoides
• Sezary syndrome
• CD30+ lymphoproliferative disorders
• Subcutaneous panniculitis like T cell lymphoma
• Cutaneous CD4+ lymphoma
• Extranodal NK/T cell lymphoma

46

What are the different types of Cutaneous B Cell lymphoma?

• Cutaneous follicle centre lymphoma
• Cutaneous marginal zone lymphoma
• Cutaneous diffuse large B Cell lymphoma

47

What is 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 (causes little or no pain)

48

What is the most common cutaneous T cell lymphoma?

mycosis fungoides

49

What makes up 50% of all primary cutaneous lymphomas?

mycosis fungoides - most common cutaneous T cell lymphoma subtype

50

In what age group is mycosis fungoides most common?

Older patients

51

In what sex is mycosis fungoides most common in?

more common in men than women

52

What are the 4 stages of mycosis fungoides?

Patch - flat red dry oval lesions, can be itchy
Plaque - patches have thickened, itchy
Tumour - large irregular lumps, can ulcerate
Metastatic - infiltration of cells into blood, LNs etc

53

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

54

What is median survival for those with sezary syndrome?

2-4 years median survival

55

How is cutaneous lymphoma treated?

– Topical steroids

– PUVA or UVB

– Localised radiotherapy

– Interferon – increases targeted immune response

– Bexarotene – retinoid anticancer drug

– Low dose Methotrexate – immune suppressant

– Chemotherapy

– Total skin electron beam therapy

56

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

57

What is the benefit of total skin electron beam therapy when compared to normal radiotherapy?

Spares deeper tissues and organs

58

Describe Extracorporeal photophoresis for skin cancer treatment

Step 1
– Patients blood is drawn and leucocytes 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

59

What cancers often metastasise to the skin (cutaneous metastases)?

Most commonly breast, colon and lung cancer

60

What make up cutaneous metastases?

Can be secondary to primary skin malignancy such as melanoma or due to primary solid organ malignancy

61

How are cutaneous metastases treated?

• Treat the underlying malignancy
• Local excision
• Localised radiotherapy
• Symptomatic