Dermatology: Skin Cancer – Flashcards
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Squamous Cell Carcinoma
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*Pathophysiology:* -Malignant tumor of squamous cells, from the epidermis and stratified squamous mucosa. -Usually seen in patients >55 y.o. in the U.S.
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Squamous Cell Carcinoma: Risk Factors
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I. Ultraviolet Radiation Risk Factors: *-Sunlight Exposure* *-Actinic keratosis:* a small, rough, raised area found on skin that has been in the sun for a long period of time, can turn into skin cancer. -White skin and poor tanning capacity -Burn scars, phototherapy, ionizing radiation (X-rays, etc). -Geographic: Regions with many sunny days. -Outdoor occupations. II. Human Papillomavirus: -Oncogenic HPV increases cancer risk. III. Other Factors: -Immunosuppressed states (Diabetes, HIV, etc). -Inflammatory skin conditions, chronic heat exposure. -Chronic radiation dermatitis -Industrial carcinogens, arsenic.
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Squamous Cell Carcinoma: HISTORY
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-Asymptomatic (patients don't complain about it, you will often identify the cancer). -Actinic Keratosis: a small, rough, raised area found on skin that has been in the sun for a long period of time, can turn into skin cancer. (Will have a history of having these lesions). -Slow growing isolated keratotic or eroded papule/plaque.
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Squamous Cell Carcinoma: Physical/Clinical Manifestations
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Physical Signs include: -Indurated plaque, papule, or nodule. -Erythematous, ulcerated, crusting lesion. -Persistent ulceration -Hyperkeryotic patch -Opaque Nodule -Pink/red, scaling, well-demarcated lesions. *^These findings are typically found on sun-exposed areas.* -Anogential areas: Tan, brown, black lesions. -Glans penis/labia minora: Erythroplasia de Queyrat. -Regional Lymphadenopathy with metastasis (4%). *Squamous cell carcinoma can be found "below the belt"* -*Squamous cell carcinoma can appear on the bottom lip!*
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Squamous Cell Carcinoma: Diagnosis
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-Punch/extensional biopsy. -"No tissue, no issue": Rule. Don't say it's not cancer until you take a biopsy to confirm.
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Squamous Cell Carcinoma: Treatment (Tx)
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-*Prevention:* Avoid sun tanning, have an annual dermatological evaluation, self-surveillance, sunscreen: Anthelios SX. (Make sure Sun Screen provides both UVA and UVB protection). -*Surgical Excision* of the cancer. -Cryosurgery -Topical chemotherapy: 5-Fluorouracil *Prognosis:* 90% remission rate.
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Basal Cell Carcinoma
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-Tends to be located in the medial/lateral canthus (around eye), Around the nose, and behind the ear. -Also in and around the nasal/labial area. *Pathophysiology:* -Malignant transformation of the epidermis that has the capacity to develop hair follicles, sebaceous, and apocrine glands. *Most common form of skin cancer*
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Basal Cell Carcinoma Risk Factors/History
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-Ultra Violet Radiation (UVR) -Risk in *white skinned/Albino* people. -Poor tanning capacity -Childhood sunburn -Prior phototherapy -*Darker skin = more protective*
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Basal Cell Carcinoma: Dx and Tx
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*Dx:* -Skin Biopsy *Tx:* -Prevention -Surgical excision -Mohs surgery: Microscopic surgery, for basal cell carcinoma lesions around the eyes) -Cryosurgery/electrosurgery/curettage (scraping off lesion) -Topical Chemotherapy: 5-Fluorouracil (only if patients can't do surgery or if it takes up a large area). -PDT (A photodynamic dye to produce a single oxygen)
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Basal Cell Carcinoma:Prognosis.
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-Excellent, 90+% cure rate. More of a cosmetic issue, usually. *Basal/Squamous cell carcinoma: Fairly benign in terms of cancer.
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Melanoma
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*Pathophysiology:* -Malignant transformation of the melanocytic nevi (birthmark). -Nevi may be preexisting or not. -Early stages characterized by epidermal and dermal confinement. -During the *Invasive/Vertical growth stage*, there is a potential for metastasis. (Grows vertically/downward, near the blood and lymph. It it reaches the lymph/blood, it eill spread and metastasize). *Melanocytes and thus, *Melanomas* also reside in the choroid of the eye, meninges, and mucosa of the alimentary and respiratory tracts. (Melanoma can happen anywhere melanocytes reside). *BRAF gene mutation*: is associated with 40-60% of melanomas. It increases melanoma risk. -Melanoma has 4 subtypes.
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Melanoma Subtype: Superficial Spreading Melanoma
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-The most common type of melanoma (70%). -Seen in ages 30-50. More common in whites. *Risk Factors:* -Changing moles, Congenital dysplastic nevi (many beauty/birth marks). -Light skin color/poor tanning, excessive preadolescent sun exposure. -Personal or family history of melanoma *History:* -Gradual change in color, shape, and/or size of nevus. *Physical/Clinical manifestations:* "ABCDE", if there are more than one of these signs, consider melanoma: -*A*symmetry -*B*orders (irregular) -*C*olor (mottled: black/brown/grey/pink) -*D*iameter ( greater or equal to 6mm) -*E*nlargement/elevation -In Males: On Trunk, In Females: lower extremities. -Also found on sun exposed areas -Will have regional lymphadenopathy.
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Melanoma Subtype: Nodular Melanoma
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-15-30% of Melanoma cases, seen in the 50 year old age range. *Risk Factors:* -Changing moles, Congenital dysplastic nevi (many beauty/birth marks). -Light skin color/poor tanning, excessive preadolescent sun exposure. -Personal or family history of melanoma *History:* -Rapid, new mole** *Physical/Clinical manifestations:* -Elevated, "blueberry-like" nodule. It's dark blue, black, "thundercloud grey". -Oval, round, sharply defined. -Size is usually 1-3 cm. -Found on the same sites as Superficial Spreading Melanoma.
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Melanoma Subtype: Acral Lentiginous Melanoma
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-Found predominantly in *African-American and Japanese* patients (50-70%). -Around the 65 year age group. *Risk Factors:* -Palm and sole precursor lesions. *History:* -Slow growing, enlarging "stain" lesion of the *palm, sole, or subungual area (under nail)* *Physical/Clinical Manifestations:* -Palm/sole: macilar, nodular 3-12cm; brown/black/blue/pale. Irregular boarders. -Subungual: Macular, papules, nodules; usually dark brown or black, with extension to the thumb and great toe nail. -Acral areas of the body (hands/feet)
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Melanoma Subtype: Lentigo Maligna Melanoma
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-Around the 65 year age group. 5% on whites. *Risk factors:* -Same as nonmelanoma Skin Cancer (Sun) *History:* -Very slow growing, history of heavily sun-damaged skin, BCC. *Physical/Clinical Manifestations:* -Flat with focal papules/nodules -Brown/black stain, blue, pink, greay. -3-20 cm. -Single lesion over sun exposed areas; rare in lower extr. -Concomitant sun-induced changes.
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Melamoma Diagnosis (Dx)
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-Total excisional or punch biopsy. (only a punch biopsy if it is on very sensitive skin surface). -LFT's (liver function tests) to check for early metastasis for the liver, etc. -Bone scan -Chest X-ray -CT scan -MRI -GI series.
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Melanoma Treatments (Tx)
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-Prevention -Surgical excision (with free margins around the lesion), amputation. -Immunomodulators: Interferon alfa-2b, interleukin 2, tumor necrosis factor (TNF). (All of these will help the immune system fight back). -Systemic chemotherapy, doesn't do much for patient. -PLX4032 (Vemurafineb): Tells melanoma cells to self destruct (apoptosis). Only if the cells arose because of the *BRAF* mutation. -Radiation
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Melanoma Complications and Prognosis
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*complications:* -Metastasis *Prognosis:* (Based on stage I disease) -*Tumor Depth* is the SINGLE MOST important prognostic indicator. The deeper, the poorer the prognosis. -Other prognostic indicators: Rapid growth, male, nonextremity involvement, ulceration.
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Kaposi's Sarcoma
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*Pathophysiology:* -Involvement of human herpes virus type 8 (HHV-8) in the widespread cellular proliferation of the endothelium of the blood/lyphatic microvasculature. -KS lesions produce self-sustaining factors and angiogenic factors, promoting their own and other cell growth. There are three well-known variants: Classic, African-Endemic, and *HIV-Associated KS*.
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HIV associated Kaposi's Sarcoma
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-Seen in young adults, homosexual and bisexual males. *Risk Factors:* -HIV infection *History* -Is asymptomatic but cosmetically deforming. -Includes ulcerative and bleeding lesions -Extremity dysfunction, pain, edema with extensive palm or sole involvement. -Urethral/Anal canal obstruction if lesions are present. (Can obstruct the orifices). -Dyspnea, cough, shortness of breath, respiratory failure with pulmonary lesions.
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HIV associated Kaposi's Sarcoma: Physicial/Clinical Manifestations
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-Ecchymotic oval macule initially, on trunk, parallel to skin tension lines. -Progression to violet, red, pink, and tan papules, plaques, nodules, and tumors. -Purple-brown with green hemosiderin halo with age. -Feels firm to hard on palpitation. -Nodules and tumors may show ulceration, erosion, crusting, hyperkeratosis. *Lymphedema*. -*Locations:* -Early involvement of face, widespread on trunk. Common in oral cavity. -Widespread organ involvement (75%) -Lymphadenopathy (50%).
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HIV associated Kaposi's Sarcoma: Dx, Tx.
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*Dx:* -Skin Bx -Culture -Chest x-ray (CXR) *Tx:* -Underlying illness (HIV/AIDS) -Intralesional chemotherapy: Vinblastine, Bleomycin. -Systemic chemotherapy: Adriamycin, Vinblastine, Bleomycin, Daunosome/Doxol -Laser surgery, radiotherapy, cryosurgery -Excisional surgery
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HIV associated Kaposi's Sarcoma: Complications and prognosis
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*Complications:* -Multiple organ dissemination *Prognosis:* -Reduced survival with GI and Pulmonary KS -Patients with minimal, slowly progressive disease, without infection and CD4+ T Cell count > 200 are more responsive to treatment.
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Benign Skin Neoplasms
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Acrochordon (Skin Tag)
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-A common, asymptomatic *benign epidermal hyperplastic lesion* -Commonly seen in the elderly, obese and in females. *Characteristics:* -Soft, usually *pedunculated papilloma*(hanging by a stalk), but may be *sessile* (flat). -Fledh colored, tan to brown, ranging from 1-10mm.
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Acrochordon (Skin Tag)
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*Distribution:* -Intertriginous areas (axilla, neck, inflammatory, inguinal/groin).
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Acrochordon (Skin Tag): Tx and complications:
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*Tx:* -Pedunculated--> Excise with scissors, electrocautery at lesion base, cryotherapy. -Sessile --> shave excision. *Complications:* -Hemmorrage, crusting, pain (upon trauma/torsion).
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Corns and Calluses
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*Occurs via a three phase pathway:* -Chronic intermittent irritation or pressure over the bony prominences of the hands, feet, and toes causes localized callus formation. -Increased corneum production and epidermal thickening = *Hyperkeratosis*). -A Hyperkeratotic nodule (*corn*), is the end product of callus formation.
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Corns and calluses: Risk Factors
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-Excessive pressure or focal irritation from poorly fitting footwear, repetitive hand/athletic activity. -Hammertoe/clawtoe deformaty, plantar warts, foreign body granuloma.
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Corns and calluses: History
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-Reveals contributory risk factors and pain upon ambulation.
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Corns and calluses: Characteristics and Distribution (3 types)
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*Hard:* (Most common form) -Firm, tender with direct pressure, dry, yellow. -Paring of upper layers shows a well-circumscribed keratin nodule with a central conical keratin core with a polished, glistening appearance. -*Located in pressure areas:* Dorsolateral aspect of the fifth toe and dorsum of interphalangeal joints of lateral toes.
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*Soft:* -Boggy, tender and white due to prespiration-induced skin maceration. Located between toes, most commonly between the 4th and 5th.
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*Plantar:* (Hand: dorsal or palmar). -Keratosis: Hyperkaryotic nodule on the sole of foot, often located over third metatarsal head.
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Corns and calluses: Tx
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*Treatment:* -Paring with a No. 15 blade and curretage of keratin core. -Warm water soaks followed by pumice stone. -Corn Plaster: Karatolytic agent with 40% salicyclic doughnut web spacers for soft corns. *-*Show modification: Low-heeled shoes with a roomy toe box, extra width, soft upper portion, and orthotic insoles. *-*Surgery: Conservative treatment failure or to correct an underlying deformity.
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Lipoma
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-Benign, slow growing, usually asymptomatic subcutaneous tumor of the adipose tissue (occasionally with conn. tissue framework), enclosed by a thin fibrous capsule. -It's the most common subcutaneous soft tissue tumor.
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Lipoma: Characteristics/ Distribution
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*Characteristics:* -Soft, round, mobile, rubbery, fluctuant (fluid-like/soft consistancy) subcutaneous tumor. -"Slippage sign" -Most are <5cm, some up to 20cm. -Overlying skin is normal. *Distribution:* -Trunk, shoulders, prosterior neck, axilla, extremities (may occur in any subcutaneous location). -May occur as submucosal fatty tumors in any organ (i.e. GI tract, heart, broncial tree).
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Lipoma: DDX
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*Liposarcoma:* -Red flags: Lesion > 5cm, location in retroperitoneum or in intramuscular locations (deep thigh), rapid growth with local nerve or bone invasion. *Sebaceous cysts:* Characteristic central punctum(you will see a dimple/punctuation in the middle) and surrounding induration. (Cannot be located on palms/soles.)
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Lipoma: Tx, Complications
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-*Surgical excisional Bx*: -Indicated for cosmetic or symptomatic lesions -Corticosteroid injections or liposuction (for small and incompletely excised lipomas) *Complications* -Cosmetic deformity. -Local nerve compression. -Cardiopulmonary and Gastrointestional obstruction. -Recurrence.
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Epidermal (Epidermoid/Sebacceous) Cyst:
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-Slow growing, result from the proliferation of epidermal cells within a circumscribed space of the dermis. -Cysts occur when the infundibulum of the hair follicle is obstructed, causing accumulation of sebum. -Cysts easily rupture due to stratified squamous epithelial wall. *The most common cutaneous cyst*
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Epidermal (Epidermoid/Sebacceous) Cyst: Symptoms + Distribution
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*Symptoms:* -Asymptomatic -Spontaneous creamy discharge with a foul, cheesy odor. *Distribution:* -Scalp (pilar cyst), Face, ears, neck, upper trunk, scrotum.
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Epidermal (Epidermoid/Sebacceous) Cyst: Treatment, Complications
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*Treatment:* -Excision *Complications:* -Recurrence, cysts can become inflamed or infected resulting in pain and tenderness.
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Keloid:
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-Excessive growth of fibrous repair tissue (scar tissue) following a skin injury, with extension beyond the site of skin disruption. -Occurs due to wound anabolism in excess of wound catabolism with respect to fibroblast deposition of bands of broad/thick, dull, pink bundles of collagen. *History:* -Usually asymptomatic, occasionally pruritic or tender.
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Keloid: Characteristics
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-Nodular or tumor-like with smooth surface, may be pedunculated. -Usually found in areas of previous trauma. -Range from soft and doughy to firm and rubbery; are round, oval or oblong with regular margins. Flesh colored, but may be bright red or blue. DDX: -*Hypertrophic scar:* Young ribrous tissue and fibroblasts in a histological hapahazard arrangement. There is no collagen band formation. Lesions regress, becoming flatter and softer over time. *Keloid does not fade away*
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Keloid: Treatment
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-Prevention, cryotherapy + intralesional glucocorticoids (Triamcinolone), silicone cream and gel sheets. *Surgical excision not recommended* *Prognosis:* -Keloids are slow growing and may continue to expand for many years without intervention.
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Pyogenic Granuloma
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-A common, benign, rapidly developing, highly friable vascular lesion (hemangioma, tumor of blood vessels). *History:* -Frequent recurrent bleeding.
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Pyogenic Granuloma: Characteristics
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-Solitary dome shaped, sessile, or pedunculated nodule with smooth surface. -color is bright red, dusky, violacious, or brown-black and less than 1.5cm. -Bleeding, ulceration, or crusting may be evident.
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Pyogenic Granuloma: Distribution
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-Head (especially on oral and nasal mucosa), neck, upper trunk, fingers, and toes most frequently. -Can occur anywhere, including the pharynx and GI tract.
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Pyogenic Granuloma: Dx, Tx, Prognosis
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*Diagnosis:* -Lesion Bx. *Treatment:* -Shave, punch, scalpel, or laser excision. *Prognosis:* -Recurrence is common.
