POM II - Malignant Skin Neoplasms - Exam 1

Actinic keratosis

UV light induced lesion considered precancerous (precursor of invasive SCC)

Actinic keratosis - Incidence

-1 per 1000 people per year

-higher in arkansas

Actinic keratosis - RF

-frequency increases with age and cumulative lifetime sun exposure

-proximity to equator and outdoor occupation can increase risks

-most common in caucasians

-more common in individuals who are immunosuppressed and in males

Actinic Keratosis - Presentation

-rough, scaly macules or patches on chronically sun-exposed skin (face, hands, ears, scalp, neck, chest, forearms, dorsal hands, shins, lips)

-feels like sandpaper

-SCC progression is around 10%

Actinic keratosis - Dx

-clinical dx

-biopsy if unsure

-prognosis is excellent if treated

Actinic keratosis - tx

-cryotherapy

-topicals: imiquimod or 5-FU, PDT tx

-prevention is best medicine - mineral SPF daily

Basal Cell Carcinoma

-most common skin cancer and most common cancer in humans

-derived from basal layer of keratinocytes of epidermis

-slow growing, rarely mets

-several types: superficial, nodular, pigmented, etc

-nodular is most common

-2 million Americans per year

Basal Cell Carcinoma - RF

-chronic UV exposure, light phenotype

-can be seen at any age

-more common in men, but increasing incidence in women

Basal Cell Carcinoma - Presentation

-slowly enlarging lesion that does not heal and bleeds easily

-usually pink, pearly white, sometimes can be pigmented

-look for telangiectasia

-flattens centrally, rolled border

Basal Cell Carcinoma - Dx

-shave bx or punch if worried about melanoma

Basal Cell Carcinoma - Tx

-complete excision

-mohs in some cases

-sometimes treat with ED&C or imiquimod

Squamous Cell Carcinoma

-2nd most common skin cancer

-invasive, cutaneous malignancy arising from keratinocytes most commonly on face, head, neck, hands

-may develop from AKs

SCC - Incidence

-lifetime risk is 9-14% for men

-4-9% for women

SCC - RF

-sun exposure

-radiation

-tobacco use

-HPV

-age

-light phenotypes

SCC - Presentation

-tender, easily bleeding

-pink/red, crusted

-dome shape with yellow/white scale

-enlarging

SCC - Dx

-biopsy

-prognosis is good if caught early

-5 yr survival rate >90%, but does have metastatic potential, usually to lymph node

SCC - Tx

-excision

-mohs

Bowen's Disease

-squamous cell carcinoma in situ (meaning it is in the superficial layer (epidermis)) and not extending into the dermis

-potential for lateral spread

Bowen's Disease - Presentation

-scaly, red, well-demarcated plaque

-sun exposed areas

-good prognosis

Bowen's Disease - Tx

-appropriate to use creams here

-imiquimod 5x week x 6 wks

-5-FU

Paget's Disease

-rare breast cancer (1-3% in women over 55) occurring around the nipple

-redness, itching, crusting

-must biopsy

-tx: mastectomy but chemo and radiation may be appropriate

Melanoma

-aggressive malignant tumor of melanocytes of skin but sometimes in mucous membranes

-cause 80% of skin cancer deaths

-early detection and tx is key

-several types

-late dx carries poor prognosis

-mets to lymph nodes, liver, lungs, brain

-carries atypical features (ABCDE)

melanoma - etiology

-incompletely understood

-UV radiation is beleived to play a role

Melanoma - incidence

-# of new cases in US rising

-lifetime risk 2.1%

-lowest incidence but highest chance of death

Melanoma - RF

-family hx or prior personal hx of melanoma

-hx of severe or blistering sunburns

-changing nevi

-giant congenital nevus (over 20 cm)

-increasing age

-light phenotype

-multiplea typical nevi

Melanoma - Porgnosis

-depends on thickness and depth

-early dx and tx has favorable prognosis

-all melanomas get close follow up

-skin checks q3 months x 1 year, then q6 months x1 year then back to yearly unless multiple nevi, dysplastic nevi

Superficial Spreading Melanoma

-most common type of melanoma (70-80% of cases)

-typically on sun-exposed skin

-men: head, neck, trunk

-women: arms and legs

-UV radiation, genetics are RF

-remains thin for a while, then grows vertically

Superficial Spreading Melanoma - Presentation

-new dark spot >6 mm

-flat

-ABCDEs

Superficial Spreading Melanoma - Tx

-wide local excision with possible SLNB, slow mohs if face or if tissue is too tight

-prognosis: best when detected early

Nodular Melanoma

-most deadly form of melanoma

-incidence: accounts for 10-15% of all melanoma cases

-equal incidence in males and females

Nodular Melanoma - Presentation

-often found on extremities

-raised

-brown/black in color

-rapidly appearing and growing

Nodular Melanoma - prognosis

-early stage survival rate around 90%

-later stages survival rate around 50%

Nodular Melanoma - Tx

-same as other melanomas

-WLE vs mohs +/- SLNB

Lentigo maligna melanoma

-subtype of melanoma in situ

-enters a vertical growth phase and invades the dermis

-RF: UV exposure, usually seen in older people

Lentigo Maligna Melanoma - Incidence

-about 80% of melanoma in situ cases

-accounts for 5-10% of all melanomas

-males and females equally at ris

Lentigo Maligna Melanoma - Presentation

-develop over several years on sun exposed skin - face, neck, arms

-flat and irregularly outlined

-may look grey

-sometimes the only diagnostic clue is that it is darker than surrounding lentigines

Lentigo Maligna Melanoma - Dx

-dermoscopy, biopsy

-if large or in cosmetically sensitive area, multiple smaller biopsies may be considered

-alternating skin exams with another provider

Lentigo Maligna Melanoma - Prognosis and tx

-prognosis: best of all melanoma types

-tx: complete surgical excision (mohs, SLNB)

Acral Lentiginous Melanoma

subtype of melanoma that occurs on acral surfaces (palms, soles, subungual areas)

Acral lentiginous melanoma - incidence

-accounts for 5% of melanoma cases

-males > females, usually older adults

-most common melanoma in asians and african americans

-least common in caucasians

Acral Lentiginous melanoma - RF

-unknown, typically occurs in minimally sun exposed areas and in patients of all phenotypes

Acral Lentiginous melanoma - presentation

-most commonly found on LE (78%)

-black, variegated brown, multicolored, irregularly shaped papule, macule, patch

-nail apparatus: Hutchinson's sign

Acral Lentiginous melanoma - dx

-dermoscopy: parallel ridges

-nails: brown band that extends the length of nail that are homogenous in color and regular in pattern indicate benign lesion

-if irregular --> malignant lesion

-biopsy!

excise, immunotherapy

what is the tx for acral lentiginous melanoma?

Dysplastic Nevus

-melanocytic proliferation showing atypia and sharing some features of melanoma

-controversial d/t a lack of consensus on how it is defined and what it represents biologically (mild mod or severe)

-believed to correlate with the overall number of melanocytic lesions in an individual and are thought to confer a 4-15 fold increased risk of melanoma