1. Chapter 111: Cutaneous Neoplasms
Lisa Spiguel, MD

2. True or False: Cutaneous melanomas account for 4 % of skin cancer diagnosis, but 75% of skin cancer deaths

3. Which of the following below is NOT a risk factor for cutaneous melanoma?
UVA exposure
UVB exposure
Tanning beds
Seborrheic Keratosis
All of the above

4. What is the most common site of distant metastasis in melanoma?
Liver
Small Bowel
Brain
Lung

5. What is the most common type of melanoma?
Lentigo maligna
Superficial spreading
Nodular
Acral lentiginous

6. What is the most indolent type of melanoma?
Lentigo maligna
Superficial spreading
Nodular
Acral lentiginous

7. What is the most aggressive type of melanoma?
Lentigo maligna
Superficial spreading
Nodular
Acral lentiginous

8. Which type of melanoma most commonly arises from a pre-existing nevus?
Lentigo maligna
Superficial spreading
Nodular
Acral lentiginous

9. Which of the following is NOT an indication for sentinel lymph node biopsy in a patient with a thin melanoma?
Presence of ulceration
Presence of regression
Invasion into reticular dermis
Increased mitotic rate
All of the above are indications for sentinel lymph node biopsy

10. A patient presents to your office with a lesion suspicious for a melanoma. You perform a biopsy that demonstrates a 1.25 mm thick melanoma. What margin is necessary during surgical excision?
0.5 cm
1 cm
2 cm
3 cm

11. A 55 you right-handed male is diagnosed with a subungual melanoma of his left index finger. The appropriate surgical resection is?
Amputation at the DIP joint
Amputation at the PIP joint
Amputation at the MCP joint
Excision with negative microscopic margins

12. Which of the following below is NOT a immunostain for melanoma?
Melan-A
HMB-45
Melatonin

13. Which of the following therapies have been approved by the FDA for the treatment of Stage IV melanoma?
IL-2
IFN α
IFN δ
Traztuzamab

14. Which of the below adjuvant therapies is used for Stage IIB or Stage III melanoma?
IL-2
IFN α
IFN δ
Traztuzamab

15. Best treatment of a single in-transit melanoma of the right lower extremity involves which of the following below?
Isolated limb perfusion
Systemic chemotherapy with Melphalan
Surgical excision
None of the above

16. I solated limb perfusion involves hyperthermic administration to the limb involved using which chemotherapeutic agent?
IL-2
IFN α
Cisplatin
Melphalan

17. Skin Cancer 1.4 million new cases of skin cancer annual in US
Nonmelanoma skin cancer types: Basal cell and Squamous cell (4:1)
Melanoma accounts for 4%, but up to 75% of skin cancer deaths
Incidence of melanoma is on the rise

18. Melanoma Risk Factors: Genetic Causes:
UVA/UVB exposure: sun exposure, occupation, history of sunburns, tanning beds
Fair complexion (inversely related to skin pigmentation)
Atypical Nevi
Dysplastic nevus syndrome: > 100 , one mole > 8 cm, 1 mole w/ atypical histology
Genetic Causes:
Mutation in CDKN2A (p16)
MC1R gene mutation
FAMM (Familial Atypical Multiple Mole Melanoma syndrome): AD
Xeroderma Pigmentosa: AR
Congenital Melanocytic Nevi (CMN)

19. Congenital Melanocytic Nevi
Appear at birth or within 1st 6 months of infancy
Incidence is 1-6%
Classification/ Risk of Malignancy:
Small < 1.5 cm
Medium cm
Giant > 20 cm/ 5-20% risk, 70% dx prior to age 10
Risk of Neurocutaneous melanocytosis:
Occurs with Giant CMN on posterior axis
Benign ormalignant leptomeningeal tumors
Dx: MRI

20. Melanoma Characteristics
A (Asymmetry) one portion of the mole does not match the other
B (Border) edges are irregular, notched, or blurred
C (Color) different shades of black or brown, patchy colors
D (Diameter) spot is 6 millimeters across, or growing larger

21. Melanoma Subtypes Lentigo maligna melanoma
10-15%
Chronically sun exposed areas
Superficial spreading melanoma
70%
Typically arises in pre-existing nevus
Nodular melanoma
15%
Most aggressive form due to rapid growth
Acral Lentiginous Melanoma
Subungual melanoma
2-8% in Caucasians, 35-60% in African Americans
Worse prognosis is related to delayed detection not aggressiveness of tumor
Others:
Mucosal, Anal, Vulvovaginal

22. Staging Breslow Staging: Clark level of Invasion:
Classifies tumor according to thickness in millimeters
Inverse correlation between thickness and survival
Clark level of Invasion:
Classifies based on level of invasion into the histologic layer of the skin
I-V
Independent Prognostic Factors:
Tumor stage, ulceration, nodal status, distant metastasis

24. TNM
Stage 0: in situ
Stage I: Local Disease
Stage II: Local Disease
Stage III: Regional nodal disease, in-transit, or satellite metastasis
Stage IV: Distant Disease

25. Evaluation Clinical Exam: ABCD Biopsy:
Full thickness biopsy to the adipose tissue:
Punch biopsy if > 2 cm lesion
Excisional biopsy if < 2 cm lesion with 1-2 mm margins
Never superficial shave biopsy

26. Treatment Surgical Excision: (Margins) - Fascia
Melanoma in situ: 0.5 cm
Thin Melanoma (≤1 mm): 1 cm
Intermediate Melanoma (1-4mm): 2 cm
Thick Melanoma (>4mm): 2 cm
Treatment of In-transit disease:
Surgical excision when the feasible and number of lesions is small
Ablative therapes
Isolated limb perfusion
Delivery of 15-25times higher than systemic doses
Melphalan chemotherapy delivered at hyperthermic temperatures 38 degree C
80-90 % response rates with complete response rates 40-60%
Indications for Sentinel Lymph Node Biopsy:
All melanomas > 1 mm (Intermediate and Thick)
Thin Melanomas/ or mm, if:
Ulceration
Regression
Into reticular dermis
Increased Mitotic Rate: > 1mitosis/mm2
Indications for Axillary Node dissection
Clinically positive nodes
+ Sentinel Lymph Node
MSLT II: + SLN  ALND vs Serial US

28. Treatment Role for Adjuvant Therapy:
IFN-α2b
RCT: Thick melanomas or + Nodal disease:
Increased median overall survival by 1 year
24% improvement in 5 yr survival
Indications for Systemic Staging: (Serum LDH, MRI Head, CT C/A/P or PET/CT)
Clinically positive nodes (FNA +)
Pathologically positive nodes
Systemic Therapy in Stage IV disease:
IL-2
Cytokine secreted by Thelper cells

29. True or False: The most common non-melanoma skin cancer is squamous cell carcinoma.

30. A 75 yo old man presents with the lesion imaged below
A 75 yo old man presents with the lesion imaged below. What is the margin need during excision?
0.5 cm
2 cm
4 cm
6 cm

31. Immunohistochemical staining is positive for which of the below for merkel cell tumors?
Melanin
cKit
CK-20

32. Which of the following below spreads via lymphatic flow?
Merkel cell carcinoma
Squamous cell carcinoma
Basal cell carcinoma
1 & 2
All of the above

33. Which of the follow below does NOT require a 2 cm margin for the treatment of squamous cell carcinomas?
Squamous cell carcinoma of the neck
Squamous cell associated with Marjolin’s ulcer
Penile squamous cell carcinoma
Vulvar squamous cell carcinoma

34. A 68 yo male presents to your clinic with the lesion below on his right upper arm. What margin of excision is needed for treatment of this lesion?
0.5 cm
1 cm
2 cm
4 cm

35. A 38 yo male is diagnosed with 8 mm penile squamous cancer at the tip of his penis. What is the treatment of choice?
Total penectomy
Partial penectomy
Exicsion with negative microscopic margins
None of the above

36. Ture or False: Moh’s surgery can be used for both basal cell and squamous cell carcinomas.

37. A 75 yo man presents to your office with a new lesion on his face
A 75 yo man presents to your office with a new lesion on his face. Your exam demonstrates the lesion below. What is your diagnosis?
Squamous cell cardcinoma
Merkel cell carcinoma
Basal cell carcinoma
Melanoma

38. True or False: Morpheaform basal cell carcinoma has the worst prognosis.

39. A 75 yo man is diagnosed with a basal cell carcinoma of the right neck
A 75 yo man is diagnosed with a basal cell carcinoma of the right neck. What margin of excision is needed for treatment?
0.5 cm
1.0 cm
1.5 cm
2.0 cm

40. NonMelanoma Skin Cancers
Basal Cell
Four times more common than squamous cell
Risk Factors
Same as melanoma
UVA/UVB exposure, higher risk in fair individuals
Radiation
Gorlin Syndrome: AD, multiple BCC, palmoplantar pits, jaw cysts, frontal bossing, hypertelorism
Squamous Cell
Risk Factors: Sun exposure, Chemicals : Arsenic, hydrocarbons (coal tars, soot, asphalt), Tobacco, HPV, Radiation

41. Basal Cell Carcinoma Exam: Pathology: Surgical Excision:
Pearly papules
Nodules with telangiectases
Central ulceration with “rolled” borders
Pathology:
Isolated areas of basaloid tumor islands arising from epidermis with peripheral palisading nuclei and stromal retraction
Surgical Excision:
mm margin
Worst Diagnosis: Morpheaform, sclerosing, or fibrosing

43. Squamous Cell 2nd most common form of skin cancer
Derived from epithelial keratinocyte
Most common skin cancer in immunocompromised patients/transplant patients
Precursor lesions:
Actinic keratoses
Bowen disease (in situ SCC)
Exam:
Nonhealing sore with ulceration and inflammatory pink borders
Erythematous papulonodule with overlying keratotic crust or ulceration
Pathology:
Malignant degeneration of epithelial cells with differentiation toward keratin formation
Surgical Excision:
1 cm margin
2 cm margin for Marjolin’s ulcer, penile and vulvar squamous cell carcinomas
Prognosis:
Metastasis to regoinal LN
Poor prognosis with 10 year survival < 20%
Distant disease 10 year survival < 10%

45. Merkel Cell Carcinoma Primary cutaneous neuroendocrine cancer
Highly aggressive with high mortality
Risk Factors:
UVA/UVB, immunosuppression,
Merkel cell polyovirus
Exam:
New-onset growing red or purple dome-shaped subcutaenous nodule
Pathology:
Blue cell tumor with positive immunohistochemical staining for CK-20
Absent staining of thyroid transcription factor-1 TTF-1
Treatment:
Wide local excision with 1-2 cm margins
Adjuvant XRT for Stage II disease
SLNB and staining for CK-20
ALND or regional radiation therapy if SLNB +
Adjuvant chemotherapy for Stage IV disease