Snapshot A 70-year-old man presents to the dermatologist’s office for his annual skin exam. He complains of a large pink lesion on his cheek that oozes and bleeds. It never seemed to heal properly. He is concerned, because he knows that he should have used more sunscreen throughout his life. Introduction Invasive primary skin malignancy arising from keratinocytes of skin or mucosa Epidemiology common in fair-skinned individuals common in elderly patients 2nd most common form of skin cancer (first is basal cell carcinoma ) risk factors sun exposure actinic keratosis immunosuppression (similar to treatment after organ transplant) arsenic exposure old scars or burns xeroderma pigmentosum ionizing radiation Pathogenesis damage to keratinocytes metastases are rare Keratoacanthoma is a variant of low-grade squamous cell carcinoma grows rapidly and regresses spontaneously Presentation Symptoms typically asymptomatic Physical exam red, poorly defined base with adherent yellow or white scale smooth, dull, red, dome-shaped nodule with ulcerated center frequently on sun-exposed areas face, neck, hands, ears common on lower lips lesions often against a background of sun-damaged skin Evaluation Diagnosis by skin biopsy atypical keratinocytes and malignant cells invasion into dermis keratin “pearls” on histology Differential Diagnosis Actinic keratosis Actinic cheilitis Treatment Surgical wide local excision with negative margins Prognosis, Prevention, and Complications Prognosis if treated, very excellent prognosis Prevention sun avoidance sunscreen use
QUESTIONS 1 of 6 1 2 3 4 5 6 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + (M1.ON.1) A 58-year-old lifeguard develops squamous cell carcinoma of the skin on his forehead. Which of the following most likely preceded the development of this carcinoma? Review Topic QID: 101308 1 Hamartomatous lesion of sebaceous glands 3% (4/134) 2 Dry, scaly, hyperkeratotic papule 68% (91/134) 3 A single, large pink patch 5% (7/134) 4 Dermatophyte infection 0% (0/134) 5 UVC exposure 23% (31/134) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.ON.51) A 71-year-old man presents to his primary care physician with the lesion seen in Figure A. He states that it has been present for several months. He has no significant past medical history and is a retired construction worker. What would be the expected pathology on biopsy? Review Topic QID: 104262 FIGURES: A 1 Palisading basal cells 14% (1/7) 2 Keratin pearls 86% (6/7) 3 S-100 postive staining cells 0% (0/7) 4 Parakeratosis 0% (0/7) 5 Hyperkeratosis 0% (0/7) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.ON.57) A 62-year-old man presents to your office for evaluation of a chronic ulcer on the plantar aspect of his right foot. He has a history of peripheral vascular disease and poorly-controlled diabetes mellitus. He states that he has had this ulcer for years, but that it seems to be growing. On examination of his right foot you note the heaped up edges surrounding the ulcer (Figure A). A wedge biopsy reveals irregular masses of anaplastic epidermal cells proliferating down to the dermis and the pathologist reports "keratin pearls". What is the diagnosis? Review Topic QID: 106379 FIGURES: A 1 Melanoma 1% (1/127) 2 Squamous cell carcinoma 83% (106/127) 3 Basal cell carcinoma 8% (10/127) 4 Osteomyelitis 2% (3/127) 5 Plantar fasciitis 4% (5/127) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2