Skin Malignancies : Mnemonics

Malignant Melanoma

Diagnosis or Clinical features:

Mnemonic: ABCDE

1. Asymmetric with non-matching sides
2. Borders are irregular
3. Color is not uniform (variegated)
4. Diameter >6 mm (pencil eraser)
5. Evolving lesions (size, shape, surface, color, symptoms)

Risk factors:

Mnemonic: MM RISK

1. Moles: atypical nevus (>5)
2. Moles: common moles (>50)
3. Red hair and/or freckling
4. Inability to tan (skin types I and II)
5. Sunburn history (severe sunburn before age 14)
6. Kindred (family history of melanoma)

Pathologic Types:

Mnemonic: Melanoma Always Spreads to Nodes (in order of worsening prognosis)

Mnemonic	Type	Incidence	Site	Growth pattern
Melanoma	Maligna – lentiginous	10-15%	Face (Precursor – Hutchison’s freckles/lentigo maligna)	long in-situ stage before vertical growth
Always	Acral lentiginous	30-70% dark skinned (most common in dark skinned) 5% fair skinned	Palm, soles, nail beds Hutchison’s sign – extension of acral lentiginous melanoma to nail folds
Spreads to	Superficial spreading	50% (most common)	Trunks (male), legs (female)	grows radially before vertically
Nodes	Nodular	15% (5% are amelanocytic)	Trunks & legs	only vertically

Clarke’s level: Anatomical measure of tumor depth –

Mnemonic for layers of skin: E-D-F; Dermis has 2 layers (P comes before R)

1. Epidermis (level I; best porgnosis)
2. Dermis – Papillary (level II)
3. Dermis – Papillary and Reticular junction (level III)
4. Dermis – Reticular (level IV)
5. Fat (level V; worst prognosis – 75% chance of 5-year recurrence)

Breslow’s thickness: the depth of invasion from the stratum granulosum

Stage	Breslow thickness	5-year survival	Resection margin
Insitu	Insitu	90-100%	0.5 cm
I	<1 mm	80-90%	1 cm
II	1-2 mm	70-80%	1-2 cm
III	2-4 mm	60-70%	2-3 cm
IV	>4 mm	50%	3 cm

If ≥ Clarke level IV, thickness >1 mm or ulceration: consider Sentinel Lymph Node Biopsy (SLNB) and possible lymphadenectomy.

Malignant MElanoma is more likely to MEtastasize.

Basal Cell Carcinoma (BCC)

It is the most common skin cancer.

Mnemonic: B’s and P’s

Involvement: Basal cell layer of epidermis

Risk factors:

1. uvB
2. Basal cell nevus syndrome (Gorlin syndrome)
3. Bazex syndrome (acral psoriasiform dermatosis associated with internal malignancies)
4. xeroderma Pigmentosum
5. Pale skin (Fitzpatrick type 1 and 2)
6. Previous skin cancer
7. Poor immune system

Site: uPPer lip or above

Histology: Peripheral Palisading

Clinical features:

Mnemonic: TURP

1. Telangiectasia
2. Ulceration
3. Rolled edges
4. Pearly papule

Types:

Mnemonic: MNoPSS

1. Morphoeic: Scar like
2. Nodular: most common, pearly papule
3. Pigmented: Melanoma like
4. Superficial: Multifocal
5. SCC mixed (Baso-squamous): More aggressive

Treatment options:

Medical	Surgical
Chemotherapy e.g. 5-FU cream	Curettage & Cautery
Cryotherapy	Surgical excision
Phototherapy	Moh’s micrographic surgery
Radiotherapy

BCC	Type	Excision margins
Primary	Small (<2 cm)	3 mm = 85% clearance 4-5 mm = 95% clearance
	Large (>2 cm) or Morpheic	5 mm = 85% clearance 13-15 mm = 95% clearance Consider Moh’s micrographic surgery (sequential horizontal tumor excision with immediate frozen section examination until clear margins are achieved)
Recurrent		5-10 mm Consider Moh’s micrographic surgery +/- Radiotherapy
Incomplete excision		Re-excision Consider surveillance

Squamous Cell Carcinoma (SCC)

Involvement: Squamous keratinocytes in the stratum spinosum

Risk factors: Like in BCC

• However, SCC is the most common skin cancer in brown & black skin (Fitzpatrick type 5 and 6)

Premalignant conditions:

Mnemonic: ABC

1. Actinic keratosis (10-15% progress to SCC)
2. Bowen’s disease (SCC in-situ; 5% progress to SCC)
3. Cheek mucosa white that cannot be brushed off (Leukoplakia; 15% progress to SCC)

Clinical features:

Mnemonic: NO SUN

1. Nodular
2. Opaque
3. Sun-exposed areas
4. Ulcerating
5. Non-distinct borders

Management:

SCC	Excision margins
<2 cm	4 mm = 95% cure
>2 cm	>5 mm = 95% cure Consider Moh’s micrographic surgery

Merkel cell carcinoma

Mnemonic: AEIOU

1. Asymptomatic/lack of pain
2. Expanding rapidly (≤ 3 months)
3. Immunosuppression (HIV, CLL, Organ transplant, Polyomavirus)
4. Older than age 50
5. Ultraviolet light skin exposed

Management:

Lesion <2 cm: Excision with 1 cm margin

Lesion 2 cm or more: Excision with 2 cm margin

Sentinel Lymph Node Biopsy (SLNB) Positive: Complete Lymph Node Dissection + Radiotherapy

Metastases: Chemotherapy + Radiotherapy