Skin Cancer

Tx and prognosis

surgical excison, cryosurgery, radiation therapy, chemotherapy, electrodesiccation and curettage. Untreated lesion may metastasize to regional lymph nodes and distant organs. High cure rate with early detection and Tx.

Breslow measurement

the depth of the tumor in millimeters.

Topical chemotherapy-Imiquimod

Imiquimod is FDA-approved only for superficial BCCs, with cure rates generally between 80 and 90 percent. The cream is rubbed gently into the tumor five times a week for up to six weeks or longer. The first in a new class of drugs that work by stimulating the immune system, it causes the body to produce interferon, a chemical that attacks cancer.

Tx and prognosis

surgical excision and possible sentinel lymph node evaluation depending on the depth. correlation of survival rate with depth of invasion. Poor prognosis unless diagnosed and treated early. spreading by local extension, regional lymphatic vessels, and bloodstream. possible use of adjuvant therapy after surgery if lesion greater than 1.5 mm in depth.

risk factors

Red or blonde hair Light-colored eyes Fair skin that freckles Chronic sun exposure Family history

A skin cancer the presents as a slay, slightly elevated lesion with an irregular border

SCC

Major difference between BCC and Squamous cell carcinomas is that

SCC have a propensity倾向 to metastasize to regional lymph nodes and distant sites

Risk factors for development of skin cancer

Sun exposure Irritants and allergens Radiation Sleep Exercise Hygiene Nutrition Occupational history of chemical carcinogens history of severe skin injury Immunosuppression therapy Exposure to ultraviolet light( natural light or indoor tanning) over long periods of time Chronic skin inflammation, burns, or scars Fair complexion ( blonde or red hair, fair skin, freckles, blue eyes) with a tendency to burn easily Presence of several large or many small moles Family or personal history of melanoma Residing in higher elevations or in close proximity to equator (thinner layer of ozone) Age older than 50 years

clinical manifestations

Superficial: thin, scaly erythematous plaque without invasion into the dermis. Early: firm nodules with indistinct borders, scaling and ulceration. Late: covering of lesion with scale or horn from keratinization, ulceration. Most common on sun-exposed areas such as face and hands

Tx and prognosis

Surgical excision, chemosurgery, electrosurgery, chemotherapy, cryosurgery. 90% cure rate. Slow-growing tumor that invades local tissue. Metastasis rare. 5-FU and immiquimod for superficial lesions, photodynamic therapy for small lesions, vismodegib (Erivedge) for metastatic or recurrent locally invasive lesions.

True or fall? Curettage and cryosurgery are not used if malignancy is suspected.

True

True or fall? A punch biopsy would not be done for a lesion greater than 5 mm in diameter.

True

Cryosurgery

Use: Actinic keratosis, Basal Cell Carcinoma (BCC), Squamous Cell Carcinoma (SCC) Freezes and destroys isolated lesions by applying liquid nitrogen (-200°C) skin becomes edematous and tender. client education: teach the client to cleanse with hydrogen peroxide and apply a topical antimicrobial until healed.

Treatment for Mycosis fungoides蕈样霉菌

XRT:TBE chemo: Topical nitrogen mustard

nonmelanoma skin cancers

actinic keratosis光化性角化病 (premalignant skin lesions) basal cell carcinoma (most common type of skin cancer; least deadly) squamous cell carcinoma ( potential to metastasize; pipe, cigar, and cigarette smoking)

Most common skin cancer

basal cell carcinoma

Basal cell carcinomas originate from

basal cells of the stratum basale地层基础

Targeted therapy

blocks or slows the spread of cancer by interfering with specific molecules (targets) that are involved in growth, progession, and spread of cancer. Vemurafenib is an oral medication used for targeted therapy to treat melanoma.

Malignant tumors of epithelial origin are called

carcinomas癌

Etiology and pathophysiology -BCC

change in basal cells. no maturation or normal keratinization. continuing division of basal cells and formation of enlarging mass. related to excessive sun exposure, genetic skin type, x-ray radiation, scars, and some types of nevi.

Actinic keratosis Tx

cryosurgery, chemical peels, laser resurfacing, topical application of 5-FU over entire area for 14-28 days or topical application of imiquimod (Aldara) for 16 wk, photodynamic therapy folwed by light irradiation. Recurrence possible even with adequate Tx.

Fitzpatrick classification of skin type (Lewis, P. 431)

determining how a patient will respond or react to facial treatments, ad how likely they are to get skin cancer. there are six different skin types, skin color, and reaction to sun exposure. type I (very white or freckled): always burn, can not tan type II (white): usually burn, sometimes tan thype III (white to olive): sometimes burn, usually tan type IV ( brown): rarely burn, always tan type V (dark brown): very rarely burn, always tan type VI (black): never burn, always tan

Chemotherapy-Interferon therapy

for postoperative Tx of stage III or greater melanomas. Nursing considerations: report and provide relief for adverse or toxic effects of chemotherapy. encourage adequate nutrition and fluid intake. instruct clients on self-injection procedure.

SCC tend to show up in what areas

head, face, neck, arms and hands (sun exposed areas)

clinical manifestations

irregular color, surface, and border. variegated color, including red, white, blue, black, gray, brown. flat or elevated. Eroded or ulcerated. often less than 1 cm in size. most common sites in lales are back, then chest. in females are legs, then back

Radiation

limited to older clients who have large, deeply invasive tumors and those who are poor surgical candidated. melanoma is relatively resistant to radiation therapy.

Basic determinant of skin color

melanin

Malignant melanoma originate from

melanocytes of the stratum basale

Etology and pathophysiology

neoplastic growth of melanocytes anywhere on skin, eyes, or mucous membranes. classification according to major histologic mode of spread. potential invasion and widespread metastases.

Malignant melanoma

new moles or change in an existing mole (can occur in intestines or any other body part structure that contains pigment cells cracks, ulcerations, bleeding possible

Basal cell carcinomas present as a

pearly gray nodule, with prominent telangectasia毛细血管扩张

Most malignant melanoma develop from

pre-existing nevi预先存在的痣

Curettage and electrodessication

removes cancerous cells with the use of a curette to scrape away cancerous tissue, followed by the application of an electric probe to destroy remaining tumor tissue.

squamous cell (epidermis)

rough, scaly lesion with central ulceration and crusting possibly bleeding localized.. may metastasize

SCC appear as

scaly flat or slightly elevated lesion

Treatment of choice for most skin cancers

surgery

only curative treatment for melanoma

surgery

Most common treatment for BCC

curettage, electrodessication, surgical excision,cryosurgery, Moh's surgery and lasers

Diagnostic and surgical therapy

skin scraping Electrodesiccation Electrocoagulation Curettage Punch biopsy Cryosurgery Excision-Mohs procedure

Basal Cell Carcinoma (BCC)

small, waxy nodule with superficial blood vessels, well defined borders erythema and ulcerations

what are the 3 types of skin cancer

squamous cell (epidermis) Basal Cell (basal epidermis Malignant melanoma (cancer of melanocytes

2nd most common skin cancer

squamous cell carcinoma

Mohs surgery

used with basal and squamous cell carcinoma Tissue us sectioned horizontally in layers and each layer is examined for presence of residual cancer; the process is continued until the samples are free of cancer. complications: skin abscess and cellulitis.

tumor staging

0-IV tumor size Nodal involvement Metastasis T-N-M

Malignant melanoma

Cause unknown (Enviornmental factors; Genetic factors)

Aids related skin cancer

Kaposis sarcoma

Purple colored nodular lesions

Kaposis sarcoma卡皮氏肉瘤

Increasing incidence of metastases for skin cancer:

BCC, SCC, Melanoma黑色素瘤

Diagnosis

Shave-biopsied, shave-excised, electrocauterized MelaFind Tumor thickness (Breslow measurement; Clark level)

us sun block with SPF of at least __

15

What % of people living to he age of 65+ will develop skin cancer

50%

BCC and SCC have a cure rate of

90-95%

Prognosis 预测for BCC

90-95%

Prognosis for melanoma

early stage 95%; late stage 13%

First degree of skin reaction

erythema红斑

Deadliest skin cancer

malignant melanoma

why do we treat keloids with XRT

to prevent recurrence

Poor prognostic indicators for malignant melanoma

tumor thickness, location of tumor, deep invasion, ulceration, lymph node involvement, mets, gender

Major factor in development of skin cancer

ultraviolet light, sun exposure

The nurse working in the dermatology clinic assesses a young adult female patient who is taking isotretinoin (Accutane) to treat severe cystic acne. Which assessment finding is most indicative of a need for further questioning of the patient? a. The patient recently had an intrauterine device removed. b. The patient already has some acne scarring on her forehead. c. The patient has also used topical antibiotics to treat the acne. d. The patient has a strong family history of rheumatoid arthritis.

ANS: A Because isotretinoin is teratogenic, contraception is required for women who are using this medication. The nurse will need to determine whether the patient is using other birth control methods. More information about the other patient data may also be needed, but the other data do not indicate contraindications to isotretinoin use. DIF: Cognitive Level: Apply (application) REF: 438-439 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take? a. Prepare the patient for a biopsy. b. Teach about the use of corticosteroid creams. c. Explain how to apply tretinoin (Retin-A) to the face. d. Discuss the need for topical application of antibiotics.

ANS: A Because the appearance of the lesion suggests actinic keratosis or possible squamous cell carcinoma (SCC), the appropriate treatment would be excision and biopsy. Over-the-counter (OTC) corticosteroids, topical antibiotics, and Retin-A would not be used for this lesion. DIF: Cognitive Level: Apply (application) REF: 431-432 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan (select all that apply)? a. Cool, wet cloths or dressings can be used to reduce itching. b. Take cool or tepid baths several times daily to decrease itching. c. Add oil to your bath water to aid in moisturizing the affected skin. d. Rub yourself dry with a towel after bathing to prevent skin maceration. e. Use of an over-the-counter (OTC) antihistamine can reduce scratching.

ANS: A, B, E Cool or tepid baths, cool dressings, and OTC antihistamines all help reduce pruritus and scratching. Adding oil to bath water is not recommended because of the increased risk for falls. The patient should use the towel to pat (not rub) the skin dry. DIF: Cognitive Level: Analyze (analysis) REF: 443-444 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching? a. The patient applies corticosteroid cream to pruritic areas. b. The patient uses Neosporin ointment on minor cuts or abrasions. c. The patient adds oilated oatmeal (Aveeno) to the bath water every day. d. The patient takes diphenhydramine (Benadryl) at night if itching occurs.

ANS: B Neosporin can cause contact dermatitis. The other medications are being used appropriately by the patient. DIF: Cognitive Level: Apply (application) REF: 441 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

An older adult patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care? a. Describe the use of topical fluorouracil on the incision. b. Teach how to use sterile technique to clean the suture line. c. Schedule daily appointments for wet-to-dry dressing changes. d. Teach about the use of cold packs to reduce bruising and swelling.

ANS: D Application of cold packs to the incision after the surgery will help decrease bruising and swelling at the site. Since the Mohs procedure results in complete excision of the lesion, topical fluorouracil is not needed after surgery. After the Mohs procedure the edges of the wound can be left open to heal or the edges can be approximated and sutured together. The suture line can be cleaned with tap water. No debridement with wet-to-dry dressings is indicated. DIF: Cognitive Level: Apply (application) REF: 444 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A nurse develops a teaching plan for a patient diagnosed with basal cell carcinoma (BCC). Which information should the nurse include in the teaching plan? a. Treatment plans include watchful waiting. b. Screening for metastasis will be important. c. Low dose systemic chemotherapy is used to treat BCC. d. Minimizing sun exposure will reduce risk for future BCC.

ANS: D BCC is frequently associated with sun exposure and preventive measures should be taken for future sun exposure. BCC spreads locally, and does not metastasize to distant tissues. Since BCC can cause local tissue destruction, treatment is indicated. Local (not systemic) chemotherapy may be used to treat BCC. DIF: Cognitive Level: Apply (application) REF: 431 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching? a. The patient has multiple dysplastic nevi. b. The patient is fair-skinned and has blue eyes. c. The patient's mother died of a malignant melanoma. d. The patient uses a tanning booth throughout the winter.

ANS: D Because the only risk factor that the patient can change is the use of a tanning booth, the nurse should focus teaching about melanoma prevention on this factor. The other factors also will contribute to increased risk for melanoma. DIF: Cognitive Level: Apply (application) REF: 428 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure? a. Curettage b. Cryosurgery c. Punch biopsy d. Surgical excision

ANS: D The description of the mole is consistent with malignancy, so excision and biopsy are indicated. Curettage and cryosurgery are not used if malignancy is suspected. A punch biopsy would not be done for a lesion greater than 5 mm in diameter. DIF: Cognitive Level: Apply (application) REF: 430-431 | 433 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed? a. "After I apply the medication, I can go ahead and get dressed as usual." b. "I will need to minimize my time in the sun while I am using the Elidel." c. "I will rub the medication gently onto the skin every morning and night." d. "If the medication burns when I apply it, I will wipe it off and call the doctor."

ANS: D The patient should be taught that transient burning at the application site is an expected effect of pimecrolimus and that the medication should be left in place. The other statements by the patient are accurate and indicate that patient teaching has been effective. DIF: Cognitive Level: Apply (application) REF: 442 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patient's instructions? a. "5-FU will shrink the lesion so that less scarring occurs once the lesion is excised." b. "You may develop nausea and anorexia, but good nutrition is important during treatment." c. "You will need to avoid crowds because of the risk for infection caused by chemotherapy." d. "Your cheek area will be painful and develop eroded areas that will take weeks to heal."

ANS: D Topical 5-FU causes an initial reaction of erythema, itching, and erosion that lasts 4 weeks after application of the medication is stopped. The medication is topical, so there are no systemic effects such as increased infection risk, anorexia, or nausea. DIF: Cognitive Level: Apply (application) REF: 441 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Actinic keratosis光化性角化病

Actinic (skin) damage, premalignant skin lesions, coomon in older white.

Pathophysiology of Non-melanoma skin cancers:

Actinic keratosis, Basal Cell Carcinoma (BCC), and Squamous Cell Carcinoma (SCC)

ABCDE rules for potential skin cancers

Asymmetry Border irregularity Color change Diameter grater than 6mm Evolving in appearance

BCC 特点

BCC is frequently associated with sun exposure and preventive measures should be taken for future sun exposure. BCC spreads locally, and does not metastasize to distant tissues. Since BCC can cause local tissue destruction, treatment is indicated. Local (not systemic) chemotherapy may be used to treat BCC.

Clinical manifesation

Flat or elevated, dry, hyperkeratotic scaly papule. possible flat, rough, or verrucous (wartlike). Adherent scale, which returns when removed. often multiple. rought scale on red base. often on erythematous sun-exposed area. increase in number with age.

Chemotherapy -Topical chemotherapy with 5-fluorouracil cream

For Tx of actinic keratoses or for widespread superficial basal cell carcinoma. The liquid or cream is gently rubbed into the tumor twice a day for three to six weeks. Pt. education: prepare the Pt. for extended Tx that will cause the lesion to weep, curst, and erode侵蚀. reassure the Pt. that the appearance of the lesion will improve after Tx. It has similar cure rates to imiquimod. Side effects are variable, and some patients do not experience any discomfort, but redness, irritation, and inflammation usually occur. Topical 5-FU causes an initial reaction of erythema红斑, itching, and erosion 糜烂 that lasts 4 weeks after application of the medication is stopped. The medication is topical, so there are no systemic effects such as increased infection risk, anorexia, or nausea

Etology and pathophysiology

Frequent occurrence on previously damaged skin (e.g., from sun, radiation, scar). Malignant tumor of squamous cell of epidermis. invasion of dermis, surrounding skin.

clinical manifestations

Nodular and ulcerative: small, slowly enlarging papule丘疹. Borders semitranslucent or pearly", with overlying telangiectasia毛细血管扩张. Erosion, ulceration, and depression of center. Normal skin markings loss. Superficial: Erythematour, pearly, sharply defined, barely elevated plaques.

Clark level

the depth of invasion of the tumor; the higher the number, the deeper the melanoma The Clark scale is a way of measuring how deeply the melanoma has grown into the skin and which levels of the skin are affected. The Clark scale has 5 levels: Level 1 is also called melanoma in situ - the melanoma cells are only in the outer layer of the skin (the epidermis) Level 2 means there are melanoma cells in the layer directly under the epidermis (the papillary dermis) Level 3 means the melanoma cells are throughout the papillary dermis and touching on the next layer down (the reticular dermis) Level 4 means the melanoma has spread into the reticular or deep dermis Level 5 means the melanoma has grown into the layer of fat under the skin (subcutaneous fat)

Excision

the incision will be closed with sutures if possible. a skin graft can be necessary for large areas. Client education: advise the client about postoperative wound care and care of the skin graft if used.

Squamous cell carcinomas originate from

upper layers of epidermis表皮

Melanoma is 80% for frequent in

whites

differentiation

分化(differentiation)指腫瘤細胞與原先正 常細胞在形態與功能上的相似程度，腫瘤 細胞愈相似於原先細胞，表示分化愈好； 愈不同於原先細胞，則分化愈差。一般而 言，良性腫瘤分化都很好，而惡性腫瘤分 化程度由良好至不好都有。

Metaplasia

化生, 是指某一種類的正常上 皮(epithelium)被另一種類的正常成熟上 皮所取代，常因外源性或內源性的刺激所 造成。通常是細胞為了適應長期環境變化 刺激所產生的結果，一旦刺激原消失即可 能會恢復(reversible)，但此處也可能有較 高的癌化機會。

Hyperplasia

增生, an abnormal increase in the number of cells Dysplasia-異生(dysplasia)乃指原本排列規律的正常 細胞與組織，演變成不規則排列的不正常 細胞及組織, 通常最嚴重的重度異生 即為癌前期病變(precancerous malignancy) Anaplasia退行性分化, 表示細胞缺乏分化 作用，被認為是腫瘤惡性化的一個重要特 徵

Dysplasia

異生(dysplasia)乃指原本排列規律的正常 細胞與組織，演變成不規則排列的不正常 細胞及組織, 通常最嚴重的重度異生 即為癌前期病變(precancerous malignancy)

Anaplasia

退行性分化, 表示細胞缺乏分化 作用，被認為是腫瘤惡性化的一個重要特 徵