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Skin Malignancy Conditions for the Physician Assistant Exam

Skin cancer is a common finding that is covered on the Physician Assistant Exam (PANCE), and it’s usually identified by a person’s primary care provider. The four cutaneous malignancies you should know about for the PANCE/PANRE are Kaposi’s sarcoma, basal cell carcinoma, squamous cell cancer, and melanoma.

Kaposi’s sarcoma

Kaposi’s sarcoma is a purplish maculopapular rash on the extremities and mucous membranes of the body. It’s associated with immunosuppression, especially HIV. This cancer can improve with the treatment of the immunosuppression. The treatment is otherwise multifactorial, involving chemotherapy, radiation, and surgery, if needed.

Basal cell carcinoma

Basal cell carcinoma is the most common skin malignancy in the United States. It isn’t considered a cancer because it doesn’t spread to other organs in the same way that most cancer does. Nevertheless, basal cell carcinoma usually requires surgical intervention because it can be an eyesore and can become disfiguring when it gets too large, especially when it affects the facial area.

The lesion is diagnosed by a biopsy. Basal cell carcinoma is more likely to occur in the fair-skinned person who spends a lot of time in the sun. About 70 percent of basal cell carcinomas occur in sun-exposed areas of the skin. Treatments can include surgery, topical chemotherapy, and radiation.

Squamous cell carcinoma

Whereas basal cell carcinoma is a benign condition, squamous cell carcinoma is a bad malignancy. You usually see it in someone who has had long-term daily sun overexposure or exposure to ultraviolet light. Older adults, especially people who are fair-skinned, are more at risk for developing this condition. It commonly occurs on the face and ears, although you can find it on the extremities and other parts of the body.

As with any skin lesion, an increase in size is a sign of a malignancy. In addition, the surface is often flaky or scaly in nature, with a reddish center. The diagnosis is made by a skin biopsy. Treatment can include surgical excision of the lesion as well as radiation. If you find evidence of metastatic spread, then the affected person may need chemotherapy.

Here are two other points concerning squamous cell carcinoma:

  • Bowen’s disease is a premalignant skin condition, also referred to as squamous cell carcinoma in situ.

  • A small percentage of actinic keratosis cases can develop into squamous cell carcinoma. You read about actinic keratosis later in “Horny growths: Examining keratosis lesions.”

Malignant melanoma

Melanoma is a very aggressive form of skin cancer. The other skin cancers, including basal cell and squamous cell cancer, are referred to as nonmelanoma skin cancers. The risk factors for developing melanoma include being fair-skinned, having had excessive exposure to ultraviolet radiation, and being older in age. The person may have a family history of melanoma as well.

One of the main tools you can use in evaluating melanoma is the alphabetic classification system — A, B, C, D, and E:

  • Asymmetry: If one side of the lesion is different from the other, the odds are higher that you’re dealing with melanoma.

  • Borders: Are the borders of the lesion regular or irregular? Are they smooth or spiculated? The more irregular they are, the greater the likelihood that you’re dealing with a malignancy.

  • Colors: The melanoma may have more than one color.

  • Diameter: The larger the lesion, the greater the risk that it’s melanoma. A skin lesion of > 9–10 mm is usually felt to be more suspicious for melanoma.

  • Evolution: Changes over time in terms of appearance and size can signal a melanoma.

Note that this classification scheme doesn’t apply to nodular melanoma, which is the most dangerous form of melanoma. There are several types of melanoma. The most common type of melanoma is superficial spreading melanoma. Lentigo maligna melanoma, which tends to develop very slowly, can be found in the facial area.

If melanoma is likely, an excisional skin biopsy is done; a shave biopsy isn’t sufficient for diagnosis. The Breslow scale is one way to tell the depth of invasion.

The treatment depends on the staging. Note that melanoma, like squamous cell carcinoma, has the ability to metastasize. Treatment can involve surgery and/or chemotherapy. Medications that boost the immune system, such as interferon, have been used in treating widely metastatic melanoma.

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