# Skin Cancer | Podcast

## Метаданные

- **Канал:** Ninja Nerd
- **YouTube:** https://www.youtube.com/watch?v=Ca9ZBUokW-4
- **Источник:** https://ekstraktznaniy.ru/video/33470

## Транскрипт

### Segment 1 (00:00 - 05:00) []

[snorts] Welcome back to the Ninja Nerd podcast. Today we're talking about skin cancer. Brand new episode. We're going to be going through a bunch of cases and figuring this out together. — Yeah, I think there's, you know, different types of skin cancer. And the three big ones that we'll talk about is going to be basil cell, squam cell, and um melanoma. And really, it's just kind of I think trying to do a podcast of what it visually looks like is obviously difficult. So, you know, I'll do the best I can to visually explain things with my mouth, but you know, in words, but I think a lot of the times it's about identifying what it looks like and then knowing what's the proper way to biopsy it. And then the other thing is just knowing potentially like what's the treatment in the scenarios where it's like maybe in a cosmetically, you know, appealing area where you want to be careful. uh what if it's advanced and it's metastatic and it's gone all over the place. What do you do? So, I think that's the big outline or kind of like objectives to talk about in this podcast. — All right. Well, let's not waste any time then. Case one, we have Mr. J, a 72-year-old male, retired sailor, comes in with a slowly enlarging pearly papule on his left cheek. His wife noticed that it bleeds very easily when he shaves. There's no pain associated. He has a history of significant sun exposure. of course he's a sailor and um no immunosuppression. Uh when you hear pearly papule, I think that's the key like you know if we can kind give you like pathommonic or buzz word terms to think about these that's the best way I would try to use it is a ply papule um rolled borders you hear the term tangiactasia which is just basically like these like small superficial blood vessels that are like near the edge of it um that's usually the key things another one is that it can have a central ulcer but I think one of the key things is it bleeds so if you keep having like a skin lesion that's a little bit like enlarged like a papule and it bleeds a and it has that kind of like papial pearly appearance with like some small little blood vessels along the edge. That's something I would always consider as a potential cause of like skin cancer. Um especially basil cell. So basil cell would definitely be the thing. And then all of these skin cancers, we all know this UV exposure is going to be one of the biggest risk factors. So prolonged chronic UV exposure basically causes it causes something called thyodine dimer. basically causes drizzation of the thymine nucleotides and it basically causes an issue where you can't allow for these proper processes to occur. When you have that DNA damage, what it does is it increases the risk of developing things like mutations. Mutations bring about the opportunity for leading to carcinogens or carcinogenesis, the formation of cancer. And so that's really the key thing is UV exposure, chronic UV exposure is going to be one of the biggest risk factors for developing skin cancer. There is other risk factors is and I think that's why this was mentioned here is it says no amunosuppression amunosuppressive states like HIV significantly increase the risk of developing something like um like squamic cell carcinoma. So having a recent transplant being on heavy degrees of immunosuppressants or having a immunosuppressive disease like HIV AIDS really increases your risk of something like squamasel. Um and then the last thing is like genetic conditions that basically put you at risk. So having mutations particularly um so I think something like uh being albino like alb alb alb alb alb vinism that you have less melanin to kind of reflect some of that sunlight and it puts you at higher risk of developing kind of like skin cancer. Um and I think the last one very rare but it's a condition called zerodma pigmentotosum. So that's another type of condition where you definitely have a pretty significant risk of developing skin cancer as well. Um but yeah, I think the biggest thing is for me looking at this patient, the way it's described, um even though I can't see it, and then having the risk factors of the UV exposure, that that's really the things that make me pretty concerned. Um now, benefit of basilc cell is it's kind of like it rarely ever metastasizes. And so that's kind of one of the benefits of this one. Um where you don't have to worry about it like metastasizing all over the place. It can happen, but it's just I think less likely. But — so I guess I'm wondering what's the big deal then. Why do you have to get this treated? — Like of course it's skin cancer. You want to get it treated. I don't want to like, you know, — just leave a big old papule there hanging on. — I don't want to just dismiss that. But if it does really metastasize, is there less of a concern or less of a rush — to handle this? — I mean, even though it doesn't like distantly metastasize, it can locally erode. So I think because it occurs more commonly on the face especially like um nose uh lips eyelids another one as well uh it can erode into the bone um and so you can get kind of local destruction from that cancer if you don't take care of it. So if it goes for a long period of time it can actually cause like local like soft tissue bone destruction. So that that's kind of the thing I would be a little bit worried about. But I think the best thing in this scenario is just a biopsy. And there's different ways you can biopsy for these. A shave biopsy is pretty good. Uh punch biopsies aren't bad. I

### Segment 2 (05:00 - 10:00) [5:00]

think you just got to be careful. Uh but I would probably do either a punch biopsy or a shave biopsy. I'd probably lean more to the shave uh biopsy in this scenario. But that's what I would do and I would see what the hisystologology shows me and that's really the key thing. A lot of the times I don't think you need to know this, but you look for what's called the term is peripheral palisating like of the actual like his hisytological appearance. Again, we're not going to focus on pathology here because I'm not I don't have a slide to pull up on the on your podcast as you're listening to — but we will this is going to be like a little extra, right? extra because of course like we always do we have a YouTube video on this — so you will get that — but I think the biggest thing is if you hear the term like palisating um peripheral palisating of some of the actual cells the basil cells and you could think about this one but I think the key thing is to if you see pearly papial rolled borders tangactasia bleeds easily usually on the face UV exposure biopsy it shave it if you don't take care of this thing it can locally cause tissue and bone destruction and I think That's the key thing to do here to see what that biopsy comes back with can guide your decision of how you treat. — So if it's localized, I'm guessing we can just quickly excise the area and get rid of it. — Yeah. Yeah, if it's like if it's not like invading pretty deep into like the dermis and getting kind of like to where it's really challenging or it's you know again I'd say like the key thing is if it hasn't metastasized, which is pretty rare, but if it hasn't gotten advanced where it's made into the bone, — yeah, — you could probably just get away with like a normal just excision. Um just an excisional removal, a surgical excision would be the key thing. Now, I think if it's like a nasty big one and it's on the face and like, you know, you don't want to have like a cosmetic like, oh, this looks a little funky kind of thing, there is another option you where they kind of take like small slices of the tumor over time and that they spare kind of the tissues and they keep going until they get good margins. You could do what's called the MO microraphic surgery. So, that's another option. I'd say that's going to be one I'd say primarily more for the face, but you could still have a pretty good like look if you got like the surgical excision. I kind of think it just depends upon the degree of the tumor. So, excise it or MO. I think that's kind of the key thing here. Um, [clears throat] if it was like superficial like on the arm or something like that, it was like in the small one. Uh, another way that we describe this is um, you know, if it's like a tiny little guy, you could do something like topical um, five floor uricil or aquamod. — Oh, wow. You can use something topical. — Yeah. If it's really superficial, it hasn't really gotten invaded in deep and down into the dermis, it's kind of like staying right there, you and it's a small one, you could consider something like topical 5FU or a micod. But if it's spread, that's when I would say you just have to unfortunately you actually have to be kind of really aggressive. So, let's say it metastasized. It's tough, but if it did, it invaded into the nearby bone and metastasized to the lungs or something like that, you have to use like, and I'm not making this up, use what's called a hedgehog pathway inhibitor. Um, I think it's called vismodigib. And basically, it's going to work to be able to kind of shut down that pathway and prevent the cancer from continuing to grow and allow for it to at least kind of slow down the growth process of it. So, generally, first line standard of care is excision. You can do that surgically. You could do the MO if it's like in a cosmetically appealing area. Again, topical 5FULAM you can do if it's a very small superficial lesion. And then if it's advanced, you have to use like targeted therapy. And we use like a hedgehog inhibitor usually for that one. — Okay. Hedgehog. — I know. It's very It's a cool name for it though. Yeah. It makes it fun. — I don't know. Sometimes science can be fun. — It could be. A lot of the time it is. — Yeah. — All right. Let's move on to case two. We have Miss L. She's a 66-year-old female who is a kidney transplant patient on long-term immunosuppression. Presents with a scaly arithmetus nodule on her lower lip that hasn't healed in two months. — Mhm. — She also has actctinic kerattosis on her forearms. — Yeah. — I'm seeing some buzzword terms here. I'm seeing some things that, you know, a nodule on her lip that hasn't healed. — Yep. — What's going through your mind? So when you hear scaly um and like arithmetus just red nodule um and then you hear the term actctinicosis like that's usually so actinic kerattosis is kind of like a scaly like it's it looks like flaky too. Um and it's kind of like it's definitely kind of more protuberant appearing on the skin. Um so it's kind of like a pre-malignant condition essentially to developing squamasel carcinoma. Um and then if they have an arithmetus nodule that's very scaly on their lower lip that's another common place for squamic cell carcinoma. Um and then you hear the term immunouppression. So when I see amunosuppression scalium nodule lower lip hasn't healed and they have actinic kertosis there are like three of the risk factors for developing I mean that's a couple squamic cell carcinoma and the way it's described describes squamic cell carcinoma. So that's what I would think for here is that there's definitely the immunouppression, the actctinic

### Segment 3 (10:00 - 15:00) [10:00]

kerattosis, and then the way it's described as being on the lower lip um scaly irrious nodule sounds like squamic cell carcinoma to me. — Okay. Well, I I'm wondering it sounds like squam carcinoma. How do [clears throat] you prove that? — You biopsy it. — Yeah, you take a piece of tissue. Again, I you could do a shave biopsy. punch biopsy and just take a look. Um, again, you know, when you talk about histologology, we're talking about it's something called keratin pearls and that's the key thing that you're going to look for on the exam or something like that if they kind of present a hisytological finding is keratin pearls and intercellular bridges. Um, so that's really the big way that we kind of see this one. It's because of the different stratum layer that it involves. It often involves usually the stratum spinosum whereas the basilc cell carcinoma involves the stratum basali. So you see the basoid cells with peripheral palacating for basil cell and then for you know your squam cell you get involvement of the stratospinosum there's heavy amounts of keratin there. So you get a lot of keratin pearls and intercellular bridges that usually form there. But that's really the key thing here. Now with squamicel it can metastasize. It's definitely a little bit more likely to metastasize than basil cell. So I think the most common area is the lymph nodes. So you got to watch out nearby lymph nodes if they spread there. That's something I would definitely consider. But again, squamic cell, basilc cell, not as highly of a metastatic skin cancer as compared to the last big honcho, which is the melanoma. But that's something I'd still watch out for — because there's a risk of nodal spread. Is this something where you would maybe consider using a sentininal lymph node biopsy? — You could I think it's only if like you — not very necessary. — No, I'd say that's definitely more necessary depending upon melanoma. So melanoma if I biopsied like melanoma and I found that it was pretty deep I have a high suspicion that it probably spread to a sentininal lymph node and then I would probably do something there. — Okay. Is the treatment strategy at all similar to basilc cell carcinoma or is there some differences? — It's almost exactly the same. — Okay. — Yeah. So that's the nice thing is you for the most part if it's like — you know relatively localized um you know I'd say for the most part you can just pretty much surgically size it get good margins. If it isn't a cosmetically appealing area, which this person seems to be on the lower lip, that's probably something I would do. Maybe like a MO microraphic surgery would maybe be preferred in this scenario. Um I think again if it's like actctinic kertosis, guess what you can treat with that — because it's kind of like a superficial premalignant condition, you can treat that with topical. That'd be a perfect example of topical 5FU or a microclimod. So I would use that as a perfect example. You see this on a board if they asked you like what would you treat this with topically? If you wanted to, you could give 5FU or amod for that kerattosis. — All right, cool. — If it did spread, let's say it metastasize, you know, again, less likely, but it's possible. You treat these with anti-PD1 inhibitors. Um, I forget what the name of it is. I think it's like similab or something. There's all these MABs. I like to remember it's a MAB. It's an it's a checkpoint inhibitor. An immune checkpoint inhibitor is the key thing. — Simlamab. — Simiplab. — I don't know. I just Am I right? — Yeah. Simiplab. I don't know if that's the pronunciation. — Yeah, I'm terrible with these. I usually just like to say Mabs. — Yeah. — So, usually any immune checkpoint inhibitor, you can remember those as your MABs. That's the way I always learned it. And so, these are really going to be the key things. So, your checkpoint inhibitors consist of anti-PD1, anti-PDL1, and anti-Cta4 inhibitors. And usually those are under the kind of broad easy way to remember as your MABs. So, epilimma, nylamab, pimberlyab, similab. So, this is definitely going to be my key go-to is my immune checkpoint inhibitor if it was metastatic. — Okay. And then I'm guessing like you said before, a really big thing with this case is that immunosuppression, you're going to have a skyrocket. — Yep. You know, high risk. Yep. Exactly. So, I think that's the key thing. Basil cell really high risk for UV exposure. Squamic cell, same thing. But even combining UV exposure and immunosuppression catapults that okay so I think those are the big things that separate when it comes to like risk factors essentially and then the way that they're described key pearly papule roll borders to angactasia basil cell scaly ariththmmitus papule that can bleed squam cell that's usually the key differences there — all right well we have one more case left sack we have case three you can probably guess what we're going to be talking about — we have miss te a 48-year-old woman comes in with a changing mole on her back. It used to be a flat and light brown mole, but now she states that it's darker, irregular. It's now raised. — Ah, shoot. — No pain, but she noticed occasional bleeding. — Her father died of melanoma at 55. — Yeah. I mean, that's that that's pretty scary. So, I do the same thing. I mean, I just went to the dermatologist recently. — Yeah. — You know, you get I was like I think I was telling I was like, "Oh, this is the sob that's going to get me. I got to I got — You know, it's it's not hard to do, right? like you go to the dermatologist and say, "All right, strip down and I want you to — check me from head to toe every nook and cranny. " — Exactly. Don't you miss a spot. You know, you can't go wrong. — Yeah. So, I think that that's why whenever you evaluate any of these like irregular pigmentations or moles, if you

### Segment 4 (15:00 - 20:00) [15:00]

will, it's really establishing a criteria or like at least a pattern. And I think the common one that most people know is the ABCDE criteria. So, you want to look at it and see if it's like asymmetric. A lot of the times when you look at moles, they're pretty much like circular. or they're relatively symmetric. You know, in this case, if it's asymmetric appearing, that's kind of a little bit concerning. Um, the next thing is like border regularity. So, does it when you look at it, is it a perfect circle or does it kind of have like, you know, some edges that are a little bit jaggedy and kind of loopy out? And then on this side, it's kind of nice and circular. That's key thing. Color. Is it dark? But more particularly, does it have variations in dark pigmentation? So, is it brown, light brown, purple, black, anything like that? That's a key thing. Um, and then diameter. Is it pretty? I think they say the pencil eraser. — That's what I learned. Yeah. — Yeah. So, greater than six millimeters is about the size or the size of a pencil eraser is one. But I think the most important thing is keeping an eye on the mole or the irregular appearing like skin lesion and saying has it changed in size? So, it started looking like this or not just in size, but did it become asymmetric? Did it become a little bit more irregular with its borders? Did the color change? Did the diameter change? So evolution is really the key thing. It used to be people saying elevating elevation like if it was elevated. It's more evolution. Has it changed rapidly or changed at all? So that's the key thing here. So she noticed that there was a changing mole on her back. Used to be flat and light brown. Now it's darker, irregular. It's raised. Those are pretty much like concerning for me. And that's right away that's a red flag and I need to go ahead and say we should biopsy this and get a pretty good wide excisional biopsy. — So that's the next step. You would do an excisional biopsy. — Yeah. — And well, what's next then? — When I get the wide excisional biopsy, you want to make sure that you get a pretty good one. And then when you do that, you want to look at the So you want to get what's called the Brelo depth. So essentially, you want to see how far does this thing go down. Yeah. And um so usually melanoma is the in is cancer of the melanocytes. So cancer of the stratum spinosum cells that's squamic cell basil cell cancer cells the cancer of those cells that's basil cell and then the melanocytes is going to be melanoma if you get cancer of that and it starts invading down into the dermis and deep deep you want to say how deep did it go. So you look at the breo depth — uh anything I think greater than 0. 8 to 1 millimeter in depth is an indication enough to say there is a concern that it could have spread to a sentininal lymph node. You need to biopsy that one. So that's what I would say is let's get the wide external biopsy, check the breast low depth first. How far is it invaded? If it's invaded pretty far, check the sentininal lymph nodes and then also evaluate them. Do they have any other concerning features that make you think that it could have spread anywhere else? Do they have any cough, hemoptsis, dysnia? Do they have any plural eusions on chest X-ray or do they on exam? Do they have any neurological changes? So headaches, altered mental status, focal neuro deficits, new onset seizures, um bone pain, fractures, hypercalcemia, alkos levels. These are all things that I'd kind of be assessing to see if I need to do thorough scans to scan their chest, scan their abdomen, scan their pelvis, scan their head to see if it's metastasized. Because one side to say, okay, it's gone to a sentininal lymph node potentially, or I'm going to do a sentininal lymph node biopsy. The other question is, has it spread anywhere else? Yeah. And that's going to guide my decisions on how I treat the patient as well. So that's kind of how I would go through this step by step. — And then when you're doing a biopsy, is it like a punch biopsy? Are you like shaving it or — never? No. Only shave and punch is for basil cell and squamus. — Okay. So for melanoma, no — no wide like u excisional biopsy. So you want to really get a good like pretty like wide excision. You want to go get good margin so that you can really make sure that you're not missing any kind of skin cancer. — Be very careful. — Exactly. Yeah. — Okay. — Yep. — All right. So my next question then is we have a good idea and let's say we know it's localized. How do we treat it and what happens if it has spread? How do we treat it? — Yeah. So let's say like you said like we checked it. Brezlo depth was good. Didn't need to do a sentinel lymph node or we did the sentinel lymph node. Nothing there. Pretty localized in that scenario. You can just again cut it out. Okay. So wide local excision establish really good margins you're done you don't need to do anything else you do the sentinel lymph node biopsy if that brezlo depth was you know again greater than 08 to 1 millimeter we could do that there — okay — let's say that you did that and it showed that there were some lymph nodes that were involved or let's say worst case scenario ah shoot it spread we he had you know some spread to the lungs he had brain because he had some neurosy symptoms you get a brain MRI um he has some spread to the bones you know things like that if that is the case um then unfortunately in those scenarios you have to change up your therapy and it's no longer excisional or surgical now it's more like amunotherapy so first line for like metastatic or really advanced melanoma

### Segment 5 (20:00 - 25:00) [20:00]

is we do you guessed it the MABs right and so it's the MABs it's going to be your immune checkpoint inhibitors now out of those we do the antiPD1 just like you would in squam cell but we also combine that with an anti-Ctla4 inhibitor all right so usually I have to because I don't remember all of these guys. I apologize. But your antiPD1 is your pimberlymab or nivelamab and then your anti-CTA4 is your epilimmaab. And again, I think there's a key thing is that you're going to be combining two of those types of agents. That's the key thing that you're going to be combining here. And that's going to be for a patient who has metastatic melanoma. There's one little thing. So, let's say that you had the patient, they have melanoma, it's metastatic, it's confirmed. Another thing that you should be doing is checking what's called a particular mutation. So the BRPH V600E mutation. Um the reason why is if you check this and it comes back that they have this, you can actually give a targeted therapy for it. So it alters the raph pathway. And so I remember that I actually do remember this one by vimu rafafhanib because it alters the raph pathway. So if you think about the vimu rafanib, it alters the raph pathway. Yeah. Or it's involving the br. So br v600. The Raf is in Braph and Rafism vimarafhanib. That's the only way I remember. Yeah. It's remember that one. But vimarafhanib is one that I would use. If they have the bra v600 mutation, you could use that one as an alternative. But otherwise, surgery for again usually localized. If you get do the sentininal lymph node biopsy and it shows that depth, you know, because the depth is beyond what it's supposed to be, you have proven there or you find it's metastasized to other areas. amunotherapy, usually dual antiPD1 and an anti-CTA4 antibbody. And then lastly, if they have that BRF uh V600D mutation, remember vimu rafafhanib and you can add that one on. Sometimes you can combine that with like a mech inhibitor, but I'm I don't think you need to know that. Just I like to remember that little thing with the vimmeranib and the braph mutation. But otherwise, that is what I would say that you use to treat um melanoma. — You briefly mentioned it before, but where does melanoma commonly spread? uh lung, liver, brain, bone. So, those are the primary ones that I would want you guys to remember. Lung is definitely a big one. Brain is a I've actually seen that one. That one's super sad because again, you don't oftent times what ends up happening with this one is that you find a patient I had a couple patients come into the, you know, the neuro ICU and they had, you know, nuanced neurological symptoms. You scan their brain and then you find that they have like these weird bleeds in the brain because it's a metastatic melanoma bleeds. It's pretty nasty one. Um, and so we ended up scanning them. We get a brain MRI. They had just tons of little like, you know, sites of metastasis and then we had to figure out where it was. So we did a CT chest app and pelvis. We kind of scanned them and then we ended up finding um, nothing. And then what we ended up doing is we ended up getting a biopsy and it came back that it was from — So it was from melanoma. Did you find the original source in the skin? — That I don't know. And at that point they had kind of like come out of our care. But yeah, I think if you would have done like a thorough evaluation, you may have found — You could have found something. Oh my god. — So I think that's the key thing is that you know it can spread and then one of the concerning areas is the brain but same thing lung is a really scary one. Liver I'd say that's probably like the you know less common. Bone is another one it can do as well. So yeah those are some concerns and I think that's why you know if you have any symptoms or even if they're diagnosed with melanoma for the most part you should kind of do a pan scan to make sure that they haven't actually metastasized. The brain MRI I would really do that one only if they had like some potential neurological symptoms. But otherwise, if they diagnose a melanoma, I don't think it's a bad thing to make sure that hasn't spread to things like the chest, spread to the bone, spread to the liver. Um, so that's what I would do is I'd check that and I would do the brain MRI if they have some neurological symptoms. But yeah, melanoma is a pretty nasty one. It's a pretty scary one and you want to make sure that you're staying on top of those moles. You know what I mean? — Yeah. — Molly moly mole. — Got to watch them moles. Now, a quick wrap up here. Zach, if we can go over some high yield exam pearls, those buzzword terms. Yeah. things that you should you got to pick up immediately with each one. — Yeah, I think just pearly papules, roll borders, tangiactasia, central ulcer, bleeds easily, basil cell, uh scaly, ryiththemmitus type of like, you know, nodules. Uh I think I would associate that with squam cell. And then for the melanoma, I would associate that with like asymmetry of a kind of an abnormal appearing like you know pigmented lesion, border irregularity, color variation, diameter greater than a pencil eraser 6 millm and then it's evolving. It's changing. Um with basilc cell it doesn't usually metastasize. It's locally destructive especially if it's on the face. It can cause like bone and you know soft tissue destruction especially near the eyes. Um and then for squamic cell it can metastasize. is usually the nearby lymph nodes that I'd be concerned about. And the melanoma is the most metastatic. Lung, liver, brains, and bone. Um, so that's the ones I'd be scared about there. And just keep an eye on that one.

### Segment 6 (25:00 - 26:00) [25:00]

Biopsying these, squaml, basilc cell, you can do a shave, punch. Melanoma has to be a wide excisional biopsy. Treatment for these, again, if it's kind of like superficial, it's localized, it's not like super kind of aggressive, you can just do like surgical excision for all of them. Moe's microraphic surgery more for like that cosmetic appearance, especially if it's on the face. Uh, and then once it starts getting metastatic for any of them, you're kind of going to target a therapy. For basilc cell, you're using the hedgehog pathway inhibitor. Um, for basil cell, you're using more of a amunotherapy. — Squamic cell, — I'm sorry, squaml. Yeah, I apologize. You're using more of a uh particularly an immune checkpoint inhibitor like an antiPD1, — right? Uh and then for metastatic melanoma, you're doing kind of a dual uh amunotherapy or immune checkpoint inhibitor. So you're doing the antiPD1 anti-CTALA4. And if they have that BRP V600E mutation, you can add on the VIMU rafanib um as the alternative therapy. But yeah, I think that's kind of the biggest thing to think about with with skin cancer. — All right. Well, hey, that's skin cancer in less than a half hour, — I would say. Pretty darn well done. — I like it. — And don't forget, of course, of you know, talking about skin cancer, you need to visually see these things. Yeah, — we got you. — It's uh up and coming. — Absolutely. Well, my friends, I really hope that you like this podcast. I hope you learned a lot. I hope that you had an opportunity that, you know, maybe if you're again, I don't know, hanging out with your family, maybe you're just trying to chill out, maybe you're on the treadmill, you're working out, you're doing dishes, you're outside cutting the grass, whatever you're doing, and you're trying to just stay busy and active. I hope that this podcast helped you in that time frame. And uh man, I just love you guys. Thank you guys so much for supporting us. And uh I wish you guys the absolute best. Love you. Thank you. And as always, until next time.