HUBIO 567: Small Group Skin Cancer 2015 Facilitator’s guide

Learning Objectives

By the end of the session, students will be able to:

1.Correctly identify common presentations of BCC, SCC, and melanoma

2.List the risk factors for melanoma and non-melanoma skin cancer

3.List the common genetic mutations in melanoma and non-melanoma skin cancer

4.Communicate the prognosis of a skin cancer based upon a pathology report

5.Rank the relative incidence and mortality of BCC, SCC, and melanoma

Student Advance Preparation:

Required prior to small group:

  • Syllabus chapter: Skin Cancer
  • Vodcast: Skin Cancer

Running the session:

  • This session is intended for a 50 minute small group of about 20 students
  • Facilitators should ideally read the syllabus chapter and view the vodcast in preparation
  • This session will include one case revolving around two separate skin lesions
  • You will need Powerpoint and a projector for the cases

Session Activity
List all session activities and time allotted for each in this table as a reference for facilitators.
Each session should include:
  1. Introduction and Overview
  2. Introduce yourselves
  3. Review session learning objectives
  4. Review session activities and structure
/ 10 minutes
  1. Case
  2. Groups will read the case and view the photos of the first lesion
  3. Students will answer each question regarding the first lesion as a group with guidance from the facilitator if needed
  4. Groups will then view the photos of the second lesion
  5. Students will answer each question regarding the second lesion as a group with guidance from the facilitator if needed
/ 30 minutes
  1. Summary and Concluding Remarks
  2. Summarize key points/take home messages
  3. Identify gaps in student knowledge or student questions for future review
  4. Bring personal clinical experiences up for discussion if relevant.
/ 10 minutes

Session Activities

  1. Introduction and Overview (10 minutes)
  • Introduce yourselves, the activity and learning objectives (slide 1 of the Powerpoint).
  • Instruct students to form small groups of 6-10, depending on the number in the room.
  • Inform students that there is one case in two parts, each with sub-questions that they should attempt to answer in small groups; after a brief time, they will be called upon at random to share their answers with the class, and the facilitator will discuss.
  • Inform students that they should be prepared to share their answers with the entire class.

2. Case(30 minutes total) Starts on the 2nd slide of the Powerpoint

Case: Dr. X

Dr. X is a 35-year old ophthalmology resident who was rubbing his shoulder and found a red bump that was bleeding.

It’s unclear how long it had been there. It was otherwise asymptomatic.

Please work in groups for the next 5 minutes and answer the following questions:

  1. How would you describe this lesion?
  2. What is your differential diagnosis?
  3. How do the three common skin cancers typically appear?
  4. What is the next step?

Detailed questions and responses below

  1. How would you describe this lesion?

The photo is deliberately imperfect to engender a differential.

Teaching point: Use of the word PAPULE.

Descriptions should include:

Primary lesion (papule) (pustule may be considered given the pinpoint white dot, but the majority of the lesion is a papule)

Secondary change (such as scale, crust etc: there is none)

Color (red, pink, or erythematous)

Size (8x5mm)

Location (L post shoulder of a light skinned male)

Arrangement/distribution (solitary)

Have students now repeat the entire description in just one line.

  1. What is your differential diagnosis?

BCC, SCC, amelanotic melanoma (melanoma with no pigment), folliculitis, acne, bug bite, others?

  1. How to the three common skin cancers typically appear?

Have the students describe how a BCC typically appears. Then advance the slide

BCC—often described as a pearly papule with rolled borders and telangiectasias. Often ulcerated in the center. Note they can have pigment but are usually not

Have the students describe how an SCC typically appears. Then advance the slide

SCC—these are usually papules with scale though they can be smooth as well. Note the SCC on the index finger in the lower right. There are smaller scaly papules on the hand as well. These are actinic keratoses that often develop into SCC with time.

Have the students describe how a melanoma typically appears. Then advance slide

Melanoma—these are usually an irregular appearing mole but can arise in large patches on the face or acral skin (palms and soles) or in nails where they present as pigmented bands. You can point out “Hutchinson’s sign” of pigment extending onto the proximal nail fold.

Teaching point: Discuss the ABCDE of melanoma:

A-Asymmetry—not symmetrical in overall appearance

B-Borders—irregular borders/ill-defined

C-Color—more than one color present in a single lesion

D-Diameter—greater than 6mm (size of a pencil eraser)

E-Evolution—evolving in color or size or new symptoms

  1. What is the next step?

Biopsy. Options might include a shave biopsy or a punch biopsy or an excisional biopsy (elliptical excision). Shave biopsy is likely adequate if melanoma is not high in the differential.

Discussing biopsy technique is beyond the scope of this course.

Biopsy returns:

FINAL DIAGNOSIS:
A) Skin, posterior shoulder, shave biopsy:
Basal cell carcinoma, nodular type, involving inked margins.

Please work in groups for the next 5 minutes and answer the following questions:

Dr. X wants to know how he got this.

What would you tell him?

We’re trying to get at risk factors, pathogenesis, and oncogenes. The bolded items below they NEED to mention or the facilitator needs to bring up.

Risk factors:

BCC is usually caused by long term sun exposure

Occurs in lighter skinned people more commonly

Occurs in areas of high sun exposure

Pathogenesis:

UV energy causes DNA mutations

These “UV-signature” mutations can be found in tumors by sequencing

Oncogenesis:

BCC commonly caused by mutations in the Hedgehog signaling pathway—Smo or Ptch genes

SCC commonly caused by mutations in the Ras or p53 genes

Melanoma associated with mutations in CDKN2A or BRAF

Dr. X asks you how common this is.

How would you interpret the following graphs to tell him about the relative incidence and mortality of BCC, SCC, and melanoma?

Advance to the next slide

Have them interpret.

BCC>SCC>melanoma for incidence but the reverse is true for mortality.

BCCs are the most common cancer but are rarely deadly

melanoma is frequently deadly but less common

Click to bring up the next question.

How would the numbers look different for chronically immunosuppressed individuals such as from organ transplant?

SCC ~65-250x more common. This is thought to be due to viral oncogenesis from HPV that is uncontrolled in chronic immunosuppresion.

•Dr. X undergoes a curative excision of his BCC.

•You ask him to follow up for a full skin exam 6 months later

•On exam, you find the following incidental lesion on his posterior thigh.

Please work in groups for the next 5 minutes and answer the following questions:

  1. How would you describe this lesion?
  2. What is your differential diagnosis?
  3. What’s the next step?

Detailed questions and responses below

  1. How would you describe this lesion?

Descriptions should include:

Primary lesion (patch or plaque acceptable) It is over 1cm and seems to be flat

Secondary change (slight scale)

Color (light brown and dark brown areas)

Size (~1.2x1.4cm)

Location (L post thigh of a light skinned male)

Arrangement/distribution (solitary)

  1. What is your differential diagnosis?

Benign nevus, atypical nevus, melanoma, seborrheickeratosis

  1. What’s the next step?

Excisional biopsy. Biopsy needs to get under the lesion as microscopic depth (aka Breslow depth) is the best predictor of prognosis in melanoma.


Biopsy returns:

FINAL DIAGNOSIS:
A) Skin, left posterior thigh, biopsy:
Malignant melanoma with the following features:
1. Approximate Breslow thickness: 1.75mm.
2. Clark's Level: IV.
3. Ulceration: Not appreciated.
4. Mitotic rate: 2/mm2.
5. Lymphocapillary invasion: Not appreciated.
6. Satellitosis: Not appreciated.
7. Perineural invasion: Not appreciated.
8. Lymphocytic infiltrate: Not appreciated.
9. Regression: Not appreciated.
10. Margins: The lateral margins are involved. The
deep margin is free in sections examined.
11. Melanoma in situ: Present.

  1. How would you tell Dr. X the diagnosis?

Discuss how to deliver bad news—Note the students have already covered this in other classes, so let them come up with the content here. Below is just a guide but is not integrated with their other courses—yet.

  1. Best done in person—don’t leave a message!
  2. Describe the results simply
  3. Wait for questions—they may not be ready for more information
  4. Be empathetic
  5. Provide more detail as they ask for it.
  6. Discuss next steps and who will contact them next
  1. What would you tell him about his prognosis?

Teaching point: Depth is the major determinant of prognosis but ulceration and mitotic rate are minor contributors.

If they want to explore prognosis more, they can use their phones/computers to look up prognosis for a melanoma Breslow depth 1-2mm without ulceration:

Breslow depth of 1-2mm, non-ulcerated is T2a.

A sentinel lymph node biopsy will likely be recommended which may provide additional staging information but T2aNxMx is Stage Ib

5-year survival is ~92%

Session Summary(10 minutes)

  • Summarize key points/take home messages from activity
  • Identify gaps or raise any issues students may have missed that would further knowledge of content addressed
  • Facilitators can bring personal clinical experiences or related stories into discussion if relevant