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Old 12-07-2011
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Skin Proliferation of atypical well differentiated keratinocytes

A 62-year-old man comes to the clinic concerned that he might have skin cancer. He is worried about two “bumps” on the back of his neck. The bumps have been present for at least 6 months and may be growing slowly, though he is not certain. He points out that he is a commercial fisherman and is often in the sun, having had countless sunburns over the years. Aside from his anxiety over the bumps on his neck, he reports feeling healthy. He denies any other lesions, and a review of symptoms is unremarkable. Physical examination reveals two firm, well marginated, reddish, 1.5-cm papules that have a rough feel and some surrounding erythema. A biopsy is performed that reveals a clonal proliferation of atypical but well differentiated keratinocytes. This patient should be told which of the following?

A. A small number of these lesions develop into squamous cell skin cancer
B. No further treatment is necessary, though suntan lotion should be used regularly
C. Prolonged sun exposure on this type of skin lesion increases the risk for melanoma
D. The biopsy and physical findings are consistent with the most common skin cancer
E. This lesion likely represents skin cancer; an operation is necessary immediately
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Old 12-07-2011
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the ans is D
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Old 12-07-2011
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A small number of these lesions develop into squamous cell skin cancer
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Old 12-07-2011
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A. A small number of these lesions develop into squamous cell skin cancer
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Old 12-08-2011
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A. A small number of these lesions develop into squamous cell skin cancer
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Old 12-08-2011
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D. The biopsy and physical findings are consistent with the most common skin cancer
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Old 12-08-2011
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The correct answer is A. This patient has actinic keratoses, which are proliferations of atypical keratinocytes in sun-exposed areas. These lesions are considered premalignant, and approximately 1 in 1000 progresses to squamous cell carcinoma, not malignant melanoma (choice C). It is advised that the lesions be removed, commonly with cryosurgery, topical 5-FU, or electrocautery. Further treatment is definitely beneficial, as it reduces the risk for malignant transformation, and should be advised, in addition to using suntan lotion (choice B).
The most common form of skin cancer is basal cell carcinoma (BCC). Superficial BCC can mimic the presentation of an actinic keratosis, but more commonly is described as a pale, “pearly” papule with surrounding telangiectasia and central depression or ulceration. Crusting and superficial bleeding are common. Further, the findings on biopsy show basal cell layer abnormalities and peripheral palisading, not just abnormal keratinocytes. It would be incorrect to suggest that this patient’s biopsy and physical findings are consistent with the most common skin cancer (choice D).
This is a premalignant lesion with some cellular atypia. It does not represent skin cancer and, although it should be removed, does not necessitate an immediate operation (choice E).
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