Transcription
Hi guys. How's it going? Hello. Hello. Hey Morgan. Hi Taylor. Hi Brianna. Hi. All right. Hello Valyria. All right guys, so we are at it. We are at Hello Dr. Russy. We You're ready? We are back for another season of 21 at 21. Um, we are getting ready for the applied exam this year. So I'm very excited to welcome you guys back. We wasted no time from the AAD to get right back in it. So hopefully you guys are recovered um that you've put away all your products. Um, and let's get to it.
So for those of you new to this channel, this is our new Bors University channel where we can go live and um, as usual, we are doing 21 questions at the um Hello Benji at the 21 hour and um tonight we are going to cover Squam. So I cover the surgical part. You're going to meet other faculty this season. We're going to do other areas. So, I find that doing squams early on, um, it's a high yield topic and it's one that can be a little bit confusing. So, let's get into it.
All right. So, question number one. A 74-year-old man with a history of kidney transplant presents with a 1.8 cm hyperkeratotic tender plaque on the right temple. The biopsy shows well-differentiated squamous cell carcinoma extending to the base. So when we think of that case scenario, what is the most important factor that I just told you that you need to think about when you answer a stem question like that? So 74-year-old man with a history of kidney transplant presents with a 1.8 cm hyperkeratotic tender plaque on the right temple. Well-differentiated squamous cell is the biopsy. Well-differentiated invasive squam. So what is the most important part of that? Gabrianna is saying immunosuppressed, immunosuppressed, death to bone, kidney transplant. Okay.
So remember that whenever we think about risk stratification for squam, right, we want to think about what makes the tumor high risk. So yes, immunosuppression is a big deal, but what are what are our high-risk factors? So one, immunosuppression, right? Solid organ transplant, remember it goes heart is number one, right? Kidney is high up there, but heart is our top one um, site on the head and the neck, especially because it's on the temple, it's another high risk. Right? The size is 1.8 cm. We typically think if it's greater than two, that's more of a problem. We want to know about perineural invasion. We don't know anything about that yet. It just said, uh, well-differentiated invasive squam. And then we want to know depth and then symptoms like pain or numbness. So we don't know anything like that yet. So whenever they're asking you these questions, right, you want to think of hello Vartan. Um, you want to think about risk stratification first. So the key things you want to find out are that Brigam and Women's classification, right? Do they have 0, 1, 2, or 3? 0, 1, 2, or 3 um, symptoms. So you want to know depth, right? So if it's bony invasion on Brigam and Women's, now you guys, we've done this on core already. If it's to bone, let's say, what what um, what level are we for Brigam and Women's? What do you guys think? Great. Yes. Good job, Parth. So, you're already at a three. Good job, Shino. So, the the clues, you're going to get case-based questions. So, they're going to tell you a size. They're going to tell you the type of um, tumor that it is, risk, well, if it's well-differentiated or not. Okay. And they're going to um, tell you exactly. And they're going to want to know what um, is it to bone, is it to fat, right? Those are the things. Good job, you guys. Hello, Skin MD. Hello, Mara Gabby Rodriguez. Okay.
So, I'm going to ask you another question. A patient with squam comes in and you decide to examine their lymph nodes. Is this a clinically relevant part of the exam? Patient comes in with a squamous cell. Is it a clinically relevant part of the exam? Yes. Why? So remember this guys, it's clinically relevant because as opposed to Merkel cell, right? Manual palpation of a of a suspicious lymph node has been shown to have a high specificity in excluding underlying metastatic Yes. disease. Correct, Dr. Fia. So remember a lot of times they're going to ask you the question of like, what to do next, and our our instincts be like, oh, order a CT, order a this, order that. Remember, palpate lymph nodes for squamous cells because of that high specificity. So if you can palpate a node, there's a high specificity that it has metastasized, there's underlying metastatic disease. Okay, very good. Um, okay.
Now, a lot of times I find that people are getting confused between NCCN and Brigam and Women's. So, let me just explain that to you in a second. So, the reason we have to differentiate between NCCN and AJCC8 and Brigam and Women's. Why? Okay. So, the first thing I want you guys to make sure you understand is that the goal of NCCN is to help with tumor stratification. Okay. So NCCN or clinically identifiable features, great. But prognostic, we want to know with Brigam and Women's or AJCC8. Why? So why do you need two things? I don't know why people do these things, but I do know that when you're thinking about squams, the reason they test you on Brigam and Women's is because they want you to understand the idea of risk stratification or prognostic staging. So it turns out that when you do the two, right, if you compare Brigam and Women's versus AJCC8, Brigam and Women's tends to outperform AJCC8 in terms of prognostic risk stratification. So why do we care about that? Compared to AJCC8, Brigam and Women's demonstrates higher specificity, okay, 93% and positive predictive value 30% for identifying cases at risk for metastasis or death. Okay, so that is why we have the two. Yes, we have AJCC8. They may ask you about that. They don't really ask about NCCN, but they will for sure ask you about Brigam and Women's. Now, you're going to be like, I can't remember all of that. Typically, it's a two-part question. So, if you can at least know the Brigam and Women's staging, which we've gone over for core, and I know you guys know, so I'm not going to belabor the point, you'll be able to get the rest of the stem. So, if you just know that part, you'll be able to eliminate two or three of the answers. Okay? So let's just remember that Brigam and Women's has higher specificity and positive predictive value compared to um AJCC8 in terms of predicting cases at risk for metastasis or death. Okay.
So, we just talked about hello Dr. Connector that if you have a patient who comes in with a squam and they show you that it's to bone, or let's say they show you a picture on the scalp and it looks like it's to bone, you're automatically at T what? T3. But yes, we can review Brigam and Women's real quick. I'll do that in one second. So, you're at T3 if you're at bone, right? Now, same scenario. What are you for AJCC8? So it's to bone, which means you're T3 for Brigam and Women's. What are you for for AJCC8? If you guys don't know, remember hearts for help. Yes, you are T4B. Good job, Parth. Good job, Leah. Yes, Isa. Yes, Taylor. So, T4B. Good job, Shino. Exactly. So, a T3 for Brigam and Women's is different than a T4B because that's AJCC.
So, now let's go over the risk factors for Brigam and Women's. There are four of them. Go ahead. I'm waiting. Hit me. Four charact four risk factors for Brigam and Women's. Go ahead. I'm waiting. You can do one at a time. You can do a bunch. You tell me. Poorly differentiated histology. That's one. Tumor greater than or equal to two. So, poorly differentiated histology. Tumor greater than or equal to two. Perineural invasion greater than or equal to 0.1 millimeters in caliber. Okay. So size greater than two, perineural invasion greater in a vessel, in a nerve greater than 0.1 millimeters in caliber. Poorly differentiated histology, tumor invasion beyond subcutaneous fat. Those are the four things. That's it. Okay. So poorly differentiated, big, invading deep, it's got a nerve, not hard to remember, right? These all sound bad. So the things like transplant and immunosuppression and BLA, those don't matter for for Brigam and Women's, okay? It's straight tumor pathology.
Okay. So now, if you have bony invasion, remember we said it's Brigam and Women's T3. What is Brigam and Women's T0? Zero. What is T0 for Brigam and Women's? What's the qualification? What is a qualification? Good. It does not exist. Remember, we are still giving you test questions that are tricks. Good. So if you have something somehow that says Brigam and Women's T0, it's a trick. It does not exist. Okay? No, there is no such thing as T0. It starts at T1. Okay? There is no such thing as T as T0. So T1 is zero high-risk factors. Okay? So just remember that no risk factors, Brigam and Women's stage zero. Okay? T2, you have two options, one high-risk factor. Okay? And then T2A or T2B is two to three. Okay? So there's it starts at one and you have 2A or 2B, and I always remember A is the first letter of the alphabet, which means they only have one high-risk factor, and T2B is they have two to three. All right. Then your T2B and then your next is T3, three, which means you have four risk factors or you have bony invasion. Bony invasion automatically T3. So there is no T4. So it's T1, T2A, T2B, and T3. That's it. Okay.
Now let's talk about AJCC8. Now again, the reason I wanted to cover this now is because I do think it's a little bit like and it takes a second to remember it and it takes a second to understand it. So I want you guys to understand it because you will get these questions on your applied exam. The other thing is when you're when you guys are using Boards University, you know, we have so many lectures that are uploaded at this point that a lot of times people are like, "Oh, I'm just going to like look at it the next day and I'm not going to come on live." I will tell you people who do well on the exam join live because we're all talking about it and there's nuances that happen in the live that you don't always get the sense of when you're when you're listening to it on replay. And you also see everyone's answers coming through. So again, it like gets you going in the sort of mode of of learning. That's just my personal opinion and I've seen it play out for the last five years. People who do the lives always do better. Okay, what you guys are going to do because you're here now. So in AJCC8, T1 and T2 are Yeah, active recall is super important. T1 and T2 are based solely on what? So now we've learned Brigam and Women's T1, T2A, T2B, T3. Now we're going to go to AJCC8. T1 and T2 are what? Size. That's right, Valyria. Exactly. It's only on size. So if you're less than 2 cm, you're a T1. If you're less, if you're greater than 2 cm, but less than 4 cm, okay, you're T2. Great. Easy. Now T3 is when the tumor is greater than 4 cm or there's minor bone invasion or there's perineural invasion or deep invasion. So that means they're T3 on AJCC8 and T4A is tumor with gross cortical bone and or marrow invasion and T4B is tumor with skull bone invasion or skull base foramen involvement. So T4B is a mess. T4A is with gross cortical bone and or marrow invasion. Okay, which is why the other one was T3 or T4A for AJCC. And then T3 is that it's big or it's got minor bone invasion or PNI or deep invasion. Okay. So remember when you see any of these pictures, you must make sure you're doing a lymph node exam for the reason we talked about in the beginning. Okay.
So the other thing I want you guys to know that although most of the poor outcomes happen with Brigam and Women's T2B and T3, remember T2B is two or three of those four risk factors and then T3 is greater than 4 cm of a tumor. 30% of nodal mets occur in Brigam and Women's T2A. So T2A, remember we said has to have how many? So T2A only needs to have one high-risk factor. So size, uh, poorly differentiated, um, perineural involvement, right? Or bone. So T2A, okay, you can have um, 30% of those cases have nodal mets. So it's only one risk factor. Exactly. So again, Brigam and Women's as compared to AJCC8 is meant for prognostic indication for your patients. Okay. So when you go into that T2A tumor, I also want you guys to think about minor risk factors, which I don't think they're going to ask you so much, but they may include this in STEM questions, like in the stem of the test question, and it might throw you off. So let's just review minor risk factors, but remember when we're thinking about Brigam and Women's, we're thinking of our four major things: tumor diameter, poorly differentiated histology, perineural invasion, and tumor invasion beyond the subcutaneous fat. Okay. Okay.
So um, so what are the minor criteria? So invasion depth in subq fat, so not beyond but in it. um, moderate differentiation, small caliber perineural invasion or lymphovascular invasion. Um, and so the reason we know those minor criteria is because if you're T2A, so you have one high-risk factor, okay? And you have more than one minor criteria, it turns out you're three times more likely to lead to a poor outcome compared with those that do not meet those criteria. Okay? So it's helping you figure out how aggressive you need to be afterwards. So remember, it's not about immunosuppression or any of those things. The minor criteria are invasion depth in the subq fat, moderate differentiation, small caliber PNI, or lymphovascular invasion. Okay. Okay.
Now, let's do a few questions. You guys are doing awesome. We've done 20 minutes. We're going to try to do eight minutes more. Okay, stay with me. You're doing great. Okay, a patient comes in with a with a suspected squam on the posterior scalp. You palpate the area and the mass is fixed. What is your next step? Is it lymph node exam, CT scan, PET CT, or MRI? The lesion is the mass is fixed. You think it's a squam and the mass is fixed. Okay. So remember we talked, you are correct based on what we talked about that you always want to check for lymph nodes. However, in this case, remember the mass is fixed. So what you're trying to do is what you're trying to figure out what your high-risk criteria are. So remember my first question when I gave you that stem that I said, what are the most important things here? So yes, you're going to palpate for lymph nodes, but you need to know right away, are any of these things high-risk factors? When we think about Brigam and Women's, is a lymph node positivity in that four criteria? That's why it's tricky. That's why I wanted to take you guys through this kind of thought process in your head. So yes, you want to make sure the patient doesn't have lymph nodes, but what you're trying to figure out for purposes of this exam is does this patient meet any of the high-risk criteria? Because automatically if you think it's a squam and it feels like it's fixed, right, your job is to look for any of the high-risk criteria. Okay, a CT sounds great. However, remember that an MRI, okay, is going to delineate bone erosion and marrow involvement more than a CT scan. I'm sorry. Don't be mad. The answer is MRI and nobody got it, but now you will. So, if you have a patient who comes in, they have a fixed mass that you suspect to be a squam on the head and neck, remember your job is to make sure for purposes of staging that you're thinking about what are the high-risk factors here and your key thing with a fixed mass is is this invading bone. So yeah, you're going to do your lymph node exam. Remember, presence or absence of lymph nodes though clinically relevant is not included in AJCC or Brigam and Women's. So you're going to make sure that you are um palpating the area, mass is fixed. Yes, you're going to do a lymph node exam, but you more importantly do an MRI, which is going to delineate bone erosion and marrow involvement. Okay, how are we feeling? I love you. You're doing great. Okay, we're doing it together, right? This is why because you see everybody's picking CT scan and I get it. But in this case, we're doing MRI. Okay, next question.
Patient comes in with a squam on the right cheek that is 3 cm. I know it's tricky, but that's why I want to go through this with you guys because squam feels like, "Oh yeah, I know about squamous cells." They're going to try to trick you. So it comes in with a squam on the right cheek that's 3 cm, poorly differentiated, and upon MO, you note a PNI of 0.1 mm. What is your next step? Are you going to do a lymph node exam, CT scan, PET CT, or MRI? So 3 cm, poorly differentiated, and a PNI of 0.1 mm. So what is your next step? Lymph node exam, CT scan, PET CT, or MRI. Okay. So, in this case, we're going to get a CT scan. Why? Okay. So we already know that this patient has Brigam and Women's T2B, right? I just told you it's poorly differentiated, size, and perineural involvement. Right? So two to three is T2B. So already we know we've got problems. So the reason you want to get a CT scan is because it's going to tell you the Brigam and Women's T2B or T3. Both of those should get a CT scan with contrast for nodal staging. Remember I said that in T2B or T3, percent of patients have a risk for metastasis, even sorry, in T2A. So now in T2B and T3, it's even higher. So you're going to get a CT scan with contrast for nodal staging. PET CT, you're really worried about distant metastasis. Okay. So CT scan with contrast. Don't worry guys, this is like day one of learning for the applied exam. We're in it together. You guys are doing awesome. Okay. All right. Next question. Yes, exactly. Van T2B is two to three. Get a CT. That is exactly right. Okay. That's the song I want you guys to remember in your head. Okay. All right. Um, okay. What? Yeah. Yeah, you would do a lymph node exam, too. I mean, they're going to have you at that point, right? Like, you're going to do a lymph node exam, but if the lymph node exam is clear, you're not going to be like, "Okay, you're good." You're still going to order a CT scan. So, you just want to make sure that um, you know, you're checking all of these things. A lymph node exam is going to be like at the first time that you do the biopsy, okay? Unless the mass is fixed, in which case you need to get an MRI for staging. Okay? Um, next question.
Why would you use 5-fluorouracil in combination with calcitriol for treatment of an actinic keratosis? Why do we use calcitriol in combination with 5-FU? So it's two things, remember, you get a synergistic effect, right? You get a synergistic effect through the induction of CD4 positive T cells, right? So you get a marked reduction in actinic damage compared with placebo and you get patient compliance. So it's 4 days for head and neck versus 10 days for trunk and extremities. Right? So you get synergistic effect with the induction of CD4 positive T cells. Okay, good. Um, what margin do you take for a squamous cell? Patient is a squamous cell on the body. What margin do you take? Yep. We do 4 mm times 4 days on the head and neck versus 10 days on the trunk and extremities. Bernie man, what's up? Yeah. So, you're going to do 4 millimeters, okay? Unless it's high risk and you're not doing MO, in which case you're going to do 6 millimeters and you're going to close it primarily, okay? Until clear margins are confirmed. So, you get 95% clearance of low-risk tumors at that point. So 4 mm if it's a regular squam, 6 mm if it's a high-risk area and you're not doing MO, and remember we're not doing flaps at that point. You're closing primarily and waiting for path. Okay, you guys are doing great. You guys are doing great. We got just a few more minutes and a few more questions. Okay, next question.
You do MO on a squamous cell and achieve clear margins, but the patient has large nerve involvement. What is the next step? Is it A adjuvant radiation therapy, B multidisciplinary conference, the role of uh, or okay, so multidisciplinary conference, C you do nothing, or D you do nodal basin imaging only. So patient, you do MO on a squam, you get clear margins, but the patient has large nerve involvement. What is the next step? Is it adjuvant radiation therapy? Is it multidisciplinary conference? Okay. Yep. So the new paper by Lauringer et al. for 5-FU calcitriol combination treatment. Thank you, Vartan. Yeah. So you're going to do multidisciplinary conference in this case, and the reason is that role of adjuvant radiation therapy is endorsed by the NCCN. However, there's no consensus guidelines. So probably um, you're going to eventually end up doing radiation, but you're going to do multidisciplinary conference first if it's a question on your exam. Okay, great job. Um, okay.
You have a patient who has a squamous cell. Should you do a sentinel lymph node biopsy if they're high risk? You have a patient who has a a squam. Do you do a sentinel lymph node biopsy? Correct. The answer is no. And the reason is because systematic review of available literature has shown that there's that relapse-free survival and overall survival were not affected by sentinel lymph nodes. You don't do a sentinel node. Okay. It turns out it makes no difference. Okay. Then random general knowledge question. What is the chance of a second non-melanoma skin cancer after diagnosis of a squam? This may come up if it's like an ethics question or patient counseling. They may test you on something kind of random like that. So, what is the chance of a second non-melanoma skin cancer after diagnosis of a squam? What do you guys think? Excuse me. Excuse me. Yes. 40% five-year probability. Yep. 40% five-year probability. So that's important to just know that little factor, 40%. Okay.
Now you know the chance of a second one. What is the chance of a third non-melanoma skin cancer after diagnosis of two squamous cells? So the chance of having another non-melanoma skin cancer after a diagnosis of a squam is 40% five-year probability. What about a third non-melanoma skin cancer after having two squamous cells? Turns out it's 82% five-year probability. So it's high. So if a person's had two squams, their chance of a of a third non-melanoma skin cancer is 82% five-year probability. Okay? And the majority of those happen in the first two years, which is why we do what? Which is why we do skin checks every six months for the first two years at least. Right?
Guys, you did it. I am happy that I was able to stump some of you guys because some of you have been with me for a couple years now, and so I'm glad I can always teach you new things. All right. All right, guys. You were amazing tonight. We're a little over. We did 33 minutes instead of 21, but a great first start for the season. We are ready to rock this applied exam. We've got so much time ahead of us. I mean, we've got like the next three months, three and a half months together. Um, check the schedule. We are on every night pretty much Monday through Friday and on Sundays, it's like a full-blown schedule. Um, so we're going to get you through this and so I don't want you guys to panic. Um, and we've got such amazing faculty that I think you're going to be really happy. There's so many different voices and perspectives that you're going to get. So many new grads that were like excited about this community and want to give back. So I think you'll see some familiar faces. For those of you I saw at the AAD, hello. Um, you know, I was so happy to see you guys. Thank you for hugging me and sorry that I was like a crazy person, but um, it's going to be great and yeah, let's be excited. We'll be a little bit nervous, but we're all going to learn together and that's the whole point, right? We are swimming with the fish as a group and you're going to be amazing. So, those are the key things to know about um squams and that's everything you need to know. Brigam and Women's, the whole thing. So, you can come back to this later on and I know, look, it's part, it's Danny. It's all good. Vartan. Excellent. Excellent. All right, you guys. Lots of love to you. Come back tomorrow night. This is our handle. And tell your friends. Come on live because trust me, you're going to do better. Yeah. Just stick with it. Don't be nervous. And don't go freaking out learning all the different things. Don't be random. Be strategic in your studying. That is key. All right, you guys. Be well.