Skin TumorsBy

Dr. Alaa A. NaifApril 19, 2015

Malignant Skin Tumors

Skin cancer is divided into: Non-melanoma skin cancer which is in turn subdivided into:

Basal cell carcinoma(BCC)Squamous cell carcinoma(SCC)

Malignant melanoma

Basal cell carcinomaThe most common skin cancer in humanBCC occurs most frequently on the head and neckMortality from BCC is quite rare

BCC types

Nodular BCC: the most common type, translucent papule or nodule with telangiectasia , sometimes with a central depression or ulcer surrounded by a rolled edgeSuperficial BCCMorpheaform BCCCystic BCC

Palisading of cells at periphery

Retraction artefact(space between the stoma and

cells)Mucin deposition

Squamous cell carcinomaThe majority of SCC occurring on the head, neck and upper extremities, present as erythematous scaly papule or nodule While melanoma among whites is responsible for 90% of skin cancer deaths before 50 years of age, in adults over 85 years of age, the majority of skin cancer deaths are attributable to SCC.

Risk factors of BCC and SCCImmunological Genetic Environmental

Organ transplantation, HIV infection and immunosuppressive drugs: due to HPV infection and immunosuppression

Xeroderma pigmentosum ( DNA repair defect) cause multiple SCC

Sun exposure

Gorlin syndrome cause multiple BCC

Ionizing radiation

Chemical exposure : tar, polycyclic hydrocarbons, nitrogen mustard and arsenic

HPV infection cause SCC

Other risk factor: thermal burns and chronic ulcers , scars (Marjolin's ulcer)

Treatment

Surgical excisionElectrodesiccation and curettageMohs Surgery: has the highest cure rate, used for high risk tumor and when tissue preservation is necessary e.g. digits, genitalia Medical therapy : imiquimod, 5-fluorouracil ,

Radiotherapy: elderly patient unfit for surgeryCryotherapy(by freezing)Photodynamic therapy( light plus photosensitizer)

BCC vs SCC

SCC BCCHas a precancerous precursor(actinic keratosis)

Doesn’t have a precancerous precursor

Related to chronic cummulative sun exposure

Related to intermittent sun exposure

Can metastasize to lymph nodes and to internal organs and cause death

Doesnt metastasize but could be invasive

HPV can cause SCC HPV cant cause BCC

More association with scar and chronic ulcer

Less association with scar and chronic ulcer

Malignant Melanoma(MM)

Is a malignant tumor arising from melanocytes. Its incidence and overall mortality rates have been rising in recent decades. Every hour , an American dies of melanomaDeath from melanoma occurs at a younger age than for other solid tumorsMelanoma incidence in Australia is the highest worldwide

Melanoma is immunogenic tumor given these facts:

( 1 )incomplete or complete regression of melanoma ,

(2)occurrence of vitiligo-like depigmentation and halo nevi ,

(3)a higher rate of melanoma in immunosuppressed patients

Types of melanomaSuperficial spreading : the most common in fair-skinned persons, on leg of female and trunk of maleNodular melanomaLentigo maligna melanomaAcral lentignious mel:occur on palm, sole and nail appratus, commonly occur in black and AsiansAmelnotic melanoma: doesn’t have any pigment

Pathology

Ill-circumscribedAsymmetricalLoss of maturationSingle cells proliferation instead of nestsCellular atypia(pleomorhism, high N/C ratio, prominent nucleoli, multiple mitotic figures)

Staging

Stage I: skin only( up to 2 mm thick) Stage II: skin only(more than 2 mm thick)

Stage III: Regional lymph nodes metastasisStage: IV: non-regional LN metastasis, skin , subcutaneous and visceral metastasis

Diagnosis

Hx: family or personal Hx of MM, a Hx of childhood sunburn , Hx of PUVA , HIV or organ transplant, , change in color size, shape, bleeding , ulceration, itchingExamination: large no. of common nevi, presence atypical nevi which must have one of ABCDE ( A: asymmetry, B: irregular border, C: color variegation, D: diameter more than 6 mm, E: evolution)Investigation:Excisional biopsy +/- Dermoscopy ,

TreatmentStage I/II : wide local excision of the lesion with safety marginStage III: Sentinel lymph node biopsyStage IV: Palliative Rx ( improve quality of life) which includes:

RadioRx, chemoRx and immunoRx e.g. BCG, IL-2

Benign Skin Tumors

Epidermoid cystThe most common cutaneous cystsMost common on the face and upper trunk

Present as a dermal nodules, may have a central punctum representing the follicle from which the cyst is derived

multiple epidermoid cysts may occur in individuals with a history of significant acne vulgaris

They are asymptomatic, but, with pressure, cysts contents may be expressed that have a malodorRupture of the cyst wall can result in an intensely painful inflammatory reaction, and this is a common reason for presentationTreatment: includesExcision is curative.

Inflamed epidermoid cysts may require incision and drainage +/_ systemic antibiotics

Milium

Are small epidermoid cysts Present as 1–2 mm white to yellow papulesMay occur as a primary, or secondary following blistering diseases or following cosmetic procedures e.g. dermabrasion or topical treatment e.g. steroidsTreatment: Most milia in newborns will resolve spontaneouslyIncising the overlying epidermis and expressing the miliumElectrodesiccation

Skin Tag

Presents as a soft skin-colored to slightly hyperpigmented pedunculated papule, usually asymptomaticPredominantly on the neck, eyelid, axilla and groinTheir incidence increases with age and more commonly seen in obese individualsLarger lesions may be associated with diabetes mellitusTreatment: simple scissor excision, electrodesiccation or cryosurgery

Actinic keratosis

Actinic keratoses (AK) are ‘premalignant’ and SCC would develop at a rate of 10-20% They present on sun-exposed skin of the head, neck, and extremities

Present as a rough erythematous papule with scale Actinic cheilitis : AK involving lower lip

Seborrheic keratosis

Common in caucasian middle-aged individuals Can develop any where except mucosal surfaces and plams and solesMore commonly present as multiple, pigmented, sharply marginated lesions‘stuck-on’ appearance

Usually asymptomaticRx: curettage, cryotherapy, electrodesiccation,

fractional laser .No risk of malignancy

Hypertrophic scar and Keloid

Result from the uncontrolled synthesis and excessive deposition of collagen at sites of prior dermal injury

They often occur after trauma e.g. laceration, burn, ear piercing, vaccination, or surgery or inflammation e.g. acne, or seldom spontaneouslyMore in darkly pigmented the skinThere is often a familial tendencyPresent as well-circumscribed pink to purple firm nodules or plaques which are painful or pruritic

Especially frequent on the earlobes, upper trunk, and the deltoid region (areas of high tension)

Melanocytes, Mast cells, Transforming growth factor-β (TGF-β) play a role in pathogenesis

Treatment: includesSurgery, intralesional corticosteroids, intralesional 5-Fluorouracil, intralesional interferon, topical silicone gel sheeting and laser

Keloid Hypertrophic Scar

Key Features

Often(might be spontaneous)

Always Preceded injury

No Yes Confned to wound margin

No Yes Spontaneous resolution

No Yes Contain myofibroblast

Poor Good Treatment Response

Acquired Melanocytic Nevus

A few nevi are present in early childhood, but they increase in number, reaching a peak in the third decade of life and tend to disappear with increasing ageCaucasians in general have greater numbers of nevi than do darker-skinned

Nevi on palms, soles, nail beds and eyes are more prevalent in blacks and Asians than in caucasians

One-third of melanomas are associated with neviAn increased number of melanocytic nevi marks increased melanoma risk.Atypical nevus is characterized by ABCDE;

A: Asymmetry, B: Irregular Border, C: Variegated Color, D: Diameter more than 6 mm, E: Evolving which mean any change in color, size or shape

There are three types:Junctional nevi are a macules. Histologically present with nests of melanocytes at the junction between the epidermis and dermis

Compound nevi with nests of melanocytes in both dermis andDermal nevi are papules with nests of melanocytes in dermis

ABCDE

Congenital melanocytic nevusPresent at birthThree types; small (less than 1.5 cm in diameter), medium (1.5-19.9 cm) and large or giant (more than 20 cm)There is a significant risk of development of melanoma of skin and meninges in giant nevusTreatment:

Small and medium: serial photography and annual follow-up

Giant: multiple staged excisions

Freckles vs LentiginesSolar Lentigines Freckles (Ephelides) Age of onset

Older age Early childhood Age of onset

Light and dark skin Light skin with red or blond hair and blue eyes

Skin color

Persist for life Fade with age Duration

No seasonal variation Darker in summer and lighter in winter

Relation to season

Larger Smaller Size

Thanks for your attention