SKIN TUMORS

Dr. Ali Al Bazzaz Plastic surgon

Epidemiology
Most common human cancer 600,000 to 800,000 cases per year in U.S. Male:Female 2-3:1 80% arise in head and neck SCCa over 60 years old BCCa over 40 years old

Etiology

Ultraviolet radiation ethnicity ionizing radiation exposure chemical exposure - arsenic burns, scarring immunosuppression

Syndromes

Xeroderma pigmentosum nevoid basal cell syndrome albinism epidermodysplastic verrucoformis epidermolysis bullosa dystrophica dyskeratosis congenital

Skin

Largest organ major functions protection sensation thermoregulation metabolic



Skin structure
Epidermis dermis hypodermis epidermal appendages

Skin Histology

Stratum corneum stratum lucidum stratum granulosum stratum spinosum stratum basale

Seborrheic Keratosis

More common in the elderlyOften pigmentedVariable size“Barnacle-like” appearanceUsually asymptomatic

Epidermal Nevus

Nevus Comedonicus

Acrochordon (Skin tags)

Occur in approximately 25% of males and females Occur in the axilla, neck and inguinal region Increase with age beginning the 20s up into the 50s Few to multiple

Epidermoid Cyst

Epidermoid Cyst
Common, affecting young and middle age adults Usually seen on the head, neck and trunk Often can identifiy a punctum Cyst contains keratin Treatment:surgical excision

Sebaceous Hyperplasia

Found on the face Singular to multiple in number Usually 2-3mm up to 6mm with umbilication Often begin to appear in the 30s and increase with age

Nevus Sebaceous of Jadassohn

Syringomas
Sweat duct tumors More common in females May first appear in adolescence, but more often in the third decade Found around eyelids and are skin colored to yellow in appearance

Eccrine Poroma

Tumor arising from the eccrine duct epithelium Often on the soles and palms Tend to be moist, red and exophytic


A benign cluster of melanocytic cells arising as a result of proliferation of melanocytes at the dermo-epidermal junction. These may all remain in contact with the basal layer (the junctional nevus) or may become dettached from the basal layer and lie free in the dermis (the compound and intradermal nevus).

Halo Nevus

Spitz Nevus
A compound nevus seen most commonly in children and with lesser frequency in adults They appear suddenly and the color is caused by increased vascularity Its pathological features can be difficult to distinguish from malignant melanoma

Blue Nevus

An area of blue-black dermal pigmentation produced by an aberrant collection of pigment producing melanocytes The brown pigment absorbs the longer wavelength of light and scatters blue light (Tyndall effect) Extend into the deep dermis, often occur on extremities and the dorsum of the hand

Dermatofibroma

Can occur on any part of the body, most common on the lower extremities, to a lesser degree on the upper extremities and trunk May be single or multiple Usually pink or brown Commonly 6mm or less Hard consistency

Keloid

An exaggerated reparative fibroblastic response to injury of the skin Genetic tendency Most commonly found on the ears, neck and trunk

Pyogenic Granuloma

A vasular nodule that develops rapidly, with a glistening moist surface Often may appear at a site of recent trauma Composed of proliferating capillaries in a loose stroma Bleeds easily

Lipoma

Actinic Keratosis
Hyperkeratotic lesions occurring in sun exposed adult skin May exist in a premalignant state for years Often begin as an area of increased vascularity with the surface becoming rough May progress to squamous cell carcinoma


Squamous Cell Carcinoma in situ(Bowen’s Disease) A persistent, progressive, nonelevated, red, scaly or crusted plaque An intraepidermal proliferation on exposed and nonexposed areas of the body Often mistaken for eczema or psoriasis

Keratoacanthoma

Rapidly evolving tumor, often in the matter of weeks, possibly of viral origin Composed of keratinizing squamous cells More common in fair skinned, elderly people May resolve spontaneously over a period of 2 to 12 months

Epidermal Malignancies

Basal Cell Carcinoma

Most common form of skin cancer Usually appears on sun damaged skin Pearly appearance with superficial telangiectasias Rarely metastasizes Derived from basal cell layer of the epidermis

Pigmented Nodular Basal Cell Carcinoma

Sclerosing Basal Cell Carcinoma

Superficial Basal Cell

Scaly patches irregular borders extremities, less common in head and neck

Morpheaform Basal Cell

Indistinct marginsflat maculescar-likeaggressive behaviordifficult to treat - Mohs’ surgery

Basal Cell Biologic Behavior

Dependent upon stroma locally invasive spread along resistant planes metastasis rare - 0.0028% to 0.1% (ALMOST NEVER METASTSIZE)

Basal Cell Biologic Behavior

Embryonic fusion planes at risk for deep invasion inner canthus philtrum chin nasolabial groove pre-auricular retro-auricular sulcus

Treatment of BCCExcision 0.5-1cm safety margin

Most useful with BCCa <2 cm 92% to 98% cure advantages quick and easy disadvantages open wound scarring

Treatment - Cryotherapy

Squamous Cell Carcinoma
Often in older fair skinned persons Hyperkeratotic and often ulcerates SCC is separated into two groups based on malignant potential

Squamous Cell Carcinoma

Sun exposure erythematous, ulcerated, crusting friable adjacent induration actinic vs. de novo

Squamous Cell Carcinoma

Squamous Cell Histopathology
Well, moderate and poorly differentiated generic adenoid bowenoid verrucous spindle cell or pleomorphic

Treatment of sqcc- Excision&1-2cm safety margin

Most often used by head & neck surgeons 93% to 95% cure advantages specimen for evaluation disadvantages expensive time-consuming scarring

Treatment - Mohs’ Surgery 96% to 99% cure

Treatment - Laser
Patients with medical diseases multiple lesions palliation

Treatment - Photodynamic Therapy

Photosensitive drug concentrated in tumor porphyrin, argon ion dye pump laser most common still experimental

Treatment - Chemotherapy

Retinoids cis-platin - most widely used bleomycin cyclophosphamide 5-fluorouracil vinblastine

MALIGNANT MELANOMA

Melanoma results from malignant transformation of the melanocyte, the pigment-producing cell of the body. As such,it can occur anywhere melanocytes are present, including skin,eye, and the mucous membranes of the upper digestive tract,sinuses, anus, and vagina. By far, the most common tissue in which melanomas arise is the skin

In Situ Malignant Melanoma

Melanoma cells confined to the epidermis Lack in invasion may persist for months to years Simple excision is often curative

Superficial Spreading Melanoma

Superficial Spreading Melanoma
Most common in middle age Develops anywhere on the body, back in both sexes and legs in females Haphazard combination on colors but may be uniformly brown or black

Acral Lentinginous Melanoma

Most common in blacks and orientals Appears on the palms, soles terminal phalanges and mucous membranes The tumor is very aggressive and metastasizes early

Nodular Melanoma

Occurs in the fifth or sixth decade More frequent in males with a ratio of 2:1 Found anywhere on the body Most frequently misdiagnosed because it can resemble a blood blister, hemangioma, dermal nevus or polyp

Amelanotic Melanoma

MANAGEMENT of malignant melanoma
Surgical excision – 3-5cm margins depending on Breslow depthInvasive primary MM on the digits can be treated by amputationNeed to investigate all MMs over 1mm for metastases – CXR, US abd or CT chest, abd, pelvis, bloods – FBP, LFTs, LDH(TUMOR MARKERS)Surgical excision+reginal chemotherapy (malfalan).Surgical excision+immunotherapy.Prophylactic lymph nodes dissection

Treatment - Regional Lymphatics

Deep invasion into muscle, bone, nerve tumors >2 cm recurrent tumors tumors arising de novo or in scarred areas

Treatment - Regional Lymphatics

Parotidectomy for periauricular tumors spare uninvolved structures post op XRT as indicated

Mortality

Exact numbers not available - not consistently reported 0.44 per 100,000 persons per year 2,000 to 3,000 deaths per year in U.S. patients 65-70 years old widespread SCCa arising in periauricular region

Conclusion

Common tumors best chance for cure is early diagnosis and treatment prevent new lesions with sun protection

NODULAR

Commoner in males Trunk is a common site Usually thick with a poor prognosis Black/brown nodule Ulceration and bleeding are common

SUPERFICIAL SPREADING

The most common type of MM in the white-skinned population – 70% of casesCommonest sites – lower leg in females and back in malesIn early stages may be small, then growth becomes irregular

ACRAL LENTIGINOUS MELANOMA

In white-skinned population this accounts for 10% of MMs, but is the commonest MM in nonwhite-skinned nations Usually comprises a flat lentiginous area with an invasive nodular component

SUBUNGAL MELANOMA

RareOften diagnosed late – confusion with benign subungal naevus, paronychial infections, traumaHutchinson’s sign – spillage of pigment onto the surrounding nailfold

LENTIGO MALIGNA MELANOMA

Occurs as a late development in a lentigo maligna Mainly on the face in elderly patients May be many years before an invasive nodule develops

AMELANOTIC MELANOMA

Diagnosis is often missed clinically The lack of pigmentation is due to the rapid growth of the tumour and the differentiation of the malignant melanocytes

METASTATIC MELANOMA

PLANTAR MALIGNANT MELANOMA
Caucasians – 1-9%Asians – 29-46%Afro-Carribean – 60-70%

SUBUNGAL MELANOMA

TRAUMA