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Skin Tumors

By
Dr. Alaa A. Al-Sahlany
May 17, 2020

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 carcinoma
The most common skin cancer in human

BCC occurs most frequently on the head and neck

Mortality 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 edge

Superficial BCC

Morpheaform BCC

Cystic BCC

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Palisading of cells at periphery

Retraction artefact(space between the stoma and cells)
Mucin deposition
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Squamous cell carcinoma

The 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.


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Risk factors of BCC and SCC

Immunological
Genetic
Environmental
Organ transplantation, HIV infection and immunosuppressive drugs: immunosuppression causes cancer due to (1) HPV infection and(2) 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)

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Treatment

Surgical excision

Electrodesiccation and curettage

Mohs Surgery: has the highest cure rate, used for high risk tumor and when tissue preservation is necessary e.g. digits, genitalia

Medical therapy : 5-fluorouracil

Radiotherapy: elderly patient unfit for surgery

Cryotherapy(by freezing)

Photodynamic therapy( light plus photosensitizer)

BCC vs SCC

SCC
BCC
Has 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 melanoma

Death from melanoma occurs at a younger age than for other solid tumors

Melanoma incidence in Australia is the highest worldwide

Types of melanoma

Superficial spreading : the most common in fair-skinned persons, on leg of female and trunk of male

Nodular melanoma

Lentigo maligna melanoma

Acral lentignious mel:occur on palm, sole and nail appratus, commonly occur in black and Asians

Amelnotic melanoma: doesn’t have any pigment

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Pathology

Ill-circumscribed
Asymmetrical
Loss of maturation
Single cells proliferation instead of nests
Cellular 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 metastasis

Stage: IV: non-regional LN metastasis, skin , subcutaneous and visceral metastasis

Diagnosis
Hx: family or personal Hx of MM, a Hx of childhood sunburn , HIV or organ transplant, , change in color size, shape, bleeding , ulceration, itching

Examination: 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 ,

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


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ABCDE
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Treatment

Stage I/II : wide local excision of the lesion with safety margin

Stage III: Sentinel lymph node biopsy

Stage IV: Palliative Rx ( improve quality of life) which includes:
RadioRx, chemoRx and immunoRx e.g. BCG, IL-2



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Benign Skin Tumors

Epidermoid cyst
The most common cutaneous cysts

Most 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 malodor

Rupture of the cyst wall can result in an intensely painful inflammatory reaction, and this is a common reason for presentation

Treatment: includes

Excision is curative.
Inflamed epidermoid cysts may require incision and drainage +/_ systemic antibiotics


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Milium
Are small epidermoid cysts

Present as 1–2 mm white to yellow papules

May occur as a primary, or secondary following blistering diseases or following cosmetic procedures e.g. dermabrasion or topical treatment e.g. steroids

Treatment: Most milia in newborns will resolve on their own

(1)Incising the overlying epidermis and expressing the milium
(2)Electrodesiccation


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Skin Tag

Presents as a soft pedunculated papule, usually asymptomatic

Predominantly on the neck, eyelid, axilla and groin

Their incidence increases with age and more commonly seen in obese individuals

Larger lesions may be associated with diabetes mellitus

Treatment: simple scissor excision, electrodesiccation


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Actinic keratosis(AK)

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


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Seborrheic keratosis

Common in caucasian middle-aged individuals

Can develop any where except mucosal surfaces and plams and soles

More commonly present as multiple, pigmented, sharply marginated lesions‘stuck-on’ appearance

Usually asymptomatic

Rx: curettage, cryotherapy, electrodesiccation, fractional laser.

No risk of malignancy

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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 spontaneously

More in darkly pigmented the skin

There is often a familial tendency

Present 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: includes

Surgery, 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


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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 age

Caucasians 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 nevi

An 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 and junction

Dermal nevi are papules with nests of melanocytes in dermis


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Congenital melanocytic nevus

Present at birth

Three types; small (less than 1.5 cm in diameter), medium (1.5-19.9 cm) and giant (more than 20 cm)

There is a significant risk of development of melanoma of skin and meninges in giant nevus

Treatment:
Small and medium: serial photography and annual follow-up
Giant: multiple staged excisions


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Freckles vs Lentigines

Solar 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


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Thanks
for your attention


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