skin tumors2 pdf - د. احسان

SKIN TUMORS

Dr. Ihsan Al-Turfy
Consultant Dermatologist
College of Medicine/Baghdad
MBChB,DDV,FICMS,CABD

Tumor

Definition

: Is an

abnormal growth of tissue.

This

abnormal growth usually but not always forms a
mass.

They can be

benign or malignant

Any cellular element of the skin can produce tumors

Benign

tumors of the skin

1.Hemangioma-. From bv
2. Lymphangioma.- Lymphatics
3.Neuroma. -Nerves

4.lipoma. Adipose tissue
5.Fibroma-- fibrous tissue

6. Epidermal cell tumors(Including its appendages):
(Keratinocytes & Melanocytes-mainly)

A. Pigmented nevi.( Melanocytes)

Melanocytic nevi

: are benign neoplasms or

hamartomas

(Hamartoma is Abnormal Collection of

normal tissue consituents)composed of melanocytes,
{the pigment-producing cells that constitutively
colonize the epidermis} ( Melanocytes are present in
the

basal layer of the epidermis

) Melanocytes are

derived from the neural crest and migrate during
embryogenesis to selected ectodermal sites
(primarily the skin and the CNS), but also to the
eyes and the ears.

Melanocytic nevi…..

They are divided into

congenital and acquired

types.

Conventional or common

acquired

melanocytic nevi

are generally less than 1cm in diameter and evenly
pigmented. They are of three types:

Junctional ,compound, and dermal

Melanocytic nevi….

Congenital

are thought to represent an anomaly in

embryogenesis and, as such, could be considered,
at least in a sense, malformations or

hamartomas

Melanocytic nevi

are

common

lesions that can be

found on the integument of almost all individuals.
Some patients present with few lesions, while others
have hundreds .Melanocytic nevi represent
proliferations of melanocytes that are in contact
with each other,

forming small collections of cells

known as nests.

Congenital

melanocytic nevi

They are present

since birth

( that is why they are

called" congenital") Are of 2 types; small

and large (

bathing trunk

), that have deep

color(usually ) with irregular border and covered by
hair.

Larger ones do have a malignant potential.

Types

of melanocytic nevi

Junctional

melanocytic nevi (directly attached to

the basal layer)

are macular or thinly papular. Junctional lesions
typically range from

brown to brownish-black

. The

darker coloration of junctional melanocytic nevi
stems from the fact that the surface epidermis is
often simultaneously hyperpigmented.

2 & 3 .

Compound and intradermal

melanocytic nevi

display

elevation

relative to surrounding uninvolved

skin. Compound melanocytic nevi are often

lighter

color than junctional nevi and range from tan to
light brown. Some compound melanocytic nevi have
areas of dark pigmentation, particularly those that
have been recently irritated or traumatized. Many
wholly

intradermal

melanocytic nevi display

significant pigmentation.

Compound nevi have both junctional and dermal

elements. While dermal nevi have no junctional
element.

The development of a

new area of pigmentation

within a long-standing nonpigmented or lightly
pigmented compound or intradermal melanocytic
nevus,is a cause for

concern.

While pigmentary

changes could be due to incidental inflammation or
recent

irritation or trauma,

the possibility of evolving

melanoma

is also a consideration in the differential

diagnosis.

Nevi & MM

Signs of suspicion of MM

in any pigmented skin lesion

(ABCDE):

symmetry in shape, one half of the lesion is

unlike

the

other half.

order is

irregular

olor is

not uniform

; mottled, different shades of black,

grey red and white.

iameter more than

0.6 cm

E: In addtion to increase in size of the lesion( which usually

brings the patient to hospital

).-Enlargement

Note

Melanocytic nevi never become malignant because of

manipulation and trauma.

The risk of malignant transformation is very small .

Management

( of melanocytic nevi): None ,but they

can be removed for

cosmetic

purposes

Epidermal cell tumors-
(keratinocytes)

Keratoacanthoma

( KA):

is a relatively

common

low-grade tumor that

originates in the pilosebaceous glands and closely
& pathologically resembles squamous cell
carcinoma(SCC). Keratoacanthoma is characterized
by

rapid growth

over a few weeks to months,

followed by

spontaneous resolution

over 4-6 months

most

cases.

KA…..

It typically

grows rapidly

, reaching 1-2 cm within

weeks, followed by a slow

involution

period lasting

up to one year and leaving a residual

scar

if not

excised. Typically are

solitary

skin-color or red

papules(or nodules) with smooth shiny surface and a
central

crateriform

ulceration or keratin plug.

Sites

:face,neck, and dorsum of the hands.

Treatment of KA

Many consider surgical treatment of KA to be

equivalent to treatment of SCC.

Other benign tumors(keratinocytes)

C. Seborrheic keratoses

are the

most common

benign

tumor in older individuals (usually never appear
before the age of 30). Seborrheic keratoses have a

variety of clinical appearances

that begin with the

appearance of one or more

sharply defined, light

brown, flat macules.

The lesions may be sparse or

numerous, asymptomatic or itchy .

SK…

The color May become

dark

brown to black with

warty stuck on appearance

Sites:

face, upper trunk & scalp are the commonest

They are

NOT premalignant

that is why treatment

should be simple like curettage or cryotherapy. We
can apply topical AHA or Retinoids.

NB being colored they should be differentiated from

malignant melanoma(ABCDE).

Histopathology of Seb K.

Epidermal proliferating cells with

basaloid

appearance. The lesions are raised above skin
surface with

papilomatosis

and

horn cyst

formation.

No tendency toward malignancy.

Treatment of seb. keratosis

Can be removed easily by curettage,cryotherapy or

electrodessication

Others :AHA, TCA,Tazarotene cr.

Other benign tumors

Trichelemmal cysts(pilar cyst)-

- from hair(External

Root sheet):Arise on the

scalp

similar to sebaceous

cyst

but has no opening( punctum) may be single or

multiple( usually familial),surgical removal is easier
than that for sebaceous cysts.

sebaceous gland

tumors--- benign seb

hyperplasia,and seb.cyst

Benign sebaceous hyperplasia

:
Is a

common

benign

condition of sebaceous glands in

adults of middle age or older. Lesions can be single
or multiple and manifest as

yellowish, soft, small

papules on the face

(particularly nose, cheeks, and

forehead).often with an umblicated center.

It may occasionally be confused with BCC
Can be removed by simple shave excision

Benign sebaceous hyperplasia..

NB occasionally oral isotretinoin may be needed for

wide spread disfiguring lesions.

Syringoma

Is a

sweat duct tumor

are

skin-colored or yellowish

, generally small, dermal

papules Most commonly, syringomas are limited to
the upper parts of the

cheeks and lower

eyelids

.They are only of cosmetic importance

Premalignant

skin conditions

Any skin condition that will lead ultimately to frank

malignancy if left untreated.

The classic example is

actinic (senile,solar)

keratosis(AK)

-AKs are amongst the most

frequently

encountered

skin lesions in clinical practice. They

present on

sun-damaged skin of

the head, neck,

upper trunk and extremities. Individuals at higher risk

of developing AKs include the elderly, lighter skin
phototypes and history of chronic sun exposure.

AK….

They present with

rough

erythematous

papule with

white to yellow scale

. size from a few millimeters

to large confluent patches several centimeters in

diameter surrounded by

photodamaged

skin

(wrinkled, telangiectatic with dyspigmentation)

Sites

: face,ears,bald scalp, and dorsa of hands.

Treatment

1.5-FU– TOPICAL.
2. Topical imiquimod.
3.Topical diclofenac.
4. PTD with topical delta-aminolevulinic

acid(generation of oxygen free radicals).

Important

malignant

tumors of the skin

1. Related to basal cells.--

BCC

2. Originating from keratinocytes.--

SCC

3 Originating from melanocytes--

4. Mycosis fungoides

(MF

) originating from T cells( T

cell lymphoma)

NB: recently kaposi’s sarcoma(malignant vascular

tumor) is raising concern in our country .

General

causes

of malignant tumors

Sun

exposure.

2.Chronic skin disease or

irritation

Including old burns

X rays

and ionizing radiation.

Genitic

diseases like xeroderma pigmentosa-- in ability

to repair Sundamaged DNA

5. Exposure to Some

chemical

s Like arsenic.

6. The presence of some

immune defects

(Genitic ,

Aquired"HIV" ,and drug induced"For organ
transplants")

HPV

(Human papIlloma virus" certain types")

NB:

susceptibility

to UVR damage

Well-known markers for UVR vulnerability
include the following:

Fair skin

(or a history of repeated sunburns)

Hazel or

blue eyes

Blonde or

red hair

Albinism

(NOT Vitiligo)

Basal cell carcinoma (

BCC

)

a nonmelanocytic skin cancer (ie, an epithelial
tumor) that

arises from basal cells

( small, cuboidal

cells found in the lower layer of the epidermis)--???.
The

prognosis

for patients with BCC is

excellent,

but

if the disease is allowed to progress, it can cause

significant morbidity

NB: Many believe that BCCs arise from

pluripotential

cells

in the basal layer of the epidermis or

follicular

structures.

BCC..

Signs and symptoms

BCC occurs mostly on the

face, head

(scalp included),

neck, and hands.Other characteristic features of
BCC tumors include the following:

Waxy

papules with central depression

Pearly

appearance Erosion or ulceration: Often

central and pigmented

Bleeding: Especially when traumatized

BCC features…

Oozing or crusted areas: In large BCCs

Rolled (raised) border

(often inetrrupted)

Translucency

Telangiectases

over the surface

Slow growing: 0.5 cm in 1-2 years
Black-blue or brown areas

Clinicopathologic

types

of BCC

Each of which has a distinct biologic behavior,
include the following:

Nodular,morpheaform, superficial, Cystic, pigmented,

keratotic

.The most common type of BCC; usually

presents as a round, pearly, flesh-colored papule
with telangiectases

Infiltrative: Tumor infiltrates the dermis in thin strands

between collagen fibers,

making tumor margins less clinically apparent

OTHER TYPES of BCC

Morpheaform:

Appears as a

white or yellow

, waxy,

sclerotic plaque that rarely ulcerates; is flat or
slightly depressed, fibrotic, and firm.

Superficial

: Seen mostly on the upper trunk or

shoulders; appears clinically as

an erythematous,

well-circumscribed patch or plaque

, often with a

whitish scale

Diagnosis

Clinical plus histopathological.
Given that BCC rarely metastasizes, laboratory and

imaging studies are not commonly clinically
indicated in patients presenting with localized
lesions.

Imaging studies may be necessary when involvement

of deeper structures, such as bone, is clinically
suspected. In such cases, computed tomography
scans or radiography can be used.

Biological behavior according to
type

Nodular, Cystic, pigmented, keratotic; the most

common type of BCC; usually presents as a round,
pearly, flesh-colored papule with telangiectases

Infiltrative: Tumor infiltrates the dermis in thin strands

between collagen fibers, making tumor margins less
clinically apparent

Micronodular: Not prone to ulceration; may appear

yellow-white when stretched,…

is firm to the touch, and may have a seemingly well-

defined border

Morpheaform: Appears as a white or yellow, waxy,

sclerotic plaque that rarely ulcerates; is flat or
slightly depressed, fibrotic, and firm.

Superficial: Seen mostly on the upper trunk or

shoulders; appears clinically as an erythematous,
well-circumscribed patch or plaque, often with a
whitish scale.

Biopsy

Types of skin biopsy that may be used to confirm the

diagnosis and determine the histologic subtype of
BCC include the following:

Shave biopsy: Most often, the only biopsy that is

required

Punch biopsy: May be indicated in the case of a

pigmented lesion if there is difficulty distinguishing
between pigmented BCC and melanoma; ensures
that the depth of the lesion can be determined if it
proves to be a malignant melanoma.

proliferation of

basiloid

( similar to basal cells) cells

within the dermis forming a peripheral

palisade

appearance( like a fence), presence of

tumour

retraction

and

stroma

are the main features. It can

be undifferentiated or differrentiated (towrd

hair, sebaceous gland or tubular glands).

Histology of BCC

Management

1.Surgery
In nearly all cases of BCC, surgery is the

recommended treatment modality.

Techniques used include the following:
a.Electrodesiccation and curettage
b.Excisional surgery
c.Mohs micrographically controlled surgery

2.Cryosurgery-freezing the skin to about 180 c
3.Radiation therapy
BCCs are usually radiosensitive; radiation therapy

(RT) can be used in patients with advanced and
extended lesions, as well as in those for whom
surgery is not suitable. Postoperative radiation can
also be a useful adjunct when patients have
aggressive tumors that were treated surgically or
when surgery has failed to clear the margins of the
tumor.

RX….

4.Photodynamic therapy (PDT)(( application of a

photosensitizer plus UV light ))

is a reasonable choice in Certain conditions .

5.Pharmacologic therapy:

Topical agents used in the treatment of superficial

BCC include the following :

RX….

Topical 5-fluorouracil 5%: May be used to treat small,

superficial BCCs in lowrisk areas

Imiquimod: Approved by the US Food and Drug

Administration for the treatmentof nonfacial
superficial BCC

Tazarotene ( is a tpoical retinoid): Can also be used

to treat small, low-risk BCCs

Squamous cell CA (SCC)

Squamous cell Ca (SSC) is the second most common

skin cancer, after basal cell carcinomas(BCC)

Site - mostly on head and neck ( development in non-

sun exposed skin usually follows chronic skin
inflammtion" old burn, lupus vulgaris, DLE" ).

Signs and symptoms
The classic presentation of a SCC is that of a shallow

ulcer with heaped-up edges, often covered by a
plaque, usually in a sun-exposed area.

SCC …

Typical
surface changes may include the following:
Scaling,ulceration, crusting,and a cutaneous horn
Less commonly, SCC presents as a pink cutaneous

nodule without overlying surface changes. Regional
spread of head and neck SCC may result in

enlarged preauricular, submandibular, or cervical

lymph nodes.

Diagnosis

The workup of suspected SCC may include the

following: Biopsy: Indicated for any lesion suspected
of being a cutaneous neoplasm

Computed tomography (CT) scanning: To evaluate for

bone or soft tissue invasion and cervical lymph
nodes at risk for metastasis

Magnetic resonance imaging (MRI): Preferred for

evaluation of perineural invasion and orbital or
intracranial extension.

Pathology

Nuclear atypia Frequent mitoses Cellula

pleomorphism Parakeratosis and hyperkeratosis.

A disorganized progression of cells from the basal to

apical layers of the epidermis. When cells break
the basal layer and invades the dermis it is called

invasive SSC With invasive SCC, nests of atypical cells

are found within the dermis, surrounded by an
inflammatory infiltrate.

Pathology…

The presence of malignant appearing
cells.SSC can be well differentiated moderately

differentiated or poorly differentiated.( The first
one has better prognosis).

Squamous cell carcinoma in situ (CIS){ malignant cells

are still within the epidermis}, sometimes referred to
as Bowen disease, is a precursor to invasive SCC.

Management

Treatment options include the following:
1.Electrodessication and curettage: Low-risk SCC on

the trunk and extremities 2. Mohs micrographic
surgery: Invasive SCC

3.Radiation therapy: As an adjuvant to surgery, to

provide improved regional control, or as primary
therapy in patients who are unable to undergo
surgical excision

Rx..

Oral 5-fluorouracil (5-FU) and epidermal growth

factor receptor (EGFR) inhibitors: Adjuvant therapy
for select highest-risk cases

Systemic chemotherapy: A consideration for

metastaticSCC

Malignant melanoma

is a neoplasm of melanocytes or a neoplasm of the

cells that develop from melanocytes. Although it
was once considered uncommon, the annual
incidence

has increased dramatically over the past few

decades. Surgery is the definitive treatment for
early-stage melanoma, with medical management
generally reserved for adjuvant treatment of
advanced melanoma.

History

The history should address the following:
Family history of melanoma or skin cancer
Family history of irregular, prominent moles
Family history of pancreatic cancer or astrocytoma
Previous melanoma (sometimes multiple; patients have

reported as many as 8 or more primary
melanomas)

History…

Previous sun exposure
Changes noted in moles (eg, size, color, symmetry,

bleeding, or ulceration)

History or family history of multiple nevus syndrome

Physical examination includes the following:
Total-body skin examination, to be performed on

initial evaluation and during all subsequent visits

Serial photography, epiluminescence microscopy,

dermoscopy ,and computerized image analysis, to
be considered as adjuncts

Skin examination involves assessing the number of

nevi present

and distinguishing between typical and atypical

lesions. Early melanomas may be differentiated
from benign nevi by the ABCDs, as follows:

A - Asymmetry
B - Border irregularity
C - Color that tends to be very dark black or blue

and variable

D - Diameter ≥ 6 mm

If a patient is diagnosed with a melanoma, examine

all lymph node groups.

NB: Dermoscopy: (a hand held device for the

examination and differentiation of pigmented
lesions Including MM) may be a useful tool.

Clinical types:

1- Lentigo maligna melanoma:
Affects the face in elderly people, irregular in shape

and pigmentation grows for

years in situ before invasion.
2- Superficial spreading melanoma:There is a radial

growth phase into the epidermis before invading
the dermis.

Clinical types…

3- Nodular melanoma: No radial growth phase, early

invasion, very aggressive.

4- Acral lentigenous melanoma: Most common type in

Iraq, affects the palms and soles, presents as
irregularly pigmented macule or patch. presence of
nodule indicates invasion

laboratory studies

The following laboratory studies are indicated:
Complete blood count
Complete chemistry panel (including alkaline

phosphatase, hepatic transaminases, total protein,
and albumin)

Lactate dehydrogenase

imaging modalities

Chest radiography
Magnetic resonance imaging of the brain
Ultrasonography (possibly the best imaging study for

diagnosing lymph node involvement)

Computed tomography of the chest, abdomen, or

pelvis

Positron emission tomography (PET; PET-CT may be

the best imaging study for identifying other sites of
metastasis)

Histopathology

Characteristic histologic findings include the following:

Cytologic atypia, with enlarged cells containing
large, pleomorphic, hyperchromic nuclei with
prominent nucleoli

Numerous mitotic figures
Pagetoid growth pattern with upward growth of the

melanocytes

Procedural management

Complete excisional biopsy of a suggestive lesion
Surgical excision or reexcision after biopsy
Elective lymph node dissection (ELND) for patients with

clinically enlarged nodes and no evidence of distant
disease

Sentinel lymph node biopsy .