CLASSIFICATION OF CUTANEOUS MALIGNANCIES

1- PREMALİGNANCİES (in situ) Actinic keratosis Actinic keratosis Bowen’s disease Bowen’s disease Lentigo maligna Lentigo maligna Keratinocyte Keratinocyte Melanocyte Melanocyte

2- COMMON CUTANEOUS MALİGNANCİES Basal cell carcinoma Basal cell carcinoma Squamous cell carcinoma Squamous cell carcinoma Keratoacanthoma Keratoacanthoma Debatable ( follicular keratinocyte, basal keratinocyte, primary germ cell ) Debatable ( follicular keratinocyte, basal keratinocyte, primary germ cell ) Keratinocyte Keratinocyte Follicular keratinocyte Follicular keratinocyte

3- MELANOMAS Malignant melanoma Malignant melanoma Lentigo maligna melanoma Lentigo maligna melanoma Melanocyte Melanocyte

4- UNCOMMON CUTANEOUS MALİGNANCİES Sweat gland carcinomas Sweat gland carcinomas Follicular carcinomas Follicular carcinomas Extramammary Paget’s disease Extramammary Paget’s disease Merkel cell carcinoma Merkel cell carcinoma Atypical fibroxanthoma Atypical fibroxanthoma Dermatofibrosarcoma protuberans Dermatofibrosarcoma protuberans Fibrosarcoma Fibrosarcoma Angiosarcoma Angiosarcoma Kaposi’s sarcoma Kaposi’s sarcoma Hemangiopericytoma Hemangiopericytoma Malignant peripheral nerve sheath tms Malignant peripheral nerve sheath tms Liposarcoma Liposarcoma Apocrine or eccrine sweat gland / duct Apocrine or eccrine sweat gland / duct Follicular epithelial cells Follicular epithelial cells Unknown- apocrine Unknown- apocrine Fibroblast or dermal dendrocyte Fibroblast or dermal dendrocyte Fibroblast Fibroblast Endothelial cell Endothelial cell Pericyte Pericyte Schwann cells Schwann cells Lipocyte Lipocyte

COMMON CUTANEOUS MALİGNANCİES Primary cutaneous cancers are classified on the basis of their cell of origin within the skin. They originate most commonly in the epidermal germinative keratinocytes or adnexal structures (e.g.,sweat apparatus, hair follicle).The two principal cutaneous epithelial cancers(nonmelanoma skin cancers- NMSC-) are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).

SQUAMOUS CELL CARCINOMA (SCC) Malignant tumour of keratinocytes, arising in the epidermis, skin appendages, and other stratified squamous mucosa. Malignant tumour of keratinocytes, arising in the epidermis, skin appendages, and other stratified squamous mucosa. SCC usually arises in epidermal precancerous lesions SCC usually arises in epidermal precancerous lesions The majority of UVR-induced lesions have a low rate of distant metastasis in otherwise healty individuals. The majority of UVR-induced lesions have a low rate of distant metastasis in otherwise healty individuals. More aggressive SCC occur in immunosuppressed individuals with a greater incidence of metastasis. More aggressive SCC occur in immunosuppressed individuals with a greater incidence of metastasis.

SCC (2) SCC (2) Etiology: Ultraviolet radiation (sunlight, phototherapy), Human Papillomavirus (HPV), Immunosuppression, Chronic inflammation ( DLE, chronic ulcers, burn scars, chronic radiation dermatitis, lichen planus of oral mucosa), Industrial Carcinogens (Pitch, tar, crude paraffin oil, fuel oil, creosote, nitrosureas), Inorganic arsenic. Etiology: Ultraviolet radiation (sunlight, phototherapy), Human Papillomavirus (HPV), Immunosuppression, Chronic inflammation ( DLE, chronic ulcers, burn scars, chronic radiation dermatitis, lichen planus of oral mucosa), Industrial Carcinogens (Pitch, tar, crude paraffin oil, fuel oil, creosote, nitrosureas), Inorganic arsenic. Differential diagnosis: Any persistent nodule, plaque, or ulcer, but especially when these occur in sun-damaged skin, on the lower lips, in areas of radiodermatitis, in old burn scars, or on the genitalia. Keratoacanthoma may be clinically indistinguishable from differentiated SCC. Differential diagnosis: Any persistent nodule, plaque, or ulcer, but especially when these occur in sun-damaged skin, on the lower lips, in areas of radiodermatitis, in old burn scars, or on the genitalia. Keratoacanthoma may be clinically indistinguishable from differentiated SCC. Course and prognosis: Significant potential for metastasis; metastases are directed to regional lymph nodes. SCC in the skin has an overall metastatic rate of 3 to 4%. Cancers arising in chronic osteomyelitis sinus tracts, in burn scars, and in sites of radiation dermatitis have a metastatic rate of 31, 20, and 18 %, respectively. Course and prognosis: Significant potential for metastasis; metastases are directed to regional lymph nodes. SCC in the skin has an overall metastatic rate of 3 to 4%. Cancers arising in chronic osteomyelitis sinus tracts, in burn scars, and in sites of radiation dermatitis have a metastatic rate of 31, 20, and 18 %, respectively. High-risk SCCs: Diameter > 2 cm, depth > 4 mm, inolvement of bone, muscle, and nerve, location on ear, lip and genitalia, tumors arising in a scar or following ionizing radiation, highly dedifferentiated tumours, in immunosuppressed patients. High-risk SCCs: Diameter > 2 cm, depth > 4 mm, inolvement of bone, muscle, and nerve, location on ear, lip and genitalia, tumors arising in a scar or following ionizing radiation, highly dedifferentiated tumours, in immunosuppressed patients. Management: Surgery, radiotherapy Management: Surgery, radiotherapy

SCC IN SITU (SCCIS) SCCIS is most common caused by UVR or HPV infection, presenting as solitary or multiple macules, papules, or plaques, which may be scaling or hyperkeratotic. SCCIS is most common caused by UVR or HPV infection, presenting as solitary or multiple macules, papules, or plaques, which may be scaling or hyperkeratotic. SCCIS commonly arises in epithelial dysplastic lesions such as solar keratoses or HPV-induced squamous intraepithelial lesions (SIL) SCCIS commonly arises in epithelial dysplastic lesions such as solar keratoses or HPV-induced squamous intraepithelial lesions (SIL) Bowen’s disease Bowen’s disease Erythroplasia of Queyrat (glans penis, labia minora) Erythroplasia of Queyrat (glans penis, labia minora) Bowenoid papulosis (anogenital) Bowenoid papulosis (anogenital) Differential diagnosis: Nummuler eczema, psoriasis, seborrheic keratosis, solar keratosis, verruca vulgaris, condyloma acuminatum, superficial BCC, amelanotic melanoma, Paget’s disease Differential diagnosis: Nummuler eczema, psoriasis, seborrheic keratosis, solar keratosis, verruca vulgaris, condyloma acuminatum, superficial BCC, amelanotic melanoma, Paget’s disease Course and prognosis: Untreated SCCIS will progress to invasive SCC. Lymph node metastasis can occur without demonstrable invasion. Course and prognosis: Untreated SCCIS will progress to invasive SCC. Lymph node metastasis can occur without demonstrable invasion. Management: Topical 5-FU, imiquimod, cryosurgery, photodynamic therapy, surgical excision Management: Topical 5-FU, imiquimod, cryosurgery, photodynamic therapy, surgical excision

BASAL CELL CARCINOMA (BCC) Most common type of skin cancer. Most common type of skin cancer. Locally invasive, destructive, but there is very limited capacity to metastasize. Locally invasive, destructive, but there is very limited capacity to metastasize. SPT I and II with prolonged sun exposure SPT I and II with prolonged sun exposure Five clinical types: Nodular BCC, Ulcerating BCC, Sclerosing BCC, Superficial spreading BCC, Pigmented BCC Five clinical types: Nodular BCC, Ulcerating BCC, Sclerosing BCC, Superficial spreading BCC, Pigmented BCC Distribution: Isolated single lesion, >90% occur in the face. Superficial spreading (multicentric) BCCs occur on the trunk. Distribution: Isolated single lesion, >90% occur in the face. Superficial spreading (multicentric) BCCs occur on the trunk. Course and prognosis: BCC does not metastasize. Course and prognosis: BCC does not metastasize.

BCC (2) Differential diagnosis: All smooth papules like dermal nevus, trichoepitelioma, dermatofibroma, and others; if pigmented, superficial spreading and nodular melanoma; if ulceratedall nonpainful firm ulcers including SCC and a (extragenital) primary chancre of syphilis. Differential diagnosis: All smooth papules like dermal nevus, trichoepitelioma, dermatofibroma, and others; if pigmented, superficial spreading and nodular melanoma; if ulceratedall nonpainful firm ulcers including SCC and a (extragenital) primary chancre of syphilis. Management: Excision with primary closure, skin flaps or grafts, cryosurgery or electrosurgery, Mohs surgery, radiation therapy, topical 5-FU, imiquimod cream, photodynamic therapy. Management: Excision with primary closure, skin flaps or grafts, cryosurgery or electrosurgery, Mohs surgery, radiation therapy, topical 5-FU, imiquimod cream, photodynamic therapy.

KERATOACANTHOMA (KA) KA is a special lesion, a pseudocancer, occurring as an isolated nodule, usually on the face, and mimicking SCC. KA is a special lesion, a pseudocancer, occurring as an isolated nodule, usually on the face, and mimicking SCC. Rapid growth! Achieving a size of 2.5 cm within a few weeks. Rapid growth! Achieving a size of 2.5 cm within a few weeks. Etiology: HPV, UVR, chemical carcinogens (pitch, tar). Etiology: HPV, UVR, chemical carcinogens (pitch, tar). Differential diagnosis: SCC, hypertrophic actinic keratosis, verruca vulgaris. Differential diagnosis: SCC, hypertrophic actinic keratosis, verruca vulgaris. Spontaneous regression in 2 to 6 months or sometimes > 1 year. Spontaneous regression in 2 to 6 months or sometimes > 1 year. Management: Surgery Management: Surgery

CUTANEOUS T CELL LYMPHOMA (CTCL) CTCL is a term that applies to T cell lymphoma first manifested in the skin. CTCL is a term that applies to T cell lymphoma first manifested in the skin. The lymph nodes and internal organs become involved in the course of the disease. The lymph nodes and internal organs become involved in the course of the disease. CTCL is a malignancy of helper T cells (CD4+). CTCL is a malignancy of helper T cells (CD4+). All Mycosis Fungoides (MF) is CTCL, not all CTCLs are MF. All Mycosis Fungoides (MF) is CTCL, not all CTCLs are MF. Differential diagnosis: Atypical or refractory “ psoriasis”, “eczema”, and poikiloderma. Differential diagnosis: Atypical or refractory “ psoriasis”, “eczema”, and poikiloderma. Management: Phototherapy (PUVA, UVB), isotretinoin, s.c interferon, topical nitrogen mustard, topical potent steroid (early patch stage), electron-beam therapy, chemotherapy. Management: Phototherapy (PUVA, UVB), isotretinoin, s.c interferon, topical nitrogen mustard, topical potent steroid (early patch stage), electron-beam therapy, chemotherapy.