I am giving you guys skin cancer

RODENT ULCER MARJOLIN’S ULCER EPITHELIOMA

RODENT ULCER

What is it?? Usually a slow-growing, locally invasive malignant tumor of pleuripotent epithelial cells Arising from basal epidermis and hair follicles, hence affecting the pilosebaceous skin

Predisposing Factors Exposure to UVR Exposure to Arsenic compounds, coal tar, aromatic compounds, IR, Coal Tar Genetic Skin Cancers White skinned people Age yrs

PATHOGENESIS No apparent precursor lesion Proportional to initial dose of carcinogen but not duration. Rarely metastise,Hard to culture,Resist transplantation Mesodermal factors acting as intrinsic promoters coupled with an initiation step

MACROSCOPIC LOCALISED Nodular Nodulocystic Cystic Pigmented Maevoid GENERALISED SUPERFICIAL Multifocal Superficial Spreading INFILTRATIVE Ice pick Morphoeic Cicatrising 90%

Variety of bcc

MICROSCOPIC Ovoid cells in nests with single outer Palisading layer

ORIGIN Basal layer of epidermis. Occasionally arises from basal cells of hair follicles and sweat glands. Seen in scalp known as TURBAN TUMOR

Why Rodent Ulcer?? LOCAL INVASION Gradually destroys tissues it comes in contact with!! LYMPHATIC SPREAD not seen Regional lymph nodes NOT enlarged. Blood spread rare

CLINICAL FEATURES SYMPTOMS: Persisting ulcer or nodule Not painful / may itch Grows slowly SIGNS: Site- 90% BCC seen on face above line joining angle of mouth to lobule of ear.

SIGNS: Site- 90% BCC seen on face above line joining angle of mouth to lobule of ear.

COMMON SITES INNER CANTHUS OF EYE OUTER CANTHUS OF EYE NOSE ON AND AROUND NASOLABIAL FOLD ON THE FORE HEAD Tear Cancer

LESION Starts as Nodule Gradually centre of nodule dies and ulcer results. EDGE- Raised & Rounded.BEADED MARGIN GROWTH SPREADS- Shape irregular. FLOOR- Dried Serum, Epithelial cells. BASE- Tissue & Tumor is eroding ie. Fat, Muscle, Bone!!

PROGNOSIS HIGH RISK > 2cm Eye, Nose, Ear Ill defined margins Recurrent ulcer LOW RISK

MANAGEMENT SURGICAL  Excision  Mohs Micrographic Surgery  Two stage surgery NON SURGICAL  Curettage  Electrodessication  Laser Vaporization  No pathological specimen  No confirmation of diagnosis  Tumor margin not confirmed RADIOTHERAPY

Mohs Micrographic Surgery

Indications POORLY DEMARCATED RECURRENT INCOMPLETELY EXCISED AREA AROUND EYES NOSE EAR

PROCEDURE Performed under LOCAL ANESTHESIA Initial SAUCERISING EXCISION of primary tumors visible extent. Sample and the defect are then marked and oriented Map of specimen drawn & characterised using different colored stains in different equators.

Histotechnician receives tissue sample from the Mohs Surgeon. Sample is sectioned and stained with H&E Mohs surgeon examines slide for tumor residue and excises the relevant mapped parts.

NON SURGICAL Radiotherapy (scars badly) Cryotherapy Topical Chemo (5-fluorouracil, imiquimod)

Follow Up Gross Margin involvement: 67% recurrence Microscopic involvement: 33% recurrence within 2 yrs. Uncomplicated completely excised: Surveillance as in HIGH Risk groups! GORLIN’s syndrome

EPITHELIOMA(SCC)

EPITHELIOMA

What is it?? SCC is a malignant tumor of keratinising cells of the epidermis or its appendages. Arises from the stratum basale of the epidermis 2 nd most common skin tumor (4 times less than BCC & affects Elderly)

PREDISPOSING FACTORS WHITE SKINNED TWICE AS COMMON IN MEN SUN EXPOSURE CLOSER TO EQUATOR

Contd. chronic inflammation (chronic sinus tracts, pre-existing scars, osteomyelitis, burns, vaccination points) immunosuppression (organ-transplant recipients). When a SCC appears in a scar it is known as a Marjolin’s ulcer.

Contd Radiation exposure Smoking HPV infection

MACROSCOPIC The early appearance of SCC may vary from smooth nodular to verrucous, papillomatous and ulcerating lesions. Eventually all lesions ulcerate

MICROSCOPIC Solid column of epithelial cells that are seen growing down into dermis. Expanding into bulb like masses. KERATINISATION, CELL NEST/Epithelial pearl appearance.

SPREAD LOCAL SPREAD LYMPHATIC SPREAD BLOOD SPREAD- rarely

HISTOPATHOLOGY Pathological pattern (e.g. adenoid), Cellular morphology (e.g. spindle) Broder’s grade(grade 1 to 4) Depth of invasion

ORIGIN a) skin denovo b)pre existing condition like Long standing ulcers Senile keratosis Leukoplakia Skin exposed to radiation lupus

PREMALIGNANT LESIONS Chronic Ulcer : MARJOLINS ulcer

FEATURES Painless!!! Less malignant than typical SCC Edge not always raised & everted Slow growing malignant lesion No lymphatic metastasis

TREATMENT Surgery : Wide excision of lesion with 1 cm margin.

OTHER PREMALIGNANT COND. Bowen disease Xeroderma pigmentosum Senile keratosis

LUPUS VULGARIS

Condition which cause chr irritation 1)Leukoplakia 2)Burn,scar,venous ulcer,OM, 3)Continous heat by a charcoal burner ie.kangri – abdomen -KANGRI CANCER

Tibetans - sleep over oven beds-KANG CANCER

Prolonged exposure to chemicals as in soot – SCC of scrotum – CHIMNEY SWEEP CANCER

SITES SKIN- anywhere

MUCOUS MEMBRANE

B/w SKIN & MUCOUS MEMBRANE

COLUMNAR EPITHELIUM

TRANSITIONAL EPITHELIUM

CLINICAL FEATURES History  Age > 40 yrs  Occupation -chimney sweepers  Duration- one or few months (variable cap growth) Symptoms  Nodule/ Ulcer  Usually Painless  Enlarged Lymph node ( unlike BCC)

LOCAL EXAMINATION Site Size and shape.- circular /oval EDGE: Raised & Everted FLOOR: Necrotic tissue, Serum, Blood. BASE: Indurated. MOBILITY: early cases can be moved later fixed Regional Lymph nodes enlarged due to 2ndry infectn Tenderness +

DDs KERATOCANTHOMA BCC INFECTED SEBORRHOEIC WART MALIGNANT MELANOMA

PROGNOSIS There are several independent prognostic variables for SCC: 1 Invasion: a Depth: the deeper the lesion, the worse the prognosis. For SCC 6 mm, 15% of SCCs will have metastasised ; b Surface size: lesions > 2 cm have a worse prognosis than smaller ones. 2 Histological grade: the higher the Broder’s grade, the worse the prognosis. 3 Site: SCCs on the lips and ears have higher local recurrence rates than lesions elsewhere, and tumours at the extremities fare worse than those on the trunk.

4 Aetiology: SCC that arises in burn scars, osteomyelitic skin sinuses, chronic ulcers and areas of skin that have been irradiated has a higher metastatic potential. 5 Immunosuppression: SCC will invade further in those with impaired immune response. 6 Prognosis: Tumours with perineural involvement have a worse prognosis and require a wider than usual clearance. The overall rate of metastasis is 2% for SCC – usually to regional nodes – with a local recurrence rate of 20%.

TNM STAGING T1=or<2cm T2 – 2-5cm T3- >5cm T4 -Muscle or bone invasion NODES N0 - N1- RLN METASTAES MO no mets M1- distant mets

investigations Incision biopsy Xray of affected part r/o bone inv Xray chest r/o mets (very rare event) Other inv for anaesthesia clearance

MANAGEMENT TREATMENT OF PRIMARY LESION  Surgery  Radiotherapy TREATMENT OF SECONDARY LYMPH NODEs  Radical Block dissection  Palliative Radiotherapy

SURGERY Wide excision is Treatment of choice after biopsy confirmation. Excision of growth performed with 2cm margin of normal tissue surrounding tumor. Tumor involving finger, toes, penis.. AMPUTATE!

Indications for Surgery Large sized lesions Involving muscle cartilage bone No radiotherapy facilities Recurrence after radiotherapy.

RADIOTHERAPY Superficial Radiotherapy has 80% cure of early lesions INDICATIONS  poorly differentiated  condition not amenable for surgery  small growth  no involvement of muscle bone cartilage

Please ponder What can I give to the world today??? Thank you