Skin Tumors By Dr. Alaa A. Naif April 19, 2015

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

Palisading of cells at periphery Retraction artefact(space between the stoma and cells) Mucin deposition

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.

Risk factors of BCC and SCC Immunological Genetic Environmental Organ transplantation, HIV infection and immunosuppressive drugs: due to HPV infection and 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)

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 : imiquimod, 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

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

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

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 , Hx of PUVA , 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 ,

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

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

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 spontaneously Incising the overlying epidermis and expressing the milium Electrodesiccation

Skin Tag Presents as a soft skin-colored to slightly hyperpigmented 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 or cryosurgery

Actinic keratosis 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

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

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 Spontaneous resolution Contain myofibroblast Poor Good Treatment Response

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 Dermal nevi are papules with nests of melanocytes in dermis

ABCDE

Congenital melanocytic nevus Present at birth Three types; small (less than 1.5 cm in diameter), medium (1.5-19.9 cm) and large or 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

Freckles vs Lentigines Solar Lentigines Freckles (Ephelides) Age of onset Older age Early childhood 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

Thanks for your attention