1. Lecture #2 Common Skin Lesions and Skin Malignancies

2. Benign Lesions

3. Seborrheic Keratosis
Seborrheic Keratosis

4. Histopathology of seborrheic keratosis: expansion of epidermis by benign, uniform small keratinocytes. Note horn cysts/pseudocysts, which correspond to small comedo-like openings clinically.

5. Clinical variant - stucco keratoses
Stucco Keratosis

6. Dermatosis Papulosa Nigra
Clinical variant - dermatosis papulosa nigra
Dermatosis Papulosa Nigra

7. Skin Tags (Acrochordon, Fibroepithelial Polyp)
Skin tags (fibroepithelial polyps)
Skin Tags (Acrochordon, Fibroepithelial Polyp)

8. Skin Tags and Acanthosis nigricans
Can be accompanied by acanthosis nigracans; indicator of insulin resistance and risk for diabetes
Skin Tags and Acanthosis nigricans

9. Hemangiomas (Cherry Angiomas)
missinglink.ucsf.edu
Hemangiomas (Cherry Angiomas)

10. Pyogenic granuloma
Pyogenic Granuloma

11. Pre-malignant and
malignant lesions

12. Skin cancer incidence >1 million new cancers per year
1 in 5 lifetime risk in America
BCC>SCC>melanoma in incidence
1 million BCC/year
250,000 SCC
70,000 melanoma (invasive)

13. Skin cancer deaths, 2009
Projected skin cancer deaths
Source: American Cancer Society

14. Actinic keratoses and Photodamage
Actinic Keratosis and photodamage on face of elderly man
Actinic keratoses and Photodamage

15. Actinic keratoses on the ear and cheek

17. Actinic Keratoses Epidemiology
Prevalence in Australia:
40-50% of >40yo
80% by age 70
Incidence increases with fair skin, male gender, age
Salasche, JAAD 42(1) S2-7

18. Actinic Keratoses: precursor lesion to SCC
~60% SCC arise from AK
Risk of progression to SCC
0.9% at 1 year
4% at 5 years
>50% spontaneously regress
Marks et al, Arch Dermatol :1039
Criscione et al, Cancer :2523

19. AK/SCC: mutations leading to cancer progression
Oncogenes
Ras
Tumor suppressors
p53: UV “signature” mutations
p16INK/CDKN2A
Increased expression of oncogenes
Decreased expression of tumor suppressors
Spencer et al, Arch Dermatol :796
Pacifico, Br J Dermatol :291

20. AK and NMSC - prevention
Sunscreen
Caffeine PO or topical
NSAIDs PO or topical
Nicotinamide 500mg PO bid
*patients with fewer Aks were more likely to have used NSAIDs; ongoing trials

21. Basal Cell Carcinoma (Nodular x2)
Nodular BCC
Basal Cell Carcinoma (Nodular x2)

22. Basal Cell Carcinoma commons.wikimedia.org/wiki/File:Skinlayers.png
Thought to arise from the basal cell layer
commons.wikimedia.org/wiki/File:Skinlayers.png

24. Basal Cell Carcinoma (Rodent ulcer)
“rodent ulcer” BCC
Basal Cell Carcinoma (Rodent ulcer)

25. Basal Cell Carcinoma (Superficial)
Superficial BCC; note resemblance to dermatitis
Basal Cell Carcinoma (Superficial)

26. Basal Cell Carcinoma (Morpheaform)
Morpheaform BCC
Basal Cell Carcinoma (Morpheaform)

27. Squamous Cell Carcinoma
SCC
Squamous Cell Carcinoma

29. Squamous Cell Carcinoma in situ (Bowen’s disease)
Bowen’s disease/squamous cell carcinoma in situ
Squamous Cell Carcinoma in situ (Bowen’s disease)

30. Squamous Cell Carcinoma
Squamous cell carcinoma on lower lip in a smoker
Squamous Cell Carcinoma

31. Squamous Cell Carcinoma (Keratoacanthoma type)
One month later
SCC, Keratoacanthoma type
Squamous Cell Carcinoma (Keratoacanthoma type)

32. melanoma
Melanoma

33. Melanoma lifetime risk was 1/600 in 1960, what was it in 2010?
B. 1/100
C. 1/50
D. 1/10

34. Melanoma lifetime risk was 1/600 in 1960, what was it in 2010?
B. 1/100
C. 1/50
D. 1/10

35. Melanoma statistics Increasing incidence #1 cancer in 25-59yo
1/67 people born in 2003 will have invasive melanoma
1 death per hour from melanoma

36. Melanoma incidence by state
Cases per 100,000 people; 2005 data
Source: Journal of the American Academy of Dermatology 2011; 65:S6-S16 (DOI: /j.jaad )

37. Melanoma risk factors Risk factor Relative risk Blue eyes Red hair
Prior melanoma
>100 common nevi
FHx (1st degree relative)
Relative risk
1.4
4.1
7.6
8.0
Melanoma risk factors

38. Melanoma risk factors
UVR – natural and artificial, is carcinogenic to humans
Melanoma risk factors – IARC monograph, Group 1 = carcinogenic to humans. Includes alpha & beta particles, X-ray, gamma radiation
El Ghissassi F, et al., Lancet Oncol 10:751, 2009 38

39. ABCDEs of melanoma A Asymmetry B Border Irregularity
C Color variegated
D Diameter > 6mm
E Evolution
ABDC’s of malignant melanoma

40. A Asymmetry
B Border Irregularity
C Color variegated
D Diameter > 6mm
E Evolution

41. Malignant melanoma with asymmetry

42. A Asymmetry
B Border Irregularity
C Color variegated
D Diameter > 6mm
E Evolution

43. Melanoma with border irregularity

44. A Asymmetry
B Border Irregularity
C Color variegated
D Diameter > 6mm
E Evolution

45. Melanoma with color variegation

46. A Asymmetry
B Border Irregularity
C Color variegated
D Diameter > 6mm
E Evolution

47. Melanoma >6mm

48. Lentigo Maligna Melanoma (Melanoma of sun damaged skin)
Melanoma subtype: lentigo maligna melanoma - note telengiectasia, mottled pigmentation in surrounding skin indicating sun damaged skin
Lentigo Maligna Melanoma (Melanoma of sun damaged skin)

49. Acral Lentiginous Melanoma
Melanoma subtype - Acral lentiginous melanoma
Acral Lentiginous Melanoma

50. Approach to the pigmented lesion

51. Where would you biopsy?

52. Where would you biopsy?

53. Where would you biopsy?

54. Approach to the pigmented lesion
Biopsy if changing (growing, bleeding, etc)
Perform excisional biopsy whenever possible
Avoid partial biopsy
Avoid shallow shave biopsy
Biopsy read by dermatopathologist
Consider referral to dermatologist

55. Melanoma prognosis: Depth
Why is proper biopsy important?