1. I am giving you guys skin cancer

2. RODENT ULCER MARJOLIN’S ULCER EPITHELIOMA

3. RODENT ULCER

4. 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

5. Predisposing Factors Exposure to UVR Exposure to Arsenic compounds, coal tar, aromatic compounds, IR, Coal Tar Genetic Skin Cancers White skinned people Age 40-80 yrs

6. 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

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

8. Variety of bcc

9. MICROSCOPIC Ovoid cells in nests with single outer Palisading layer

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

11. 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

12. 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.

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

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

15. 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!!

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

18. 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

19. Mohs Micrographic Surgery

20. Indications POORLY DEMARCATED RECURRENT INCOMPLETELY EXCISED AREA AROUND EYES NOSE EAR

21. 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.

22. 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.

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

24. 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

25. EPITHELIOMA(SCC)

26. EPITHELIOMA

27. 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)

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

29. 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.

30. Contd Radiation exposure Smoking HPV infection

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

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

33. SPREAD LOCAL SPREAD LYMPHATIC SPREAD BLOOD SPREAD- rarely

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

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

36. PREMALIGNANT LESIONS Chronic Ulcer : MARJOLINS ulcer

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

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

39. OTHER PREMALIGNANT COND. Bowen disease Xeroderma pigmentosum Senile keratosis

40. LUPUS VULGARIS

41. 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

42. Tibetans - sleep over oven beds-KANG CANCER

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

44. SITES SKIN- anywhere

45. MUCOUS MEMBRANE

46. B/w SKIN & MUCOUS MEMBRANE

47. COLUMNAR EPITHELIUM

48. TRANSITIONAL EPITHELIUM

49. 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)

50. 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 +

51. DDs KERATOCANTHOMA BCC INFECTED SEBORRHOEIC WART MALIGNANT MELANOMA

52. 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.

53. 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%.

54. 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

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

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

57. 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!

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

59. 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

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