SKIN TUMOURS

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SKIN TUMOURS

• PROF.K.S.RAVISHANKAR M.S,F.I.C.S
• SHREE BALAJI MEDICAL COLLEGE

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ANATOMY OF SKIN
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SKIN TUMOURS SITES
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CLASSIFICATION OF SKIN TUMOURS

• BENIGN
• EPIDERMAL
• SEBORRHIC KERATOSIS
• PAPILLOMA
• TRICHILEMMAL TUMOUR
• SEBACEOUS ADENOMA
• SEBACEOUS EPITHELIOMA
• HYDROCYSTOMA,SYRINGOMA,SPIRADENOMA
• DERMAL
• -NEUROFIBROMA
• DERMATOFIBROMA

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CLASSIFICATION OF SKIN TUMOURS

• MALIGNANT TUMOURS
• SQUAMOUS CELL CARCINOMA
• BASAL CELL CARCINOMA
• MALIGNANT MELANOMA
• MALIGNANT SKIN ADNEXAL TUMOUR
• SECONDARIES IN SKIN (eg. sister joseph nodule)

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SKIN ADNEXAL TUMOURS

• Tumours arising from accessory skin structures
  like sebaceous glands , sweat glands , hair
  follicles
• CLASSIFICATION
• ECCRINE GLAND TUMOURS
• Syringoma , Hidradenoma,Syringo cystadenoma
• HAIR TUMOURS
• Trichoepithelioma,Tricholemmoma

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PRE MALIGNANT LESIONS

• Actinic Keratosis- 5-20 will develop
  Squamous/basal cell ca
• Actinic Cheilitis
• Pagets disease of nipple
• Xeroderma pigmentosa
• Chronic Radiation Keratosis
• Bowens Disease
• Bowenoid Papulosis
• Leukoplakia / Erythroplakia
• Dysplastic Melanocytic Nevi (DMN)

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BCC AND SCC

• Risk factors-
• ACTINIC LIGHT- 90 OF TUMORS OCCURS IN SUN
  EXPOSED AREAS.
• ARSENIC- EXPOSURE PREDISPOSE TO DEVELOPMENT OF
  BOWENS DISEASE,MULTIPLE SCC AND BCC.
• IRRADIATION-FOR BENIGN CONDITIONS
• COAL TAR EXPOSURE
• IMMUNOSUPPRESSION-POST TRANSPLANT

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• CHRONIC INFLAMMATION AND TRAUMA-
• CHRONIC OSTEOMYELITIS, FISTULAS,THERMAL OR
  ELECTRICAL BURNS.
• ATROPHIC SKIN LESIONS-DISCOID LUPUS.
• VACCINATION SCARS.

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HEREDITARY FACTORS

• XERODERMA PIGMENTOSA-AUTOSOMMAL RECESSIVE.
• BASAL CELL NEVUS SYNDROMEAUTOSOMAL DOMINANT.
• INFECTIVE FACTOR-
• HUMAN PAPPILOMA VIRUS TYPES 5 AND 8-
• VERRUCUS
• SCC OF GENITALS-HPV 1618
• PERIUNGUAL SCC.

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Actinic keratosis
Xeroderma pigmentosa
Bowens disease of penis
Leukoplakia
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BASAL CELL CARCINOMA

• Most common skin cancer arising from the basal
  layer of epidermis and its appendages
• Low metastatic potiential
• Locally invasive, aggressive, and destructive to
  skin and bone.

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ETIOLOGY OF BCC

• Sun exposure is the most important environmental
  cause of BCC.
• Ionizing radiation causes mutation of tumor
  suppressor genes
• UV B light 280-320nm,
• UV A light 320-400nm
• Amount of UV B exposure during
• childhood and adolescence is
• directly proportional to risk for BCC

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Clinical presentation

• Distribution of BCC
• 70 on face
• 25 on trunk
• 5 on penis, vulva, or perianal skin
• Clinical subtypes (4)
• Nodular- most common
• Superficial- small buds of tumour masses
• Pigmented- resembles naevus or melanoma
• Morpheaform- aggressive behavior, worst prognosis

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PIGMENTED
NODULAR
SUPERFICIAL
MORPHEA FORM
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DIAGNOSIS

• Initial evaluation involves
• Assessment of location
• Punch or excisional biopsy
• Staging

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SQUAMOUS CELL CA
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SQUAMOUS CELL CA TYPES

• Bowens disease
• SCCA in situ
• Full thickness dysplasia
• Bowenoid SCCA
• Looks like bowens
• Invades through BM
• Adenoid SCCA
• Nodular ulcerative lesion
• Often periauricular

• Generic SCCA
• Most common
• Highest rate of metastasis
• Verrucous SCCA
• Verruciform lesions
• Invades by blunt, pseudopod-like growth
• Spindle SCCA
• Indistinct clinically

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CLINICAL FEATURES

• An ulcerative or ulceroproliferative lesion
• Raised and everted edge
• Indurated, bloody discharge from lesion
• Regional lymph nodes commonly involved
• Variants- marjolins ulcer and verrucous
  carcinoma

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Histology of SCC

• Malignant whorls of squamous cells with
  epithelial or keratin pearls are characteristic.
• Broders classification
• I-Well differentiated75 keratin pearls
• II-Moderately differentiated 50 keratin pearls.
• III- Poorly differentiated 25 keratin pearls
• IV- lt 25 keratin pearls

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DIAGNOSIS

• Although the diagnosis of SCC is often strongly
  suspected based on clinical findings, a skin
  biopsy is required for definitive diagnosis.
• A shave biopsy, punch biopsy, incisional biopsy,
  or excisional biopsy, wedge biopsy may be used.
• All skin biopsy samples obtained to diagnose SCC
  must reach at least the depth of the mid dermis
  to allow for determination of the presence or
  absence of invasive disease.

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STAGING

• TX - Primary tumor cannot be assessed
• T0 - No evidence of primary tumor
• Tis - Carcinoma in situ
• T1 - Tumor less than 2 cm in greatest diameter
• T2 - Tumor 2-5 cm in greatest diameter
• T3 - Tumor greater than 5 cm in greatest diameter
• T4 - Tumor with deep invasion into cartilage,
  muscle, or bone.

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Regional lymph nodesN

• NX Regional lymph nodes cannot be assessed
• NO No regional lymph node metastasis
• N1 Regional lymph node metastasis,
• DISTANT METASTASISM
• MX Presence of distant mets cannot be
  assessed
  
• M0 No distant metastasis
• M1 Distant metastasis

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MANAGEMENT

• ACTINIC KERATOSIS-LIQUID NITROGEN , ELECTRICAL
  CURETTAGE.
• BCC-TRADITIONAL SURGICAL RESECTIONS, MOH S
  MICROGRAPHIC SURG
• INDICATIONS FOR MOHS SURG-
• LOCATED IN REGIONS WHERE HIGH RISK FOR TUMOR
  RECURRENCE AREAS,
• DIAMETER gt1CM ON FACE,
• PERINEURAL INVASION,
• MORHEFORM,SCLEROTIC AND INFILTRATIVE TYPE BCC.

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• ELECTRO CURETTAGE,
• CRYOSURGERY,
• RADIOTHERAPHY,
• EXTENSIVE RESCTION AND RECONSTRUCTION
  -AMPUTATION IN CERTAIN CASES
• CHEMOTHERAPHY-
• NO ADJUVANT ROLE,MAY BE OF USE N METASTATIC
  SKIN LESIONS

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MOHS SURGERY
SUPERFICIAL BRACHYTERAPY
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FOLLOW UP

• Low-risk tumors are usually cured with
  appropriate surgical therapy recurrence may
  occur.
• Thus, patients with a history of SCC should be
  evaluated with a complete skin examination every
  6-12 months.
• Patients with high-risk tumors require skin and
  lymph node examinations at 3- to 6-month
  intervals for at least 2 years after diagnosis.

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Marjolins ulcer

• Well differentiated squamous cell ca that occurs
  in chronic scars like burn scar, scar of venous
  ulcer
• No lymphatics in scar tissue hence no spread to
  regional lymph nodes.
• Scar contains no nerves, hence painless.
• Wide excision or amputation for larger lesions
• Radiotherapy contraindicated for fear of
  transformation into poorly differentiated sq cell
  ca.

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Verrucous cancer

• Dry, exophytic,warty growth
• No lymph node spread
• No blood spread
• Surgery is the treatment of choice- wide excision
• Examples
• Giant Condyloma Acuminatum (Buschke-Lowenstein
  tumour)- in genitalia
• Carcinoma cuniculatum-( Verrucous ca of feet)
• Oral florid verrucous ca

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Melanoma - Outline

• General statistics and development
• Risk factors and patient assessement
• Pathology and prognosis
• Work-up and staging
• Surgical treatment
• Lymph node controversy/sentinel node
• Adjuvant therapy

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Melanoma - Statistics

• Mortality increase 2nd only to lung
• 5th most prevalent, incidence 7/year increase
• 5 skin cancer, 75 skin cancer death
• Men common sites- front and back of trunk
• Women common sites- lower leg
• Mostly arise from benign naevus or adjacent area

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Development of Nevi

• Junctional nevi
• nests along dermal-epidermal junction
• Compound nevi
• invade dermis, first as nests then cords and
  single cells
• Dermal nevi
• junctional component lost only in papillary and
  reticular dermis
• Histologically, nevi are classified generally
  as having atypical cells, as in dysplastic nevi,
  or normal cytology, as in the common nevus.

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Junctional Nevi
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Compound Nevi
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Dermal Nevi
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Dysplastic Nevi
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Types of Melanoma

• Acral lentiginous
• Amelanotic melanoma
• Superfical spreading melanoma
• Lentigo maligna melanoma
• Nodular melanoma

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Superficial spreading

• Most common, 70 of all melanomas
• 4th to 5th decade
• Clinically variable pigmentation,irregular
  borders, biphasic growth
• Histologically-asymmetry, poor circumscription
  and lack of maturation

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Superficial spreading
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Lentigo maligna

• 20 of cutaneous melanomas
• Most benign form of melanoma
• Longest radial growth phase gt15 yrs
• Occurs in Hutchinsons freckle
• Elderly sun exposed areas
• Clinical dark, irregular ink spot

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Lentigo maligna
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Nodular melanoma

• 12 of all melanomas
• Most malignant type
• Aggressive vertical growth phase
• Sun-exposed and nonexposed areas
• Usual presentation- darkly pigmented raised nodule

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Nodular melanoma
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Acral lentiginous melanoma

• Occurs in palms,soles and subungual areas
• Worse prognosis than superficial spreading
• Pigment spread to the proximal or lateral nail
  folds is termed the Hutchinson sign, which is a
  hallmark for acral lentiginous melanoma.

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AMELANOTIC MELANOMA

• Appear pink but close inspection reveals
  pigmentation
• Lack of pigmentation causes delay in diagnosis.
• Worst prognosis of all melanomas

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Melanoma

• 70 of melanomas occur on a pre existing nevus.
• 30 of melanomas occur de-novo

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When to suspect malignant transformation in a
mole?

• Asymmetrical outline--- A
• Border irregularity-------B
• Colour change------------C
• Diametergt6mm-----------D
• Elevation------------------E

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Diagnosis

• Excision biopsy of suspected lesions mainstay of
  diagnosis
• Performed with 1-2mm margin and has to be full
  thickness to ascertain the following
• Tumor thickness (Breslow depth)
• Presence of ulceration
• Anatomic level of invasion (Clark level)
• Presence of mitoses
• Presence of regression
• Lymphatic/vessel invasion or vascular involvement
• Host response (tumor-infiltrating lymphocytes)

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• LYMPHATIC SPREAD-SINGLE REGIONAL LYMPHNODESN1,
• MULTIPLE NODES2-3 NODESN2A
• SATELLITE NODULE AND INTRANSIT NODULES WITHOUT
  NODES
• MORE THAN FOUR NODES WITH INTRANSITN3.

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DISTANT METASTASES- METS TO SKIN SUBCUTANEOUS
TISSUEDISTANT NODESM1A M1B METS TO
LUNG M1C ANY VISCERAL METS WITH RAISED LDH
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SENTINEL LYMPH NODE BIOPSY

• Sentinel lymph node biopsy (SLNB) is indicated
  for pathologic staging of the regional nodal
  basin for primary tumors greater than or equal to
  1 mm depth and when certain high-risk histologic
  features (eg, ulceration, extensive regression)
  are present in thinner melanomas lt 1mm)

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STAGING-CLARKES AND BRESLOW
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Staging-Clark

• Level I - in situ at basement membrane
• Level II - through basement membrane into
  papillary dermis
• Level III - spread to papillary/reticular
  interface
• Level IV - spread to reticular dermis
• Level V - sub-cutaneous invasion

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Staging-Breslow

• lt0.76 mm - thin
• 0.76 - 1.49 - intermediate
• 1.50 - 4.00 - intermediate
• gt4.00 mm - thick
• Latest Breslow classification
• lt1mm- Thin melanomas
• 1-4mm- Intermediate thickness melanomas
• gt4mm- Thick melanomas

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AJCC Staging
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Work-up

• Labs and imaging
• CXR , CT chest and LFT
• HN CT neck routine
• If stage III(regional) or IV (distant) - CT head,
  chest, abdomen, pelvis
• Hpe S-100 and homatropine methylbromide (HMB45)
  stains are positive in melanoma.

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Surgical Treatment

• Treatment of Primary (WLE)
• Current recommendations for margins of excision
  are as follows
• Lesions lt1 mm in thickness - 1 cm margin
• Lesions 1-2 mm in thickness - 2 cm margin
• Lesions gt2mm in thickness 3 cm margin
• All depths to underlying muscle fascia

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• Management of lymph nodes
• SLN biopsy
• Node dissection
• Isolated limb perfusion

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• Adjuant chemotherapy
• Cytotoxic drugs
• Interferon
• BCG
• Metastatic disease
• Bleomycin, Oncovin, Lomustin Dacarbazin
• Tamoxifen
• interleukin

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• Prognosis
• anatomic site, ulceration, gender, histologic
  type, nodal disease
• head and neck, trunk and acral regions worse
  prognosis
• women better prognosis than men
• Ulceration, angiogenesis and vascular
  invasion-poor prognosis

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Prognosis

• Breslow (thickness in millimeters) strongest
  predictor

Depth of tumor invasion 5 yr survival ()
lt0.5 mm 99
gt 3 mm 30
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Prognosis

• Clark level less predictive, thin melanomas
  useful(lt1mm)

Level Tumor extent 5 yr Survival ()
I Tumor is confined to epidermis (in situ) 100
II Tumor extends beyond basal lamina into papillary dermis 85
III Tumor extends into papillary dermis and abuts onto, but does not invade, the reticular dermis 65
IV Tumor extends into reticular dermis 50
V Tumor extends into subcutaneous fat 15
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Prognosis

• Survival according to regional lymph node
  involvement

Node involvement 5 yr survival ()
Negative nodes 75 (85 for negative SLN)
1 3 positive nodes 50
4 or more positive nodes 25
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Prognosis

• Survival according to metastatic spread

Stage Extent 5 yr survival ()
II Local recurrences within 3 cm of primary site 30
III Satellitosis lt20
IV Distant metastases lt10
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NECROLYTIC MIGRATORY ERYHTEMA
ACANTHOSIS NIGRICANS
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Thank You