MALIGNANT TUMORS OF SKINDR MUKHILESH R M.S.,

Salient Features Of Skin Malignancies

Most commonly epidermal origin

Basal cell carcinoma

Squamous cell carcinoma

Malignant melanoma

Skin adnexal tumors are rare.

Chemical carcinogens play a major role.

Basal Cell Carcinoma Most common skin tumor, originates from basal layer of epidermis

Slowly growing , locally invasive – RODENT ULCER.

26 histological variants.

Most common are

Nodular

Superficial speading

Infiltrative

Pigmented & Morpheaform

Predisposing factors

BCC

UV rays

Middle aged, men

White skin,

genetics

Arsenics, coal , tar

Pathogenesis

No apparent precursor lesion

Locally infiltrative.

Rarely metastasise.

Never lympatic spread

Ovoid cells in nests with outer pallisading layer.

Contd… Nodulocystic

Waxy , cream coloured with rolled, pearly borders

surrounding central ulcer.

Morpheaform

Type IV collagenase and spread rapidly

Flat, plaque like lesion

Basosquamous variant

Highly aggressive

Metastasize similar to SCC and aggressive treatment required.

Prognosis

High risk BCC

>2cm

Specific location – nose , ear, eyes

Ill-defined margins

Recurrent tumors

immunosuppression

Management of BCC

Surgical VS Non Surgical

Non surgical

Curettage

Electrodessication

Laser vapourisation

Destroy any potential tissue sample for pathological confirmation and

margin analysis

Surgical Management

Complete tumor removal , with pathological confirmation and margin analysis.

Large tumors invading adjacent structure with aggressive histology – WIDE LOCAL EXCISION

0.5-1cm margin

Reconstructive procedures

MOHS Micrographic Surgery

Excision of skin cancer under microscopic control.

Minimise recurrent rates with maximum conservation.

Indicated in

Poorly demarcated,

Recurrent / incompletely excised

Near vital structures

Can also be used for SCC, lentigo maligna,DFS

Contd…

Under local anesthesia

Saucerising excision of primary tumor

Sample and defect are marked and

orientedStained with H&E.

Examination of slide for residual tumor

Excise more tissue from mapped area.

Contd…

Other Modalaties

Radiotherapy

Topical treatments

5-fluorouracil

Imiquimod

Cryotherapy

Cutaneous Squamous Cell Carcinoma

Malignant tumor of keratinising epithelium of epidermis

2nd most common tumor

Cumulative sun exposure and damage

Associated with pre-existing scars, osetomyelitis, burn.

Marjolin’s ulcer

Pathogenesis

SCC

Sun exposure

Chemical carcinogens

HPV 5 & HPV 16Tobacco use

Scars and sinuses

Pathology

Smooth nodular to verrucous , papillamatous and ulcerating lesions.

Everted edges and surrounded by inflamed, indurated skin.

Distant metastasis.

Secondary lymph nodes involvement.

Differential Diagnosis Of SCC

Actinic keratosis

BCC

Keratoacanthoma

Pyoderma gangrenosum

Warts

Microscopic Appearance

Irregular masses of squamous epithelium proliferate and invade dermis.

KERATIN PEARLS

Perineural / vascular invasion

Positive for cytokeratin 1 and 10

Border’s histological grading

Ratio of pleomorphic and anaplastic to normal cells

Prognosis

Invasion Depth – deeper lesion , worse the prognosis Surface size - >2 cm

Histological grade

Site Lips and ears – increase recurrent rate

Immunosuppression

Perineural and vascular involvement

Aetiology

TNM Classification

Size

• T1 - <2cm• T2 - 2-5 cm• T3 - >5cm • T4 - muscle or

bone involvement

Nodes

• N0 - no regional nodes

• N1 - regional nodes

Metastasis

• M0 - no metastasis

• M1- distant metastasis

Grade

• G1- low grade• G2-

moderately differentiated

• G3- high grade

Management

Surgical excision – accurate histology

Margins to be assessed

4mm clearance for <2cm

1 cm clearance for >2cm

Radiotherapy resistant – Veruccus carcinoma

Malignant Melanoma

Cancer of melanocytes

Wherever melanocytes exist

Bowel mucosa

Retina

Leptomeninges

Macroscopic Features In Nevi Suggesting Malignant Melanoma

Contd…

Tingling

Itching

Serosanguinous discharge

Blood supply

Melanomas >1mm have blood supply – doppler positive pigmented

lesion

Types Of Malignant Melanoma

Superficial spreading

Nodular melanoma

Lentigo maligna melanoma

Acral lentiginous melanoma

Amelanotic melanoma

Desmoplastic melanoma

Superficial Spreading Melanoma

Commonest type – 70%

Arise from pre – existing nevus

Rapid growth of darker pigmented are in a junctional nevus.

Predominantly radial growth phase.

Nodularity can occur – vertical growth phase.

Nodular Melanoma

More aggressive

Increased vertical growth than radial phase

Middle age men.

Usually trunk.

Sharply demarcated, blue-black papules 1-2cm.

Lack horizontal growth phase.

Lentigo Maligna Melanoma

Hutchinson’s melanotic freckle

Slow growing, variegated, brown macule

Intense sun exposure.

Women > men

Less metastaic potential

Better prognosis

Acral Lentiginous Melanoma

Soles of feet and palms of hand

Rare in white skinned people

Flat, irregular macule.

Can mimic a fungal infection

Biopsy of the nail matrix rather than just the pigment.

Hutchinson’s sign nail-fold pigmentation then widens progressively to

produce a triangular pigmented macule with nail dystrophy.

Miscellaneous

Amelanotic melanoma

Not pigmented

Poor prognosis

Desmoplastic melanoma

Head and neck

Perineural invasion

High recurrent rate

Histology

Malignant changes of melanocytes in basal epidermis

Horizontal growth phase – cells spread along the dermo-epidermal junction

Vertical growth phase – dermis may be invaded and increased metastatic potential.

Satellite nodules

Lesions situated with in 2-5cm of the primary

Intransit lesions

Situated >5cm , proximal to lymphnode basin

Management

History and clinical examination

Excision biopsy with 2mm margin of skin and subdermal fat.

Incisional biopsy – large lesion / facial lesions where excision results in

scarring.

Staging of melanoma

Clarkes’ staging

Breslows’ classification

Staging Of Melanoma

Management Of Malignant MelanomaPigmented

lesion

Biopsy

Diagnosis of melanoma

<1mm depth

Excision - 1cm margin

2-4mm depth

Excision -2cm margin

>4mm depth

Excision – 3cm margin

Management of lymphnodes

Based on breslow thickness.

<1mm least beneficial with prophylactic dissection.

>4mm increased chance of both lymphatic and distant metastasis.

Intermediate thickness

Elective prophylactic lymph node dissection

Sentinel lymphnode biopsy

Sentinel Lymphnode Biopsy

Sentinel Lymphnode Biopsy

Other Modalities

Chemotherapy

Melphalan

Vemurafenib

Isolated limb perfusion therapy

Immunotherapy

IFN / TNF ALPHA

Radiotherapy