skin tumours 2008

8/6/2019 Skin Tumours 2008

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TUMOURS OF SKIN

Dr F BhattiPennine VTSSept 08


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SOURCES

GPNotebookhttp://www.gpnotebook.co.uk/simplepage.cfm?ID=-1925906417

Dermnethttp://www.dermnetnz.org/

Atlas of Dermatology

http://www.danderm-pdv.is.kkh.dk/atlas/index.html

eMedicine


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Benign Co nditi o ns

. Ephelide

. Melanotic Naevi

. Granuloma Telangiectaticum

. Haemangioma of skin

. Dermatofibroma

. Papilloma

. Seborrhoeic Keratosis. Squamous Cell Papilloma

. Warts


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Pr emalignant Co nditi o ns

Bowens DiseaseKeratoacanthoma

Marjolins UlcerPagets disease of the NippleSenile Keratosis


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Malignant Co nditi o ns

Basal cell Carcinoma

Squamous cell CarcinomaMalignant MelanomaMycosis FungoidesKaposis Sarcoma


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Basal Cell Ca rc in o ma

L ocally invasive carcinoma of the basal layer of theepidermis. It almost never metastasizes but it may kill bylocal invasion

Commonest skin cancer

Middle aged or elderly, related to sunlight exposure, fairskinned people, M:F approximately 2:1

Lesions occur in exposed areas of the skin (75% occur inthe head and neck)

Gorlin's syndrome. Patients with this condition appear tohave a great tendency to develop basal cell epitheliomata


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C lini c al subtypes

1. No dula r BCCMost common type on the faceSmall, shiny, skin coloured or pinkishlumpBlood vessels cross its surfaceMay have a central ulcer so its edges

appear rolledOften bleeds spontaneously then seemto heal overCystic BCC is soft, with jelly-likecontentsRodent ulcer is an open soreMicronodular and microcystic types mayinfiltrate deeply

2 .S upe rf ic ial BCCOften multipleUpper trunk and shoulders, or anywherePink or red scaly irregular plaquesSlowly grow over months or yearsBleed or ulcerate easily


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Continued BCC

3 . Mo r ph o ei c BCCAlso known as sclerosing BCCUsually found in mid-facial sitesSkin-coloured, waxy, scar-likeProne to recur after treatment

May infiltrate cutaneous nerves (perineural spread)

4 . P igmented BCCBrown, blue or greyish lesion

Nodular or superficial histology

May resemble melanoma

5 . Basisquam o us BCCMixed basal cell carcinoma (BCC) and squamouscell carcinoma (SCC)

Potentially more aggressive than other forms of BCC


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Differential diagnosesNo dula r BCC. Fibrous papule. Naevus

. Seborrhoeic keratosis

. Amelanotic melanoma

S upe rf ic ial BCC. Nummular eczema

. Psoriasis

. Extramammary Paget Disease

. Bowens Disease

P igmented BCC. Malignanat Melanoma. Pigmented Seborrhoeic

keratosis. Traumatised naevus

Mo r phea f o r m BCC. Scar

. L ocalised scleroderma


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Basal Cell Carcinoma


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More BCC


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H igh R isk BCC

They have a high recurrence rate after treatment.

Histological sub-type / features

Sites Head & Neck area.Size greater than 2 cm.

Immunosuppressant.

Genetic disorders e.g.Gorlins Syndrome.

L ow-R isk BCC

Size L ess than 2 cm.

Site Torso, L imbs.


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T r eatment

Surgery, L ocal Radiotherapy, Cryotherapy, or Curretage.Up to 85% superficial BCCs are cured by Photodynamictherapy, with excellent cosmetic results. It is less successfulfor other typesCurettage and cautery with histology is only adequate forsmall lesions.Systemic chemotherapy is ineffective, though topical 5-Fluorouracil cream may be helpful, particularly for multipletumours.

Imiquimod cream . The cream is applied to superficial BCCsthree to five times each week, for 6 to 16 weeks. results inan inflammatory reaction, maximal at three weeks. Up to85% of suitable BCCs disappear, with minimal scarring.Recurrence is common (0.15 - 15%)


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S quam o us Cell Ca rc in o ma

Malignant tumour of the epidermis in which the cells, if differentiated, show keratinformation. Invasive SCC refers to cancer cells that have grown into the dermis.

Associated with:

. Excessive sunlight exposure and pre-existing solar keratosis

. Exposure to chemical carcinogens such as coal tar products

. Chronic irritation/ inflammation (Marjolin's ulcer)e.g. margins of osteomyelitic sinuses/ long-standing ulcers

. Patients with immunosuppression e.g.Renal transplant patients

. Genetic predisposition e.g. Xeroderma Pigmentosum , Albinism

. Pre-malignant conditions e.g. Bowen's disease, L eukoplakia

Rare in patients under 60 years of age unless immunosuppressed

S ites:Men - scalp and ears Women - lower legs

Both sexes - back of hands, face


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Continued SCC

D iff e r ential D iagn o sis

Basal cell carcinoma

Keratocanthoma

Malignant melanoma

Solar keratosis

Pyogenic granuloma

Infected seborrheic wart

Clini c al f eatu r es

Rapidly expanding painless, ulcerated nodule rolled indurated margin. Mayhave a cauliflower-like appearance with areas of bleeding, ulceration or serousexudation.About 55% of lesions occur in the head and neck region. About 25% of lesionsoccur on the hands and arms.Metastasis may occur via local draining lymph nodes and beyond.


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Contd SCC

. 5% of SCCs metastasise.

. More likely if the original SCC was on the lip or ear; or if it waslarge, deeply invading or involving nerve fibres (perineural spread).

. 80% of cases, the metastases develop in the nearest lymph glands.

. Metastases are more difficult to treat than the original skin lesion.Increased risk if the immune system is functioning poorly e.g.

Organ transplantationCLL AlcoholismMultiple skin cancersGenetic defect in skin repair e.g., xeroderma pigmentosum


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SCC of different types/Sites

When confined to the epithelium is called SCC in situ ,Intraepidermal SCC orBowens disease.

SCC in situ of mucosal surfaces includes:Oral leukoplakiaVulval intraepithelial neoplasiaPenile intraepithelial neoplasiaBowenoid papulosis

There are some special types of invasive SCC of the skin :K eratoacanthoma ( pseudocancer) a rapidly growing keratinising skinnodule that may resolve without treatment. BUT appearances can bedeceptive so still refer unless youre a dermatologist.

Carcinoma cuniculatum (verrucous carcinoma), a slowly-growing wartytumour found on the sole of the foot

Invasive SCC types/sites includeVulval SCCOral SCC


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Bowens Disease


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SCC


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Pigmented SCC


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Other SCC

Superficial BCC

Oral SCC-L

eucoplakia


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Keratoacanthoma


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T r eatment

. Depends upon size, location, number to be treated & the preference of the doctor

. Established lesions

.Physical treatment e.g. cryotherapy, curettage, local excision.Topical treatment options include:. Topical Cytotoxic preparations (e.g. 5-fluorouracil),. Topical Retinoids. Salicylic acid in Emulsifying Ointment. Topical Diclofenac Gel (this is licensed for Rx of Actinic

Keratosis in UK). Imiquimod 5% cream used 3 times per week for 16

weeks is an effective treatment for Actinic Keratoses. Systemic treatment may be given for extensive or

resistant lesions e.g. Systemic Retinoids. Screening - for other skin lesions more common in patients with marked sunshine

exposure e.g. SCC, BCC,Melanomas


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U r gent r e f e rr al if :

. Histological Diagnosis of SCC

. With non-healing keratinizing or crusted tumours larger than 1 cm withsignificant induration on palpation. They are commonly found on theface, scalp or back of the hand with a documented expansion over 8

weeks. Who have had an organ transplant and develop new or growingcutaneous lesions as squamous cell carcinoma is common with

immunosuppression but may be atypical and aggressive

**Use the 7-point weighted checklist for assessment of pigmented skinlesion****There is controversy about Ac tini c Ke r at o sis ; whether its a premalignantcondition or early SCC. In a study of 459 patients with cutaneous SCC, therewere associated adjacent actinic keratoses in 97%. Reported r ate o f p r o g r essi o n t o invasive SCC varies but accepted as around 1 in 1000 **


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Malignant Melanoma

Malignant tumour of epidermal melanocytes.Accounts for less than 1% of allcancersNon-pigmented skin , exposed to excessive sunlight, especially if sunburnensues.Spread occurs via superficial lymphatics to give satellite lesions, to regionallymph nodes via deep lymphatics, and via haematogenous spread to the lung,liver and brain. Haematogenous spread usually follows lymphatic.Range of colours and uniformity, often may bleed and ulcerate. It may causepigmented lesions in the mouth.Malignant melanomas undergo two growth phases - radial and vertical. Verticalinvasion is a poor prognostic sign.

Different types :. Superficial spreading (48%). Nodular (23%). L entigo maligna (15%). Acral lentiginous including periungual (6%)

. Amelanotic melanoma


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ContdMelanoma TypesThose that start off as flat patches (i.e. have a horizontal growth phase)

include:Superficial spreading melanoma (SSM)L entigo maligna melanoma (sun damaged skin of face, scalp and neck)Acral lentiginous melanoma (on soles of feet, palms of hands or underthe nails the subungual melanoma)They tend to grow slowly, but at any time, they may begin to thickenup or develop a nodule (i.e. progress to a vertical growth phase).

Melanomas that quickly involve deeper tissues include:Nodular melanoma (presenting as a rapidly enlarging lump)Mucosal melanoma (arising on lips, eyelids, vulva, penis, anus)Desmoplastic melanoma (fibrous tumour with a tendency to growdown nerves)

Combinations may arise e.g. nodular melanoma arising within a superficialspreading melanoma.


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Malignant Melanoma features:

Grossly:Size : . most malignant melanomas are greater than 10mm in diameter

. most benign tumours are less than 6mmSymmetry : . malignant lesions are usually asymmetrical with respect to cell

type, extension and degree of pigmentation

Dermoscopy: Handheld device, relatively new technique, visualisation through stratumcorneum

Without Dermoscopyresembles Seborrheic Keratoses

With a Dermoscope, branched streaksat the edge of the and white areas within arevisible, which suggestsmelanoma. A biopsy confirmedthe lesion was melanoma


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Superficial spreading melanoma

Typical SSMM

SSMM withRegression

Amelanotic Melanoma


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Lentigo Maligna Melanoma

sun damaged skin of face, scalp and neck

L entigo maligna melanoma

L entigo maligna

Nodular melanoma inlentigo maligna


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Acral lentiginous melanoma


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Nodular melanoma

amelanotic nodular melanoma


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D iff e r ential D iagn o sis (MM)

Benign NaeviDermatofibromaPigmented Basal Cell CarcinomaPyogenic GranulomaKaposi's SarcomaVascular malformations

Seborrhoeic Keratosis


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T r eatment

Surgery depends on the thickness of the melanoma and its site.Most thin melanomas do not need extensive surgery

For thicker melanomas (those over 1 mm or so in depth), a muchwider area of skin is cut out. Draining lymph node biopsies may alsobe needed.

Pr o gn o sis :

Death is unlikely if a melanoma has a Breslow depth of less than onemillimetre (T1). About half the patients are dead within 5 years if

their melanoma is more than 4 mm thick (T4).


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finis

skin tumours 2008

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