Benign and Malignant Neoplasms of Skin Flashcards
Benign Cutaneous Neoplasms
•All adults have benign cutaneous neoplasms•As varied as they are common•Most never come to medical attention•Concerns may be cosmetic or suspicious for skin cancer•Proper training enables proper triage
Seborrheic Keratosis
- Common
- Skin-colored, pink, brown
- Stuck on appearance, raised on top of the skin
- Sign of Leser Trelat•Abrupt appearance of multiple lesions•Rare paraneoplastic phenomenon•Stomach, colon cancer
Seborrheic Keratosis
Dermatosis Papulosa Nigra
- Variant of seborrheic keratosis
- Common in Black and Asian patients
- Etiology unclear, ~ 50% have family history
- Face and neck
Verruca Vulgaris
- Caused by HPV
- >150 types infect the skin or mucosa, most cause benign papillomas or warts
- Anogenital warts (condyloma acuminata) is a highly prevalent STI caused by HPV-6 or -11 (low-risk types)
- High-risk types, HPV-16,-18, are major cause of cervical/anal cancers
- Immunosuppressed patients are at higher risk of worse infection
- Treatment: destruction modalities and imiquimod•Highly effective prophylactic HPV vaccines are available
Verruca Vulgaris
Infantile Hemangioma
- Most common benign soft tissue tumor of infancy
- Growth pattern: precursor lesion may be present at birth; early proliferation (through 2 months of age); gradual, spontaneous involution (by age 10)
- May be associated with extracutaneous findings when occurring at certain anatomic sites (e.g., the face, neck, lumbosacral area)
- Residual skin changes (e.g., scarring, atrophy, etc) may persist after involution is complete
- Treatment: topical timolol for small, superficial lesions; systemic β-blockers for complicated lesions
Infantile Hemangioma
Cherry Angioma
•A common, benign lesion found in most individuals by the age of 60 years, often in large numbers•Red, dome-shaped papules up to several millimeters in diameter that begin appearing during adult life, most commonly on the trunk and upper extremities•Consist of dilated, congested capillaries and postcapillary venules within the papillary dermis
Glomus tumor
•Originates from cells of the glomus body (a normal AV shunt supplied with nerve fibers, serves a temperature-regulating function)•Glomus bodies are highly concentrated in fingertips•Most common on hands and subungual region•Subungual lesions are painful•Small reddish or bluish papule
Nevus
- Proliferation of melanocytes•Majority appear within first two decades of life•Factors related to development:
- Heredity•Degree of sun-exposure in childhood•Skin-type
- Mean number in White teens approx 15-25 vs < 5 in skin of color
- Many different types of nevi
Types of Nevi
A junctional nevus is a brown to black macule with melanocytic nests at the junction of the epidermis and dermis
A compound nevus is a brown papule with combined histologic features of junctional and intradermal nevi
An intradermal nevus is a skin-colored or light brown papule with nests of melanocytes in the dermis
Acral Nevus
Blue Nevus
Blue color due to location deep in the dermis (Tyndall effect)
Halo nevus
•Zone of depigmentation surrounding nevus•Immune response against nevus cells•Melanoma undergoing regression may appear white or grey
Congenital Nevus
•Present at birth or develops shortly after•Small•<1.5 cm in diameter (in adults)•Medium:•between 1.5 and 20 cm in diameter (in adults)•Large and giant congenital nevi•>20 to 40 cm and >40 cm in diameter (in adults), respectively•Significantly higher risk for developing melanoma than do ordinary nevi
Nevus Spilus
•Tan patch with superimposed “speckles” that develop over time•Darker macules and papules vary from lentigines (sun spots) to junctional and compound nevi to Spitz and blue nevi•Small risk of cutaneous melanoma
Monitoring of Nevi
•Growth of lesion•Large lesion•Change in color•Several colors•Irregular borders•Itching•Tenderness•Bleeding•Irritation
Melanoma Epidemiology
•Accounts for <5% all skin cancers, but majority of skin cancer related deaths•Incidence increasing faster than any other cancer•More than 20 times more common in Whites than Blacks•Lifetime risk of development•2.6% (1 in 38) for Whites•0.1% (1 in 1,000) for Blacks•0.58% (1 in 172) for Hispanic•Average age at diagnosis is 65 years•One of the most common cancers in young women
Etiology Melanoma
•Incompletely understood•UV radiation is believed to play a role in some melanomas•Mutations in the following genes associated with melanoma tumor syndromes and some other familial tumor syndromes•CDKN2A/CDK4: familial atypical multiple mole melanoma•BAP1: BAP1 cancer syndrome•MITF: MITF tumor syndrome
Risk Factors
•Family history (1st degree relative) or prior personal history of melanoma•History of severe or blistering sunburns•Changing mole•Giant congenital nevus (>20cm)•Older age•Lighter skin phototype•Multiple atypical nevi
Melanoma Types
•Superficial spreading (most common)•Nodular•Lentigo maligna melanoma•Acral lentiginous (least common)
Superficial Spreading
•~70% of all cases•Grows slowly over month to years•Macule, patch or slightly raised plaque with varied color, irregular borders•Sun-exposed skin•More commonly seen on legs of women and trunk of men
Nodular Melanoma
•15-30% of all cases•Most aggressive type of melanoma• 2nd most common type•Vertical growth phase only
Lentigo Maligna Melanoma
•Radial growth: lentigo maligna (in situ melanoma in sun-damaged skin)•Vertical growth: lentigo maligna melanoma•Usually on the face or other sun-exposed areas•Older patients•Less aggressive
Acral Lentiginous Melanoma
•Rare, approximately 5% of all melanomas•Represents a disproportionate percentage in Blacks (up to 70%) and Asians (up to 45%) •Occurs on the palms, soles, and nail apparatus•Often misdiagnosed which leads to diagnosis delays•Very poor prognosis
Bob Marley died in 1981 aged 36 from a melanoma that started under his big toenail in 1977. The first doctor that he consulted thought that the lesion on his toe was a soccer injury. After it began to look worse, Marley consulted another doctor who biopsied the spot and discovered that it was melanoma.
Workup and Treatment
•History, review of systems and physical exam•Sentinel lymph node biopsy for certain lesions•Metastatic work up (imaging, labs) if physical evidence of disease or nodal disease on sentinel lymph node biopsy•Initial treatment is usually surgical excision•More advanced disease, therapies targeted to specific genetic mutations and immunotherapies•Referral to oncology
Non-melanoma Skin Cancer (NMSC)
•Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)•Most common cancers in White patients•1 in 5 Americans will develop skin cancer in their lifetime (95% NMSC)
In individuals
with fair skin, approximately 75–80% of NMSCs are BCCs and up to
25% are SCCs1. Because the incidence of NMSC continues to rise,
these neoplasms represent a significant health problem from the standpoint
of patients’ well-being and from the perspective of healthcare
expenditures.
Risk Factors for NMSC
•Sun exposure•Tanning bed use•Occupational: airline pilots, farmers, sailors/fishermen•Ionizing radiation exposure•Genetic syndromes (e.g., XP, albinism)•Immunosuppression•Carcinogen exposure (e.g., arsenic )•HPV infection
Basal Cell Carcinoma (BCC)
•Most common skin cancer in White, Hispanic, Asian patients•2nd most common skin cancer in Black patients•Sun-exposed sites•Incidence of metastasis <1%•Pink, pearly papule with telangiectasias; sometimes with ulceration
Pigmented BCC
More common in skin of color
Advanced BCC
•If untreated, can invade deeper tissues including muscle, cartilage, and even bone••Treatment options: radiation, vismodegib (inhibits hedgehog signaling pathway)
Squamous Cell Carcinoma (SCC)
•Most common skin cancer in Black patients•2nd most common skin cancer in White, Hispanic, Asian patients•Multiple morphologies, nodules, papules with keratotic ‘horns’•Pathogenesis: malignant transformation of keratinocytes•UV radiation induces DNA damage including formation of pyrimidine dimers•HPV•Risk of metastasis•SCCs located on the ear, lip and genitalia more likely to metastasize
Clinical Spectrum of SCC
A.Eroded and keratotic nodule, developed at the site of trauma on the shin
B.Large, fungating nodule on the dorsum of the hand
C.Multiple eroded superficial SCCs in association with actinic damage
Keratoacanthoma
•Rapidly enlarging papule evolves into a sharply circumscribed, crateriform nodule with a keratotic core over a period of a few weeks•May resolve slowly over months•Head and neck or in sun-exposed areas of the extremities, with or without symptoms of pain or tenderness.
SCC in Skin of Color
•More likely to present in non sun-exposed areas•Lower extremities•Anogenital region•Risk factors: chronic ulcers, chronic inflammatory disorders, burn scars, immunosuppression, trauma, HPV•Delays to diagnosisIncreased risk of metastasis and death
Treatment of NMSC
- Surgical excision
- Mohs surgery•Specialized type of skin cancer surgery that removes the skin cancer and clears the margin while preserving the tissue around it•Face, ears, large tumors
- Electrodessication and curettage•Used for superficial skin cancers like in-situ SCC or superficial BCC
- Topical chemotherapy: imiquimod cream, 5-fluorouracil cream
- Used for superficial skin cancers like in-situ SCC or superficial BCC
Sunscreen and Photoprotection
Angiosarcoma
•Uncommon malignant neoplasm of endothelium•Predilection for skin/superficial soft tissue•Most commonly affects the scalp and face of the elderly and areas of chronic lymphedema or radiodermatitis•Grows rapidly, recurs locally, and metastasizes widely•Poor prognosis, five-year survival <15%•Most long-term survivors received early radical ablative surgery
Kaposi Sarcoma
•Malignant neoplasm of lymphatic endothelial cell origin•Human herpesvirus-8 (HHV-8) the implicated agent•Multifocal, systemic disease (may involve lymph nodes, lungs, GI tract, liver, and spleen)•Pink patches to dark violet plaques, nodules or polyps•Chemotherapy and/or radiation is favored over surgery due to multifocal nature of disease
KS Types
Classic
•Mediterranean and Ashkenazi Jewish descent•Men, age 50 and 70 years•Indolent course, most commonly on the legs
African Endemic
•Males in equatorial Africa•4 variants: nodular, florid, infiltrative, and lymphadenopathic•Lymphadenopathic type mostly affects children and is fatal
Iatrogenic
•From prolonged high-dose systemic immunosuppression from medications•Mostly limited to skin, infrequent visceral involvement•May resolve when immunosuppression is discontinued
AIDS-Associated
•Affects HIV+ patients with advanced immune impairment and CD4 + T-cell counts of <500, AIDS-defining illness•More likely than classic KS to have a rapidly progressive course•Introduction of ART dramatically decreased incidence, morbidity, and mortality
Giant congenital nevus
Melanoma
sebhorric keratosis
Cherry angioma
VV
BCC
ks
IH
