Skin tumors Flashcards
What is the 2nd most common skin cancer?
SQUAMOUS CELL CARCINOMA (epithelioma)
- in old men
- occurs in pre-existing lesion (venous ulcer or burn)
- grossly proliferative/ulcerative/red plaque like
What are the predisposing factors for SSC?
- prolonged exposure to UVR or tar
- previous irradiation
- long standing irradiation (marjolin ulcer)
- PREMALIGNANT LESIONS
What are the premalignant lesions that predispose to SSC?
- senile keratosis
- Bowen’s disease
- Paget’s disease
- leukoplakia
- chronic scars
What is the clinical picture of a SSC?
- ulcero-proliferative lesion
- raised & everted edge, fixed indurated base, necrotic floor with bloody discharge
- induration extends beyond the margin
- regional lymph nodes are hard, nodular, initially mobile eventually fixed
histo -> malignant epithelial cells with central Keratin pearls surrounded by prickle cells
What other variants of SSC are present?
MARJOLIN’S ULCER -> no lymph node involvement
VERRUCOUS CARCINOMA -> no lymph node involvement
What is the TNM staging of for skin cancer (other than melanoma)?
T0: no tumor T1: <2cm T2: 2-5cm T3: >5cm T4: spread to cartilage, muscle or bone
N0: no nodes
N1: regional nodes ++
What is Broder’s classification of SSC?
I -> Well differentiated 75% or more Keratin pearls
II -> moderately differentiated 50-75% keratin pearls
III -> poorly differentiated 25 - 50% keratin pearls
IV -> <25% keratin pearls
What investigations should be done for suspected SSC?
- edge biopsy
- take a whole lymph node
How should SSC be treated?
- radiotherapy (BRACHYTHERAPY) -> doesnt effect nearby structures
- wide excision with safety margin -> skin graft or flap
- amputation 1 joint above
- block dissection of regional lymph nodes
- if LN + -> chemotherapy (methotrexate, vincristine, bleomycin)
- cryo probe or topical fluorouracil or electrodessication -> field therapy
What is the treatment of a Verrucous carcinoma?
wide excision
What makes the prognosis of SCC worst?
- tumor size >2cm
- ill defined borders
- associated immunosuppression
- poorly differentiated
- perineural involvement
- invasion
What is the commonest skin tumor?
BASAL CELL CARCINOMA
- more common in whites, males, & middle aged or elderly
- high exposure to UV light
- only locally malignant -> erodes deeply into local tissues including cartilages & bone causing extensive local destruction
RODENT ULCER
What is the most common site for occurrence of a rodent ulcer?
- face above the line drawn between angle of mouth & ear lobule
- TEAR CANCER
What are the types of of BCC?
- NODULOCYSTIC & NODULOULCERATIVE (commonest)
- nodular
- ulcerative
- pigmented BCC (mimics melanoma)
- field fire or forest fire BCC
What is forest fire BCC?
wide area involvement with central scabbing & peripheral active proliferating edge
What are the clinical features of a BCC?
- nontender, dry, slowly growing, non mobile ulcer with RAISED & BEADED edge
- central scab
- beading area is active proliferating cells
- DIRECT SPREAD ONLY (no LN involvement)
What is considered a high risk BCC lesion?
- > 2cm
- near eye/nose/ear
- ill-defined margin
- recurrent tumors
- immunosuppressed
How should a BCC be treated?
- radiosensitive
- radiotherapy if its FAR from eyes
- no radiotherapy if it erodes bones
- wide excision with skin graft or flap
- laser surgery, cryosurgery
- local 5FU ointment
What are the indications for surgery in BCC?
- rodent ulcer eroding cartilage or bone
- close to the eye
- recurrent
- radio-resistant
- small lesion
A hemartomata of melanocytes due to excessive stimulation is called?
NAEVI
- presents during birth of later on
What are the types of NAEVI?
- hairy mole
- lentigo (flat black spot replace basal epidermis)
- intradermal naevus (cluster of dermal melanocytes in face)
- junctional naevus (immature unstable & PREMALIGNANT)
- compound naevus (intradermal + junctional) potentially malignant
What is a malignant tumor arising from the epidermal melanocytes? MOST AGGRESSIVE MALIGNANT TUMOR
MELANOMA
+ dopa test
What are the risk factors for developing a malignant melanoma?
- exposure to UV light
- Albinism & Xeroderma pigmentosa
- Junctional Naevus
- Large congenital naevi (larger than 20cm)
- family history
- immunosuppression or post renal transplant or NHL
How do we know a benign naevi is turning malignant?
MAJOR SIGNS -> change in size (more than 6mm), shape, & color
- inflammation, crusting, bleeding, itching
- nodularity, ulceration, halo around mole
- satellite lesions
- doppler positive pigmented lesions (>0.9mm thick have blood supply)
What is the most common site in females for development of melanoma?
leg
What is the most common site in males for development of melanoma?
front or back of trunk
What classification is based on the thickness of the tumor in melanoma?
BRESLOW'S CLASSIFICATION I -> less than 0.75mm II -> between 0.76 to 1.5mm III -> 1.51 to 4mm IV -> more than 4mm
What classification of melanoma is based on the depth of invasion?
CLARK'S LEVELS level 1 -> epidermis level 2 -> papillary dermis level 3 -> fill papillary dermis completely level 4 -> reticular dermis level 5 -> subcutaneous tissue
what is the common site for an extra cutaneous melanoma?
ocular
What is the most common clinical type of a melanoma?
SUPERFICIAL SPREADING 64%
- in middle age
- more radial growth
- from pre existing naevus
- better prognosis
What type of melanoma occurs in a younger age group of men on their trunk or head & neck, and has more vertical growth?
NODULAR MELANOMA 12-25%
- more aggressive
- poor prognosis
which melanoma is the least malignant, is common in old age & face, is slow growing, variegated, brown macule/lentigo?
LENTIGO MALIGNA MELANOMA (Hutchinson’s melanotic freckle) 7-15%
- in elderly women
- common in face neck & hands
What type of melanoma occurs in palms, soles & subungual region (under nail)?
ACRAL LINTIGINOUS MELANOMA 5%
- least common
- poor prognosis
- more vertical growth phase
- mimics fungal infection/pyogenic granuloma
What is the WORST type of melanoma that is S100 & HMB45 +ve?
AMELANOTIC MELANOMA
- tumor cells loose their capacity to synthesize melanin
- pinkish FLESHY growth of rapidly progressive tumour
- mimics soft tissue sarcoma
Which melanoma has high affinity for perineural invasion?
DESMOPLASTIC MELANOMA
- common in head & neck with higher recurrence rate
What are the clinical features of melanoma?
- can start from pre-existing naevus (JUNCTIONAL) or as de novo in normal skin
- no induration
- pigmentation with irregular surface margin
- rapid growth
- ulceration, bleeding, itching, change in color
How does the spread of melanoma occur?
- spreads to regional lymphatics
- in-transit nodules or satellite nodules (retrograde spread to lymphatics)
- blood to lungs, liver, brain, skin, or bones (BLACK SECONDARIES)
What is the TNM staging for melanoma?
T0: no tumor N0: no nodes
T: in situ N1a: 1 node micrometastasis
T1a: <1mm no ulceration N1b: 1 node macrometastasis
T1b: <1mm with ulceration N2a: 2 or 3 nodes micrometastasis
T2a: 1-2mm no ulceration N2b: 2 or 3 nodes macrometastasis
T2b: 1-2mm with ulceration N2c: satellite of in transit lesions
T3a: 2-4mm no ulcerations N3: 4 or more nodes; nodes with satellite or in transits
T3b: 2-4mm with ulcerations
T4a: >4mm no ulcerations M0: no blood spread
T4b: >4mm with ulcerations M1a: skin, subcutaneous tissue, distant node
M1b: lung spread
M1c: other viscera or distant spread & increase in LDH
what are the 5 most important features of melanoma?
- asymmetry
- border irregularity
- color variation
- diameter >6mm
- elevation
what are the tumor markers for melanoma?
- MELAN-A
- S100
- HMB45
- LDH
What investigations should be done for melanoma?
- excision biopsy of primary
- lymph node excision
- US & chest X-ray to see metastasis
- CT scan of head chest abdomen pelvis
- urine for MELANURIA -> advanced disease
- sentinel lymph node biopsy
What is the treatment for primary melanoma?
- wide excision with clearance margin 2cm
- in fingers & toes -> disarticulation
- if area is wide -> amputate 1 joint above
- in anal canal -> abdominoperineal resection
- in eye -> enucleation of eye
- immunotherapy using tumour antibodies BCG, levamisole in advamced melanomas
- radiotherapy on beneficial in secondaries in brain & bones
When should chemotherapy be used in case of melanoma?
- secondaries in liver, lungs, or bone
- after surgery IV (melphalan & carboplatin)
