W4 Lumps Flashcards
Papule:
Nodule:
Vesicle:
Cyst:
P: Solid raised lasion <1cm
N: >1cm papule, may be palpable
V: <0.5cm, serous filled (>0.5cm is a bulla)
C: Epith. Cavity w/fluid > forms nodule
Macule:
Plaque:
Pustule:
Scale:
M: flat discolored patch
P: solid, raised, flat skin
Pu: pus filled elevation
S: shedded keratin epith., easily detached from base epith.
Atrophic:
Hyperkeratosis:
Acanthosis:
A: thinning (layer loss)
H: thickening of keratin (from tumors) > seen as scales
Ac: thickening on epidermal prickle cell layer
Atypia:
Dysplasia:
Neoplasia:
GF coding occogenes / tumor suppressor gene disorder:
Benign N > non-invasive / localised
Malignant N > progressive / locally invasive / metastasis risk
Non-neoplasic lesions:
Hordeolum
Chalazion
Epidermal inclusion cyst
Dermoid
Cyst of zeiss/moll
Xanthelasma
Molluscum contagiosum
Benign epithelial tumors:
Verruca vulgaris
Squamous/Basal cell papilloma
Actinic/solar keratosis
Keratoacanthoma
Freckle
Melanocytic neavi
Syringoma
Malignant tumors:
Basal/Squamous cell carcinoma
Sebaceous gland carcinoma
Malignant melanoma
Hordeolum description:
Acute lid gland infection (u/Staphlococcus aureus)
External: “Stye”, lash + associated zeis/moll gland at lid margin
Internal: Meibomian in tarsel plate
Hordeolum pathophysiology:
Bacterial infection (staph) > inflammatory cascade to remove pathogen > swelling
Chronic Blepharitis > Increased staph population/vulnerability > recurrent hordeola
Hordeolum management:
Self limiting 1w
w/compress 5m bid
Lubricants as needed
Chloramphenicol .5% qid if intense
Hordeolum symptoms:
Well defined hyperemic subcutaneous nodule, (u/with cellulitis)
Internal: larger w/tarsel edema
Tender to touch w/pain on blink
Chalazion pathophys:
Obstruction of sebaceous gland (meibomian/zeis) > extracellular lipid leakage > Sterile inflammation > influx of epithelioid / giant cells, neutrophils, lymphocytes, eosinophils
Chalazion symptoms:
Well defines, enlarging nodule in tarsal plate.
Erythema, oedema, tender
Chronic lesions are firm and painless
Chalazion management:
Spontaneous resolution, otherwise chronic
Acute lesion > w/compress
Chronic > corticosteroid injection / incision
Maintain lid hygiene to prevent reoccurance
Epidermal inclusion cyst:
Epidermis enters dermis > epidermal growth with stratified squamous keratinized epith.
Firm, slow growing, round skin coloured nodule with smelly keratin fluid
Asymptomatic, unless mechanical complications occur (DED/epiphora) requiring excision
Dermoid:
Congenital (eyebrow) /aquired benign tissue malformation from epidermal inclusion in dermis.
Unlike inclusion cyst, is lined with mature epidermal formation, grows at rate of surrounding tissue
Requires excision otherwise inflammatory response when dermoid contacts other tissues
Cysts of zeiss/moll
Benign lesion on ant. Lid margin, non-tender, skin coloured
Zeis > Lash associated Sebaceous gland obstruction > ^sebum
Small round non-translucent
Moll > apocrine gland > sweat filling
Small round translucent
Requires excision to reduce recurrence
Xanthelasma
Common cutaneous lesion, ^with age / associated inflammation
^cholesterol > lipid histocyte (macrophage/foam cell) accumulation > BV cell cluster in superficial dermis
Soft yellow plaque on medial lids
Asymptomatic, excision/ablation/trichloroacetic acid (cosmetic)
Molluscum contagiosum symptoms and management:
Single/multiple small/round/raised/waxy nodules.
Related tox conjuntivitis > chronic unilateral irritation, w/conj. SPEE/hyperaemia, follicles, mucoid disc.
Self limiting in 3-12mo, associated cornea/conj. Complications required excision
Molluscum contagiosum patho:
Viral infection, ^with kids (3y)
DNA poxvirus contact/formites > skin infection > nodules w/intracytoplasmic inclusions > toxic inclusion protein contact with conj. > toxic follicular conjuntivitis
Squamous cell papilloma:
HPV infection of squamous epith. > prolif. Of keratinocytes > hyperkeratotis squamous epith. Projections
Unlike wart, presents as either, skin tag/ pale finger lesion/ broad-base lesion(sessile)
Asymptomatic, excision if desired
Verruca vulgaris:
Wart. Common, benign
HPV infection via contact/formites > viral proliferation of keratinocytes > thickening of stratum corneum (keratinised skin)
Small, skin col. Painless papules, w/scaly hyperkeratinisation > finger projections.
Viral shedding > pap conjuntivitis / keratitis
Self limiting, otherwise cryo w/excision
Actinic (solar) keratosis patho:
Epithelial, pre-malignant slow growth. 40% ^40y, 60% ^60y
UV/cauc. > genetic damage/immunosuppression > p53/16 TS protein alteration > irregular squam. Epith. Proliferation > abnormal (nuclear atypia) keratinocyte tumor at basal epidermis > growth w/o superficial layer involvement.
Keratoacanthoma:
Rare, rapid nodule. With ^age
UV > p53 alteration < proliferation of acanthotic squam. Epith.
Small papule > tender red nodule with keratin cap > keratotic horn > receding epidermis/horn loss > resoultion from 6-12w
No biopsy (false positive for SCC)
Cryo excision if possible
Basal cell papilloma:
80% 26-50y > 100% ^50y
UV/unknown origin (idiopathic) > elevation of squamous epith. Via basal cell proliferation
Single/several round, brown plaques, appearing stuck on. w/ keratin horn.
Benign, cryo excision (cosmetic)
Known as Seborrheic keratosis/senile verruca
Actinic keratosis symptoms and management:
Well defined macules of variable colour (from brown>pink), w/ hyperkeratosis (plaque/horn), non-tender w/stinging
May regress/unchange/progress through basement (SCC)
Requires biopsy > cryo excision
Melanocytic naevi presentation and management:
Junctional naevus: uniform brown macule in kids, at junction of dermis and epidermis
Compound neavus: junctional neavus cells move into dermis > raised papule w/uniform colour
Intradermal naevus: increased epidermal cells in dermis > larger colourless lesion
Asymptomatic, excision (cosmetic)
Freckle:
Common benign area of pigmentation
UVB radiation > melanocytic hyperactivity > melanin production > hyperpigmentation of basal cells
Well-defined flat macule/papule w/variable colour
Requires follow-ups, UV protection to avoid darkening
Melanocytic neavi patho:
UV/genetics/idiopathic > melanocyte aggregation/proliferation
Acquired neavi grow/change with time, low malignancy, congenital neavi have 25% melanoma development
Capillary hemangioma:
Proliferation of vascular endoth. Within dermis and subcutaneous tissue
1% neonates, 1/3 present at birth, 2/3 develop by 6m, resolve by 7y
Superficial lesion > raised red strawberry nodule on brow
Subcutaneous lesion > spongy blue mass
Deep lesion > proptosis/globe displacement
Corticosteroid injection if lesion alters globe/muscle function
Pyogenic granuloma:
Rapid vasular growth (neither pyogenic or granulomatous)
Red nodule w/bleeding
Requires excision, otherwise will atrophy > fibrosis > resolution
Syringoma:
Skin coloured papules from sweat glands on lid/adnexa, with females, may be unilateral
Sporadic proliferation of intraepidermal cells in eccrine gland ducts > duct lining thickening
Excision (cosmetic)
Portwine stain:
Benign BV malformation, doesn’t blanch w/pressure or regress like capilliary hemangioma
Well demarcated soft, flat, pink skin
Laser therapy for cosmetics
Neurofibroma
Neurofibromatosis (genetic disorder) > NF1 mutation > non-myelinated schwan cell proliferation
Dermal > raised small round nodule (tender if subcutneous)
Plexiform > Sup. Eyelid mass (cant be removed w/o lid damage)
Basal cell carcinoma discription:
Most common skin cancer from UV, Aus has greatest incidence 1% pop/year
Arise from pluripotent stem cells, as they require less UV exposure than SCC
BCC patho:
UV > proliferation (^mutation) / gene alteration / immunosupression > tumor mutations* > unregulated proliferation of abmormal basal cells
Tumor mutations in BCC:
Patched mutations / Sonic hedgehog pathway: altered “patched/smoothend” genes > sonic signalling pathway upregulation > ^activation of genes for cell differentiation
Mutations in detox proteins: altered genes for glutathione-S-peroxidase enzyme > decreased skin oxidation defence
Mutation in p53 ts gene > unregulated abnormal cell growth (noted in 50%)
Any of these mutations > basal tumors
BCC symptoms:
Superficial: well defined red patch. Slow growth, w/crusting and irritation
Nodular: Pearly/translucent/skin c./pink papule/nodule. Growth > rolled edge w/central depression > ulceration w/bv
Morphoeic/sclerosing: white/waxy patch from longstanding presence
* Locally invasive, rarely metastatic
BCC management:
Biopsy as:
Superficial/morphoeic BCC appear as eczema/scar, nodular appears as several lesions(SCC).
Removed via radiotherapy
Squamous cell carcinoma discription:
2nd most common skin cancer, arise from actinic keratosis
Risk increases with smoking (3.3x or 1.9x for former smokers) / immunosupression
Related to UVA(320-400nm) and UVB (280-320nm)
Metastasis risk <1%, increasing with size/depth
SCC patho:
UV > proliferation (^mutation) / gene alteration / immunosupression > p53 / melanocortin-1 receptor gene alteration > unregulated proliferation of squamous epith. w/o apoptosis > dermis invading tumor
SCC presentation:
Erythematous, tender papule/nodule. Commonly presents as ulcer with hyperkeratosis/horn.
Lesion expansion > recurrent culceration/bleeding
SCC management:
Cryo to differentiate from actinic keratosis > persisting lesions are excised vis +/- Moh’s technique
Excision > 90% cure rate
Risk decreased via sun protection, antioxidants and NSAIDs
Sebaceous gland carcinoma description:
Rare, very malignant neoplasm from seb. Glands on lids. ^from 60y, 60% on sup. lids
UV > meibomian/zeiss Proliferation (or brow/caruncle) > neoplasm of lipid cells
SGC presentation and management:
Nodular: yellow nodule in tarsal place (like chalazion)
Spreading: thickened tarsal plate w/annilation of meibomian gland orifice > blepharitis appearance
Pagetoid spread: neoplasm invasion of epith. > adnexa/conj. Lesion
Biopsy to rule out bleph. Or chalazion > excision
Malignant melanoma patho:
Genetics/naevi/freckle/UV > malignant transformation of intraepidermal atypical melanocytes
Lentigo: diffuse proliferation along basal layer
Superficial spreading: nests throughout epidermis
Pagetoid spread: invasion of superficial epidermis from below
Nodular: large / poorly differentiated cells
Malignant melanoma presentation and treatment:
Lentigo maligna: flat macule, w/variable pigmentation / irregular margins. Slow progression
Superficial spreading: small raised papule w/ irregular margins. Rapid progression
Nodular: pigmented or amelanotic, symmetrical. Rapid progression w/bleeding ulcers
Biopsy > Moh’s technique excision
Differentiation between naevus and melanoma:
Asymmetry
Boarders (irregular/poor definition)
Color (variable pigmentation)
Diameter (>6mm)
Evolution
Pingueculum:
^ between 70-80y / UV exposure > p53 alteration > degeneration of stromal elsatin/collagen > nodular hyperplasia w/actinic keratosis / epith. Thinning /calcification
No treatment > UV protection > lubricants (DED) > FML qid 7d (flare-up) > excision
Pterygium patho following UV:
^pro-inflammatory cytokines (IL/TNF-a) > inflammatory influx
Epidermal GF / PDGF > cell proliferation / migration
^expression of pro-angiogenic factors (IL-6/8, VEGF, MMPs) > vascularisaion
^MMPs > ECM remodelling > Bowmans layer breakdown
Lesion invades cornea following bowmans damage
UV factors in pterygium formation:
Fibrovascular proliferation of degenerative bulbar conj. UV > several causative factors:
Endogenous photosensitiser activation > ^ROS > oxidation breaks ECM > altered collagen/elastin synthesis
^Expression of epidermal GFs > cytokine production (IL-6/8) and MMP-1
Genetic mutations (possible p53)
Pterygium symptoms:
Wing fibrovascular growth at 3/9o’clock, from limbus over cornea. Can form iron deposition at boarder (Stockers line)
WTR astigmatism when on visual axis, can flare up
Pterygium management:
Monitor for growth > UV protection > lubricants (DED) > FML qid 1w (Flare-up) > excision w/conj. Autograft (visual effect)
Surgery requires excision of growth and adjacent tenons capsule, with conj. Autograft. Heals in 7-14 days with strong pain for 1-2 weeks. Glasses can be used after 6w, commonly recurrs
Pseudopterygium:
Conj. Adherence to corneal stroma following inflammation > wedge shaped conj. Fold over cornea
Can occur from any angle (not 3/9’)
Cannot be removed easily > lubricants > FML qid 1w (DED)
Conj. Inclusion cyst:
Inplantation of epith. Into conj. (trauma/surj) > proliferation > double epith. Cyst w/fluid
Commonly transparent (can be opaque), blink disruption
Requires opthal puncture
Conjunctival dermoid:
Foetal development with epidermal injection in dermis > epith. Fibrous growth w/dermal features
Well-demarcated solid white mass (often w/hairs)
Usually just observed > excision
Associated with goldenhar’s syndrome
Conj. Papilloma:
HPV infection of conj. Squamous epith. > viral transformation and proliferation of keratinocytes
Prolonged proliferation > squamous atypia > OSSN
Pink vascular finger lesions (papilloma) with narrow base (pedunculated) or broad (sessile)
Asymptomatic w/ slow spontaneous resolution > excision (irritating)
Conj. Actinic keratosis:
Benign proliferation, commonly over pterygium / pingueculum
UV/age/smoking/caucasian > proliferation (^mutation)/gene alteration/ immunosuppresstion > p53/16 TS gene alteration > unregulated irrgular squam. Epith. Proliferation > hyperheratinised lesion
Flat, white, plaque. Slow growth.
Requires biopsy (similar to CIN)
conjunctival Pyogenic granuloma:
Rapid, benign fibrovascular lesion (neither pyogenic or greanulomatous)
Conj. Damage > inflammation w/abnormal healing
Red elevation w/ vascular supply
Requires corticosteroid treatment
Conjunctival lymphangioma:
Proliferation of endothelial lymph channels > mass of dilated channels > clear channels can fill with blood > red raised channels
Excision usually have incomplete removal
Capillary haemangioma:
2% neonates, 1/3 at birth, 2/3 develop by 6m
Proliferation of vascular endothelial cells, forming highly vascularised red stromal mass.
75% Self resolves by 7y > corticosteroid injections
Types of ocular surface neoplasia:
Squamous neoplasia occurs on conj. As either localised in epith. (CIN) or as aggressive lesion through basement membrane invading stroma (SCC)
OSSN patho:
UV + HPV > reactivation of HPV > E7 HPV proteins promote proliferation / E6 proteins disable p53 gene > growth
Risk increased with:
HPV infection, UV, caucasian, age, smoking, immunosupression, AIDS, prior Skin SCC
OSSN symptoms:
Leukoplakic: localised thickening od stratifies squamous epith. W/ white keratotis plaque
Papillomatous: vascularised mass, w/ BV corkscrews to supply metabolic proliferating cells
Gelatinous: poorly defined, transparent thickening of squamous epith.
All stain with NaFl due to irregular tight junctions of abnormal squamous cells
Squamous cell carcinoma:
Mass of dysplastic stratified squamous epith. Invading corneal stroma > likely metestasis to lymph
Conjunctival intraepithelial neoplasia:
Partial replacement of conj. Epith. With abnormal epith.
Mild > lower third of epith. Replaced with dysplasic cells
Moderate > middle third
Severe > upper third
Carcinoma in situ > full replacement
Conjunctival naevi:
UV/genetics/idiopathic > junctional naevi (melanocyte clum in basal epith.) > melanocyte migration into stroma > stromal pigmentation
Well-defined boarders, raised, varied pigment on limbal conj. (elsewhere is suspicious), 1/2 w/ microcysts (not present on melanomas), mobile.
Requires periodic measurement/photography > excision w/cryo
Signs of conj. Naevi developing into malignant melanoma:
Development post 20y
Sudden onset / rapid growth / pigment change
Abnormal location (fornices/palpebral conj.)
Increased thickness w/feeder BVs
Primary acquired melanosis patho:
Proliferation of melanocytes in basal conj. ^with caucasion at 55y
No Atypia > hyperpigmentation, low proliferation, low metastasis risk
Atypia > ^melanocyte proliferation, w/abnormal cell structures. 50% metastasis by 5y
Conjuntival melanoma patho:
Develops usually at 60y
15% de novo, 75% PAM, 10% naevi > abnormal melanocyte proliferation through conj. Stroma > 25% metastasis to lymph/brain/liver/lung
Risk increases w/ >2mm, caruncle/fornix involvement
Conjuntival melanoma presentation and management:
Raised dark lesion on conj. Fixed to episclera
May have PAM, or amelanotic, BV feeders
Biopsy > excision > radiation therapy
Recurrance of 25% 5y > 65% 15y
PAM presentation and management:
Flat hyperpigmentation (brown/gold), mobile.
Requires observation > biopsy > Atypia excision
Complexion related (racial) conjuntival melanosis:
Benign hyperpigmentation from excess melanocytes of basal conj. Epith.
Diffuse, patchy, flat pigmentation
Required observation
Lymphoid tumor:
Proliferation of T/B cells in conj.
Smooth, elevated, diffuse mass in conj. Stroma w/ pink colour.
Slow growth, w/malignant risk
Requires biopsy (either benign or malignant) > systemic lymphoma check > chemotherapy
Ocular melanocytosis:
Bluish pigmentation of periocular skin/sclera
Basically physiological, w/ low metastatic risk
Iris naevi:
Raised melanocyte proliferation in iris stroma.
Metastasis risk 8%, increased with: age < 40, inferior location, feathery margins
Requires observation
Freckle is smaller and flat
Iris melanoma:
8% of all uveal melanomas with 5% metastasis by 10y following treatment
Usually asymptomatic, >3mm diameter, >1mm depth, located inf. w/BV, cataracts/ectropion (uncommon).
Requires iridetomy
Iridociliary epithelial cyst:
Cyst on iric/ciliary, arising from pigmented epith.
Requires OCT to resolve sinister pathology
Choroidal neavus:
Benign pigment in 5-10% caucasians
Proliferation of spindle cell melanocytes usually in younger years. Suspicious if older.
Usually <5mm diameter, <1mm deep, w/yellow drusen.
Requires monitoring
Signs of choroidal naevus forming malignancy:
Growth
Blur, metamorphospia, VF loss, photopsia
>5mm diameter, >1mm deep
Presence of orange lipofuscin
Near OD
Associated serous RD
Choroidal melanoma:
80% of uveal melanomas, usually sporadic, otherwise from naevi. 1% have metastasis at time of detection, with 50% mortality at 10y. Commonly metastaise to liver, lungs, bone
Causes blur/metamorphopsia, painless VF loss, floaters
Signs of choroidal melanoma:
Elevated nodular mass under RPE
60% near OD/fovea
Clumps of orange pigment lipofuscin
RPE atrophy/drusen/exudative RD
Choroidal metastasis:
Breast and lung cancer usually metastasise to choroid, with low mortality
Fast growing elevation under RPE > serous RD w/pigment change
Congenital hypertrophy of the RPE:
Scattered pigment on fundus.
Uncommonly atypical CHRPE have comma formation, related to FAP > colon cancer
