ppt on basics of skin tumors, squamous cell carcinoma , bcc, melanoma for medical sudents.

1. MALIGNANT TUMORS OF SKIN
DR MUKHILESH R M.S.,

2. 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.

3. 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

4. Predisposing factors
UV rays
Arsenics,
coal , tar
BCC
White
skin,
genetics
Middle
aged,
men

5. Pathogenesis
 No apparent precursor lesion
 Locally infiltrative.
 Rarely metastasise.
 Never lympatic spread
 Ovoid cells in nests with outer pallisading layer.

6. 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.

7. Prognosis
 High risk BCC
 >2cm
 Specific location – nose , ear, eyes
 Ill-defined margins
 Recurrent tumors
 immunosuppression

8. Management of BCC
 Surgical VS Non Surgical
 Non surgical
 Curettage
 Electrodessication
 Laser vapourisation
 Destroy any potential tissue sample for pathological confirmation and
margin analysis

9. 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

10. 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

11. Contd…
Under local
anesthesia
Saucerising excision
of primary tumor
Sample and defect
are marked and
oriented
Stained with H&E.
Examination of
slide for residual
tumor
Excise more tissue
from mapped area.

12. Contd…

13. Other Modalaties
 Radiotherapy
 Topical treatments
 5-fluorouracil
 Imiquimod
 Cryotherapy

14. 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

15. Pathogenesis
Sun exposure
Scars and
sinuses
Chemical
carcinogens
SCC
Tobacco use
HPV 5 & HPV
16

16. Pathology
 Smooth nodular to verrucous , papillamatous and ulcerating lesions.
 Everted edges and surrounded by inflamed, indurated skin.
 Distant metastasis.
 Secondary lymph nodes involvement.

17. Differential Diagnosis Of SCC
 Actinic keratosis
 BCC
 Keratoacanthoma
 Pyoderma gangrenosum
 Warts

18. 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

19. 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

20. 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
• G2moderately
differentiated
• G3- high
grade

21. Management
 Surgical excision – accurate histology
 Margins to be assessed
 4mm clearance for <2cm
 1 cm clearance for >2cm
 Radiotherapy resistant – Veruccus carcinoma

22. Malignant Melanoma
 Cancer of melanocytes
 Wherever melanocytes exist
 Bowel mucosa
 Retina
 Leptomeninges

24. Macroscopic Features In Nevi
Suggesting Malignant Melanoma

25. Contd…
 Tingling
 Itching
 Serosanguinous discharge
 Blood supply
 Melanomas >1mm have blood supply – doppler positive pigmented
lesion

26. Types Of Malignant Melanoma
 Superficial spreading
 Nodular melanoma
 Lentigo maligna melanoma
 Acral lentiginous melanoma
 Amelanotic melanoma
 Desmoplastic melanoma

27. 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.

28. 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.

29. Lentigo Maligna Melanoma
 Hutchinson’s melanotic freckle
 Slow growing, variegated, brown macule
 Intense sun exposure.
 Women > men
 Less metastaic potential
 Better prognosis

30. 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.

31. Miscellaneous
 Amelanotic melanoma
 Not pigmented
 Poor prognosis
 Desmoplastic melanoma
 Head and neck
 Perineural invasion
 High recurrent rate

32. 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.

33.  Satellite nodules
 Lesions situated with in 2-5cm of the primary
 Intransit lesions
 Situated >5cm , proximal to lymphnode basin

34. 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

35. Staging Of Melanoma

37. Management Of Malignant Melanoma
Pigmented
lesion
Biopsy
Diagnosis of melanoma
<1mm depth
Excision - 1cm
margin
2-4mm
depth
Excision -2cm
margin
>4mm depth
Excision – 3cm
margin

38. 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

39. Sentinel Lymphnode Biopsy

40. Sentinel Lymphnode Biopsy

41. Other Modalities
 Chemotherapy
 Melphalan
 Vemurafenib
 Isolated limb perfusion therapy
 Immunotherapy
 IFN / TNF ALPHA
 Radiotherapy