TUMOURS OF SKIN

Dr F BhattiPennine VTS Sept ‘08

SOURCES

GPNotebook

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

Dermnet

http://www.dermnetnz.org/

Atlas of Dermatology

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

eMedicine

Benign Conditions

. Ephelide

. Melanotic Naevi

. Granuloma Telangiectaticum

. Haemangioma of skin

. Dermatofibroma

. Papilloma

. Seborrhoeic Keratosis

. Squamous Cell Papilloma

. Warts

Premalignant Conditions

Bowen’s Disease Keratoacanthoma Marjolin’s Ulcer Paget’s disease of the Nipple Senile Keratosis

Malignant Conditions

Basal cell Carcinoma Squamous cell Carcinoma Malignant Melanoma Mycosis Fungoides Kaposi’s Sarcoma

Basal Cell Carcinoma

Locally invasive carcinoma of the basal layer of the epidermis. It almost never metastasizes but it may kill by local invasion

Commonest skin cancer

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

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

Gorlin's syndrome. Patients with this condition appear to

have a great tendency to develop basal cell epitheliomata

Continued.. BCC

Common sites are in normal and sun damaged skin on the face, in a region above a line drawn between the corner of the mouth and the lobe of the ear

The initial lesion is a small pearly-white nodule with visible (telangiectatic) blood vessels; early lesions may bleed and ulcerate and then heal again

Red nodule forms which expands to leave a characteristic rolled edge with central ulceration ('rodent ulcer')

30% multiple, invasion is usually local. Metastasis is rare - metastatic rate is 0.0028%

Clinical subtypes

1.Nodular BCC Most common type on the face Small, shiny, skin coloured or pinkish

lump Blood vessels cross its surface May have a central ulcer so its edges

appear rolled Often bleeds spontaneously then seem

to heal over Cystic BCC is soft, with jelly-like contents Rodent ulcer is an open sore Micronodular and microcystic types may

infiltrate deeply

2.Superficial BCC Often multiple Upper trunk and shoulders, or anywhere Pink or red scaly irregular plaques Slowly grow over months or years Bleed or ulcerate easily

Continued …BCC

3. Morphoeic BCC Also known as sclerosing BCC Usually found in mid-facial sites Skin-coloured, waxy, scar-like Prone to recur after treatment May infiltrate cutaneous nerves (perineural spread)

4. Pigmented BCC Brown, blue or greyish lesion Nodular or superficial histology May resemble melanoma

5. Basisquamous BCC Mixed basal cell carcinoma (BCC) and squamous

cell carcinoma (SCC) Potentially more aggressive than other forms of

BCC

Differential diagnosesNodular BCC. Fibrous papule. Naevus. Seborrhoeic keratosis. Amelanotic melanoma

Superficial BCC. Nummular eczema. Psoriasis. Extramammary Paget Disease. Bowen’s Disease

Pigmented BCC . Malignanat Melanoma. Pigmented Seborrhoeic

keratosis. Traumatised naevus

Morpheaform BCC. Scar. Localised scleroderma

Basal Cell Carcinoma

More BCC

High Risk 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.Gorlin’s Syndrome.

Low-Risk BCC Size – Less than 2 cm. Site – Torso, Limbs.

Treatment

Surgery, Local Radiotherapy, Cryotherapy, or Curretage. Up to 85% superficial BCCs are cured by Photodynamic

therapy, with excellent cosmetic results. It is less successful for other types

Curettage and cautery with histology is only adequate for small lesions.

Systemic chemotherapy is ineffective, though topical 5-Fluorouracil cream may be helpful, particularly for multiple tumours.

Imiquimod cream . The cream is applied to superficial BCCs three to five times each week, for 6 to 16 weeks. results in an inflammatory reaction, maximal at three weeks. Up to 85% of suitable BCCs disappear, with minimal scarring.

Recurrence is common (0.15 - 15%)

Squamous Cell Carcinoma

Malignant tumour of the epidermis in which the cells, if differentiated, show keratin formation. 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, Leukoplakia

Rare in patients under 60 years of age unless immunosuppressed Sites:

Men - scalp and ears Women - lower legs Both sexes - back of hands, face

Continued …SCC

Differential Diagnosis

Basal cell carcinoma

Keratocanthoma

Malignant melanoma

Solar keratosis

Pyogenic granuloma

Infected seborrheic wart Clinical features

Rapidly expanding painless, ulcerated nodule rolled indurated margin. May have a cauliflower-like appearance with areas of bleeding, ulceration or serous exudation.

About 55% of lesions occur in the head and neck region. About 25% of lesions occur on the hands and arms.

Metastasis may occur via local draining lymph nodes and beyond.

Contd… SCC

. 5% of SCCs metastasise.

. More likely if the original SCC was on the lip or ear; or if it was large, 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 transplantation CLL Alcoholism Multiple skin cancers Genetic defect in skin repair e.g., xeroderma pigmentosum

SCC of different types/Sites

When confined to the epithelium is called SCC in situ ,Intraepidermal SCC or Bowen’s disease.

SCC in situ of mucosal surfaces includes: Oral leukoplakia Vulval intraepithelial neoplasia Penile intraepithelial neoplasia Bowenoid papulosis

There are some special types of invasive SCC of the skin: Keratoacanthoma (pseudocancer)– a rapidly growing keratinising skin nodule

that may resolve without treatment. BUT appearances can be deceptive so still refer… unless you’re a dermatologist.

Carcinoma cuniculatum (‘verrucous carcinoma’), a slowly-growing warty tumour found on the sole of the foot

Invasive SCC types/sites include Vulval SCC Oral SCC

Bowen’s Disease

SCC

Pigmented SCC

Other SCC

Superficial BCC

Oral SCC-Leucoplakia

Keratoacanthoma

Treatment

. 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

• Urgent referral if :

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

. Who have had an organ transplant and develop new or growing cutaneous 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 skin lesion****There is controversy about Actinic Keratosis; whether its a premalignant condition or early SCC. In a study of 459 patients with cutaneous SCC, there were associated adjacent actinic keratoses in 97%. Reported rate of progression to invasive SCC varies but accepted as around 1 in 1000**

Malignant Melanoma

Malignant tumour of epidermal melanocytes.Accounts for less than 1% of all cancers

Non-pigmented skin , exposed to excessive sunlight, especially if sunburn ensues.

Spread occurs via superficial lymphatics to give satellite lesions, to regional lymph 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 cause pigmented lesions in the mouth.

Malignant melanomas undergo two growth phases - radial and vertical. Vertical invasion is a poor prognostic sign.

Different types :. Superficial spreading (48%) . Nodular (23%)

. Lentigo maligna (15%) . Acral lentiginous including periungual (6%)

. Amelanotic melanoma

Contd…Melanoma Types

Those that start off as flat patches (i.e. have a horizontal growth phase) include:

Superficial spreading melanoma (SSM) Lentigo maligna melanoma (sun damaged skin of face, scalp and neck) Acral lentiginous melanoma (on soles of feet, palms of hands or under

the nails – the subungual melanoma) They tend to grow slowly, but at any time, they may begin to thicken up 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 grow down

nerves) Combinations may arise e.g. nodular melanoma arising within a superficial

spreading melanoma.

Malignant Melanoma features:

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

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

type, extension and degree of pigmentation

Dermoscopy: Handheld device, relatively new technique, visualisation through stratum corneum

Without Dermoscopy resembles Seborrheic Keratoses

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

Superficial spreading melanoma

Typical SSMM

SSMM with Regression

Amelanotic Melanoma

Lentigo Maligna Melanoma sun damaged skin of face, scalp and neck

Lentigo maligna melanoma

Lentigo maligna

Nodular melanoma in lentigo maligna

Acral lentiginous melanoma

Nodular melanoma

amelanotic nodular melanoma

Differential Diagnosis (MM)

Benign Naevi Dermatofibroma Pigmented Basal Cell Carcinoma Pyogenic Granuloma Kaposi's Sarcoma Vascular malformations Seborrhoeic Keratosis

Treatment 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 much wider area of skin is cut out. Draining lymph node biopsies may also be needed.

Prognosis :

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

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

Moral of the story:

. Do an ABCDE/ 7 points assessment

. Appearances can be deceptive so if in doubt ask someone

finis