Skin Tumours

Dr. C. S. SirkaAIIMS,

Bhubaneswar

Digital Lecture Series : Chapter 22

CONTENTS

Introduction Classification Seborrheic keratosis Sebaceous cyst Steatocystoma multiplex Keratoacanthoma Syringoma Cylindroma Acrochordon Keloid Haemangioma

Angiokeratoma Neurofibroma Actinic keratosis Cutaneous horn Bowen’s disease Squamous cell carcinoma Basal cell carcinoma Paget’s disease Malignant melanoma Cutaneous T cell lymphoma MCQs Photo Quiz

Introduction

Skin tumours are relatively common. A great majority of skin tumours rarely attract attention of patients

or physicians. Genetic and environmental factors are known to play an important

role in most tumours. The prevalence of tumours like actinic keratoses, and malignant

melanomas is less in dark skin. Confirmation of diagnosis is by biopsy and immunohistochemistry.

Classification

Skin tumours are broadly classified as benign, premalignant and malignant.

Other classification is based on their origin: • Epidermal• Appendageal – Pilar (hair), sebaceous and sweat gland• Melanocytic• Mesodermal origin (vascular and connective tissue)

Tumors arising from epidermis

Benign Seborrheic keratosis Sebaceous cyst Steatocystoma multiplex Keratoacanthoma

Premalignant Actinic keratoses Leukoplakia Cutaneous horn Bowen’s disease

Malignant Squamous cell carcinoma Basal cell carcinoma Paget’s disease

Tumors of epidermal appendages

Benign Trichoepithelioma Syringoma Cylindroma

Malignant Basal cell carcinoma Adnexal carcinoma

Tumors arising from Melanocyte

Malignant melanoma

Tumors of mesodermal origin

Connective Tissue Dermatofibroma Acrochordon (skin tag) Keloid

Vascular Tumors Hemangioma Angiokeratoma Glomus tumor

Other Cutaneous tumors

Cutaneous Metastasis

Breast, lungs, colon, kidney, ovary, metastatic melanoma.

Lymphomas and Leukemias

Cutaneous T-cell Lymphomas : Mycosis fungoides, Sezary syndrome.

Benign Tumours

Seborrheic keratoses

A common, benign tumor. Common >30 years of age Develops on sun damaged skin It is a brownish to black papule,

plaque or nodule on skin with sharp border ‘stuck on appearance .‘

Seborrheic keratosis

Dermatosis papulosa nigra: Variant of seborrheic keratosis Pigmented round smooth papule. Common in black Occurs >40 years of age Common sites are face and

trunck

Seborrheic keratosis

Stucco keratoses Common in elderly individual. Mostly occurs at ankle. It is a white papule with rough surface. Easily lifted off without bleeding. Diagnosis is mostly clinical.

Treatment

Counseling about photo protection. Change of life style (avoid undue sun exposure). Topical 5- flurouracil (5%) cream and Imiquimod (5%) cream. Oral Isotretinoin. Cryotherapy with liquid nitrogen or CO2 snow for extensive area. Electrodesiccation and curettage. Photodynamic therapy. CO2, Er:YAG lasers, dermabrasion.

Sebaceous Cyst

Characterized by cystic swelling with central punctum. Cyst is filled with Keratin. Originates from hair follicle. Usually asymptomatic. Becomes tender or painful on infection. Treatment is surgical excision along with cystic wall.

Sebaceous Cyst

Steatocystoma multiplex

An benign, epidermal polycystic disease. A autosomal dominant inheritance. The defect is in Keratin 17 Characterized by subcutaneous cystic swelling, smooth papule or nodular

looking lesion an midline of face. On puncturing it give oily discharge.

Treatment : Incision & drainage, Aspiration.

Steatocystoma multiplex

Keratoacanthoma

A low-grade skin tumor of hair follicle. Arise from the neck of hair follicle. Characterized by dome-shaped, smooth wall inflamed skin lesion

with centre capped by keratinous scales and debris. Common on sun-exposed skin. Microscopically it resembles squamous cell carcinoma.

Treatment

Intralesional injection of methotrexate or 5-fluorouracil. Excision. Mohs surgery. Electrodessication. Curettage . Cryosurgery . Radiotherapy.

Syringomas

Sweat duct tumors. Typically found in clustered on

eyelids, rarely on other sites. Skin-colored or yellowish firm

round papule, flat top and polygonal.

Asymptomatic.

Treatment : Retinoids Electrocautery Erbium or carbon dioxide lasers.

Cylindroma

An autosomal dominantly inherited condition. Known a turban tumor . Malignant transformation of cylindroma is very rare. Commonly occurs on head and neck. Characterized by dome shaped smooth shiny nodules with

telangiectasia on the surface.

Treatment : Wide excision.

Acrochordons (skin tags)

Benign pedunculated overgrowth on skin Occurs on skin folds(neck, axilla and groin) Common in obese

Treatment : Scissors excision with/ without local anesthesia Electrocautery or cryosurgery

Acrocohordon

Keloid

Hereditary predilection to develop keloid. Aautosomal dominant and recessive factors are responsible. Characterized by overgrowth of fibrous tissue at the site of injury. May extend to surrounding skin beyond the site of injury. Frequently occurs on chest, upper back and extremities.

Keloid on the chest

Hemangioma

Benign tumours of blood vessel.

Occurs in1-3% of newborns and about 10% upto 1 year.

Characterized by raised erythematous macule or plaque.

Occurs due to endothelial cell hyperplasia.

Extensive cutaneous hemangiomas is associated with visceral involvement

Common type are strawberry hemangiomas.

Treatment : Oral corticosteroid , beta-blocker propranolol, topically beta

blocker Timolol, rarely interferon or vincristine.

Injection of sclerosing agents.

Hemangioma

Angiokeratoma

A benign cutaneous lesion of capillaries. Characterized as small red to blue color lesion with and

hyperkeratosis. Angiokeratoma corporis diffusum refers to Fabry's disease (a distinct

condition). The lesions occasionally bleed.

Treatment : Lasers. Surgical removal

Treatment

Massage. Pressure bandage or garments. Silicone elastomer pads. Intralesional Triamcinolone acetonide injection at 3-6 weeks. Intralesional Triamcinolone acetonide injection + Hyaluronidase

and/or 5-Flurouracil. Surgical excision followed by Intra-lesional injections. Intralesional bleomycin. Cryotherapy with liquid nitrogen + Intralesional injections. Lasers : CO2 and Nd Yag.

Neurofibroma

Autosomal dominant inherited condition. Known as von Recklinghausen’s disease. Neurofibromas are characterized by skin colored, soft, sessile or

pedunculated papules or nodules. Plexiform neurofibromas occur along the course of nerves as

irregular masses. Button-hole sign is positive (tumor can be compressed into skin

easily). Often it is associated with

cafe au lait spots, freckle like lesion and low intelligence.

Treatment

Genetic counseling. Counseling regarding course of disease. Treatment is mostly symptomatic.

Premalignant Tumours

Actinic keratoses

Premalignant condition. Common above middle age and elderly. Cumulative sun exposure on fair skin (type I and II). Characterized by papule or plaque with rough surface. Its better felt than seen (rough to feel). May develop cutaneous horn or become malignant. 10-20% of lesions progress to squamous cell carcinoma. Diagnosis is clinical & biopsy.

Treatment

Avoidance of undue sun exposure. Protective clothing, Use of sunscreen. Topical keratolytic agent. Oral Isotretinion. Curettage Electrodessication Cryotherapy with liquid nitrogen Shaving Chemical peeling with Trichloroacetic acid(TCA)

Cutaneous Horn

Hard, yellowish brown, horny outgrowth, often curved with circumferential ridges.

Surrounded by acanthotic collarette.

Inflammation and induration beneath indicates malignant change.

Seen on exposed areas specially upper part of face and ears.

Bowen's disease

A squamous cell carcinoma in situ. An early stage intraepidermal squamous cell carcinoma. Common above 60 years. Common at genitalia. Typically presents as a gradually enlarging, well-demarcated

erythematous plaque with irregular border, crusted or scaling surface.

Bowen's disease

Treatment

Photodynamic therapy Cryotherapy. Topical 5-fluorouracil and imiquimod. Excision.

Malignant Tumours

Squamous Cell Carcinoma

Malignancy arising from keratinocytes. It spreads by invasion and metastasis. Commonest site head and neck (mucosa & mucocutaneous junction).

Predisposing factors : Skin types I - III, UV radiation, exposure to arsenic and hydrocarbon,

chronic inflammation, irritation, smoking and chewing tobacco.

Characterized by : Plaques, ulceration, Verrucous lesions. May arise denovo or on a premalignant lesion Enlarged lymph regional node.

Squamous Cell Carcinoma

Treatment

Wide local excision with histologic confirmation of margins. Mohs’ micrographic surgery. Radiation therapy or chemotherapy for metasis.

Basal Cell Carcinoma

Synonym : Basalioma, Rodent ulcer Most common cutaneous malignancy Occurs from the basal cells of skin Common on sun damaged skin Locally invasive, slow growing and rarely metastasizes Occurs on sun damaged skin, age > 40 years

Basal Cell Carcinoma

Characterized by : Skin to pink colored dome-shaped lesion with visible blood vessels. Grows slowly , centre flattens, can ooze and crust. Rolled out margin, beaded edges with telangiectaisa. Locally invasive.

Basal Cell Carcinoma

Basal Cell Carcinoma

Treatment : Excision Curettage Electrodessication Mohs surgery Cryosurgery Photodynamic therapy Topical 5FU.

Paget's disease

Paget’s disease is a common adenocarcinoma of mammary gland. Extramammary Paget’s disease is a rare (common at vulva and

penis). It is slow-growing, noninvasive intraepithelial adenocarcinoma. Symptoms are non specific localized itching, burning and sore with

local destruction.

Treatment : Surgical excision.

Malignant melanoma

Malignancy of melanocytes. Common in skin (Type I & II). Personal / family history of atypical nevi or melanoma is common. Sun exposure increases the risk. 30% arise from pre-existing nevi whereas 70% arise de novo.

Suspicion : Irregularly pigmented macule or plaque → change in color, shape

and size. Nodular variant → dermal involvement → high risk of metastasis →

poor prognosis.

Malignant melanoma

Clinical course

ABCDE of melanoma : Asymmetry Border irregularity Color variability Diameter > 1 cm Evolutionary change

Treatment : Complete excision with free margin of at least 1cm. Lymph node resection. Chemotherapy and immunotherapy.

Cutaneous T cell lymphoma

It is a class of non-Hodgkin lymphoma. CTCL is caused by a mutation of T cells. The malignant T cells initially migrate to the skin, causing

various lesions. They appears as rash, macule, plaque, tumor and rarely ulcerated

lesion and metastize.

Cutaneous T cell lymphoma

Treatment

Topical and oral corticosteroids, Bexarotene Phototherapy & Photochemotherapy. Local and total skin electron beam therapy (TSET) Conventional Radiation Therapy Photopheresis Interferon. Methotrexate. Cyclophosphamide

MCQ’s

Q.1) A 80 year old male farmer, presented with brown plaque with verrucous surface on face and extensors of forearm. The diagnosis is

A. Viral wartsB. DPNC. Bowen’s diseaseD. Seborrheic keratosis

Q.2) A female from West Bengal presented with slightly raised erythematous plaque on upper back with keratoderma of palm and sole. There was family history of similar complaints. The diagnosis is

E. PsoriasisF. Bowens diseaseG. CTCLH. Eczema

MCQ’s

Q.3) Which is not correct for suspecting malignant melanoma?A. Irregularly pigmentationB. Eczematous changeC. Soft consistencyD. Ulceration

Q.4) Which one does not represent ABCDE of melanoma?E. AsymmetryF. Border irregularityG. Color variabilityH. Diameter > 1 cmI. Elevated lesion

MCQ’s

Q.5) Which vascular lesion disappears by one year?A. Strawberry angiomaB. Port wine stainC. Salmon patchD. Cherry angioma

Q. Identify this lesion?

Photo Quiz

Q. Identify this lesion?

Photo Quiz

Q. Identify this lesion?

Photo Quiz

Thank You!