SKIN

MALIGNANCIES
BY: DR. NANG’OLE
 CONT
•Commonest of all malignancies globally
•Basal cell carcinoma contributes to about 77%
•SCC 20%
•Malignant melanoma 3%
•There is a general increase in incidence due to global
warming (UV light) and an aging population
 Etiology/ predisposing factors
•Chronic sun exposure: to fair skin individuals; Fitzpatrick
type one and two
•Male sex
•Low altitude
•Chronic wounds/ burns: (> 6 weeks – 3 months)
•Premalignant skin lesions; giant hairy nevus
 Inherited conditions predisposing to skin
malignancies
•Xeroderma pigmentosa:
•AR disorder
•Defective DNA with increased sensitivity to sunlight
•Basal cell nevus syndrome, also referred to as the Gorlin’s
syndrome
•Has multiple basal cell nevus, jaw cysts & pitting of the sole and
feet
•Albinism
•AR
•Tyrosine kinase enzyme involved: defect with melanin synthesis
•Predisposed to all types of skin malignancies
 Common skin malignancies (globally)
A. BCC: ~77%
B. SCC: ~20%
C. Malignant melanoma: ~10%
 A. Basal Cell Carcinoma
•Malignancies of the basaloid cells.
•Commonly located around skin appendages such as
sebaceous glands & sweat glands.
•UP to 77% incidence in the USA
 Anatomical location
•93% in the head and neck region
•7% the rest of the body
•Common sites are the:
•Nose region
•Cheek
•Periorbital region
•Others: Pre – auricular region
 Types of BCC
1. Nodular ulcerative
2. Superficial
3. Pigmented
4. Sclerosing
 1. Nodular ulcerative type
•Usually single lesions on the face region
•Grow slowly & tend to ulcerate.
•Most common of the BCCs
•Used to be called the mole type or rodent ulcers
Lesion that is suspicious for malignancy e.g.
Nodular ulcerative BCC
 2. Superficial BCC
•Usually multiple lesions
•Common on the trunk
•May resemble eczema or psoriasis
 3. Pigmented BCC
•Resembles nodular BCC with black pigmentation.
 4. Sclerosing type
•Yellow white in appearance
•Morpheaform in appearance with ill defined orders
•Resembles scleroderma
•Commonest recurrent disease
•May involve deep structures
•Difficult to treat
 Histology
•Microscopically: involves basaloid cell in the dermis
•There is proliferation of similar cells
•Oval in shape with deep staining nuclei with scant cytoplasm
•Outmost palisading layer on the periphery
•Stroma fibrous reaction
 Diagnosis
•Tissue biopsy
•Curettage
•Shave biopsy
•Punch biopsy
•Incisional biopsy
•Excisional biopsy
 Treatment
•Most are treated by either curettage or excisional
biopsy with about 5mm margin
•Cryotherapy, 5 – FU are other treatment options
•Mohs angiographic therapy surgery
•BCCs rarely spread therefore no role of
radiotherapy
 Recurrent BCCs
•Common with the nodular ulcerative type and
sclerosing type
•Common sites:
•Centre of the face, eyelid, periorbital region, the nose & post
auricular region
•Treatment, confirm with biopsy
•Then Mohs surgery.
Differentials:
Nodular
ulcerative BCC
SCC
Leishmaniasis
Fungal infection
Cancrum Oris
 B. Squamous cell carcinoma
•Arises from the keratinizing cells or the spindle cell of
the epithelium
•Common in older patients, Male > female
 Etiology
•UV light radiations, sun exposure in susceptible
groups such as albinism, xeroderma
•Chronic ulcers e.g. Marjolin’s ulcer
•Cytotoxic drugs
•Immunosuppressant drugs
 Macroscopically there are 2 types:
1. Verrucous/ exophytic
•Cauliflower appearance
•Slow growing; deeply locally invasive and less likely to metastasize
2. Nodular/ ulcerative type
•Rapid growth
•Ulcerate early
•Likely to spread
 Anatomical distributions
•Predominantly in the head and neck region.
•Have a higher incidence on the trunk when compared to
BCCs.
 Clinical features
•Chronic ulcer that doesn’t heal.
•Bleeds easily.
•Undermined ulcer.
•Raised edges.
•Painless wound.
•May be painful when there is:
•Superimposed infection
•There is erosion into the nearest neural structures
•Signs of metastasis into nodes, chest
 Management
•History & PE.
•Investigations to R/O spread: CT, MRI.
•Biopsy to confirm the histological type.
•Definitive treatment:
•Surgical: (mainstay of treatment) wide local excision,
where possible Mohs micrographic surgery
•Radiotherapy: palliative or curative
 Recurrence / Metastasis of CCs
•Poorly differentiated lesions have ~28% recurrence rate.
Well differentiated ones have ~7% recurrence rate.
•There is an increased likelihood for recurrence with
perineural invasion.
•SCCs are more likely to recur than BCCs.
•Metastasis is more likely to occur with the Marjolin's
ulcers or the malignancies of the Xeroderma pigmentosa.
 Cont.
• SCCs of the nose & ear are likely to
spread as opposed to SCCs on other
sites.
•Follow up is done every 6 months for
st
the 1 5 years & every year for the
next 5 years.
 C. Malignant Melanoma
•Malignancy involving the melanocytes
•Predominantly involves skin, but can involve
any melanocytes in the body
•Melanocytes are of neural crest cells of origin
in retina, meninges
•Contributes to about 3% of skin malignancies in
the USA
 Cont.
•Important global issue
•There is an increase in the incidence esp. among the
Caucasians.
•Early diagnosis, better outcome
•Late diagnosis, worse outcome
•Sun exposure is the major etiological role in Caucasians
•Blacks & colored, predominant in non sun exposed areas
 Melanocytic nevus
•May transform to malignant melanoma
•Should check for the following:
•A-Asymmetry
•B-Bleeds easily
•C-Color changes
•D-Diameter > 6mm
•E-Edge irregularity
 Types of malignant melanoma
1. Lentigo maligna (solar)
•Commonest type
•Associated with chronic sun exposure
•Onset is seen in older people
•Not associated with nevus
•Has few genomic aberrations
 Cont.
2. Acral lentigous melanoma
•Commonest type in Blacks & Hispanics
•Incidence is 1:100000 & us the same in all races
•Occurs in sun – protected areas
•Has a greater number of chromosomal aberrations
•Occurs on the sole of the feet, palms & mucus
membranes
 Cont.
3. Nodular melanoma
•Descriptive term
•Term that seems to demonstrate rapid tumor
progression irrespective of the intraepithelial growth
pattern or location
4. Amelanotic melanoma
•Non pigmented melanoma
•Can be difficult to diagnose
 Clinical features
•More common in Caucasians
•M:F ratio similar, women slightly more
th th
•4 to the 7 decade of life, rare in childhood
•Common site among the Caucasians is the trunk, upper
extremities and head and neck region
•In Blacks/Asians: palms, sole of feet especially
subungual region (always suspect a lesion below the nail
fold).
 Morphological features
•Size, often greater than 1cms
•Borders: irregular and notched borders
•Color: black
•Asymmetrical lesion
•Initially may be flat but later on either become plague or
nodular
•May bleed easily
 Histopathological features
•Proliferation of the melanocytes
•Initially confined to the epidermis then later on
progress to the papillary and reticular dermis
•Nucleus hyperchromatism is noted
•Nuclei pleomorphism with pigmentation
 Spontaneous regression of melanoma
•Has been noted
•It is a poorly understood phenomenon
•Thought to either be cytokine mediated or cell mediated
immune mechanism.
 Spread /metastasis
•Local spread
•Lymphatic spread: MC mode of spread
•Vascular invasion
•Along surfaces of blood vessels, referred
to as angiotropic spread or along nerves,
referred to as neurotropic spread
 Satellite lesion
•Very common
•Due to cutaneous spread of the disease, could
be:
•Local satellite (within 5 cm from the primary
lesion
•Intransit satellite: satellites between primary
lesion and the regional nodes, at least 5cm
from the primary lesion
 Visceral spread
•Commonest site is the lungs, followed by
the liver
•Other sites are the brain and bone
 Prognostic factors
•Main determinant for survival is the depth of the lesion,
also referred to us the Breslow depth/ Clark level.
•Lesions <0.75mm depth: survival is almost 100% in 5
years.
•Therefore, early diagnosis of malignant melanoma is
associated with good survival.
 Other prognostic factors include
•Tumor thickness, worse with more depth
•Ulceration: worse prognosis
•Mitotic rates: the higher the rates the worse the prognosis
•Tumor infiltration with lymphocytes: better prognosis
•Angiotropism or Neurotropism: worse prognosis
•Tumor cell type: spindle cell type better prognosis
•Age: worse prognosis with increasing age
•Sex: women have a better prognosis than men
•Anatomic location: lesion on the extremities have a better
prognosis than axial lesions/trunk.
 PRINCIPLES OF MANAGEMENT OF
MELANOMA
•SURGERY is the mainstay of treatment
•Melanoma is poorly radio or chemosensitive
•Optimal biopsy for examination of the entire lesion
if possible, if not the punch biopsy to determine the
Breslow/Clarks level.
•Complete physical & radiological evaluation of the
patient to rule out distant spread.
 Cont.
•Sentinel lymph node biopsy for lesions >1mm in depth
could be done by use of radioactive dye e.g. Technetium
99 or methylene blue.
•If nodes are +ve then regional node clearance should be
done
•If –ve, then nodal clearance is not necessary
•If there is clinical evidence of nodal involvement, nodal
clearance should be done.
 Surgical margins
•Depends on the Breslow levels
•Melanoma of up to 2mm in depth, then the
margins should be at least 1cm wide.
•Melanoma of >2 mm in depth, then the
margins should be up to 2cm wide.
 Follow up
st
•Every 3 – 6 months for the 1 5 years of life.
•Every 6 months – 1 yr. for the next 5 years of life.
•Do the following on F/UP:
•CXR
•Abdominal CT scan
•U/S
•LDH levels: rising levels point towards metastatic
disease; low levels point towards tumor remission
 TAKE HOME MESSAGE
•WHEN YOU GET A CHRONIC
WOUND (>6 weeks – 3 months)
ALWAYS DO A BIOPSY &
HISTOLOGY TO R/O
MALIGNANCY.