Skin Cancer

Skin cancer:
• Non-melanoma skin cancer (NMSC)
• Melanoma.
• NMSC:
– Basal cell carcinoma (BCC)
– Squamous cell carcinoma (SCC)
– Others
Non-melanoma skin cancer (NMSC):

Risk factors:
1. Host susceptibility factors:
– Inherited susceptibility:
o Xeroderma pigmentosum.
– Chronic injury and scarring.
– Immunosuppression.
2. Environmental risk factors:
– Ultraviolet (UV) radiation.
– Chemical carcinogens.
– Human papillomavirus (HPV)

Basal cell carcinoma (BCC)

BCC is the most common malignant tumor of the skin. Rarely metastasizes but is
capable of production of significant destruction and disfigurement.
Origin (histogenesis):
Pluripotent immature cells of the epidermis that form continuously during life and
have similar pluripotentiality as embryonic germ cells.
Clinical features:
• It usually occurs over 40 years of age.
• More in males.
• Typically seen on the face, ears scalp, neck.
• Nodular BCC comprises 50–80% of all BCCs.
• Nodular BCC is composed of one or a few small, waxy, semitranslucent
nodules, forming around a central depression that may or may not be
ulcerated, crusted, and bleeding. The edge of larger lesions has a characteristic
rolled border. Telangiectases course through the lesion. Bleeding on slight
injury is a common sign.
Diagnosis:
Clinically and confirmed by histopathological examination of excisional
biopsy.
Treatment:
• The aim of treatment is for a permanent cure with the best cosmetic results.
• Treatment of BCC is usually surgical excision.
• A minimum 5-year follow-up is indicated.

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A rolled pearly border surrounds an ulcer

A. A glistening, smooth plaque on the lower eyelid with multiple telangiectasias. B. An oval, pearly nodule
on the nose close to the inner canthus.

Left: A smooth, pearly tumor with telangiectasia below the lower eyelid. Tumor feels hard, is well defined, and is
asymptomatic.Right. A large, firm reddish glistening nodule with small ulcerations on the nose.

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Squamous cell carcinoma(SCC)

A malignant tumor arising from the keratinocytes of the epidermis. It may occur anywhere on
the skin or on mucous membranes. Metastases occur in 3% of patients.

Clinical features:
 More in males. It may occur anywhere on the skin or on mucous membranes.
 Usually sun-exposed areas, but other areas may be affected.
 SCC does not often arise from healthy-looking skin.
 Commonly, there are signs of photodamage or a risk factor including
premalignant dermatoses (AK, Bowen’s disease, leukoplakia), long-standing
ulcers or scars.
 The change from a premalignant lesion to SCC is heralded by the occurrence of
induration and surrounding inflammation.
 The first clinical evidence of SCC is induration of preexisting lesion.
 The area may be plaque-like, verrucous, tumid or ulcerated.
 The induration extends beyond the visible margin of the lesions, which are firm in
consistency.
 The evolution of SCC is usually faster than that of BCC.
 Regional lymph nodes may become enlarged from metastases.
 Spread by blood stream is uncommon.

Squamous cell carcinoma: invasive on the lip, two stages of development Right. A large but subtle nodule, which
is better felt than seen, on the vermilion border of the lower lip with areas of hyperkeratosis and erosion, arising in
the setting of dermatoheliosis of the lip (cheilitis actinica). Left. This nodule is larger and can be felt to infiltrate
the entire lip.

Prognosis:
Prognosis as regards local recurrence and metastatic risk is worse in high risk cases:
 Ill-defined border
 Size is greater than 2 cm,
 Recurrent cases
 SCC on non-exposed sites,

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 SCC arising in areas of Bowen’s disease,
 SCC arising in immunosuppressed patients and
 SCC arising at sites of scarring and chronic ulcers.
Diagnosis:
Clinically and confirmed by histopathological examination of excisional biopsy.
Treatment:
 Surgical excision with a safety margin depending on the depth of the lesion.
 Mohs’ micrographic surgery offers advantages over conventional surgical
excision and is regarded as the treatment of choice for high-risk SCCs.
 Radiotherapy is used for very large or rapidly extending tumors especially in
elderly or debilitated patients, and as adjuvant therapy in high-risk tumors after
surgical excision.
 Chemotherapy.

Malignant melanoma

Melanoma is a malignant tumour arising from the epidermal melanocytes. It is an

example of a malignancy strongly influenced by environmental factors that develop in
a genetically susceptible host.
Episodes of severe sunburn are risk factors in most cases. Other risk factors
include a positive family history, increased number of melanocytic naevi and presence
of atypical naevi.
Clinical features:
• Patients with sporadic melanoma are more frequently fair-skinned, with a
tendency to burn easily and tan poorly on exposure to sunlight. They also have
large numbers of simple melanocytic naevi and a tendency to freckle.
• A new or changing mole is the most common warning sign for melanoma.
• ABCDE criteria for naevus (mole) follow up:
 Asymmetry: If the 2 halves of the lesion not identical.
 Border: If irregular borders are present or develop.
 Color: If color becomes variegated.
 Diameter: If (>6 mm)
 Evolving: If there is rapid change in size.

Superficial spreading melanoma:

 The commonest type of melanoma on white skin.
 About 50% of cases occur on a pre-existing melanocytic naevus.
 The commonest sites are the female leg and the male back.
 Early presentation is by an irregularly shaped brown macular lesion showing
different colours (brown, black, red and grey) and a diameter of 4-5mm.
 Growth of the lesion occurs in 2 phases: early horizontal and late vertical, in
which the lesion becomes palpable.

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Nodular melanoma:
 This variety is more common in males.
 trunk a common site.
 It has a poor prognosis because of rapid growth, relative lack of melanin and
misdiagnosis with angioma.
 The lesion is a nodule (dome-shaped, reddish-brown, polypoid or pedunculated).
Ulceration and bleeding occur frequently.
Lentigo maligna melanoma:
The lesion is a flat, brown or black, irregularly shaped and occurs mainly on
the face, hand or leg. There may be central regression while the peripheral
margin continues to extend. In time, a raised central nodule will develop
indicating transition to the vertical growth phase.

Acral lentiginous melanoma (palmoplanter malignant melanoma):

 This type comprises 50% of melanomas on dark-skinned races.
 The lesions usually occur on the sole but may occur on the palm.
 lesion is a large, macular, lentiginous pigmented area around an invasive raised
tumour.
 Any tender growing nodule on the sole should be suspected for melanoma.

Superficial spreading melanoma:.Right: Barely elevated small plaque that has a relatively regular border but is
striking with regard to the variegation in color: tan, dark brown, and even black with an orange portion on the
right. Left: Superficial spreading melanoma: arising within a dysplastic nevus

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Nodular melanoma A. A 9-mm dome-shaped smooth nodule with a flatter brownish rim arising on the back of a
38-year-old male. B. A 1-cm black papule on the posterior thigh of a 60-year-old female. The lesion had been
present for less than 1 year. C. An eroded, bleeding, brown nodule having a mushroom-like configuration giving it
a stuck-on appearance. D. Large (5 cm) irregular, black, bleeding nodule sitting on the skin like a mushroom.

Lentigo maligna melanoma: This is an advanced lesion with a macular component and a reddish,
ulcerated nodule. The lesion measured 10 mm in depth, and there were enlarged inguinal lymph nodes.

Acral lentiginous melanoma: There is a highly variegated macular component–brown to gray and black; the
nodular component is hyperkeratotic, reddish, and ulcerated.

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Subungual malignant melanoma:
• This is diagnosed at a late stage of development because of earlier confusion
with a benign melanocytic naevus, a traumatic haemorrhage under the nail,
subungual wart or onychomycosis.
• Any pigmentation of the nail bed should be examined with great care,
particularly if there is full-length involvement of the nail and if the nail fold is
also affected. This is known as Hutchinson’s sign.
Management of melanoma:
• Clinical diagnosis,
• Biopsy confirmation and also to measure the thickness of the melanoma which
is an essential guide to further management.
• Definitive surgical excision,
• Appropriate treatment of draining lymph nodes,
• Routine follow-up of patients with melanoma
• Management of patients with distal metastases and palliative care.