Course of Dermatology

Course of Dermatology

Epidermal Malignant
Tumors
YIN GUANGWEN
Dep. of Dermatology,First Teaching
Hospital of Zhengzhou University
Malignant Epidermal Tumors
 Malignant Epidermal Tumors include
– Squamous cell carcinoma(SCC)
– Basal cell carcinoma(BCC)
– Bowen’s disease and so on
Squamous cell carcinoma
 Definition
A malignant tumour derived from keratinocytes.
 Cutaneous squamous cell carcinoma (SCC) is the second most
common form of skin cancer and frequently arises on the sun-
exposed skin of the middle aged and elderly.
 A few may develop in scar tissues.
 High-risk SCC has a considerable metastatic rate and requires
careful evaluation and treatment.
 SCC possesses a higher potential for metastasis than BCC.
 Epidemiology
Race
- SCC is common in whites. Those with Irish or
Scottish ancestry have the highest incidence in the
US. SCC is rare in African Americans.
Sex
- SCC is twice as common in men as in women.
Age
- The typical age at presentation of SCC is
approximately 70 years.
 Epidemiology
Frequency
- In the US:
For the last 30 years the incidence of SCC has steadily risen, likely
due to an increase in the annual sun exposure of the general
population. Annual incidence is approximately 105 per 100,000.
- Internationally:
The highest incidence of SCC in the world is found in Australia.
Annual incidence is approximately 166 per 100,000.
 Clinical Features (Ⅰ)
– Frequently, Squamous cell carcinoma begins at the site of
actinic keratosis on sun-exposed areas such as the face
and backs of the hands.
– The lesions may be superficial,discrete,and hard, and
arises from an indurated,rounded,elevated base.
– SCC occurrs not only on the skin but also on the mucous
membranes.
– It is dull red and contains telangiectasia.
– In other instances,the tumors begin as
small,erythematous,infiltrated,hard,scaly plaques,on skin
that has been damaged by x-rays,scars,or chronic ulcers
 Clinical Features (Ⅱ)
– In the course of a few months the lesion becomes
larger,deeply nodular,and ulcerated.
– The ulcer is at first superficial and is hidden by a crust.
– In the early phases this tumor is localized,elevated,and
freely movable on the underlying structures.
– Later it gradually becomes diffuse,more or less
depressed,and fixed.
– The tumor above the level of the skin may be dome-
shaped,with a corelike center that later ulcerates.
– The surface in advanced lesions may be cauliflower-like,
– purulent,malodorous exudate.
The ulcer is at first superficial and is The ulcer is deep
hidden by a crust

Squamous cell carcinoma on the right cheek of an old man

 Squamous cell carcinoma
Larger,deeply nodular
lesion,and ulcerated

Squamous cell carcinoma on the left cheek of an old woman

 Nodular lesion, Later it gradually
becomes diffuse,and fixed

Purulent malodorous
exudate

Squamous cell carcinoma on the face of an middle-age man

 SCC occur on the scar.
A big nodular lesion,the surface is
cauliflower-like

Squamous cell carcinoma of the wrist of left arm

SCC occur on the scar.

Squamous cell carcinoma of the wrist of right arm

 Purulent malodorous exudate

Squamous cell carcinoma on the back of right hand

 A big nodular lesion,the surface is cauliflower-like

Squamous cell carcinoma on the both sides of the back of hands

Purulent malodorous exudate

Squamous cell carcinoma of the ankle of left leg

Scc occurs on the mucous membrane

Squamous cell carcinoma of the lower lip

 Squamous cell
carcinomama occurs
on the mucous
membrane.

Squamous cell carcinoma of the lower lip

Squamous cell carcinoma

Squamous cell carcinoma of the tongue

Squamous cell carcinoma

The surface is
cauliflower-
like.

Squamous cell carcinoma of the penis

Squamous cell carcinoma of the penis
 Etiology
Many causative factors have been identified in
squamous cell carcinoma
– Ultraviolet light certainly is a major factor.
– Both UVB and UVA are important.
– UVB may predispose to skin cancer not only through its
DNA-damaging action but also via local injury to
Langerhans cells.
– Photochemotherapy,psoralens plus UVA light(PUVA),as
used in the United States,is associated with squamous
cell carcinoma formation.
 Etiology
– Thermal injury to the skin may produce thermal keratoses
and squmous cell carcinoma,the constant exposure to hot
tea as experienced by tea tasters may produce oral cancer.
– Chemical carcinogenesis is a classic cause of skin cancer.
Best known are the effects of polycyclic aromatic
hydrocarbons,which include 3,4-benzpyrene.
 Etiology
– Chronic radiation dermatitis from X-radiation or
radium may produce squamous cell carcinoma.
– Human papillomavirus (HPV) ,especially of types
16,18,30,and 33,is associated with squamous cell
carcinoma.It occurs in sun-exposed areas.
– Most of which are of the squamous cell type,arise in
chronic ulcers,sinuses,and scars.
– Certain dermatoses ,such as nevus sebaceus also has an
risk.
 Metastases
 The rate of squamous cell carcinoma metastasis from all
skin sites ranges from 0.5% to 5.2%
 Careful attention should be paid to regional lymph nodes
 Local recurrence and metastasis are related to
⑴ treatment modality
⑵ prior treatment
⑶ location
⑷ size
⑸ depth
⑹ histologic differentiation
(7) host immunosuppression
 Histopathology
 Squamous cell carcinoma is characterized by irregular
nests of the epidermal cells invading the dermis to
varying degrees.
 The degree of cell differentiation has been used to
grade squamous cell carcinoma.
 It is believed that the greater the differentiation,the less
the invasive tendency,thereby the better the prognosis.
Histopathology of squamous cell carcinoma

Irregular nests of the epidermal cells invading the dermis

Histopathology of squamous cell carcinoma

Irregular nests of the epidermal cells invading the dermis

 Diagnosis
 The diagnosis is usually based on the
following fact
– History
– Clinical features
– Histopathology
– Necessary differential diagnosis
Histological examination is necessary to
confirm the diagnosis.
 Treatment
 Once a histological diagnosis has been established by
biopsy,the tumour can be treated by excision or
radiotherapy.
 Because of the possibility of metastasis from squamous
cell carcinoma,treatment should be thorough.
 Surgical excision
- Surgical excision with an adequate margin of normal
tissue is the preferred option.
 Radiation therapy is also effective.
Patients should be on regular follow-up thereafter to
detect recurrence.
 Prevention
It has been estimated that the regular use of a
sunscreen with a sun protection factor of 15 or
greater for the first 18 years of life would
reduce the lifetime incidence of nonmelanoma
skin cancers by 78%
Basal cell carcinoma
 Definition
A common,slowly growing,and locally destructive tumour
thought to arise from a subset of the basal cells in the
epidermis.
 Basal cell carcinoma (BCC) is the most common
malignant skin tumour.
 It typically occurs in areas of chronic sun exposure.
 BCC is usually slow growing and rarely metastasizes, but
it can cause significant local destruction and disfigurement
if neglected or treated inadequately.
 Prognosis is excellent with proper therapy.
 Incidence and Epidemiology

Frequency
 In the US: Annual incidence is 900,000 people
(550,000 male, 350,000 female).
 The estimated lifetime risk of BCC in the white
population is 33-39% in men and 23-28% in women.
 Incidence and Epidemiology
 Race: BCC is generally a disorder of Caucasian
individuals, especially those with very fair skin. It is
rare in individuals with dark skin.
 Sex: The male-to-female ratio is approximately 3:2.
 Age: BCC most commonly occurs in adulthood,
especially in the elderly population.
 Mortality
These neoplasms are often very friable and prone to
ulcerate, Death due to BCC is extremely rare.
 Etiology
Ultraviolet radiation
- This is the most important and common cause of BCC.
- Shorter wavelength ultraviolet (UV) radiation (290-320
nm) is believed to play a greater role in BCC formation
than is longer wavelength ultraviolet A (UVA) radiation
(320-400 nm).
- In addition, chronic sun exposure appears to be
important in the development of BCC.
 Etiology
- A long latency period of 20-50 years is typical
between the time of UV damage and clinical onset of
BCC.
Other radiation
- X-ray exposure has been associated with BCC
formation.
Immunosuppression
- Immunosuppression has been associated with a
modest increase in the risk of BCC.
 Clinical features Ⅰ
Sites of predilection
– Any part of the body may involved.
– The lesions are most frequently found on the face.
– 85% are found in the head and neck regions.
– 25% to 30% are found especially on the nose.
– The forehead,ears and cheeks are also often involved.
– In general,BCC are seen predominantly on exposed
sites.
 Clinical features Ⅱ
Skin lesions
- Initially, the lesion is a reddish,dome-shaped nodule with
a translucent surface and visible,dilated surface
capillaries.
- As it expands,the central area may show necrosis and
ulceration,leaving the characteristic rolled edge.
-Bleeding on slight injury is a common sign.
- Although these lesions do not metastasize,they may
cause extensive and distressing local destruction of soft
tissue,cartilage,and even bone.
 Dome-shaped nodule with a translucent surface
and visible, dilated surface capillaries.

Basal cell carcinoma on the junction of nose and cheek

of an young man
Basal cell carcinoma
As lesion expands,the
central area may
show necrosis and
ulceration,leaving the
characteristic rolled
edge

Basal cell carcinoma on the nose of an old woman

Showing central ulceratiom
Basal cell carcinoma
Significant local
destruction and
disfigurement

Showing
necrosis,ulceration,
telangiectases and a
crusted erosion.

Basal cell carcinoma on the nose of an young woman

Basal cell carcinoma
Significant local
destruction and
disfigurement

Basal cell carcinoma on the nose of an old man

 Nodular basal cell
carcinoma
presenting as a waxy
translucent papule
Basal cell carcinoma on the
with central
junction of nose and
depression and a few
cheek
small erosions
of an
young man

Basal cell carcinoma on the junction of nose and eyelid of an young

woman, approximately 1 cm in diameter
Basal cell carcinoma on the junction of nose and cheek of an old man
Basal cell carcinoma on the right cheek of an middle-age man
Basal cell carcinoma

Basal cell carcinoma on the junction of nose and upper lip

of an old woman
Basal cell carcinoma on the junction of nose and upper lip
of an middle-age man
Basal cell carcinoma

This translucent
pink papule has
telangiectases and a
crusted erosion.
 Histopathology
A mass of basophilic keratinocytes is seen
pushing down into the dermis but retaining its
contact with the overlying epidermis.
 Histopathology of
Basal cell carcinoma

Nodular aggregates of basaloma cells are present in the dermis,

retaining its contact with the overlying epidermis.
 Histopathology of
Basal cell carcinoma

Nodular aggregates of basaloma cells are present in the dermis

Histopathology of
Basal cell carcinoma

Nodular aggregates of basaloma

cells are present in the dermis
 Diagnosis
- Diagnosis of skin tumour should include a careful
physical examination, not only of the target lesion but
also search for the presence of other skin tumours.
- A general examination paying special attention to
regional lymph nodes is necessary, although distant
metastasis in BCC is rare.
- Skin biopsy is indicated to confirm the diagnosis.
 
 Treatment
 The aim in treatment is for a permanent cure with the
best cosmetic results.
 Each lesion of basal cell carcinoma must be thoroughly
evaluated individually.
 Age ,sex,and the size,site,and type of lesion are
important factors to be considered when choosing the
proper method of treatment.
The next methods are the common method
used in the treatment of these diseases

 Surgical excision
 Radiation therapy
 Cryosurgery
 Electrosurgery

No single treatment method is ideal for all lesions