TUMOURS OF SKIN

Dr F Bhatti
Pennine 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
ed.. 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 diagnoses
Nodular BCC Pigmented BCC
. Fibrous papule . Malignanat Melanoma
. Naevus . Pigmented Seborrhoeic
. Seborrhoeic keratosis keratosis
. Amelanotic melanoma . Traumatised naevus

Superficial BCC Morpheaform BCC

. Nummular eczema . Scar
. Psoriasis . Localised scleroderma
. Extramammary Paget Disease
. Bowen’s Disease
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

Oral SCC-
Leucoplakia

Superficial BCC
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 streaks

at the edge of the and white areas within are
visible, 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

Nodular melanoma in
lentigo maligna

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