Skin Tumors

1. Skin Tumors

2. Introduction • The great majority of cutaneous tumors are of little consequence and may never attract the attention of the patient or his physician • Genetic and environmental factors play an important role • Many skin tumors (e.g. actinic keratoses, basal cell carcinomas, squamous cell carcinomas and malignant melanomas) would all become less common if fair skinned people protected themselves adequately against sunlight. • Accurate diagnosis is a must for proper management of skin tumors. Biopsy as and when in dilemma is a must.

3. Classification • Tumors of skin are broadly classified as Benign, Premalignant and Malignant • They may also be classified according to their origin as: • Epidermal • Appendageal - Pilar(hair), sebaceous and sweat gland • Melanocytic • Mesodermal origin (vascular and connective tissue)

4. Tumors arising from epidermis • Premalignant • Actinic keratoses • Leukoplakia • Cutaneous horn • Bowen’s disease • Paget’s disease • Malignant • Squamous cell carcinoma Benign • Seborrheickeratoses • Epidermal nevi • Epithelial cyst • Steatocystoma multiplex • Keratoacanthoma

5. Tumors of epidermal appendages • Malignant • Basal cell carcinoma • Adnexal carcinoma Benign • Trichoepithelioma • Syringoma • Cylindroma

6. Tumors arising from Melanocyte Malignant melanoma

7. Tumors of mesodermal origin • Vascular Tumors • Hemangioma • Angiokeratoma • Glomus tumor • Kaposi’s sarcoma Connective Tissue • Dermatofibroma • Acrochordon (skin tag) • Keloid • Neurofibroma

8. Other Cutaneous tumors • Cutaneous Metastasis Breast, lungs, colon, kidney, ovary, metastatic melanoma • Lymphomas and Leukemias Cutaneous T- cell Lymphomas: Mycosis fungoides, Sezary syndrome

9. Seborrheickeratoses • Common, benign, persistent, epidermal lesion appearing as macule or papule, brownish to grey or black in colour • Greasy surface with plugged horns and a classical ‘stuck on’ appearance • Seen mainly on the face, trunk and extremities in adults over 30 years of age, often bilaterally symmetrical and along skin cleavage lines • Dermatosispapulosanigra: a variant seen as heavily pigmented papules on face in Indian skin Contd…

10. Seborrheickeratoses • Stucco keratoses: White lesions with a rough surface and ‘stuck-on’ appearance on the ankles of elderly; easily lifted off the skin with a finger nail without causing bleeding • Diagnosis is clinical and biopsy in suspect cases to rule out malignancy

11. Treatment • Curettage • Electrodessication • Cryotherapy with liquid nitrogen • Shaving • Chemical peeling with Trichloroacetic acid(TCA)

12. Acrochordons (skin tags) • Common benign and fleshy papular overgrowths occurring in skin folds of obese middle aged women • Skin-colored or brown, pedunculated or sessile most often seen in axillae, groins and on neck and eyelids • Usually asymptomatic, but maybe tender if irritated by friction, jewellery or clothing

13. Treatment • Scissors excision with/ without local anesthesia gives the best cosmetic result • Electrocautery or cryosurgery are other options

14. Sebaceous cyst • Firm, subcutaneous, keratin-filled cyst originating from a hair follicle • Arises spontaneously after puberty; usually single, on the trunk, neck and post auricular area • Fixed to overlying skin by a punctum representing the follicle • May get infected, rupture and trigger a foreign body reaction leading to scarring • Can recur post drainage if cyst wall persists

15. Treatment • Elective surgical excision with the cyst wall to prevent recurrence and scarring • Inflamed cysts need to be incised and drained just like an abscess • Recurrent cysts that have previously ruptured and scarred are best excised with the surrounding scar after the inflammation subsides

16. Keloids • Benign, cutaneous lesions produced by overgrowth of dense fibrous tissue • Uncontrolled synthesis and deposition of dermal collagen • May extend to surrounding skin beyond the site of injury • Common in young patients, rare in infancy and old age. Females more predisposed than males. • Trigger factors unknown • May occur de novo but generally occur after injury, burns, surgery, laser therapy or acne Contd…

17. Keloids • Most frequently on upper back and chest, neck, shoulders, jaw, ear lobes and legs • These areas exert high tension on healing wounds • Hereditary predilection (autosomal dominant and recessive factors) known

18. Clinical course • Early stage : Soft and pink resembling a hypertrophic scar • Late stage : Firm and white, protuberant and more extensive than original trauma, with irregular borders having claw like extensions Keloids attain a steady state size by gradual growth and are unlikely to regress on their own

19. Treatment • Intra-lesional steroid (ILS) injections : • Triamcinoloneacetonide 10-40 mg/ml in varying dilutions injected every 3-6 weeks till lesion flattens • Combination of ILS + Hyaluronidase or 5-Flurouracil for faster regression of keloids • Surgical excision followed by ILS • Intralesionalbleomycin • Cryotherapy with liquid nitrogen + ILS • Constant pressure on the keloid with pressure garments or silicone elastomer pads for extensive lesions on extremities • Lasers: CO2 ,Nd: Yag

20. Neurofibromas • Solitary tumor occurs occasionally, multiple neurofibromas are more common • Seen as part of an autosomal dominant inherited condition - Neurofibromatosis (von Recklinghausen’s disease) • Neurofibromas are pink or skin colored, soft, sessile or pedunculated papules or nodules • Plexiformneurofibromas occur along the course of peripheral nerves creating irregular masses or tender nodules • Button-hole sign: tumor compressible through a deficient dermis • May feel ‘knotty’ or ‘wormy

21. Neurofibromas • Solitary tumor occurs occasionally, multiple neurofibromas are more common • Seen as part of an autosomal dominant inherited condition - Neurofibromatosis (von Recklinghausen’s disease) • Neurofibromas are pink or skin colored, soft, sessile or pedunculated papules or nodules • Plexiformneurofibromas occur along the course of peripheral nerves creating irregular masses or tender nodules • Button-hole sign: tumor compressible through a deficient dermis • May feel ‘knotty’ or ‘wormy

22. Treatment Excision advised in cases of : • Cosmetically unacceptable or painful lesions • Lesions on vital structures • Lesions suspected of undergoing malignant change

23. Hemangiomas • Benign red, purple or blue vascular neoplasms occurring within the first year of life; seen in 1-3% of newborns and 10% of 1 year olds • They exhibit endothelial cell hyperplasia • More likely to be seen in girls and premature infants; predilection for the head and neck • Can appear at any site including the oral or genital mucosa • Multiple cutaneoushemangiomas may be associated with visceral hemangiomas Contd…

24. Hemangiomas • Lesions may ulcerate, bleed and get infected • Hemangiomas near eyes, ears, mouth or viscera can threaten the function of these organs • Hemangiomas and Portwine stain - common vascular malformation • Hemangioma (hamartoma) • Portwine stain (vascular esctasia)

25. Clinical course • Early hemangiomas may appear flat and pale white with few telangiectasia and dilated blood vessels • In growth phase, they are bright red(superficial) and purple(deep) and feel firm and rubbery • Involutinghemangiomas are slate-gray and begin to soften

26. Treatment • Benign and self- limiting; therefore no treatment is required in most cases • Parents need to be reassured about the course of the growth and its subsidence in 5-7 years • Recurrent bleeding, infection, ulceration or pressure on vital structures need active treatment • Treatment options: Steroids, sclerotherapy, embolisation, compression, laser therapy

27. Actinic keratoses • Common, persistent keratotic lesions with malignant potential • Predisposing factors: Cumulative sun exposure, fair skin (type I and II) • Affect the middle aged and elderly in temperate climates but younger people in the tropics

28. Clinical features • Pink or gray rough scaling macules or papules in the sun exposed areas; roughness better felt than seen • 10-20% of lesions progress to squamous cell carcinoma • Diagnosis is clinical but biopsy is warranted where malignancy is suspected

29. Treatment • Cryotherapy with liquid nitrogen or CO2 snow is simple and effective • Electrodesiccation and curettage for larger lesions • 5- flurouracil (5%) cream and imiquimod (5%) cream for multiple lesions • Photodynamic therapy • CO2, Er:YAG lasers, dermabrasion

30. Cutaneous horn • Hard, yellowish brown, horny outgrowth, often curved with circumferential ridges • Surrounded by acanthoticcollarette • Inflammation and induration beneath indicates malignant change • Seen on exposed areas specially upper part of face and ears

31. Squamous Cell Carcinoma (SCC) • Invasive, primary skin malignancy arising from keratinocytes of skin or mucosa • Can be fatal by local spread or metastasis if left untreated • Sites: Most commonly seen on head, neck or hands of elderly patients. Mucosae and mucocutaneous junction more common in Indians; sun exposed areas commonly in whites

32. Predisposing factors • Skin types I - III, UV exposure, radiation, arsenic and hydrocarbon, chronic inflammation, burns( Marjolin’s ulcer) • Spices, spirits, smoking (and chewing tobacco), syphilis, sharp tooth predispose to oral SCC • Human papilloma virus (HPV) infection is risk factor for cervical and genito-anal SCCs • May arise de novo or from precursor skin lesions

33. Precursor skin lesions • Lupus vulgaris • Hypertrophic lichen planus • Stasis ulcers • Discoid lupus erythematosus • Sinuses as in chronic osteomyelitis, pilonidal sinus, hidradenitissuppurativa • Post burns or vaccination scars • Actinic keratosis • Bowen’s disease

34. Clinical features • De novo: sharply defined, smooth, dull red, firm, dome shaped nodule with crusted centre. Removal of crust shows foul smelling keratin debris. • Surrounding skin shows signs of photodamage such as wrinkling and telangiectasia • From prior skin lesions: irregular borders, induration; bleeding heralds the onset of malignancy • Regional lymph node enlargement and metastases to other organs known if left untreated

35. Treatment • Wide local excision with histologic confirmation of margins • Regional lymph node dissection if involved • Mohs’ micrographic surgery • Radiation therapy or chemotherapy in inoperable cases • SCCs on lip, scalp and ear - more aggressive and more likely to metastasize • Ensure regular follow-up to look for recurrence

36. Basal Cell Carcinoma (BCC) Synonym : Basalioma, Rodent ulcer • Most common cutaneous malignancy • Locally invasive and destructive; usually slow growing, rarely metastasizes • Fair skin, sun exposure, ionizing radiation and age > 40 years are risk factors • Seen mainly on sun-exposed areas like face, scalp, ears and neck, less often on trunk and extremities

37. Clinical course • Nodulo-ulcerative type begins as a flesh coloured waxy nodule with telangiectasia → enlarges → central ulceration → deepens → rolled out, beaded edges → destroys structures locally as deep as bone or cartilage → aptly named ‘rodent ulcer’ • Rare metastasis (about 10%) but recurrence known after inadequate treatment

38. Treatment • Simple excision with a margin of 2-5 mm is the treatment of choice. • Mohs’ micrographic surgery for recurrent BCCs • Curettage and cautery, cryotherapy for small lesions • Radiation therapy, photodynamic therapy and topical immunomodulators for localised, well defined growths or for patients refusing surgery • 5 year cure rates are almost 90% for primary and 83% for recurrent BCCs

39. Malignant melanoma • Increasingly common malignancy of melanocytes, most often arising in the skin • Potentially curable with early diagnosis and treatment; late diagnosis carries poor prognosis

40. Predisposing factors • Fair skin (Type I & II) • Personal / family history of atypical nevi or melanoma • Presence of congenital nevi (number is proportional to risk) • History of frequent sunburn

41. Clinical course • 30% of melanomas arise in pre-existing nevi whereas 70% arise de novo • Begins as irregularly pigmented macule or plaque → change in color, shape and size • Nodular variant → dermal involvement → high risk of metastasis → poor prognosis

42. Prognostic factors ABCDE of melanoma • Asymmetry • Border irregularity • Color variability • Diameter > 1 cm • Evolutionary change

43. Management • Diagnosis : Biopsy is the most definitive diagnostic tool. Excision biopsy preferred • Treatment : Complete excision of the lesion with a free margin of at least 1cm is the only reliable therapy For local, regional or distant metastasis, options include wide excision, lymph node resection, chemotherapy and immunotherapy

44. Thank you