Malignant tumours of the skin

Aavani Jayan 20M004

Abhindev S M 20M005
CLASSIFICATION OF SKIN TUMOURS

Epidermal

● Benign - papilloma, seborrhoeic keratosis

● Malignant - BCC, SCC

Melanocytic

● Benign - all types of naevi

● Malignant melanoma

Skin adnexal tumour

● Benign - syringoma , hidradenoma, sebaceous adenoma, trichofolliculoma, trichilemmoma

● Malignant - hidradenocarcinoma, sebaceous carcinoma

Dermal tumours

● Neurofibroma, dermatofibroma, dermatofibrosarcoma protuberans

Skin adnexal tumors
Classification

● Eccrine gland tumours: Syringoma, hidradenoma, syringo-cystadenoma

● Hair tumours: Trichoepithelioma, tricholemmoma
● Benign or malignant

Features

● They are tumours arising from accessory skin structures like sebaceous glands, sweat glands,
hair follicles
● Presents as protruding well-localised swelling in the skin
● Trichoepithelioma is seen in nasolabial fold, mimics BCC, presents as small cutaneous nodule
● Tricholemmoma is also called as naevus sebaceous of Jadassohn. It is hamartoma from hair
follicle which can turn into BCC in 10% of cases
 ● Adenoma sebaceum is seen in tuberous sclerosis as red papules in face which appears
below 10 years. It is often called as Bourneville's disease
● Calcifying epithelioma of Malherbe/pilomatrixoma is benign hair matrix cell tumour seen
below the age of 10 years, containing basaloid and eosinophilic ghost cells with calcification.
● Malignant skin adnexal tumour forms a nodular, hard, indurated swelling in the skin, often
with involvement of regional lymph nodes which are hard and nodular
● It mimics squamous cell carcinoma of skin

Differential diagnosis

● Squamous cell carcinoma of skin; Dermatofibrosarcoma protuberans

Diagnosis

● Biopsy- excision or incision type; FNAC of lymph node.

Treatment

● Benign tumour - excision

● For malignant tumour - wide excision and regional lymph node block
dissection when required.
● Prognosis is good. It is better than squamous cell carcinoma.
DERMATOFIBROMA
● Benign tumour arising from skin from dermal dendritic cells.
● It is formation of firm, single or multiple nodules occurring commonly in extremities
(limbs).
● It can be red, brownish yellow (due to lipid), or bluish black (due to hemosiderin).
● Dermatofibroma is common in females (4:1). It typically shows dimple/ buttonhole
sign wherein applying lateral pressure creates a central depression.
● Histologically, spindle cells are arranged in 'mat like' or 'cart-wheel' pattern.
● It is also called as dermal histiocytoma/dermal dendrocytoma
Treatment : Excision
Differential diagnosis : Squamous cell carcinoma of skin; Melanoma; Basal cell
carcinoma; Skin adnexal tumour.
DERMATOFIBROSARCOMA PROTUBERANS
● It is a low grade fibrosarcoma which grows slowly but persistently. Arises from dermal
fibroblasts.
● Occurs in head and neck, limbs, abdominal wall and back. Trunk is the commonest site (50%).
● It is not a rare entity, often attains a large size with multiple, nodular, hard, swelling with often
involvement of lymph nodes. Malignant spindle cells are seen histologically.
● Rarely it spreads into lungs through blood.
● It mimics squamous cell carcinoma of skin and skin adnexal tumour.
● With melanin pigmentation it is called as Bednar's tumour.
Diagnosis : Biopsy of the lesion; Chest X-ray, CT scan; FNAC of the lymph node.
Treatment : Wide excision and follow up; Recurrence is common- 50%; Prognosis is good.
KERATOACANTHOMA (MOLLUSCUM SEBACEUM)

● It is an overgrowth and subsequent spontaneous regression of pilosebaceous

glands with proliferation of squamous cells protruding out of the duct
● Common in adult males (3: 1)
● Typical locations are sun exposed areas
● Common in Caucasians after 50 years of age.

Causes: Human papillomavirus; genetic; immunosuppression; UV rays, trauma are

considered.

● It presents as a rapidly growing, painless, single swelling in the skin with

central brown area
 ● It grows usually for 4 weeks and later shows spontaneous regression in 4 months. It is a
pseudomalignancy.
● During regression phase, central area separates from the lesion leaving a deeply seated
scar.
● Even though it is usually benign, 6% of cases may be invasive squamous cell carcinoma and
often called as keratoacanthoma variant.
● Commonly keratoacanthoma is solitary, but rarely can be multiple, giant or generalised.

Features

● Mobile, hard, painless, nontender, lump with a central brownish volcano like area. It is
common in face. It can be recurrent in lips and fingers.
● Lymph nodes are not enlarged.

Differential diagnosis: Squamous cell carcinoma.

Treatment: excision
RHINOPHYMA
● It is a glandular form of acne rosacea causing immense thickening of distal
part of skin of nose with visible openings of sebaceous follicles. Nose is
bluish red in colour with dilated capillaries.
● It is due to hypertrophy and adenomatous changes in sebaceous glands.
Cosmesis is the main problem.
● Male to female ratio is 12:1. Three per cent cases may have occult BCC in it.
But rhinophyma itself will not cause BCC

Treatment: Excision of excess tissue and reconstruction, dermabrasion, laser

resurfacing, cryosurgery.
 SEBORRHOEIC KERATOSIS
● Benign overgrowth of the basal layer of epidermis with excess of small darkly
stained basal cells, which protrudes from the surface of the epidermis.
Features
● Common in elderly. Common sites are the back, face, neck
● It grows slowly with widening in area without altering in thickness
● It often gets infected but uncommon to bleed on touch.
● Pigmented due to melanin and so mimics naevus or melanoma.
● Common in Caucasians. It is familial-autosomal dominant gene related.
● Often when it falls off, it leaves a pale pink patch on the skin with visible small
surface capillaries.
● It is not a premalignant condition.
 ● 'Stuck on' appearance is characteristic.
● Differential diagnosis: Melanoma, pigmented BCC,
naevus

Treatment
● Excision cures the condition.
● Shave excision or curettage or cautery or cryosurgery
can be done.Scarring may be a problem.
SQUAMOUS CELL CARCINOMA(Epithelioma)
● 2nd(20%) most common skin cancer. It is common in males.
● It occurs in premalignant conditions like Bowen's disease, Paget's disease,
leukoplakia, chronic scars, chemically induced chronic irritation, radiodermatitis,
senile keratosis, e.g. Kangri cancer in Kashmir, Chimney scrotal cancer, Kang cancer
of Tibetans.
● Arises from squamous layer of the skin. It occurs in a pre-existing predisposing
lesion; occasionally can develop in de novo skin.
● It can be grossly proliferative/ulcerative/ulceroproliferative/ red plaque like.
Proliferative type is cauliflower like.
● Exposure to UV 8 rays (ultraviolet rays are A, B, C types) causes SCC by direct
carcinogenic effects on keratinocytes, unrepaired mutations , decreased immune
surveillance response, inhibition of tumour rejection, mutation of p53 suppressor
gene
Common sites : Dorsum of hand, limbs, face, and skin of abdominal wall SCC can occur in external
genitalia, mucocutaneousjunction, oral cavity, respiratory system, oesophagus, gallbladder, in urinary
bladder as metaplasia from transitional cell lining

Features

● An ulcerative or ulceroproliferative or proliferative lesion. Raised and everted edge; lndurated base
and edge; Bloody discharge from the lesion.
● Regional lymph nodes are commonly involved
● Usually blood spread does not occur. 5% can develop metastatic SCC; risk factors
are-immunosuppression, large growth, perineural and deep infiltrative,
Histology:

● Malignant whorls of squamous cells with epithelial

or keratin pearls are characteristic feature.

● Spindle cells, invasion, deep and peripheral margin clearance.

● Desmoplastic, mucinous, pigmented, acantholytic- are other variants.
● High risk features are-depth >2 mm, poorly differentiated, perineural invasion.
Differential diagnosis: BCC; Melanoma; Keratoacanthoma; Skin adnexal tumours; Actinic keratosis;
Pyogenic granuloma.
Investigations
● Wedge biopsy from the edge.
● FNAC from lymph node.
● CT scan to identify nodal disease; MRI to identify local extension is useful
Treatment
● Radiotherapy using radiation needles, moulds, etc. is given. Wide excision, 2 cm clearance followed
by skin grafting or fl aps.
(Presently for tumour less than 2 cm, 4 mm clearance and for tumour more than 2cm,1cm clearance is
sufficient). Wide excision should show clearance both at margin as well as in the depth. If muscle, fascia,
cartilage are involved, it should be cleared. Reconstruction is usually done by primary split skin grafting .
Delayed skin grafting also can be done once wound granulates well. Often flaps of different types may be
needed depending on the site of lesion.
● For lymph nodes, block dissection of the regional lymph nodes is done.
● Curative radiotherapy (RT) is also useful in tumours which are not adherent to deeper planes or
cartilage as SCC is radio-sensitive. It is also useful in recurrent SCC and in patients who are not fit
for surgery. A dose of 6000 Gy units over 6 weeks; 200 units/day is used. Recurrence after RT is
treated by surgical wide excision.
● In advanced cases with fixed lymph nodes, palliative external radiotherapy is given to palliate pain,
fungation and bleeding.
● Chemotherapy is given using methotrexate, vincristine,bleomycin, cisplatin, carboplatin.
● Field therapy using cryoprobe or topical fluorouracil or electrodessication.
MARJOLIN'S ULCER
● It is well-differentiated squamous cell carcinoma which occurs in chronic
scars like burn scar, scar of venous ulcer. It occurs in unstable scar of long
duration. It is slowly growing, locally malignant disease. It is a curable
malignancy.
● lndurated, painless, nontender, ulcer with raised and everted edge with scar in
surrounding area is typical. There is marked fibrosis.
● Wedge biopsy from the edge, MRI of the part and regional node area confirms
the diagnosis.
Treatment: Wide local excision; in case of large ulcer, amputation is required.
BASAL CELL CARCINOMA
● Low grade, locally invasive, carcinoma arising from basal layer of skin (or adnexal basal
layer of hair follicle) or muco- cutaneous junction. It does not arise from mucosa.
● It is the commonest (70%) malignant skin tumour.
● It is more common in white-skinned people than blacks.
● Common in places where exposure to UV light is more (Australia).
● Other causes are arsenics,coal tar, aromatic hydrocarbons, skin tumour syndromes,
xeroderma pigmentosa, albinism. It is common in males, common in middle-aged and
elderly. Common site is face-above the line drawn between angle of mouth and ear lobule
(90%) - Onghren 's line.
● It is called as tear cancer because it is commonly seen in area where tears roll down.
● Often it can occur in mucocutaneous junctions..
● It is only locally malignant. It does not spread through lymphatics nor through the blood.
But it erodes deeply into local tissues including cartilages, bones causing extensive local
destruction. Hence the name "rodent ulcer".
Types
● Nodular - common in face, classic type.
● Cystic/nodulocystic.
● Ulcerative-Rodent (Jacob) ulcer.
● Multiple, often associated with syndromes and other malignancies.
● Pigmented BCC-mimics melanoma.
● Geographical or field fire or forest fire BCC is wide area involvement with
central scabbing and peripheral active proliferating edge.
● Basisquamous- behaves like squamous cell carcinoma which spread into
lymph nodes. BCC which has not been treated for long time can turn into
basosquamous carcinoma.
Clinicopathological Types

a. Superficial type - small buds of tumour masses, common in young people.

b. Morpheic type-dense stroma with basal cells and type IV collagen; spreads
rapidly; sclerosing BCC.

c. Fibroepithelioma type of Pinkus shows elongated cords of basaloid cells with

mesh work, common in lower back.It contains outer palisading columnar cells
with central polyhedral cells but no prickle cells or keratinisation.
Features

● Ulcer on the face in a middle-aged man which is nontender, dry, slowly

growing, nonmobile, with raised and beaded edge withcentral scab, often with
central depression or umbilication.
● Site of beading signifies the area of active proliferating cells. In between
beaded areas dormant nonactive cells are present.
● No lymph node or blood spread occurs. Due to large sized tumour
cells/tumour cluster, it does not spread through lymphatics.
● BCC can be low risk or high-risk.
Differential diagnosis: Squamous cell carcinoma; Melanoma; Keratoacanthoma;
Seborrhoeic keratosis.

Investigations: Wedge biopsy, X-ray of the part, CT scan dermoscopy is very

useful.

Treatment:

It is radiosensitive. If lesion is away from vital structure (like away from eyes), then
curative radiotherapy can be given. Radiotherapy is not given, once it erodes
cartilage or bone .
 Surgery

● Wide excision (4-6 mm clearance) with skin grafting, primary suturing or flap
(Z plasty, rhomboid flap, rotation flap) is the procedure of choice.
● Cryosurgery.
● MOHS (Microscopically Oriented Histographic Surgery) is useful to get a
clearance margin and in conditions like SCC close to eyes, nose or ear, to
preserve more tissues. Under local anaesthesia, a saucerised excision of the
primary tumour is done and quadrants of the specimen are mapped with
different colours. Specimen is sectioned from margin and depth, and it is
stained using eosin and haematoxylin.Residual tumour from relevant mapped
area is excised and procedure is repeated until clear margin and clear depth
are achieved.
● Laser surgery, photodynamic therapy (using aminolevulinic acid
lotion),cryosurgery, curettage and electrodesiccation.
TURBAN TUMOUR
● It is a descriptive term wherein entire scalp looks like a turban because of multiple scalp
swellings. It can be due to multiple cylindroma; multiple hidradenomas; subcutaneous
neurofibromas; nodular multiple basal cell carcinoma.
● Multiple cylindroma is usually considered disease under this term.Multiple firm pinkish
nodules in the scalp are the presentation in multiple cylindroma. They are rare, often locally
malignant, grows slowly over the span of many years to cover entire scalp with reddish
lobulated lesion.
● Hidradenoma is a rare benign sweat gland tumour. Multiple tumours commonly look like a
turban in the scalp. They are painless, disfiguring, cosmetically problematic, soft, boggy,
non-fluctuant, non-compressible cutaneous swellings; commonly observed in middle age
group.
● Multiple sebaceous cysts over the scalp mimic the same.
● Management is initial biopsy to find out the cause; then wide excision with skin grafting.
NAEVI (MOLES)

● It is excessive proliferation of melanocytes.

● It is hamartoma of melanocytes due to excessive stimulation.
● The risk in a small or medium-sized mole turning into melanoma is under 1%.
● It may present during birth or appear later.
Types

● Hairy mole is a mole with a hair growing on its surface.

● Nonhairy mole.
● Blue naevus. It is seen in children. It is located deep in the dermis, hence
appears blue. It is common in buttock (Mongolian spot), hand, feet.
● Junctional naevus. It lies centred in the junctional layer (basal layer) of the
epidermis as clusters. It is immature, unstable and premalignant.
Microscopically there is proliferation of melanocytes at the epidermal
junction. Features of malignant transformation are-change in the size, colour,
bleeding, ulceration, crusting, satellite spots.
● Compound naevus. It is combination of intradermal and junctional naevus.
lntradermal part is inactive but junctional part is potentially malignant.
● Juvenile melanoma (Spitz naevus). It appears as junctional like mole before
puberty. It is seen in children on face. They present as brownish red nodular
lesion which needs always excision.
● Hutchinson's freckle. It is seen in elderly with large area of dark pigmentation.
In the macular stage it is smooth and brown. In the tumour stage it is dark
and irregular. It can turn into melanoma commonly.
● Halo naevus-: Halo of depigmentation around the pigmented naevus. This
halo is due to antibody response to melanocytes. Halo naevus is often seen
along with vitiligo. Similar halo may develop around a malignant melanoma
lesion.
● lntradermal naevus: Cluster of dermal melanocytes is seen without junctional
component. Common in face.
● Spindle cell naevus-. It is dense, black pigmented lesion containing spindle
cells and atypical melanocytes at dermo- epidermal junction; seen in females
on high with malignant potential.
● Naevus spilus: It is hyperpigmented speckles throughout, also called as
speckled lentiginous naevus. Malignant potential is rare.
● Naevus of Ota is dermal melanocytic hamartoma seen in distribution area of
trigeminal nerve(ophthalmic/maxillary). It is seen in oriental and African race
adolescent females (thigh) with a hormonal influence.
● Dysplastic naevus is proliferation of atypical melanocytes from epidermal
basal layer having variegated irregular look; it is usually >5 mm in size; can be
familial ; 10% cases may turn into superficial spreading melanoma.
● Congenital naevus: It is present since birth.
Treatment

Excision. Always should be sent for histopathology.

References

SRB’s Manual of Surgery 7th edition.

THANK YOU