Salient Features Of Skin Malignancies
Most commonly epidermal origin
Basal cell carcinoma
Squamous cell carcinoma
Skin adnexal tumors are rare.
Chemical carcinogens play a major role.
Basal Cell Carcinoma
Most common skin tumor, originates from basal layer of epidermis
Slowly growing , locally invasive – RODENT ULCER.
26 histological variants.
Most common are
Pigmented & Morpheaform
coal , tar
No apparent precursor lesion
Never lympatic spread
Ovoid cells in nests with outer pallisading layer.
Waxy , cream coloured with rolled, pearly borders
surrounding central ulcer.
Type IV collagenase and spread rapidly
Flat, plaque like lesion
Metastasize similar to SCC and aggressive treatment required.
High risk BCC
Specific location – nose , ear, eyes
Management of BCC
Surgical VS Non Surgical
Destroy any potential tissue sample for pathological confirmation and
Complete tumor removal , with pathological confirmation and margin analysis.
Large tumors invading adjacent structure with aggressive histology – WIDE LOCAL EXCISION
MOHS Micrographic Surgery
Excision of skin cancer under microscopic control.
Minimise recurrent rates with maximum conservation.
Recurrent / incompletely excised
Near vital structures
Can also be used for SCC, lentigo maligna,DFS
of primary tumor
Sample and defect
are marked and
Stained with H&E.
slide for residual
Excise more tissue
from mapped area.
Cutaneous Squamous Cell Carcinoma
Malignant tumor of keratinising epithelium of epidermis
2nd most common tumor
Cumulative sun exposure and damage
Associated with pre-existing scars, osetomyelitis, burn.
HPV 5 & HPV
Smooth nodular to verrucous , papillamatous and ulcerating lesions.
Everted edges and surrounded by inflamed, indurated skin.
Secondary lymph nodes involvement.
Irregular masses of squamous epithelium proliferate and invade dermis.
Perineural / vascular invasion
Positive for cytokeratin 1 and 10
Border’s histological grading
Ratio of pleomorphic and anaplastic to normal cells
Depth – deeper lesion , worse the prognosis
Surface size - >2 cm
Lips and ears – increase recurrent rate
Perineural and vascular involvement
• T1 - <2cm
• T2 - 2-5 cm
• T3 - >5cm
• T4 - muscle or
• N0 - no
• N1 - regional
• M0 - no
• M1- distant
• G1- low grade
• G3- high
Surgical excision – accurate histology
Margins to be assessed
4mm clearance for <2cm
1 cm clearance for >2cm
Radiotherapy resistant – Veruccus carcinoma
Cancer of melanocytes
Wherever melanocytes exist
Macroscopic Features In Nevi
Suggesting Malignant Melanoma
Superficial Spreading Melanoma
Commonest type – 70%
Arise from pre – existing nevus
Rapid growth of darker pigmented are in a junctional nevus.
Predominantly radial growth phase.
Nodularity can occur – vertical growth phase.
Increased vertical growth than radial phase
Middle age men.
Sharply demarcated, blue-black papules 1-2cm.
Lack horizontal growth phase.
Lentigo Maligna Melanoma
Hutchinson’s melanotic freckle
Slow growing, variegated, brown macule
Intense sun exposure.
Women > men
Less metastaic potential
Acral Lentiginous Melanoma
Soles of feet and palms of hand
Rare in white skinned people
Flat, irregular macule.
Can mimic a fungal infection
Biopsy of the nail matrix rather than just the pigment.
Hutchinson’s sign nail-fold pigmentation then widens progressively to
produce a triangular pigmented macule with nail dystrophy.
Head and neck
High recurrent rate
Malignant changes of melanocytes in basal epidermis
Horizontal growth phase – cells spread along the dermo-epidermal
Vertical growth phase – dermis may be invaded and increased metastatic
Lesions situated with in 2-5cm of the primary
Situated >5cm , proximal to lymphnode basin
History and clinical examination
Excision biopsy with 2mm margin of skin and subdermal fat.
Incisional biopsy – large lesion / facial lesions where excision results in
Staging of melanoma
Management of lymphnodes
Based on breslow thickness.
<1mm least beneficial with prophylactic dissection.
>4mm increased chance of both lymphatic and distant metastasis.
Elective prophylactic lymph node dissection
Sentinel lymphnode biopsy