Malignant tumors of skin

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ppt on basics of skin tumors, squamous cell carcinoma , bcc, melanoma for medical sudents.

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Malignant tumors of skin

  1. 1. MALIGNANT TUMORS OF SKIN DR MUKHILESH R M.S.,
  2. 2. Salient Features Of Skin Malignancies  Most commonly epidermal origin  Basal cell carcinoma  Squamous cell carcinoma  Malignant melanoma  Skin adnexal tumors are rare.  Chemical carcinogens play a major role.
  3. 3. 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  Nodular  Superficial speading  Infiltrative  Pigmented & Morpheaform
  4. 4. Predisposing factors UV rays Arsenics, coal , tar BCC White skin, genetics Middle aged, men
  5. 5. Pathogenesis  No apparent precursor lesion  Locally infiltrative.  Rarely metastasise.  Never lympatic spread  Ovoid cells in nests with outer pallisading layer.
  6. 6. Contd…  Nodulocystic  Waxy , cream coloured with rolled, pearly borders surrounding central ulcer.  Morpheaform  Type IV collagenase and spread rapidly  Flat, plaque like lesion  Basosquamous variant  Highly aggressive  Metastasize similar to SCC and aggressive treatment required.
  7. 7. Prognosis  High risk BCC  >2cm  Specific location – nose , ear, eyes  Ill-defined margins  Recurrent tumors  immunosuppression
  8. 8. Management of BCC  Surgical VS Non Surgical  Non surgical  Curettage  Electrodessication  Laser vapourisation  Destroy any potential tissue sample for pathological confirmation and margin analysis
  9. 9. Surgical Management  Complete tumor removal , with pathological confirmation and margin analysis.  Large tumors invading adjacent structure with aggressive histology – WIDE LOCAL EXCISION  0.5-1cm margin  Reconstructive procedures
  10. 10. MOHS Micrographic Surgery  Excision of skin cancer under microscopic control.  Minimise recurrent rates with maximum conservation.  Indicated in  Poorly demarcated,  Recurrent / incompletely excised  Near vital structures  Can also be used for SCC, lentigo maligna,DFS
  11. 11. Contd… Under local anesthesia Saucerising excision of primary tumor Sample and defect are marked and oriented Stained with H&E. Examination of slide for residual tumor Excise more tissue from mapped area.
  12. 12. Contd…
  13. 13. Other Modalaties  Radiotherapy  Topical treatments  5-fluorouracil  Imiquimod  Cryotherapy
  14. 14. 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.  Marjolin’s ulcer
  15. 15. Pathogenesis Sun exposure Scars and sinuses Chemical carcinogens SCC Tobacco use HPV 5 & HPV 16
  16. 16. Pathology  Smooth nodular to verrucous , papillamatous and ulcerating lesions.  Everted edges and surrounded by inflamed, indurated skin.  Distant metastasis.  Secondary lymph nodes involvement.
  17. 17. Differential Diagnosis Of SCC  Actinic keratosis  BCC  Keratoacanthoma  Pyoderma gangrenosum  Warts
  18. 18. Microscopic Appearance  Irregular masses of squamous epithelium proliferate and invade dermis.  KERATIN PEARLS  Perineural / vascular invasion  Positive for cytokeratin 1 and 10  Border’s histological grading  Ratio of pleomorphic and anaplastic to normal cells
  19. 19. Prognosis  Invasion  Depth – deeper lesion , worse the prognosis  Surface size - >2 cm  Histological grade  Site  Lips and ears – increase recurrent rate  Immunosuppression  Perineural and vascular involvement  Aetiology
  20. 20. TNM Classification Size • T1 - <2cm • T2 - 2-5 cm • T3 - >5cm • T4 - muscle or bone involvement Nodes • N0 - no regional nodes • N1 - regional nodes Metastasis • M0 - no metastasis • M1- distant metastasis Grade • G1- low grade • G2moderately differentiated • G3- high grade
  21. 21. Management  Surgical excision – accurate histology  Margins to be assessed  4mm clearance for <2cm  1 cm clearance for >2cm  Radiotherapy resistant – Veruccus carcinoma
  22. 22. Malignant Melanoma  Cancer of melanocytes  Wherever melanocytes exist  Bowel mucosa  Retina  Leptomeninges
  23. 23. Macroscopic Features In Nevi Suggesting Malignant Melanoma
  24. 24. Contd…  Tingling  Itching  Serosanguinous discharge  Blood supply  Melanomas >1mm have blood supply – doppler positive pigmented lesion
  25. 25. Types Of Malignant Melanoma  Superficial spreading  Nodular melanoma  Lentigo maligna melanoma  Acral lentiginous melanoma  Amelanotic melanoma  Desmoplastic melanoma
  26. 26. 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.
  27. 27. Nodular Melanoma  More aggressive  Increased vertical growth than radial phase  Middle age men.  Usually trunk.  Sharply demarcated, blue-black papules 1-2cm.  Lack horizontal growth phase.
  28. 28. Lentigo Maligna Melanoma  Hutchinson’s melanotic freckle  Slow growing, variegated, brown macule  Intense sun exposure.  Women > men  Less metastaic potential  Better prognosis
  29. 29. 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.
  30. 30. Miscellaneous  Amelanotic melanoma  Not pigmented  Poor prognosis  Desmoplastic melanoma  Head and neck  Perineural invasion  High recurrent rate
  31. 31. Histology  Malignant changes of melanocytes in basal epidermis  Horizontal growth phase – cells spread along the dermo-epidermal junction  Vertical growth phase – dermis may be invaded and increased metastatic potential.
  32. 32.  Satellite nodules  Lesions situated with in 2-5cm of the primary  Intransit lesions  Situated >5cm , proximal to lymphnode basin
  33. 33. Management  History and clinical examination  Excision biopsy with 2mm margin of skin and subdermal fat.  Incisional biopsy – large lesion / facial lesions where excision results in scarring.  Staging of melanoma  Clarkes’ staging  Breslows’ classification
  34. 34. Staging Of Melanoma
  35. 35. Management Of Malignant Melanoma Pigmented lesion Biopsy Diagnosis of melanoma <1mm depth Excision - 1cm margin 2-4mm depth Excision -2cm margin >4mm depth Excision – 3cm margin
  36. 36. Management of lymphnodes  Based on breslow thickness.  <1mm least beneficial with prophylactic dissection.  >4mm increased chance of both lymphatic and distant metastasis.  Intermediate thickness  Elective prophylactic lymph node dissection  Sentinel lymphnode biopsy
  37. 37. Sentinel Lymphnode Biopsy
  38. 38. Sentinel Lymphnode Biopsy
  39. 39. Other Modalities  Chemotherapy  Melphalan  Vemurafenib  Isolated limb perfusion therapy  Immunotherapy  IFN / TNF ALPHA  Radiotherapy

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