Three cases of cutaneous malignancies are presented that were referred to a dermatologist. Case 1 involved a 58-year-old woman with vulvar carcinoma in situ that was treated with wide local excision and lymph node resection. Case 2 was a 56-year-old woman with pigmented basal cell carcinoma below her right eye, treated with Mohs micrographic surgery. Case 3 was a 65-year-old woman with multiple actinic keratotic lesions and squamous cell carcinomas on her skin from sun exposure, treated with wide local excision and radiation therapy. Early diagnosis and multidisciplinary treatment approaches were important for good patient outcomes in these cases of skin malignancies.

1. AN EARLY DIAGNOSIS AND
THERAPEUTIC APPROACH OF MALIGNANCY
THROUGH THE LENS OF A
DERMATOLOGIST
DR M KAVYA
1st year Post graduate

2. Introduction
• Skin tumors develop due to proliferation of a group of cells with differentiation
towards single or multiple components of the skin.
• Cutaneous malignancies account for 1-2% of all the diagnosed cancers in India.
• Clinical presentation ranging from small papules to large fungating masses and
are less common in brown skinned people.
• Nevertheless, it is important to be familiar with the entire range of benign and
malignant neoplasms of the skin.

3. •Based on primary site of origin skin tumors can be divided into
•We hereby report 3 cases of cutaneous malignancies that were referred by various
departments in view of skin lesions.
SKIN TUMORS
Keratinocytic
Eg. Benign acanthomas
AK
SCC
BCC
Melanocytic
Nevi
Malignant melanoma
Appendageal
Eccrine tumors
Apocrine tumors
Sebaceous
follicular
Soft tissue
Vascular
Lymphatic
Smooth and skeletal
muscle tumors

4. CASE 1:
• Department of Obstetrics and gynaecology has referred a 58 year female patient
with complaints of itching over the genitals since 2 years.
• HOPI : 7 years ago patient had suddenly noticed a red lesion over the labia majora,
but no progression in size and shape.
• 3 years after this, patient developed itching over the vulvovaginal region followed by
a small growth over labia majora.
• The growth being insidious in onset had gradually progressed to a size of 7 x 4.5cm
extending onto labia majora.
• Burning sensation over the lesion along with 10kg weight loss in the past 3 months.
• 3 years ago, hysterectomy was done for AUB ( ? Fibroids ).

5. • PAST HISTORY : - No history of similar complaints in the past
- K/c/o DM since 15yrs on T.Gliclazide + Metformin
- K/c/o HTN since 15yrs on T.Amlodipine + Atenolol 50/5
• MENSTRUAL HISTORY : Attained menopause 10 years ago
• PERSONAL HISTORY : Normal
• FAMILY HISTORY : Insignificant
• GENERAL PHYSICAL EXAMINATION:
LYMPH NODE LEFT Inguinal LN RIGHT Inguinal LN
SIZE & Number
5 in number
0.5cm x 0.5cm
2 discrete LN
2cm x 1.5cm
CONSISTENCY Firm and non tender Firm and non tender

6. Under 10x magnification Under 40x magnification
Diffuse erythematous fleshy
irregular growth of 5 x 2cm.
Leucoplakia (+) Tenderness (+)
Bilateral assymetrical & discrete
group of inguinal lymph nodes on
palpation were firm & non-tender.
Right LNs - 0.5 x 0.5cm
Left LNs - 2 x 1.5cm
A 4mm punch biopsy was taken and on microscopy, a strip of squamous
epithelium with hyperplasia and loss of polarity was noticed.
These epithelial cells were showing hyperchromatic pleomorphic nuclei
with scanty cytoplasm.
Findings were suggestive of severe dysplasia to carcinoma insitu of
vulva.

7. • Along with MRI all the necessary investigations were done to rule out metastasis
• The patient was referred to the concerned Gynaecological oncologist
• Wide local excision with lymph node resection was performed and patient’s prognosis is good.
BEFORE SURGERY AFTER SURGERY

8. CASE 2 :
• Department of General surgery has referred a 56yr old female with complaints of black-
colored growth below the right eye since 2 years.
• HOPI:
• 2 years ago she started developing a pea-sized black-colored growth below the right eye.
• It was insidious in onset and gradually progressed to attain a size of 3.5 x 3cm
encroaching onto the right lower eyelid.
• H/o itching, pain, bloody discharge occasionally over the lesion resulting in the formation
of mild central clearing.

9. • O/E: A single well-defined hyperpigmented nodular growth
of 3.5 x 3cm with irregular surface seen below the right eye.
PAST HISTORY
No H/O similar complaints
No other comorbidities
MENSTRUAL HISTORY Attained menopause 7 years ago.
PERSONAL HISTORY Normal
FAMILY HISTORY Insignificant
GENERAL
EXAMINATION
Normal

10. Focal deposits of Melanin pigment within tumor cells and stroma
Islands of tumor cells with peripheral palisading
• Tumor cells arranged in islands, nests and trabecular
pattern.
• Hyperchromatic nuclei and scanty cytoplasm.
• The deposits were suggestive of
pigmented basal cell carcinoma

11. • All the necessary investigations were done.
• Patient was referred to Basavatarakam hospital for further management.
• Mohs micrographic surgery was performed and now patient is in sound health.
BEFORE SURGERY AFTER SURGERY

12. CASE 3:
• A 65-year-old female patient with vitiligo universalis came with multiple skin colored to red
elevated lesions over both UL and trunk since 1 year associated with itching and burning.
• HOPI: One year back patient travelled to USA for 6 months following which she started
developing skin-colored to red pea nut-sized patches and plaques over both upper limbs.
• Insidious in onset and gradually progressing to involve trunk and associated with itching.
• A few of them progressed to an irregular and nodular growth of approx 2 x 2cm over the right arm.
• H/o photosensitivity present.
• PAST HISTORY: No history of comorbidities and similar complaints in the past.
• MENSTRUAL HISTORY: attained menopause 12 years ago
• PERSONAL HISTORY: Normal
• FAMILY HISTORY: Insignificant

13. • GENERAL PHYSICAL EXAMINATION: Normal
• O/E: Multiple well defined erythematous and hyperpigmented plaques associated with
crusting and scaling [actinic keratotic lesions] over both upper limbs and face.
• 5 well defined erythematous fleshy growths over the actinic keratotic lesions ranging from
1x1cm to 3 x 4cm distributed over the extensor aspect of right arm, neck and upper back.
• Initially developed actinic keratotic lesions have transitioned into squamous cell carcinoma.
• BIOPSY– one from the growth and another from the plaque.
• Excision biopsy[growth] revealed squamous epithelial cells arising from epidermis
extending into the dermis.
• Some large cells with abundant eosinophilic cytoplasm and keratin pearls being suggestive
of Squamous cell carcinoma.
• Features of Actinic keratosis were observed in another biopsy.

14. • Patient was treated by Wide local excision + 45 cycles of EB radiotherapy.
• Other AK lesions were treated with Sunscreens, emollients, cryotherapy [AK lesions]
showing improvement
• Patient is in good condition with no complaints. Patient was advised strict sun protection.
LESIONS BEFORE TREATMENT LESIONS AFTER TREATMENT

15. CONCLUSION :
▪ Early diagnosis of cutaneous malignancies reduces mortality and morbidity significantly.
▪ Managing malignancies depends on the coordinated efforts of multiple departments along
with dermatologists.
▪ Accurate suspicion of skin cancer by a primary care physician facilitates diagnostic
confirmation and early treatment. In contrast, failure to refer a patient with a particular
disease or to appropriately assess its urgency will unfortunately lead to patients being held on
waiting lists with negative consequences on morbidity.
▪ Here all the three patients were diagnosed early and were treated immediately. This is
important here because “ it was found before it had the opportunity to spread to other parts
of the body “
▪ Multi disciplinary approach played a key role in this success story.

16. REFERENCES :
1. Bhagyashree Babanrao Supekar 1, Suyash Singh Tomar 1 PMID: 34446952
PMCID: PMC8375545 DOI: 10.4103/ijd.IJD_543_19
2. Guillermo Sánchez 1, John Nova,
PMID: 27455163 PMCID: PMC6457780 DOI: 10.1002/14651858.CD011161.pub2
3. ANTHONY F. JERANT, M.D., JENNIFER T. JOHNSON Et al Am Fam Physician. 2000;62(2):357-368
4. Arch Dermatol, 117 (1981), pp. 260-262
THANK YOU