cutaneous malignancies

1. CUTANEOUS
MALIGNANCIES

2. ⦁ DERMIS
⦁ 15 – 20 times thicker than epidermis
⦁ Collagen, elastic fiber, ground substance
⦁ Nerve, vessels, lymphatics
⦁ Fibroblast, mast cell, histiocytes, lymphocytes
⦁ Papillary layer
⦁ Reticular layer
⦁ EPIDERMIS
⦁ 5% of total skin
⦁ Thickest @ palms, soles, back and buttocks
⦁ 5 layers-SC,SG,SS,SB,SL
⦁ Keratinocytes, Melanocytes, Langerhans cells

3. CLASSIFICATION OF SKIN TUMOURS

4. ⦁ Most common risk factors is exposure to ultraviolet (UV) light
⦁ BCC accounts for 75% of cases of NMSC
⦁ SCC accounts for the remaining majority of NMSC

5. CUTANEOUS SCC
• Second most common skin cancer
• Malignant tumour of keratinising cells of the epidermis or its appendages.
• ETIOLOGY

6. ⦁ UVB radiation – chronic uv exosure
⦁ Sun light exposure
⦁ Increase in incidence in sunnier climates
⦁ Lower rates in darker skin types
⦁ Use of tanning devices is associated with 2.5-fold increase in SCC risk and 1.5-fold increase
in BCC risk
⦁ Phototherapy, utilized in the treatment of various skin diseases, is also associated with
increased risk of NMSC
⦁ Exposures to arsenic, organic hydrocarbon, ionizing radiation, and cigarette smoke have
been associated with increasing risk for SCC

7. ⦁ Human papillomavirus(HPV) pathogenic for SCC
⦁ HPV prolong keratinocyte cell cycle, with degradation of p53
⦁ Impaired immunity, especially cell- mediated , is a well-established cause of SCC
⦁ Chronically immunosuppressed patients who undergone organ transplantation
⦁ Immunosuppressive drugs such as azathioprine, cyclosporine, and prednisone increase
the risk for SCC by 50%

8. • PREMALIGNANT CONDITIONS
• ACTINIC KERATOSIS
• BOWENS DISEASE
• LEUKOPLAKIA
• ERYTHROPLAKIA
• KERATO ACANTHOMA
• XERODERMA PIGMENTOSUM
• RADIATION DERMATITIS

9.  BOWENS DISEASE
 An early stage intraepidermal SCC – SCC insitu
 Common above 60 years
 Common at genitalia
 Typically presents as a gradually enlarging, well-demarcated erythematous plaque with
irregular border, crusted or scaling surface

10. ⦁ Actinic keratosis
 Common above middle age and elderly
 Characterized by papule or plaque with
rough surface
 May develop cutaneous horn or become
malignant
 10-20% of lesions progress to SCC

11. • COMMON SITES
• Dorsum of hand, limbs, face, and skin of abdominal wall
• SCC can occur in external genitalia,
• mucocutaneous junction,
• oral cavity,
• respiratory system,
• oesophagus, gall- bladder,
• in urinary bladder as metaplasia from transitional cell lining.

12. EXAMINATION

13. • VARIANTS OF SCC:
• Marjolins ulcer – scc occurring in chronic scars with out lymph node spread – no
lymphatics in scar tissue
• Verrucous carcinoma

14. HISTOLOGY
• An invasive, epidermal keratinising tumour characterised by proliferation of atypical squamous cells
with ‘keratin pearls’

16. TREATMENT
⦁ Choice of treatment depends on:
⦁ Risk stratification of the tumor, patient preference or suitability, and availability of local
services
⦁ High-risk tumor have greater risk of recurrence and require more aggressive
treatment – multimodal treatment

17. TREATMENT
• Wide excision with 2cm clearance followed by SSG or Flap
reconstruction
• Gold standard surgery is Mohs Micrographic Surgery(MMS)
• Amputation with one joint above.
• For lymph nodes, block dissection of the regional lymph nodes is
done.

18. • Chemotherapy is given using methotrexate, vincristine, bleomycin.
• Field therapy using cryo-probe or topical fluorouracil or
electrodessication.
• Brachytherapy using radiation needles,moulds may be given.

19. • Radiotherapy is also useful in tumors which are not adherent to deeper
planes or cartilage as SCC is radiosensitive.
• Effective treatment modality for patients who are unable to undergo
surgery
• Efficacy is overall lower than with surgery
• Beneficial postoperatively for tumors with perineural invasion
• When complete margin excision is not possible

20. BASAL CELL CARCINOMA
• It is the commonest (70%) malignant skin tumour.
• It is more common in white-skinned people
• This tumour of low-grade malignancy
• there is no precursor skin lesion for BCCs
• It does not arise from mucosa
• Common in face above the line joining angle of mouth to ear lobule
• Onghren’s line

21. • EXAMINATION:
• starts as a small brownish-red painless nodule
with translucent colour and shiny surface
showing a network of capillaries.
• Tumor becomes ulcerated with a well defined
hard and raised edge with a beaded
appearance.
• There is a central scab; the margin gradually
spreads and infiltrates into the surrounding
tissues as well as deeper tissues even up to the
bone.
• This characteristic feature of eroding the
tissues, which come in contact with it, has given
it the name ‘rodent’.
• No lymphatic or blood spread – no distant mets

22. • TYPES:
• Nodular – most common
• Cystic/nodulocystic
• Ulcerative
• Multiple – syndromic
• Pigmented BCC – mimics Melanoma
• Basi-squamous – behaves like SCC
• Geographical/ field fire type BCC – widely spreading with active proliferating edge

23. • TREATMENT:
• Wide excision (1 cm clearance) with skin grafting/ primary suturing/ flap is the procedure
of choice – Mohs Micrographic Surgery is the gold standard
• Cryosurgery
• Laser treatment – for superficial BCC
• Radiosensitive tumor – RT if not amenable to surgery/ near vital structures - RT is not
given to BCC of ear and close to lacrimal canaliculi
• Excellent prognosis if completely removed

24. MMS

25. RISK FACTORS FOR RECURRENCE OF NMSC
SCC
• Tumour size greater than 2 cm
• Tumour thickness greater than 4 mm
• Moderate or poor histological
• differentiation
• Anatomic site over ear, lip, Genitalia
• Perineural invasion, Lympho-vascular
invasion
• Immunosuppressed patients
• Tumours arising from chronic scars or
ulcers
BCC
• Tumour size greater than 2cm
• Infiltrative, micronodular
• Histological subtype
• Perineural invasion
• Anatomic site over central face

26. MALIGNANT MELANOMA

27. • Arise from melanocytes in basal layer in the epidermis
• The worst prognosis and morbidity in all skin cancers
• Accounts for 4% of all skin cancers
• Responsible for > 77% of all skin cancer deaths
• Mostly arise from skin ( 95 % )
• Also found in the eyes, ears, GI tract, and mucous membranes
• Can also present as metastasis with unknown primary

28. PRECURSOR LESIONS
• Atypical or Dysplastic nevi
• Congenital nevi
• Acquired nevi

29. RISK FACTORS
MODIFIABLE
• Amount of UV exposure
• Severity of UV exposure
• Occupational exposure to coal tar,
arsenic or radium
• Immunosuppression
NON MODIFIABLE
• Very fair skin
• Higher no of nevi
• Nevi developed in adult hood
• Histologically
• dysplastic nevi
• Family history of melanoma
• Personal or family history of BCC or
SCC

30. SIGNS OF MELANOMA
• A changing mole
• Most common warning sign
• Pruritis
• most common early sign of melanoma is pruritis
• Bleeding and ulceration are late signs showing advanced disease

31. WARNING SIGNS (ABCDE)
• Asymmetry – one half does not match the other
• Border- Irregular/ poorly defined
• Colour - Variable. Tan brown/black. Red Blue, white
• Diameter - >6mm
• Evolving in color/size/ shape over time

32. TYPICAL PRESENTATION
• Non painful, firm itchy lesion, in sun exposed sites, with a recent change in
colour/ size, with ulcer formation often covered with a crust.
• Bleeding and sub acute infection is common.
• The regional lymph nodes are involved quite early. Nodes are hard to firm in
consistency
• Satellite nodules may be seen in the skin and subcutaneous tissue between the
primary tumor and the nearest regional lymph nodes.

34. TYPES
• Superficial spreading – 70% - trunk
and legs
• Nodular melanoma – worst prognosis
– common in legs and trunk
• Lentigo maligna – best prognosis –
head neck and arms
• Acral lentiginous – palm, soles, hand
and subuncal areas
• Amelanotic melanoma

35. HISTOPATHOLOGICAL CLASSIFICATION
• According to the histological invasion of tumor
• CLARK’S LEVELS
• BRESLOW’S THICKNESS

36. • CLARK’S CLASSIFICATION
• According to the depth of tumor invasion
• Level 1: Only in epidermis
• Level 2: Extension into papillary dermis
• Level 3: Filling of papillary dermis completely
• Level 4: Extension into reticular dermis Level
• 5: Extension into subcutaneous tissue

37. • BRESLOW CLASSIFICATION
• Based on the thickness of invasion – most
important prognostic indicator until nodal
spread
• Level 1: less than 0.76 mm thick
• Level 2: between 0.76– 1.50 mm
• Level 3: between 1.50 - 4.00 mm
• Level 4: exceed 4.00 mm in thickness

38. PROGNOSTIC FACTORS
Stage I : No metastasis (Local Disease)
Stage II : Nodal metastasis (Regional Disease)
Stage III : Distant Metastasis (Systemic Diasese

39. TREATMENT
• The treatment of choice of melanoma is wide
surgical excision with a negative margin
• Surgical treatment options includes:
• Biopsy
• Wide Local Exsicion
• Staging with Sentinel Lymph Node biopsy
• Therapeutic Lymph Node Dissection

41. • The only adjuvant therapy approved is high-dose Interferon alfa-2b administered
at a dose near the maximally tolerated dose, with 1 month of IV therapy
• Radiotherapy is only used as a palliative therapy for pain management

42. CONCLUSION
• The important principles in the management of cutaneous malignancies are
the same
• Clinicians must have a low threshold for biopsy of new or changing skin
lesions.
• The diagnosis is made by biopsy and histologic analysis.
• Surgical excision should be performed, with histologically negative margins.
• Further treatment and follow-up schedules will be determined by the specifc
diagnosis.