Basal Cell Carcinoma (BCC)
BCC is the most common cancer in humans.
Caused by UVR; PTCH gene mutation in most cases.
Clinically different types: nodular, ulcerating, pigmented, sclerosing , and superficial.
BCC is locally invasive, aggressive, and destructive but slow growing, and there is very limited (literally no) tendency to metastasize.
Skin Lesions: There are five clinical types:
1- Nodular
2- Ulcerating
3- Sclerosing (Cicatricial),
4- Superficial,
5- Pigmented.
Basal Cell Carcinoma (BCC)
BCC is the most common cancer in humans.
Caused by UVR; PTCH gene mutation in most cases.
Clinically different types: nodular, ulcerating, pigmented, sclerosing , and superficial.
BCC is locally invasive, aggressive, and destructive but slow growing, and there is very limited (literally no) tendency to metastasize.
Skin Lesions: There are five clinical types:
1- Nodular
2- Ulcerating
3- Sclerosing (Cicatricial),
4- Superficial,
5- Pigmented.
Invasive Squamous Cell Carcinoma (SCC)
SCC of the skin is a malignant tumor of keratinocytes, arising in the epidermis.
SCC usually arises in epidermal precancerous lesions and, depending on etiology and level of differentiation, varies in its aggressiveness.
The lesion is a plaque or a nodule with varying degrees of keratinization in the nodule and/or on the surface.
Thumb rule:
Undifferentiated SCC: is soft and has no hyperkeratosis;
Differentiated SCC: is hard on palpation and has hyperkeratosis.
Exposure:
Sunlight. Phototherapy, PUVA (oral psoralen + UVA). Excessive photochemotherapy can lead to promotion of SCC, particularly in patients with skin phototypes I and II or in patients with history of previous exposure to ionizing radiation or methotrexate treatment for psoriasis.
Lesions :
Indurated papule, plaque, or nodule ; adherent thick keratotic scale or hyperkeratosis ; when eroded or ulcerated, the lesion may have a crust in the center and a firm, hyperkeratotic, elevated margin
Clark levels
level I, intra-epidermal;
level II, invades papillary dermis;
level III fills papillary dermis;
level IV, invades reticular dermis;
level V, invades subcutaneous fat.
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2. Objectives of this presentation
① To understand the difference between SCC, BCC and
SGC
a. Better diagnosis
b. Better management
② To understand which is the local and metastasizing
tumour
③ Be able to identify the histological slides
a. OSCE exam for part I
7. 90% of all
eyelid tumour
Arises from
Stratum basale
Outer root sheath of the hair follicle
Only in hair-bearing tissue
Commonly at lower eyelid
8. Slowly-growing tumour, locally invasive
Non-metastasizing
Can recur if incompletely treated – more difficult to treat
9.
10. Common sites
(1) Inferior 50-60%
(2) Medial 25-30%
- Most dangerous
- Spread via lacrimal
system and spread
(4) Lateral 5%
(3) Superior 15%
11. Risk Factors
Prolonged exposure to sunlight
Fair-skinned
Blue-eyed, red-haired
English, Irish or Scottish ancestry
Male, > 50 years old
History of cigarette-smoking
Prior basal cell carcinomas
Family history of skin cancer
12. Young patients or positive family history –
look for possible system associations
Basal Cell Nevus syndrome
(Gorlin’s syndrome)
- Multiple nevoid
- Skeletal anomaly
Xeroderma pigmentosa
- Excessive sensitivity to sun
- Defect in repair mechanism for
UV-induced DNA damaged-cells
14. 1. Nodular BCC
• Slowly-growing
• 1-2 years to reach 0.5 mm
diameter
• Shiny and firm
• Pearly nodule
• With dilated surface vessels
15. 2. Rodent Ulcer
• Central ulceration
• Pearly raised rolled edges
• Dilated vessels over its margins
• Telangectasis
16. 3. Sclerosing BCC
• Less common and difficult to
diagnose – beneath the epidermis
• Indurated plaque
• Loss of lashes
Mistaken diagnosis: Chronic
blepharitis
17. Histological Features
epithelial proliferation arising from the basal layer of the epidermis
Normal dermis Desmoplastic stroma – pale-pink
stroma supporting neoplastic cells
23. 40 times less than BCC
Arises from the squamous layer
May arise
De novo
From pre-existing actinic keratosis
From carcinoma in-situ
SPREAD
Regional LN 20% of cases
Lymphatics and perineural invasion
37. Highly-malignant
Arises from
Meibomian glands
Glands of Zeis
Sebaceous gland of the caruncle, eyebrow or face
Commonly at upper eyelid
Multifocal origin, spread superficially
38. Epidemiology
Females, > 50 years old
Most common eyelid tumour after BCC
1.5-5% of all eyelid tumour
Adverse Prognostic Factor
Upperlid involvement
Tumour size > 10mm
Duration of symptoms > 6 months
Mortality rate 22%
39. Spread
Via lymph node
Perineural to intracranial via orbit
51. Please remember…
Any chronic unilateral blepharitis should raise the
possibility of sebaceous gland carcinoma.
Any case of recurrent chalazion, think of malignancy!
57. Choose one answer
Squamous cell carcinoma in situ is defined as a
pathologic anatomic limitation by which one of the
following:
a) Superficial epithelium
b) Stromal keratocytes
c) Basal epithelium
d) Basement membrane
58. Choose one answer
Appropriate management of multiple or recurrent chalazia
includes:
a) Needle biopsy
b) Local antibiotics
c) Full-thickness biopsy
d) Shave biopsy
59. Reference
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2992157/
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Editor's Notes
The proliferated cells appear blue and are present in nests of different sizes. Note the sharp demarcation of the pale-pink area of stroma supporting the neoplastic cells from the underlying (normal) dark-pink dermis (d, relatively normal dermis). This stromal change, called desmoplasia (ds, desmoplastic stroma), is characteristic of neoplastic lesions. Compare with the benign lesions in Figs 6.24 to 6.27, where the dermis does not show such a change.
The nests are composed of atypical basal cells and show peripheral palisading (pp). Mitotic figures are present. Again, note the pseudosarcomatous change (desmoplasia) (ds, desmoplastic stroma) of the surrounding supporting stroma, which is light-pink and contains proliferating fibroblasts.
Higher magnification illustrates characteristic features of basal cell carcinoma, including atypical cells and separation artifact between nests of cells and desmoplastic surrounding connective tissue.
he most frequent sites of periocular involvement are the lower eyelid (49%), medial canthus (36%), and the upper eyelid (23%).
Histologic section of the excisional biopsy shows epithelial cells with an overall pink color that infiltrate the dermis deeply. The overlying region is ulcerated.
C, Increased magnification shows the invasive squamous neoplastic cells making keratin (pearls) in an abnormal location (dyskeratosis). Numerous mitotic figures are present. Note the pseudosarcomatous (dysplastic) change in the surrounding stroma.
Oil red-O fat stain shows marked positivity in the cytoplasm of abnormal cells. Any recurrent or suspect chalazion should be sampled for biopsy.