skin tumors

I am giving you guys skin cancer
RODENT ULCER
MARJOLIN’S ULCER
EPITHELIOMA
RODENT ULCER
What is it??
• Usually a slow-growing, locally
invasive malignant tumor of
pleuripotent epithelial cells
• Arising from basal epidermis and
hair follicles, hence affecting the
pilosebaceous skin
Predisposing Factors
• Exposure to UVR
• Exposure to Arsenic compounds, coal
tar, aromatic compounds, IR, Coal
Tar
• Genetic Skin Cancers
• White skinned people
• Age 40-80 yrs
PATHOGENESIS
• No apparent precursor lesion
• Proportional to initial dose of
carcinogen but not duration.
• Rarely metastise,Hard to
culture,Resist transplantation
• Mesodermal factors acting as
intrinsic promoters coupled with an
initiation step
MACROSCOPIC
LOCALISED
•Nodular 90%
•Nodulocystic SUPERFICIAL
•Cystic
•Multifocal
•Pigmented
•Superficial
•Maevoid
Spreading
GENERALISED
INFILTRATIVE
•Ice pick
•Morphoeic
•Cicatrising
•
Variety of bcc
MICROSCOPIC
Ovoid cells in nests with single outer Palisading layer
ORIGIN
• Basal layer of epidermis.
• Occasionally arises from basal cells of hair
follicles and sweat glands.
• Seen in scalp known as TURBAN TUMOR
Why Rodent Ulcer??
• LOCAL INVASION
• Gradually destroys tissues it comes in
contact with!!
• LYMPHATIC SPREAD not seen
• Regional lymph nodes NOT enlarged.
• Blood spread rare
CLINICAL FEATURES
• SYMPTOMS:
Persisting ulcer or nodule
Not painful / may itch
Grows slowly
• SIGNS:
 Site- 90% BCC seen on face above line
joining angle of mouth to lobule of ear.
SIGNS:
Site- 90% BCC seen on face above line
joining angle of mouth to lobule of ear.
COMMON SITES
• INNER CANTHUS OF EYE
• OUTER CANTHUS OF EYE
• NOSE
• ON AND AROUND NASOLABIAL FOLD
• ON THE FORE HEAD
Tear Cancer
LESION
• Starts as Nodule
• Gradually centre of nodule dies and ulcer
results.
• EDGE- Raised & Rounded.BEADED
MARGIN
• GROWTH SPREADS- Shape irregular.
• FLOOR- Dried Serum, Epithelial cells.
• BASE- Tissue & Tumor is eroding ie. Fat,
Muscle, Bone!!
PROGNOSIS
HIGH RISK
• > 2cm
• Eye, Nose , Ear
• Ill defined margins
•Recurrent ulcer
LOW RISK
MANAGEMENT
SURGICAL
NON SURGICAL
 Excision
 Curettage
 Mohs Micrographic Surgery  Electrodessication
 Two stage surgery
 Laser Vaporization
RADIOTHERAPY
No pathological specimen
No confirmation of diagnosis
Tumor margin not confirmed
Mohs Micrographic Surgery
Indications
• POORLY DEMARCATED
• RECURRENT
• INCOMPLETELY EXCISED
• AREA AROUND EYES NOSE EAR
PROCEDURE
• Performed under LOCAL ANESTHESIA
• Initial SAUCERISING EXCISION of primary
tumors visible extent.
• Sample and the defect are then marked
and oriented
• Map of specimen drawn & characterised
using different colored stains in different
equators.
• Histotechnician receives tissue sample from
the Mohs Surgeon.
• Sample is sectioned and stained with H&E
• Mohs surgeon examines slide for tumor
residue and excises the relevant mapped
parts.
NON SURGICAL
• Radiotherapy (scars badly)
• Cryotherapy
• Topical Chemo (5-fluorouracil, imiquimod)
Follow Up
• Gross Margin involvement: 67%
recurrence
• Microscopic involvement: 33% recurrence
within 2 yrs.
• Uncomplicated completely excised:
Surveillance as in HIGH Risk groups!
• GORLIN’s syndrome
EPITHELIOMA(SCC)
EPITHELIOMA
What is it??
• SCC is a malignant tumor of keratinising
cells of the epidermis or its appendages.
• Arises from the stratum basale of the
epidermis
• 2nd most common skin tumor (4 times less
than BCC & affects Elderly)
PREDISPOSING FACTORS
• WHITE SKINNED
• TWICE AS COMMON IN MEN
• SUN EXPOSURE
• CLOSER TO EQUATOR
Contd.
• chronic inflammation (chronic sinus tracts,
pre-existing scars, osteomyelitis, burns,
vaccination points)
• immunosuppression (organ-transplant
recipients).
• When a SCC appears in a scar it is known
as a Marjolin’s ulcer.
Contd
• Radiation exposure
• Smoking
• HPV infection
MACROSCOPIC
• The early appearance of SCC may vary
from smooth nodular to verrucous,
papillomatous and ulcerating lesions.
• Eventually all lesions ulcerate
MICROSCOPIC
• Solid column of epithelial cells that are
seen growing down into dermis.
• Expanding into bulb like masses.
• KERATINISATION, CELL NEST/Epithelial
pearl appearance.
SPREAD
• LOCAL SPREAD
• LYMPHATIC SPREAD
• BLOOD SPREAD- rarely
HISTOPATHOLOGY
•
•
•
•
Pathological pattern (e.g. adenoid),
Cellular morphology (e.g. spindle)
Broder’s grade(grade 1 to 4)
Depth of invasion
ORIGIN
a) skin denovo
b)pre existing condition like
• Long standing ulcers
• Senile keratosis
• Leukoplakia
• Skin exposed to radiation
• lupus
PREMALIGNANT LESIONS
Chronic Ulcer : MARJOLINS ulcer
FEATURES
• Painless!!!
• Less malignant than typical SCC
• Edge not always raised & everted
• Slow growing malignant lesion
• No lymphatic metastasis
TREATMENT
• Surgery : Wide excision of lesion with 1 cm
margin.
OTHER PREMALIGNANT
COND.
Bowen disease
Xeroderma
pigmentosum
Senile keratosis
LUPUS VULGARIS
•
•
•
•
Condition which cause chr irritation
1)Leukoplakia
2)Burn,scar,venous ulcer,OM,
3)Continous heat by a charcoal burner
ie.kangri – abdomen -KANGRI CANCER
•
Tibetans - sleep over oven beds-KANG
CANCER
•
Prolonged exposure to chemicals as in
soot – SCC of scrotum – CHIMNEY
SWEEP CANCER
SITES
SKIN- anywhere
MUCOUS MEMBRANE
B/w SKIN & MUCOUS
MEMBRANE
COLUMNAR EPITHELIUM
TRANSITIONAL EPITHELIUM
CLINICAL FEATURES
• History
 Age > 40 yrs
 Occupation -chimney sweepers
 Duration- one or few months (variable cap
growth)
• Symptoms
 Nodule/ Ulcer
 Usually Painless
 Enlarged Lymph node ( unlike BCC)
LOCAL EXAMINATION
• Site
• Size and shape.- circular /oval
• EDGE: Raised & Everted
• FLOOR: Necrotic tissue, Serum, Blood.
• BASE: Indurated.
• MOBILITY: early cases can be moved later
fixed
• Regional Lymph nodes enlarged due to
2ndry infectn
• Tenderness +
DDs
• KERATOCANTHOMA
• BCC
• INFECTED SEBORRHOEIC WART
• MALIGNANT MELANOMA
PROGNOSIS
• There are several independent prognostic variables for SCC:
1 Invasion:
a Depth: the deeper the lesion, the worse the prognosis. For
SCC < 2 mm, metastasis is highly unlikely, whereas if>6 mm,
15% of SCCs will have metastasised ;
b Surface size: lesions > 2 cm have a worse prognosis than
• smaller ones.
2 Histological grade: the higher the Broder’s grade, the worse the
prognosis.
3 Site: SCCs on the lips and ears have higher local recurrence
• rates than lesions elsewhere, and tumours at the extremities
• fare worse than those on the trunk.
• 4 Aetiology: SCC that arises in burn scars, osteomyelitic
skin
• sinuses, chronic ulcers and areas of skin that have been
irradiated
• has a higher metastatic potential.
• 5 Immunosuppression: SCC will invade further in those
with
• impaired immune response.
• 6 Prognosis: Tumours with perineural involvement have
a worse
• prognosis and require a wider than usual clearance.
• The overall rate of metastasis is 2% for SCC – usually to
• regional nodes – with a local recurrence rate of 20%.
TNM STAGING
•
•
•
•
T1=or<2cm
T2 – 2-5cm
T3- >5cm
T4 -Muscle or
bone invasion
•
•
•
•
•
•
NODES
N0 N1- RLN
METASTAES
MO no mets
M1- distant mets
investigations
•
•
•
•
Incision biopsy
Xray of affected part r/o bone inv
Xray chest r/o mets (very rare event)
Other inv for anaesthesia clearance
MANAGEMENT
• TREATMENT OF PRIMARY LESION
 Surgery
 Radiotherapy
• TREATMENT OF SECONDARY LYMPH
NODEs
 Radical Block dissection
 Palliative Radiotherapy
SURGERY
• Wide excision is Treatment of choice after
biopsy confirmation.
• Excision of growth performed with 2cm
margin of normal tissue surrounding tumor.
• Tumor involving finger, toes, penis..
AMPUTATE!
Indications for Surgery
• Large sized lesions
• Involving muscle cartilage bone
• No radiotherapy facilities
• Recurrence after radiotherapy.
RADIOTHERAPY
• Superficial Radiotherapy has 80% cure of
early lesions
INDICATIONS
 poorly differentiated
 condition not amenable for surgery
 small growth
 no involvement of muscle bone cartilage
Please ponder.........What can I give to the
world today???
Thank you
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