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  1. SKIN : TUMOURS BY PROF. MOHAMED EL GHARBAWI e-mail: elgharma2@yahoo.comWeb Site:

  2. OBJECTIVES OF THIS LECTURE TO KNOW: • Embryology, Anatomy and Histology and Physiology of Skin • Benign tumors of skin • Malignant tumors of skin

  3. EMBRYOLOGY • Ectoderm forms the surface epidermis and the associated glands. • Mesoderm forms the underlying connective tissue of dermis and hypodermis. • Neural crest cells migrate into the forming epidermis and the skin is populated by specialized sensory endings. • Foetal skin has the ability to heal without a scar in contrast to adult skin, this may relate to differences in the foetal extracellular matrix structure.

  4. ANATOMY 1

  5. ANATOMY 2 • Skin is the protective cover of all the body • Largest organ • 15% of body weight • Formed of Epidermis: superficial & cellular Dermis: deep & tough connective tissue Hypodermis: subcutaneous tissue • Skin appendages Sweat glands, Sebaceous glands, Hair follicles

  6. ANATOMY 3



  9. PHYSIOLOGY • Protection • Keeps body temperature • Preserves body fluids • Prevents invasion by Micro organisms • Cosmetic appearance • Smoothness and easy range of movements

  10. BENIGN SKIN TUMOURS 1 • EpitheliumPAPILLOMA Single or multiple Sessile or pedunculated Villous or nodular Viral etiology / Hereditary Rare to be malignant Excision


  12. BENIGN SKIN TUMOURS 2 • Pigmented cells (Melanocytes, Melanophores) Benign melanoma (Mole, Nevus) There are many types of benign melanomas (Nevi) @ Intradermal (simple) nevus Commonest type Melanocytes in the dermis Flat or nodular May have hairs May turn malignant (observe signs)

  13. BENIGN SKIN TUMOURS 3 @ Junctional nevus: Melanocytes are present in basal cell layer of epidermis extending to dermis @ Compound nevus: Melanocytes in dermis with activity at the junction @ Freckles: The basal cell layer is replaced with Melanocytes over a large area. Hutchinson’s freckles, special type, in old age , > in face , Turn malignant commonly @ Blue nevus: Melanocytes are spindle shaped deep in dermis Bluish in color and may turn malignant Treatment : Surgical excision (for cosmosis, irritation, Turn Malignant)


  15. BENIGN SKIN TUMOURS 3 • Dermis Dermatofibroma (Sub epidermal nodular fibrosis) A small firm nodule May change Malignant Dermatofibrosarcoma (low grade fibrosarcoma) Wide surgical excision with safety margin


  17. BENIGN SKIN TUMOURS 4 • Sebaceous glandSebaceous Adenoma Commonly arise in face and scalp Slowly growing Pinkish in color lobulated with narrow stalk May change malignant (accelerated growth, ulceration, recurrence after excision) Wide excision with safety margin


  19. BENIGN SKIN TUMOURS 5 • Cutaneous NervesNeurofibroma Discussed with Peripheral nerves • Cutaneous Blood VesselsGlomangioma Discussed with vascular tumours • Connective Tissue Fat Lipoma Discussed with tumours of sub cutaneous tissue

  20. PRE MALIGNANT SKIN LESIONS 1 • Xeroderma Pigmentosa: Abnormal Sensitivity to Sun light Hyperpigmentation of exposed skin (e.g. face) Hereditary Affects children Skin is atrophied Pre malignant: Basal cell & squamous cell carcinoma Prognosis: Poor


  22. PRE MALIGNANT SKIN LESIONS 2 • Senile Squamous Keratosis Common on dorsum of hands and face With exposure to sun Commonly affect fare skin people Small, scaly and pigmented lesions Predispose to skin malignancy Treatment: Topical 5 FU ointment Curettage, Cryosurgery Last : Excisional biopsy


  24. PREMALIGNANT SKIN LESIONS 3 • Seborrheic Keratitis Occur on face and trunk Multiple pigmented greasy lesions Treatment: Like Senile squamous Keratosis • Chronic Radio-Dermatitis Long exposure to irradiation Atrophic skin Dry, keratotic and may be ulcerated skin Treatment: Excision with flap as supplying vessel is obliterated


  26. PRE MALIGNANT SKIN LESIONS 4 • Chronic Infections & Scaring 1. T B, Leprosy 2. Chronic Sinuses 3. Marjolin’s Ulcer (Over a scar area/ Chronic irritation) • Bowen’s Disease Squamous cell carcinoma in situ Occurs in non exposed areas e.g. abdominal skin Slowly growing Well defined, brown and thickened lesions Treatment: As Senile Keratosis



  29. MALIGNANT SKIN TUMOURS • RODENT ULCER (Basal Cell Carcinoma) (SHOULD KNOW) • Epithelioma (Squamous Cell Carcinoma) (SHOULD KNOW) • Malignant Melanoma ( SHOULD KNOW) • Sarcomas

  30. RODENT ULCER (1)( BASAL CELL CARCINOMA) • Predisposing Factors:- Exposure to sun (Prolonged) Hyperkeratosis Xeroderma Pigmentosa • Incidence:- Males > Females Common > 40Y Rare in Dark skin

  31. RODENT ULCER (2)BASAL CELL CARCINOMA • Pathology:- From Basal Cell Layer of Epidermis 90% above a line from angle of Mouth to Lobule of Ear ( > Inner Canthus and Nasolabial Fold) But may arise anywhere in skin May arise in Esophagus, Mouth or Mucocutaneous junction of Anal Canal Only direct spread (Locally Malignant, erodes locally) NO SPREAD BY LYMPH OR BLOOD

  32. RODENT ULCER (3)BASAL CELL CARCINOMA • Microscopy:- The Dermis is infiltrated with rounded masses of tumor cells Peripheral cells are low columnar cells arranged side by side (Palisade Appearance) Inner cells are oval, no prickle cells and no Keratin


  34. RODENT ULCER (5)BASAL CELL CARCINOMA • Macroscopy:- (Types) 1. Nodular (Button) type A slowly growing small nodule. Common early lesion, Center then degenerate and dimples forming a button like lesion Center then ulcerate forming the classical Rodent Ulcer Type


  36. RODENT ULCER (7)BASAL CELL CARCINOMA 2.Classical Rodent Ulcer type Commonest type Number: commonly single, may be multiple Site: Common on face above a line from angle of mouth to lobule of ear Size: Variable Shape: Irregular, oval, rounded Edge: Rolled in (inverted), Beaded Floor: Necrotic, Granular, May be a crust Margin: May show blood vessels (Telangectetic) Base: Indurated but not beyond ulcer limits

  37. RODENT ULCER(BASAL CELL CARCINOMA) HISTORY Gradual onset started as a small nodule then ulcerated 4 years duration Progressive Little pain during last 6 months GENERAL EXAMINATION No lymphadenopathy (Locally malignant), regional lymph node enlargement may be due to Secondary infection or presence of combined squamous & basal cell tumor LOCAL EXAMINATION Number: single Site: lateral side of face lateral to left eye (above the line From angle of mouth to lobule of ear Size: 4 X 4 Shape: rounded ,irregular Floor: granular , small dry crust which reappear if removed Edge: raised, rolled in, beaded Margin: may be telangeactitic v Base: Indurated ,does not extend beyond margin

  38. RODENT ULCERBASAL CELL CARCINOMA Single ulcer, At Nasolabial fold, 3 X 3 Cm Rounded in shape, Granular floor with dry crust, Raised and rolled in edge, little telangeactetic vessels at the margin Induration at the base does not extend beyond the margin, No regional lymp node enlargment

  39. RODENT ULCER (8)BASAL CELL CARCINOMA 3. Uncommon Types @ Cystic type: ( Adenoid cystic basal cell carcinoma) Not truly cystic @ Solid type: Slowly growing raised above surface Not ulcerating @ Invasive type: Invade deeply to tissues e.g. Skull @ Pigmented Rodent ulcer: Mistaken for Melanoma @ Field-Fire type: Flat with spreading edge @ Turban Type: Spreading over the scalp, no ulcer


  41. RODENT ULCER (10)BASAL CELL CARCINOMA • SPREAD Basal Cell Carcinoma Is Locally Malignant disease Erode deeply (Rodent Ulcer) No Lymphatic or Blood Spread Regional Lymph Nodes are not enlarged except: 1. With Secondary Infection (enlarged, tender) 2. Baso- Squamous Carcinoma

  42. RODENT ULCER (11)BASAL CELL CARCINOMA COMPLICATIONS: 1. Infection Secondary local infection: enlarged tender LN Regional infection to meninges after deep bone erosions 2. Disfigurement due destruction to surroundings 3. Bleeding from facial vessels 4. Cavernous sinus thrombosis 5. Change to Baso- squamous Carcinoma (part of edge become everted rolled out, Rapid growth, enlarged hard indurated draining LN, Indurated base extend beyond the margin)

  43. BASOSQUAMOUS CARCINOMATo be treated as Epithelioma

  44. RODENT ULCER (12)BASAL CELL CARCINOMA • DD : 1. Squamous Cell Carcinoma (Epithelioma): Mostly, below a line from angle of mouth to lobule of ear Hard indurated regional LN Histopathology 2. Keratoacanthoma: Rapid growth, elevated, dome shaped, umbilicated with central keratin plug Regressing lesions within 6-9 months leaving a scar • INVESTIGATION: Biopsy/ Histopathology

  45. RODENT ULCER (12)BASAL CELL CARCINOMATREATMENT RADIOTHERAPY SURGERY Indications Fixity to bone or cartilage Early small lesions Failure of irradiation Technique: Excision with 1 inch safety margin, Frozen section to assure free surgical limits Closure by primary sutures, Split or full thickness graft Treat infection first • It is radio- sensitive • Suitable to face & old age • May be superficial irradiation Or Radium needles (7000 r) to be removed after a week Disappears in 2-3 Months • Cotra indications: Recurrence post irradiation Invasion of bone or cartilage Important organ in the field e.g. Eye ball


  47. EPITHELIOMA (1)SQUMOUS CELL CARCINOMA • Predisposing Factors Prolonged exposure to sun (Farmers, Sailors) Old Scars (Marjolin’s ulcer) Leukoplekia Post radiation Dermatitis • Incidence Males > Females Old age groups More with exposure to sun ( > in exposed areas)

  48. EPITHELIOMA (2)SQUAMOUS CELL CARCINOMA • Pathology From prickle cell layer of stratified squamous epithelium (skin , mucous membrane) In face: Common below a line extending from angle of mouth to lobule of ear Any where in skin cover or mucous membrane lining (tongue, oesophagus, mouth, lower lips, anus) Where metaplasia happen in bronchus, GB

  49. EPITHELIOMA (3)SQUMOUS CELL CARCINOMA • Spread Direct local spread to the surroundings Early lymphatic spread to regional LNs Rare and late blood spread • Microscopy Solid columns (groups) of epithelial cells growing into the dermis (Nests or pearls) Central Keratin surrounded with prickle cells May be differentiated (cell nests, Keratin) on Undifferentiated (no cell nests, no keratin)