TUMOURS OF SKIN

1. TUMOURS OF SKIN Dr F Bhatti Pennine VTS Sept ‘08

2. SOURCES • GPNotebook http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1925906417 • Dermnet http://www.dermnetnz.org/ • Atlas of Dermatology http://www.danderm-pdv.is.kkh.dk/atlas/index.html ‏ • eMedicine

3. Benign Conditions . Ephelide . Melanotic Naevi . Granuloma Telangiectaticum . Haemangioma of skin . Dermatofibroma . Papilloma . Seborrhoeic Keratosis . Squamous Cell Papilloma . Warts

4. Premalignant Conditions • Bowen’s Disease • Keratoacanthoma • Marjolin’s Ulcer • Paget’s disease of the Nipple • Senile Keratosis

5. Malignant Conditions • Basal cell Carcinoma • Squamous cell Carcinoma • Malignant Melanoma • Mycosis Fungoides • Kaposi’s Sarcoma

9. Basal Cell Carcinoma • Locally invasive carcinoma of the basal layer of the epidermis. It almost never metastasizes but it may kill by local invasion • Commonest skin cancer • Middle aged or elderly, related to sunlight exposure, fair skinned people, M:F approximately 2:1 • Lesions occur in exposed areas of the skin (75% occur in the head and neck)‏ • Gorlin's syndrome. Patients with this condition appear to have a great tendency to develop basal cell epitheliomata

10. Continued.. BCC • Common sites are in normal and sun damaged skin on the face, in a region above a line drawn between the corner of the mouth and the lobe of the ear • The initial lesion is a small pearly-white nodule with visible (telangiectatic) blood vessels; early lesions may bleed and ulcerate and then heal again • Red nodule forms which expands to leave a characteristic rolled edge with central ulceration ('rodent ulcer') • 30% multiple, invasion is usually local. Metastasis is rare - metastatic rate is 0.0028%

11. Clinical subtypes 1.Nodular BCC • Most common type on the face • Small, shiny, skin coloured or pinkish lump • Blood vessels cross its surface • May have a central ulcer so its edges appear rolled • Often bleeds spontaneously then seem to heal over • Cystic BCC is soft, with jelly-like contents • Rodent ulcer is an open sore • Micronodular and microcystic types may infiltrate deeply 2.Superficial BCC • Often multiple • Upper trunk and shoulders, or anywhere • Pink or red scaly irregular plaques • Slowly grow over months or years • Bleed or ulcerate easily

12. Continued …BCC 3. Morphoeic BCC • Also known as sclerosing BCC • Usually found in mid-facial sites • Skin-coloured, waxy, scar-like • Prone to recur after treatment • May infiltrate cutaneous nerves (perineural spread) 4. Pigmented BCC • Brown, blue or greyish lesion • Nodular or superficial histology • May resemble melanoma 5. Basisquamous BCC • Mixed basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) • Potentially more aggressive than other forms of BCC

13. Nodular BCC . Fibrous papule . Naevus . Seborrhoeic keratosis . Amelanotic melanoma Superficial BCC . Nummular eczema . Psoriasis . Extramammary Paget Disease . Bowen’s Disease Pigmented BCC . Malignanat Melanoma . Pigmented Seborrhoeic keratosis . Traumatised naevus Morpheaform BCC . Scar . Localised scleroderma Differential diagnoses

14. Basal Cell Carcinoma

15. More BCC

16. High Risk BCC • They have a high recurrence rate after treatment. • Histological sub-type / features • Sites – Head & Neck area. • Size – greater than 2 cm. • Immunosuppressant. • Genetic disorders e.g.Gorlin’s Syndrome. Low-Risk BCC • Size – Less than 2 cm. • Site – Torso, Limbs.

17. Treatment • Surgery, Local Radiotherapy, Cryotherapy, or Curretage. • Up to 85% superficial BCCs are cured by Photodynamic therapy, with excellent cosmetic results. It is less successful for other types • Curettage and cautery with histology is only adequate for small lesions. • Systemic chemotherapy is ineffective, though topical 5-Fluorouracil cream may be helpful, particularly for multiple tumours. • Imiquimod cream . The cream is applied to superficial BCCs three to five times each week, for 6 to 16 weeks. results in an inflammatory reaction, maximal at three weeks. Up to 85% of suitable BCCs disappear, with minimal scarring. • Recurrence is common (0.15 - 15%)‏

18. Squamous Cell Carcinoma Malignant tumour of the epidermis in which the cells, if differentiated, show keratin formation. Invasive SCC refers to cancer cells that have grown into the dermis. Associated with: . Excessive sunlight exposure and pre-existing solar keratosis . Exposure to chemical carcinogens such as coal tar products . Chronic irritation/ inflammation (Marjolin's ulcer)e.g. margins of osteomyelitic sinuses/ long-standing ulcers . Patients with immunosuppression e.g.Renal transplant patients . Genetic predisposition e.g. Xeroderma Pigmentosum , Albinism . Pre-malignant conditions e.g. Bowen's disease, Leukoplakia Rare in patients under 60 years of age unless immunosuppressed Sites: Men - scalp and ears Women - lower legs Both sexes - back of hands, face

19. Continued …SCC Differential Diagnosis • Basal cell carcinoma • Keratocanthoma • Malignant melanoma • Solar keratosis • Pyogenic granuloma • Infected seborrheic wart Clinical features • Rapidly expanding painless, ulcerated nodule rolled indurated margin. May have a cauliflower-like appearance with areas of bleeding, ulceration or serous exudation. • About 55% of lesions occur in the head and neck region. About 25% of lesions occur on the hands and arms. • Metastasis may occur via local draining lymph nodes and beyond.

20. Contd… SCC . 5% of SCCs metastasise. . More likely if the original SCC was on the lip or ear; or if it was large, deeply invading or involving nerve fibres (perineural spread). . 80% of cases, the metastases develop in the nearest lymph glands. . Metastases are more difficult to treat than the original skin lesion. Increased risk if the immune system is functioning poorly e.g. • Organ transplantation • CLL • Alcoholism • Multiple skin cancers • Genetic defect in skin repair e.g., xeroderma pigmentosum

21. SCC of different types/Sites When confined to the epithelium is called SCC in situ ,Intraepidermal SCC or Bowen’s disease. SCC in situ of mucosal surfaces includes: • Oral leukoplakia • Vulval intraepithelial neoplasia • Penile intraepithelial neoplasia • Bowenoid papulosis There are some special types of invasive SCC of the skin: • Keratoacanthoma (pseudocancer)– a rapidly growing keratinising skin nodule that may resolve without treatment. BUT appearances can be deceptive so still refer… unless you’re a dermatologist. • Carcinoma cuniculatum (‘verrucous carcinoma’), a slowly-growing warty tumour found on the sole of the foot Invasive SCC types/sites include • Vulval SCC • Oral SCC

22. Bowen’s Disease

23. SCC

24. Pigmented SCC

25. Other SCC Oral SCC-Leucoplakia Superficial BCC

26. Keratoacanthoma

27. Treatment . Depends upon size, location, number to be treated & the preference of the doctor . Established lesions .Physical treatment e.g. cryotherapy, curettage, local excision .Topical treatment options include: . Topical Cytotoxic preparations (e.g. 5-fluorouracil), . Topical Retinoids . Salicylic acid in Emulsifying Ointment . Topical Diclofenac Gel (this is licensed for Rx of Actinic Keratosis in UK) . Imiquimod 5% cream used 3 times per week for 16 weeks is an effective treatment for Actinic Keratoses . Systemic treatment may be given for extensive or resistant lesions e.g. Systemic Retinoids . Screening - for other skin lesions more common in patients with marked sunshine exposure e.g. SCC, BCC,Melanomas

28. Urgent referral if : .Histological Diagnosis of SCC . With non-healing keratinizing or crusted tumours larger than 1 cm with significant induration on palpation. They are commonly found on the face, scalp or back of the hand with a documented expansion over 8 weeks . Who have had an organ transplant and develop new or growing cutaneous lesions as squamous cell carcinoma is common with immunosuppression but may be atypical and aggressive **Use the 7-point weighted checklist for assessment of pigmented skin lesion** **There is controversy about Actinic Keratosis; whether its a premalignant condition or early SCC. In a study of 459 patients with cutaneous SCC, there were associated adjacent actinic keratoses in 97%. Reported rate of progression to invasive SCC varies but accepted as around 1 in 1000**

29. Malignant Melanoma • Malignant tumour of epidermal melanocytes.Accounts for less than 1% of all cancers • Non-pigmented skin , exposed to excessive sunlight, especially if sunburn ensues. • Spread occurs via superficial lymphatics to give satellite lesions, to regional lymph nodes via deep lymphatics, and via haematogenous spread to the lung, liver and brain. Haematogenous spread usually follows lymphatic. • Range of colours and uniformity, often may bleed and ulcerate. It may cause pigmented lesions in the mouth. • Malignant melanomas undergo two growth phases - radial and vertical. Vertical invasion is a poor prognostic sign. • Different types : . Superficial spreading (48%) . Nodular (23%) . Lentigo maligna (15%) . Acral lentiginous including periungual (6%) . Amelanotic melanoma

30. Contd…Melanoma Types Those that start off as flat patches (i.e. have a horizontal growth phase) include: • Superficial spreading melanoma (SSM) • Lentigo maligna melanoma (sun damaged skin of face, scalp and neck) • Acral lentiginous melanoma (on soles of feet, palms of hands or under the nails – the subungual melanoma) They tend to grow slowly, but at any time, they may begin to thicken up or develop a nodule (i.e. progress to a vertical growth phase). Melanomas that quickly involve deeper tissues include: • Nodular melanoma (presenting as a rapidly enlarging lump) • Mucosal melanoma (arising on lips, eyelids, vulva, penis, anus) • Desmoplastic melanoma (fibrous tumour with a tendency to grow down nerves) Combinations may arise e.g. nodular melanoma arising within a superficial spreading melanoma.

31. Malignant Melanoma features: Grossly: Size: . most malignant melanomas are greater than 10mm in diameter . most benign tumours are less than 6mm Symmetry: . malignant lesions are usually asymmetrical with respect to cell type, extension and degree of pigmentation Dermoscopy:Handheld device,relatively new technique, visualisation through stratum corneum Without Dermoscopy resembles Seborrheic Keratoses With a Dermoscope, branched streaks at the edge of the and white areas within are visible, which suggests melanoma. A biopsy confirmed the lesion was melanoma

32. Superficial spreading melanoma Typical SSMM SSMM with Regression Amelanotic Melanoma

33. Lentigo Maligna Melanoma sun damaged skin of face, scalp and neck Lentigo maligna melanoma Nodular melanoma in lentigo maligna Lentigo maligna

34. Acral lentiginous melanoma

35. Nodular melanoma amelanotic nodular melanoma

36. Differential Diagnosis (MM) • Benign Naevi • Dermatofibroma • Pigmented Basal Cell Carcinoma • Pyogenic Granuloma • Kaposi's Sarcoma • Vascular malformations • Seborrhoeic Keratosis

37. Treatment • Surgery depends on the thickness of the melanoma and its site. Most thin melanomas do not need extensive surgery • For thicker melanomas (those over 1 mm or so in depth), a much wider area of skin is cut out. Draining lymph node biopsies may also be needed. Prognosis : Death is unlikely if a melanoma has a Breslow depth of less than one millimetre (T1). About half the patients are dead within 5 years if their melanoma is more than 4 mm thick (T4).

38. Moral of the story: . Do an ABCDE/ 7 points assessment . Appearances can be deceptive so if in doubt ask someone

39. finis