NEOPLASM OF SKIN

KUSUM,MSC.NURSING
1 ST Y E A R

SKIN NEOPLASM
Skin neoplasms, are skin growths with differing causes and varying degrees of

malignancy.

Malignant skin cancer is named after the type of skin cell it arises from.

Skin cancer generally develops in epidermis.

RISK FACTORS

Fair complexion, blue eyes, blond or red hair.

Working outdoors.

Older people with sun damaged skin.

History of radiation treatment of skin conditions.

Exposure to certain chemical agents .(arsenicals, nitrates, tar,paraffins)

Burn scars , damaged skin in areas of chronic osteomyelitis, fistulae openings.

Long term immunosuppressive therapy, including organ transplant.

Presence of human papillomavirus.

Malignant Conditions

CLASSIFICATION :
Basal cell Carcinoma

Squamous cell Carcinoma

Malignant Melanoma

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

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%

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

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

Differential diagnoses
Nodular BCC
. Fibrous papule
. Naevus
. Seborrhoeic keratosis
. Amelanotic melanoma

Pigmented BCC

Superficial BCC

Morpheaform BCC

. Nummular eczema
. Psoriasis
. Extramammary Paget Disease
. Bowens Disease

. Malignanat Melanoma
. Pigmented Seborrhoeic keratosis
. Traumatised naevus

. Scar
. Localised scleroderma

Basal Cell Carcinoma

More BCC

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.Gorlins Syndrome.

Low-Risk BCC

Size Less than 2 cm.

Site Torso, Limbs.

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%)

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
Both sexes - back of hands, face

Women - lower legs

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.

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

SCC of different types/Sites

When confined to the epithelium is called SCC in situ ,Intraepidermal SCC or Bowens
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
youre a dermatologist.
Carcinoma cuniculatum (verrucous carcinoma), a slowly-growing warty tumour found
on the sole of the foot
Sites include :
Vulval SCC
Oral SCC

Bowens Disease

SCC

Pigmented SCC

Other SCC

Oral SCCLeucoplakia

Superficial BCC

Keratoacanthoma

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

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

ContdMelanoma 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.

Malignant Melanoma features:

Grossly:
Size:

Symmetry:

. most malignant melanomas are greater than 10mm in diameter

. most benign tumours are less than 6mm
. 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

In Situ Malignant Melanoma

Melanoma cells

confined to the
epidermis
Lack in invasion may
persist for months to
years
Simple excision is
often curative

Superficial Spreading Melanoma

Most common in

middle age
Develops anywhere on
the body, back in both
sexes and legs in
females
Haphazard
combination on colors
but may be uniformly
brown or black

NODULAR MELANOMA

Spherical blue berry-like nodule with relatively smooth surface & relatively uniform blue black,
blue-gray, or reddish blue color.

Occurs commonly on TORSO & EXTREMITIES.

Invades directly into the subjacent dermis .

May be elevated with smooth surface of rose gray or black color.

Lentigo Maligna Melanoma

sun damaged skin of face, scalp and neck

Lentigo maligna melanoma

Nodular melanoma in
lentigo maligna

Lentigo maligna

LENTIGO MALIGNANT MELANOMA

Appears as tan , flat muscle- malignant degeneration is manifested by changes in color,

size, and topography.

Evolves slowly

Occurs on exposed skin surfaces of people in their 40s and 50s.

Acral lentiginous melanoma

Nodular melanoma

amelanotic nodular melanoma

ACROLENTIGINOUS MELANOMA
Irregular pigmented macules, which develop nodules.

Occurs commonly on palms, soles, nailbeds, and rarely on mucous membranes.

Most common in Asians and Blacks.

Treatment

Complete excision of lesion -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.

Systemic chemotherapy.

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 .

COMPLICATIONS
1.

BCC arising around the eyes, nasolabial folds, ear

canal, or posterior sulcus may invade deeply &
cause extensive destruction into muscle,bone , and
dura matter.

2. SCC may metastasize in 3% to 4% of cases.

3. If left untreated , melanoma will invade over

months to years.