I am giving you guys skin cancer

RODENT ULCERMARJOLIN’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•Nodulocystic•Cystic•Pigmented•Maevoid

GENERALISED

SUPERFICIAL•Multifocal•Superficial Spreading

INFILTRATIVE•Ice pick•Morphoeic•Cicatrising

90%

• Variety of bcc

MICROSCOPICOvoid 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 noduleNot painful / may itchGrows 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 Excision Mohs Micrographic Surgery Two stage surgery

NON SURGICAL Curettage Electrodessication Laser Vaporization

No pathological specimenNo confirmation of diagnosisTumor margin not confirmed

RADIOTHERAPY

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

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