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Malignant Skin Tumors PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Malignant Skin Tumors" by Dr N. K. Kansal.

This medical PowerPoint presentation talks about Malignant skin tumors, also known as skin cancer. Malignant skin tumors are abnormal growths of skin cells that can invade and damage surrounding tissues and organs. There are three main types of skin cancer: basal cell carcinoma, squamous cell carcinoma, and melanoma.

Tags : Malignant skin tumors, skin cancer, basal cell carcinoma, squamous cell carcinoma, melanoma, Dermatology, Dermatology PowerPoint presentation

Published on : Mar 31, 2023 | Views : 2198 | Downloads : 11

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Malignant Skin Tumors Dr N. K. Kansal Associate Professor
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Malignant tumor A tumor is an abnormal mass of tissue - growth of which exceeds & is uncoordinated with that of normal tissue with capacity to metastasize to lymph nodes and other organs Deals chiefly with the malignant tumors arising from epidermal cells
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Basal cell carcinoma Squamous cell carcinoma Malignant melanoma
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Basal cell carcinoma (BCC) The most common cancers in humans All BCCs - Mutations activating the Hedgehog signaling pathway Exposure to UV light Associated with PTCH1 gene mutation in most cases BCCs are locally destructive but rarely metastatic BCCs - primarily treated by surgical excision, electrodesiccation & curettage, Mohs micrographic surgery and topical agents
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Epidemiology BCC - The most common cancer in humans Estimated - >3 million new cases occur each year in the USA Men - affected slightly more often than are women Tumors - More frequent in patients older than 60 years of age Majority of BCCs- located on the head and neck
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Risk factors Risk factors for BCC - ultraviolet radiation (UVR) exposure, light hair and eye color, northern European ancestry and inability to tan BCC is rare in dark skin - the inherent photoprotection of melanin & melanosomal dispersion
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Clinical Features Subtypes Nodular BCC - the most common clinical subtype Pigmented BCC - a subtype of nodular BCC that exhibits increased melanization Superficial BCC - most commonly on the trunk Morpheaform (sclerosing/infiltrating) BCC - an aggressive growth variant Basosquamous carcinoma - a form of aggressive growth BCC; can be confused with squamous cell carcinoma (SCC) Fibroepithelioma of Pinkus
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Clinical Features Presence of any nonhealing lesion  Should raise the suspicion of skin cancer BCC - usually on sun-exposed areas of the head & neck Can occur anywhere on the body Commonly seen features - translucency, ulceration, telangiectasias, and the presence of a rolled border Characteristics - Differ for different clinical subtypes
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Nodular BCC The most common clinical subtype Occurs most often on the sunexposed areas of the head & neck Appears as a translucent papule or nodule Usually telangiectasias and often a rolled border Larger lesions with central necrosis - referred to by the historical term ‘rodent ulcer’
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Pigmented BCC A subtype of nodular BCC – exhibits increased melanization Pigmented BCC - Presents as a hyperpigmented, translucent papule
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Superficial BCC Superficial BCC - most commonly on the trunk Appears as - a well-demarcated erythematous patch The DD nummular (discoid) dermatitis An isolated patch of “eczema” that does not respond to treatment - raise suspicion for superficial BCC
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Morpheaform BCC An aggressive growth variant Lesions of morpheaform BCC - have an ivorywhite appearance May resemble a scar or a small lesion of morphea The appearance of scar tissue [in the absence of trauma/ previous surgical procedure or the appearance of atypical-appearing scar tissue at a previously treated lesion] - alert for possibility of morpheaform BCC The extent - often larger than the clinical appearance
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Basosquamous carcinoma A form of aggressive growth BCC Can be confused with squamous cell carcinoma (SCC) Histologically - Shows both basal cell and SCC differentiation in a continuous fashion
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Diagnosis Diagnosis - Accurate interpretation of the skin biopsy results The preferred method of biopsy - shave biopsy, punch biopsy Punch biopsy - Useful for flat lesions of morpheaform BCC & for recurrent BCC occurring in a scar During biopsy - adequate tissue
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Management Management of BCC - guided by anatomic location & histological features Approaches include standard surgical excision or destruction by various other physical modalities, Mohs micrographic surgery (MMS) topical chemotherapy Best chance to cure - Through ‘adequate initial treatment’  recurrent tumors are more likely to be resistant to further treatments May cause further local destruction
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Mohs micrographic surgery Developed in 1938 by Frederic E. Mohs, a general surgeon A microscopically controlled surgery used to treat common types of skin cancer During the surgery, after each removal, the tissue is examined for cancer cells Provides informed decision for additional tissue removal Improves prognosis - After 5 years, MMS-treated BCCs recurred in 1.4% of primary & 4% of recurrent tumors Preferred treatment for any BCC where tissue conservation is desired
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Standard surgical excision Curettage & desiccation Cryosurgery Imiquimod (5% cream) 5-Fluorouracil Photodynamic therapy (PDT)
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Squamous cell carcinoma (SCC) SCC - second most common skin cancer, in immunocompetent after basal cell carcinoma The most common skin cancer - in immunosuppressed organ transplantation recipients Majority of SCC - present with early-stage disease Prognosis - excellent in the majority of cases Risk of developing metastasis from SCC is generally low
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Risk factors Ultraviolet radiation (both UVB and UVA) – most important environmental risk factor for the development of SCC with a strong dose-response association Genetic predisposition - potentiate the risk of environmental factors such as UVR Clinical skin phenotypes - Light complexion (as in photo types I, II) Physical & chemical carcinogens- Arsenic, used in various medications, tainted wine and unprocessed well water may stimulate skin carcinogenesis; Cutting oils - a risk of SCC development in certain industrial occupations; SCC on the scrotum of chimney sweeps - attributed to chronic exposure to ash & polycyclic aromatic hydrocarbons derived from carbon compounds (e.g. coal tar)
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Immunosuppression including iatrogenic (e. g. solid organ transplantation recipients, with autoimmune or rheumatoid disease), Hematopoietic stem cell transplantation, Infection with HIV/AIDS Viral infection – HPVs Chronic inflammation & chronic injury of the skin – chronic ulcers (Marjolin’s), burn scars & radiation dermatitis Chronic inflammatory disorders - discoid lupus erythematodes, mucosal & hypertrophic lichen planus, lichen sclerosus & dystrophic epidermolysis bullosa
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Epidemiology SCC incidence - increases with age; most patients =/> 60 Higher in men than in women Sun-sensitive individuals with red hair, blue eyes & fair complexion -higher risk than individuals with darker pigmentation Race- Australians, exposed to very high, long-term UVR levels – more likely to develop SCC than other populations
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Clinical Features Variable & depends on the histologic subtype and location Typically, SCCs arise on sun-exposed areas The face, head, and neck region & the forearms & dorsum of the hands The typical clinical finding – includes slowly enlarging, firm, skin-colored to erythematous plaques or nodules Marked hyperkeratosis Ulceration, exophytic or infiltrative growth patterns - seen
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Verrucous SCC Verrucous SCC - a slowly growing ulcerated plaque or an exophytic cauliflower-like slowly growing tumor Typical locations Oral cavity (oral florid papillomatosis) Genitoanal region (giant condyloma acuminatum; Buschke-Löwenstein) Plantar skin (epithelioma cuniculatum) Amputation stumps Less common than other forms of invasive SCC
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Diagnosis The standard pathology report to indicate: Histologic subtype (acantholytic, spindle cell, verrucous, or desmoplastic type) Grade of differentiation (G1 to G4) Maximum vertical tumor diameter in millimeters Extent of dermal invasion (Clark level) Presence or absence of perineural, vascular, or lymphatic invasion Information about whether the margins are free or not
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Treatment Treatment modality for the primary lesion - major determinant for the risk of local recurrence Ideal management - local tumor control along with maximal preservation of function and cosmesis
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Surgical excision Surgery excision - preferably microscopically controlled surgery (Mohs surgery) - primary mode of therapy For localized lesions - cure rate of 95% SCC - local in-transit metastasis- may be removed by wide surgical excision or treated by irradiation of a wide field around the primary lesion Treatment of nodal metastasis - lymph node dissection, radiation, or a combination of both
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Other therapies Topical therapeutic treatments- e.g. imiquimod, topical or intralesional 5-fluoruracil, cryotherapy & PDT – Lack of evidence for the efficacy Radiation therapy - patient preference and other factors, e.g. problematic locations for surgery
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Limited data on the efficacy of chemotherapy for metastatic SCC Standard options in metastatic or unresectable disease – systemic platinum-based chemotherapeutic regimens, 5- fluorouracil/capecitabine, or monotherapy/chemotherapy with methotrexate
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Prognosis Majority of SCCs- low risk If early stage- result in a high cure rate with excellent prognosis Prognosis for locally advanced SCC at the time of diagnosis & patients with progressive disease after first-line surgical therapy - usually poor A poorer outcome of immunosuppressed patients with advanced disease
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Melanoma Melanoma (Gr. melas [dark], oma [tumor]) - malignant tumor arising from melanocytic cells Can occur anywhere where melanocytes are found The most frequent type - cutaneous melanoma Also at the mucosal, the uveal, or even the meningeal membrane 10% melanomas – detected by lymph node metastases [with so-called “unknown primary”]
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Epidemiology Rising incidence worldwide - Countries with white inhabitants, with highest incidence rates in Australia (35 new cases/year/100,000) North America (21.8 new cases/100,000) Europe (13.5 new cases/100,000) Median age - for melanoma diagnosis is 63 years with 15% being <45 years Melanoma – Accounts for only 4% of all skin cancer diagnoses in the USA Responsible for 75% of skin cancer deaths
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Risk factors History of sunburns and/or heavy sun exposure Fitzpatrick skin phototypes I & II Blue or green eyes, blonde or red hair, fair complexion >100 typical nevi, or any atypical nevi Prior personal or family history of melanoma p16 mutation
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Clinical Features Subtypes Superficial spreading melanoma Nodular melanoma Lentigo maligna Lentigo maligna melanoma Acral lentiliginous melanoma Desmoplastic melanoma Mucosal melanoma
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Superficial spreading melanoma Most common subtype, accounting for approximately 70% Most common on intermittently sunexposed areas The lower extremity of women; the upper back of men Irregular borders and irregular pigmentation May present subtly as a discrete focal area of darkening Varying shades of brown typify most melanocytic lesions Also aspects of dark brown to black, blue-gray, red, and gray-white (which may represent regression) may be found
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Nodular melanoma Approximately 15%-30% of all melanomas The trunk - the most common site Remarkable for rapid evolution - often arising over several weeks to months May lack an apparent radial growth phase Typically appears as a uniformly dark blue-black or bluish-red raised lesion 5% are amelanotic
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Lentigo maligna & Lentigo maligna melanoma Lentigo maligna - melanoma in situ with a prolonged radial growth phase Eventually becomes invasive  Lentigo maligna melanoma Diagnosed most commonly in the seventh to eighth decades (uncommon before the age 40) Most common location - the chronically sun-exposed face, on the cheeks and nose in particular Clinical appearance - flat, slowly enlarging, brown, freckle-like macule with irregular shape & differing shades of brown and tan
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Complications Usually based on metastatic disease - symptoms associated with the affected organ Pain (any metastases) Convulsion (brain metastases) Instabilities, # - (bone metastases) Later - symptoms associated with progression of the disease & death in the palliative setting Cutaneous changes - localized or diffuse hypo- or hyperpigmentation Development of a melanoma-associated vitiligo [an accompanying autoimmune disease against melanocytes] - in 4%; associated with a better prognosis
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Diagnosis Early detection - the key to improve prognosis Melanoma - Change in color and increase in size (or a new lesion) are the 2 most common early characteristics noticed by patients that may be useful in discriminating between melanoma and other benign lesions Physical examination Dermascopy
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Pathology- Excisional skin biopsy Large lesion and/or located on anatomic areas such as the palm/sole, digit, face, or ear, an incisional skin biopsy may be performed Lymph node examination f/b USG/excisional biopsy Tomographic investigations like computed tomography (CT), magnetic resonance imaging (MRI) & positron emission tomography (PET) - generally not recommended at the stage of primary melanoma - rate of false positive findings is far too high (8%-15%), e.g. unspecific lung lesions
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Management The standard of therapy - wide local excision (WLE) The purpose - to prevent local recurrence due to subclinical persistent disease The risk of satellite metastases - related to primary melanoma thickness Current recommendations on the clinical margins - depending on the Breslow thickness of the primary For melanoma in situ - a 0.5-1-cm margin For melanoma <1±mm Breslow depth –a 1-cm margin For melanoma 1 to 2±mm thick - a 1- to 2-cm margin For melanoma >2±mm thick - a 2-cm margin is recommended
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Wider excisions with up to 5-cm margins - not show a benefit for local recurrence rate Standard of therapy for macroscopic (stage IIIB/IIIC) lymph nodes –CLND of the involved regional basin Uncontrolled nodal disease - Major cause of melanoma-related morbidity with a significant high negative impact on QoL CLND for regional metastatic melanoma - associated with long-term survival
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Adjuvant therapy Adjuvant therapy - for patients with surgically resected disease who are at high risk for relapse such as those with thick primary melanomas or nodal disease Interferon-alpha Anti-CTLA-4 antibody (ipilimumab) – an immune checkpoint blocker Adjuvant radiotherapy after CLND
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