Download MBBS Dermatology PPT 20 Naevi Tumors Lecture Notes

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? Circumscribed, non-neoplastic skin or mucosal lesion,
? usually present at or soon after birth.
? Term should always be qualified according to the cell or tissue of

origin, for example "connective tissue nevus" or "vascular nevus".

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? Nevi generally represent clones of genetically altered cells arising

from mosaicism.
Benign tumor

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? A localized proliferation of cells of one type,

? which has some degree of autonomous control of growth,

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? but a normal differentiation.

In situ tumor

? A localized collection of morphologically malignant epidermal cells,

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? which have still not invaded the basement membrane

? so it essentially applies to epidermal tumors.

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Malignant tumor

? A collection of morphologically malignant cells

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? with full capacity to metastasize to lymph nodes and other organs.


? Others:
? Underlying skin diseases

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? oculocutaneous albinism
? Xeroderma pigmentosum
? Epidermodysplasia verruciformis
? Chronic venous ulcers

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EPIDERMAL TUMORS AND NEVI

? SEBORRHEIC KERATOSIS

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? Benign epidermal tumor,

? seen after age of 50.

? Morphology: Multiple, well-defined, hyperpigmented papules with a

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"stuck on" appearance, a greasy surface, and keratinous plugs.

? Sites: Face, trunk, and upper extremities.

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? Treatment: Can be left alone, remove if cosmetically disfiguring.

Biopsy if diagnosis is in doubt (to rule out malignant melanoma).

? Biopsy- horn pseudocysts

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? small black papules, limited to

the upper part of face.

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?

Skin Tags

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? Familial
? Associated with obesity.
? Acanthosis nigricans.
? Diabetes.

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? Soft, skin-colored or pigmented, pedunculated papules
? Neck, axillae, and groins.
? radiofrequency

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Melanocytic Nevus

Congenital melanocytic nevi

? Derived from epidermal melanocytes and nevus cel s have a predilection

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for deeper penetration.

? Present at birth.

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? single,multiple.

? Color varies from brown to black

? lesions darken and enlarge as the child grows.

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? With age, the lesions also become raised and develop rugosities

(cerebriform appearance).

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? Coarse hair develops in 90% of lesions

?
? Giant lesions are usually seen on the trunk and because they may

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cover large areas of the trunk, are called "bathing trunk nevi".

? Complications: potential for malignant transformation is definitely

more in giant congenital melanocytic nevi (bathing trunk nevi).

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? Meningeal involvement and spina bifida, seen in lesions located over

vertebral column.

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ACQUIRED MELANOCYTIC NEVI

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JUNCTIONAL MELANOCYTIC NEVUS


COMPOUND MELANOCYTIC NEVUS

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INTRADERMAL MELANOCYTIC NEVUS


OTHERS

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? MONGOLION SPOTS
? Bluish ill-defined macules
? Lumbosacral region.
? Regress by age of 4 years

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?

? NEVUS OF OTA

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? Present at birth.
? Or appears in infancy.
? Macular pigmentation, which has two components: More prominent

slate grey hyperpigmentation due to dermal melanocytes. Brownish

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epidermal pigmentation.

? Distribution along the maxillary division of the trigeminal nerve.
? Pigmentation of sclera (slate gray) and conjunctiva (brown) often

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present


?

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? Halo nevus or Sutton's nevus:
? Melanocytic nevus which develops a halo of depigmentation
? over period of many years, the nevus involutes and
? the depigmented halo repigments.

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COMPLICATIONS

? INFLAMMATION

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? MALIGNANT CHANGE-
? The following changes in a melanocytic nevus are suspect and

warrant a biopsy:

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? Change in size and pigmentation.
? Change in shape and contour.
? Itching, inflammation, ulceration, and bleeding.

?

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Verrucous Epidermal Nevus ? localised/

generalised

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Variants

? ILVEN

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? NEVUS COMEDONICUS

? NEVUS SEBACEOUS

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?

Becker's Nevus

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? Common condition.
? More frequent in men.
? Begins shortly before, at or after puberty.
? Appears as a hyperpigmented (light-dark brown) patch, which has a

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characteristic splashed appearance.

? Over period of time, coarse dark hairs appear on the lesion
? Chest and shoulders.

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Epidermoid and Trichelemmal Cysts

? freely mobile over underlying

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structures

? tethered to the skin.
? Characteristically, have a central

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punctum through which cheesy

material can be expressed

? Sites

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? Complications

? Epidermoid cyst: Face, upper

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? Secondary infection.

back, and retroauricular region

? Rupture in the dermis and

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induce a foreign body reaction.

? Trichilemmal cyst : Most

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? Dystrophic calcification

frequent on the scalp.

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? MILIA:
? small subepidermal keratin cysts.
? small, firm, white papules,

which are less than 2 mm in

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diameter.

? De novo on the face
? At sites of healed subepidermal

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blisters e.g., bullous pemphigoid

Premalignant Lesions

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? cutaneous horn
? keratoacanthoma
? Bowen's disease
? actinic keratoses
? arsenical keratoses

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cutaneous horn

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?Cutaneous horn (cornu cutaneum)

? A conical hypertrophic protuberance emanating from a skin-

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colored to erythematous papular base

? Height at least one-half of the largest diameter

? Thirty-eight percent to 40 percent of all cutaneous horns

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represent AKs


? Is a morphological diagnosis.

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? Occurs secondary to:
? Epidermal nevus.
? Warts.
? Seborrheic keratoses.
? Rarely, underlying squamous cell carcinoma.

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keratoacanthoma

? Rapidly growing, skin-colored

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nodule, which develops a central

horny plug ; the plug falls off to

leave a crater.

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? Most lesions resolve

spontaneously, leaving a

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depressed (cosmetically

unacceptable) scar.

? Few (very few!!) transform into

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squamous cell carcinoma.
Keratoacanthoma

? Solitary or multiple

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? rapid growth
? 1 to 2.5 cm
? ulcer with keratinous material
? spontaneous resolution

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Bowen's Disease

? Carcinoma in situ
? erythematous plaque
? irregular borders

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? enlarging psoriasiform plaque
? indentations (reniform margin)


BOWEN'S DISEASE

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? A: psoriasiform plaque, showing

irregular indentations.

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? B: infiltration of the lesion

indicates development of

squamous cell carcinoma

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? Treatment
? Excision,
? cryotherapy, or

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? topical 5-fluorouracil (5-FU).


? Actinic keratoses: pink irregular

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macules and papules with dry

adherent scales.

? middle aged and elderly.

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? Face, scalp, and dorsae of hand.
? Suspect transformation into

squamous cell carcinoma (a rare

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occurrence), if the lesion

enlarges rapidly, ulcerates or

bleeds.

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? arsenic keratoses: multiple corn-

like papules.

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? rain drop pigmentation
MALIGNANT EPIDERMAL TUMORS

? BASAL CELL CARCINOMA

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? SQUAMOUS CELL CARCINOMA

? MALIGNANT MELANOMA

1. BASAL CELL CARCINOMA

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? The most common cancer

affecting humans

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? Slow growing

? At least 75% first tumours are on

the face

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? Relatively `benign' in most cases

? but if left untreated can be

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disfiguring and life threatening
Basal Cell Carcinoma

? Raised, with pearly border
? prominent vasculature

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? ulceration
? nodular most common

TYPES OF BCC

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NODULAR
? Usually begin as a small

pink `pearly' papule

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? Develop a depression in

the centre

? Rolled edge

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? Overlying telangiectasia
Superficial Basal Cell

? Scaly patches

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? irregular borders
? extremities, less common in head

and neck

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MORPHOEIC

? White or waxy

? Always on face

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? Presents as a spontaneous `scar'

? Margins are usually much wider than

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what is clinically visible


Pigmented BCC

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? Basal Cell Carcinoma----

histopathology is diagnostic

? Cells resemble those of stratum

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basale

? peripheral palisading

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? stromal retraction
? Course
? Slowly progressive,
? locally invasive (especially noduloulcerative variant) neoplasm,
? eating into underlying structures like cartilage or bone, if left

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untreated.

? Lymphadenopathy and distant metastasis do not occur.

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? Surgical excision is treatment of choice in most cases.

? All variants of BCC except the morphoeic variant are excised with a

0.5 cm of skin margin.

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? Morphoeic variant is excised with wider margin (up to 2 cm) because

the lateral extent is often indistinct.

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Squamous cell carcinoma

? Etiology:
? Damaged skin (photodamaged/scarred/ulcerated skin/leucoplakia/

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erythroplasia),

? topical and systemic carcinogens- Pitch tar, mineral oils, and inorganic

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arsenic

? human papilloma virus
? immunosuppression - HIV
? Certain rare genetic disorders, with defective DNA repair

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mechanisms, such as xeroderma pigmentosum

? A: raised ulcer with indurated

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base and everted margin

(cauliflower-like) on the lower lip.

? B: raised ulcer with indurated

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base and everted margin at site

of radiation dermatitis.
? Metastases

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? Lymphadenopathy: Regional lymphadenopathy. Nodes hard and

sometimes fixed to underlying structures and tethered to skin.

? Visceral metastases: Infrequent.

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? scc


? characteristic histology.

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Malignant Melanoma

? Etiology:

Clinical variants :

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? Multifactorial.

lentigo maligna melanoma,

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? Actinic damage important.

superficial spreading melanoma

? Evidence of nevi in 25% of

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(SSM),

patients with MM.

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acral lentiginous melanoma, and
nodular malignant melanoma

(NMM).
SSM most frequent while NMM is

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the most aggressive.

? Asymmetrical pigmented nodule,
? Border irregularity,

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? Color variability,
? Diameter >0.5 cm,
? Elevation irregularity.

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Subungual

Metastatic melanoma

melanoma

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? histological grading using

Breslow's method.

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? measures the vertical distance

(in mm) from granular cell layer

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to the deepest part of tumor,

using a microscopic micrometer.

? prognostic predictor.

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Benign Tumors of Skin Appendages


Malignant Tumors of Skin Appendages

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Paget's Disease

? Paget's disease of breast:
? sharply marginated plaque with

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a slightly raised edge and an

irregular outline.

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? If the crusts are removed, a red,

glazed, moist surface is revealed.

? Note destruction of nipple.

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Benign Tumors and Nevi of Dermis


? Port-wine stain: deeply

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erythematous, telangiectatic

slightly bosselated lesion on the

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face.

? Usually present at birth.

? Salmon patch

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? Is a capil ary malformation

? Commonest vascular malformation

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present at birth.

? salmon patch involutes by the age

of one.

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? Presents as telangiectatic macules.

? Nape of neck, forehead, and

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eyelids.

? Treatment None required.

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? Venous malformation: a soft

compressible bluish swelling,

which increases in size when

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dependent

? Lymphatic malformations
? Usually present at birth.

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? Characterized by a cluster of

thin walled vesicles (resembling

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frog spawn).


Infantile hamangioma

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? Lesion appears within a few

weeks of birth and grows for a

few months.

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? Spontaneous regression occurs

with minimal atrophy in most

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patients.

? Soft, brightly red (strawberry

colored) nodule with pale

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stippling indicating resolution

? Complications:

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? Treatment

? Large swellings near orifices

? Small lesions: Resolve

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(oral, nasal, anogenital)

spontaneously.

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interfere with function.

? Large symptomatic lesions:

? Bleeding may follow trauma.

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? Systemic steroids

? Ulceration especially in large

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? Propranolol

lesions and in intertriginous area. ? Lasers: pulsed dye laser in

residual lesions.

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Beningn acquired

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hemangioma/ pyogenic

granuloma

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Malignant Tumors of Dermis

Cutaneous T Cell Lymphoma (Mycosis Fungoides)
? Lymphoma of helper T cel s.

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? Initial patch stage of wel -defined, bizarre

shaped, atrophic patches; poikiloderma

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? later infiltrated plaque stage and then

? tumor stage with aggressive course.

? Characteristic histology with presence of

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atypical cel s (Pautrier's microabscesses);

epidermotropism

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? Treatment: Early stage: Topical steroids,

topical nitrogen mustard, PUVA, acitretin

and electron beam treatment.

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? Tumor stage: Chemotherapy.

? Others:
? LCH

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? Kaposi sarcoma
QUESTIONS (please answer in one word)

? 1. Horn pseudocysts are a feature of ?
? 2. Virus which is implicated in the pathogenesis of skin malignancies-

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? 3. Bathing trunk nevus is a type of-
? 4. melanocytic nevus surrounded by a depigmented halo is
? 5.Name a premalignant lesion of skin
? 6.Pautrier microabscesses are seen in

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? 7. What is the diagnosis in case of pigmented macules present over

left cheek distributed over maxillary division of trigeminal nerve-

? 8. Which of the malformation is most likely to involute

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spontaneously?

? 9. Grouped open and closed comedones arranged linearly are seen in
? 10. . Breslow's method is used for histological staging of

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