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Epidermal Nevi, Neoplasms, and Cysts Part II

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Squamous cell carcinoma of the lip Sun damage on the lower lip can result in actinic cheilitis and even squamous cell carcinoma as shown here. – PowerPoint PPT presentation

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Title: Epidermal Nevi, Neoplasms, and Cysts Part II


1
Epidermal Nevi, Neoplasms, and Cysts Part II
  • Rick Lin, D.O., MPH, Dermatology ResidentTexas
    Division of KCOM Dermatology Residency Program

2
Basal Cell Carcinoma
  • Basal Cell Epithelioma
  • Basalioma
  • Rodent ulcer
  • Jacobis ulcer
  • Rodent carcinoma

3
BCC What are they?
  • PEARLY PAPULES OR NODULES
  • ROLLED BORDER
  • TELANGIECTASES
  • CENTRAL ULCER
  • CRUSTING
  • BLEED EASILY

4
BCC Where are they?
  • HEAD, NECK 85
  • NOSE, 30
  • FOREHEAD
  • EARS
  • CHEEKS
  • UPPER TRUNK

5
BCC When?
  • OFTEN 1/3 OF ALL CA IN USA.
  • Chronic UVB, X-ray
  • Immunosuppression
  • Renal Transplant
  • Genetics

6
BCC Who?
  • ELDERLY MIDDLE AGED
  • Ages 40-79
  • ANGLO-SAXON Blue Eyes, Fair Skin
  • X-Ray Exposure, ie Physicians, Dentists,
    Technicians, Workers

7
BCC How?
  • Arise from immature pluripotential cells.
  • Mutations in the HEDGEHOG pathway (genes which
    controls cell growth)
  • PATCHED (tumor suppressor) inactivated.
  • HEDGEHOG and SMOOTHENED (cell growth inhibitors)
    activated.
  • P53 and RAS mutations also play a role.

8
BCC look-alikes SGH
9
BCC look-alikes KA
10
BCC Look alikes SCC
11
BCC Variants
  • SUPERFICIAL BCC
  • MORPHEAFORM BCC
  • PIGMENTED BCC
  • CYSTIC BCC
  • BASAL CELL NEVUS SYNDROME(GORLINS SYNDROME)

12
SUPERFICIAL BCC
  • PSORIASIFORM
  • TRUNK
  • LIMBS
  • FLAT GROWTHS
  • YOUNGER PATIENTS

13
MORPHEAFORM BCC
  • RESEMBLES LOCALIZED SCLERODERMA
  • ALMOST ALWAYS ON THE CHEEKS OR FOREHEAD
  • MOHS SURGERY
  • AGGRESSIVE

14
PIGMENTED BCC
  • DARK SKINNED PATIENTS
  • LATIN AMERICANS
  • JAPANESE
  • NOT BLACKS (we have one black patient in the
    clinic though)
  • ARSENIC INGESTION
  • 6 OF ALL BCC

15
BCC CYSTIC/SOLID
  • DOME SHAPED
  • BLUE GRAY
  • CYSTIC NODULES
  • 4-8 OF ALL BCCS

16
Fibroepithelioma of Pinkus
  • Premalignant fibroepithelial tumor
  • Elevated, skin-colored sessile lesions on the
    lower trunk
  • Histology interlacing basocellular sheets that
    extend downward from surface to form an
    epithelial meshwork enclosing a hyperplastic
    mesodermal stroma

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  • A composite scan power view showing anastomosing
    bands of epithelium separated by large amounts of
    stroma. The stroma accounts for over 50 of the
    total volume of the tumor.

20
  • Another composite scan power view. This is from a
    section taken parallel to the one above. The
    strands of epithelium are generally more delicate
    than those seen above.

21
  • Peripheral palisading of nuclei is associated
    with a cleft between the epithelium and the
    delicately fibrillar, slightly basophilic stroma.
  • This clefting resembles that seen in basal cell
    carcinomas.
  • Amyloid (AMY) is seen below an area wherein
    parallel, coarse collagen fibers (VC) are
    oriented perpendicular to the interface of the
    epithelium and stroma. 

22
BCC TREATMENT
  • EXCISION
  • FULGURATION AND CURETTAGE
  • IONIZING RADIATION
  • CRYOSURGERY
  • TOPICAL 5-FU
  • LASER
  • MOHS MICROGRAPHIC 99 CURE

23
Solitary Basal Cell Carcinoma in Young Persons
  • Solitary Basal Cell Carcinoma in Young Persons
  • These lesions usually located in the region of
    embryonal clefts in the face
  • Deeply invasive
  • Deep surgical excision is much safer than
    curettage for their removal

24
NEVOID BCC SYNDROME
  • JAW CYSTS
  • PALMAR PITS
  • SKELETAL DEFECTS
  • FRONTAL BOSSING
  • CALCIFICATION OF FALX CEREBRI
  • MOHS SURGERY

25
Jaw Cysts
  • 70 of the patient.
  • Both Mandible and Maxilla
  • Mandibular involvement twice as often
  • Jaw pain, unable to close mouth, tenderness
  • First decade onset, maybe the first presentation

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Pits of hands and feet
  • 87 of patients
  • Second Decade of life

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Skeletal Defects
  • Spinal Bifida
  • Deformed ribs
  • Scoliosis and Kyphosis
  • Shorten metacarpal and metatarsal bones
  • Dimple on the fourth metacarpophlangeal joint
    (Albrights sign)

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CNS disorders
  • Calcification of
  • falx cerebri,
  • falx cerebelli, and
  • dura or basal ganglia

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Intraepidermal Epithelioma
  • Tan-brown, keratotic scaly, flat, someimes
    verrucous lesions. Clinically resembles
    Seborrheic keratosis.
  • Simple excision or EDC
  • Also Known as
  • Borst Jadassohn epithilioma
  • Intraepidermal epithelioma of Jadassohn

35
Intradermal Nests of Basaloid Cells
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Squamous cell carcinoma
  • Squamous cell carcinoma (SCC) is a malignant
    neoplasm of keratinocytes with many features one
    of which is the production of keratin.
  • SCC can be categorized histologically into in
    situ (intraepidermal) or invasive (penetrating
    the dermal-epidermal junction).
  • Some examples of in situ SCC include Bowen's
    disease and erythroplasia of Queyrat.

38
Squamous cell carcinoma
  • Squamous cell carcinoma is the second most common
    skin cancer after basal cell carcinoma.
  • It typically occurs on sun-exposed areas of the
    body and is more common in light-skinned men
    greater than 55 years.
  • The incidence of SCC increases closer to the
    equator.

39
Predisposing factors for SCC
  • family history of skin cancer
  • precursor lip lesions from smoking
  • actinic keratosis
  • old burn scars
  • Immunosuppression
  • ultraviolet radiation
  • radiation therapy
  • chemical carcinogens such as soot and arsenic

40
Squamous cell carcinoma
  • Lesions on the lower lip (13.7), or in a scar
    (37.9), have up to a 40 probability of
    metastasizing.
  • Desmoplastic SCC are 6 times more likely for
    metastasis
  • Lesions on sun-damaged skin have a 2 tendency to
    metastasize.
  • Metastasis is primarily by way of the lymphatics,
    generally first to regional lymph nodes.

41
Treatment
  • Treatment choice is dependent on lesion type,
    size, location, depth of penetration and the
    patient's age and general health.
  • Treatment modalities include excisional surgery,
    curettage and electrodessication, cryosurgery,
    radiation therapy, Mohs surgery, and laser
    surgery.

42
SCC with cutaneous horn
  • Here is a cutaneous horn, overlying a tumor
    which on biopsy proved to be a squamous cell
    carcinoma. The presence of cutaneous horn is
    grounds for a biopsy of the underlying lesion.

43
Encrusted squamous cell carcinoma
  • Another firm tumor on the abdomen, this time
    with both scale and crust. Biopsy of this tumor
    revealed squamous cell carcinoma.

44
Chronic sun exposure and squamous cell carcinoma
  • This gentleman was in his 60s when he presented
    to the clinic because of the frequent development
    of skin cancers. You can see his scarred skin
    from the multiple previous procedures. On the
    superior aspect of the left breast is a crusted
    lesion which to palpation is firm. Biopsy
    confirms SCC.

45
Squamous cell carcinoma of the lip
  • Sun damage on the lower lip can result in
    actinic cheilitis and even squamous cell
    carcinoma as shown here.

46
Squamous cell carcinoma of the scalp
  • In his 30s when he presented to the clinic, this
    engineer had spent some years in Saudi Arabia and
    had neglected a growth on the top of his head at
    the site of a burn. At the time of presentation
    the tumor had been present for about 2 years.
    Biopsy revealed SCC and a workup revealed distant
    metastases. Shortly after presentation, he died
    from this tumor.

47
Squamous cell carcinoma of the scalp
  • Crusted and eroded tumor of the scalp in this
    elderly man was histologically SCC.

48
Actinic keratosis
  • These are scaly papules which occur on exposed
    skin of older, fairer-skinned, persons resulting
    from chronic overexposure to ultraviolet light
    from the sun. A small percentage of these lesions
    do develop into invasive squamous cell carcinoma.

49
Actinic keratosis
  • Here on the top outer edge of the ear is a
    palpably rough area, an actinic keratosis in one
    of the more common presentation sites for men.
    (In women, the ear is often protected from excess
    sunlight by the hair).

50
Marjolins Ulcer
  • SCC arise in chronic ulcers, sinuses, and scars
    of various etiologies
  • Burns are most common cause

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Acantholytic SCC
  • Fast growing tumor
  • Oral cavity and conjunctiva may also be involved
  • Acantholysis with adenoid preliferation
  • Surgical excision is preferred treatment.

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Verrucous Carcinoma
  • Slow-growing lesion and very invasive
  • May invade the bony structures around the tumor
  • Bulbous rete ridges that are topped by an
    undulating keratinized mass.
  • Excision or Mohs

55
Verrucous carcinoma can occur on the foot, in the
groin, or in the mouth. It is a low grade tumor
that seldom metastasizes. Note the destruction of
normal structures in this verrucous carcinoma of
the toe.
56
Verrucous carcinoma of the groin. Note the
destruction of the penis.
57
Verrucous carcinoma is very low grade and has
almost no atypia on histologic examination.
Diagnosis is made by the extent of invasion. It
is important to get a large, deep biopsy when one
suspects this type of tumor.
58
Bowens Disease
  • SCC in situ
  • Stains for mucin is negative for Bowens but
    positive for Pagets
  • No dyskeratosis in Pagets
  • Wind blown pattern in histology
  • Tinea circinata must be considered as well as
    Pagets

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Erythroplasia of Queyrat
  • Bowens located on glans penis
  • Treat with 5-FU is effective because of the
    absence of follicles
  • Resemble Zoons Balanitis

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Balanitis Plasmacellularis (ZOON)
  • Zoons Balanitis is a condition found on the
    glans penis and/or inner surface of the prepuce
    of the uncircumcised, middle-aged to older male.
  • presents most often as a solitary, glistening,
    red or cayenne pepper-colored, persistent plaque
    on the glans penis or inner surface of the
    prepuce of the uncircumcised male

64
Balanitis Plasmacellularis
  • Histologically, the epidermis appears thinned,
    often showing an absence of the upper layers
  • The upper dermis demonstrates a lichenoid
    infiltrate with copious plasma cells

65
Balanitis Plasmacellularis
  • Treatments start with topical therapies.
  • Mild topical steroids are the initial treatment
    of choice, however, recurrence upon their
    discontinuation is the rule.
  • Circumcision is curative in nearly all cases.
    Close follow-up is recommended.

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Pseudoepitheliomatous Keratotic and Macaceous
Balanitis
  • Rare condition
  • Ulceration, cracking, and fissuring on surface of
    glans
  • Phimosis will develop in adult life
  • Many believe it to be a form of verrucous
    carcinoma
  • Require Mohs or 5-FU

70
Pagets Disease of the Nipple
  • Unilateral sharply defined eczema caused by
    epidermal metastases from underlying ductal
    adenocarcinoma of the breast
  • Presence of padget cells
  • CEA and apocrine epithelial antigen usually
    positive
  • Bilateral lesions suggests neurodermatitis,
    contact, or nummular.

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Involvement of the epidermis by malignant
adenocarcinoma cells. The cells are large with
abundant clear cytoplasm and large anaplastic
nuclei with prominent nucleoli.
73
Extramammary Pagets
  • presents clinically as an erythematous plaque,
    often several centimeters in dimension, and such
    lesions are sometimes pruritic.
  • Delay in diagnosis is common as many of these
    cases are erroneously treated for dermatitis or
    superficial fungus infection prior to the
    establishment of the real diagnosis.

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Low power view from one part of the biopsy.
78
Medium power view of above. The cells are large
and have a rather bland appearance in this area.
Some are found singly in a pagetoid distribution,
and others are in clusters. The intervening
keratinocytes are free of atypia.
79
High power view of above. This solitary focus of
lumen production was found after examining
numerous sections. 
80
Composite high power . These cells are
cytologically malignant. Some have vacuolated
cytoplasm.
81
Trabecular Carcinoma (Merkel Cell Carcinoma)
  • Rapid growing nodule
  • Head and neck (44) leg (28) arm (16) and
    buttock (9)
  • Region nodal metastases is 53
  • Distant metastases is 75

82
Trabecular Carcinoma (Merkel Cell Carcinoma)
  • Local recurrence 26 to 44
  • 5 Year survival rate 30 to 64
  • Prognosis is worse than Melanoma
  • Mohs excision, some recommended 3 cm margin

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Merkel cell carcinoma with formation of lobular
structures in dermis and prominent lymphocytic
infiltration
85
Nevus Sebaceus(Organoid Nevus)
  • AKA Nevus Sebaceus of Jadassohn
  • Present at birth, usually near vertex of scalp
  • BCC may develop from the lesion 5-10 of the time
  • Deletion of Patched gene has been identified and
    may be responsible for development of BCC

86
Nevus Sebaceus(Organoid Nevus)
  • May be associated with development of
    intracranial masses, seizure, MR, skeletal
    abnormalities, ocular lesions, hamartomas of the
    kidney
  • Excision recommended if possible.
  • Patient with BCC on scalp during the inspection.

87
There are no large, anagen phase hair follicles
in most of the field, and there are no fibrous
tracks of the type that follow a telogen phase
follicle. This is characteristic of nevus
sebaceus of Jadassohn. The variety and degree of
proliferation of follicular components varies
from lesion to lesion.
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Sebaceous Neoplasms
  • Spectrum of sebaceous neoplasms
  • Sebaceous Hyperplasia ? Sebaceous Adenoma ?
    Sebaceoma ? Sebaceous Epithelioma ? Sebaceous
    Carcinoma

90
Sebaceous Hyperplasia
  • AKA senile sebaceous hyperplasia and senile
    sebaceous adenoma
  • Proliferation of mature sebaceous glands
  • Germinative layer 1 cell thick
  • Lobules may be grouped around a central dilated
    duct

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Sebaceous Adenoma
  • Sebaceous adenoma presents as a yellow
    circumscribed nodule located either on face or
    scalp.
  • Histologically sebaceous adenoma is a
    multilobulated tumour sharply demarcated from the
    surrounding tissue.
  • Two types of cells are present in the lobules.
  • The large mature sebaceous cells (sebocytes) are
    present at the centre. Smaller,undifferentiated
    basaloid cells in the periphery

93
Sebaceous Adenoma
  • Proliferation of sebaceous glands
  • Germinative layer comprise to to 50 of lobules
  • Retains lobular architecture
  • The cellular lobules contain ductal structures
    with holocrine secretion. Sometimes lobules
    contain cystic spaces in the center due to
    disintegration of mature sebaceous cells.

94
  • Very low power (direct scan of glass slide) view.
    The tumor communicates with the surface in
    multiple points, and holocrine secretion is
    prominent along the surface.

95
Low power view. Note the holocrine secretion
along the surface.
96
  • High power view. Most of the tumor cells have
    well-differentiated sebaceous cytology.

97
Sebaceous EpitheliomaSebaceoma
  • Circumscribed, symmetric lobules
  • Larger lobules extending into deeper dermis
  • gt50 germinative cells
  • Same morphologic characteristic as basal cell
    carcinoma
  • Histologically, consists of neat oval nests of
    irregularly shaped basaloid cells.

98
Tumor lobules have invaded into the reticular
dermis in the lower right corner of this picture.
99
Low power view of one of the nests of tumor in
the lower right hand corner of the picture above.
There is focal retraction from the surrounding
stroma, and there is sebaceous differentiation
within the central part of this tumor nest.
100
Sebaceous Gland Carcinoma
  • Rare carcinoma arise on the eyelids from
    meibomian or Zeis glands. Upper eyelid 75 of
    the time
  • Fatal metastasic disease occur 20-30 of eyelid
    cases
  • May be seen in Muir-Torre syndrome
  • Histologically, shows lobules containing
    sebaceous cells with numerous mitotic figures.
    Nuclei are lighter than those of the sebaceous
    epithelioma.

101
Sebaceous Gland Carcinoma
  • Large, asymmetric, infiltrative
  • Generally lacks well defined lobules
  • May have pagetoid spread
  • Necrosis
  • Mature sebocytes maybe few or rare
  • Pleomorphic, mitotically active basaloid cells

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Muir-Torre Syndrome
  • The criteria for diagnosis include presence  of
    sebaceous neoplasm (adenoma, sebaceoma or
    carcinoma), presence of internal malignancy (eg.
    colorectal carcinoma) .
  • Keratoacanthomahas been frequently noted in this
    syndrome.

104
Muir-Torre Syndrome
  • Patients with multiple sebaceous  neoplasms of
    the skin should be examined for   other visceral
    malignancies,(eg. colonic,hematologial,urothelial
    ,kidney,endometrial etc) .

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