I am giving you guys skin cancer. RODENT ULCER MARJOLIN’S ULCER EPITHELIOMA.
Transcript of I am giving you guys skin cancer. RODENT ULCER MARJOLIN’S ULCER EPITHELIOMA.
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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