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NEOPLASTIC DISEASES OF

SKIN

PONGSAK MAHANUPAB,M.D.
Department of Pathology
Faculty of Medicine Integumentary System ( 330203) Sept.2
วัตถุประสงค์เชิงพฤติกรรม
เมื่อสิ้นสุดการเรียนการสอน นักศึกษาสามารถ
1. ทราบชนิดเนื้องอกของผิวหนังที่พบได้บ่อย
รวมทั้งซีสต์ของผิวหนัง
2. ทราบพยาธิกำาเนิดของเนือ้ งอกของผิวหนัง
3.
ทราบลักษณะที่เห็นด้วยตาเปล่าและลักษณะที่เห็นจากกล้อง
จุลทรรศน์ของเนื้องอกเหล่านัน้
Content

1. Tumors of epidermis
- Squamous cell carcinoma
- Basal cell carcinoma
- Actinic keratosis
Content

2. Tumors of skin appendages


- Syringoma
- Trichoepithelioma
- Sebaceous carcinoma
Content

3. Tumors of melanocytes
- Nevus
- Malignant melanoma
4. Tumors of blood and lymphatic
vessels
- Hemangioma, lymphangioma
Content
5. Cysts of the skin
- Epidermal inclusion cyst
6. Tumor-like lesions of skin
- Seborrheic keratosis
- Keratoacanthoma
- Keloid/hypertrophic scar
Tumors of Epidermis
SQUAMOUS CELL
CARCINOMA

•Most common skin tumor


arising on sun-exposed
sites of older people
•Occur anywhere on skin
and squamous lining
mucosa

•Damaged skin ,scar from


burn,
stasis ulcer
• Predisposing factors :
sunlight, industrial
carcinogens ( tars and oils ),
chronic ulcer and draining
osteomyelitis, old burn scars,
ingestion of arsenicals,
ionizing radiation, tobacco
and betel nut chewing
•Increase incidence in
immunosuppressed
patient
( chemotherapy, organ
transplant ), xeroderma
pigmentosum
Gross :
- Nodular, ulcerated, scaly
•Histopathology
- True invasive carcinoma
- Irregular mass of
atypical squamous cells
proliferation downward
into dermis ( breakthrough
basement membrane )
Intercellular bridge
- Cell : - Hyperplasia
- Polygonal shape
- Nuclear
hyperchromasia
- Vary in size and
shape
( pleomorphism )
- Intercellular
bridge,atypical mitosis,
Keratin
pearl
True invasive
carcinoma
Irregular mass of
atypical squamous cells
proliferation downward
into dermis
Individual
keratinization
Intercellular
bridge
BASAL CELL
CARCINOMA
•Exclusively on hair
bearing skin
•Usually single
•Adults
•Do not metastasize
•Common, slow-growing
•A tendency to occur at
sites subject to chronic
sun-exposed and in
lightly pigmented
people
•High incidence in
immunosuppression
and in patients with
defects in DNA
replication or repair
•Predisposing factors
1. Light skin color,
prolong exposure to
strong sunlight
2. Ray
3. Burn and other
scars
•Gross
- Pearly papules often
with dilated
subepidermal vessels
( telangiectasia )
- Some containing
melanin pigment
similar to nevi or
- Ulceration
- Local invasion to
muscle, bone and
sinuses
- Do not occur in
mucosal surface
•Clinical
1. Noduloulcerative
( rodent ulcer )
2. Pigmented
3. Morphea - like
4. Superficial
5. Fibroepithelioma
• Histopathology
- Nodular mass of basaloid cells,
extend into dermis
- Cell
- Large, oval , elongated nuclei,
little cytoplasm, poorly defined
- No intercellular bridge
- Nuclei : uniform , resemble
basal cell,
nonanaplastic
- No abnormal mitosis, no
- Two patterns of growths
1. Multifocal ( multifocal
superficial type )
- spreading many sq.cm.
of skin surface
2. Nodular
- growing downward into
dermis as cords or
islands
Continuation from basal
cell layer
CONTINUATION FROM
BASAL CELL LAYER
PERIPHERAL
PALISADING

PROLIFERATI
ON OF
BASALOID
CELLS
ACTINIC KERATOSIS

- Premalignant lesion
( precancerous lesion )
- Result from chronic
exposure to sunlight
- High incidence in lightly
pigmented individual

- Ionizing radiation,
hydrocarbons, arsenicals
may induce
•Gross
- <1 cm. in diameter, tan
brown, red or skin colored,
scaly
- Rough, sandpaper-like
consistency
- Increase keratin similar
to cutaneous horn
- site of involvement :- sun
exposure area ( face, arm,
dorsum of hands ), lip
( actinic cheilitis )
•Erythematous scales -
somes are pigmented,
peripheral spreading
•Can develop into
squamous cell
carcinoma ( about 20
%),
Multiple lesions on areas exposed
to sun
Minimally elevated, slightly scaly,
flesh colored to pink
•Microscopic
- Cytologic atypia at the
lower most layers, may be
associated with
hyperplasia of basal cells
- Atrophy:- thinning of
epidermis
- Basal cells:- dyskeratosis
with pink or reddish
- Stratum corneum is
thickened with retained
nuclei ( parakeratosis )
- Presence of intercellular
bridge
- Dermis :- thickened,
blue-gray elastic fibers
(elastosis), a probable
result of abnormal dermal
elastic fiber synthesis by
sun-damaged fibroblasts
focal or confluent
parakeratosis
Cellular atypia and
mitotic figure in deep
epidermal layer, may
bud in to superficial
dermis
Normal
epidermis
HYPERKERAT
OSIS AND
PARAKERATO
SIS
Tumors of Skin
Appendages
SKIN APPENDAGE TUMORS

- Hundreds of benign tumor


arising from appendages
- Often clinical
nondescript, solitary or
multiple papules or
nodules

- Some have a
predisposition for
occurrence on specific
- Syringoma :- lesions of
eccrine differentiation ,
multiple small tan papules
in the vinicity of the lower
eyelid
Small papules, 1-2 mm., mainly at
lower eyelid
Epithelial strands of small
basophilic cells, characteristics
of cystic duct ( commalike or
tadpole ) lined by a double-
layer of flattened epithelial
cells containing colloid material
- Trichoepithelioma :-
follicular differentiation,
multiple , semitranslucent,
dome-shaped papules
- Face, scalp, neck, upper
trunk
SEBACEOUS CARCINOMA

- Most frequently on eyelid


( Meibomian gland )
- Easily mistaken from
chronic
blepharoconjunctivitis or
Gross:
- Nodule, may or may not
ulcerate
Great masquerader
Chalazion - like
Microscopic :
- Irregular lobular
formation, variation in
lobular size
- Foamy cytoplasm of
malignant cells
- Variation in size and
shape of nuclei ( nuclear
pleomorphism )
- Foamy cytoplasm,
demonstration of fat by
frozen section, staining
with oil red O
Irregular lobular masses of
cells resemble sebaceous
cells, bizarre and invasive
Foamy
cytoplasm
Fat stain
( Oil red O )
Pagetoid epidermal
invasion
Tumors of Melanocytes
NEVUS
( MOLE ,
NEVOCELLULAR
NEVUS,
MELANOCYTIC
NEVUS, PIGMENTED
NEVUS )
•Benign neoplastic
proliferation of
melanocytes
•Adolescent and early
adulthood
•Tan to brown , small <
6mm., solid papules, well
defined round borders
•Microscopic
- Presence of nevus cell
(melanocyte ) arranged in
clustered or nests
- Level of nevus cell
JUNCTIONAL
ACTIVITY
Junctional nevus
- Well circumscribed
nests either entirely
within lower epidermis
or bulging downward into
dermis but still in
contact with epidermis
NEVUS CELL

JUNCTIONAL NEVUS
Compound nevus
- Junctional + intradermal
(dropping of)
- Three types of nevus
cells
A, B and C
N

COMPOUND NEVUS
Type A : upper dermis, “
epithelioid cell “ cuboid,
abundant cytoplasm,
varying amount of melanin
pigment
TYPE A NEVUS
CELL
Type B : middle,
smaller, less
cytoplasm,less melanin,
resemble lymphoid cells
Type C : lower, resemble
fibroblast or Schwann
cells, elongated, spindle-
shaped nuclei, strands,
rarely contain melanin
TYPE C NEVUS
CELL
Intradermal
nevus
- No junctional
activity
NEVUS CELL
MALIGNANT
MELANOMA
•Originate from
melanocytes
at DE - junction
•More than half, arise de
novo
•Cause : sunlight,
intermittent sunburn
• Presence of pre-existing
nevus
• Clinical warning signs
1. Enlargement of pre-existing
mole
2. Itching or pain in pre-existing
mole
3. Development of new pigmented
lesion during adult life
4. Irregularity of border of
•Classification
- Radial growth :
horizontally growth within
epidermis and superficial
dermis

- Vertical growth :
dermal layer as expansile
•Microscopic
- Melanoma cell - larger
than nevus cells, larger
nuclei, irregular contour,
prominent red nucleoli
- Poorly formed nests or
individual cells
- Pagetoid invasion of
epidermis
PROMINENT
NUCLEOLUS
Pagetoid skin
invasion
Tumors of Blood and
Lymphatic Vessels
HEMANGIOMA
- Extremely common,
particularly in infancy and
childhood about 7 % of all
benign tumors
- Most benign pediatric
hemangiomas are capillary
and cavernous
- Presence from birth and
expand along with the
growth of children

- Many regress
spontaneously at or before
puberty
Capillary Hemangioma

- Composed of blood vessels


that resemble capillary, narrow,
thin-walled, and lined by relatively
thin endothelium

- Grow rapidly in the first few


months, begin to fade when the
child is 1 to 3 years old, and
regress by age 7 in 75-90% of
Gross :
- Few millimeters to
several centimeters
- Bright red to blue
- Level with the surface of
skin or slightly elevated
Cavernous Hemangioma

- Less common
- Gross:- red-blue, soft spongy ,
2 cm.
- Microscopic : sharply defined,
not encapsulated, large, cavernous
vascular spaces, intravascular
thrombosis with associated
dystrophic calcification
Lymphangioma

- Lymphatic analoque of the


hemangioma
- 1. Simple (capillary)
lymphangioma
2. Cavernous
lymphangioma
(cystic hygroma)
Lymphatic space
Lymphatic
space
Cysts of The Skin
EPITHELIAL CYST
( EPIDERMAL OR
INFUNDIBULAR
CYST )
•Slow growing, elevated,
round, firm
intradermal or
subcutaneous tumor
•Histopathology
- Wall : true epidermis
( infundibular
epithelium )
- Content : horny
material,
laminated layer
- Rupture : foreign body
CYSTIC CAVITY

W
ALL
KERATIN

CAVITY
FOREIGN BODY
REACTION
Tumor-like Lesions
SEBORRHEIC
KERATOSIS
• Very common, often multiple
• Trunk, face,extremity
(except palm,and sole )
• Do not appear before middle
age
• Sharply demarcated, brown ,
slightly raised, stuck on the
- Stuck on
lesion
- Sharply
defined
- Softly
lobulated
papule or
plaque
- Warty
surface
•Histopathology
- Hyperkeratosis,
acanthosis
- Basaloid cells:
proliferation of small ,
uniform, relatively
large nuclei
- Horn cysts
ACANTHOSIS
Epidermal hyperplasia Proliferation of
basaloid cells
( acanthosis )

Horn
cyst
PROLIFERATION OF BASALOID CELLS WITH
MELANIN PIGMENT
HORN CYST
KERATOACANTHOMA
•Solitary or multiple
•Common, clinically and
histologically resemble
squamous cell carcinoma
•Elderly
•Firm,dome- shaped nodule
1 - 2.5 mm.
•Reach full size within 6
- 8 W,
involuted
spontaneously about
one year
•Increase incidence in
immunosuppressed
Raised smooth
edge and
umbilicated,
crusted center
lesion
•Histopathology
- Large center,
irregular shape
crater,keratin
- Lips or buttress
- Base : irregular
epidermal
LIP

CRATER
LIP
dome-or cup-
shaped
elevated wall
central keratin
mass
BASE
FIBROEPITHELIAL
POLYP
• Acochordon, squamous
papilloma, skin tag
• Common
• Middle age and old
• Neck, trunk, face,
intertriginous area
• Soft, flesh - colored, baglike,
•Histopathology
- Fibrovascular core
- Benign squamous
epithelium
KELOID / HYPERTROPHIC
SCAR

Initially have the same


clinical appearance, red,
raised, firm and posses
smooth, shiny surface
Hypertrophic scars
flatten spontaneously in
1 or several years,
keloids persist and may
even extend beyond the
site of original injury
- Usually follow an injury
- Occasionally, there is a
familial predilection for
keloid formation
- Keloids are much more
common in blacks than in
whites
Microscopic
- New collagen formation,
arrangement of newly
formed collagen
- Collagen bundles are
arranged in a whorl or
nodular pattern
- Collagen: thick, highly
compacted, hyalinized
bundles lying in a
concentric arrangement
Hypertrophic scars :- remain
within boundaries of the
wound, flat or slightly
elevated
Keloids :- extending beyond
the confines of the original
wound and usually
protruding prominently
above the skin

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