SKIN: TUMORS AND

TUMOR LIKE
CONDITIONS
TOPIC OUTLINE:
EPIDERMIS
SEBORRHEIC KERATOSIS
ACROCHORDON
SQUAMOUS CELL CARCINOMA
BASAL CELL CARCINOMA
OBJECTIVES:
To be familiar with some of the clinically
important epidermal, melanocytic and dermal
tumors
To differentiate SCCA from BCCA and its
variants
Understand the pathophysiology of each
tumors and correlate it clinically
Identify the treatment options and prognosis
SEBORRHEIC KERATOSIS
Benign
Pigmented
Basal keratinocytic proliferation
Trunk
Laser-Trelat sign
GROSS:
MICROSCOPIC:
PATTERNS
Acanthotic- most frequent, thick layers of
epidermal basal cells are seen interspersed with
pseudohorny cyst
Hyperkeratotic
Adenoid
Acantholytic
Desmoplastic – simulate invasive squamous cell
ca
Immunohistochem:
Keratinocytes
 express Low Molecular Weight Keratin
 Deficient in High Molecular Weight Keratin
Irritated seborrheic keratosis
Squamous metaplasia is pronounced
Misdiagnosed as basosquamous ca
NOT related to HPV
 INSTEAD, HPV CAN BE IDENTIFIED IN THE SEBORRHEIC
KERATOSIS-LIKE LESIONS OF PATIENTS WITH
EPIDERMODYSPLASIA VERRUCIFORMIS AND THOSE
EXHIBITING BOWENOID CHANGES
Malignant neoplasm (BCCa)
Contiguous or adjacent to the lesion
Treatment:
Superficial curettage
Freezing
ACROCHORDON
Fibroepithelial papilloma
Fibroepithelial polyp
Fibroma molle
Skin tag
GROSS:
MICROSCOPIC:
Acquired (digital) fibrokeratoma
Collagenous protrusions covered by
hyperkeratotic epidermis
Usually seen around interphalangeal joints
SQUAMOUS CELL CARCINOMA
(SCCA)
Actinic induced
Induction of p53 mutation by ultraviolet light
Sun exposure
Lack of pigmentation in the skin
Scca as a complication of the ff:

Xeroderma pigmentosa – diminished capacity for

DNA repair following ultraviolet radiation
 BCCA
 Malignant melanoma
Epidermoplasia verruciformis – generalized
virally induced dermatosis
Cutaneous scars from various type:
Marjolin’s ulcer (burn)
X-ray
Epidermolysis bullosa
Chronic osteomyelitic sinuses
Necrobiosis lipoidica
Hidradenitis suppurativa or acne aggregata seu
conglobata
Chemical exposure
Organ transplanttaion
PUV-treated psoriatic patients
HIV infection
Ichthyosis, epidermal nevus, porokeratosis
and congenital lympedema
SCCA
LPO
HPO
Invasion of the dermis is sine qua non for
diagnosis
Can be subjective
But of no great practical importance, since
treatment and prognosis is the same
Immunohistochem:
Express :
 High molecular weight keratin
 Involucrin
 Epithelial membrane antigen (EMA)
 CEA
 Vimentin (poorly differentiated tumor)

 Laminin and type IV collage – can be seen surrounding

tumor nests
Negative:
BerEP4
OTHER MICROSCOPIC TYPES
Spindle SCCA (metaplastic carcinoma)
Sun exposed area
Lips
Express vimentin
SPINDLE CELL SCCA
Adenoid (pseudoglandular; acantholytic)
SCCA
lack of cell cohesiveness caused by a
desmosomal defect (acantholysis)
Sun exposed
Immunohistochem:
 Reduction of cell adhesion molecule syndecan-1
ACANTHOLYTIC SCCA
Verrucous CA
Extremely well differentiated type
Carcinoma or epithelioma cuniculatum
Ulcerated, fungating and polypoid mass with
openings of sinus tracts onto the skin surface
TREATMENT SCCA
Complete excision
Alternative therapies:
Curettage and electrodessication
Cryotherapy
Radiation therapy
Prognosis:
Excellent (actinic induced tumor)
Best prognostic determinators are
 Staging
 Level of dermal invasion
 Vertical tumor thickness
BASAL CELL CARCINOMA (BCCA)
Most frequent form of skin cancer
Sun exposed skin in direct proportion to the
number of pilosebaceous unit present therein
May also developed in:
sunlight protected skin
Nevus sebaceous of jadassohn
Lower leg in asso w/chronic venous stasis
Arsenic ingestion
X-ray exposure
Skin injury
May also developed in:
Chicken pox scars
Tattoos
Hair transplantation scars
Immune suppression
Clinical appearance may be variable....
Nodular
Ulcerative
Superficial
Erythematous
Sclerosing (morphea like)
Basal cell nevus syndrome (Gorlin’s syndrome)
Multiple basal cell ca
Palmar pits
Calcification of dura
Keratinous cysts of the jaws
Skeletal animalies
Occasional abnormalities of the CNS, mesentery
and endocrine glands
PALMAR PITS
MULTIPLE BCCA
Suspect when:
BCCA are seen in young people
Multiple tumor
Superficial multicentric type
Osteoid is a occasional finding
MICROSCOPIC (BCCA)
Arise from:
Basally located cells of the epidermis and
pilosebaceous units
 DIFFERENTIATE INCOMPLETELY IN THE DIRECTION OF
ADNEXAL (PRIMARILY FOLLICULAR) STRUCTURES
 EPIDERMAL ATTACHMENT IS PRESENT
May have the ff patterns:
Solid
Cystic
Adenoid
Keratotic
Pigmented
Infiltrating
Sclerosing (morphea-like)
Characteristics:
Palisading
Surrounded by a typical loose stroma
Containing microblast
Mucinous change
Cleft like retraction spaces
Melanin can accumulate in the dermal
macrophages
May occur:
Mitotic activity
Marked atypia
Bizarre (monster) tumor cells
Giant cell formation
Histochemical/immunohistochem:
Positive:
Keratin (low molecular weight type)

BerEP4
Negative :
EMA
CEA
Involucrin
Molecular
Over expression of p53 protein
Bcl-2 (differentiate with actinic keratosis)
Genetic:
Clonal chromosome abberation (numerical
changes +18, +9, +20, +7 and +5
Loss of heterozygosity (9q22.3)
Trisomy 6
OTHER MICROSCOPIC TYPE
Superficial BCCA
Arises in thin epidermis (trunk), sparse, fine hairs
High recurrence
Basosquamous (metatypical) CA
Also contain atypical squamous cells
More aggressive than conventional BCCA
High proportion metastasize
Granular basal cell CA
Tumor cells with cytoplasmic granules
Clear cell basal cell ca
Prominent cytoplasmic vacuoles
Signet ring configuration
Fibroepithelial tumor / Pinkus’ tumor/
Fibroepithelioma
Polypoid variant
Occur at the back
Abundant stoma
Infundibulocytic basal cell ca
Hair follicle differentation
SPREAD AND METASTASIS
Grow in slow, indolent fashion
If untreated invade subcutaneous fat, skeletal
muscle and bone (“ulcus rodens”)
Tumor in the face may invade the skull, nares,
orbit, temporal bone
Distant metastasis is extraordinarily rare
Regional LN, lungs, bones and liver
Basosquamous type
Treatment :
Excision
Curretage and dessication
Irradiation
Recurrence :
Radiation therapy
Surgical re-excisison
Mohs’ surgery