MALIGNANT SKIN DISORDERS

I. Squamous Cell Carcinoma

II. Basal Cell Carcinoma
III. Melanoma
IV. Paget’s Disease

I. SQUAMOUS CELL CARCINOMA

• the __________ common form of skin cancer.
• Most cases of SCC of the skin are induced by _________________.
• Major Risk Factor: __________________________
o face, scalp, neck, dorsal hands are favored locations.
• Becomes relatively more common as the amount of UVR increases.
• Immunosuppression increases risk of development.
• Patients with epidermodysplasia verruciformis (EDV) also develop SCCs on sun-
exposed sites, associated with unique HPV types.
o These unique EDV HPV types (e.g., HPV-5, HPV-8) may also play a role in SCCs
that develop in immunosuppressed persons.

• Because the vast majority of cutaneous SCCs are induced by UVR, sun protection, with
avoidance of the midday sun, protective clothing, and the regular application of a
sunblock of SPF 30 or higher, is recommended. Some researchers have suggested that
smoking is also a risk factor for cutaneous SCC, but this is controversial.

Clinical features
• May occur on sun-exposed areas such as the face and backs of the hands.
• The lesion may be superficial, discrete, and hard and arises from an indurated,
rounded, elevated base.
• It is dull red and contains telangiectasias.
• In the course of a few months, the lesion becomes larger, deeply nodular, and
ulcerated.
• May be covered in _____.
• In the early phases, this tumor is localized, elevated, and freely mobile over underlying
structures; later it gradually becomes diffuse, more or less depressed, and fixed. The growth
eventually invades the underlying tissues.
• The surface in advanced lesions may be cauliflower-like, composed of densely packed,
filamentous projections, between which are clefts filled with a viscous, purulent,
malodorous exudate.
• Predisposing factors: ______, ________, _________.
• _____________ - A cutaneous malignancy setting of previously injured skin, longstanding
scars, and chronic wounds.
 Histopathology
• _______ nests, cords, or sheets of neoplastic keratinocytes invading the dermis to
various depths.
• Thickness is an important risk factor for metastasis, with thickness >2 mm associated
with a metastatic rate of 4% and >6 mm with a rate of 16%. Less than 5% of patients
with metastatic SCC had a primary cutaneous SCC <2 mm in thickness.

Management
• The primary treatment of SCC of the skin is surgical.
• Oral retinoids may be useful as a preventive strategy in patients with
immunosuppression who develop frequent cancers.
• PDT might be beneficial to reduce the number of SCCs occurring in areas of prior UV
damage where SCCs have already occurred, and pembrolizumab may have a role in
treating advanced disease.

II. BASAL CELL CARCINOMA

• Basal cell carcinoma (BCC) is the ________ common cancer in the United States,
Australia, New Zealand, and many other countries with a largely white, fair-skinned
population with moderate sun exposure.
• Main risk factor is ____________
• Intermittent intense sun exposure, as identified by prior sunburns; radiation therapy; a
positive family history of BCC; immunosuppression; a fair complexion, especially red
hair; easy sunburning (skin types I or II); and blistering sunburns in childhood are risk
factors for the development of BCC.
• Slow growing and tends to be more ulcerative.
• Lesions tend to bleed without pain.
• Metastasis is ___________, occurring in 0.0028%–0.55% of BCCs
Types:
• Morpheaform, or Cicatricial BCC
• Infiltrative BCC
• Micronodular BCC
• Superficial BCC
• Pigmented BCC
• Rodent Ulcer
• Fibroepithelioma of Pinkus
• Polypoid BCC
• Porelike BCC
• Aberrant BCC
• Solitary Basal Cell Carcinoma in Young Persons
 Etiology
• BCCs arise from immature pluripotential cells associated with the hair follicle.
Mutations that activate the hedgehog signaling pathway, which controls cell growth,
are found in most BCCs.

• The affected genes are those for sonic hedgehog, patched 1, and smoothened (SMO).
Inactivation of patched 1 is most common, and SMO mutations are associated with
10%–20% of sporadic BCCs.

Histopathology
• The basaloid epithelium typically forms a palisade with a cleft forming from the
adjacent tumour stroma. Centrally the nuclei become crowded with scattered mitotic
figures and necrotic bodies evident.

Management
• Strict sun avoidance and maximum sun protection
• Topical Tazarotene and Imiquimod for superficial tumors.
• Oral retinoids may slow progression.
• Surgery
o Curettage and desiccation
o Excision
o MOHs Micrographic surgery

III. MELANOMA
• Asymmetry
• Borders (irregular)
• Color (variegated),
• Diameter (greater than 6 mm)
• Evolving over time

• Tumors that arise from the ___________________________

• Melanoma characteristically metastasizes quite often, and can travel to most other
tissues in the body. This metastasis confers a _______ prognosis in patients, with a
median life span of 6 to 8 months after diagnosis.
• Incidence is increased in ______ skinned people.
• Not usually encountered in the darker races, and _______ lesions account for a greater
share of melanomas in dark-skinned individuals.
• Lowest incidence in Asians.
• The most important risk factor for the development of melanoma is
__________________________.
Types:
• Lentigo Maligna (Lentiginous Melanoma on Sun-Damaged Skin)
• Superficial Spreading Melanoma
• Acral-Lentiginous Melanoma
• Mucosal Melanoma
• Nodular Melanoma
• Polypoid Melanoma
• Desmoplastic Melanoma
• Amelanotic Melanoma
• Soft Tissue Melanoma and Clear Cell Sarcoma

Management:
• Wider excision of the scar or tumor.
• Depending on the stage, a sentinel lymph node biopsy is done.
• Adjuvant treatment
• Chemotherapy and immunotherapy
• Prevention: _______________________

IV. Paget’s Disease (PD)

Types:
1. Paget’s Disease of the breast
2. Extramammary Paget’s disease

• Paget disease (PD) of the nipple affects women primarily (there are very rare male cases).
• Between _____ to ______ of breast carcinomas present with PD
• Characterized by a unilateral, __________, erythematous, and at times crusted patch or plaque
affecting the nipple and occasionally the areola.
• About 5% of patients have PD without confirmed evidence of underlying carcinoma, and the
remaining 95% have either an invasive or an intraductal carcinoma in proportions of 35%–65%,
depending on the reporting center. In rare cases, even when no underlying carcinoma is found
on surgical removal, the sentinel node may be positive.
• The presence of unilateral eczema of the nipple recalcitrant to simple treatment should lead
to suspicion of PD, and the lesion should be biopsied.
• Paget’s disease usually is associated with extensive DCIS and may be associated with an
invasive cancer.
Histopathology
• A nipple biopsy specimen will show a population of cells that are identical to the underlying
DCIS cells (pagetoid features or pagetoid change). Pathognomonic of this cancer is the
presence of large, pale, vacuolated cells (Paget cells) in the rete pegs of the epithelium.

Paget disease without palpable mass and negative mammogram:

• Consideration of wide excision of nipple with radiation
• Mastectomy is also an option
Paget disease with palpable mass or abnormal mammogram findings:
• Mastectomy
• Breast conservation surgery and whole breast radiation
• Presence of underlying in situ or invasive carcinoma in mastectomy specimen of majority of
patients.
• Evaluation of axilla is the same for other breast cancers and depends on underlying type.