Common Skin and soft tissue tumors Dr.

Muhammed naeem

Learning objectives :
1- Identifying the common Benign skin and soft tissue lesions
2- Identifying the common premalgnant skin lesions
3-Classification and guidelines of management of common
malignant skin tumors

Common Benign skin and soft tissue lesions:

Cysts:
a) Epidermal Cyst (or Sebaceous Cyst):
 May be incorrectly called a sebaceous cyst caused by trapping of a segment
of epidermis within the dermis due to trauma.
 They can occur at any age and virtually any body location. Most commonly,
they occur in areas of increased pilosebaceous activity on the head and upper
trunk.
 Clinical presentation: Fluctuant, flesh-colored, well-circumscribed nodules .
Punctum may be visible. Contains foul-smelling keratinous debris .
 epidermal cysts are lined by true epidermis that forms a granular layer and
keratin.
 Gorlin and Gardner syndrome may be associated with epidermal cysts.
 Treatment: Simple excision if uninfected; If infected, a course of antibiotics
is recommended in an effort to prevent rupture and drainage so that excision
can be accomplished.

punctum
b) Dermoid cyst:
 appears at birth or early childhood.
  Dermoid cysts are subcutaneous cysts that form along lines of embryologic
effusion.
 Clinical presentation: Similar to epidermal inclusion cysts.
 Dermoid cysts are lined by epidermis and epidermal appendages. Usually the
appendages are fully matured and contain hair follicles, sebaceous glands,
eccrinc glands, and infrequently apocrine glands
 Anatomic location: Most commonly found along supraorbital ridge,
lateral brow, or nasal midline( require preoperative CT scan to exclude
an intracranial extension) and occasionally on the neck. Dermoid cysts on
the head may be attached to the periosteum..
 Treatment: Excision.

Lipomas:
Soft tissue
 is the most common tumor in man.
 Lipoma is a dermal or subcutaneous collection of benign adipose tissue.
 Most lesion are solitary , asymptomatic and occur commonly in trunk and extremities.
 Dercum syndrome: is a rare condition characterized by multiple, painful lipomas. These
lipomas mainly occur on the trunk, the upper arms and upper legs.
 Treatment: usually removed for cosmetic reasons or on occasion pain, as a result of a
neural or vascular component {angiolipoma) or when they compress an adjacent nerve.( mostly in the extremities)
Large lipomas (>10cm) as well as deep-seated one (intramuscular ), should arouse the
suspicion of malignant change. The most frequent malignant counterpart is the
liposarcoma.
 lipoma

Pyogenic Granulomas:
 Pyogenic granulomas are shiny nodules of proliferative vascular tissue covered by a
fragile epidermal layer.
 Commonly occurring in children and in pregnant women, they can occur at any age and
may be the result of minor trauma.
 Treatment options include curettage and surgical excision.

Neurofibromas:
 benign nerve sheath tumors that may arise anywhere along a nerve sheath from the dorsal
root ganglion to the terminal nerve branches.
 Neurofibromas occur in five main types: localized cutaneous neurofibromas, diffuse
cutaneous neurofibromas, localized intraneural neurofibromas, massive soft tissue
neurofibroma and plexiform neurofibromas.
 occur as solitary lesions or as other evidence of the neurocutaneous syndrome(von
Recklinghausen, or as neurofibromatosis type I).
Neurofibromatosis-1(autosomal dominant):
Diagnostic criteria are met in an individual if two or moxe of the following are
found:
 Cafe-au-lait spots (Six or more over 5 mm in greatest dimmsion in prepubertal
individuals and over 15 mm in postpubertal individuals)
 Two or more neurofibromas of any type or one plexiform neurofibroma
 Freckling in the axillary or inguinal region
  Optic glioma
 Two or more Lisch nodules (hamartomas of the iris)
 A distinctive osseous lesion such as sphenoid wing dysplasia or thinning of long
boncortex with or without pseudoarthrosis
 A first-degree relative (parent, sibling, or offspring) with NFl by the above criteria.

 Malignant degeneration occurring in up to 13% of patients with NF1.

 Surgical resection remains the mainstay of treatment for enlarging or symptomatic
tumors

Premalignant Lesions
Actinic Keratosis. most common premalignant skin conditions. Caused by sun exposure in
people with Fair skin . it occasionally evolve into squamous cell cancers .

Leukoplakia: is white intraoral plaque and is the most common precancerous lesion of the oral
cavity.
Cutaneous Horn: yellowish brown protuberant "horns" and are found on the face and ears.
Bowen's Disease: is squamous carcinoma in situ of the skin. This tumor presents as a slowly
growing, red lesion with a scaly surface and irregular borders.
 Erythroplasia of Queyrat: Bowen’s disease of the glans penis, vulva.

Keratoacanthoma: is a rapidly growing nodule (over weeks to months) with a central

ulceration or keratin plug that is found mainly in sun-exposed skin . Left untreated, it may
spontaneously involute. Keratoacanthoma is felt to be a low-grade variant of cSCC. Surgical
excision is recommended.

Xeroderma pigmentosum (XP): This is an autosomal recessive disorder, characterized by

damage to DNA repair. These patients have extreme sun sensitivity and develop many cutaneous
malignancies. The lesions require surgical excision, but the outcome is usually poor.
Nevus sebaceus of Jadassohn: Present at birth on scalp or face. Well-circumscribed,
hairless, yellowish plaque that becomes verrucous and nodular at Puberty. 10%-15% malignant
degeneration to BCC.

Atypical Moles-Dysplastic Nevi. Dysplastic nevi are melanocytic nevi that have the clinical
features of melanoma: asymmetry, border irregularity, color variability, and diameter greater
than 6 mm . When patients present with many atypical moles, they are at higher risk for
melanoma.

Congenital melanocytic neavus ( giant hairy neavus ) : hairy dark patch,

When small : has very low risk ( < 1% ) for transformation to melanoma
When large : risk for transformation doesn’t exceed 5%
Treatment includes with 1- surgical excision with skin graft for cosmetic
2- tissue expansion
 Common Malignant Skin Tumors
i. Basal Cell Carcinoma (BCC)
• BCC is the most common form of skin cancer.
 It is 4-5 times more common than squamous cell carcinoma (SCC).
‫كلش مهمة ال‬
Risk Factors
risk factors
 Fitzpatrick skin type I,II,III
 Sun exposure
 Advancing age
 Immunosuppression: AIDS, organ transplant medications
 Carcinogen exposure: UV and ionizing radiation, arsenic, hydrocarbons.
 Genetic mutations:
o Albinism:
o Nevoid basal cell syndrome (Gorlin’s syndrome)
o Xeroderma pigmentosum (XP)
 Premalignant lesions :Nevus sebaceous of Jadassohn.

Biology: Tumors originate from the pluripotential epithelial cells of epidermis and hair
follicles (basal keratinocytes) at the dermoepidermal junction.

Metastasis: is rare, with less than 0.05%.

 Types of BCC Slow growing
Nodular BCC
 Nodular: Most common characterized by well-defined borders, flesh-colored, 1- Nodular
pearly nodule with overlying telangiectasias. May be ulcerated: Central ulcer 2- nodulocystic
surrounded by rolled border --rodent ulcer 3- noduloulcerative
( rodent ulcer )
 Superficial spreading: second most common type. Located in epidermis, no
dermal invasion .Flat, pink, scaly patches with ulcerations and crusting, usually
multiple, on trunk.
 Micronodular: Small rounded nodules of tumor the size of hair bulbs
 Infiltrative: Opaque yellow-white color, blends with surrounding skin
 Pigmented: Pigmentation from melanin . Often confused with melanoma
 Morpheaform (sclerosing or fibrosing): most aggressive appear as enlarging
scar” without history of trauma . Rarely ulcerates. High incidence of positive
margins after excision
Diagnosis: Tissue biopsy definitively establishes the diagnosis and characterizes the histologic
subtype. Additional workup is generally not required. Staging of BCC is rarely performed due to
the very low frequency of spread to lymph nodes or distant sites.

Treatment: Treatment modalities include medical, destructive, and surgical excision.

A. Medical:
a. Imiquimod 5% (Aldara) or 5-fluorouracil : Topical cream effective for
multiple, low-risk superficial BCC and SCC in situ
b. Radiotherapy (RT): reserved for ages 60 years
B. Destructive Usually not recommended
1. Curettage and electrodesiccation (C&E)
2. Cryosurgery: Cooling tumor cells to - 40° C during repetitive freeze-thaw cycles
destroys malignant tissue.
3. Laser phototherapy (CO2 laser) ‫يجي امسيكيو‬
C. Surgical excision: Primary surgical excision: for tumors <1 cm a clinical margin of 4
to 5 mm, and for tumors > 1 cm a clinical margin of 5to 10 mm is recommended
 ii. Cuetaneous squamous cell
carcinoma
SCC is second most common skin cancer after BCC.
Common on face, hands, forearms.
risk ‫ال‬
‫ مهمة‬factors Risk Factors
 Fitzpatrick skin type: Types I and II have increased risk
 Sun exposure: Cumulative exposure strongly correlated to SCC
 Carcinogen exposure: Arsenic, organic hydrocarbons
 Viral infection: HPV and herpes simplex
 Radiation: Long-term latency between exposure and disease
 Immunosuppression:
 Chronic wound caused by thermal burn, osteomyelitis
 Psoralen and ultraviolet A light (PUVA) for psoriasis treatment
 Premalignant lesions4
• Actinic keratosis/solar keratosis
• Bowen’s disease
• Leukoplakia
• Keratoacanthoma

Biology: SCC originate in the stratum spinosum of the epidermis .

Metastasis: Rate of regional metastasis ranges from 0.5% to 10%.
 Types of SCC:
 Verrucous: Exophytic and slow growing. Common on palms and soles. Less
likely to metastasize

 Ulcerative: Aggressive with raised borders and central ulceration (EVERTED

edge) . Commonly metastasizes to regional lymph nodes
  Marjolin’s ulcer: Typically arise in chronic wounds (burn scars, fistulas).
Metastasis to lymph nodes is common.
 Subungual: Squamous changes involving the nail bed.

 Diagnosis of cSCC is made by tissue biopsy. Palpable nodes should be biopsied by fine
needle aspiration. Routine imaging study for cSCC is not indicated, but should be
obtamed m patients that exhibit specific neurological symptoms or regional
lymphadenopathy.

Treatment
Biopsies of suspicious lesions are essential. Treatment modalities include medical,
destructive, and surgical excision.
I. Medical
 Radiation:
 Oral medications ( Retinoids) have been effective in decreasing the development of
precancers and skin cancers
 Topical : 5-FU excellent for treating premalignant lesions (e.g., actinic keratosis)
 Chemotherapy: Usually reserved for adjuvant therapy with large tumors, recurrent or
metastatic disease.
Cisplatin with or without 5-FU produces limited results.
II. Destructive Usually not recommended
• Curettage and electrodesiccation
cryosurgery:
III. Surgical
• Excision: the recommended surgical margin for low-risk lesions is 4 mm, and for high-
risk lesions it is 6 to 10 mm
Lymphadenectomy: This is indicated for clinically palpable nodes.
 iii. Malignant Melanoma
Risk factors for melanoma can be divided into:
i. host factors :
 Fitzpatrick I-ll skin types, and blue/green eye
 Predisposing conditions (congenital giant nevi ,atypical nevi)
 personal history of melanoma
 familial melanoma accounts for approximately 10% of all cases
 Age: 50% occur in patients older than 50 years

ii. environmental factors.:

 sun exposure, particularly intermittent and intense exposure. UV A and UVB exposure
are both strongly associated with melanoma.

TYPES:
 Superficial spreading melanoma: Most common: 50%-70%.
 Nodular melanoma: 15%-30% of all cases. Aggressive,
 Lentigo maligna: Least aggressive subtype, More common in women
 Acral-lentiginous melanoma: Usually on palms, soles of feet, subungual, Has poor prognosis
 Desmoplastic melanoma: 1% of all cases, Propensity for perineural invasion
 Amelanotic melanoma: No pigment by light microscopy.
‫مهمة‬ Common clinical features of melanoma lesions: (ABCDE)
1. Asymmetry
2. Border irregularity
3. Color variation
4. Diameter >6 mm
5. Enlarging/evolving lesion
 Diagnosis of primary melanoma is made by histologic analysis of full-thickness biopsy
specimens
1. Excisional biopsy is preferred for lesions <1.5 cm in diameter.
2. Incisional biopsy is appropriate when suspicion is low, the lesion is large (>1.5 cm) or is
located in a potentially disfiguring area (face, hands, and feet),
 Avoid shave biopsies

Major prognostic factors: Tumor thickness, Nodal status, and Metastases—TNM

a) Tumor thickness: ( tumor depth ( thickness) is the most important prognostic factor )
1. Breslow thickness is the distance between the granular layer of the epidermis and the
deepest part of the melanoma and reported in millimeters. Breslow scale reports depth in millimetres using a
device called micrometer ‫فال تخربطون بني االثنني‬

2. Clark level is based on invasion through the histologic layers of the skin.
Level I: tumour confined to the epidermis.
Level II: tumour extending into the papillary dermis.
Level III: tumour extending to the junction between the papillary and reticular dermis.
Level IV: tumour extending into the reticular dermis.
Level V: tumour extending into subcutaneous fat.
b) Nodal status: Micrometastases are diagnosed after sentinel lymph node biopsy
Macrometastases are defined as clinically detectable nodal metastases.
c) Metastases: defined by
Site of distant metastasis(lung, liver,…) and elevation of serum LDH.
Intransit metastases are located in the subcutaneous tissue between the primary
lesion and the regional lymph node basin.
Satellite lesions are metastases within the skin.

Other significant prognostic factors

1. Anatomic location: Trunk scalp, mucosa and perineum lesions generally carry worse
prognosis than those on the extremities.
2. Sex: For a given melanoma, women generally have a better prognosis;
3. Ulceration is a poor prognostic sign
4. Tumor type: Acral lentiginous melanoma has poor prognosis

Surgical Management:
1. Wide and Deep Excision: surgical margins are largely based on the thickness of the
primary lesion(Breslow thickness).

TUMOR THICKNESS EXCISION MARGIN

In situ 0.5 cm
Less than 1.0 mm. 1 cm
1.0 to 4.0 mm 2 cm
Greater than 4.0 mm 2-3cm
2. Lymph nodes:
1. Sentinel lymph node biopsy (SLNB): Staging procedure, not a therapeutic
treatment.
2. Therapeutic lymph node dissection (LND): Performed for positive SLNB patients
or clinically palpable disease.