Tumor Ganas Kulit

Aji Prima Putra (2006112029)

Preseptor : dr. Adi Rizka, Sp.B(K)Onk

Skin cancers are best divided into melanoma and nonmelanoma.
Melanoma
 Melanoma
• Melanoma is a cancerous growth of melanocytes.
• 1 out of 39 men and 1 out of 58 women will be
diagnosed with melanoma during their lifetime.
• Rising incidence is thought to be increasing sun
exposure, especially early in life
• Leading cause of death 1 to 2% of all cancer death
• Largely a disease of whites, low incidence in asian
• 5-10 % of melanoma are familiar. (p16/CDKN2A )
 Melanoma arises from the melanocyte, a neural crest–
derived cell that migrates during embryogenesis predominantly
to the basal layer of the epidermal skin and less commonly to
the other tissues in the body such as mucosa of the upper
aerodigestive and the lower genitourinary tract, the meninges,
and the ocular choroid, where melanoma is rarely encountered.
 Typical tumour progression
• Benign naevus (typical mole) • Vertical growth phase 
– controlled proliferation of – malignant cells invade
melanocytes the basement membrane and
• Dysplastic naevus (atypical mole) proliferate vertically downwards
– abnormal proliferation of into the dermis.
melanocytes resulting in a pre- • Metastasis 
malignant lesion with atypical – malignant cells may spread to
cellular structure. other areas of body. Typically
• Radial growth phase  they travel to regional lymph
– melanomas tend to extend nodes first; but they may
superficially and outwards spead to other areas of the skin /
initially. Melanocytes acquire the soft tissue, or to solid organs
ability to proliferate horizontally (such as the lungs, liver, bone
in the epidermis, but few cells or brain).
invade the papillary dermis.
Clinical Features of Cutaneous Melanoma
(ABCDE)
• Maybe painless or itching and discomfort
• Rarely (<1 %) lack pigment
• In melanoma in situ, the transformed
melanocyte is restricted to the epidermal
layer of skin.
• Invasive melanoma is defined by its invasion
of the dermis quantified by Clark and Breslow.
 Cutaneous melanoma subtypes
SUPERFICIAL SPREADING MELANOMA
• Incidence: Accounts for 70% of all
melanomas, tends to occur in younger
patients (median age, 50)
• Anatomic site: Any; predominantly
trunk and extremities, anatomic sites
associated with intermittent sun
exposure
• Clinical appearance: Change in the
appearance of a large mole, asymmetry,
irregular border, variegated color
(brown, black, pink, white, gray, and
blue), often arising in a precursor mole
• Can be associated with mutation in
BRAF
 Cutaneous melanoma subtypes
NODULAR MELANOMA

• Incidence: Accounts for 15% of

melanomas
• Anatomic site: Any
• Clinical appearance: Rapidly
enlarging, elevated, or polypoid
lesion; often arising in normal skin;
often blue, black, or pink and can be
amelanotic
 Cutaneous melanoma subtypes

LENTIGO MALIGNA MELANOMA

• Incidence: Accounts for 4% to 10% of all
melanoma; tends to occur more
commonly in older patients
• Anatomic site: Areas with chronic
exposure to the sun, head and neck
regions, and distal extremities
• Clinical appearance: Macular (flat)
lesion; arising in a lentigo maligna,
which often appears as a flat, light
brown skin lesion
• Can be associated with mutation in KIT
 Cutaneous melanoma subtypes
ACRAL LENTIGINOUS MELANOMA
• Incidence: 5%–10%
• Anatomic site: Most commonly
on the palms or soles or
subungual (under the nail bed)
• Clinical appearance: Darkly
pigmented, flat to nodular
lesion, highly irregular borders
• Can be associated with
mutation in KIT
 BIOPSI
• A biopsy should be performed on any skin lesion suspected to
be melanoma.
• Adequate biopsy specimens are essential for the diagnosis of
the primary melanoma in order to assess key microscopic
features: Breslow depth or thickness, mitotic rate, and
presence or absence of ulceration.
• Excision of the entire lesion is preferred; partial biopsies
increase the risks of both misdiagnosis (false negative or false
positive) and microstaging inaccuracy (either the biopsy
transects the base of the melanoma or fails to sample the
deepest portion of the melanoma).
 Breslow Thickness
• Breslow used an ocular micrometer to measure the vertical
depth of penetration of tumor from the granular layer of the
epidermis or from the base of the ulcerated melanoma to the
deepest identifiable contiguous melanoma cell.
 Increasing thickness is associated with a higher risk
of recurrence of melanoma and therefore death. In
addition, the thicker the primary melanoma, the more
likely that there is microscopic involvement of regional
lymph nodes.
AJCC STAGING (2018)
 Wide local excision (WLE)
WLE represents the standard treatment for primary
melanoma. Involves removal of the biopsy scar with a
surrounding margin of ‘healthy’ skin, with fat, down to muscular
fascia. This margin is determined by the Breslow thickness.
Basal Cell Carcinoma
 BCC (Basal Cell Carcinoma)

• Basal-cell carcinoma (BCC) is a slow-growing, locally

invasive, malignant epidermal (basal layer) skin
tumour.
• Accounts for apporcimately 80% of all skin cancer.
• BCCs are locally destructive and rarely metastasize
• The presence of an irregular pink / skin-coloured
lesion; commonly on the face or neck.
 BCC (Basal Cell Carcinoma)
• Etiologi
– UVR expossure
– Severe sunburn during childhood and adolescence
• Risk factor
– Fitzpatrick skin types 1 and 2
– Red hair
– Freckling in childhood
– Family history of skin cancer
– Male sex
– Celtic ancestry
RISK FACTORS
Clinical Features
 Nodular BCC
• Nodular BCCs comprise about 60-80%
of cases and occur most commonly
on the head.
• Nodular BCCs are red / flesh-coloured
and have well-defined borders with
overlying telangiectasias. As they
grow, they may develop central
ulceration (Rodent ulcer).
• They commonly arise on the face,
particularly on the forehead, temples,
nose and upper lip. However, they
rarely develop on mucosal surfaces.
 Superficial BCC
• Superficial BCCs present as an
erythematous plaque, most
commonly on the trunk and limbs.
• Superfical BCCs present as slow-
growing erythematous plaques that
may be dry or crusted or have a slight
bluish tinge. They represent
approximately 10-30% of BCCs and
are often difficult to distinguish from
dermatitis or SCC. Occasionally,
nodular BCCs can emerge within
these lesions.  
• Numerous superficial BCCs may be
indictive of arsenic exposure.
 Morphoeic (Infiltrative) BCC
• Morphoeic BCCs present as a scar-like lesion or indentation; they commonly
occur on the upper trunk or face.
• Morphoeic BCCs are typically difficult to distinguish. They present as a whitish,
compact, poorly-defined plaque or scar. They are often deeply invasive.
 Pigmented BCC
• Pigmented BCCs may be difficult to distinguish from melanoma.
• These represent approximately 5% of BCCs. Pigmentation is caused by
melanin production, hence why these lesions are often mistaken for
melaonomas. In clinical practice, these lesions are often excised with a
narrow (2mm) margin in the same manner as any pigmented lesion
suspicous of melanoma.
 Basosquamous
• A rare, but aggressive form of BCC with increased risk of recurrance and even
metastasis.
• A contraversial sub-type. Essentially a BCC with differentiation towards SCC.
Hence, why it possesses macro- and histopathological features of both. A
potentially aggressive skin cancer with metastatic potential.
 high-risk BCC
• Size > 2 cm
• Site (around eyes, nose, lips and ears)
• Poorly-defined margins
• Histological sub-type (morpoeic, infiltrative,
micronodular, basosquamous)
• Histological features (e.g. perineural / perivascular
invasion)
• Previous treatment failure
• Immunosuppression
Management may be surgical or non-surgical and based upon a clinical-suspicion
(e.g. what the lesion looks like) or upon a biopsy result (tissue diagnosis).
• treatments that do not permit histological confirmation (tissue
diagnosis) are only used for LOW RISK lesions.

• Lesions should be excised down to subcutaneous fat to ensure

that the entirely of skin (epidermis and dermis) has been
included in the excision sample.
– Low-risk lesions (small <2 cm, well-defined) - 4-5 mm margin
provides 95% clearance.
– High-risk lesions (large >2cm, poorly-defined) - 5 mm margin
provides 82% clearance; consider referral for Moh’s Surgery.
– Recurrent lesions - referral to Skin MDT; re-excision of scar (5-10 mm
margins) or Moh’s Surgery +/- Radiotherapy.
Squamous cell carcinoma
 Squamous cell carcinoma (SCC)

• SCC is a malignant tumor of keratinocytes of the skin or

mucosal surfaces.
• SCC has greater metastatic potential than BCC and causes the
majority of NMSC deaths.
• SCC occurs more than BCC in African Americans and Asians.
• SCC and BCC share many common risk factors, the most
important being solar radiation. The incidence of SCC is
increasing, especially on the head and neck area as a result of
exposure to sunlight.
 Carcinogen –
DNA damage

Failed DNA
RISK FACTORS DNA Repair
repair

Multistage
Cell apoptosis
Process

Ceratinocytes
DNA Mutation

Increase
proliferation
RISK FACTORS
 Clinical Manifestation
• Usually appears on areas of skin that are heavily damaged by
sun exposure. The most common sites include the head or
neck, back, forearms, and dorsum of the hand.
• The color varies from flesh toned to erythematous with
variable degrees of scale, crusting, ulceration, and
hyperkeratosis.
• They can present as nodular lesions or plaques, with differing
degrees of keratinization, which can be in the form of a keratin
horn or plug.
• SCCs also present as ulcers, or arise from chronic wounds, such
as burn scars, benign ulcers and sinus tracts (Marjolin’s ulcer).
 Management

Surgical Non Surgical

• Excisional
• Radiotherapy
• Moh’s Surgery
• Topical
• Curettage
chemotherapy
• Electrodessication
• Photodynamic
• Cryosurgery
therapy (PDT)
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