handout skin diseases: an integrated clinicopathologic approach- med 1 dr. m. g. joseph, professor...
TRANSCRIPT
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Handout
SKIN DISEASES: An Integrated Clinicopathologic
Approach- Med 1
Dr. M. G. Joseph, Professor
Dept. of Pathology, LHSC
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Specific Objectives
• Recognize common skin tumours, basics. An integrated clinicopathologic approach
• Summarize important points learned from previous and upcoming clinical
lectures…where to focus (few clinical images from previous lectures are used to re-emphasize concepts)
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Dermatology Mini Atlas WebCT
For Self Study/ Practice Review
• Important for end of the course Image Quiz examination
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Skin Tumours Basics
Behaviour • Benign Tumour • Malignant Tumour
Histogenesis (origin) • Epidermal • Dermal • Adnexal
Primary vs metastatic tumour
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SKIN TUMOURS (Histogenesis)
• Epidermis - Squamous cells - Basal cells - Melanocytes
• Adnexal tumours • Dermal (Mesenchymal)
- Collagen - Smooth muscle - Blood vessel - Nerve
• Lymphoma/leukemia
• Metastatic tumours
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How to Describe a Lesion SCALDA for Tumours
• Size
• Color
• Arrangement (configuration)
• Lesion morphology
• Distribution
• Always check hair, nail, mucosa, intertriginous areas
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Skin Cancer Basics
• Skin cancer is the most common form of cancer in human.
• It is estimated that approximately 75,000 canadians will develop skin cancer every year
• 3 histologic types account for about 99% of all skincancers.- Basal cell ca, Squamous cell ca, Melanoma
• All are caused by chronic sun exposure - Cumulative amount important for squamous cell ca - Intermittency and amount of exposure important
for basal cell ca and melanoma
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Skin Cancer, Common Types
• Basal cell carcinoma - Most common type of skin cancer, 80% of all cancers, sun damaged skin, elderly
- Several subtypes of BCC, nodular most common
- Slow growing, locally invasive, do not metastasize
- Histology- malignant proliferation of basaloid cells of epidermis
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Basal cell carcinoma 2 Common subtypes
Nodular UlceronodularA well circumscribedPearly white/pink nodule Ulcerated nodule
with surface telengiectasia with rolled edges
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Nodular Basal Cell Carcinoma
A well circumscribed nodule, origin from basal cells of epidermis and infiltration into dermis
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Basal cell carcinoma
B
C
A
Nests of basaloid cells (A), peripheral palisading of nuclei (B), loose fibrous stroma (C)
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Multiple BCCs in a young patient
Gorlin Syndrome
Multiple BCCs Young patient Back
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Look for …….. Palmar pits Bifid ribs
From: Gorlin, 2004.
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Nevoid BCC (Gorlin Syndrome)
• Autosomal dominant, 0.4% of all BCC cases
• Most cases reflect mutation in the patched gene (PTCH) chromosome 9q22-q31 cause upregulated cell proliferation
• 2% of patients under age 45 years with BCC have NBCC syndrome
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Gorlin Syndrome
1. Predisposition to various tumours Odontogenic keratocysts Medulloblastoma brain Fibromas of ovary, heart
2. Other skin manifestations Palmar and plantar pits Multiple epidermal cysts
3. Cleft lip/ palate, macrocephaly
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Skin Cancer, Common Types
• Squamous cell carcinoma - Second most common cancer of skin - Sun damaged skin, elderly - Locally invasive, can metastasize (5-10%) - Histology: malignant proliferation of epidermal keratinocytes. - squamous cell carcinoma is of 2 types
• Insitu squamous ca (Bowen’s disease) • Invasive squamous ca
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Bowen’s disease - insitu SCC
Sharply demarcated red scaly patch
Proliferating malignant keratinocytes confined to epidermis Origin - epidermal squamous cells
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Invasive Squamous Cell Carcinoma
SCALDA skin colored indurated and ulcerated nodule on lip
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Invasive Squamous cell carcinoma
B
A
Origin- from squamous epithelium, invades into dermis Malignant squamous cells (A) invading dermis (B)
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Skin Cancer
• Malignant Melanoma – Malignant tumour of melanocytes
- Least common, most deadly type of skin cancer
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Common Benign/premalignant Tumours of skin
• Seborrheic keratosis
• Corn, Skin tag
• Wart, Molluscum contagiosum
• Solar keratosis (premalignant)
• Dermatofibroma
• Epidermal cyst, Pilar cyst
• Keratoacanthoma (benign vs malignant, contraversial)
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Seborrheic keratosis A common benign epidermal tumour
SCALDA
multiple brown scaly papules /plaques stuck on appearance on the trunk
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Seborrheic keratosis pigmented type
Single well circumscribed brown scaly papule/nodule, Stuck on (pigmented sebka)
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Skin tag, benign
Soft skin colored pedunculated papule/nodule
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Corn, benign: painless keratotic papule, clear core, central depression
Thick stratum corneum (hyperkeratosis)
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Wart: scaly verrucous flesh colored papule/nodule, red spots (arrow)
HPV Virus cause Hyperkeratosis, acanthosis, viral changes in cells (arrow) dilated vessels (red arrow)
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Molluscum Contagiosum
Multiple umbilicated skin coloured sma papules Pox virus- cause
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Actinic Keratosis (premalignant squamous lesion)
Multiple poorly demarcated reddish brown rough scaly papules and plaques on sun damaged skin
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Actinic Keratosis
Parakeratosis (arrow)
B
For information only
A Atypical keratinocytes (A) Sun damaged dermis (B)
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Keratoacanthoma (Benign ?)
1.5 cm well circumscribed skin colored nodule with central keratin filled Crater Rapid growth in few wks Spontaneous remission in few weeks
SCALDA
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Keratoacanthoma vs SQCC
Clinical similarity, excise completely
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Keratoacanthoma Squamous cell ca
Benign proliferation of Malignant proliferationkeratinocytes of keratinocytes
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2 common benign skin cysts basics
Epidermal cyst (most common, face, neck, trunk)
Pilar cyst (scalp)
Cyst: sac filled with fluid or semisolid material (fluctuant) and is lined by epithelium
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Epidermal cyst (most common benign skin cyst in dermis)
Slowly growing, painless, round, soft, mobile, fluctuant skin coloured nodules, may have a central punctum
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Inflammed epidermal cysts (painful)
Punctum
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Pilar cyst (second common skin cyst scalp)
Lining epithelium and keratin are different from epidermal cyst, clues for pathologist
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Common Benign Dermal Tumours - origin
Dermatofibroma - fibroblast
Lipoma - lipocytes (fat cells)
Hemangioma - blood vessel
Neurofibroma - nerve
Pyogenic granuloma -blood vessel
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This firm nodule is present for years. Dermatofibroma (benign
dermal tumour)
Tan firm papule, may be pigmented, dimple sign
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Firm well circumscribed brownish red nodule on le
Dermatofibroma
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Dermatofibroma (Dimple sign/ Fitzpatrick’s sign)
Benign proliferation of fibroblasts
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Hemangioma Benign vascular tumour, congenital or acquired, small or large, flat or elevated
Cherry red colour
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Pyogenic granuloma, benign (Lobular capillary hemangioma)
A pedunculated red nodule that bleeds, history of trauma
Vascular proliferation
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Melanocytic Tumours
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Melanocytic Neoplasia
• Benign nevus - lentigo simplex, junctional N, compound N, intradermal N
- Spitz N, Blue N, Halo N, Congenital N.
• Dysplastic nevus (atypical nevus)
• Malignant melanoma (insitu/invasive)
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Evolution of Benign Nevus
• Lentigo simplex
• Junctional nevus
• Compound
• Intradermal
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Nevus evolution
Junctional, Compound, Intradermal N
Lentigo simplex JN CN IDN
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Life cycle of nevus
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Compound nevus
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2 pigmented lesions present for the past 10 years. What are they?
Blue nevus Halo nevus
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Halo nevus (Regressing Nevus)
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This patient has dysplastic nevus syndrome
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Dysplastic nevus ABCD criteria
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Dysplastic Nevus- Clinical
• Large size (5mm-12mm.) - 72%
• Irregular
• Asymmetry
• Irregularity of colour-84%
• Presence of a central papule and peripheral macular component
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Dysplastic Nevus
• Dysplastic nevus syndrome: Affected people develop large number of dysplastic nevi and are associated with increased incidence of melanoma
• Isolated dysplastic nevi in patients without personal or family history of melanoma is main source of controversy, incidence 5-20%
For information only
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Dysplastic nevus
For information only This Nevus shows architectural and cytological atypia
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Dysplastic Nevi –Key Points
• Considered as a risk marker for melanoma, risk increases with number of nevi. • May be potentially a precursor for melanoma, dysplastic nevus present adjacent to an invasice melanoma in 36% of melanoma cases.
• Individual lesions, sig . unknown • Patients with many lesions should be periodically monitored
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Malignant melanoma, basics Objectives
• How to diagnose melanoma
• List 4 types of melanoma
• List 5 prognostic factors of melanoma
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How to Diagnose Melanoma (ABCDE check list)
• Asymmetry
• Border irregularity-notched border
• Color variegation-red, white, blue
• Diameter greater than 6mm
• Elevation/enlargement (recent)
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4 Types of Melanoma
• Lentigo maligna (insitu), lentigo maligna melanoma (invasive)
• Superficial spreading melanoma, in situ and invasive
• Acral lentiginous melanoma, in situ and invasive
• Nodular melanoma (always invasive)
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4 Types of Melanoma (important slide)
The most common form of melanoma: -in African-Americans is acral lentiginous Melanoma -associated with chronically sun-exposed skin is lentigo maligna melanoma
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1 Superficial spreading M, leg
2 Nodular M
Nodular melanoma, small3 Acral lentiginous M
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4. Lentigo maligna M face
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Normal to insitu melanoma evolution
Normal Pagetoid intraepidermal spread
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Invasive melanoma - invasion into dermis Breslow thickness- prognostic factor 1
Breslow thickness: measured from epidermal granular layer to deepest melanoma cell in dermis
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Clark level l – V - prognostic factor 2
I II
III
IV
V
I Confined to epidermis (in situ) II Invasion of papillary dermis III Fills the papillary dermis
IV Invasion of reticular dermis V Invasion of subcutaneous fat