Identifying skin neoplasms benign vs malignancy YiSheng Kam

Identifying skin neoplasms benign vs. malignancy Yi-Sheng Kam, D. O. CPT MC USA Dept. of Family Medicine Eisenhower Army Medical Center

Introduction �Skin is largest organ system �Skin condition is one of the common complaint to office visit �Understanding from benign to malignant lesion �Incidence of skin cancer is increasing �Lack of evidence to support mass screening

History/questions �Important question to ask for a new rash/lesion �How long? �Onset, and how is it now different? �Where? Site of onset and where is it now/evolution? �What treatments, and how did it response, this time and previously? �Symptoms with the lesion, such as itching or pain? �Anyone else affected or have a similar history? �Previous rash/lesion and treatment? �Anything new or different with medications, exposures, travel, heat, cold, stress, occupational/recreational or personal care products? �ROS if indicate for systemic disease

Describing primary lesions � Macula � Flat, non-palpable e. g Mongolian spots � Papule � Superficial, palpable, solid and less than 0. 5 cm diameter � Plaques � Plateau like elevation above skin surface occupying large surface, e. g psoriasis � Wheal (urticaria) � Round or flat topped, pale red papule or plaque, change in shape, disappear in 24 -48 hrs � Nodules and tumors � Palpable, solid, round or ellipsoidal and can involve anywhere of skin (epi/dermis and subcutaneous tissue) � Pustules � Circumscribed, superficial cavity that contains a purulent exudate � Vesicles (<0. 5 cm) and bulla (>0. 5 cm) � Circumscribed, elevated, superficial cavity containing fluid � Erosions and ulcers � Ulcer is a skin defect, loss of epidermis and upper papillary layer of the dermis � Erosion only involves epidermis

PHYSICAL EXAMINATION �The most important and useful characteristics on an exam is the type of lesion and distribution of lesions �Type � Flat, elevated or depressed � Color and blanching � Consistency/palpation (soft, firm, hard, fluctuant, hot, cold, mobility, tenderness, depth of lesion) �Distribution � Extent: isolated, localized, regional, generalized, universal � Pattern: symmetrical, exposed areas, sites of pressure, intertriginous area �Shape (round, oval, polygonal, polycyclic, annular, serpiginous, umbilicated) �Arrangement of multiple lesions � � Group: Herpetiform, zosteriform, arciform, annular, reticulated, linear, serpiginous Disseminated: Scattered discrete lesions or diffuse

PHYSICAL EXAMINATION �ABCDE rule �A asymmetry �B border �C for color �D for diameter (size of a pencil eraser) �E for elevation �Changes; bleeds, fast growing, scaly or crusted growth, sore that won’t heal, itches

Basal Cell Carcinoma �Basal cell carcinoma �Most common skin neoplasm and low metastatic potential, �Usually located on the face or the backs of the hands �Risk factors includes sun, Caucasians �Six types � Nodular (most common), pigmented, cystic, sclerosing, superficial and nevoid �Low risk if it is less than 1. 5 cm in diameter �Prevention � Avoid sun exposure/burn, use sunscreen �Treatment-almost all curable � Surgical, cryotherapy, curettage, laser, referral

Actinic keratosis �Actinic keratosis (solar keratoses) �Premalignant lesions arising from chronic sun-damaged areas (scalp, face, ears, bald scalp, fair skin) �Most does not progress to squamous cell carcinoma (SCC), 1/1000 but 60% of SCC are from actinic keratosis �Irregular, usually 2 -5 mm, scaly, flesh color to dark brown, macular or large hyperkeratotic or papule, often multiple lesion �Prevention � Avoid sun exposure/burn, use sunscreen �Treatment-curable � Surgical, liquid nitrogen, topical 5 fluorouracil or imiquimod

Squamous Cell Carcinoma �Squamous cell carcinoma (SCC) � Second most common skin cancer � Most common elderly, increase in light skinned, family history � Common on sun expose area � Up to 60% occurs at site of actinic keratosis � Chronic immunosuppression increases SCC (lesser extent BCC), other risk includes chronic inflammation or arsenic exposure � Moderate rapidly growing, nodular or papular, scaling, reddishbrown, pink or flesh colored, plaque, erythematous or eroded � Prevention � Avoid sun exposure/burn, use sunscreen � Treatment-almost all curable � Surgical and referral

Malignant Melanoma �Most serious form of skin cancer � 6 most common cancer in the United States �Prognosis depends on depth of the primary tumor, anatomic location, and presence and extent of metastatic disease �Radial growth phase � Primarily confined to the epidermis and divides into two � Malignant melanoma in situ (MMIS) is proliferation restricted to the epidermis � Microinvasive extend to dermis �Vertical growth phase � Invasive, extending deeply into the dermis �Metastasizes first to the regional lymph nodes and then to secondary sites, most commonly skin, subcutaneous soft tissue and anywhere like lung or brain.

Malignant Melanoma � Four types � Superficial spreading � � Most common, may develop anywhere on the body but appears with increased frequency on the upper backs and legs. Associated with preexisting dysplastic nevus. � Irregular border � Ranging from a few millimeters to several centimeters � Nodular melanoma � Dark brown or reddish brown, dome-shaped, pedunculated or nodular lesion � Lentigo maligna melanoma � Horizontal or radial growth before vertical growth phase � Acral lentiginous melanoma (lease common) � Palmar and plantar , digits and the subungual areas , all ethnic groups � Appears as a dark brown to black, unevenly pigmented patch � Lesion becomes raised or develops ulceration likely invasion to deep tissues

Malignant Melanoma �Treatment: �Referral �Laser or other physical destruction should never be used �Excisional biopsy with a normal skin broader 1 to 2 mm �Follow in 3 months, 6 months then yearly

Screening yourself �Early detection, greater chance of cured �Self exam monthly �Examine entire skin surface from head to soles and palms with full length mirror and held mirror

UV expsoure �UV light exposure result in DNA damage, particular p 53 tumor suppressor gene �UV B radiation �Primary factor leading to SCC , basal and melanoma �UV A radiation �Associated with increase incidence of SCC, BC and aging �Tanning beds emits UV A �Pass through clouds and car window www. skincancer. org

Sunscreen protection � Sunscreen � 15 -30 minutes before exposure, SPF 30 or higher � SPF –sun protection factor � � � SPF 15 allows 15 times longer in the sun Re-apply in 2 hrs One teaspoon rule: � � � face including ear and neck front body Back of body Each arm or leg not covered with clothing Damage protection 15=92%, 30=97%, 40=97. 5% � Physical (barrier) both UVA/UVB -titanium dioxide, zinc oxide, talc � Can stain clothing � Chemical (absorb) suncreens � UV B radiation; para-aminobenzoic acid (PABA), salicylates, camphor derivatives, and cinnamates � UVB and UVA ; Benzophenones � � Coppertone “shade” SPF 45 sunblock with parsol Neutrogena Ultra Sheer Dry-Sunblock

Benign neoplasms of skin �Nevus (mole) �Benign, can be acquired or sun exposure, peak in early adulthood �Most adult have about 20 nevi �Lesion usually <1 cm, pigmented macules, papules or nodules �Evaluation of nevi from junctional (dermalepidermal junction), compound (involves papillary dermis) and finally dermal nevi (into dermis, grows or remains intradermal). �Congenital nevi are presents at birth, usually not thought to be risk for melanoma.

Benign neoplasms of skin �Dysplastic or atypical nevi are pigmented lesions with irregular borders , colors ranging from red to brown to tan or black (less), typically flat but can be raised or palpable if large. �Large number to range to 100 nevi and strong family history of melanoma has high risk of developing to melanoma. �Halo nevi are pigmented nevi with surrounding white halo. � Unknown etiology, likely reactive against melanocytes. � Concern if multiple and adulthood; indicated for thorough skin indication. �Diagnosis clinical appears and dysplastic/atypical is confirmed on histology. �Treatment consist of elliptical entire pigmented excision

Benign neoplasms of skin �Acrochordons (skin tags) �Outgrowth of normal skin, usually occur in sites of friction like axilla, neck and inguinal. Increase over time and during pregnancy �Skin-colored, oval or round, pedunculated lesions on narrow stalks �Treatment: Excision, cryosurgery, electrodessication �Cheery Angioma (De Morgan spots) �Mature capillary proliferation, most commonly on trunk and bleed profusely if rupture. �Dome-shaped, 0. 1 -0. 4 cm diameter �Treatment: Cosmetic, shave excision and electrocauterization, laser (expensive)

Benign neoplasms of skin �Dermatofibroma �Firm, discrete 0. 3 -1. 0 cm, nontender, hyperpigmented nodules, commonly on lower extremities from repeat trauma. �Lesion dimples when pinched �Treatment � If symptomatic, bleeds, change size or color indicate for shave excision or cryosurgery

Benign neoplasms of skin �Lipoma �Most benign neoplasms, is collections of mature fat, occurs anywhere of the body. �Soft, rounded, moveable overlying skin, small but may enlarged >6 cm �Treatment: Rapidly enlarging or firm biopsy is indicated. Surgery with removal of fat cells and fibrous capsule for cosmetic, pain or concerns.

Benign neoplasms of skin �Epidermal inclusion cyst �Most common cause of cutaneous cysts �Freely movable cyst/nodule, arising from epidermis or epithelium of hair follicle. Rupture is common and contains keratin and lipid. �Treatment: uninfected often resolve by itself and recur. Complete excision best not inflames, waiting for 4 -6 weeks. Drain and send for culture if infected. �Pyogenic granuloma (granuloma telangiectaticum) �Capillary proliferation, usually from trauma, more frequent during pregnancy at gingiva �Erythematous, dome-shaped papule that bleeds easily develop days to weeks. �Treatment: Cosmetic, bothersome and easily bleeds

Benign neoplasms of skin �Seborrheic keratoses �Common epidermal tumors from benign proliferation of immature keratinocytes, usually develop after 50 �Sudden appearance of multiple has been associated with GI or lung cancer. �May be inherited AD, few to hundreds, start as macule with 1 -3 mm tan lesion early but can range from 1 -6 cm, classically “stuck on”, “greasy”, brown, flat or slightly raised, warty, scaly hyperpigmented lesion �Treatment: Cosmetic, concerns. Liquid nitrogen but may not respond with thicker lesion. � Snip or shave excision � Electrocautry � Excisional biopsy into subcutaneous fat indicated if suspicion lesion �

Benign neoplasms of skin �Venous lakes �Dilated capillaries on face, lips and ears of elderly, dark blue to violaceous, asymptomatic, soft papule and bleeds easily follow trauma. �Disappear when compressed and epiluminescence microscopy �Management is cosmetic with electrosurgery or laser, rarely surgical excision.

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