Precancerous or malignant skin diseases

Precancerous or malignant skin diseases

Introduction

Precancerous or premalignant skin diseases there are some skin condition in which under certain circumstances can be changed or transformed into skin cancer such as squamous cell carcinoma , basal cell carcinoma and malignant melanoma if they left without any treatment

These skin condition include the following

• Keratocanthoma
• Bowen,s disease
• Solar or senile keratosis
•  Chronic radiodermatitis
• Xeroderma pigmentosa
• Carcinogens agents
• Leukoplakia
• Chronic scars Marjolin,s ulcer
• Lupus vulgaris or Tuberculosis of skin T.B of skin
• Moles or naevi

Each disease will be discussed separately as follow

Keratocanthoma

• Others names adenoma sebaceum ,molluscum pseudocarcinomatosum or molluscum sebaceum
• It is means overgrowth of hair follicle cells with producing central plug of keratin with subsequent regression
• May be self limiting benign tumor or neoplasm or may due to an unusual response to infection
• Certain causes unknown
• Common in  male adults
• It take from 2-4 weeks to grow and from 2-3 months to regress normally single lesion
• Common site on the face
• Appear as hard separated central core then the lump collapses leaving a deep indrawn scar
• May mistake for squamous cell carcinoma  but it differs from it by it is has slow rate of growth does not have a central dead core and gradually become an ulcer
• Rare under change to squamous cell carcinoma
• Treatment by surgical removal or excision to confirm the diagnosis and prevent depressed scar formation and its changes to malignancy

Bowen,s disease

• Pre-malignant intra-epidermal carcinoma or carcinoma in situ
• Slow growing lesion and common in old age
• May look like as eczema
• Can occur on any part of the body especially the trunk
•  Appear as thickened brown or pink colour with well defined plaque
• Appear also as flat papular clusters covered with crusts
• Causes may be associated with sun damage ,arsenic exposure,viral infection such as human paplilloma virus and immune-suppression such as AIDS 
• Can be changed into squamous cell carcinoma
• Appear under microscope as full thickness dysplasia of the epidermis
• Erythroplasia of Queyrat is bowen,s disease of the glans of the pens or prepuce in male and also same in  female
• Treatment by surgical removal or excision with safety margin about 0.5 cm or cryotherapy  cauterization or diathermy coagulation

Solar or senile keratosis

• Exposure to sun is the important predisposing factor
• Resulting from solar damage to the skin and hyperkeratosis of the skin
• Common found in old weather-beaten man eg farmers  on the backs of fingers and hands, face and helix of the ears and in fair- skinned
• Skin appear as yellow, grey, or has brown crusty patches from which arise prodtruding plaques of horny skin and have dry hard scale
• Common changes to squamous cell carcinoma if not treated
• Appear under microscope as hyperkeratosis and epidermal dysplasia
• Can develop tethering ,fixity, or regional enlarged are worrying features
• Treatment Surgical removal,shaving,cryotherapy or topical or local appilcation of 5- fluorouracil chemotherapy drug

Chronic radiodermatitis

• Result from prolonged exposure of skin to ionized irradiation which result in  varying degree of skin damage after several months to several years irradiation known as carcinogens which can causes damage DNA cells and transformed it into cancer cells
• Common in those handling radioactive materials or delivering X rays
• Usually affects face and hands
• Skin appear as chronic inflammation from prolonged irradiation irritation and the skin appear as atrophic indurated plaques with yellowish or whitish colour with telangiectasia ,radionecrosis and ulceration can occur especially in moist areas
• Can be changes to squamous cell carcinoma and basal cell carcinoma

Xeroderma pigmentosa

•  Xeroderma mean skin dryness  and change in the color (pigment) of the skin pigmentosum

• Also called XP disease
• Causes it is an autosomal recessive genetic disorders of DNA repair
• The patient have no any ability to repair damage caused by ultraviolet rays of the sun
• Rare disease which characterized by an extreme abnormal sensitivity to sunlight
• Common site affection are the eye and any areas of the skin exposed to the sun
• The symptoms and signs appear commonly during infancy or early childhood
• Many children develop a severe sunburn on exposure to sunlight even for just few minutes causing redness and blistering which may  persist for weeks
• The child develop freckling in the skin exposed areas to the sun such as in the arms ,face and eyelids and lips the skin become scaly and dry with irregular dark spot on the skin
•    Can be changed to malignancy or skin cancer such as squamous cell carcinoma at early age during childhood especially in those does not protect from the sun
• Most people develop multiple skin cancer during their life which can develop in the lips , tongue,face,eyelids and also on the scalp
• The eyes become so sensitive to the ultraviolet of the sun may become painful irritated with blood shot with clouding in front of the cornea and corneal ulceration the patient can not see clear and the eyelashes fall out and the eyelids become atrophic and thin and may turn abnormally inside called entropion or turn outside called ectropion which associated with impair vision field
• Some patient may develop progressive neurological disorders such as hearing loss inability to walking difficulty in swallowing which called dysphagia difficulty in speech and fits or seizures
• Poor prognosis few patient may survive up to their adolescence
• Treatment by surgical removal with grafting and protective measures against sunlight eg sun - screen ointments

Carcinogenic agents

These are substance when become in contact with skin for prolonged period can develop skin cancer these substance acts as carcinogens which can produce DNA  damage of the normal cells and transformed it into cancer cells such as exposure to pitch,tar and soot  for more see here

Leukoplakia

• Leukoplakia means white patches it is also called leukokeratosis or idiopathic keratosis or idiopathic white patches
• Appears as adherent white patches on the mucous membrane of the oral cavity and lips also can occur in other mucous membrane such as gastrointestinal tract , urinary tracts and genitals
• Leukoplakia may confused with other lesion causes white patches  in the mouth such as oral candidiasis or fungal infection and lichen planus
• Common occur in smoking and chewing tobacco but other causes may unknown
• Precancerous or malignant lesion which can be changed into squamous cell carcinoma eg cancer lips or esophagus
• Patient may complaining from nothing or from pain or discomfort and presence of white or grey patches
• Treatment by surgical removal , electrocautery and cryotherapy

Chronic scar or marjolin,s ulcer

• The name is applied to malignant change in a scar ,ulcer or sinus such as chronic varicose ulcer , an unhealed burn, the sinus of chronic esteomyelitis and chronic wounds
• It has the following criteria slow rate of growth because the lesion is relatively avascular  has no pain or painless ulcer because the tissue does not contain cutaneous nerves secondary metastases do not occur in the regional lymph nodes because the lymphatic vessels have been destroyed but if the ulcer invades normal tissue surrounding the scar then the ulcer take rapid rate of growth and become painful and can give lymphatic metasese
• Common change to malignancy such as squamous cell carcinoma later may develop to basal cell carcinoma
• Treatment by  wide surgical removal with safety margin about 1 cm or radiotherapy

Lupus vulgaris

• Also called tuberculosis of the skin or T.B of the skin
• Caused by mycobacterium tuberculosis which it is the micro-organism of TB
• Has the following criteria painful cutaneous lesion with nodular appearance common seen in the face around the nose,lips ,cheeks,ears and neck may develop into disfiguring skin ulcer and deformity , lesion may persist for many years
• Has progressive and persistent form of skin T.B
• Appear as small reddish or brownish small nodules with gelatinous consistency called apple -jelly nodules
• Can be changed into malignancy or skin cancer such as squamous cell carcinoma
• Treatment by anti-tubercolsis drugs such as rifampicin , isoniazid,pyrazinamide,streptomycin and ethambutol

Moles or navei

• Common precancerous skin lesion
• Mainly junctional naevus and compound naevs can change or transformed into skin cancer
• Junctional naevus appear as tiny dark points they are not raised above the skin the melanocytes lie in the deeper layers of the epidermis
• Compound naevus the melanocytes are present in both the dermis and epidermis
• They can changed into malignant melanoma
• There are warring criteria with moles which if present so it is need for immediate investigations and deal with it to exclude the malignant changes these criteria are

The mole become increased in size

The mole become change in its colour either increased or decreased in pigmentation

The mole become have fissuring and ulceration

The mole become painful and itching

The mole become indurated and bleeding

There is spread of pigment as sattelite nodules around it due to lymphatic permeation

 

 

tags:skin,precancerous,premalignant,lupus,vulgaris,xeroderma,leukoplakia,marjolin

Malignant melanoma and Amelonatic

Malignant melanoma and Amelonatic

Introduction

Malignant melanoma it is a type from skin cancer which arise from epidermal skin layer  from melanocyte cells or pigment cells which responsible for release of melanin pigment which give the skin it is colour malignant melanoma can arise in any part in the body which containing melanocyte cells such as in the skin of the head and neck, trunk , lower and upper limbs

 There are special site of malignant melanoma  which can be arise such as mucosal as mucous membrane of the nose or the mouth( sublingual), eye as conjunctiva , choroid and pigmented layer of the retina and genitalia

 Also there are hidden area of malignant melanoma which can be found such as pia and arachnoid matter which they are  the layer of brain covering and adrenal medulla
 Malignant melanoma it is the most aggressive type of skin cancer which it is more common in Caucasian than black

Melanocytes produce melanin pigment during exposure to the sun to protect us from the burning effect of the sun

Skin cancer when arise from the basal layer of the epidermis is called basal cell carcinoma see here
When arise from squamous cell layer is called squamous cell carcinoma see here

When arise from the melanocytes cell producing pigment is called malignant melanoma
 

What are the causes of malignant melanoma

There are predisposing factors which associated with malignant melanoma formation such as

• Exposure to the sunlight in which the ultraviolet rays cause damage to the DNA nucleous especially intermittent exposure is more closely associated with melanoma than regular exposure
• Sunbeds and tanning lamps carry a potential risk
• Albinism and xeroderma pigmentosum have higher risk
• Red fair haired skin
• Hereditary or genetic inheritance
• Gaint congenital naevi of more than 20 cm in diameter have increased risk of malignant change which may occur in the first 10 years of life

What are premalignant condition of melanoma

• Congenital gaint or bathing trunk naevus or mole
• Melanosis of the eye conjunctiva
• Hutchinson,s freckle or lentigo which mean presence of large area of pigmentation in old age patient more than 60 years on the face and is slow growing mainly smooth but may developed rough ares of junctional activity which are at increased risk of malignant change
• Junction melanoma in which the melanocytes lies in the deep layers of the epidermis they appear as tiny dark points and look as if paint is sprinkled on the skin
• Compound melanoma in which the melanocytes are present both in the dermis and epidermis

What are symptoms and signs of malignant melanoma

Any individual with mole or naevi in his skin body should be aware about the warring signs which if present this may indicated of malignant transformation  these warring signs such as

• If the mole become increased in size
• If the mole colour changed either decreased or increased pigment
• If the mole become has fissuring 
• If the mole become ulcerated
• If the mole become painful
• If the mole become bleeding
• If the mole become indurated
• If the mole become itchy
• If the mole pigment spread as satellite nodules around it due to lymphatic permeation

The physician should be asked about

• If there is family history of previous malignant melanoma
• If there is family history of multiple melanoma syndrome
• If there is recent history of mole changes in its colour size shape or become painful or ulcerated or itching or bleeding
• If there is previous history of intermittent sun exposure
• If there previous history of pancreatic cancer or astrocytoma
• If there is previous history of skin cancer

The physician should be examined the whole body skin to detect any suspected lesion to deal with it also if the individual notice any abnormalities in the mole or naevi such as warring signs he should be immediately investigated by the physician to excluded any malignant transformation

   

What are the types of malignant melanoma

There are many types of malignant melanoma such as

Superficial spreading malignant melanoma

• Account for about 65%
• Commonest types
• Can occur on any part of the body
• Usually palpable but thin with irregular edge
• Has variable colour but common black  with satellites
• Occur on the leg of female and back of male also present in the palm of the hand and sole of the foot

Nodular melanoma

• Account for about 27%
• Thick protruding with a smooth surface and regular outline
• May become bleeding and ulcerated
• Commonly black lump with rapid growth
• Most dangerous

 Lentigo maligna melanoma

• Account for about 7%
• Malignant melanoma arsing in Hutchinson melanotic freckle
• Malignant areas are thicker than the surrounding pigmented skin
• Usually dark in colour
• Very rare to be ulcerated
• Irregular common present in the face
• Best prognosis

Acral lentiginous melanoma

• Account for about 1%
• Rare type
• Can be present in the palm of the hand and sole of the foot
• Can also present as a chronic paronychia or sub-ungual  haematoma
• Has irregular expanding area of brown or black pigmentation on the palm ,sole or beneath a nail as sub-ungual melanoma
• Poor prognosis

Amelanotic melanoma

• Account for about 1%
• May be pink with some pigmentation at the base
• Presents with lymph nodes involvement
• Worse prognosis

What are the classification and staging of malignant melanoma

The malignant melanoma can be classified and staged as follow

Histological classification

Clark-McGovern Level

Level 1 : In situ melanoma - melanoma confined to the basal epidermis with no dermal invasion

Level 2 : Invasion of the subepidermal and connective tissue known as the papillary dermis

Level 3 : Invasion of the level of the junction between the papillary and reticular dermis

Level 4 : Invasion of the reticular dermis

Level 5 : Invasion of the subcutaneous tissues

Breslow Tumor Thickness Measurement TTM

The thickness is measured by an optical micrometer from the top of the granular layer of the epidermis to the deepest melanoma cells in the dermis

A modified version of the American Joint C omittee on Cancer|Union Internationale Contre le Cancer AJCC|UICC staging system is the most widely used

AJCC staging

pTx  Primary tumor cannot be assessed

pT0  No evidence of primary tumor

Clark level  I    pTis : Melanoma in situ intra-epidermal

Clark level  II   pT1 :Less than 0.75 mm thick and invades the papillary dermis

Clark level  lII  pT2 :0.75-1.5 mm thick with or without invades to papillary -reticular dermis interface

Clark level IV pT3 : 1.5-4 mm thick with or without invades reticular dermis

pT3a  1.5- 3 mm thick

pT3b  3-4 mm thick

pT4  more than 4 mm thick

TNM system T means tumor N mean lymph nodes M means distant metastases

Stage I       pT1|2 :N0.M0

 Stage II      pT3|4 : N0 ,M 0

 Stage III     Any pT:N1-2 ,M0

Stage IV   Any pT: any N,M1

Investigations of malignant melanoma

Laboratory

Complete blood count for surgical fitness

Lactic dehydrogenase may be raised

Other according to the case

Radiological

Chest X rays and CT scanning

Utrasound and CT scanning of the abdomen and pelvis

MRI scanning of the brain

PTE scanning for detection of metastases

Other investigations according to the case

Biopsy

Biopsy taken either from the primary tumor or from the regional lymph nodes

  Biopsy from the tumor

Either by removal part from the tumor called incisional biopsy or removal the whole tumor called excisional biopsy then the biopsy taken for histopathological examination under microscope for detection of cancer cells

Biopsy from the lymph nodes

Fine needle aspiration cytology FNAC

 For detection cytology of cancer cells such as loss of cellular cohesiveness : nuclei oriented in different directions and irregularly spaced cells become detached from one another

pleomorphism : variation in size ,shape and number of nucleoli

nuclear to cytoplasmic ratio increased abnormal mitoses and so on

Sentinal lymph nodes biopsy

Sentinal node means its the first lymph nodes received the cancer metastases and taken the dye in this technique the tumor is injected by special dye called patent blue dye around it then wait about 5-10 minute untill the dye can reach the regional lymph nodes then the sentinal nodes can by identified by gamma prob which appear as a hot spot  or by incision over the regional lymph nodes in which the sentinal nodes appear taken the blue dye and can be seen easily then taken for microscopic examination for detection of cancer cells in such case immunohistochemical staining can be used which give best result than cytological one

The aim from these sentinal nodes may to avoid complete removal of the regional lymph nodes but remove only the node taken the dye and have cancer cells to prevent the complications of removal of the all regional nodes such as lymph-edema

Treatment of the malignant melanoma

Treatment of malignant melanoma can be divided into treatment of the primary tumor ,treatment of the regional lymph nodes and treatment of inoperable case and distant metastases

Treatment of the primary tumor

Surgical removal or excision

Surgical removal of the tumor with safety margin which depend on the maximum tumor thickness according to Breslow method such as 

Melanoma in situ remove 5 mm margin , tumor thickness from 0,1-1.5 pT1-2 remove 10 mm margin

Thickness from 1.6-4 mm pT3 remove 10-20 mm margin

Thickness more than 4 mm pT4 remove 20-30 mm margin

Some prefer to remove 5 cm as safety margin including the deep fascia followed by plastic reconstruction of the defect left 

In case of melanoma of the eye treated by removal of the whole eye by operation called eye enucleation

In case of melanoma of digit or finger treated by removal of that affected digit or finger by operation called amputation

Treatment of regional lymph nodes

Prophylactic block dissection of the nodes in case of stage 1 or if there is no clinical lymph nodes are detectable surgical clearance after FNAC confirmation is indicated

Therapeutic block dissection of the lymph nodes as in case of stage 2

Sentinal lymph biopsy see above

Treatment of inoperable cases such as in case of stage 3 and 4 and recurrent melanoma and in transit metastases

Palliative surgical removal

Surgical removal or excision  of the tumor to relieve the pain itching ulceration or bleeding

Chemotherapy

Vincrestine - DTIC which can be given by intravenous infusion then reach the tumor throgh systemic circulation

Melphanan phenyl alanine mustard  it is most effective line of treatment for in transit metastases can be given by intra-arterial perfusion using special pump

For more details see here

 

Radiotherapy
  

Can be used for bone and brain metastases

For more details see here

 

Fast neutrons

Using high energy cyclotron better than irradiation

Immunotherapy

USING Interleukin 2 which responsible for induction cytotoxic T- cells

Interferon- beta has been used in the past for node positive patients but its benefit is unclear

Prognosis of malignant melanoma

This depend on the tumor thickness lymph nodes involvement metastases also depend on the anatomical site of the melanoma such as trunk and scalp melanoma have bad prognosis than peripheral lesion and type of the growth superficial spreading melanoma better than penetrating ulcerating lesion

tags:skin,cancer,malignant,melanoma,amelonatic,acral,hutchinson,frekle,lentigo

Epithelioma or squamous cell carcinoma

Epithelioma or squamous cell carcinoma

Introduction

Epithelioma or squamous cell carcinoma it is a malignant tumor or neoplasm which arise from squamous cell layer of the epidermis of the skin  so epithelioma it is a type from skin cancer

Skin cancer can be divided into main types non melanoma skin cancer type which include squamous cell carcinoma SCC and basal cell carcinoma BCC  and melanoma skin cancer type which include malignant melanoma

What are the causes of squamous cell carcinoma

• Exposure to sunshine
• Exposure to irradation
• Exposure to carcinogenic agents such as pitch ,tar, betel nuts
• Human papilloma virus
• Immunosuppressive drugs
• Chronic ulceration such as marjolin,s ulcer is malignant change in a longstanding scar , ulcer or sinus which typically seen in chronic varicose ulcer unhealed burn, sinus of chronic esteomyelitis
• Lupus valgaris and warts

Marjolin,s ulcer has the following criteria

• Slowly growing ulcer
• Painless ulcer
• Transformed into squamous cell carcinoma
• Spread to lymphatic late
• The edge of the ulcer not always raised and everted such as in SCC
• Unusual nodules or changes in a chronic non healing ulcer or scar should be viewed with suspicion and take biopsy from that lesion early
• Other features may be masked by the presence of previous ulcer or scar
• Need vigorous treatment

What are the premalignant condition of the skin

• Senile or solar keratosis  which usually multiple lesion on the face and backs of the hands in patient past middle life fair skinned appear as dry hard scaly
• Seborrhoeic keratosis
• Chronic radiodermatitis
• Xeroderma pigmentosa
• Bown,s disease
• Leukoplakia

Any changes in the pre-exsiting skin lesions such as warts or mole should be rise suspicion of malignant changes such as

If the patient has mole or warts and he notice that

• It become increased in size
• It colour become changed either increased or decreased in pigmentation
• The lesion become itchy
• The lesion become bleeding
• The lesion become swollen
• The lesion become painful
• The lesion become has fissuring or ulceration
• The lesion become indurated
• Spread of pigment as sattelite nodules around it due to lymphatic permeation

Symptoms signs and pathology of squamous cell carcinoma

Squamous cell carcinoma is a common invasive malignant epidermal tumor which can spread to the lymphatic and may give metastasis first lymph node become hard and mobile but later become fixed to deeper structures but rare to give blood metastasis

Very common skin cancer which occur commonly in older aged patient

More common in male than female

Common site at sun exposed areas such as face back of the hands also can occurs in lips gums tongue esophagus genitals and anal margins

Squamous cell carcinoma can be appear as

Hyperkeratotic and crusty on sun damaged skin eg ear pinna

Friable or papilliferous varities

Malignant ulcer or squamous cell carcinoma ulcer which have the following criteria

• Size small or moderate or large size
• Edge of the ulcer raised everted nodular edges
• Base of the ulcer hard indurated and is often fixed to the deeper structures
• Floor of the ulcer irregular composed of necrotic material scab or haemorrhagic tumor tissue

Pathology of squamous cell carcinoma

Malignant or carcinomatous ulcer as above when see by the eye

Solid columns of epithelial cells growing into the dermis with epithelial pearls or nest of central keratin surrounded by prickle cells this is see under microscope

Treatment of squamous cell carcinoma

There are different ways to treated squamous cell carcinoma such as

Surgical removal or excision

Surgical removal of the lesion with safety margins to avoid it is recurrence and the defect left is closed by plastic skin flap or grafts

Irradiation therapy

Which can be used in multiple session

  

contraindication

 Very small ulcer because it is better to surgical removal

Ulcer near the eye to protect eye against irradiation effect  but this can be protected by using a lead shield

Ulcer infiltrating the bone or cartilage because the cancer cells become hidden and efficient dose will causes irradiation bone or cartilage necrosis and if small dose it will be carry the risk of recurrence

 Recurrent ulcer

Cases resistant to irradiation

For more about cancer treatment by radiotherapy see here

 

Currettage and cautery

In this methods the lesion is currette by using spoon like called currette followed by using electric current called cautery to kill or destroyed malignant cells

Cryosurgery

In this method a cryo device is used to freeze the lesion and kills the cancer cells using nitrogen liquid

Topical chemotherapy

Local treatment by using 5- flurouracil in small and superficial lesions but recurrent rate is high than with other forms of treatment

Treatment of the regional lymph nodes

If the lymph nodes are involved the block lymph nodes dissection is indicated

How cancer skin can be prevented see here

 For basal cell carcinoma or rodent ulcer see here
For malignant melanoma see here
 

tags:epithelioma,cancer,squamous,carcinoma,skin,nest,keratin,margolins,ulcer

Skin cancer types diagnosis and treatment

Skin cancer types diagnosis and treatment

Introduction

Skin cancer means malignant tumor or neoplasm which arise from the layers of the skin which divided into outer epidermis layer which contains basal cell layer that contains dendritic pigment producing cells called melanocyte , squamous cell layer ,granular cell layer and horny cell layer and  dermis layer and subcutanous layer the skin cancer either arise from the basal cell layer and called basal cell carcinoma or from the squamous cell layer and called squamous cell layer those types are called non melanoma skin cancer or from melanocyte cell layer and called malignant melanoma this type is called melanoma skin cancer

What are the types of skin cancer

 The skin cancer can be divided into three mains  types

• Basal cell carcinoma or rodent ulcer
• Squamous cell carcinoma
• Malignant melanoma

Basal cell carcinoma BBC or rodent ulcer causes types symptoms signs  pathology and treatment see here

  Squamous cell carcinoma or epithelioma causes types symptoms signs pathology and treatment see here

Malignant melanoma causes types symptoms signs pathology and treatment see here

How skin cancer can be prevented see here
 

tags:cancer,skin,diagnosis,types,epithelioma,rodent,melanoma,cell,carcinoma,squamous

Basal cell carcinoma or rodent ulcer

Basal cell carcinoma or rodent ulcer

Introduction

Basal cell carcinoma BCC is a malignant tumor or neoplasm which arise from the basal cell layer of the skin and is considered most common type of skin cancer which also known as rodent ulcer

It is locally malignant tumor that so it is never or very rare to spread or metastasize to other blood or lymph nodes or  organs and it is slowly growing which may take years it also called non melanoma skin cancer together with squamous cell carcinoma but malignant melanoma are called melanoma skin cancer

What are the site of basal cell carcinoma

BCC can be arise from any part of the skin including the anal margin but about 90% occur on the face above a line joining the angle of the mouth to the external auditory meatus or to the lobule of the ear (seborrheic area) they are especially common around the eye nasolabial folds and hairline of the scalp

They are more common in male the female common in old age

What are the causes of basal cell carcinoma

• Exposure to sunlight
• Exposure to X rays radiation
• Exposure to arsenic
• Basal cell naevus syndrome which it is dominantly inherited associated with multiple basal cell carcinoma
• People with inherited defects such as albinism and xerodermia pigmentos
• White skinned with prolonged exposure to sun
• Immunocompremised patient

What are symptoms signs and pathology of basal cell carcinoma

Basal cell carcinoma  can be present  either with small nodule pearly white or blue translucent on the sun exposed area common on the face with dilated capillaries over it vessels within the tumor it the earliest lesion and called nodular or button type

   

Basal cell carcinoma can be present with ulcer which called rodent ulcer and this the commonest pictures of basal cell carcinoma

The rodent ulcer have the following criteria

• Size can take any size either small moderate or large size
• Shape either rounded or oval or irregular
• Edge raised ,rolled in and beaded
• Floor not raised red and granular or may be covered with scabs crusts and blood
• Base indurated but not extended beyond the edge
• Margin showing dilated blood vessels telangectasia
• Discharge the ulcer may discharge blood or pus

Basal cell carcinoma can also present as scarring or cystic or pigmented lesion as pigmented basal cell carcinoma  but less common

Basal cell carcinoma can be as superficial type which found on the trunk and presents as red scaly patch and raised edge or present as turban tumor such as cylindroma over the scalp or flied fire type or multifocal which emerge from the epidermis and spread over several cms

What are the complications of basal cell carcinoma

Basal cell carcinoma can be direct spread to underlying structures such as the causing eroded the underlying skull and may destroy the face nose and eye

Basal cell carcinoma can causes bleeding from erosion of blood vessels

 Basal cell carcinoma can be changed into squamous cell or carcinoma or epitheliomatous transformation  called basosquamous carcinoma

 it may causes secondary infection meningitis and cavernous sinus thrombosis this due to it site on the face but this is rare

Investigations

Biopsy

Taken  a biopsy from the lesion either by incisional  by removal small part of the  lesion or excisional by removal the whole lesion then examined under microscope to detect cancer cells which appear as solid rounded mass with dark staining cells arising from the basal cell layers of the skin with no prickle cells no epithelial pearls which seen in squamous cell carcinoma 

Each mass consists of a palisade arrangement of columnar epithelium at the periphery and polyhedral cells at the center with no cell nests

Treatment of basal cell carcinoma

There are many ways to treated basal cell carcinoma which give good results and that is depend on the site of the lesion age of the patient the size of the lesion  if there contraindication for operation or the patient refuse
the aim of this treatment is to destroyed  or to remove the tumor completely to avoid it is recurrence again these methods including either by surgical  removal or irradiation or currettage and cautery or cryosurgery or topical chemotherapy such as

Surgical removal or excision

Which means complete removal of the lesion with removal of healthy skin part about 1 cm as a safety margin then defect which left after removal it is either closed directly if the defect very small or closed by plastic closure by skin flapping or grafts

Most common indications for surgery are
very small ulcers are better to excised ,ulcers near the eye ulcer infiltrating to bone or cartilage   recurrent ulcers and cases resistant to irradiation

Irradiation therapy

Indicated in cases where surgery is difficult to done given on multiple session

Currettage and cautery

Which consists o scooping  out the basal cell carcinoma by using spoon like instrument called curette then cauterization using electric current is applied to control the bleeding and kills the remaining cancer cells better for small cancer such as in the trunk and extrimties

Cryosurgery

This done by special cryo device  to freezing the cancer cells and kill them by using liquid nitrogen

Topical chemotherapy

This is local treatment by using such as 5- fluorouracil is used in small and superficial lesions but recurrence rates are common

For sqaumous carcinoma or epitheluoma see here

For malignant melanoma see here
  
tags:basal,carcinoma,rodent,cell,ulcer,basosquousam,palisade