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R. Skin Tumours
·
Anatomy
·
Classication of Skin
Tumours
·
Skin Adnexal Tumours
·
Dermatobroma
·
Dermatobrosarcoma
Protuberans
·
Keratoacanthoma
·
Rhinophyma
·
Seborrhoeic Keratosis
·
Squamous Cell
Carcinoma
·
Marjolin’s Ulcer
·
Basal Cell Carcinoma
·
Turban Tumour
·
Naevi
·
Melanoma
ANATOMY
Skin is the largest organ in the body with surface area of up to
18,000 sq cms and having 15% of body weight. Its functions
are—protective barrier to deeper tissues from infections, chemicals, other agents like heat, solar rays, etc; thermoregulation;
fluid, electrolyte, acid and base balance maintenance; perception.
Epidermis
Epidermis is avascular.
Epidermis is 5% of the total skin. It is thickest (0.5–1 mm)
in palm, sole, back and buttocks. It is thinnest in eyelids
(0.05–0.09 mm).
Epidermis has got 5 layers—stratum corneum; granulosum;
spinosum; basale and basement membrane. Epidermis
contains keratinocytes (maintains homeostasis, secretes
Fig. 1.4 99: Extensive infective destruction of the eyelids, face exposing
bone and deeper structures. Maggots are seen on the surface. It
mimics carcinoma but it was of infective origin. Phagedena is infective
destruction without proliferation. It often mimics malignancy.
cytokines); melanocytes (secretes melanin); Langerhans cells
(antigen presenting cells which migrate to regional lymph
nodes to reach immune system).
x Stratum corneum—1/3 of epidermis
x Stratum granulosum—1–3 layers of cells
x Stratum spinosum—3–5 layers of cells
x Stratum basale—columnar cells
x Stratum lucidum is seen in palms and sole.
Melanocytes—one melanocyte is seen for every 10 basal cells
Langerhans cell—a clear cell in stratum spinosum.
Basement membrane is seen at dermo-epidermoid junction.
Fig. 1.498: Skin anatomy.
Dermis
It contains collagen fibres, elastic fibres, capillaries, venules,
arterioles, lymphatics, nerves, erector pilorum muscle, sweat
glands (eccrine, apocrine), sebaceous glands. Merkel cells,
Meissner and Pacinian corpuscles are receptors in dermis.
Dermis constitutes 95% of the skin. Dermis is 15–40 times
thicker than epidermis.
Dermis constitutes papillary and reticular dermis. Dermis
contains type I and II collagen. Main adnexal structures of
the skin are–sweat glands, sebaceous glands, hair follicles
with their germinal centres. The apocrine glands are located
in axilla and anogenital regions. Sebaceous glands secrete
sebum to keep the skin soft and oily. The ducts open at the
hair follicles and at the skin surface. Pilosebaceous unit
contains hair follicle and sebaceous gland.
CLASIFICATION OF SKIN TUMOURS
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CLASSIFICATION OF SKIN TUMOURS
B
Epidermal
x Benign—papilloma, seborrhoeic keratosis
x Malignant—BCC, SCC
Melanocytic
x Benign—all types of naevi
x Malignant melanoma
Skin adnexal tumour
x Benign—syringoma, hidradenoma, sebaceous adenoma, tricho-
folliculoma, trichilemmoma
x Malignant—hidradenocarcinoma, sebaceous carcinoma
Dermal tumours
x Neurofibroma, dermatofibroma, dermatofibrosarcoma protu-
berans
Note:
• Skin cancer is the most common of all cancers.
Skin cancers (SC) are also classified as melanotic (MSC) or
•
nonmelanotic (NMSC). NMSC are commonest (95%). BBC is 80%;
SCC is 18%. Patient who had BCC/SCC has higher risk to develop 2nd
new skin cancer (35% in 3 years; 50% in 5 years). NMSC can be low
risk or high risk groups. Lesion more than 2 cm in trunk and limbs;
more than 1 cm in forehead and neck; more than 6 mm in central face;
poorly defined margin; recurrent type; moderate or poor differentiation;
perineural/vascular invasion; presence of immunosuppression; previous
RT— are high risk lesions.
• Multiple sebaceous adenomas with visceral malignancy are called as
Torre-Muir syndrome.
•
Secondaries in skin can occur like Sister Mary Joseph nodules around
the umbilicus. (Sister Mary Joseph was Superintendent Nurse in St
Mary’s hospital, 1856–1939).
• Etiologies of skin cancers are—exposure to UV solar radiation (UV-B)
with cumulative life time exposure; xeroderma pigmentosa; syndromes
like Torre—Muir’s, Grolin’s, Rombo’ Bazex; albinism; phenylketonuria;
HPV; immunosuppression in transplant patients; AIDS; other malignancies like myeloma, lymphoma, lukaemia; chronic scars/ulcers; SLE;
lichen planus; chronic osteomyelitis; chemicals like coal tar, arsenicals;
cigarette smoking.
SKIN ADNEXAL TUMOURS
Classification
¾
Eccrine gland tumours: Syringoma, hidradenoma,
syringo-cystadenoma.
¾
Hair tumours: Trichoepithelioma, tricholem moma.
¾
It may be benign or malignant.
Features
¾
They are tumours arising from accessory skin structures
like sebaceous glands, sweat glands, hair follicles.
¾
It is not uncommon.
¾
It presents as protruding well-localised swelling in the skin.
¾
Trichoepithelioma is usually seen in nasolabial fold;
mimics BCC; presents as small cutaneous nodule.
¾
Tricholemmoma is also called as naevus sebaceous of
Jadassohn. It is a hamartoma from hair follicle which can
turn into BCC in 10% of cases.
¾
Adenoma sebaceum is seen in tuberous sclerosis as red
papules in face which appears below 10 years. It is often
called as Bourneville’s disease.
¾
Calcifying epithelioma of Malherbe/pilomatrixoma is
benign hair matrix cell tumour seen below the age of 10
years, containing basaloid and eosinophilic ghost cells
with calcification.
¾
Malignant skin adnexal tumour forms a nodular, hard,
indurated swelling in the skin, often with involvement of
regional lymph nodes which are hard and nodular.
¾
It mimics squamous cell carcinoma of skin.
Differential diagnosis:
Dermatofibrosarcoma protuberans.
Diagnosis:
Biopsy—excision or incision type; FNAC of lymph
node.
Treatment
¾
Benign tumour—excision.
¾
For malignant tumour—wide excision and regio nal lymph
node block dissection when required.
Prognosis is good. It is better than squamous cell carci-
noma.
Squamous cell carcinoma of skin;
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CHAPTER 1R General Surgery: Skin Tumours
A
Figs. 1.500A and B: (A) Abdominal wall cutaneous secondaries;
primary is from carcinoma stomach; (B) Sister Mary Joseph secondary
nodule in umbilicus.
Probability is the rule of life, especially under the skin. Never make a positive diagnosis.—William Osler
Note:
• Merkel cell carcinoma is aggressive malignant condition arising
from neuroendocrine receptor cells of the skin (dermis) which
mimics histologically oat cell carcinoma. It is common in white elderly
females (4:1) may be due to UV rays. Treatment is wide excision with
radiotherapy.
• Adenocarcinoma arising from the apocrine glands of skin is called as
extramammary Paget’s disease of skin (intraepidermal adenocarcinoma)
commonly observed in perianal region.
– It can occur in genitalia or in axilla (more apocrine glands). In
25% of cases, the condition is associated with an underlying in
B
situ or invasive carcinoma. Presentation is like red plaque/white/
depigmented areas/crusts/scales mimicking dermatitis, eczema,
fungal infections. Condition is often associated with GI or urinary
malignancies (40%). Biopsy of lesion, CT evaluation for other
malignancies, wide local excision and radiotherapy—are the
management principles.
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SRB’s Manual of Surgery
Fig. 1.504: Malignant skin tumour with ulceration of the skin over
chest wall. Axillary nodes were enlarged in this patient.
DERMATOFIBROMA (Sclerosing Angioma or Subepi-
Fig. 1.501: Skin adnexal tumour (benign) in the face.
Fig. 1.502: Skin adnexal tumour (malignant) turned
out to be of hair follicle origin.
thelial Benign
It is a benign tumour arising from skin from dermal dendritic
cells.
It is formation of firm, single or multiple nodules occurring
commonly in extremities (limbs).
It can be red, brownish yellow (due to lipid), or bluish black
(due to haemosiderin).
Dermatofibroma is common in females (4:1). It typically
shows dimple/buttonhole sign wherein applying lateral pressure creates a central depression.
Histologically, spindle cells are arranged in ‘mat like’ or
‘cart-wheel’ pattern.
It is also called as dermal histiocytoma/dermal dendrocy-
toma.
Treatment: Excision.
Differential diagnosis: Squamous cell carcinoma of skin;
Melanoma; Basal cell carcinoma; Skin adnexal tumour.
Nodular Fibrosis)
A
Figs. 1.503A and B: Skin adnexal tumour—preauricular region;
(B) Skin adnexal tumour. Vascularity is increased and it is malignant.
B
Fig. 1.505: Dermatofibroma in leg.
DERMATOFIBROSARCOMA PROTUBERANS
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It is a low grade fibrosarcoma which grows slowly but persis-
tently. It arises from dermal fibroblasts.
Occurs in head and neck, limbs, abdominal wall and back.
Trunk is the commonest site (50%).
It is not a rare entity, often attains a large size with multiple,
nodular, hard, swelling with often involvement of lymph
nodes. Malignant spindle cells are seen histologically.
Rarely it spreads into lungs through blood.
It mimics squamous cell carcinoma of skin and skin adnexal
tumour.
Positive for CD34 and ring chromosome.
With melanin pigmentation it is called as Bednar’s tumour.
Diagnosis: Biopsy of the lesion; Chest X-ray, CT scan; FNAC
of the lymph node.
Causes: Human papilloma virus; genetic; immunosuppres-
sion; UV rays, trauma are considered.
It presents as a rapidly growing, painless, single swelling in
the skin with central brown area.
It grows usually for 4 weeks and later shows spontaneous
regression in 4 months. It is a pseudomalignancy.
During regression phase, central area separates from the
lesion leaving a deeply seated scar.
Even though it is usually benign, 6% of cases may be
invasive squamous cell carcinoma and often called as
keratoacanthoma variant.
Commonly keratoacanthoma is solitary, but rarely can be
multiple, giant or generalised.
A
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CHAPTER 1R General Surgery: Skin Tumours
A B
Figs. 1.506A and B: Dermatofibrosarcoma.
Fig. 1.507: Dermatofibrosarcoma protuberans.
Treatment: Wide excision and follow up; Recurrence is
common—50%; Prognosis is good.
KERATOACANTHOMA (MOLLUSCUM
SEBACEUM)
It is an overgrowth and subsequent spontaneous regression
of pilosebaceous glands with proliferation of squamous cells
protruding out of the duct which are common in adult males
(3:1) and places where more sebaceous glands are found.
Typical locations are sun exposed areas. It is common in
Caucasians after 50 years of age.
B
Figs. 1.508A and B: Typical keratoacanthoma with central brownish
area. It is self-limiting disease. It is crateriform ulcer.
Features
Mobile, hard, painless, nontender, lump with a central
brownish volcano like area. It is common in face. It can be
recurrent in lips and fingers.
Lymph nodes are not enlarged.
Differential diagnosis: Squamous cell carcinoma.
Treatment: Excision. The tissue is sent for histopathological
study.
RHINOPHYMA (Potato Nose) (Bottle Nose)
It is a glandular form of acne rosacea causing immense
thickening of distal part of skin of nose with visible openings of sebaceous follicles. Nose is bluish red in colour with
dilated capillaries.
It is due to hypertrophy and adenomatous changes in seba-
ceous glands. Cosmesis is the main problem.
Male to female ratio is 12:1. Three per cent cases may have
occult BCC in it. But rhinophyma itself will not cause BCC.
Treatment: Excision of excess tissue and reconstruction,
dermabrasion, laser resurfacing, cryosurgery.
It’swhentheshopenshismouththathegetscaught.
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SRB’s Manual of Surgery
Figs. 1.509: Rhinophyma. Typical look and site.
SEBORRHOEIC KERATOSIS (Seborrhoeic Wart, Basal
Cell Papilloma)
It is a benign overgrowth of the basal layer of epidermis with
excess of small darkly stained basal cells, which protrudes from
the surface of the epidermis to give oily appearance.
A
C
Fig. 1.510C
Figs. 1.510A to C: Seborrhoeic keratosis in face, ear and in
periumbilical region. It is not a premalignant condition.
Features
It is common in elderly. Common sites are the back, face, neck.
It grows slowly with widening in area without altering in
thickness.
It often gets infected but uncommon to bleed on touch.
It is pigmented due to melanin and so mimics naevus or
melanoma.
It is common Caucasians. It is familial—autosomal dominant
gene related.
Often when it falls off, it leaves a pale pink patch on the skin
with visible small surface capillaries.
It is not a premalignant condition.
Note: Solar keratosis is a premalignant condition.
It is hard and stiffer than normal skin.
Lymph nodes are not involved.
It does not occur in palms and soles.
It can be picked off from the skin.
‘Stuck on’ appearance is characteristic.
Differential diagnosis: Melanoma, pigmented BCC, naevus,
Treatment:
¾
Excision cures the condition.
¾
Shave excision or curettage or cautery or cryosurgery
can be done. Scarring may be a problem.
B
Figs. 1.510A and B
PREMALIGNANT CONDITIONS OF THE SKIN
B
x Bowen’s disease of skin: It is an intradermal pre can cerous
condition. It presents as brownish indu ra tion with a well-defined
edge. Microscopically it contains large clear cells. Eventually, it
will turn into carci noma (10%). Entire epidermis is disorganised
and irregu lar. It shows parakeratosis, acanthosis, hyperkeratosis.
Chronic solar exposure; arsenic; human papilloma virus 16 are
the aetiologies. Topical 5 fluorouracil or imiquimod; 4 mm margin
surgical excision; MOHS; laser are the therapeutic options
Erythroplasia of Queyrat is Bowen’s disease occurring over
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glans penis
x Paget’s disease of nipple
x Leukoderma
x Senile or solar keratosis: It is multiple, dry, hard, scaly, lesions on
the face and back of hands due to exposure to sunlight, occurs
after middle age. This is sunray induced hyperkeratosis with
irregular, firm, raised or flat patch. Squamous cell carcinoma
develops later after 10 years. Lesion in such situation becomes
non-healing, indurated with central crust with everted edge; hard
enlarged regional lymph nodes may be palpable
x Radiodermatitis, arsenic dermatitis
x Chronic scars develop into Marjolin’s ulcer
x Albinism
x Xeroderma pigmentosa wherein there is defective DNA excision
repair mechanism. It turns into malignant melanoma, BCC, SCC
x Chronic lupus vulgaris
x Prolonged irritation of skin by various chemicals like dyes, tar,
soot.
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CHAPTER 1R General Surgery: Skin Tumours
Fig. 1.512: Squamous cell carcinoma eyelid. Note the involvement.
Fig. 1.511: Bowen's disease (John T Bowen, 1912).
SQUAMOUS CELL CARCINOMA (Epithelioma)
It occurs in premalignant conditions like Bowen’s disease,
Paget’s disease, leukoplakia, chronic scars, chemically
induced chronic irritation, radioder matitis, senile keratosis,
e.g. Kangri cancer in Kashmir, Chimney scrotal cancer, Kang
cancer of Tibetans.
It arises from squamous layer of the skin. Usually it occurs in
a pre-existing predisposing lesion; occasionally can develop
in de novo skin.
It can be grossly proliferative/ulcerative/ulceroproliferative/
red plaque like. Proliferative type is cauliflower like.
It expresses cytokeratins one and ten.
It is the 2nd (20%) most common skin cancer.
It is common in males.
Exposure to UV B rays (ultraviolet rays are A, B, C types)
causes SCC by direct carcinogenic effects on keratinocytes,
unrepaired mutations, decreased immune surveillance
response, inhibition of tumour rejection, mutation of p53
suppressor gene (seen in 90% SCC).
Fig. 1.513: Squamous cell carcinoma on the labia.
Other risk factors are—inheritance, human papilloma virus
(HPV 16-18), premalignant conditions (see box), ionising
radiation, carcinogens, chronic scar (Marjolin’s), immunosuppression (azathioprine, etc.), chemicals (arsenic).
AETIOLOGY OF SCC
B
x Bowen’s disease. Exposure to UV B rays
x Chronic scars and sinuses (burns; osteomyelitis; venous ulcer)
x Lupus vulgaris
x Solar keratosis—20% chances of SCC
x Senile keratosis
x Xeroderma pigmentosa
x Tobacco use
x Viral cause—human papilloma virus (HPV) five and sixteen
x Chemically induced chronic irritation
x Radiodermatitis
x Kangri cancer—it is due to constant placing of the hot charcoal pot
(kangri) over the abdominal wall to control cold. Seen in Kashmir
x Kang cancer is seen in buttocks and heel of Tibetans due to
sleeping over oven bed to control cold
x Chimney sweep cancer is observed in scrotum due to constant
irritation by tar
x SCC is more common in immunosuppressed individuals, immu-
nosuppressive drugs like azathioprine, cyclosporine, prednisolone; risk becomes 10% in 10 years of intake of these drugs and
40% in 20 years.
When door is closed, many more is open. Money can't buy life.—Bob Marley
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Common sites are: Dorsum of hand, limbs, face, and skin of
abdominal wall SCC can occur in external genitalia, mucocutaneous junction, oral cavity, respiratory system, oesophagus,
gallbladder, in urinary bladder as metaplasia from transitional
cell lining.
Features
An ulcerative or ulceroproliferative or proliferative lesion.
Raised and everted edge; Indurated base and edge; Bloody
discharge from the lesion.
Regional lymph nodes are commonly involved, which are
SRB’s Manual of Surgery
hard, nodular, initially mobile but eventually fixed to underlying structures.
Usually blood spread does not occur. 5% can develop
metastatic SCC; risk factors are—immunosuppression,
large growth, perineural and deep infiltrative, poorly differentiated.
A B
Figs. 1.514A and B: Squamous cell carcinoma foot—ulceroproliferative
lesion with fungating inguinal node secondaries. It is an advanced
disease. Opposite inguinal nodes are also significantly enlarged.
A
Figs. 1.516A and B: Carcinoma cuniculatum—in heel and under
great toe which is a low grade verrucous type of SCC.
Fig. 1.517: Verrucous carcinoma of penis. It is an exophytic, dry,
warty, locally malignant lesion (Squamous cell carcinoma).
B
A
Figs. 1.515A and B: Recurrent SCC in amputated stump. Note the
enlarged significant lymph nodes in the groin.
VARIANTS
B
x Marjolin’s ulcer which occurs in chronic scar is a type of squa-
mous cell carcinoma without lymph node spread.
x Verrucous carcinoma is a squamous cell carcinoma, commonly
occurring in mucous membrane or muco cutaneous junction
without lymph node spread. It is dry, exophytic, warty, indurated
growth. It has good prognosis. It is a curable malignancy.
x A rare multiple self-healing SCC is observed usually in face as
familial autosomal dominant (Ch 9q) disease in Western Scotland-
Ferguson-Smith syndrome.
x SCC often associated with BCC also.
B
Fig. 1.518: Squamous cell carcinoma and BCC in
face of a patient.
Histology
¾
Malignant whorls of squamous cells with epithelial or
keratin pearls are characteristic feature.
¾
Spindle cells, invasion, deep and peripheral margin clearance.
¾
Desmoplastic, mucinous, pigmented, acantholytic—are
other variants.
¾
High risk features are—depth >2 mm, poorly differenti-
ated, perineural invasion.
BRODER’S CLASSIFICATION
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B
I: Well differentiated: 75% or more keratin pearls
II: Moderately differentiated: 50–75% keratin pearls
III: Poorly differentiated: 25–50% keratin pearls
IV: Undifferentiated/anaplastic: <25% keratin pearls. It is seen in
20% of SCCs.
Fig. 1.519: Typical epithelial pearls seen in squamous cell carcinoma.
Differential diagnosis: BCC; Melanoma; Keratoacanthoma;
Skin adnexal tumours; Actinic keratosis; Pyogenic granuloma.
Investigations
¾
Wedge biopsy from the edge.
¾
FNAC from lymph node.
¾
CT scan to identify nodal disease; MRI to identify local
extension is useful.
excision should show clearance both at margin as well as in
the depth. If muscle, fascia, cartilage are involved, it should
be cleared. Reconstruction is usually done by primary split
skin grafting (SSG/Thiersch). Delayed skin grafting also can
be done once wound granulates well. Often flaps of different
types may be needed depending on the site of lesion.
MOHS procedure is also useful.
Amputation with one joint above.
For lymph nodes, block dissection of the regional lymph
nodes is done.
Curative radiotherapy (RT) is also useful in tumours which
are not adherent to deeper planes or cartilage as SCC is radiosensitive. It is also useful in recurrent SCC and in patients
who are not fit for surgery. A dose of 6000 cGy units over
6 weeks; 200 units/day is used. Recurrence after RT is treated
by surgical wide excision.
In advanced cases with fixed lymph nodes, palliative external
radiotherapy is given to palliate pain, fungation and bleeding.
Chemotherapy is given using methotrexate, vincristine,
bleomycin, cisplatin, carboplatin.
Field therapy using cryo probe or topical fluorouracil or
electrodessication.
VERRUCOUS CARCINOMA
B
x Dry, exophytic, warty growth, HPV association
x No lymph node spread
x No blood spread, well differentiated
x Surgery is the treatment—wide excision
x No radiotherapy
x Examples:
– Verrucous carcinoma of genitalia (Buschke-Lowenstein
disease)
– Oral florid verrucous carcinoma
– Verrucous carcinoma of foot (plantar aspect)—carcinoma
cuniculatum—Ackerman tumour
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CHAPTER 1R General Surgery: Skin Tumours
Fig. 1.520: Squamous cell carcinoma in the foot. It is proliferative
cauliflower like lesion. Wedge biopsy has to be done.
Treatment
Radiotherapy using radiation needles, moulds, etc. is given.
Wide excision, 2 cm clearance followed by skin grafting or
flaps.
(Presently for tumour less than 2 cm, 4 mm clearance and for
tumour more than 2 cm, 1 cm clearance is sufficient). Wide
Adversity reveals genius, prosperity conceals it.
PROGNOSTIC FACTORS IN SCC
B
x Tumour size > 2 cm is worse
x Tumour border—ill-defined border is worse
x Lymphovascular invasion worsens the prognosis
x Associated immunosuppression is worse
x Differentiation—poorly differentiated is worse
x Perineural involvement has worse prognosis
x Invasion; depth < 2 mm has got better prognosis; depth more
than 6 mm has got worst prognosis
x Local recurrence rate is 20%. Recurrence period is 5 years, not
beyond
MARJOLIN’S ULCER (RENE MARJOLIN,
PARIS—1828)
It is well-differentiated squamous cell carcinoma which
occurs in chronic scars like burn scar, scar of venous ulcer. It
occurs in unstable scar of long duration. It is slowly growing,
locally malignant disease. It is a curable malignancy.
As it develops in a scar due to chronic irritation and there are
no lymphatics in scar tissue, it will not spread to lymph nodes.
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As scar is relatively avascular it grows slowly. As scar does
not contain nerves, it is painless. Once it reaches the normal
skin it may behave like any other squamous cell carcinoma,
i.e. it will spread to lymph nodes.
Indurated, painless, nontender, ulcer with raised and everted
edge with scar in surrounding area is typical. There is marked
fibrosis.
Wedge biopsy from the edge, MRI of the part and regional
node area confirms the diagnosis.
Treatment: Wide local excision; in case of large ulcer, ampu-
tation is required.
Note:
SRB’s Manual of Surgery
RT should not be given as it may turn into poorly differentiated SCC.
Fig. 1.521: Marjolin’s ulcer foot in a pre-existing burns scar. It is a
well-differentiated squamous cell carcinoma occurring in an unstable
scar of long duration.
Basal cell naevus syndrome (Gorlin syndrome) with BCC;
medulloblastoma; bifid ribs.
It is only locally malignant. It does not spread through
lymphatics nor through the blood. But it erodes deeply into
local tissues including cartilages, bones causing extensive
local destruction. Hence the name “rodent ulcer”.
Types
Nodular—common in face, classic type.
Cystic/nodulocystic.
Ulcerative—Rodent (Jacob) ulcer.
Multiple, often associated with syndromes and other malig-
nancies.
Pigmented BCC—mimics melanoma.
Geographical or field fire or forest fire BCC is wide area
involvement with central scabbing and peri
proliferating edge.
Basisquamous—behaves like squamous cell carcinoma
which spread into lymph nodes. BCC which has not been
treated for long time can turn into basisquamous carcinoma.
Note:
Nodulocystic and noduloulcerative is the commonest form (70–90%).
pheral active
BASAL CELL CARCINOMA (Rodent Ulcer)
It is a low grade, locally invasive, carcinoma arising from basal
layer of skin (or adnexal basal layer of hair follicle) or mucocutaneous junction. It does not arise from mucosa.
It is the commonest (70%) malignant skin tumour.
It is more common in white-skinned people than blacks.
Common in places where exposure to UV light is more
(Australia).
Other causes are—arsenics, coal tar, aromatic hydrocarbons,
skin tumour syndromes, xeroderma pigmentosa, albinism.
It is common in males, common in middle-aged and elderly.
Common site is face—above the line drawn between angle
of mouth and ear lobule (90%)—Onghren’s line.
It is called as tear cancer because it is commonly seen in
area where tears roll down.
Often it can occur in mucocutaneous junctions.
A
Figs. 1.523A and B: (A) BCC in perianal region. It is nodular type.
Wide excision is required; (B) Nodular BCC in the nose (common
in face).
Fig. 1.524: Sebaceous epidermal naevus. It is common in females,
often extensive, begins in childhood. It needs surgical excision and skin
grafting. It has got 10% chances of turning into BCC.
B
Fig. 1.522: Note the common site of BCC—in the face above the line
drawn between angle of mouth and ear lobule—Onghren‘s line.
Clinicopathological Types
a. Superficial type—small buds of tumour masses, common in
young people.
b. Morpheic type—dense stroma with basal cells and type IV
collagen; spreads rapidly; sclerosing BCC.
c. Fibroepithelioma type of Pinkus shows elonga ted cords of
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basaloid cells with mesh work, common in lower back.
It contains outer palisading columnar cells with central poly-
hedral cells but no prickle cells or kerati
Fig. 1.525: BCC lesions in different places (multiple).
nisation.
Features
Ulcer on the face in a middle-aged man which is nontender,
dry, slowly growing, nonmobile, with raised and beaded edge
with central scab, often with central depression or umbilication.
Site of beading signifies the area of active pro liferating cells.
In between beaded areas dormant nonactive cells are present.
No lymph node or blood spread occurs. Due to large sized
tumour cells/tumour cluster, it does not spread through
lymphatics.
BCC can be low risk or high-risk.
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CHAPTER 1R General Surgery: Skin Tumours
A
B
Figs. 1.526A and B: Basal cell carcinoma in different locations. Note
the nodularity and ulceration. Note the beaded edge.
HIGH-RISK BCC
B
x Size >2 cm Recurrent tumours
x Near the eye/nose/ear Immunosuppressed individuals
x Ill-defined margins
Differential diagnosis: Squamous cell carcinoma; Melanoma;
Keratoacanthoma; Seborrhoeic keratosis.
Investigations: Wedge biopsy, X-ray of the part, CT scan
dermoscopy is very useful.
Treatment:
¾
It is radiosensitive. If lesion is away from vital structure
(like away from eyes), then curative radio
therapy can be
given. Radiotherapy is not given, once it erodes carti-
lage or bone. RT is not given to BCC of ear and close to
lacrimal canaliculi.
¾
Surgery:
INDICATIONS FOR SURGERY
B
x Rodent ulcer eroding into cartilage or bone
x BCC close to the eye
x Recurrent BCC after RT
¾
Wide excision (4–6 mm clearance) with skin grafting,
primary suturing or flap (Z plasty, rhomboid flap, rotation
flap) is the procedure of choice.
¾
Cryosurgery.
¾
MOHS (Microscopically Oriented Histographic Surgery)
(Federic E Mohs, American Surgeon) is useful to get a
clearance margin and in conditions like BCC close to
eyes, nose or ear, to preserve more tissues. MOHS is
becoming popular in BCC/dermatofibrosarcoma protuberans/melanoma. Procedure is done by dermatological
surgeon along with a histotechnician/histologist. Under
local anaesthesia, a saucerised excision of the primary
tumour is done and quadrants of the specimen are
mapped with different colours. Specimen is sectioned by
histotechnician from margin and depth, and it is stained
using eosin and haematoxylin. It is studied by MOHS
surgeon or histologist. Residual tumour from relevant
mapped area is excised and procedure is repeated until
clear margin and clear depth are achieved. Clearance must
be complete and proper in BCC otherwise there will be
very high chance of recurrence (70%).
Other Methods
Laser surgery, photodynamic therapy (using aminolevulinic
acid lotion), cryosurgery, curettage and electrodesiccation, 5
fluorouracil local application (5% cream), topical 5% imiquimod,
immunotherapy using Euphorbia peplus.
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