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32 Cards in this Set

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Case history:
A 25-year-old Caucasian woman presents with a small papule on her leg

Clinical features: Dermatofibroma
Very common lesions
Usually present on the extremities
May be present for years or decades before spontaneously regressing
Gross features: Dermatofibroma (DF)
Small (3-10 mm), firm, pink to brown (hyperpigmented), dull to shiny lesions with ill-defined borders
Usually solitary and more frequently involve the legs and arms than the trunk
Histologic features: Dermatofibroma
Characterized by an interlacing fascicles of spindle-shape cells.
The overlying epidermis is often thickened (acanthotic)

The bland spindle cells have elongated nuclei and a small rim of blue cytoplasm.
What Other Skin Lesions Are in the Differential Diagnosis of DF?
Melanoma
Scar
Nevus
Kaposi sarcoma
Metastatic carcinoma
What Is the Etiology of DF?
Unknown
Possibly a reaction to minor skin injury such as insect bites
Case history:
An elderly man presented with an ulcerated papule on the skin of the neck

Gross features: Basal Cell Carcinoma
Pearly papule
May have telangiectasia and ulceration

Most arise in the head and neck regions

Cross section of white-tan tumor with cystic degeneration and some hemorrhage
Histologic features: Basal Cell Carcinoma
**Islands and cords** of basaloid cells arising from the basal layer of the epidermis with hyperchromatic nuclei, often accompanied by stromal separation artifact (clefting)

**Palisading** of tumor cells forming the periphery of tumor islands
What Are Some Predisposing Factors for Basal Cell Carcinoma?
They are seen almost exclusively on hair-bearing skin, especially on the face
They usually occur in persons with light skin
Prolonged exposure to sunlight is an important cause, although that alone is not sufficient to produce a BCC
Do BCCs Metastasize?
As a rule, basal cell carcinomas do not metastasize
However, metastasis to lymph nodes, lungs and bones have been reported in very large and longstanding lesions
BCC can also be deeply invasive and can invade bone
Case history:
A 67-year-old man presented with a 1-year history of a “sore that would not heal” on his forehead

Gross features: Squamous Cell Carcinoma (SCC)
Most often presents as a nodule with central ulceration and a pink, elevated, indurated border that does not heal spontaneously
Histologic features: SCC
Pleomorphism, nuclear hyperchromasia, intercellular bridges, dyskeratosis (abnormal keratinization of individual cells) and atypical mitotic figures
Keratin pearls seen in well-differentiated SCC

Areas of “solar keratosis” may often be seen in areas adjacent to the SCC
What Is the Metastatic Potential of Cutaneous Squamous Cell Carcinoma?
Those arising from sun-damaged skin have a very low propensity for metastasis (0.5%)
Lesions of the lower lip are also induced by sun exposure but they carry a higher incidence of metastasis (16%)
Chronic non-healing wounds, burns and stasis ulcers can give rise to squamous cell carcinomas
Cutaneous carcinomas arising from these lesions have a higher rate of metastasis, as well as those arising from the oral mucosa, glans penis and vulva
What Is the Relationship Between Actinic (Solar) Keratoses and Squamous Cell Carcinomas?
Actinic (solar) keratoses are multiple erythematous, scaly lesions on sun-exposed skin (face, scalp, hands) of individuals having fair complexions
They are considered pre-cancerous lesions with scattered atypical keratinocytes within an epidermis overlying solar elastosis
Some actinic keratoses evolve into squamous cell carcinoma
Case history:
This patient is a 41-year-old man who presented with an 18-month history of a pigmented lesion on his mid-back
His wife called this lesion to his attention because of its *enlarging size* and **variation in color**

Gross features: Melanoma
ABCDE criteria
Asymmetry
Border
Color
Diameter greater than 10 mm
Elevation or Enlargement of the lesion
Histologic features: Melanoma
Tumor cells have large, irregular, hyperchromatic nuclei, often with prominent nucleoli
Pagetoid spread of malignant cell into the epidermis is usually seen, as well as individual melanocytes packed together along the dermoepidermal junction
Radial Growth and Vertical Growth of Malignant Melanoma
Vertical growth phase corresponds to frank deep dermal invasion and is associated with the potential for metastasis.

Radial growth phase refers to an early lesion when atypical melanocytic cells proliferate horizontally in the superficial, papillary dermis
Melanoma in radial growth phase has little potential for metastasis
The prognosis is excellent if the lesion is completely excised
Histologic features: Melanoma
Cytoplasm of tumors cells contain variable amounts of dusty melanin pigment
Occasionally no pigment is visible with H&E stains
What stain to use if no pigment is visible in H&E stain to look for melanoma?
Immunohisto-chemical stains as this one for HMB-45 help identify melanin producing cells when no pigment is visible with H&E stains
Breslow Depth Staging Scheme for Invasive Malignant Melanoma
Tumor thickness measured from the top of the granular layer to the deepest extension of the tumor
Has been shown to be the single most important factor in predicting survival for stage I patients (that is, without palpable regional lymph node enlargement)
Overall, malignant melanomas less than 0.76 mm thick rarely metastasize (close to 0% risk of mortality)
Those between 0.76 to 1.5 mm thick have intermediate risk (23%)
Tumors thicker than 1.5 mm have a 37% mortality rate
Ocular melanoma
Most common malignant neoplasm of the eye
Often see extensive local invasion and late metastases
How Does a Compound Nevus Differ From Melanoma?
A compound nevus (CN) is a benign tumor characterized by nevus cells at the dermoepidermoid junction and within the dermis
CN’s are usually small pigmented asymptomatic papules or macules
Melanoma is a malignant melanocytic tumor
Case history:
A HIV+ 18-year-old woman was noted to have multiple small skin-colored dome shaped papules with umbilicated centers in the genital region and lower extremities
She also had multiple purple colored patches and nodules, some ulcerated, in the skin of the left lower extremity and on the oral mucosa

Gross features: Kaposi sarcoma
Purple patches, papules, nodules which may ulcerate
Histologic features: Kaposi sarcoma
Infiltrative neoplasm composed of spindled endothelial cells forming slit shaped vascular spaces
There is erythrocyte extravasation and hemosiderin deposition within the tumor
KS epidemiology
In the non-immunocompromised population, Kaposi sarcoma occurs more commonly among elderly Jewish males of European ancestry
In this group of patients, the disease is usually limited to the lower extremities

In immunocompromised patients, the lesions not only involve skin but also internal organs
What happens if the immune is restored to KS tumor?
If normal immune function is restored, the tumors will regress
Gross features: Kaposi sarcoma
Lesions may involve not only the skin but may also disseminate and affect any organ in the body (lymph node and small bowel, vetebral body etc)
What virus is associated with KS?
Kaposi sarcoma is known to be associated with human herpesvirus type 8 (HHV 8) in both immunocompetent and immunocompromised individuals.
Case history:
A 60-year-old male with history of renal cell carcinoma treated by nephrectomy 20 years ago presents with a solitary vascular appearing lesion on his forehead

Metastatic Tumors of the SKIN
Clinical features:
Three to four percent of malignant tumors may metastasize to the skin
Most patients have a history of prior cancer
Sometimes, however, the metastases may be the first sign of cancer
Gross features: Metastatic Carcinoma
Metastases usually present as a solitary firm nodule with a thickened fibrotic appearance
Some tumors, however, present with multiple nodules
Their appearance reflects their origin
What Extracutaneous Neoplasms Frequently Involve the Skin?
Any tumor can present as a skin metastasis.
Common primary solid tumors that spread to the skin are breast, gastric, lung, colon, renal, uterine, prostate and liver cancer.
Neuroblastoma in children also may spread to the skin.
Gross features: Metastatic Carcinoma
Certain areas of the skin are predisposed to metastases localizing near the site of primary cancer.
Abdominal wall metastasis at the umbilicus (Sister Mary Joseph’s nodule), often from adenocarcioma of stomach, kidney, or ovary
What Is a Chloroma?
Hematologic malignancies, e.g. leukemia may involve the skin.
Chloroma refers to any tumor, usually a myelogenous leukemia, AML, that produces a green-colored tumor.