Skin
Types of Ulcers (Based on Edge)
- Sloping:
- Venous ulcer, healing ulcer.
- Punched out:
- Arterial ulcer, neuropathic ulcer, bed sores, syphilis.
- Undermined:
- TB ulcer.
- Rolled out:
- Basal cell carcinoma (Rodent ulcer),
- Marjolin's ulcer.
- Cauliflower:
- Squamous cell carcinoma.
Basal Cell Carcinoma (BCC) / Basalioma / Rodent Ulcer:
- AKA Rodent ulcer / Basalioma
Rodent ulcer
Hedgehog pathway inhibitor
Artificial (Artefact) Palaruvi (Peripheral True Palisading)
- Commonality:
- Most common human cancer
- Growth & Metastasis:
- Very slow-growing
- Very locally invasive
- Rarely metastasizes (good prognosis)
- A/w Gorlin syndrome
- Origin: Basal layer of epidermis or follicular structures
- Features:
- Locally invasive (does not metastasize)
- lymph nodes negative.
- M/c subtype is Nodular
Clinical:
- Most common site:
- Face (medial canthus)
- above line joining angle of mouth to earlobe
- Pearly nodule with
- rolled out edges, indurated margins.
- Ulcer with
- overhanging thready margins
- Telangiectasias (fine blood vessels)
- Bleeds on touch
Microscopic Features:
- Peripheral True palisading.
- Retraction artifact.
Treatment for BCC:
- Mohs micrographic surgery
- Small, low-risk, or superficial:
- Imiquimod,
- 5-Fluorouracil,
- Photodynamic Therapy (PDT),
- intralesional alpha 2B therapy
- Large or recurrent:
- Wide local excision
- Targeted:
- Vismodegib (hedgehog pathway inhibitor)
Malignant Melanoma
- Origin: Melanocytes
- Metastasis: Very common
Types:
Type | Description |
Superficial spreading | • m/c in pre-existing mole • Seen in sun exposed areas • e.g : Subungual melanoma (Hutchinson sign) |
Lentigo maligna | • In situ melanoma in elderly • Best prognosis • Insitu melanoma |
Acral melanoma | • m/c in dark skinned patients |
Nodular melanoma | • Most aggressive, rapid vertical phase of growth • Worst prognosis • Amelanotic melanoma : Variant of nodular type |
Hutchinson's
- H → Herpes Zoster Ophthalmicus
- U → subUngual Melanoma (superficial spreading melanoma)
- Hutchinson sign
- T → Triad → congenital syphillis
- Peg shaped teeth
- Interstitial Keratitis (IK + SNHL)
- SNHL
- CH → Chauffeur's Fracture/Backfire Fracture
- Intra articular #
- Son → looking older → Hutchison Gilford
- LMN A gene defect (laminopathy).
- Progeria (onset: Child)
- PUPIL → Hutchinson Pupil
- Herniation of uncus (medial temporal lobe) → compresses ipsilateral CN III → same side pupillary dilatation.
- Kernohan’s notch phenomenon:
- False localizing sign
- Ipsilateral pupil dilatation
- Ipsilateral UMN palsy
Precursor Lesions:
- Large congenital melanocytic nevi (CMN):
- Trunk, especially >20 cm with satellite lesions
- High chance of conversion
- Junctional nevi: Highest risk of transformation
- Atypical or dysplastic nevi
Investigations:
- Biopsy (Confirmatory):
- IHC markers
- S-100, Melan-A, HMB-45.
ABCDE Changes (for pre-existing mole -> malignant transformation):
- Asymmetry: Mole asymmetrical
- Borders: Irregular
- Color: Different colours
- Diameter: Larger than pencil eraser
- >6 mm.
- Evolution: Sudden changes in size, shape, colour
Staging:
- Clarke & Breslow:
- Depends on depth of invasion.
- TNM staging.
Management:
- Wide local excision.
- Margins measured before excision, based on Breslow depth
- Sentinel lymph node biopsy
Prognostic Factor:
- Lymph node status >>> Breslow thickness
- mitotic rate, ulceration
- Special Stains:
- Masson fontana
- Enzyme stain:
- Dopa oxidase.
- Immunohistochemistry:
- HMB45
- S100
- Mnemonic: Her Brain was full of Black Malam (Brain has melanin in substantia nigra) → She was dumb (Mandana → masson fontana)→ But Dope (Dopa oxidase) looking and good hump (HMB45) and base (Stratum basale)
Marjolin's Ulcer
- Low-grade squamous cell carcinoma arising from:
- chronic venous ulcers (e.g., venous ulcer)
- Post-burn scar
- Chronic osteomyelitis
- Post-radiation ulcer
- Slow growing
- Due to being relatively avascular
- Painless
- Due to absence of nerves in scar tissue
- No secondary deposits
- Due to no lymphatics in scar tissue
- Radioresistant
- Due to avascularity
Management:
- Wedge biopsy
- Wide Local Excision (WLE).
Erythrasma
- Contributing factors:
- Warm and humid environments
- Poor hygiene
- Appearance: Red or brown patches
- Organism features:
- Corynebacterium minutissimum
- Gram-positive bacterium
- Colonizes the skin
- Common sites:
- Groin
- Armpits
- Between toes
Soft Tissue Sarcoma (STS)
Site of Soft Tissue Sarcoma in Order
- Lower limb (Commonest site) > Upper limb > Trunk > Retroperitoneum > Head and neck.
Most Common Types:
- Overall STS:
- Liposarcoma.
- M/c Retroperitoneal tumor
- Liposarcoma
- STS in children:
- Rhabdomyosarcoma.
- STS in males:
- Malignant fibrous histiocytoma.
Clinical Features:
- Lump/mass (most common).
Spread:
- Hematogenous > Lymphatic (Rare).
- Limbs to Lungs.
- Retroperitoneum to Liver.
- Exceptions (STS spreading to LN)
- Mnemonic: MARCES:
- Malignant fibrous histiocytoma
- Angiosarcoma
- Rhabdomyosarcoma
- Clear cell
- Epithelioid
- Synovial
- Management for these:
- Lymph node (LN) clearance.
Investigations:
- Tru-cut/Core biopsy (Confirmatory).
- Staging: PET-CT.
Management:
- Wide local excision + Radiotherapy + Chemotherapy.
Prognostic Factor:
- Grade of tumor (most important)
Desmoid Tumour
- Type: STS of anterior abdominal wall.
- Location: Seen at scar sites.
- Features: Increased chances of recurrence.
- Association: Gardner Syndrome.
- Management: Wide local excision.
Gardner Syndrome
- Skin: Sebaceous cysts.
- Fibrous tissue: Fibromas.
- Bone: Osteomas.
- Dental: Supernumerary teeth
- GI: Intestinal polyposis.
- Desmoid tumor
- Mnemonic: Gardener (gardening through body layers)
Fibrosarcoma
- Microscopic Pattern: Herringbone pattern
- Hypoglycemia - Paraneoplastic syndrome
- Mnemonic: Fibrosarcoma → Tiger nte skin (pattern similar app.) um bonum (Herringbone) vachitulla fiber
Leiomyosarcoma (Smooth Muscle Cancer)
- Mnemonic:
- Leo (Leomyosarcoma) → Vijay (Vimentin) with Cigar (Cigar shaped nuclei) → smooth (smooth muscle) actor (Actin positive)
- Malignant smooth muscle tumor.
- Microscopic: Nuclei appear like cigars.
- M/c Smooth muscle sarcoma of Stomach
- IHC Stains:
- Vimentin positive (all sarcomas) and
- Smooth muscle actin positive.
- Exhibits cigar-shaped nuclei.
- Cigar-shaped nuclei seen in
- anything to do with smooth muscle
- Normal smooth muscle
- Leiomyoma
- Leiomyosarcoma
- Diagnostic criterion for Leiomyosarcoma
- Mitosis (≥ 10 mitosis per 10 HPF).
Rhabdomyosarcoma (Skeletal Muscle Cancer)
- Embryonal Rhabdomyosarcoma:
- Known as Sarcoma Botryoides.
- "Botryoides" means grape-like
- Microscopic:
- Cambium layer (cells accumulated in one area).
- Cells are very long → strap cells or tennis racket cells.
- Special Stain:
- PTAH (Phosphotungstic Acid Haematoxylin).
- "PTAH" sounds like "pai" (strength for skeletal muscle).
- IHC Stains:
- Vimentin positive
- Desmin positive
- MyoD positive.
- Mnemonic: Rhabdomyosarcoma → → Sar (Vimal (Vimentin)) →
- Tennis (Tennis racket cells) kambiyil (Cambium layer) strap chyth → Ptah (PTAH → Phosphotungistic acid hematoxylin) nnu adich
- Myran (myoD) Desp (desmin) ayi
Tennis Racket Appearance
Condition | Context / Type |
Rhabdomyosarcoma | Skeletal muscle tumor |
Langerhans cell histiocytosis | Seen on electron microscopy |
Giardia lamblia | Parasite (microbiology) |
Clostridium tertium | Bacteria (not tetani) |
Angiosarcoma
- Most Common Organ:
- Most commonly in the liver.
- Most common cause for malignant cancer of heart in adults
- Causes: VAT chemicals:
- V: Vinyl chloride (plastics, polyvinyl chloride).
- A: Arsenic (pesticides).
- T: Thorotrast (thorium-based contrast dye, old radiology use).
- Thorotrast,
- Thorotrast linked to
- HCC,
- cholangiocarcinoma &
- renal cell carcinoma.
- Angiosarcoma (VAT → Plastic)
- Histology:
- Anastomosing vascular channels.
- Highly pleomorphic cells.
- IHC markers:
- von Willebrand factor.
- Factor VIII.
- VEGF.
- CD31 (PCAM)
- Mnemonic: Plastic (Plastic industry) ittu Vaattan (VAT) poyapo Liveril blood cancer vannnu
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