皮肤肿瘤课件_4

BenignandMalignantSkinTumors 全猛 Title 1 Introduction2 SeborrheicKeratosis3 MelanocyticNevi4 NevusSebaceousandEpidermalNevus5 ActinicKeratosis6 NonmelanomaSkinCancer7 Melanoma8 SkinCancer EarlyDetectionandFollow Up 1 Introduction Skinneoplasmsarecommonconcernsforwhichpatientsseekmedicalattention Familiaritywiththesebenignandmalignanttumorsisessentialforappropriateevaluationandmanagement Inthecurrentera skincanceristhemostcommonneoplasminhumans morethan1millionnewcaseswillbediagnosedintheUnitedStatesthisyear Pigmentedlesionsposeaparticularchallengebecausemelanoma thepotentiallylethalformofskincancer isalwayspartofthedifferentialdiagnosis Fortunately earlydetectionandprompttreatmentofskincancer especiallyinthecaseofmelanoma improveoverallprognosisandsurvival Thischapterreviewstheepidemiology pathogenesis clinicalpresentation histopathology andmanagementofcommonbenignandmalignantskintumorsincludingseborrheickeratoses melanocyticnevi actinickeratoses squamouscellcarcinoma SCC basalcellcarcinoma BCC andmelanoma 2 SeborrheicKeratosis DefinitionandEpidemiology Pathogenesis ClinicalPresentation Histopathology Treatment DefinitionandEpidemiology Seborrheickeratosesarecommon benignneoplasmsoftheskinwithcharacteristicclinicalandhistopathologicfeatures Whetherappearingassolitaryormultiplelesions theincidenceincreaseswithage Seborrheickeratosesarerarelypresentbeforethethirdtofourthdecadesandhaveaprevalenceof80 100 inpeopleolderthan50years Pathogenesis Thepathogenesisofthesecommongrowthsisnotentirelyknownbutislikelytobemultifactorial Theproposedriskfactorsincludeaging ultraviolet UV lightexposure andmutationsinfibroblastgrowthfactors ClinicalPresentation Theface neck andtrunkarecommonlyaffectedsites whilethepalmsandsolesarespared Earlylesionsappearashyperpigmentedmacules laterevolvingintoround oval lightbrowntoblackpapulesorplaqueswithsharpdemarcation Thesurfaceiswaxyorverrucouswitha stuck on appearance A 暗角化丘疹 B 扁平隆起斑丘疹 表面粗糙 有厚油脂性鳞屑痂 C 扁平乳头样丘疹 有一层油脂性鳞屑性痂 D 大多脂溢性角化病初期为褐色斑和背部疣状丘疹 Histopathology Seborrheickeratosesarebenignsquamousproliferationswithvariabledegreesofacanthosis hyperkeratosis andpapillomatosis Theyarecomposedofcellswithbasaloidmorphology whichinreactiontoirritationformstructuresknownas squamouseddies Thepresenceofhornpseudocystsandmelaninpigmentisacommonfinding Histopathology A 典型脂溢性角化病病理改变 B 乳头样增生 假性角囊肿基底处于同一平面上 Treatment Seborrheickeratoseshavetraditionallybeenconsideredasbenignneoplasms however differenttypesofskincancershavebeenreportedinassociationwithseborrheickeratoses Moreover recentdatasuggestthepotentialformalignanttransformationofseborrheickeratoses 30Biopsyshouldbeconsideredinlesionsthatappearirritatedorhaveundergoneclinicalchanges Ifmalignancyisnotaconcernafterclinicalevaluation treatmentofseborrheickeratosesisdoneforcosmeticreasonsortoalleviatepotentiallyassociatedsymptomsofpruritus inflammation orbleeding Widelyusedtreatmentsincluderemovalwithcryosurgery liquidnitrogen curettage CO2laserablation focalchemicalpeeling trichloroaceticacid electrodessication orsurgicalexcision 3 MelanocyticNevi DefinitionandEpidemiology Pathogenesis ClinicalPresentation Management DefinitionandEpidemiology Melanocyticneviormolesareverycommonbenignskinneoplasmsthatresultfromtheproliferationofnevuscells whichareslightlyalteredmelanocytes Dependingonthetimeofappearance theseneoplasmsaresubdividedintocongenitaloracquired Theprevalenceofacquirednevidependsonseveralfactorsincludingskintype age geneticpredisposition andsunexposure Thesecommonneoplasmstypicallyappearafter6 12monthsofage increaseinnumberduringchildhoodandadolescence peakinthethirddecade andtendtodisappearwithincreasingage DefinitionandEpidemiology Congenitalmelanocyticneviare bydefinition presentatbirth althoughsometimestheyarenotnoticeduntillaterduringthefirstyearoflife Theirincidencehasbeencalculatedbetween0 2 and2 1 ofnewborns 25Traditionally congenitalnevihavebeenclassifiedaccordingtotheirsizeassmall 20cm Thisclassificationisbasedonthegreatestdiameterofthenevusinadulthood Theatypicalordysplasticnevusisasomewhatcontroversialterm whichreferstomelanocyticneviwithabnormalorunusualclinicaland orhistopathologicfeatures Asopposedtoacquiredmelanocyticnevi atypicalmolesbegintoappeararoundpubertyandmaycontinuetodeveloppastthefourthdecade Theprevalenceofdysplasticneviisvariable rangingfrom7 to18 Pathogenesis Multiplefactorsareinvolvedinthepathogenesisofacquiredmelanocyticnevianddysplasticnevi Thesefactorsincludeskintype geneticpredisposition andsunexposure Congenitalmelanocyticnevidevelopbetweenweeks5and25ofgestation Theyarethoughttoresultfromadysregulatedgrowthandarrestofmelanocytesduringmigrationfromtheneuralcresttotheskin 6Geneticandfamilialpredispositionisparticularlyimportantinasubsetofpatientswithaconditionknownasfamilialatypicalmultiplemolemelanoma FAMMM syndrome PatientswithFAMMMsyndromehavelargeamountsofacquiredmelanocyticnevi someofwhichareatypical andhaveincreasedriskofmelanoma ClinicalPresentation Melanocyticnevipresentaswell defined roundoroval symmetriclesionsmeasuringfrom2to6mmindiameter Theclinicalappearancedependsonthelevelwherethenevuscellsarelocated Neviwithapredominantepidermalcomponent junctionalnevi appearflatwithauniformbrowntoalmostblackcolor Whenthenevuscellsinvolveboththeepidermisandthedermis compoundnevi thenevuswillriseabovetheskinsurfaceandshowlightershadesofbrownwhencomparedtothejunctionalcounterpart Anintradermalnevus nevuscellspredominantlyinthedermis istypicallyaraised dome shapedpapule withpigmentationrangingfromlightbrowntofleshcolor ClinicalPresentation Theclinicalfeaturesofdysplasticneviincludeadiameterlargerthan5mm irregularpigmentation ill definedorirregularborders asymmetry andirregularsurface Figure16 6 Theyaremostcommonlylocatedonthetrunk althoughtheymaypresentanywhereintheskin Congenitalnevioccurmostoftenonthetrunk followedbytheextremities head andneck Congenitalneviareusuallylightbrowninthefirstfewweeksoflifeandfrequentlyundergomultipleclinicalchanges includingdarkening developmentofhair nodules verrucoustexture erosions orulcerations Figure16 7 Thesechangesareseenparticularlyinlargecongenitalmelanocyticnevi notsoofteninsmallormediumsizednevi Patientswithlargecongenitalnevimayalsopresentsatellitenevi whichreferstosmallormedium sizedcongenitalnevidistantfromthelargerlesion ClinicalPresentation Recommendedfollow upforpatientswithatypicalneviorafamilyhistoryofskincancerisatleastanannualfullskinexamination Patientsshouldalsobeencouragedtoperformaself skinexaminationonamonthlybasis Anychanging growing orbleedinglesionshouldbeevaluatedbythephysician Sincesunexposureisthemostpreventableriskfactorforskincancer sunsafetytipssuchasdailyapplicationandreapplicationofbroadspectrumsunscreen wearingsunprotectiveclothing withsunglassesandhats seekingshadeduringpeaksunhours 10a m to4p m andavoidingtanningbedsshouldbesuggestedtoallpatients 3 A 先天性黑色素痣 B 交界痣 对称 边界规则 呈褐色斑疹 C 复合痣 椭圆形 褐色 边界规则对称的丘疹 D 皮内痣 肉色 隆起丘疹 E 发育不良痣 非典型 褐色 不规则边界及表面的非对称斑疹 F 先天性痣 边缘变化较温和 Management Therationaleforremovalofacquiredmelanocyticnevi typicalandatypical reliesontheirassociatedpotentialriskformelanoma and insomecases aesthetics Althoughmelanomascanarisefrommelanocyticnevi mostmelanomaswilldevelopasdenovolesions andmostnevi typicalandatypical willnotprogresstomelanoma Forthisreason prophylacticexcision isgenerallynotrecommended unlessthereareconcerningclinicalchangesthatsuggestmelanoma Althoughlasers cryosurgery andchemicalpeelshavebeenusedtoremovebenign appearingmelanocyticnevi thesemodalitiesaregenerallynotconsideredappropriatetherapyforanevuswithatypicalfeatures sincenotissuewillbeavailableforhistologicinterpretationandanundetectedmelanomacouldpotentiallybepresentintheresiduallesion Ifanatypicalnevusissuspected anexcisionalbiopsyispreferable Management Treatmentofcongenitalneviisbasedonthesizeandthelocationofthelesion Largecongenitalnevihaveanincreasedriskofmelanoma particularlyduringchildhoodandadolescence Managementremainscontroversialassomeauthorsbelievethattheriskisnotsignificantenoughtowarrantlarge complicatedsurgicalprocedures 6However ifacongenitalnevus regardlessofsize isimpairingachild sselfconfidenceorsocialdevelopment possibleexcisionshouldbeinvestigated Treatmentoptionsincludesurgicalexcisionaloneorinconjunctionwithtissueexpansionand orskingrafting curettage dermabrasion chemicalpeeling andlasers Theriskofmelanomainsmallandmediumcongenitalneviisnotwelldeterminedandisthoughttobesimilartotheriskinacquiredmelanocyticnevi Forthisreason surgicalexcisionshouldbeconsideredonanindividualbasis 4 NevusSebaceousandEpidermalNevus Althoughnotascommonasmelanocyticnevi nevussebaceousandepidermalnevusaretwononmelanocyticcongenitalconditionswithpotentialimportantimplications Nevussebaceousisacongenitalovalorlinear hairlessverrucousplaquemostcommonlyfoundonthescalpandface Ittypicallyundergoesdistinctphasesofgrowthduringchildhood puberty andadulthood Differentbenignandmalignantneoplasmscanpotentiallyariseinanevussebaceous particularlyduringpubertyandadulthood Basalcellcarcinoma BCC isthemostcommonlyreportedmalignantneoplasminthistypeofnevi Treatmentofnevussebaceousissurgicalexcision 4 NevusSebaceousandEpidermalNevus Pastrecommendationsforremovalofalllesionsarenowquestionedsincetheincidenceofmalignanttransformationislow Currentpracticeadvocatesobservationandremovaloflesionsclinicallysuspiciousformalignancy Epidermalnevuspresentwithinthefirstyearoflifeaswellcircumscribed linear orwhorledplaquescommonlyfoundonthetrunkandextremities Figure16 9 Withtime thesurfacemaybecomemoreverrucous andpigmentationcanvaryfromskincolortopinktohyperpigmented Inasubsetofpatients theepidermalnevusaswellasthenevussebaceousandotherlesscommonskinlesionscanhaveassociatedsystemicinvolvement termedepidermalnevussyndrome Themostcommonextracutaneousmanifestationsinvolvethoseinthecentralnervoussystem skeletalsystem andeyes A 皮脂腺痣 橙黄色蜡状斑块 B 表皮痣 线性 浅棕色 疣状 乳头状瘤的斑块 5 ActinicKeratosis DefinitionandEpidemiology Pathogenesis ClinicalPresentation Histopathology Treatment DefinitionandEpidemiology Actinickeratosesareultraviolet UV lightinduced insituepidermaldysplasias alsoknownassolarkeratoses Historicallyconsideredapremalignantneoplasmwiththepotentialtodevelopintoasquamouscellcarcinoma SCC recentdebatehascenteredonthecontroversyofwhethertheyrepresentaprecancerousconditionversusaninsituSCC Actinickeratosesoccurprimarilyinfairskinnedindividualswithahistoryofchronicsunexposure WithskinphototypesI III theprevalenceinpatientsolderthan40yearshasbeencalculatedat40 Inpatientsolderthan60years theprevalenceincreasesto80 Pathogenesis NaturalUVradiation mainlyUV B 290 320nm isthemainassociatedriskfactorinthedevelopmentofactinickeratosesinfair skinnedindividuals Otherknowncausesincludepriorexposuretox irradiation repeatedUVlightexposurefromartificialsources andexposuretochemicals includingpolycyclicaromatichydrocarbonsandarsenic ClinicalPresentation Mostcommonly actinickeratosespresentasred scalingpapulesorplaquesonsun exposedareas mainlyontheface scalp dorsumofhands andshoulders Figures16 10and16 11 Althoughusuallypresentingasmultiplelesions singleactinickeratosiscanoccur Onaverage theymeasure1 3mmindiameter butlargerorconfluentlesionscanalsobepresent Thesurfaceisroughonpalpation andearlyactinickeratosescanbemoreeasilyfeltthanseen Notinfrequently thepatientmayreportpruritus tenderness andburningsensation GiventhecausaleffectofUVlightexposure thesurroundingskintypicallyrevealssignsofsundamage includingtelangiectasiasandblotchypigmentation Otherclinicalpresentationsincludethepigmentedactinickeratosis thecutaneoushorn actiniccheilitis andlichenplanus likekeratosis Thecutaneoushornisahypertrophicvariantofspecialconsideration sinceupto8 9 oftheselesionsareactuallySCCs 49Sincethepigmentedactinickeratosiscaneasilybeconfusedwithasolarlentigooralentigomaligna histopathologicanalysisisrequiredfordifferentiation A 呈红色 额头和头皮上的粗糙斑块 B 多粗糙 手背上的鳞片状丘疹 Histopathology Thehallmarkofactinickeratosisisthepresenceofdysplastickeratinocytesintheepidermisassociatedwithprominentparakeratosis whichcanalternatewithorthokeratosis Inearlylesions dysplasticcellsarescatteredandinvolvethebasallayersonly Asthedysplasiaspreadstothefullthicknessoftheepidermis thediagnosisofinsituSCCiswarranted Treatment ThemainrationalefortreatingactinickeratosesistopreventmalignanttransformationintoSCC butcosmesisandsymptomaticreliefmayalsoplayarole Multipletreatmentmodalities includingsurgicalandmedicaloptions areavailable Thetreatmentofchoicemustbetailoredtotheindividual Factorssuchasthenumberandlocationofthelesions clinicalsubtype andpatientpreference mustbetakenintoaccount Inmanycases acombinationofsurgicalandmedicaltreatmentsisoptimal Whenevertheclinicaldiagnosisisnotclear abiopsyshouldbeconsidered Treatment Proceduraloptionsincludecryosurgery curettageandelectrodessication dermabrasion laserablationwithCO2orerbium YAGlasers photodynamictherapy medium depthchemicalpeeling andsurgicalexcision Medicaltreatmentoptionsareusedmainlyforpatientswithmultipleorwidespreadlesions Theseoptionsinclude5 fluorouracilcream solution imiquimodcream diclofenacgel oralandtopicalretinoids andinterferon 2b Regardlessofthetreatmentmodalitychosen photoprotectionmustalwaysbeadvisedinanattempttopreventorreducethenumberofactinickeratosesinthefuture 6 Melanoma DefinitionandEpidemiology Pathogenesis ClinicalPresentation StagingandPrevention Treatment DefinitionandEpidemiology Cutaneousmelanomaisaneoplasmthatarisesfrommelanocytesasadenovolesion butitmayalsodevelopfromcongenitaloracquirednevi Otherpotentialsitesinwhichmelanomascanformincludemucousmembranes retina leptomeninges lymphnodes andgastrointestinalandgenitourinarytracts Aroundtheworld theincidenceofmelanomahasbeenincreasingsteadily withnon Hispanicmenolderthan65yearsshowingthehighestincreaseinrate 17Theestimatednumberofcasesofmelanomain2007was59 940 33 910inmales and26 030infemales accordingtotheAmericanCancerSociety 4givingmenanapproximately1 5timeshigherriskofdevelopingmelanomawhencomparedtowomen Thepeakincidenceofmelanomaisamongpeopleaged20 45years incontrasttononmelanomaskincancer whichoccursmainlyinolderpatients DefinitionandEpidemiology Mortalityratesshowvariablepatternsdependingonthegeographiclocation EventhoughthemortalityrateintheUnitedStateshasremainedstableinmenandevendecreasedamongwomen theworldwidetrendisforuniformlyincreasingmortalityrates Thisincreaseinmortalityisparticularlynoticeableinoldermenandwomen Deathsfrommelanomain2007wereestimatedtobe8 110 Ontheotherhand earlydetectionandeducationprogramshaveledto5 yearsurvivalratesexceeding90 incertaincountriesincludingtheUnitedStates Thishighlightstheimportanceofadequateclinicaldiagnosticskillstodetectearlydisease Althoughanyonecandevelopmelanoma theparticularriskfactorsincludeadvancedage malegender familyhistoryofmelanoma personalhistoryofmelanomaornonmelanomaskincancer organtransplantrecipient lowsocioeconomicstatus atypicalnevi andfairskinnedindividuals Pathogenesis Melanomadevelopsfromacombinationofconstitutionalpredisposingandenvironmentalfactors particularlyUVradiation Theroleofsunexposureandmelanomaformationiscomplex andbothnaturalandartificialUVlighthavebeenlinkedtothedevelopmentofmelanoma particularlywhenexposureoccursbeforetheageof35years 23Thehostfactorsassociatedwithincreasedriskofmelanomaincludenumberofmelanocyticnevi bothdysplasticandnondysplastic familyhistory immunosuppression andcertainphenotypiccharacteristicssuchasblueorgreeneyes blondorredhair andskinsensitivitytothesun 32Geneticandmolecularabnormalitiesassociatedwithsomeofthesehostfactors andthereforelinkedwithmelanoma includemutationsinCDKN2Ageneandmelanocortin 1receptor Pathogenesis ThemodelofprogressionfromnormalmelanocytestomelanomawasproposedbyClark Thismodelreferstostepwisehistologicchanges startingwiththeacquiredmelanocyticnevusundergoingaberrantdifferentiationandnuclearatypiaresultingintheformationofprimarymelanoma whichinitiallyhasaradialgrowthphasefollowedbyaverticalgrowthphase endingwiththedevelopmentofmetastaticmelanoma ClinicalPresentation Clinicalevaluationofpigmentedlesionscanbecomplicated becausemelanomaispartofthedifferentialdiagnosis Aconventionalguide particularlyforevaluationofnevi istheABCDEacronym whichlistsclinicalcharacteristicsthatcanbeassociatedwithmelanoma TheacronymstandsforAsymmetry Borderirregularity Colorvariation Diameterlargerthan6mm andEvolvingreferringtochangesinsize shape surface shadesofcolor orpresenceofsymptomssuchaspruritusandpain1 Althoughnotperfect itrepresentsanappropriategeneralguidebothforhealthcareprovidersandforpatients The uglyducklingsign isanotherusefulclinicalfindingthatreferstotheatypicalappearanceofapigmentedlesionwhencomparedwithsurroundingnevi 19Dermoscopyorepiluminescencemicroscopyhasgainedpopularityastheoneaidingintheearlyclinicaldiagnosis Thisisanoninvasivetechniqueusingahigh resolution optical handhelddeviceordermoscopetoenhancevisualizationofmicroscopicstructuresofpigmentedlesions ClinicalPresentation Aclinicopathologicclassificationdividesmelanomasintosuperficialspreading lentigomaligna nodular andacrallentiginous Approximately70 ofcasesofmelanomaaresuperficialspreadingmelanoma mostoftenoccurringonthebackofthelegsofwomenandonthebacksofmen Althoughacrallentiginousisingeneralanuncommonsubtype itrepresentsthemostcommontypeofmelanomaamongAsian Hispanic andAfricanpatients A 黑色素瘤 大而不规则的色素沉淀 非对称斑块 B 呈隆起状黑色素瘤病损 StagingandPrevention In2001theMelanomaStagingCommitteeoftheAmericanJointCommitteeonCancer AJCC publishedthemostrecentmelanomaTNMstagingclassification 7Depthofinvasionisthemostimportanthistologicprognosticparameterinprimarymelanoma BreslowdepthandClarklevelaretwodifferentclassificationsofdepthofinvasionthathavebeenrecognizedfordecades Breslowdepthisaquantitativemeasurementofthedepthofinvasionbymeasuringthetumorthicknesswithanocularmicrometer Clark sstagingreferstothehistologiclevelofinvasion usingtheepidermis papillarydermis reticulardermis andsubcutaneousfatasthehistologicboundaries Withthe2002AJCCstagingclassification tumorthicknessmeasuredbyBreslowdepthwasdeterminedtobetheprimaryfactorforTsta