DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRY

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1 DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRY David R. Carr, MD I HAVE NO RELEVENT RELATIONSHIPS WITH ANY COMPANIES

2 The most likely diagnosis is A. Actinic lentigo B. Eschar C. Blue nevus D. Melanoma E. Pigmented basal cell carcinoma

4 The most likely diagnosis is A. Actinic lentigo B. Eschar C. Blue nevus D. Melanoma E. Pigmented basal cell carcinoma

5 Melanoma Melanoma is a common cutaneous malignancy, with an increasing incidence (from 1 in 1500 in 1935 to 1 in 50 in 2010). Approximately 30% of melanomas develop in preexisting melanocytic lesions, the remaining 70% develop de novo.

6 Melanoma Clinically, the six signs of melanoma are covered by the ABCDE pneumonic. A symmetry B order C olor D iameter E volving There are four major types of melanoma: superficial spreading (70%), nodular (15%), lentigo maligna melanoma (5%), and acral lentigenous melanoma (5-10%).

7 2009 AJCC Melanoma Staging Guidelines Major changes from 2002 Mitotic rate replaces level of invasion as a primary criterion for defining T1b melanoma Clark level only used as default criterion for thin melanomas Lymph node micrometastasis (even when only detected with immunohistochemistry) are classified as Stage III SLN biopsy as standard of care

8 Melanoma (Dermoscopy) -Multiple colors -Regression structures -Homogenous area -Asymmetry -Atypical network Image: Malvehy et al. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. JAAD. 2007;57:84.

9 Melanoma (Dermoscopy) -Multiple colors -Regression structures -Homogenous area -Asymmetry -Atypical network Image: Malvehy et al. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. JAAD. 2007;57:84.

10 Actinic Lentigo Presents as a light to medium brown macule Eschar Presents as a hard, usually darkened plaque overlying an area of necrosis

11 Blue Nevus Pigmented basal cell carcinoma More likely to be found on an older patient with sun-damaged skin. Pearly nodule with dark brown to black pigment. Well-circumscribed steel-blue macule/papule/nodule

12 The most likely diagnosis is A. Branchial cleft cyst B. Lipoma C. Mucocele D. Pyogenic granuloma E. Venous lake

14 The most likely diagnosis is A. Branchial cleft cyst B. Lipoma C. Mucocele D. Pyogenic granuloma E. Venous lake

15 Mucocele Translucent papule usually on the lower lip Mucus extravasated into surrounding soft tissues 2 to trauma to minor salivary glands A pseudocyst Asymptomatic, rapid onset Most resolve spontaneously

16 Pyogenic Granuloma A. Present as a beefy red papule, often with an epithelial collaret Venous Lake Presents as a blue to purple macule on the lip

17 Other Distractors A. Branchial cleft cyst: Presents as a subcutaneous nodule on the lateral neck. It is a congenital epithelial cyst due to failure of obliteration o fthe second branchial cleft. B. Lipoma: Presents as a soft, subcutaneous nodule

18 This 10 year old patient presents with a plaque present since birth, that has become more raised. What is the diagnosis?: A. Comedonal acne B. Flat warts C. Epidermal nevus D. Nevus sebaceous E. Seborrheic keratosis

20 This 10 year old patient presents with a plaque present since birth, that has become more raised. What is the diagnosis?: A. Comedonal acne B. Flat warts C. Epidermal nevus D. Nevus sebaceous E. Seborrheic keratosis

22 Nevus sebaceous Presents in early childhood on scalp or face Solitary, circumscribed, oval or linear alopecic plaque Younger: orange-yellow, smooth and waxy Older: orange-yellow to brown and verrucous Neoplasms commonly arise in association with NS Trichoblastoma and syringocystadenoma papilliferum May be associated with internal abnormalities Especially when large Neurologic, skeletal, ocular

23 Comedonal acne Discrete papules with a central white or black coloration Flat Warts Thin, flat skin colored to light brown papules

24 Epidermal nevus Flat tan to brown patches at birth - thickened and verrucous with age Seborrheic keratosis Verrucous, skin colored to brown stuck-on plaque

25 The most likely diagnosis is: A. Amelanotic melanoma B. Glomus tumor C. Infantile hemangioma D. Kaposi sarcoma E. Pyogenic granuloma

27 The most likely diagnosis is: A. Amelanotic melanoma B. Glomus tumor C. Infantile hemangioma D. Kaposi sarcoma E. Pyogenic granuloma

29 Pyogenic granuloma Rapidly growing, friable, red papule or polyp of skin or mucosa Frequently ulcerates Children and young adults Gingiva, fingers, lips and face Gingival lesions common in pregnancy Association with systemic retinoids May persist indefinitely if not removed

epidermis suggests pyogenic granuloma A red to purple papule, nodule

30 Amelanotic melanoma Infantile hemangioma A skin colored to pink plaque, papule or nodule; the beefy red color and collarete of epidermis suggests pyogenic granuloma A red to purple papule, nodule or plaque; the beefy red color and collarete of epidermis suggests pyogenic granuloma

31 Kaposi Sarcoma Deep red to purple macule, papule or plaque

32 Other distractors Glomus tumor: A skin-colored to bluish papule on the distal digit, often with accompanying nail dystrophy

33 The most likely diagnosis is: A. Melanoma B. Junctional nevus C. Compound nevus D. Spitz nevus E. Intradermal nevus

35 The most likely diagnosis is: A. Melanoma B. Junctional nevus C. Compound nevus D. Spitz nevus E. Intradermal nevus

36 Spitz nevus A pink/reddish papule that is typically smooth, well defined and dome-shaped A melanocytic proliferation that usually occurs in first two decades of life Characteristic histologic features that can be confused with melanoma

37 Junctional nevus Dark brown macule with symmetry and clear borders. Melanoma Asymmetry, boarder irregularities, color variation, and large size

38 Compound nevus Light to dark brown papule with symmetry and clear borders. Intradermal nevus Skin colored papule.

39 The most likely diagnosis is: A. Actinic keratosis B. Eczema C. Infiltrative BCC D. Rosacea E. Sarcoidosis

41 The most likely diagnosis is: A. Actinic keratosis B. Eczema C. Infiltrative BCC D. Rosacea E. Sarcoidosis

43 Basal cell carcinoma Pink to red, translucent, papules or plaques with overlying telangiectasias History of bleeding Most common malignancy in humans Nodular, superficial, micronodular, morpheaform and infiltrative subtypes

44 Other distractors Actinic keratosis Would have more overlying keratotic debris and would not have a papular components Eczema Erythematous patches and plaques. Again, would not appreciate a papular component and would be less well defined Rosacea Diffuse erythema, particularly over the mid face. There may be a papulopustular component. Sarcoidosis Red-brown to violaceous papules and plaques, particularly over the face, lips, neck, and upper extremities

45 A 62 year old white male presents with a 2 year history of this slowly expanding, tender plaque. What is the most likely diagnosis? A. Chancre B. Lichen planus C. Lichen simplex chronicus D. Psoriasis E. Squamous cell carcinoma

47 A 62 year old white male presents with a 2 year history of this slowly expanding, tender plaque. What is the most likely diagnosis? A. Chancre B. Lichen planus C. Lichen simplex chronicus D. Psoriasis E. Squamous cell carcinoma

48 Squamous cell carcinoma Pink to red papules, plaques, or nodules on sun exposed skin Occasionally symptomatic with pain or itching Surface may be smooth, keratotic, or ulcerated SCC related to arsenic exposure develops predominately on the palms and soles

50 Lichen Planus -Purple, polygonal, pruritic papules with lichenoid scale

51 Other incorrect answers Chancre is painless ulcer of primary syphilis. LSC in the male genital area is almost always on the scrotum, not a localized area on the shaft. Psoriasis on the penis is most commonly on the glans, not the shaft

52 The most likely diagnosis is: A. Squamous cell carcinoma B. Basal cell carcinoma C. Wart D. Trichofolliculoma E. Epidermal inclusion cyst

54 The most likely diagnosis is: A. Squamous cell carcinoma B. Basal cell carcinoma C. Wart D. Trichofolliculoma E. Epidermal inclusion cyst

55 Trichofolliculoma Follicular hamartoma where a formed follicular structure comes out of a central infundibular space Presents as a papule, sometimes with a central tuft of hair (as in the kodachrome) Benign lesion

often has scale, crust, or a keratin plug Presents as a pink

56 Squamous cell carcinoma Basal cell carcinoma Squamous cell carcinoma: Is not as smooth appearing as a cylindroma and often has scale, crust, or a keratin plug Presents as a pink smooth, glistening plaque or nodule, sometimes with ulceration.

57 Wart Exophytic, verrucous papule, often with characteristic punctate black dots (thrombosed capillaries) Epidermal Inclusion Cyst Subcutaneous nodule with a central punctum

58 A 40 year old kidney transplant recipient presents with this persistent periungal growth. A. Wart B. Molluscum contagiosum C. Aquired digital fibrokeratoma D. Arsenical keratosis E. Seborrheic keratosis

60 A 40 year old kidney transplant recipient presents with this persistent periungal growth. A. Wart B. Molluscum contagiosum C. Aquired digital fibrokeratoma D. Arsenical keratosis E. Seborrheic keratosis

61 Wart (Verruca vulgaris) Asymptomatic, verrucous papules May occur anywhere, but more commonly on the hands and feet Do not become clinically apparent until several months after inoculation Caused by human papillomavirus (HPV)

62 Acquired Digital Fibrokeratoma Benign, solitary, skin-to-pink colored, slightly keratotic exophytic papulonodule

63 Molluscum contagiosum Other distractors Presents as a pink, small papules, often with a central umbilication. Arsenical keratosis Keratotic papules often found on the palms and soles (associated with arsenic exposure). Seborrheic keratosis Firbrown macules, papules, plaques, or polypoid lesions, often with a verrucous or stuck-on appearance.

64 A 45 year old white male presents with a history of multiple basal cell carcinomas and these hand findings. What is the most likely diagnosis? A. Non-syndromic basal cell carcinomas B. Basal Cell Nevus Syndrome C. Rombo Syndrome D. Bazex-Dupre-Christol Syndrome E. Brooke-Spiegler Syndrome

66 A 45 year old white male presents with a history of multiple basal cell carcinomas and these hand findings. What is the most likely diagnosis? A. Non-syndromic basal cell carcinomas B. Basal Cell Nevus Syndrome C. Rombo Syndrome D. Bazex-Dupre-Christol Syndrome E. Brooke-Spiegler Syndrome

67 Basal Cell Nevus Syndrome (Gorlin s Syndrome) AD inheritance, Mutation in PATCHED (PTCH) Cutaneous: BCC, palmar pits, Other: odontogenic keratocysts (radiolucent, mandible > maxilla), lamellar calcification of falx cerebri, frontal bossing, hypertelorism, broad nasal root, pectus deformity, and osseus anomalies of the ribs, spine and skull Risk for calcified multinodular ovarian fibroma +/- mental impairment

68 Rombo Syndrome AD Distractors Cutaneous: vermiculate atrophoderma, multiple BCC, trichoepitheliomas, acrocyanosis Bazex-Dupre-Christol Syndrome X-linked dominant, Cutaneous: Follicular atrophoderma, multiple BCC, hypotrichosis and hypohidrosis

69 Brooke-Spiegler Mutation in CYLD gene Distractors Cutaneous: Multiple trichoepitheliomas, spiradenomas, and cylindromas. May have BCC s, but often not a prominent feature. Other: Infrequently associated with parotid and salivary gland tumors

70 A 66 year old female presents for evaluation of facial papules that began 2 years previously, at the same time the patient was diagnosed with bladder cancer. Histopathology revealed sebaceous epitheliomas and PCR showed high-frequency microsatellite instability. What is the diagnosis? A. Cowden Syndrome B. Muir Torre Syndrome C. Gardner Syndrome D. Tuberous Sclerosis E. Birt-Hogg-Dube Syndrome

72 A 66 year old female presents for evaluation of facial papules that began 2 years previously, at the same time the patient was diagnosed with bladder cancer. Histopathology revealed sebaceous epitheliomas and PCR showed high-frequency microsatellite instability. What is the diagnosis? A. Cowden Syndrome B. Muir Torre Syndrome C. Gardner Syndrome D. Tuberous Sclerosis E. Birt-Hogg-Dube Syndrome

73 Muir-Torre Syndrome An autosomal dominant syndrome considered a subtype of hereditary non-polyposis colorectal cancer (HNPCC) syndrome (Lynch Syndrome) Associated with carcinomas Adenocarcinoma of the colon Genitourinary carcinomas Cutaneous manifestations Sebaceous neoplasms and keratoacanthomas Caused by mutations in DNA mismatch repair genes (MSH2, MSH1, MSH6) leading to microsatellite instability

74 Cowden Syndrome AD, mutation in PTEN Distractors Cutaneous: trichilemmomas, acral keratoses, oral papillomas Other: thyroid (adenomas, follicular carcinoma) and breast (fibrocystic disease and carcinoma) Gardner Syndrome AD, mutation in APC Cutaneous: epidermoid cysts, osteomas, desmoid tumors Other: premalignant polyposis of intestine and adenocarcinoma of GI tract)

75 Tuberous Sclerosis Distractors AD, Mutation in TSC1 and TSC2 genes Cutaneous: Hypopigmented macules, facial angiofibromas, collagenomas and periungal fibromas Other: gingival fibromas, dental pits, hamartomas in numerous organs, seizures Birt-Hogg-Dube Syndrome -AD, mutation in FLCN gene (codes for folliculin) Cutaneous: Fibrofolliculoma, trichodiscoma, acrochordon Other: Pneumothorax: 50 fold increase, Lung cysts, Renal cancer: 7 fold increase

76 A 52 year old male presents for evaluation of his right inguinal fold. The patient has used topical antifungals for one year without resolution. What is the most likely diagnosis? A. Bowen disease B. Extramammary Paget C. Inverse psoriasis D. Lichen planus E. Lichen simplex chronicus

78 A 52 year old male presents for evaluation of his right inguinal fold. The patient has used topical antifungals for one year without resolution. What is the most likely diagnosis? A. Bowen disease B. Extramammary Paget C. Inverse psoriasis D. Lichen planus E. Lichen simplex chronicus

80 Extramammary Paget disease Slow-growing, well-demarcated pink or red plaque Scattered areas of white scale give a strawberries and cream appearance Pruritus and burning is common Vulva is the most frequently affected site, followed by perianal region in men Almost exclusively seen in elderly white population Associated underlying malignancy in 14% to 20%

81 The most likely diagnosis is: A. Minocin (minocycline) pigmentation B. Vitiligo C. Lichen sclerosis D. Tinea versicolor E. Idiopathic guttate hypomelanosis

83 The most likely diagnosis is: A. Minocin (minocycline) pigmentation B. Vitiligo C. Lichen sclerosis D. Tinea versicolor E. Idiopathic guttate hypomelanosis

84 Vitiligo Aquired pigment disorder of the skin and mucous membranes Has well circumscribed, depigmented macules and patches Several subtypes: Localized: Focal, Segmental, Mucosal Generalized: Acrofacial and Vulgaris Universal Repigmentation first noted in perifollicular skin

85 Minocycline Pigmentation Type I: Blue-black pigmentation in scars Type II: Blue-grey pigmentation in previously normal appearing skin Type III: Brownish discoloration of sunexposed skin

86 Minocycline Pigmentation Type I: Blue-black pigmentation in scars Type II: Blue-grey pigmentation in previously normal appearing skin Type III: Brownish discoloration of sunexposed skin

87 Tinea versicolor Hypopigmented or hyperpigmented macules with light scale Predominantly on the upper chest and back, though it can also involve the face and extremities

88 -Lichen sclerosis: -Often presents with hypopigmented papules and plaques with epidermal atrophy and follicular plugging. -most commonly affects genital skin, though may be extragenital -Idiopathic guttate hypomelanosis: -very common disorder Other incorrect answers -sharply defined, white macules -spontaneous repigmentation not reported -most commonly on the shins and forearms

89 The most likely diagnosis is: A. Allergic contact dermatitis B. Metastatic breast carcinoma C. Majocchi granuloma D. Seborrheic dermatitis E. Seborrheic keratoses

91 The most likely diagnosis is: A. Allergic contact dermatitis B. Metastatic breast carcinoma C. Majocchi granuloma D. Seborrheic dermatitis E. Seborrheic keratoses

92 Cutaneous metastases Females: breast, melanoma Males: melanoma, lung, colon Often in anatomic vicinity of primary tumor Morphology varies, but most typical is firm, painless, erythematous, expanding dermal nodule that may ulcerate Usually associated with advanced disease and poor prognosis

93 Metastatic renal cell carcinoma

94 Metastatic prostate carcinoma

95 A 15 year old patient present with a recently changing mole over the mid chest. What is the diagnosis? A. Agminated Spitz nevi B. Halo nevus C. Hypopigmented macules of tuberous sclerosis D. Tinea versicolor E. Vitiligo

97 A 15 year old patient present with a recently changing mole over the mid chest. What is the diagnosis? A. Agminated Spitz nevi B. Halo nevus C. Hypopigmented macules of tuberous sclerosis D. Tinea versicolor E. Vitiligo

98 Halo nevi Most common in teenagers with many nevi Mean age, 15 years 20% of people also have vitiligo Asymmetric, irregular halo seen with melanoma Examine patients >40 years carefully for melanoma Lymphocytic infiltrate

99 Halo nevus

100 The most likely diagnosis is: A. Ashy dermatosis B. Pityriasis rubra pilaris C. Pustular acne D. Keratosis pilaris E. Lichen amyloid

101

102 The most likely diagnosis is: A. Ashy dermatosis B. Pityriasis rubra pilaris C. Pustular acne D. Keratosis pilaris E. Lichen amyloid

103 Keratosis Pilaris Autosomal dominant with variable penetrance Numerous small, rough, pink or tan papules Most commonly dorsal upper arms, thighs, buttocks, flanks. Less commonly face Keratin plugging at follicular orifice Usually improves with increasing age Treatments are invariably ineffective

104 The most likely diagnosis is: A. Nevus spilus B. Blue nevus C. Lentigo D. Traumatic tattoo E. Pigmented basal cell carcinoma

105

106 The most likely diagnosis is: A. Nevus spilus B. Blue nevus C. Lentigo D. Traumatic tattoo E. Pigmented basal cell carcinoma Photo courtesty of Matt Zirwas, MD

107 Blue nevus Common blue nevus is a well-circumscribed steel-blue macule/papule/nodule most commonly beginning in early life; 50% occur on the dorsal, distal extremities Cellular blue nevus is a blue or bluish black, firm nodule most commonly on buttock/sacrococcygeal region or scalp in middleaged women Common blue nevi are usually <1cm while cellular blue nevi are commonly >1cm Given their dark color, they must be distinguished from melanoma

108 Nevus Spilus A light tan to brown macule with speckled darker brown macules or papules. Pigmented BCC More likely to be found on an older patient with sun-damaged skin. Pearly nodule with dark brown to black pigment.

109 Lentigo Traumatic tattoo More brown in color and macular Could have the same color as a blue nevus but is macular and not papular tic tattoo

Benign versus Cancerous Lesions How to tell the difference FMF 2014 Christie Freeman MD, CCFP, DipPDerm, MSc

1 Benign versus Cancerous Lesions How to tell the difference FMF 2014 Christie Freeman MD, CCFP, DipPDerm, MSc Benign lesions Seborrheic Keratoses: Warty, stuck-on Genetics and birthdays Can start in late