Leiomyoma

Leiomyoma (70) is derived from the arrector pili muscle of hair follicles or from muscle fibers present in the wall of blood vessels. In the multiple familial type, lesions are distributed over neck and limbs. Onset is in childhood and tumors are red, pink, or brown. A characteristic feature is that pain can be elicited by pressure or low temperature. Also, lesions may shrink when the skin is chilled. The solitary leiomyoma occurs anywhere in the body including the nipple and areola. It is also painful. On histopathological examination there are interlacing fascicles of smooth muscle cells with elongated, blunt, cigar-shaped nuclei.

Surgical excision is the treatment of choice for these tumors.

MALIGNANT TUMORS OF THE SKIN S

Basal Cell Carcinoma |

Basal cell carcinoma (BCC) is the most common of human cancers (Table 2). It >3

develops from the epidermis at the level of the bulge region of hair follicles. Most studies favor unicentric origin. Multiple risk factors are recognized, including ultraviolet (UV) and ionizing radiation, arsenic, chronic wounds, immunosuppression, § and reduced DNA-repair mechanisms. The most significant is chronic exposure to @

Table 2 Malignant Tumors of the Skin

Basal cell carcinoma Superfical multicentric Nodular Morpheaform Fibroepithelioma of Pinkus Squamous cell carcinoma

1. In situ

Bowen's disease Erythroplasia of Queyrat

2. Invasive

3. Verrucous

Buschke- Lowenstein tumor Oral florid papillomatosis Carcinoma cuniculatum Keratoacanthoma

Common solitary keratoacanthoma Giant keratoacanthoma Keratoacanthoma centrifugum marginatum

Multiple self-Healing keratoacanthoma (Ferguson-Smith syndrome) Eruptive keratoacanthoma of the Gryzbowski type Malignant melanoma

Superficial spreading melanoma Nodular melanoma Lentigo maligna melanoma Acral lentiginous melanoma Amelanotic melanoma Desmoplastic neurotrophic Adnexal carcinomas

1. Hair follicles: Pilomatrix carcinoma

2. Sweat Glands

Microcystic adnexal carcinoma Malignant eccrine spiradenoma Malignant chondroid syringoma Eccrine porocarcinoma Malignant clear cell hidradenoma Eccrine mucinous carcinoma Primary cutaneous adenoid cystic carcinoma Malignant cylindroma Paget's disease of the nipple Extramammary Paget's disease Malignant hidradenoma papilliferum Apocrine carcinoma

3. Sebaceous glands: Sebaceous Gland Carcinoma Merkel cell carcinoma

Sarcomas

1. Fibrous tissue >3

Fibrosarcoma

Dermatofibrosarcoma protuberans

Table 2 (Continued)

Atypical fibroxanthoma Malignant fibrous histiocytoma

2. Vascular tissue

Angiosarcoma Kaposi's sarcoma Hemangiopericytoma

3. Muscular tissue

Leiomyosarcoma Cutaneous rhabdomyosarcoma

4. Neural tissue

Malignant peripheral nerve sheath tumor Malignant granular cell tumor

5. Liposarcoma

6. Epithelioid sarcoma Cancer metastatic to the skin

UV radiation in individuals with fair skin, blue eyes, blond hair, and poor tanning ability. Estimates in the Unites States indicate approximately 700,000 new BCCs every year (71). The tumor occurs most frequently in individuals 60 years of age and older and predominates in men. BCC is more common in Whites in whom it forms 70% of skin cancers, compared to 24% in Japanese, and 8% in African-Americans. Approximately 80% of tumors involve the head and neck regions, with almost 30% affecting the nose. Up to 13% of cases present with multiple BCCs, and patients with only one lesion have a cumulative 5 year risk of 45% of showing another BCC (72). The nevoid basal cell carcinoma syndrome (Gorlin's syndrome) is characterized by innumerable BCCs, jaw cysts, palmar and plantar pits, skeletal abnormalities, and calcification of the falx cerebri (73).

Nodular BCC is a translucent pearly papule or nodule with telangiectasias (Fig. 18). It frequently ulcerates, hence the term rodent ulcer. Approximately 70% of tumors belong to this variety, with 7% showing hyperpigmentation due to melanin (pigmented BCC).

Superficial BCC appears as an erythematous scaly patch of variable size. It may contain some areas of atrophy, hypopigmentation and scarring. It resembles tinea, psoriasis, or eczema clinically.

Morpheaform BCC is an indistinct white-to-yellow plaque with marked induration and surface telangiectasias. It is also termed desmoplastic or sclerosing BCC (Fig. 19).

Fibroepithelioma of Pinkus resembles a benign fibroma: the lesion is a smooth, pedunculated, erythematous nodule occurring on the back (Fig. 20).

On histological examination BCC shows islands of basaloid cells with peripheral palisading and tumor-stromal separation artifact (Fig. 21). Occasionally, the cells show features of both BCC and squamous cell carcinoma and the term basos-quamous carcinoma is applied (74). Overall, there are four main histological patterns:

described above, some with cystic degeneration.

Nodular BCC: Approximately 70% of tumors show basaloid nodules as §

Figure 18 Nodular basal cell carcinoma of the nose. This lesion shows characteristic pearly border and surface telangiectasias.

Figure 19 Morpheaform basal cell carcinoma on the midcentral forehead. The plaque is slightly depressed, indurated, and hypopigmented. This variety of basal cell carcinoma is characterized by extensive subclinical extension and aggressive histologic characteristics.

Figure 21 Typical nodular basal cell carcinoma shows multiple nodules of basophilic epithelial cells with peripheral palisading.

Superficial BCC: Ten percent of tumors show small buds of basaloid cells arising from the epidermis. It is difficult to delineate lateral margins.

Micronodular BCC: Smaller round lobules or buds with marked subclinical extension.

Aggressive growth BCC: Nearly 10%-15% of cases comprise this group. The morpheaform or sclerosing variety is characterized by small spiky islands in a markedly sclerotic stroma. The infiltrative type shows, in addition, a variable nodular component.

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