Skin Tumors Practice Questions

Q: A 25 -year-old patient presents with multiple sebaceous adenomas over the neck and chest. His father too had a similar skin disease and died due to colorectal carcinoma. What is the diagnosis?

Muir Torre syndrome. ***Muir Torre syndrome*** - This syndrome is characterized by the presence of at least one sebaceous gland tumor (like **sebaceous adenoma**, sebaceous epithelioma, or sebaceous carcinoma) and at least one internal malignancy, most commonly **colorectal carcinoma** or urogenital cancer. - The patient's presentation with **multiple sebaceous adenomas** and a family history of **colorectal carcinoma** (father) is highly indicative of Muir Torre syndrome, which is a variant of **Lynch syndrome**. *Pseudoxanthoma elasticum* - This is an inherited disorder affecting **elastic fibers** in the skin, eyes, and blood vessels, leading to yellowish papules that coalesce into plaques, often in flexural areas. - It is not typically associated with **sebaceous adenomas** or **colorectal carcinoma**. *Bournville disease* - This is a historical term for **tuberous sclerosis complex**, a genetic disorder characterized by tumor growth in multiple organs including the brain, heart, kidneys, and skin. - Skin manifestations include **ash-leaf spots**, facial angiofibromas, and shagreen patches, but not **sebaceous adenomas** in the context of internal malignancy like colorectal cancer. *Sweet syndrome* - Also known as **acute febrile neutrophilic dermatosis**, Sweet syndrome is characterized by the sudden onset of painful, erythematous plaques and nodules accompanied by fever and neutrophilia. - It is often associated with malignancy (especially hematologic), infection, or drugs, but it does not present with **sebaceous adenomas** or a familial link to specific carcinomas like colorectal cancer.

Q: Identify the condition which is present since birth: (AIIMS May 2017)

Congenital nevus. **Correct: *Congenital nevus*** - A congenital nevus is a **melanocytic nevus** that is present at **birth** or appears shortly thereafter, characterized by a proliferation of **melanocytes** in the skin - These nevi can vary in size and appearance, often appearing as darkly pigmented, sometimes hairy patches - By definition, this is the condition present since birth as asked in the question *Incorrect: Epidermal verrucous nevus* - An **epidermal verrucous nevus** is a common **hamartoma of the epidermis** that can be present at birth or develop in early childhood, characterized by **verrucous** (wart-like) or ridge-like papules and plaques - While it can be congenital, its distinctive **verrucous texture** (wart-like appearance) differentiates it from the smooth, pigmented melanocytic lesion - Not the best answer as the question specifically asks for a condition present since birth, and congenital nevus is more definitively congenital *Incorrect: Melano-acanthoma* - **Melano-acanthoma** is a rare, benign, typically **pigmented lesion** that usually arises in older adults, often on the **trunk or face** - Its late-onset presentation (typically in adulthood) makes it unlikely to be present since birth - This is an acquired condition, not congenital *Incorrect: Malignant melanoma* - **Malignant melanoma** is a serious form of **skin cancer** that typically develops from pre-existing moles or new lesions, most commonly in adulthood - While congenital nevi can rarely undergo malignant transformation into melanoma, melanoma itself is generally not present at birth - Characterized by rapid changes in size, shape, or color (ABCDE criteria), which distinguishes it from stable congenital lesions

Q: Comment on the image shown:

Arsenical keratosis. ***Arsenical keratosis*** - The image shows characteristic **raindrop pigmentation** (alternating hypo/hyperpigmented macules) and **palmar/plantar keratoses** pathognomonic of chronic **arsenic toxicity**. - Associated with **Blackfoot disease** (peripheral vascular disease) and increased risk of **skin malignancies**, distinguishing it from benign hyperkeratotic conditions. *Corn* - A corn presents as a **single, localized lesion** with a **painful central core**, unlike the multiple diffuse keratotic lesions with pigmentary changes seen here. - Corns are **friction-induced** and lack the characteristic **raindrop pigmentation** associated with arsenic exposure. *Callosity* - Callosity results from **repeated friction and pressure** causing broad, flat hyperkeratotic thickening without pigmentary changes. - It lacks the **alternating hypo/hyperpigmented macules** and **corn-like keratoses** characteristic of arsenical toxicity. *Warts* - **Viral warts** caused by **HPV** show **black puncta** (thrombosed capillaries) and **papillomatous surface** upon examination. - They present as **elevated, rough lesions** without the **raindrop pigmentation** and flat keratotic appearance of arsenical keratosis. *Cutaneous horn* - A **cutaneous horn** appears as a **solitary, conical projection** of keratin resembling an animal horn, typically on sun-exposed areas. - It presents as a **single horn-like protrusion** rather than the **multiple flat keratoses** with pigmentary changes shown in arsenical keratosis.

Q: What is the best management of the case shown?

Stop smoking and screen for cancer. ***Stop smoking and screen for cancer*** - The image shows **smoker's palate (nicotinic stomatitis)**, characterized by diffuse white thickening of the palatal mucosa with red dots representing inflamed salivary gland orifices. This condition is caused by **chronic heat exposure from smoking**. - While generally benign, smoker's palate indicates a high risk for other **oral cancers**, particularly those involving the lips, tongue, and floor of the mouth, necessitating smoking cessation and regular screening. *Dapsone plus steroids* - This combination is typically used for **autoimmune blistering diseases** like **dermatitis herpetiformis** or **pemphigoid**, which present with different clinical features. - Smoker's palate is not an autoimmune condition and would not respond to these treatments. *Vitamin supplements* - Vitamin supplements are not a treatment for smoker's palate, as it is a localized lesion caused by irritation from smoke. - While general nutritional support is good, it doesn't address the underlying cause or potential complications of this specific condition. *Antifungals for oral candidiasis* - **Oral candidiasis (thrush)** typically presents as removable white plaques on the oral mucosa, often associated with immunosuppression or antibiotic use. - The lesions in the image are firmly attached, non-removable, and show specific morphological changes (red dots), which are not characteristic of candidiasis.

Q: The following lesion was noticed in a patient with history of involuntary weight loss. What is the diagnosis?

Leser-Trelat sign. ***Leser-Trelat sign*** - The image illustrates numerous rapidly appearing or increasing **seborrheic keratoses**, which, when accompanied by symptoms like **involuntary weight loss**, are highly suggestive of the Leser-Trelat sign. - The Leser-Trelat sign is a **paraneoplastic syndrome** commonly associated with **gastrointestinal adenocarcinomas** or **lymphoid malignancies**. *Acanthosis nigricans* - This condition presents as **dark, velvety patches** on the skin, typically in body folds like the neck, armpits, and groin. - While it can be associated with malignancy (especially gastric adenocarcinoma), the image shows multiple, distinct seborrheic keratoses rather than diffuse hyperpigmentation. *Actinic keratosis* - Actinic keratoses are **premalignant lesions** caused by chronic sun exposure, appearing as rough, scaly patches on sun-exposed areas. - They are typically single or a few scattered lesions and do not usually erupt rapidly or widely as shown, nor are they directly associated with systemic malignancy in the same way as Leser-Trelat. *Intertriginous candida* - Intertriginous candidiasis is a **fungal infection** that occurs in skin folds, characterized by **redness, itching, and satellite lesions**. - The lesions in the image are distinct, raised, and brownish, not consistent with the erythematous and often moist presentation of intertriginous candidiasis.

Q: A 38-year-old man presents with the manifestation shown in the image. He has a number of family members suffering from the same condition, though the severity is different in different members. Which of the following statements is false regarding this condition?

Basal cell carcinoma. ***Basal cell carcinoma*** - Basal cell carcinoma is a type of skin cancer that is **not typically a primary manifestation** of Neurofibromatosis Type 1 (NF1). - While individuals with NF1 may have an increased risk of certain cancers, basal cell carcinoma is **not one of the characteristic features** of the condition. - **This statement is FALSE**, making it the correct answer to this question. *Autosomal dominant condition* - Neurofibromatosis Type 1 (NF1) is inherited in an **autosomal dominant pattern**, meaning only one copy of the mutated gene is needed to cause the disorder. - The patient's history of **multiple family members** suffering from the same condition with varying severity is consistent with autosomal dominant inheritance. - **This statement is TRUE.** *Chromosomal abnormality seen in chromosome 17* - Neurofibromatosis Type 1 is caused by a mutation in the **NF1 gene**, located on **chromosome 17 (17q11.2)**. - This gene encodes for **neurofibromin**, a tumor suppressor protein, and its dysfunction leads to the characteristic features of NF1. - **This statement is TRUE.** *Café-au-lait spots and neurofibromas are characteristic features* - The image displays characteristic features of NF1, including **café-au-lait spots** (large, hyperpigmented macules) and **neurofibromas** (benign tumors of nerve sheath cells). - These are classic diagnostic findings in Neurofibromatosis Type 1, along with axillary/inguinal freckling and Lisch nodules. - **This statement is TRUE.**

Q: A 70 year old man with history of smoking has a 1 cm ulcerative lesion over the vermilion of his upper lip. What is he likely to be suffering from?

Squamous cell carcinoma. ***Squamous cell carcinoma*** - **Squamous cell carcinoma (SCC)** is a **common malignancy** of the lip, particularly in older men with a history of **smoking** and **sun exposure**. - **Ulcerative lesions** on the vermilion border are characteristic clinical features of SCC, necessitating biopsy for confirmation. *Spindle cell carcinoma* - **Spindle cell carcinoma** is a rare, aggressive variant of **squamous cell carcinoma**, but it is not the most likely primary diagnosis given the typical presentation. - Diagnosis typically requires **histopathological examination** showing spindle-shaped malignant cells, which cannot be determined clinically. *Basal cell carcinoma* - **Basal cell carcinoma (BCC)** is more common on sun-exposed areas of the face but is rare on the **vermilion border of the lips**. - BCC lesions typically present as **pearly nodules** with **telangiectasia** or **rolled borders**, rather than a purely ulcerative lesion as described. *Adenoid squamous carcinoma* - **Adenoid squamous carcinoma** is also a rare variant of **squamous cell carcinoma** that exhibits glandular differentiation. - This specific subtype is not the most common presentation for an ulcerative lip lesion, making simple **squamous cell carcinoma** a more likely diagnosis.

Q: A 65-year-old man presents with a slowly growing, hyperkeratotic lesion on his right temple. The lesion has been present for approximately 8 months. He has a history of significant sun exposure. Examination reveals a 1.5 cm scaly, erythematous plaque with adherent scale. Biopsy shows atypical keratinocytes extending from the epidermis into the dermis. Which of the following is the most likely diagnosis?

Squamous cell carcinoma. ***Squamous cell carcinoma*** - The description of a **slowly growing, hyperkeratotic lesion** on a **sun-exposed area** (right temple) in an elderly man is highly suggestive of **squamous cell carcinoma (SCC)**. The lesion being a **scaly, erythematous plaque with adherent scale** further supports this. - The biopsy finding of **atypical keratinocytes extending from the epidermis into the dermis** is the definitive histological hallmark of invasive SCC. *Actinic keratosis* - While actinic keratosis is a **premalignant lesion** that can progress to SCC, it typically presents as smaller, rough, sandpaper-like papules or patches. - The key differentiating factor here is the biopsy finding of **atypical keratinocytes extending into the dermis**, which denotes invasion and thus a diagnosis of SCC, not just actinic keratosis. *Keratoacanthoma* - **Keratoacanthomas** are rapidly growing, dome-shaped nodules with a central keratin plug, often resolving spontaneously. - Although they are a variant of SCC, the description of a **slowly growing lesion present for 8 months** and the plaque-like appearance are less typical for a classic keratoacanthoma. *Basal cell carcinoma* - **Basal cell carcinoma (BCC)** usually presents as a **pearly nodule with telangiectasias**, a rodent ulcer, or a waxy papule. - The biopsy demonstrating **atypical keratinocytes** (which originate from the spinous layer of the epidermis) extending into the dermis is characteristic of SCC, not BCC, which originates from the basal layer of the epidermis.

Q: A 55-year-old man with a history of sun exposure presents with a slowly growing, pearly nodule with telangiectasias on his nose. The lesion occasionally bleeds when traumatized. Biopsy shows basaloid cells arranged in palisading patterns. Which of the following mutations is most likely involved in the pathogenesis?

PTCH1 gene mutation. **PTCH1 gene mutation** - The clinical presentation of a **pearly nodule with telangiectasias** on the **nose**, history of **sun exposure**, and **basaloid cells arranged in palisading patterns** on biopsy are classic for **basal cell carcinoma (BCC)** [1]. - Mutations in the **PTCH1 gene**, a tumor suppressor gene involved in the **Hedgehog signaling pathway**, are found in the majority of sporadic BCCs and are central to its pathogenesis [2,3]. *P53 mutation* - While **P53 mutations** are common in many cancers, including **squamous cell carcinoma** [3], they are not the primary driver mutation for basal cell carcinoma in the way PTCH1 mutations are. - Loss of P53 function typically leads to uncontrolled cell growth and reduced apoptosis, but it's a general cancer mechanism rather than a specific one for BCC. *EGFR mutation* - **EGFR mutations** are primarily associated with certain types of **lung adenocarcinoma** and **glioblastoma**, not basal cell carcinoma. - These mutations lead to constitutive activation of the **epidermal growth factor receptor** signaling pathway, promoting cell proliferation and survival in those specific cancers. *KIT mutation* - **KIT mutations** are most commonly found in **gastrointestinal stromal tumors (GIST)** and certain types of **melanoma**. - The KIT receptor tyrosine kinase plays a role in cell growth and differentiation in specific cell lineages, distinct from the epidermal cells involved in BCC. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Skin, pp. 1158-1162. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 306-307. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Disorders Involving Inflammatory And Haemopoietic Cells, pp. 643-644.

Q: A 68-year-old man presents with a slowly enlarging patch on his left cheek that occasionally bleeds. Examination reveals a 1.5 cm erythematous patch with telangiectasias and rolled borders. The lesion has central crusting. Which of the following treatments would be most appropriate?

Mohs micrographic surgery. ***Mohs micrographic surgery*** - The description of a slowly enlarging patch with **telangiectasias**, **rolled borders**, and **central crusting** is highly suggestive of a **basal cell carcinoma (BCC)**, especially given its location on the **face**. - **Mohs micrographic surgery** is the most appropriate treatment for BCCs, particularly on the face, due to its **high cure rate** and **tissue-sparing properties**, which is crucial for cosmetic outcomes. *Oral antibiotics* - This treatment is indicated for **bacterial infections** and would not be effective for a suspected skin malignancy like BCC. - The clinical presentation does not suggest an active bacterial infection requiring systemic antibiotic therapy. *Photodynamic therapy* - This therapy uses a photosensitizing agent and light to destroy abnormal cells and is suitable for **superficial BCCs** or **actinic keratoses**. - However, for a lesion with **rolled borders** and **central crusting**, particularly on the face, **Mohs surgery** offers better cure rates and margin control. *Topical steroids* - **Topical steroids** are used to reduce inflammation and would be ineffective for treating a **basal cell carcinoma**. - Their use might even mask the progression of the malignancy.

Question 1

A 25 -year-old patient presents with multiple sebaceous adenomas over the neck and chest. His father too had a similar skin disease and died due to colorectal carcinoma. What is the diagnosis?

Accepted Answer

Muir Torre syndrome

Answer

Pseudoxanthoma elasticum

Answer

Bournville disease

Answer

Sweet syndrome

Question 2

Identify the condition which is present since birth: (AIIMS May 2017)

Accepted Answer

Congenital nevus

Answer

Epidermal verrucous nevus

Answer

Melano-acanthoma

Answer

Malignant melanoma

Question 3

Comment on the image shown:

Accepted Answer

Arsenical keratosis

Answer

Corn

Answer

Callosity

Answer

Warts

Answer

Cutaneous horn

Question 4

What is the best management of the case shown?

Accepted Answer

Stop smoking and screen for cancer

Answer

Dapsone plus steroids

Answer

Vitamin supplements

Answer

Antifungals for oral candidiasis

Question 5

The following lesion was noticed in a patient with history of involuntary weight loss. What is the diagnosis?

Accepted Answer

Leser-Trelat sign

Answer

Acanthosis nigricans

Answer

Actinic keratosis

Answer

Intertriginous candida

Question 6

A 38-year-old man presents with the manifestation shown in the image. He has a number of family members suffering from the same condition, though the severity is different in different members. Which of the following statements is false regarding this condition?

Accepted Answer

Basal cell carcinoma

Answer

Autosomal dominant condition

Answer

Chromosomal abnormality seen in chromosome 17

Answer

Café-au-lait spots and neurofibromas are characteristic features

Question 7

A 70 year old man with history of smoking has a 1 cm ulcerative lesion over the vermilion of his upper lip. What is he likely to be suffering from?

Accepted Answer

Squamous cell carcinoma

Answer

Spindle cell carcinoma

Answer

Basal cell carcinoma

Answer

Adenoid squamous carcinoma

Question 8

A 65-year-old man presents with a slowly growing, hyperkeratotic lesion on his right temple. The lesion has been present for approximately 8 months. He has a history of significant sun exposure. Examination reveals a 1.5 cm scaly, erythematous plaque with adherent scale. Biopsy shows atypical keratinocytes extending from the epidermis into the dermis. Which of the following is the most likely diagnosis?

Accepted Answer

Squamous cell carcinoma

Answer

Actinic keratosis

Answer

Keratoacanthoma

Answer

Basal cell carcinoma

Question 9

A 55-year-old man with a history of sun exposure presents with a slowly growing, pearly nodule with telangiectasias on his nose. The lesion occasionally bleeds when traumatized. Biopsy shows basaloid cells arranged in palisading patterns. Which of the following mutations is most likely involved in the pathogenesis?

Accepted Answer

PTCH1 gene mutation

Answer

P53 mutation

Answer

EGFR mutation

Answer

KIT mutation

Question 10

A 68-year-old man presents with a slowly enlarging patch on his left cheek that occasionally bleeds. Examination reveals a 1.5 cm erythematous patch with telangiectasias and rolled borders. The lesion has central crusting. Which of the following treatments would be most appropriate?

Accepted Answer

Mohs micrographic surgery

Answer

Oral antibiotics

Answer

Photodynamic therapy

Answer

Topical steroids

Skin Tumors — MCQs

Skin Tumors — MCQs

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