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?
Q222
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?
Q223
A 52-year-old man presents with a rapidly growing, dome-shaped nodule on his right arm that developed over 6 weeks. Examination reveals a 2 cm, symmetrical, crateriform nodule with a central keratin plug. Which of the following is the most likely diagnosis?
Q224
A 60-year-old white man with a past medical history significant for hypertension and hyperlipidemia presents to his family medicine physician with concerns about a 'spot' on his ear. He has been a construction worker for 35 years and spends most of his time outside. His family history is insignificant. On physical examination, there is a dark lesion on his left ear. The patient states that he has always had a mole in this location but that it has recently become much larger. A review of systems is otherwise negative. Which of the following lesion characteristics would be MOST reassuring among the given options?
Q225
Rodent ulcer is
Q226
Most common subtype of Rodent ulcer is:
Q227
The most common location of spider nevi is:
Q228
A 35 years old male came with a progressive plaque over buttock for the last 2 years. The plaque is annular in shape with scarring in centre. Most likely diagnosis is:
Q229
A farmer presented with a black mole on the cheek. It increased in size, more than 6mm with irregular borders and a central black lesion, what could be the diagnosis?
Q230
A 50-year-old woman with long-standing discoid lupus develops a rapidly growing keratotic nodule within an old lesion. Most appropriate management is:
Skin Tumors Indian Medical PG Practice Questions and MCQs
Question 221: 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?
A. Actinic keratosis
B. Keratoacanthoma
C. Squamous cell carcinoma (Correct Answer)
D. Basal cell carcinoma
Explanation: ***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.
Question 222: 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?
A. Oral antibiotics
B. Mohs micrographic surgery (Correct Answer)
C. Photodynamic therapy
D. Topical steroids
Explanation: ***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 223: A 52-year-old man presents with a rapidly growing, dome-shaped nodule on his right arm that developed over 6 weeks. Examination reveals a 2 cm, symmetrical, crateriform nodule with a central keratin plug. Which of the following is the most likely diagnosis?
A. Keratoacanthoma (Correct Answer)
B. Squamous cell carcinoma
C. Basal cell carcinoma
D. Melanoma
Explanation: ***Keratoacanthoma***
- The rapid growth over 6 weeks and the classic description of a **dome-shaped, crateriform nodule with a central keratin plug** are highly characteristic of a keratoacanthoma.
- While histologically similar to well-differentiated squamous cell carcinoma, its distinct clinical presentation with spontaneous regression potential often differentiates it.
*Squamous cell carcinoma*
- Although it can present as a nodule, it typically exhibits slower growth and is less likely to have the classic **crateriform shape with a central keratin plug** that rapidly evolves over weeks.
- Aggressive types can grow rapidly but often present with ulceration or induration rather than the specific dome-shaped morphology described.
*Basal cell carcinoma*
- Usually presents as a **pearly nodule** with telangiectasias, often with a rolled border, and grows slowly over months to years.
- It lacks the characteristic **crateriform appearance** and rapid growth seen in this case.
*Melanoma*
- Characterized by asymmetry, irregular borders, varied colors, and a diameter greater than 6 mm (ABCDEs).
- While some nodular melanomas can grow rapidly, they typically lack the distinct **crateriform morphology** and central keratin plug.
Question 224: A 60-year-old white man with a past medical history significant for hypertension and hyperlipidemia presents to his family medicine physician with concerns about a 'spot' on his ear. He has been a construction worker for 35 years and spends most of his time outside. His family history is insignificant. On physical examination, there is a dark lesion on his left ear. The patient states that he has always had a mole in this location but that it has recently become much larger. A review of systems is otherwise negative. Which of the following lesion characteristics would be MOST reassuring among the given options?
A. Single, dark color (Correct Answer)
B. Changing over time
C. Lesion asymmetry
D. Irregular, indistinct borders
Explanation: ***Single, dark color***
- A **single, uniform dark color** in a mole is a reassuring characteristic, indicating a stable pigmentation pattern, as opposed to multiple colors or shades which are concerning for melanoma [1].
- While the patient notes the mole has grown, a uniform color suggests it has maintained its benign pigment distribution rather than showing chaotic growth patterns [1].
- This is the most reassuring finding among the options presented.
*Changing over time*
- Any **change in an existing mole**, whether in size, shape, color, or elevation (the "E" in ABCDE criteria), is the most significant warning sign for potential malignancy, making it highly concerning [1].
- The patient's statement that the mole has "recently become much larger" directly points to this concerning characteristic [1].
*Lesion asymmetry*
- **Asymmetry** ("A" in ABCDE) means that if you draw a line through the mole, the two halves do not match, which is a key indicator of potential melanoma and is not reassuring [1].
- Benign moles are typically symmetrical.
*Irregular, indistinct borders*
- **Irregular or indistinct borders** ("B" in ABCDE) are a hallmark characteristic of melanoma, as malignant cells tend to invade surrounding tissue in an uneven manner [1].
- Benign moles usually have smooth, well-defined borders.
Question 225: Rodent ulcer is
A. Squamous cell carcinoma
B. Basal cell carcinoma (Correct Answer)
C. Rhinophyma
D. Adenocarcinoma (glandular cancer)
Explanation: ***Basal cell carcinoma***
- The term **"rodent ulcer"** is a historical and descriptive term for a specific type of **basal cell carcinoma (BCC)**, characterized by a **pearly raised border** and a central ulceration.
- This appearance, with its rolled edges and sometimes visible telangiectasias, gives the impression of a lesion gnawing away at the tissue, hence the "rodent" description.
*Squamous cell carcinoma*
- While also a common skin cancer, **squamous cell carcinoma (SCC)** typically presents as a **scaly, crusted nodule or plaque** with irregular borders, or a non-healing ulcer that does not have the classic rolled border of a rodent ulcer.
- It is more prone to **metastasis** than BCC.
*Rhinophyma*
- **Rhinophyma** is a severe form of **rosacea** that causes a bulbous, red, and swollen nose due to hyperplasia of sebaceous glands and connective tissue.
- It is a **benign condition** and not a form of skin cancer or ulcer.
*Adenocarcinoma (glandular cancer)*
- **Adenocarcinoma** is a type of cancer that originates in **glandular tissue**, such as in the breast, prostate, colon, or lung.
- It is **not a primary skin cancer** and does not typically present as a "rodent ulcer" on the skin surface.
Question 226: Most common subtype of Rodent ulcer is:
A. Superficial
B. Nodular (Correct Answer)
C. Pigmented
D. Cystic
Explanation: ***Nodular***
- The **nodular** subtype is the most common presentation of **basal cell carcinoma (rodent ulcer)**, accounting for 60-80% of cases.
- It typically appears as a **pearly nodule** with rolled borders and telangiectasias.
*Superficial*
- The **superficial** subtype is the second most common, accounting for 15-20% of basal cell carcinomas.
- It presents as a **red, scaly patch**, often mistaken for eczema or psoriasis.
*Pigmented*
- The **pigmented** subtype is less common, characterized by the presence of **melanin**, making it appear dark brown or black.
- It can be confused with melanoma due to its dark coloration.
*Cystic*
- The **cystic** subtype is a rare form of basal cell carcinoma, characterized by a **fluid-filled lesion**.
- It often appears as a translucent nodule with a soft, jelly-like consistency.
Question 227: The most common location of spider nevi is:
A. Upper and lower extremities
B. Abdomen
C. Back
D. Neck and shoulder (Correct Answer)
Explanation: ***Neck and shoulder***
- **Spider nevi**, or **spider angiomas**, are most commonly found on the **face, neck, upper chest, and arms** due to their association with areas drained by the superior vena cava.
- This distribution is thought to be related to higher blood flow and hormonal influences in these regions.
*Abdomen*
- While spider nevi can appear on the trunk, they are **less common** on the abdomen compared to the upper body.
- Their presence on the abdomen, especially in large numbers, might suggest severe **liver disease**.
*Upper and lower extremities*
- Spider nevi are **less frequently observed** on the extremities, particularly the lower limbs.
- When present on the extremities, they may be isolated and are less indicative of systemic conditions compared to those on the upper body.
*Back*
- The back is **not a primary location** for spider nevi.
- Their occurrence on the back is generally isolated and less common than on the face, neck, or chest.
Question 228: A 35 years old male came with a progressive plaque over buttock for the last 2 years. The plaque is annular in shape with scarring in centre. Most likely diagnosis is:
A. Kala azar
B. Lupus vulgaris (Correct Answer)
C. Borderline leprosy
D. Tinea corporis
Explanation: ***Lupus vulgaris***
- This is a chronic and progressive form of **cutaneous tuberculosis** characterized by plaques that often have a distinctive **annular shape** and can lead to **scarring, atrophy**, or even **ulceration** in the center.
- The slow, progressive nature over two years, with a central scar, aligns well with the typical presentation of lupus vulgaris, especially in areas like the buttocks or face.
*Kala azar*
- Also known as **visceral leishmaniasis**, it primarily affects internal organs and is characterized by **fever, hepatosplenomegaly**, and **pancytopenia**.
- While it can present with dermal lesions (post-kala azar dermal leishmaniasis), these are typically **nodular** or **macular**, not annular plaques with central scarring in the initial presentation.
*Borderline leprosy*
- Leprosy presents with diverse skin lesions, but these are typically characterized by **hypopigmented** or **erythematous patches/plaques** with **sensory loss**.
- The lesions of borderline leprosy are generally not described as annular plaques with prominent central scarring in the absence of other typical neurological features.
*Tinea corporis*
- This is a superficial fungal infection of the skin, commonly presenting as an **annular (ring-shaped)** lesion with an **erythematous, scaly border** and central clearing.
- However, tinea corporis rarely causes **significant scarring** and chronic, progressive plaques over two years are atypical for this condition, which is usually more acute and responsive to antifungal treatment.
Question 229: A farmer presented with a black mole on the cheek. It increased in size, more than 6mm with irregular borders and a central black lesion, what could be the diagnosis?
A. Superficial spreading melanoma (Correct Answer)
B. Acral lentigo melanoma
C. Lentigo maligna melanoma
D. Nodular melanoma
Explanation: ***Superficial spreading melanoma***
- This is the most common type of melanoma and often presents as a **mole with irregular borders**, varying colors, and a diameter greater than 6mm, consistent with the description.
- The lesion typically grows **radially** across the skin surface before beginning vertical growth, indicated by the increase in size.
*Acral lentigo melanoma*
- This type of melanoma primarily affects the **palms, soles, and nail beds**, which is inconsistent with a lesion on the cheek.
- It often appears as a **dark brown or black patch** that slowly enlarges, but its location is characteristic.
*Lentigo maligna melanoma*
- This melanoma typically occurs in **chronically sun-damaged skin** of the elderly, often on the head and neck, but usually presents as a **flat, irregularly shaped, tan or brown patch** with varying shades, which may not fit the description of a central black lesion within a larger mole.
- It has a dominant **radial growth phase** and progresses slowly over many years before developing a nodular component.
*Nodular melanoma*
- This type is characterized by its **rapid vertical growth** and appearance as a **raised, dark, often dome-shaped lesion** from the outset.
- While it can be black, the description of an "increased in size" mole with irregular borders and a central black lesion points more towards a spreading type rather than a rapidly growing nodule from the beginning.
Question 230: A 50-year-old woman with long-standing discoid lupus develops a rapidly growing keratotic nodule within an old lesion. Most appropriate management is:
A. Start topical steroids
B. Increase hydroxychloroquine dose
C. Surgical excision with margins (Correct Answer)
D. Add systemic steroids
Explanation: ***Surgical excision with margins***
- A rapidly growing **keratotic nodule** within a long-standing **discoid lupus erytematosus (DLE)** lesion is highly suspicious for transformation into **squamous cell carcinoma (SCC)**.
- **Surgical excision** with appropriate margins is the definitive diagnostic and therapeutic approach for suspected SCC.
*Start topical steroids*
- Topical steroids are used for the inflammatory component of DLE but will not address a potentially malignant **keratotic nodule**.
- Delaying definitive treatment for a suspected malignancy with steroids could lead to progression.
*Increase hydroxychloroquine dose*
- **Hydroxychloroquine** is a systemic treatment for DLE but works slowly and is not effective for a rapidly growing, potentially malignant nodule.
- It would not provide immediate or curative treatment for a suspected **squamous cell carcinoma**.
*Add systemic steroids*
- Systemic steroids treat the inflammatory and autoimmune aspects of DLE, but they would not eliminate a **neoplastic growth**.
- While they might transiently reduce associated inflammation, they do not treat or prevent the progression of skin cancer.
