Skin Tumors Practice Questions

Q: What is the most common location for extramammary Paget's disease in women?

Vulva and perianal area. ***Vulva*** - Extramammary Paget's disease predominantly occurs in the **vulvar region**, where it manifests as **red, scaly lesions** [1]. - It is associated with **apocrine gland** involvement and may show underlying malignancy in some cases. *Ovary* - The ovaries are not typical locations for **Extramammary Paget's disease**, as it primarily affects surface epithelium rather than **internal structures**. - Any lesions in the ovaries would raise suspicion for different **pathologies**, such as ovarian tumors, rather than Paget's disease. *Vagina* - Paget's disease does not commonly affect the vagina [1]; it is more associated with **external genitalia** like the vulva. - Vaginal lesions would likely indicate other conditions such as **vaginal carcinoma** or other inflammatory processes. *Uterus* - The uterus is not a site for **Extramammary Paget's disease**; this condition is specific to areas with **apocrine glands**. - Uterine issues are generally related to different diseases, such as **endometrial cancer** or **leiomyoma**. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, p. 1004.

Q: Erythematous cutaneous nodules may be caused by the following except:

Herpes Simplex Virus (HSV). ***Herpes Simplex Virus (HSV)*** - HSV typically causes **vesicles, blisters, and ulcers**, not erythematous cutaneous nodules. - While it can manifest with various skin findings, **nodules** are not a characteristic presentation. *Bartonella* - **Bacillary angiomatosis**, caused by *Bartonella* species, presents with **vascular proliferation** that can appear as erythematous papules or nodules. - It is frequently seen in **immunocompromised individuals**. *Acanthamoeba* - **Acanthamoeba** infections can lead to disseminated disease in immunocompromised patients, presenting with **cutaneous nodules, plaques, or ulcers**. - These skin lesions are a manifestation of **hematogenous spread**. *Kaposi's sarcoma* - Kaposi's sarcoma lesions are characteristically **violaceous or brownish-red papules, plaques, or nodules** that are often erythematous in early stages. - It is a **vascular neoplasm** strongly associated with **HHV-8 infection**, particularly in immunocompromised patients.

Q: Mycosis fungoides primarily involves which type of immune cell?

T lymphocytes. ***CD4+ T Cells*** - Mycosis fungoides is a type of **cutaneous T-cell lymphoma**, primarily involving **CD4+ T cells** which infiltrate the skin [1][2]. - The disease is characterized by **pleomorphic** skin lesions caused by **malignant T-cell proliferation** [3]. *K Cells (not primarily involved in mycosis fungoides)* - K Cells are involved in **immunological responses** but are not specifically linked to mycosis fungoides. - They do not play a primary role in **cutaneous lymphoproliferative disorders**. *B Cells (involved in humoral immunity)* - B Cells are mainly responsible for **antibody production**, which is not the primary mechanism in mycosis fungoides. - The condition involves **T cell malignancy**, rather than abnormalities in B cell function. *NK Cells (part of innate immunity)* - NK Cells are important for **innate immunity** and target viral and tumor cells but are not primarily involved in this lymphoma. - Mycosis fungoides is characterized by **T cell-mediated responses**, not NK cell activity. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 613-614. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Skin, p. 1162. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 564-565.

Q: Eleven-month-old child presents with an erythematous lesion that has been decreasing in size. What is the most likely diagnosis?

Strawberry hemangioma (Infantile hemangioma). ***Strawberry hemangioma (Infantile hemangioma)*** - **Infantile hemangiomas** (also known as strawberry hemangiomas) are common benign vascular tumors of infancy that typically **proliferate rapidly** in the first few months of life and then undergo **spontaneous involution** (decreasing in size) over several years. - The child's age (11 months) and the description of an **erythematous lesion decreasing in size** are highly consistent with the natural history of an infantile hemangioma in its involution phase. - Most infantile hemangiomas begin involution after 12 months and continue to regress over 5-7 years. *Melanocytic nevus* - A **melanocytic nevus** (mole) is a benign proliferation of **melanocytes** and typically presents as a brown or black lesion. - These lesions tend to be stable in size or grow slowly and **do not spontaneously decrease in size**. *Port wine stain (Nevus flammeus)* - A **port wine stain** is a capillary malformation that appears as a **flat, pink, red, or purple patch** from birth. - Unlike hemangiomas, port wine stains are **permanent vascular malformations** and do not involute; in fact, they may darken and thicken over time. *Cavernous hemangioma* - **Cavernous hemangiomas** represent deeper infantile hemangiomas with **subcutaneous involvement**, appearing as deeper, bluish, or skin-colored masses. - While they also undergo involution like superficial strawberry hemangiomas, they present differently as **deeper lesions** rather than the bright erythematous superficial appearance described in this case. - The primarily **erythematous** presentation in this case is more characteristic of a superficial (strawberry) hemangioma.

Q: Which of the following are risk factors for cutaneous lymphoma?

All of the options. ***All of the options*** - **All listed factors**, including age, gender, and a weakened immune system, are recognized risk factors for the development of cutaneous lymphoma. - The risk of cutaneous lymphoma generally **increases with age**, shows a slightly higher incidence in **males**, and is significantly elevated in individuals with **compromised immune systems**. *Age* - While age is a risk factor, it is only one component among several that contribute to the overall risk of developing cutaneous lymphoma. - The incidence of most lymphomas, including cutaneous forms, typically **increases with advancing age**, but other factors also play a critical role. *Gender* - Like age, gender is a recognized risk factor, with a slightly **higher incidence in males** compared to females. - However, gender alone does not fully explain the risk, as environmental and other host-related factors also contribute. *Weakened immune system* - A weakened immune system is a significant risk factor, as it impairs the body's ability to control abnormal cell growth, including cancerous lymphocytes. - However, it is not the sole risk factor; individuals with healthy immune systems can also develop cutaneous lymphoma due to other contributing factors.

Q: A giant congenital melanocytic nevus is usually of what size?

20 cm or greater. ***20 cm or greater*** - A **giant congenital melanocytic nevus (GCMN)** is defined by its substantial size, typically measuring **20 cm or more in diameter** in an adult. - This large size is a key feature distinguishing it from smaller congenital nevi and is associated with a **higher risk of malignant transformation** and neurological complications such as **neurocutaneous melanosis**. *5-10cm* - A nevus of this size would be classified as a **small to medium congenital melanocytic nevus**, not a giant one. - While these nevi carry some risk of malignancy, it is significantly **lower than that of GCMN**. *10-15 cm* - This range falls under the category of a **medium congenital melanocytic nevus**. - While larger than small nevi, it does not meet the established criteria for a **giant congenital melanocytic nevus**. *15-20 cm* - A nevus of 15-20 cm is considered a **large congenital melanocytic nevus**, but it is still usually classified just below the threshold for a true **giant congenital melanocytic nevus** which is typically 20 cm or more. - Although it approaches the giant classification, the **20 cm demarcation** is critical for defining GCMN.

Q: Which melanoma subtype has the worst prognosis?

Nodular melanoma. ***Nodular melanoma*** - This subtype has the **worst prognosis** among melanoma subtypes due to its aggressive growth pattern. - It exhibits **vertical growth from the outset** with no radial growth phase, leading to rapid deep invasion. - Typically presents at a more advanced stage with greater **Breslow thickness** at diagnosis. - High metastatic potential and rapid progression contribute to poorer survival rates. *Acral lentiginous melanoma* - Occurs on **palms, soles, and subungual areas** and is more common in darker-skinned populations. - Poor outcomes are primarily due to **delayed diagnosis** and late presentation rather than inherently aggressive biology. - When diagnosed at comparable stages, prognosis is similar to other melanoma subtypes. *Superficial spreading melanoma* - The **most common melanoma subtype** (60-70% of cases). - Has a prolonged **horizontal (radial) growth phase** before vertical invasion. - Generally better prognosis due to longer period allowing for **early detection and treatment**. *Lentigo maligna melanoma* - Occurs on **chronically sun-damaged skin**, typically on the face and neck of elderly patients. - Has a prolonged **in situ phase** (lentigo maligna) before invasive melanoma develops. - Generally has a **better prognosis** when detected and treated during the in situ phase.

Q: A young boy presented with a lesion over his right buttock, which had peripheral scaling and central scarring. What is the most appropriate investigation to confirm the diagnosis?

Biopsy. ***Biopsy*** - A lesion with **peripheral scaling** and **central scarring** strongly suggests conditions such as **discoid lupus erythematosus** or potentially **tinea profunda** (Majocchi's granuloma), making a biopsy the most definitive diagnostic tool. - A **biopsy** allows for histopathological examination, which can identify specific cellular and architectural changes characteristic of these dermatological conditions, differentiating between inflammatory, infectious, and autoimmune causes. *Tzank Smear* - A **Tzank smear** is primarily used to detect multinucleated giant cells seen in **herpes simplex** or **varicella zoster virus infections**. - This technique is not suitable for diagnosing lesions characterized by scaling and scarring, which point to chronic inflammatory or granulomatous processes. *KOH preparation* - A **KOH preparation** (potassium hydroxide) is used to identify **fungal elements** such as hyphae and spores in skin scrapings. - While it could rule out a superficial fungal infection, the presence of **central scarring** suggests a more chronic and deeper process not typically diagnosed by KOH alone. *Sabouraud's agar* - **Sabouraud's agar** is a culture medium specifically used for growing **fungi** from skin scrapings or biopsies. - While it can help confirm a fungal infection, a **biopsy** remains crucial for histological evaluation, especially when a lesion presents with scarring and atypical morphology.

Q: For the treatment of basal cell carcinoma, what is the popular surgery that is carried out?

Mohs surgery. ***Mohs surgery*** - **Mohs micrographic surgery** is the most popular and highly effective procedure specifically designed for **basal cell carcinoma (BCC)**, especially on the face and other cosmetically sensitive areas. - It involves the **progressive removal** of thin layers of skin, which are immediately examined under a microscope, allowing for complete tumor removal while preserving maximum healthy tissue. - Mohs surgery has the **highest cure rate** (95-99%) for BCC and is particularly preferred for high-risk locations, recurrent tumors, and poorly defined borders. *Superficial laser surgery* - While lasers can sometimes be used for very superficial skin lesions, **superficial laser surgery** is generally not the primary treatment for established **BCC** due to the risk of incomplete removal and recurrence. - It lacks the **histological margin control** provided by Mohs surgery, which is crucial for ensuring complete eradication of BCC. *Curettage and electrodesiccation* - **Curettage and electrodesiccation** is an alternative surgical treatment for small, low-risk BCCs in non-critical areas. - However, it has **lower cure rates** (85-95%) compared to Mohs surgery and does not provide histological margin assessment. - It is less preferred for facial BCCs where cosmetic outcome and complete removal are critical. *Wide local excision* - **Wide local excision** is a standard surgical approach that removes the tumor with predetermined margins (typically 4-5 mm for BCC). - While effective, it requires **larger tissue removal** compared to Mohs surgery and lacks the real-time microscopic margin control. - Mohs surgery remains more popular due to its tissue-sparing nature and higher cure rates, especially in cosmetically sensitive areas.

Question 1

What is the most common location for extramammary Paget's disease in women?

Accepted Answer

Vulva and perianal area

Answer

Uterine cervix and endometrium

Answer

Breast tissue only

Answer

Ovary and fallopian tubes

Question 2

Erythematous cutaneous nodules may be caused by the following except:

Accepted Answer

Herpes Simplex Virus (HSV)

Answer

Acanthamoeba

Answer

Kaposi's sarcoma

Answer

Bartonella

Question 3

Mycosis fungoides primarily involves which type of immune cell?

Accepted Answer

T lymphocytes

Answer

NK cells

Answer

B lymphocytes

Answer

Plasma cells

Question 4

Which of the following statements about Mycosis fungoides is not true?

Accepted Answer

It has an indolent course but is not easily amenable to treatment.

Answer

Pautrier's microabscesses are characteristic histopathological features

Answer

It is the most common form of cutaneous lymphoma

Answer

Erythroderma is seen and it spreads to peripheral circulation

Question 5

Eleven-month-old child presents with an erythematous lesion that has been decreasing in size. What is the most likely diagnosis?

Accepted Answer

Strawberry hemangioma (Infantile hemangioma)

Answer

Melanocytic nevus

Answer

Port wine stain (Nevus flammeus)

Answer

Cavernous hemangioma

Question 6

Which of the following are risk factors for cutaneous lymphoma?

Accepted Answer

All of the options

Answer

Weakened immune system

Answer

Age

Answer

Gender

Question 7

A giant congenital melanocytic nevus is usually of what size?

Accepted Answer

20 cm or greater

Answer

5-10cm

Answer

10-15 cm

Answer

15-20 cm

Question 8

Which melanoma subtype has the worst prognosis?

Accepted Answer

Nodular melanoma

Answer

Superficial spreading

Answer

Lentigo maligna melanoma

Answer

Acral lentiginous melanoma

Question 9

A young boy presented with a lesion over his right buttock, which had peripheral scaling and central scarring. What is the most appropriate investigation to confirm the diagnosis?

Accepted Answer

Biopsy

Answer

Tzank Smear

Answer

KOH preparation

Answer

Sabouraud's agar

Question 10

For the treatment of basal cell carcinoma, what is the popular surgery that is carried out?

Accepted Answer

Mohs surgery

Answer

Superficial laser surgery

Answer

Curettage and electrodesiccation

Answer

Wide local excision

Skin Tumors — MCQs

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