Skin Tumors — MCQs

Skin Tumors Indian Medical PG Practice Questions and MCQs

Question 21: Buschke Lowenstein tumor is described as:

A. Condyloma lata
B. Molluscum contagiosum
C. A benign lesion of the penis
D. Verrucous carcinoma of the penis (Correct Answer)

Explanation: **Explanation:** **Buschke-Lowenstein Tumor (BLT)**, also known as **Giant Condyloma Acuminatum**, is a rare, slow-growing, cauliflower-like growth typically found in the anogenital region. It is classified as a **Verrucous Carcinoma**, which is a low-grade, well-differentiated variant of squamous cell carcinoma (SCC). 1. **Why Option D is Correct:** BLT is histologically benign-looking but clinically malignant. It is characterized by local invasion, massive size, and a high rate of recurrence. While it rarely metastasizes, it causes extensive local tissue destruction. It is strongly associated with **Human Papillomavirus (HPV) types 6 and 11**. 2. **Why Other Options are Incorrect:** * **Option A (Condyloma lata):** These are flat, moist, wart-like lesions seen in **Secondary Syphilis** (caused by *Treponema pallidum*), not a tumorous growth. * **Option B (Molluscum contagiosum):** These are small, pearly, umbilicated papules caused by the **Poxvirus**. They do not exhibit the massive, invasive growth seen in BLT. * **Option C (Benign lesion):** Although BLT starts from a viral wart (Condyloma acuminatum), it is considered a **locally invasive carcinoma**. Labeling it purely "benign" is incorrect because of its destructive nature and potential for malignant transformation into frank SCC. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Appearance:** "Cauliflower-like" mass in the perianal or penile region. * **Histology:** Shows "pushing" borders rather than the "infiltrative" borders seen in typical SCC. * **Treatment of Choice:** Wide local surgical excision. * **Key Association:** HPV 6 and 11 (low-risk types), though it behaves aggressively.

Question 22: What is the term for soft, velvety, verrucous hyperpigmentation of the axillae, especially when associated with adenocarcinoma of the stomach in an adult?

A. Pemphigus
B. Acanthosis (Correct Answer)
C. Pemphigoid
D. Contact dermatitis

Explanation: **Explanation:** The clinical description of soft, velvety, verrucous hyperpigmentation in intertriginous areas (like the axillae) is the hallmark of **Acanthosis Nigricans (AN)**. **Why Acanthosis is correct:** Acanthosis nigricans is characterized by epidermal keratinocyte and dermal fibroblast proliferation, stimulated by high levels of insulin or insulin-like growth factors. While commonly associated with insulin resistance (Type 2 Diabetes, obesity), the **sudden onset** of extensive, rapidly progressing AN in an adult is a classic **paraneoplastic syndrome**. It is most frequently associated with **adenocarcinoma of the stomach** (gastric cancer), where the tumor secretes Transforming Growth Factor-alpha (TGF-α). **Why other options are incorrect:** * **Pemphigus:** An autoimmune blistering disease characterized by intraepidermal bullae and a positive Nikolsky sign; it does not present as velvety hyperpigmentation. * **Pemphigoid:** An autoimmune subepidermal blistering disease typically seen in the elderly; it presents with tense bullae rather than verrucous plaques. * **Contact Dermatitis:** An inflammatory reaction to allergens or irritants presenting with erythema, itching, and scaling, not chronic velvety thickening. **High-Yield NEET-PG Pearls:** * **Tripe Palms:** Velvety thickening of the palms; often co-exists with malignant AN. * **Leser-Trélat Sign:** Sudden eruption of multiple seborrheic keratoses; also a paraneoplastic sign of internal malignancy (often GI). * **Histopathology:** Shows hyperkeratosis and papillomatosis. Despite the name, "acanthosis" (thickening of the stratum spinosum) is actually minimal.

Question 23: All of the following are true about Xeroderma pigmentosum except?

A. Skin manifestations appear within the first 2 years of life.
B. Increased risk of non-melanotic skin cancers.
C. Nucleotide excision repair defect.
D. Autosomal dominant inheritance. (Correct Answer)

Explanation: **Explanation:** **Xeroderma Pigmentosum (XP)** is a rare genodermatosis characterized by extreme photosensitivity and a high predisposition to skin malignancies. **1. Why Option D is the Correct Answer:** Xeroderma pigmentosum is inherited in an **Autosomal Recessive** pattern, not autosomal dominant. It involves mutations in genes (XPA through XPG) responsible for the **Nucleotide Excision Repair (NER)** pathway. This pathway is essential for repairing DNA damage (specifically pyrimidine dimers) caused by Ultraviolet (UV) radiation. **2. Analysis of Other Options:** * **Option A (Skin manifestations in first 2 years):** This is a true statement. Children with XP typically present early with severe sunburn after minimal sun exposure and the development of diffuse freckle-like hyperpigmentation (lentigines) in sun-exposed areas before age 2. * **Option B (Increased risk of non-melanotic skin cancers):** This is true. Due to the inability to repair UV-induced DNA damage, there is a >1000-fold increased risk of **Basal Cell Carcinoma (BCC)** and **Squamous Cell Carcinoma (SCC)**. There is also a significantly increased risk of Malignant Melanoma. * **Option C (Nucleotide excision repair defect):** This is the fundamental biochemical hallmark of the disease. The NER mechanism fails to excise bulky DNA adducts formed by UV light. **Clinical Pearls for NEET-PG:** * **Ocular involvement:** Photophobia, keratitis, and corneal opacities are common. * **Neurological features:** Some variants (e.g., **De Sanctis-Cacchione syndrome**) present with microcephaly, intellectual disability, and ataxia. * **Diagnosis:** Suggested by clinical features and confirmed by functional assays for DNA repair or genetic testing. * **Management:** Strict UV protection (sunscreen, protective clothing) and regular dermatological surveillance are the mainstays of treatment.

Question 24: Birt-Hogg-Dube syndrome is associated with which of the following?

A. Renal cell carcinoma (Correct Answer)
B. Lung carcinoma
C. Stomach carcinoma
D. Ovarian carcinoma

Explanation: **Explanation:** **Birt-Hogg-Dubé (BHD) syndrome** is a rare autosomal dominant genodermatosis caused by a mutation in the **FLCN gene**, which encodes the protein **folliculin**. It is characterized by a triad of cutaneous, pulmonary, and renal manifestations. 1. **Why Renal Cell Carcinoma is correct:** Patients with BHD have a significantly increased risk (up to 7-fold) of developing renal tumors. The most characteristic histological subtype is the **chromophobe renal cell carcinoma** or **oncocytoma** (often hybrid tumors), though clear cell and papillary types can also occur. These tumors are frequently bilateral and multifocal. 2. **Why other options are incorrect:** * **Lung carcinoma:** While BHD is strongly associated with the lungs, it causes **pulmonary cysts** and **spontaneous pneumothorax**, not lung carcinoma. * **Stomach/Ovarian carcinoma:** There is no established or statistically significant association between BHD syndrome and gastric or ovarian malignancies. **High-Yield Clinical Pearls for NEET-PG:** * **Cutaneous Triad:** Look for **Fibrofolliculomas** (most common/pathognomonic), Trichodiscomas, and Acrochordons (skin tags) appearing after puberty on the face and neck. * **Genetics:** Mutation in the **FLCN gene** on chromosome **17p11.2**. * **Pulmonary:** Multiple thin-walled lung cysts, typically in the basal lobes, leading to recurrent spontaneous pneumothorax. * **Radiology:** CT scans are used for surveillance of renal masses and identifying basal lung cysts.

Question 25: The ABCDE principle is used for assessing which type of skin malignancy?

A. Squamous cell carcinoma
B. Basal cell carcinoma
C. Malignant melanoma (Correct Answer)
D. Verrucous carcinoma

Explanation: **Explanation:** The **ABCDE principle** is a clinical mnemonic used for the early detection and screening of **Malignant Melanoma**, the most aggressive form of skin cancer. Since early diagnosis is critical for survival, this rule helps clinicians and patients differentiate a benign nevus (mole) from a potential melanoma. The mnemonic stands for: * **A – Asymmetry:** One half of the lesion does not match the other. * **B – Border:** Irregular, notched, or blurred edges. * **C – Color:** Variegated shades (brown, black, tan, red, or blue) within the same lesion. * **D – Diameter:** Usually >6 mm (though smaller melanomas exist). * **E – Evolving:** Any change in size, shape, color, or new symptoms like itching/bleeding. **Why other options are incorrect:** * **Basal Cell Carcinoma (BCC):** The most common skin cancer; typically presents as a pearly papule with telangiectasia and a central "rodent ulcer." It does not follow the ABCDE pattern. * **Squamous Cell Carcinoma (SCC):** Often arises from actinic keratosis and presents as a firm, erythematous, scaly plaque or ulcerated nodule. * **Verrucous Carcinoma:** A low-grade variant of SCC that appears as a slow-growing, cauliflower-like (warty) mass, commonly found in the oral cavity or on the sole of the foot (epithelioma cuniculatum). **High-Yield Clinical Pearls for NEET-PG:** * **Breslow’s Depth:** The most important prognostic factor for melanoma (measures vertical thickness). * **Ugly Duckling Sign:** A lesion that looks different from all other moles on a patient’s body is highly suspicious for melanoma. * **Commonest Site:** In fair-skinned individuals, it is the back (males) and lower legs (females). In Asians, **Acral Lentiginous Melanoma** (palms, soles, nails) is the most common subtype.

Question 26: A 43-year-old female presents with pigmentation on the neck, axilla, and other flexures. She has had diabetes for several years, which is not well-controlled. She is concerned about the possibility of skin cancer. Which of the following is NOT a premalignant condition?

A. Solar keratosis
B. Acanthosis nigricans (Correct Answer)
C. Bowen's disease
D. Porokeratosis

Explanation: ### Explanation The correct answer is **B. Acanthosis nigricans**. **1. Why Acanthosis Nigricans is the correct answer:** Acanthosis nigricans (AN) is a **benign** cutaneous marker characterized by hyperpigmented, velvety plaques in intertriginous areas (neck, axilla). In this patient, it is associated with **insulin resistance** (Type 2 Diabetes), where high insulin levels cross-react with IGF-1 receptors on keratinocytes and fibroblasts, causing hyperplasia. While AN can occasionally be a paraneoplastic sign of internal malignancy (typically gastric adenocarcinoma), the skin lesion itself is **not premalignant**—it does not transform into skin cancer. **2. Why the other options are wrong (Premalignant conditions):** * **Solar (Actinic) Keratosis:** The most common premalignant skin lesion. It is caused by UV damage and can progress to **Squamous Cell Carcinoma (SCC)**. * **Bowen’s Disease:** This is **SCC in-situ**. It involves the full thickness of the epidermis but has not yet breached the dermo-epidermal junction. It is, by definition, a pre-invasive malignancy. * **Porokeratosis:** A disorder of keratinization characterized by a "cornoid lamella" on histology. All clinical variants (especially the linear type) have a risk of malignant transformation into SCC or BCC. **3. NEET-PG High-Yield Pearls:** * **Tripe Palms:** A variant of AN involving the palms, highly suggestive of internal malignancy (Lung or Gastric CA). * **Sign of Leser-Trélat:** Sudden eruption of multiple seborrheic keratoses; another important paraneoplastic marker. * **Erythroplasia of Queyrat:** Bowen’s disease occurring on the glans penis. * **Mnemonic for Premalignant Lesions:** "S-B-P" (Solar Keratosis, Bowen’s, Porokeratosis) + Xeroderma Pigmentosum and PUVA therapy scars.

Question 27: What is the characteristic pathological feature of pyogenic granuloma?

A. Epithelioid cells
B. Cavernous hemangioma
C. Granulation tissue (Correct Answer)
D. Giant cells

Explanation: **Explanation:** **Pyogenic granuloma** (also known as Lobular Capillary Hemangioma) is a common, benign vascular lesion of the skin and mucous membranes. Despite its name, it is neither "pyogenic" (pus-forming) nor a true "granuloma." **Why Granulation Tissue is Correct:** The hallmark pathological feature of pyogenic granuloma is a **circumscribed proliferation of capillaries** arranged in a lobular pattern, embedded in an edematous stroma. This histological appearance closely mimics **granulation tissue** (the tissue formed during wound healing, consisting of new capillaries and fibroblasts). Over time, the lesion may develop a "collarette" of epithelium at its base. **Analysis of Incorrect Options:** * **A. Epithelioid cells:** These are activated macrophages characteristic of granulomatous inflammation (e.g., Sarcoidosis or TB), not vascular tumors. * **B. Cavernous hemangioma:** These consist of large, dilated, blood-filled vascular spaces. Pyogenic granuloma is a *capillary* proliferation, not cavernous. * **D. Giant cells:** While occasionally seen in inflammatory responses, they are not a defining or characteristic feature of pyogenic granuloma. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** A rapidly growing, friable (bleeds easily with minor trauma), pedunculated red nodule. * **Common Sites:** Gingiva (often in pregnant women, where it is called **Granuloma Gravidarum** or "pregnancy tumor"), fingers, and face. * **Trigger:** Often follows minor trauma. * **Treatment of Choice:** Surgical excision or curettage with cautery of the base to prevent recurrence.

Question 28: Which of the following is true regarding basal cell carcinomas?

A. Usually metastasize to regional lymph nodes.
B. Common on the face and neck. (Correct Answer)
C. Common in females.
D. Radio resistant.

Explanation: **Explanation:** Basal Cell Carcinoma (BCC) is the most common skin cancer worldwide. It arises from the non-keratinizing cells of the basal layer of the epidermis. **1. Why Option B is Correct:** BCC is primarily driven by cumulative exposure to ultraviolet (UV) radiation. Consequently, about **80-90% of cases occur on sun-exposed areas**, specifically the **face and neck**. The most common site is the nose. A classic clinical feature is the "pearly papule" with telangiectasia and a rolled-out border. **2. Why Other Options are Incorrect:** * **Option A:** BCC is characterized by slow growth and local invasion (hence the name "Rodent Ulcer"), but it **rarely metastasizes** (incidence <0.1%). Metastasis, when it occurs, is usually to regional lymph nodes. * **Option C:** BCC is actually **more common in males** than females, likely due to higher cumulative occupational and recreational sun exposure. * **Option D:** BCC is **radiosensitive**. While surgical excision (Mohs Micrographic Surgery) is the gold standard, radiotherapy is an effective primary treatment for patients who are not surgical candidates or for tumors in difficult anatomical locations. **High-Yield Clinical Pearls for NEET-PG:** * **Mohs Micrographic Surgery:** The treatment of choice for high-risk BCC (recurrent tumors or those on the "H-zone" of the face) as it offers the highest cure rate and maximum tissue conservation. * **Gorlin Syndrome (Basal Cell Nevus Syndrome):** An autosomal dominant condition (PTCH1 gene mutation) characterized by multiple BCCs at a young age, odontogenic keratocysts, and bifid ribs. * **Hedgehog Signaling Pathway:** Mutations in the *PTCH* or *SMO* genes are central to BCC pathogenesis. **Vismodegib** is a targeted SMO inhibitor used for metastatic or locally advanced BCC.

Question 29: What is the commonest site of melanoma on the orofacial skin?

A. Lower lip
B. Malar region (Correct Answer)
C. Forehead
D. Upper lip

Explanation: **Explanation:** The **malar region** (cheeks) is the most common site for primary cutaneous melanoma on the orofacial skin. This is primarily because facial melanomas are frequently of the **Lentigo Maligna Melanoma (LMM)** subtype, which occurs on chronically sun-damaged skin in elderly individuals. The malar area receives significant cumulative ultraviolet (UV) radiation, making it a hotspot for melanocytic proliferation. **Analysis of Options:** * **Malar Region (Correct):** High UV exposure and a large surface area make this the predominant site for facial melanomas, particularly the Lentigo Maligna type. * **Upper Lip (Incorrect):** While melanoma can occur here, it is statistically less common than the malar region. Interestingly, in the context of non-melanoma skin cancers, Basal Cell Carcinoma (BCC) is more common on the upper lip. * **Lower Lip (Incorrect):** The lower lip is a classic site for **Squamous Cell Carcinoma (SCC)** due to direct vertical sun exposure, but primary cutaneous melanoma is rare here. * **Forehead (Incorrect):** Although a sun-exposed site, the incidence of melanoma on the forehead is lower than on the cheeks/malar prominence. **High-Yield Clinical Pearls for NEET-PG:** * **Lentigo Maligna (Hutchinson’s Melanotic Freckle):** This is the pre-invasive (in situ) stage of LMM, commonly seen on the faces of the elderly. * **ABCDE Criteria:** Used for clinical diagnosis (Asymmetry, Border irregularity, Color variegation, Diameter >6mm, Evolving). * **Prognostic Factor:** The most important prognostic factor for cutaneous melanoma is **Breslow’s Depth** (vertical thickness in mm). * **Mucosal Melanoma:** If the question refers to the *oral cavity* (not orofacial skin), the **hard palate** and **maxillary gingiva** are the most common sites.

Question 30: Spontaneous regression is seen in all of the following conditions except?

A. Salmon patch
B. Small cavernous hemangioma
C. Portwine stain
D. Strawberry angioma (Correct Answer)

Explanation: ### Explanation The core concept tested here is the distinction between **vascular tumors** (which often proliferate and then involute) and **vascular malformations** (which are permanent and grow proportionately with the child). **Why Option D is the Correct Answer (in the context of the question):** There appears to be a technical discrepancy in the question's framing versus standard medical facts. **Strawberry Angioma (Infantile Hemangioma)** is the classic example of a lesion that **does** undergo spontaneous regression (involution). By age 9, approximately 90% of these lesions have regressed. However, in many traditional Indian medical PG entrance exams, this question is a "repeat" where the intended answer is often **Port-wine stain (Option C)**, as it is a malformation that **never** regresses. *Note: If the question asks which does NOT regress, the medically accurate answer is **Port-wine stain**. If the key provided is D, it contradicts standard dermatology (Nelson’s/Fitzpatrick), as Strawberry angiomas are famous for regression.* **Analysis of Options:** * **Salmon Patch (Nevus Simplex):** These are "fading" macular stains (e.g., Stork bite, Angel’s kiss). Most on the face regress spontaneously by age 1–2. * **Small Cavernous Hemangioma:** While deeper than strawberry hemangiomas, many infantile cavernous hemangiomas also follow a pattern of proliferation followed by slow spontaneous involution. * **Port-wine Stain (Nevus Flammeus):** This is a capillary malformation. It is present at birth, persists throughout life, and tends to darken and become verrucous/thickened with age. It **never** regresses spontaneously. * **Strawberry Angioma:** Characterized by a rapid growth phase followed by a slow involution phase (50% gone by age 5, 70% by age 7). **NEET-PG High-Yield Pearls:** 1. **Kasabach-Merritt Syndrome:** Associated with Tufted Angioma or Kaposiform Hemangioendothelioma (not simple strawberry hemangiomas), leading to consumptive coagulopathy. 2. **Sturge-Weber Syndrome:** Associated with Port-wine stains in the V1/V2 distribution of the trigeminal nerve. 3. **Treatment of Choice:** For proliferating hemangiomas requiring intervention, **Oral Propranolol** is now the first-line treatment.

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Benign Epithelial Tumors

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Premalignant Epidermal Tumors

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Basal Cell Carcinoma

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Squamous Cell Carcinoma

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Melanocytic Nevi

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Melanoma

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Merkel Cell Carcinoma

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Vascular Tumors and Malformations

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Cutaneous Lymphomas

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Soft Tissue Tumors

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Metastatic Skin Tumors

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Skin Cancer Prevention and Screening

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Skin Tumors — MCQs

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