Skin Tumors Practice Questions

Q: A 62-year-old man develops itchy, scaling, and non-scaling patches and plaques over his chest and back. The rest of the examination is normal, except for lymphadenopathy. Examination of the blood film and skin biopsy histology reveal unusually large monocytoid cells. Which of the following is the most likely diagnosis?

Primary cutaneous T-cell lymphoma. **Explanation:** The clinical presentation of itchy, scaling, and non-scaling patches and plaques in an elderly patient, associated with lymphadenopathy and specific histological findings, is classic for **Mycosis Fungoides (MF)**, the most common form of **Primary Cutaneous T-cell Lymphoma (CTCL)**. 1. **Why the correct answer is right:** The "unusually large monocytoid cells" described in the blood film and skin biopsy refer to **Sezary cells** (T-helper cells with cerebriform, folded nuclei). In CTCL, malignant T-lymphocytes migrate to the skin (epidermotropism), forming Pautrier’s microabscesses. The progression from patches to plaques and the involvement of lymph nodes (suggesting advanced stage or Sezary Syndrome) align perfectly with this diagnosis. 2. **Why incorrect options are wrong:** * **Leukemia:** While leukemia can involve the skin (Leukemia cutis), it typically presents as nodules or purpura rather than chronic scaling patches and plaques. * **Visceral B-cell lymphoma:** These usually present with deep-seated nodules or tumors without the superficial "eczema-like" scaling patches characteristic of T-cell skin infiltration. * **Viral infection (EBV):** While EBV is associated with certain lymphomas (like Burkitt’s), it does not typically present with this specific chronic, plaque-like cutaneous morphology or monocytoid T-cell infiltration. **NEET-PG High-Yield Pearls:** * **Pathognomonic sign:** **Pautrier’s microabscesses** (clusters of atypical T-cells in the epidermis). * **Sezary Syndrome Triad:** Erythroderma (exfoliative dermatitis), lymphadenopathy, and >1000/mm³ Sezary cells in peripheral blood. * **Immunophenotype:** Most cases are **CD4+** (T-helper cells). * **Clinical Clue:** Always suspect CTCL in "chronic dermatitis" or "psoriasis" that is refractory to standard treatment in elderly patients.

Q: Erythroplasia of Queyrat occurs in which anatomical location?

Penis. **Explanation:** **Erythroplasia of Queyrat (EQ)** is a clinical variant of **Squamous Cell Carcinoma in situ (Bowen’s Disease)** that specifically occurs on the **glans penis or the prepuce (inner foreskin)** in uncircumcised men. Histologically, it represents full-thickness dysplasia of the squamous epithelium without invasion into the basement membrane. * **Why Option B is Correct:** The term "Erythroplasia of Queyrat" is reserved for Bowen’s disease involving the **mucosal or transitional surfaces of the penis**. It typically presents as a well-demarcated, velvety, bright red plaque. Chronic irritation, friction, and lack of circumcision are significant risk factors. * **Why Options A, C, and D are Incorrect:** * **Scrotum:** Bowen’s disease on the keratinized skin of the scrotum is simply called "Bowen’s Disease," not EQ. * **Testis/Bladder:** These are internal organs. EQ is a cutaneous/mucosal malignancy of the external genitalia. **High-Yield Clinical Pearls for NEET-PG:** 1. **Bowen’s Disease vs. EQ:** Both are SCC in situ. Bowen’s occurs on sun-exposed or keratinized skin; EQ occurs on the glans penis/prepuce. 2. **Bowenoid Papulosis:** Another differential for penile lesions; it presents as multiple small, brown-to-red papules and is strongly associated with **HPV types 16 and 18**. 3. **Progression:** EQ has a higher rate of progression to invasive Squamous Cell Carcinoma (approx. 10-30%) compared to Bowen’s disease on the skin. 4. **Treatment:** Options include topical 5-Fluorouracil, Imiquimod, or Mohs Micrographic Surgery.

Q: Rodent ulcer is:

Basal cell carcinoma. **Explanation:** **Basal Cell Carcinoma (BCC)** is the most common skin cancer globally. The term **"Rodent Ulcer"** is a classic clinical description for a specific morphological variant of BCC (nodulo-ulcerative type). It is so named because the ulcer appears as if a rodent has "gnawed" into the skin, characterized by a central depression/ulceration surrounded by a raised, pearly, "rolled-out" border with telangiectasia. * **Why Option C is correct:** BCC arises from the basal layer of the epidermis. It is locally invasive and destructive (hence the "gnawing" appearance) but rarely metastasizes. It typically occurs on sun-exposed areas, particularly the upper face (above the line joining the lobe of the ear to the angle of the mouth). * **Why Options A & B are wrong:** A rodent ulcer is a neoplastic process, not an infection (bacterial/fungal) or an immunological hypersensitivity reaction. * **Why Option D is wrong:** While Squamous Cell Carcinoma (SCC) also presents as an ulcer, it typically lacks the characteristic pearly, rolled borders of BCC and has a higher potential for lymphatic metastasis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Nose (specifically the nasolabial fold). * **Risk Factor:** Chronic UV radiation exposure (UVB). * **Histopathology:** Shows "Peripheral Palisading" of nuclei and "Retraction Artifacts" (clefts between tumor nests and stroma). * **Inherited Syndromes:** Gorlin Syndrome (Basal Cell Nevus Syndrome) – associated with PTCH gene mutation, odontogenic keratocysts, and bifid ribs. * **Treatment of Choice:** Surgical excision; **Mohs Micrographic Surgery** is the gold standard for high-risk areas (face).

Q: All are true about basal cell carcinoma except?

The most common site is acral parts.. **Explanation:** **Basal Cell Carcinoma (BCC)** is the most common skin cancer globally. Understanding its behavior and origin is crucial for NEET-PG. **Why Option D is the Correct Answer (The False Statement):** The most common site for BCC is **sun-exposed areas**, particularly the **face** (specifically the upper two-thirds of the face, above a line joining the lobe of the ear to the corner of the mouth). **Acral parts** (palms and soles) are extremely rare sites for BCC because these areas lack pilosebaceous units, from which BCC is thought to originate. In contrast, Acral Lentiginous Melanoma is the classic malignancy associated with acral sites. **Analysis of Other Options:** * **Option A:** BCC is indeed **locally aggressive**. It is often nicknamed a "rodent ulcer" because, if left untreated, it can invade deeply into local tissues, including muscle and bone. * **Option B:** It is characterized by **slow growth** and an extremely low rate of metastasis (<0.1%). Its morbidity arises from local destruction rather than systemic spread. * **Option C:** The molecular hallmark of BCC is the constitutive activation of the **Hedgehog signaling pathway**, most commonly due to mutations in the **PTCH1 gene** (as seen in Gorlin Syndrome) or the **SMO gene**. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factor:** Chronic UV light exposure is the primary trigger. * **Clinical Presentation:** Classically presents as a pearly, translucent papule with **telangiectasia** and a rolled-out border. * **Histopathology:** Shows "islands" of basaloid cells with **peripheral palisading** and retraction artifacts (clefts). * **Treatment of Choice:** Surgical excision; Mohs micrographic surgery is preferred for high-risk facial areas.

Q: A 50-year-old man presents with a rapidly developing 1-cm nodule on the back of his hand over a three-month period. The lesion is firm, flesh-colored, and has sharply rising edges with a central crater from which keratoacanthoma debris can be expressed. It has a "volcano-like" appearance. What is the most likely diagnosis?

Keratoacanthoma. **Explanation:** The clinical presentation is classic for **Keratoacanthoma (KA)**. The hallmark of KA is its **rapid growth phase** (typically reaching full size in 4–8 weeks) followed by a period of stability and, occasionally, spontaneous involution. The pathognomonic description is a **"volcano-like"** or dome-shaped nodule with a **central keratinous plug** (crater). It is histologically similar to well-differentiated squamous cell carcinoma (SCC), and many experts now consider it a subtype of SCC. **Why other options are incorrect:** * **Lipoma:** These are slow-growing, soft, subcutaneous fatty tumors. They lack the central crater, rapid growth, and "volcano" morphology. * **Malignant Melanoma:** Usually presents as an asymmetrical pigmented macule or papule with irregular borders (ABCDE criteria). While nodular melanoma exists, it does not typically feature a central keratin-filled crater. * **Pyogenic Granuloma:** While it grows rapidly, it is a vascular lesion that appears bright red (friable), bleeds easily with minor trauma, and lacks a central keratin plug. **NEET-PG High-Yield Pearls:** * **Morphology:** Dome-shaped nodule + Central keratinous crater = Keratoacanthoma. * **Growth Pattern:** Rapid initial growth (weeks) followed by potential spontaneous regression (leaving a scarred area). * **Common Site:** Sun-exposed areas (back of hands, face) in elderly patients. * **Association:** Multiple keratoacanthomas are seen in **Muir-Torre syndrome** (associated with internal malignancies, especially GI). * **Management:** Despite potential regression, the treatment of choice is **surgical excision** because it is clinically difficult to distinguish from invasive SCC.

Q: Multiple squamous papillomas are characteristic of which condition?

Cowden syndrome. **Explanation:** **Cowden Syndrome (Multiple Hamartoma Syndrome)** is an autosomal dominant disorder caused by a mutation in the **PTEN gene**. The hallmark of this condition is the development of multiple hamartomas across various organs. In the oral cavity, these manifest as **multiple squamous papillomas** (often giving a "cobblestone" appearance to the gingiva and tongue). Cutaneous markers are highly diagnostic and include trichilemmomas, acral keratoses, and palmoplantar keratoses. **Analysis of Incorrect Options:** * **Condyloma acuminatum:** Caused by HPV types 6 and 11, these are anogenital warts. While they are papillomatous, they typically present as "cauliflower-like" clusters in the genital region rather than generalized multiple squamous papillomas associated with systemic syndromes. * **Heck disease (Focal Epithelial Hyperplasia):** Caused by HPV types 13 and 32, it presents as multiple smooth, flat-topped papules on the oral mucosa, primarily in children. These are not classified as classic squamous papillomas. * **Fordyce granules:** These are ectopic sebaceous glands appearing as small, yellowish-white papules on the oral mucosa or vermilion border. They are a normal anatomical variant, not neoplastic or papillomatous. **High-Yield Clinical Pearls for NEET-PG:** * **PTEN Mutation:** Cowden syndrome is part of the PTEN Hamartoma Tumor Syndrome (PHTS) spectrum. * **Malignancy Risk:** Patients have a significantly increased risk of **Breast cancer** (most common), **Thyroid cancer** (follicular variant), and **Endometrial cancer**. * **Lhermitte-Duclos disease:** A rare cerebellar dysplastic gangliocytoma is a pathognomonic feature of Cowden syndrome. * **Trichilemmomas:** Small, flesh-colored papules on the face are the most characteristic cutaneous finding.

Q: What is the treatment of choice for basal cell carcinoma located at the inner canthus of the eye?

Wide excision and reconstruction. **Explanation:** **Basal Cell Carcinoma (BCC)** is the most common skin malignancy, frequently occurring on sun-exposed areas of the face. The **inner canthus of the eye** is considered a "high-risk" anatomical site due to its proximity to vital structures (lacrimal apparatus, orbit) and the tendency of tumors here to exhibit aggressive local invasion. **Why Option D is Correct:** The gold standard treatment for BCC is **surgical excision**. For high-risk areas like the inner canthus, **Wide Excision with Reconstruction** (or ideally, **Mohs Micrographic Surgery**) is preferred. This approach ensures clear histological margins (minimizing recurrence) while allowing for functional and cosmetic restoration of the eyelid and tear duct system. **Why Other Options are Incorrect:** * **A & B (Radium/Radiotherapy):** While BCC is radiosensitive, radiation near the eye carries a high risk of complications, including cataracts, keratitis, and damage to the lacrimal gland. It is generally reserved for elderly patients who are unfit for surgery or as adjuvant therapy. * **C (Chemotherapy):** Systemic chemotherapy is not the primary treatment for localized BCC. Targeted therapies (like Vismodegib) are only used for metastatic or locally advanced disease where surgery is impossible. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Lower eyelid (followed by inner canthus). * **Mohs Micrographic Surgery:** The treatment of choice for BCC in "H-zone" areas (nose, ears, periocular) to ensure the highest cure rate and tissue conservation. * **Characteristic feature:** "Pearly" papule with telangiectasia and a "rolled-out" border. * **Metastasis:** Extremely rare; BCC is characterized by local destruction ("Rodent Ulcer").

Q: Which of the following statements regarding Kaposi's sarcoma is incorrect?

Lymph node involvement suggests a poor prognosis. **Explanation:** Kaposi’s Sarcoma (KS) is a multicentric angioproliferative neoplasm caused by **Human Herpesvirus 8 (HHV-8)**. **Why Option D is the correct (incorrect statement):** In Kaposi’s Sarcoma, particularly the African (Endemic) and AIDS-associated (Epidemic) types, lymph node involvement is common and does not necessarily correlate with a poor prognosis. Unlike epithelial malignancies where nodal spread indicates advanced staging and poor survival, KS is a systemic vascular tumor. The prognosis in AIDS-associated KS is more accurately determined by the **ACTG (AIDS Clinical Trials Group) staging**, which focuses on tumor extent (T), immune status/CD4 count (I), and systemic illness (S). **Analysis of other options:** * **Option A:** While KS is an AIDS-defining illness, it can occur in patients with **normal CD4+ counts** (>500 cells/mm³), especially in the Classic (Mediterranean) and Endemic forms. * **Option B:** **HHV-8** (also known as KSHV) is the essential causative agent found in all four clinical variants of KS. It infects endothelial cells, leading to spindle cell transformation. * **Option C:** KS exhibits the **pseudo-Koebner phenomenon**, where new lesions can develop at sites of trauma or previous inflammation. **High-Yield Clinical Pearls for NEET-PG:** * **Histology:** Characterized by "slits" formed by spindle cells containing extravasated RBCs. * **Promontory Sign:** Small vessels protruding into newly formed vascular spaces (characteristic of early lesions). * **Four Types:** Classic (elderly men), Endemic (African), Iatrogenic (transplant-related), and Epidemic (AIDS-associated). * **Treatment:** Highly Active Antiretroviral Therapy (HAART) is the first-line treatment for AIDS-related KS. Localized lesions can be treated with intralesional vinblastine or cryotherapy.

Q: What is the most common site for Basal cell carcinoma?

Face. **Explanation:** **Basal Cell Carcinoma (BCC)** is the most common skin cancer worldwide. The primary risk factor is cumulative exposure to ultraviolet (UV) radiation, which causes DNA damage in the basal cells of the epidermis. **Why Face is Correct:** Approximately **80-90% of BCCs occur on the head and neck**, with the **face** being the most frequent site. Specifically, the area above a line joining the lobe of the ear to the angle of the mouth (the "mask area" or upper face) is most susceptible. The nose is the single most common anatomical subunit involved. This is due to the high density of pilosebaceous units and maximal sun exposure in these regions. **Why Other Options are Incorrect:** * **Trunk:** While the trunk is a common site for the *Superficial* subtype of BCC, it is far less frequent than the face for BCC overall. * **Neck:** Although part of the head and neck region, the incidence on the neck is lower than on the central facial features. * **Extremities:** These areas are more commonly associated with Squamous Cell Carcinoma (SCC) or are less frequently involved in BCC compared to the face. **High-Yield Clinical Pearls for NEET-PG:** * **Most common subtype:** Nodular BCC (presents as a pearly papule with telangiectasia). * **Classic Description:** "Rodent Ulcer" (locally invasive but rarely metastasizes). * **Characteristic Histology:** Peripheral palisading of nuclei and retraction artifacts. * **Gold Standard Treatment:** Mohs Micrographic Surgery (highest cure rate, tissue-sparing). * **Inherited Syndrome:** Gorlin Syndrome (Nevoid BCC syndrome) – associated with PTCH gene mutation.

Question 1

A 62-year-old man develops itchy, scaling, and non-scaling patches and plaques over his chest and back. The rest of the examination is normal, except for lymphadenopathy. Examination of the blood film and skin biopsy histology reveal unusually large monocytoid cells. Which of the following is the most likely diagnosis?

Accepted Answer

Primary cutaneous T-cell lymphoma

Answer

Leukemia

Answer

Visceral B-cell lymphoma

Answer

Viral infection (usually Epstein-Barr)

Question 2

Erythroplasia of Queyrat occurs in which anatomical location?

Accepted Answer

Penis

Answer

Scrotum

Answer

Testis

Answer

Bladder

Question 3

Rodent ulcer is:

Accepted Answer

Basal cell carcinoma

Answer

Infectious ulcer

Answer

Hypersensitivity reaction

Answer

Squamous cell carcinoma

Question 4

All are true about basal cell carcinoma except?

Accepted Answer

The most common site is acral parts.

Answer

It is a locally aggressive tumor.

Answer

It is slow growing and rarely metastasizes.

Answer

It is associated with mutations that activate Hedgehog pathway signaling.

Question 5

A 50-year-old man presents with a rapidly developing 1-cm nodule on the back of his hand over a three-month period. The lesion is firm, flesh-colored, and has sharply rising edges with a central crater from which keratoacanthoma debris can be expressed. It has a "volcano-like" appearance. What is the most likely diagnosis?

Accepted Answer

Keratoacanthoma

Answer

Lipoma

Answer

Malignant melanoma

Answer

Pyogenic granuloma

Question 6

All of the following statements about malignant melanoma are true except:

Accepted Answer

The most common type is superficial spreading melanoma.

Answer

Prognosis is better in females than in males.

Answer

Acral lentiginous melanoma carries a good prognosis.

Answer

Stage IIA shows satellite deposits.

Question 7

Multiple squamous papillomas are characteristic of which condition?

Accepted Answer

Cowden syndrome

Answer

Condyloma acuminatum

Answer

Heck disease

Answer

Fordyce granules

Question 8

What is the treatment of choice for basal cell carcinoma located at the inner canthus of the eye?

Accepted Answer

Wide excision and reconstruction

Answer

Radium implant

Answer

Radiotherapy

Answer

Chemotherapy

Question 9

Which of the following statements regarding Kaposi's sarcoma is incorrect?

Accepted Answer

Lymph node involvement suggests a poor prognosis

Answer

May occur even in the presence of a normal CD4+ T cell count

Answer

HHV-8 has been strongly implicated as a cofactor in the pathogenesis

Answer

Koebner's phenomenon may be seen

Question 10

What is the most common site for Basal cell carcinoma?

Accepted Answer

Face

Answer

Trunk

Answer

Neck

Answer

Extremities

Skin Tumors — MCQs

Skin Tumors — MCQs

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