Skin Tumors Practice Questions

Q: A patient presents with a pruritic lesion over the left shoulder exhibiting cigarette paper atrophy and poikiloderma, along with generalized lymphadenopathy. Histopathological examination of the lesion reveals CD4-positive Sézary-Lutzner cells. What is the dermoepidermal manifestation of this disease?

Pautrier's microabscess. ### **Explanation** The clinical presentation of **cigarette paper atrophy**, **poikiloderma** (a combination of atrophy, telangiectasia, and hyper/hypopigmentation), and generalized lymphadenopathy, combined with the presence of **CD4+ Sézary-Lutzner cells** (cerebriform nuclei), is diagnostic of **Mycosis Fungoides (MF)**, the most common type of Cutaneous T-Cell Lymphoma (CTCL). **Why Option A is Correct:** The hallmark histopathological feature of Mycosis Fungoides is **epidermotropism**—the migration of atypical T-lymphocytes into the epidermis without significant spongiosis. When these malignant T-cells (Sézary-Lutzner cells) aggregate into small clusters within the epidermis, they form **Pautrier’s microabscesses**. This is a pathognomonic finding for MF. **Why the Other Options are Incorrect:** * **Option B (Pinpoint ulcers):** These are typically seen in conditions like Ecthyma or certain vasculitides, not characteristic of CTCL. * **Option C (Discharging sinus):** This is a feature of deep fungal infections (e.g., Mycetoma) or Scrofuloderma (Cutaneous TB), where an underlying focus drains to the surface. * **Option D (Miliaria):** This refers to "prickly heat" caused by the blockage of sweat ducts, presenting as transient vesicles or papules. **High-Yield Clinical Pearls for NEET-PG:** * **Stages of MF:** It progresses through three stages: **Patch** (cigarette paper atrophy/poikiloderma) → **Plaque** → **Tumor**. * **Sézary Syndrome:** This is the leukemic variant of CTCL characterized by the triad of **erythroderma**, **generalized lymphadenopathy**, and **atypical T-cells** (>1000/mm³) in the peripheral blood. * **Immunophenotype:** The malignant cells in MF are typically **CD4+** (T-helper cells). * **Histology Tip:** Look for "Lining up" of atypical lymphocytes along the basal layer of the epidermis (halos around cells).

Q: Which of the following is also known as self-healing carcinoma?

Keratoacanthoma. **Explanation:** **Keratoacanthoma (Option A)** is classically known as "self-healing carcinoma" because it is a rapidly growing skin tumor that histologically resembles well-differentiated squamous cell carcinoma (SCC) but undergoes spontaneous regression over several months. It typically presents as a firm, dome-shaped, flesh-colored nodule with a characteristic **central keratinous plug** (crateriform appearance). The life cycle involves three stages: rapid proliferative phase, stable phase, and spontaneous involution, leaving a depressed scar. **Why other options are incorrect:** * **Basal Cell Carcinoma (BCC):** The most common skin cancer. It is slow-growing and locally invasive ("rodent ulcer") but does not regress spontaneously. * **Leukoplakia:** A clinical term for a white patch on the mucosa that cannot be characterized clinically or pathologically as any other disease. It is a **premalignant** condition, not a self-healing one. * **Squamous Cell Carcinoma (SCC):** While Keratoacanthoma is considered a low-grade variant of SCC by some, true SCC is invasive, does not self-heal, and has a significant risk of metastasis. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Morphology:** "Volcano-like" or "Crateriform" nodule with a central keratin plug. * **Growth Pattern:** Rapid growth (weeks) followed by spontaneous resolution (months). * **Syndromic Association:** Multiple keratoacanthomas are seen in **Ferguson-Smith syndrome** (familial) and **Grzybowski syndrome** (generalized eruptive). * **Muir-Torre Syndrome:** Association of keratoacanthomas/sebaceous tumors with internal visceral malignancies (most commonly colon cancer). * **Treatment:** Although they can self-heal, surgical excision is usually performed because they are clinically difficult to distinguish from invasive SCC.

Q: Which of the following skin findings is NOT typically associated with an underlying internal malignancy?

Granuloma annulare. **Explanation:** The correct answer is **Granuloma annulare**. This condition is a benign, self-limiting inflammatory dermatosis characterized by dermal papules arranged in an annular (ring-like) pattern. While it is classically associated with **Diabetes Mellitus**, it is not considered a paraneoplastic syndrome and does not typically signal an underlying internal malignancy. **Analysis of Incorrect Options:** * **Acanthosis Nigricans & Annular Erythema:** Malignant Acanthosis Nigricans (sudden onset, extensive, involving palms/soles) is strongly associated with **Gastric Adenocarcinoma**. * **Bullous Pyoderma & Migratory Necrotizing Erythema:** Bullous Pyoderma Gangrenosum is often linked to **Acute Myeloid Leukemia (AML)**. Necrolytic Migratory Erythema is the pathognomonic cutaneous marker for a **Glucagonoma** (alpha-cell tumor of the pancreas). * **Erythema Gyratum Repens:** This is one of the most specific paraneoplastic markers. It presents with a "wood-grain" appearance and is associated with **Lung, Breast, or Esophageal cancers** in over 80% of cases. **High-Yield Clinical Pearls for NEET-PG:** 1. **Leser-Trélat Sign:** Sudden eruption of multiple seborrheic keratoses; associated with GI malignancies. 2. **Bazex Syndrome (Acrokeratosis paraneoplastica):** Psoriasiform plaques on acral sites; associated with SCC of the upper aerodigestive tract. 3. **Sweet Syndrome:** Neutrophilic dermatosis often associated with AML. 4. **Tripe Palms:** Velvety thickening of palms; associated with Lung (if alone) or Gastric (if with Acanthosis Nigricans) cancer.

Q: Which of the following is NOT a risk factor for malignant melanoma?

HPV infection. **Explanation:** Malignant melanoma is a neoplasm arising from melanocytes. Its pathogenesis is primarily linked to genetic predisposition and ultraviolet (UV) radiation, rather than viral oncogenesis. **Why HPV infection is the correct answer:** Human Papillomavirus (HPV) is strongly associated with squamous cell carcinomas (especially of the cervix, anus, and oropharynx) and certain types of non-melanoma skin cancers (like Verrucous carcinoma). However, **HPV has no established causal link to malignant melanoma.** Melanoma is driven by mutations in the MAPK pathway (e.g., BRAF, NRAS), not viral integration. **Analysis of Incorrect Options:** * **Giant Congenital Nevi:** These are large pigmented lesions present at birth. They carry a significant lifetime risk (approx. 5–10%) of transforming into melanoma, especially if they exceed 20 cm in projected adult diameter. * **Family History:** About 10% of patients have a positive family history. Mutations in the **CDKN2A** gene (encoding p16) are the most common genetic risk factor identified in familial melanoma. * **Exposure to UV Light:** This is the most important environmental risk factor. **Intermittent, blistering sunburns** (especially in childhood) are more closely linked to melanoma than chronic, cumulative exposure. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Back (males), Lower limbs (females). * **Prognostic Marker:** **Breslow’s Depth** (vertical thickness) is the most important prognostic factor. * **ABCDE Criteria:** Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolving. * **Common Mutation:** **BRAF V600E** is the most frequent mutation (targeted by Vemurafenib). * **Tumor Marker:** S-100, HMB-45, and Melan-A.

Q: Multiple cutaneous sebaceous adenomas are seen in which of the following conditions?

Muir Torre syndrome. **Explanation:** **Muir-Torre Syndrome (MTS)** is the correct answer. It is a rare autosomal dominant genodermatosis and is considered a phenotypic variant of **Lynch Syndrome (Hereditary Non-Polyposis Colorectal Cancer - HNPCC)**. * **Pathophysiology:** It is caused by germline mutations in DNA mismatch repair (MMR) genes, most commonly **MSH2** (90%) and MLH1. * **Clinical Presentation:** The hallmark is the association of at least one **sebaceous gland tumor** (sebaceous adenoma, sebaceoma, or sebaceous carcinoma) and at least one **internal malignancy** (most commonly colorectal, followed by urogenital). Sebaceous adenomas are the most characteristic cutaneous marker for this syndrome. **Analysis of Incorrect Options:** * **Cowden Syndrome:** Part of the PTEN hamartoma tumor syndrome. Characterized by multiple **trichilemmomas** (hair follicle tumors), oral papillomas, and acral keratoses. It carries a high risk of breast, thyroid, and endometrial cancers. * **Gardner Syndrome:** A variant of Familial Adenomatous Polyposis (FAP). Cutaneous markers include **epidermoid cysts**, desmoid tumors, and lipomas, alongside intestinal polyposis and osteomas. * **Turcot Syndrome:** Characterized by the association of colonic polyposis with **Central Nervous System (CNS) tumors** (e.g., medulloblastoma or glioblastoma). **High-Yield Clinical Pearls for NEET-PG:** * **Muir-Torre Marker:** The **sebaceous adenoma** is the most specific cutaneous marker for internal malignancy in MTS. * **Keratoacanthomas:** MTS is also associated with multiple keratoacanthomas, often with sebaceous differentiation. * **Screening:** Any patient presenting with a sebaceous adenoma (outside the head and neck) should be screened for internal malignancies via colonoscopy.

Q: A 15-year-old girl has developed multiple skin nodules over the past 10 years. Physical examination reveals 20 scattered, 0.3-cm to 1-cm, firm nodules on her trunk and extremities, along with 12 light brown macules averaging 2 to 5 cm in diameter on the trunk. Slit-lamp examination shows pigmented nodules in the iris. A sibling and a parent are similarly affected, and genetic analysis shows a loss-of-function mutation. Which of the following inheritance patterns is most likely present in this family?

Autosomal dominant. ### Explanation The clinical presentation described is a classic case of **Neurofibromatosis Type 1 (NF1)**, also known as von Recklinghausen disease. **Why Autosomal Dominant is correct:** NF1 is one of the most common **autosomal dominant** disorders, caused by a mutation in the *NF1* gene on chromosome 17, which encodes the protein **neurofibromin** (a tumor suppressor). * **Clinical Evidence:** The patient exhibits the classic triad: multiple **neurofibromas** (skin nodules), **Café-au-lait spots** (light brown macules), and **Lisch nodules** (pigmented iris hamartomas). * **Inheritance:** The fact that a parent and sibling are also affected, spanning multiple generations, is a hallmark of autosomal dominant inheritance. It has high penetrance but variable expressivity. **Why other options are incorrect:** * **Autosomal recessive:** These disorders typically appear in a single generation (horizontal transmission) and often involve enzyme deficiencies. NF1 involves a structural/tumor suppressor protein and shows vertical transmission. * **Mitochondrial:** This follows maternal inheritance (all children of an affected mother, none of an affected father). Here, the involvement of a "parent" (unspecified gender) and the known genetics of NF1 rule this out. * **Multifactorial:** This involves multiple genes and environmental factors (e.g., diabetes, hypertension). NF1 is a monogenic (single-gene) disorder. **Clinical Pearls for NEET-PG:** * **Diagnostic Criteria (NIH):** Requires $\geq$ 2 of: $\geq$ 6 Café-au-lait spots, $\geq$ 2 neurofibromas, axillary/inguinal freckling (**Crowe sign**), Lisch nodules, optic glioma, or a first-degree relative with NF1. * **Genetics:** Chromosome **17** (NF**1** has **17** letters). * **Associated Tumors:** Increased risk of Pheochromocytoma, Wilms tumor, and Malignant Peripheral Nerve Sheath Tumors (MPNST).

Q: Which type of nevus is typically found deep within the connective tissue?

Blue nevi. **Explanation:** The correct answer is **Blue nevi**. **1. Why Blue Nevi is Correct:** Blue nevi are characterized by the proliferation of spindle-shaped, dendritic melanocytes located **deep within the dermis** (connective tissue). Unlike common nevi, these melanocytes fail to migrate to the dermo-epidermal junction during embryogenesis and remain trapped in the deeper layers. The characteristic blue color is a result of the **Tyndall effect**: shorter wavelengths of light (blue) are reflected by the deep-seated melanin, while longer wavelengths (red) are absorbed by the overlying tissue. **2. Why Other Options are Incorrect:** * **Junctional nevi:** In these lesions, the nests of melanocytes are located strictly at the **dermo-epidermal junction**. They are clinically flat (macular) and represent the earliest stage of a common acquired nevus. * **Intramucosal nevi:** This term refers to the location (mucous membranes, such as the oral cavity) rather than the depth within the connective tissue architecture. While they are the mucosal equivalent of intradermal nevi, the "Blue nevus" is the classic histological example of deep dermal/connective tissue deposition. **3. NEET-PG High-Yield Pearls:** * **Common Blue Nevus:** Most common on the dorsum of hands and feet. * **Cellular Blue Nevus:** A larger variant, often found on the buttocks or sacrococcygeal region; it must be differentiated from malignant melanoma. * **Histology:** Look for heavily pigmented, elongated, dendritic cells interspersed among thickened collagen bundles. * **Progression:** Common acquired nevi usually follow a sequence: Junctional $\rightarrow$ Compound $\rightarrow$ Intradermal (where cells "drop" into the dermis but are not as deep or dendritic as blue nevi).

Question 1

A patient presents with a pruritic lesion over the left shoulder exhibiting cigarette paper atrophy and poikiloderma, along with generalized lymphadenopathy. Histopathological examination of the lesion reveals CD4-positive Sézary-Lutzner cells. What is the dermoepidermal manifestation of this disease?

Accepted Answer

Pautrier's microabscess

Answer

Pinpoint ulcers

Answer

Discharging sinus

Answer

Miliaria

Question 2

Which of the following is also known as self-healing carcinoma?

Accepted Answer

Keratoacanthoma

Answer

Basal cell carcinoma

Answer

Leukoplakia

Answer

Squamous cell carcinoma

Question 3

Which of the following skin findings is NOT typically associated with an underlying internal malignancy?

Accepted Answer

Granuloma annulare

Answer

Acanthosis nigricans and annular erythema

Answer

Bullous pyoderma and migratory necrotizing erythema

Answer

Erythema gyratum repens

Question 4

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

Accepted Answer

Acral lentiginous melanoma has a better prognosis than superficial spreading melanoma.

Answer

Clark's classification is used for prognosis.

Answer

Women generally have a better prognosis than men.

Answer

Limb perfusion is used for local treatment.

Question 5

Which of the following is NOT a risk factor for malignant melanoma?

Accepted Answer

HPV infection

Answer

Giant congenital nevi

Answer

Family history of melanoma

Answer

Exposure to UV light

Question 6

Multiple cutaneous sebaceous adenomas are seen in which of the following conditions?

Accepted Answer

Muir Torre syndrome

Answer

Cowden syndrome

Answer

Gardner syndrome

Answer

Turcot syndrome

Question 7

A 15-year-old girl has developed multiple skin nodules over the past 10 years. Physical examination reveals 20 scattered, 0.3-cm to 1-cm, firm nodules on her trunk and extremities, along with 12 light brown macules averaging 2 to 5 cm in diameter on the trunk. Slit-lamp examination shows pigmented nodules in the iris. A sibling and a parent are similarly affected, and genetic analysis shows a loss-of-function mutation. Which of the following inheritance patterns is most likely present in this family?

Accepted Answer

Autosomal dominant

Answer

Autosomal recessive

Answer

Mitochondrial

Answer

Multifactorial

Question 8

A 20-year-old female received treatment for bronchial asthma. She noticed a mole recently. Which characteristic of a mole carries a high risk for malignancy?

Accepted Answer

Irregular margin

Answer

Mole on the face

Answer

Size 6 mm

Answer

Hyperpigmentation

Question 9

Which type of nevus is typically found deep within the connective tissue?

Accepted Answer

Blue nevi

Answer

Junctional nevi

Answer

Intramucosal nevi

Answer

None of the above

Question 10

A 65-year-old light-complexioned male presents with a solitary scaly plaque-like lesion on his forearm, present for many years. The lesion is 0.5 cm in diameter. Shave biopsy reveals intraepithelial squamous cell carcinoma (Bowen's disease) that was incompletely excised. What is the most appropriate further treatment?

Accepted Answer

Excision and repair of this area, ensuring clear surgical margins

Answer

Wide excision of the lesion and sentinel node biopsy

Answer

Referral for local radiation therapy

Answer

No further treatment indicated

Skin Tumors — MCQs

Skin Tumors — MCQs

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