Skin Tumors Practice Questions

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.

Q: Which of the following skin lesions does not change or remains the same throughout life?

Portwine stain. **Explanation:** The correct answer is **Port-wine stain (PWS)**. The fundamental medical concept here is the distinction between **vascular malformations** and **vascular tumors**. 1. **Why Port-wine Stain is correct:** A Port-wine stain (Nevus Flammeus) is a **capillary malformation** present at birth. Unlike hemangiomas, it is composed of mature, dilated dermal capillaries. It follows the rule of "permanent and progressive": it does not involute, grows proportionately with the child, and often becomes darker, thicker, or more nodular (verrucous) in adulthood. It is a permanent lesion that persists throughout life unless treated with lasers (e.g., Pulsed Dye Laser). 2. **Why the other options are incorrect:** * **Salmon Patch (Nevus Simplex):** Also known as "Stork bites" or "Angel kisses," these are transient capillary ectasias. Most fade and disappear spontaneously within the first 1–2 years of life. * **Strawberry Angioma / Capillary Hemangioma:** These are **vascular tumors** (Infantile Hemangiomas). They typically follow a predictable life cycle: a rapid proliferative phase after birth, followed by a slow spontaneous involution phase. Approximately 50% disappear by age 5, and 90% by age 9. **High-Yield Clinical Pearls for NEET-PG:** * **Sturge-Weber Syndrome:** A PWS in the V1/V2 distribution of the trigeminal nerve may be associated with glaucoma and leptomeningeal angiomatosis (look for "tram-track" calcifications on CT). * **Klippel-Trenaunay Syndrome:** PWS associated with limb hypertrophy and venous malformations. * **Treatment of Choice:** The **Pulsed Dye Laser (585 or 595 nm)** is the gold standard for treating Port-wine stains. * **Mnemonic:** Malformations (PWS) are **Permanent**; Hemangiomas (Strawberry) **Halt and Heal**.

Q: A 55-year old male presents for evaluation of a lesion on his lower lip for the past year. He is employed as a landscaper and reports infrequent use of sun protection. He denies any pertinent medical history. Physical examination reveals a 5 mm erythematous, ulcerative nodule located within the vermilion of the right lateral aspect of the lower lip. Biopsy confirms the presence of invasive squamous cell carcinoma and the patient is referred for Mohs micrographic surgical excision. Which of the following lymph nodes would be most critical to evaluate for metastasis?

Submandibular lymph nodes. **Explanation:** The lymphatic drainage of the lip follows a specific anatomical pattern, which is crucial for predicting the metastatic spread of Squamous Cell Carcinoma (SCC). 1. **Why Submandibular Lymph Nodes are correct:** The **lateral aspects of the lower lip** and the entire upper lip drain primarily into the **submandibular lymph nodes** (Level IB). Since the patient has a lesion on the lateral aspect of the lower lip, these are the first-line nodes for metastatic evaluation. 2. **Why other options are incorrect:** * **Submental lymph nodes:** These nodes primarily receive drainage from the **central (medial) portion** of the lower lip and the tip of the tongue. * **Posterior cervical chain:** These nodes (Level V) typically receive drainage from the scalp, nasopharynx, and oropharynx; they are not the primary drainage site for the lips. * **Jugulodigastric lymph node:** Part of the deep cervical chain (Level II), these nodes receive secondary drainage from the submandibular nodes or primary drainage from the tonsils and posterior tongue. **Clinical Pearls for NEET-PG:** * **SCC of the Lip:** The lower lip is the most common site for oral SCC (90%), usually due to chronic UV exposure (as seen in this landscaper). * **Drainage Rule:** Central lower lip → Submental nodes; Lateral lower lip/Upper lip → Submandibular nodes. * **Prognosis:** SCC of the lip has a higher metastatic potential compared to SCC of the skin, making nodal assessment vital. * **Mohs Micrographic Surgery (MMS):** The gold standard for SCC in "high-risk" zones (like the lip) to ensure complete margin control while sparing tissue.

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.

Question 1

What is the most common site for Basal cell carcinoma?

Accepted Answer

Face

Answer

Trunk

Answer

Neck

Answer

Extremities

Question 2

Which of the following skin lesions does not change or remains the same throughout life?

Accepted Answer

Portwine stain

Answer

Salmon patch

Answer

Strawberry angiomas

Answer

Capillary hemangiomas

Question 3

A 55-year old male presents for evaluation of a lesion on his lower lip for the past year. He is employed as a landscaper and reports infrequent use of sun protection. He denies any pertinent medical history. Physical examination reveals a 5 mm erythematous, ulcerative nodule located within the vermilion of the right lateral aspect of the lower lip. Biopsy confirms the presence of invasive squamous cell carcinoma and the patient is referred for Mohs micrographic surgical excision. Which of the following lymph nodes would be most critical to evaluate for metastasis?

Accepted Answer

Submandibular lymph nodes

Answer

Submental lymph nodes

Answer

Posterior cervical chain

Answer

Jugulodigastric lymph node

Question 4

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 5

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 6

Which of the following characterises malignant change in a nevus?

Accepted Answer

Itching

Answer

Darkening

Answer

Hemorrhage

Answer

All of the above

Question 7

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 8

Which of the following is NOT true about rodent ulcer (basal cell carcinoma)?

Accepted Answer

It is radiosensitive.

Answer

Lymph node involvement is typically absent.

Answer

It commonly presents as a facial lesion.

Answer

Blood-borne metastasis is rare.

Question 9

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 10

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

Skin Tumors — MCQs

Skin Tumors — MCQs

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