Benign Skin Tumors — MCQs
Which of the following conditions is associated with acanthosis nigricans?
Skin biopsy shows psoriasiform hyperplasia with neutrophilic microabscesses in stratum corneum. Most likely diagnosis?
Acanthosis nigricans is characterized by all of the following except?
Lesions of Nevus of Ota commonly involve which cranial nerve?
A patient has multiple meningiomas, acoustic neuroma and hyperpigmented skin lesions; most likely diagnosis is –
Which one of the following is the most common CNS tumor associated with type I neurofibromatosis?
What is the most likely diagnosis for a 15 mm hyperpigmented lesion on the shoulder that is enlarging and has hair growing from it?
A patient presents with a gradually progressive, painless mass persisting for 10 years. The mass is firm to nodular and shows variable consistency within different areas of the swelling. What is the most probable diagnosis?
Pautrier's microabscess is a histological feature of which disease?
A 22 year old woman comes with a non progressive mass in the left breast since 6 months. There are no associated symptoms. Examination shows a mobile mass not attached to the overlying skin or underlying tissue. The possible diagnosis is
Benign Skin Tumors Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following conditions is associated with acanthosis nigricans?
- A. Obesity
- B. Gastric adenocarcinoma
- C. Type 2 Diabetes Mellitus (Correct Answer)
- D. All of the options
Explanation: Acanthosis nigricans is characterized by velvety, hyperpigmented skin lesions, often in intertriginous areas, and is a common cutaneous marker for insulin resistance, which is central to Type 2 Diabetes Mellitus [1]. The elevated insulin levels stimulate epidermal keratinocytes and dermal fibroblast proliferation, leading to the characteristic skin changes. While malignant acanthosis nigricans is associated with internal malignancies, particularly adenocarcinomas of the gastrointestinal tract (like gastric), it is a less common cause than insulin resistance. This form is usually more extensive and rapidly progressing than the benign variant. Obesity is strongly associated with insulin resistance, making it an indirect cause of acanthosis nigricans. However, acanthosis nigricans is a direct indicator of insulin resistance, which can occur with or without significant obesity. While all listed conditions can be associated with acanthosis nigricans, Type 2 Diabetes Mellitus is the most direct and common condition explicitly linked to the underlying pathophysiology of insulin resistance [1]. Gastric adenocarcinoma causes a malignant form, and obesity is a risk factor for insulin resistance, but T2DM directly reflects the metabolic state responsible for the skin changes.
Question 2: Skin biopsy shows psoriasiform hyperplasia with neutrophilic microabscesses in stratum corneum. Most likely diagnosis?
- A. Psoriasis (Correct Answer)
- B. Seborrheic dermatitis
- C. Pityriasis rosea
- D. Lichen planus
Explanation: ***Psoriasis*** - **Psoriasiform hyperplasia**, characterized by regular epidermal acanthosis and elongated rete ridges, is a classic histological feature of psoriasis. - The presence of **neutrophilic microabscesses (Munro microabscesses)** in the stratum corneum is a pathognomonic finding for psoriasis. *Seborrheic dermatitis* - Histologically, seborrheic dermatitis typically shows **irregular acanthosis** with parakeratosis and a **perivascular lymphocytic infiltrate**, but not regular psoriasiform hyperplasia or Munro microabscesses. - There may be *spongiosis* and neutrophils in the stratum corneum, but not the distinct microabscesses seen in psoriasis. *Pityriasis rosea* - Pityriasis rosea histology often reveals **focal parakeratosis**, **spongiosis**, and a **perivascular lymphocytic infiltrate** with extravasated red blood cells. - It does not demonstrate the characteristic regular psoriasiform hyperplasia or neutrophilic microabscesses of psoriasis. *Lichen planus* - Lichen planus is characterized by a **"sawtooth" rete ridge pattern**, a **band-like lymphocytic infiltrate** at the dermo-epidermal junction, and **colloid bodies (Civatte bodies)**. - It does not exhibit psoriasiform hyperplasia or neutrophilic microabscesses in the stratum corneum.
Question 3: Acanthosis nigricans is characterized by all of the following except?
- A. Associated with thick skin with hyperpigmentation
- B. May be a sign of internal malignancy
- C. Common in obese people
- D. Histologically there is hypermelanosis (Correct Answer)
Explanation: ***Histologically there is hypermelanosis*** - This statement is **FALSE** and is the correct answer to this "EXCEPT" question - The characteristic dark appearance of acanthosis nigricans is **NOT due to increased melanin** (hypermelanosis) - Histologically, the key features are **hyperkeratosis, papillomatosis, and mild acanthosis** - There is typically **minimal or no increase in melanocytes or melanin pigment** - The hyperpigmentation seen clinically is an optical effect from the thickened, hyperkeratotic epidermis *May be a sign of internal malignancy* - This statement is **true**; acanthosis nigricans can be a paraneoplastic syndrome associated with internal malignancies - **Malignant acanthosis nigricans** is particularly associated with **gastrointestinal adenocarcinomas** (especially gastric) - This form typically has sudden onset, rapid progression, and more widespread involvement *Common in obese people* - This statement is **true**; acanthosis nigricans is frequently associated with **insulin resistance** - Commonly seen in individuals with **obesity, type 2 diabetes, and metabolic syndrome** - This benign form typically affects flexural areas (neck, axillae, groin) *Associated with thick skin with hyperpigmentation* - This statement is **true**; these are the hallmark clinical features of acanthosis nigricans - Presents as **velvety thickening** and **dark brown to black hyperpigmentation** - Typically affects intertriginous areas and skin folds
Question 4: Lesions of Nevus of Ota commonly involve which cranial nerve?
- A. Oculomotor nerve (Cranial Nerve III)
- B. Trigeminal nerve (Cranial Nerve V) (Correct Answer)
- C. Spinal accessory nerve (Cranial Nerve XI)
- D. Facial nerve (Cranial Nerve VII)
Explanation: ***Trigeminal nerve (Cranial Nerve V)*** - Nevus of Ota is a **dermal melanocytosis** typically presenting as bluish-gray patches on the face, specifically within the distribution of the **ophthalmic (V1)** and **maxillary (V2) divisions** of the trigeminal nerve. - The lesions often involve the **periorbital region**, forehead, and cheek, corresponding to the sensory innervation fields of these trigeminal nerve branches. *Oculomotor nerve (Cranial Nerve III)* - The oculomotor nerve primarily controls **eye movements** and **pupil constriction**. - While Nevus of Ota can occasionally involve the eye itself (e.g., episcleral melanocytosis), its cutaneous lesions are not distributed along the oculomotor nerve's innervation pattern. *Spinal accessory nerve (Cranial Nerve XI)* - The spinal accessory nerve is a **motor nerve** responsible for controlling the **sternocleidomastoid** and **trapezius muscles**. - It has no sensory or cutaneous distribution relevant to the facial lesions seen in Nevus of Ota. *Facial nerve (Cranial Nerve VII)* - The facial nerve primarily controls **facial expressions** and taste sensation from the anterior two-thirds of the tongue. - Although it innervates facial muscles, its cutaneous sensory distribution is minimal, and the characteristic skin lesions of Nevus of Ota do not follow its pattern.
Question 5: A patient has multiple meningiomas, acoustic neuroma and hyperpigmented skin lesions; most likely diagnosis is –
- A. Neurofibromatosis (Correct Answer)
- B. Von Hippel lindau disease
- C. Sturge weber syndrome
- D. Tuberous sclerosis
Explanation: ***Neurofibromatosis*** - The combination of **multiple meningiomas**, **acoustic neuroma** (specifically bilateral in NF2) [1], and **hyperpigmented skin lesions** (cafe-au-lait spots in NF1, or multiple cutaneous neurofibromas) is highly characteristic of neurofibromatosis. - This presentation suggests either **Neurofibromatosis type 1 (NF1)** with meningiomas (less common but possible) or, more strongly, **Neurofibromatosis type 2 (NF2)** due to the bilateral acoustic neuromas and the presence of meningiomas, with hyperpigmentation being a variable feature [1]. *Von Hippel-Lindau disease* - This disorder is characterized by **hemangioblastomas** of the retina and central nervous system, **renal cell carcinoma**, and **pheochromocytomas**. - It does not typically involve meningiomas, acoustic neuromas, or hyperpigmented skin lesions. *Sturge-Weber syndrome* - This is a neurocutaneous disorder featuring a **port-wine stain (facial nevus flammeus)**, leptomeningeal angioma, and **glaucoma**. - The clinical picture of meningiomas, acoustic neuroma, and hyperpigmented skin lesions does not align with Sturge-Weber syndrome. *Tuberous sclerosis* - This condition is characterized by the growth of numerous **benign tumors in many different organs**, including the brain (tubers, subependymal giant cell astrocytomas), skin (facial angiofibromas, shagreen patches, ash-leaf spots), kidneys (angiomyolipomas), and heart (rhabdomyomas). - While it has **skin lesions** and **brain tumors**, these are distinct from meningiomas and acoustic neuromas, which are not typical features.
Question 6: Which one of the following is the most common CNS tumor associated with type I neurofibromatosis?
- A. Optic nerve glioma (Correct Answer)
- B. Meningioma
- C. Acoustic schwannoma
- D. Low grade astrocytoma
Explanation: ***Optic nerve glioma*** - **Optic nerve gliomas** are the most frequently encountered central nervous system tumors in patients with **Type 1 neurofibromatosis (NF1)**, occurring in about 15% of individuals. - They are typically low-grade **astrocytomas** and can cause vision loss and proptosis depending on their size and location. *Meningioma* - While more common in **Type 2 neurofibromatosis (NF2)**, meningiomas can occur in NF1, but are not the most common CNS tumor. - Meningiomas are tumors that arise from the **meninges**, the membranes surrounding the brain and spinal cord. *Acoustic schwannoma* - **Bilateral acoustic schwannomas (vestibular schwannomas)** are the hallmark feature of **Type 2 neurofibromatosis (NF2)**, not NF1 [1]. - These tumors arise from the Schwann cells of the **vestibulocochlear nerve** and can cause hearing loss and balance issues [1]. *Low grade astrocytoma* - While optic nerve gliomas are a type of low-grade astrocytoma, this option is too general; **optic nerve glioma** is the specific and most common presentation in NF1. - Other forms of low-grade astrocytomas can occur in NF1 but are not as universally characteristic as optic nerve gliomas.
Question 7: What is the most likely diagnosis for a 15 mm hyperpigmented lesion on the shoulder that is enlarging and has hair growing from it?
- A. Melanocytic nevus
- B. Becker nevus (Correct Answer)
- C. Sebaceous nevus
- D. Comedo nevus
Explanation: ***Correct: Becker nevus*** This diagnosis is supported by the description of a **hyperpigmented lesion** that is **enlarging** and has **hair growing from it**, typically appearing during adolescence or young adulthood. **Becker nevus** often presents as an **irregular, hyperpigmented patch**, usually on the shoulder or upper trunk, and is characteristically associated with **hypertrichosis** (increased terminal hair growth). The combination of location (shoulder), enlargement, and hair growth in a 15 mm lesion is classic for Becker nevus. *Incorrect: Melanocytic nevus* While **melanocytic nevi** are hyperpigmented, they typically do not continue to **enlarge significantly** after childhood and generally do not develop new onset **hypertrichosis** as a primary feature. The size (15 mm) and progressive growth combined with hair development are more characteristic of a Becker nevus than a common melanocytic nevus. *Incorrect: Sebaceous nevus* **Sebaceous nevi** are typically **yellow-orange to tan, waxy plaques**, often on the scalp or face, with a cobblestone or papillomatous texture. They are not primarily characterized by **hyperpigmentation** and terminal hair growth, but rather by sebaceous gland proliferation. *Incorrect: Comedo nevus* A **comedo nevus** presents as a linear or unilateral group of **dilated follicular openings** filled with keratinous material, resembling blackheads. It is not characterized by diffuse **hyperpigmentation** or the increased terminal hair growth described in this case.
Question 8: A patient presents with a gradually progressive, painless mass persisting for 10 years. The mass is firm to nodular and shows variable consistency within different areas of the swelling. What is the most probable diagnosis?
- A. Dermoid cyst
- B. Malignancy
- C. Sebaceous cyst
- D. Pleomorphic adenoma (Correct Answer)
Explanation: ***Pleomorphic adenoma*** - A **gradually progressive**, **painless mass** that has been present for 10 years, with a **firm to nodular** consistency and variability at different sites, is highly characteristic of a pleomorphic adenoma. - This benign tumor of salivary glands is known for its **slow growth** and **variable histological composition**, leading to its characteristic consistency. *Dermoid cyst* - Dermoid cysts are typically **present from birth** or early childhood and tend to be **soft and doughy** in consistency, rather than firm or nodular with variable consistency. - While painless, their growth pattern and texture differ from the described mass. *Malignancy* - A mass that has been present for **10 years** and is still described as **gradually progressive** but painless is less likely to be a malignancy, as most malignant tumors tend to grow more rapidly and often present with pain or other symptoms over such a long period. - Malignancies usually demonstrate a more infiltrative and aggressive growth pattern. *Sebaceous cyst* - A sebaceous cyst (epidermoid cyst) typically presents as a **smooth, movable, dome-shaped lump** and contains a cheesy, malodorous material, which is not consistent with a firm to nodular mass with varying consistency. - While they can be long-standing and painless, their characteristic feel and contents are different.
Question 9: Pautrier's microabscess is a histological feature of which disease?
- A. Sarcoidosis
- B. Tuberculosis
- C. Mycosis fungoides (Correct Answer)
- D. Pityriasis lichenoides chronica
Explanation: ***Mycosis fungoides*** - **Pautrier's microabscesses** (intraepidermal collections of neoplastic T-lymphocytes) are a characteristic histological hallmark of **mycosis fungoides**, a cutaneous T-cell lymphoma [1]. - These collections are typically seen in the **epidermis**, especially in the patch and plaque stages of the disease, reflecting the **epidermotropism** of the malignant T-cells [1]. *Sarcoidosis* - Characterized by **non-caseating granulomas** in various organs, including the skin. - **Pautrier's microabscesses** are not a feature of sarcoidosis. *Tuberculosis* - Identified by the presence of **caseating granulomas** composed of epithelioid cells, lymphocytes, and Langerhans giant cells. - It does not involve the formation of **intraepidermal microabscesses** of lymphocytes. *Pityriasis lichenoides chronica* - A benign inflammatory skin condition characterized by a **lymphocytic vasculitis** and interface dermatitis. - Histology shows a **wedge-shaped inflammatory infiltrate** in the dermis with interface changes, but not Pautrier's microabscesses. **References:** [1] 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.
Question 10: A 22 year old woman comes with a non progressive mass in the left breast since 6 months. There are no associated symptoms. Examination shows a mobile mass not attached to the overlying skin or underlying tissue. The possible diagnosis is
- A. Fibroadenoma (Correct Answer)
- B. Cystasarcoma Phylloides
- C. Scirrhous Carcinoma
- D. Fibroadenosis
Explanation: ***Fibroadenoma*** - This is the most common benign breast tumor in young women, typically presenting as a **mobile, non-tender, firm mass** with no attachment to surrounding tissues. - The history of a **non-progressive mass** over six months in a 22-year-old woman is highly characteristic of a fibroadenoma. *Cystasarcoma Phylloides* - While it can present as a mobile mass, phyllodes tumors tend to grow **rapidly** and can reach a large size, which contradicts the "non-progressive" nature of the mass described. - Phyllodes tumors often have a **leaf-like architectural pattern** histologically and can be benign, borderline, or malignant. *Scirrhous Carcinoma* - This is a type of invasive ductal carcinoma that typically presents as a **hard, irregular, fixed mass** that is often attached to the skin or underlying tissue, unlike the mobile mass described here. - It is common in older women and often associated with **skin dimpling** or nipple retraction. *Fibroadenosis* - This refers to a group of benign breast changes, often presenting with generalized **lumpiness, pain, or tenderness** that fluctuates with the menstrual cycle, rather than a discrete, solitary mass. - It usually presents as **multiple, diffuse nodules** rather than a single, well-defined mass.
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