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ORIGINAL ARTICLE
Year : 2021  |  Volume : 66  |  Issue : 3  |  Page : 284-290
Clinical spectrum of cutaneous malignancies in central India: A retrospective study


1 From the Department of Dermatology, Venereology and Leprology, Government Medical College, Nagpur, Maharashtra, India
2 From the Department of Pathology, Government Medical College, Nagpur, Maharashtra, India

Date of Web Publication13-Jul-2021

Correspondence Address:
Vaishali H Wankhade
Department of Dermatology, Venereology and Leprology, Government Medical College and Hospital, Nagpur – 440 003, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_543_19

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   Abstract 


Introduction: Cutaneous malignancies account for 1%–2% of all the diagnosed cancers in India. Nonmelanoma skin cancers (NMSCs) include basal cell carcinomas (BCC) and squamous cell carcinomas (SCC). Others include melanoma, cutaneous lymphomas, and sarcomas. Exposure to ultraviolet (UV) rays is the most important risk factor associated with skin malignancies, although various other factors are also implicated. Aims and Objectives: The aims of this work were to study clinical spectrum with age and sex distribution of cutaneous malignancies and metastasis; to study clinicopathological variants of each type of cutaneous malignancies; and to study the risk factors associated with cutaneous malignancies. Patients and Methods: It was a retrospective analysis of clinically and biopsy proven cases of cutaneous malignancies from January 1, 2016 to January 31, 2018. Medical records of patients were assessed with respect to demographic information, clinical examination, dermoscopy, and histopathology. Statistical analysis was done using mean, proportion, and percentage. Results: Sixty-six cases with cutaneous malignancies were recruited. There was female preponderance. The most common age group affected was 60–70 years. BCC was the most common malignancy (41%) followed by SCC (30%), malignant melanoma (9%), and cutaneous T-cell lymphoma (1.5%). Head and neck was the most common site involved. The most common clinical type of both BCC and SCC was the nodular type. Acral lentiginous was the most frequent subtype of melanoma reported. The most common predisposing for NMSCs was prolonged sun exposure (46%). Conclusion: This study highlights an increasing trend of NMSCs with female preponderance. Head and neck is the most common site involved. Increased risk of NMSCs is seen with increased sun exposure and predisposed genetic conditions. T-cell lymphoma was common than B-cell type. The most common internal malignancy to cause cutaneous metastasis was breast carcinoma.


Keywords: Cutaneous malignancy, cutaneous metastasis, sun exposure


How to cite this article:
Supekar BB, Tomar SS, Wankhade VH, Bhushan R, Singh RP, Bhat DM. Clinical spectrum of cutaneous malignancies in central India: A retrospective study. Indian J Dermatol 2021;66:284-90

How to cite this URL:
Supekar BB, Tomar SS, Wankhade VH, Bhushan R, Singh RP, Bhat DM. Clinical spectrum of cutaneous malignancies in central India: A retrospective study. Indian J Dermatol [serial online] 2021 [cited 2021 Oct 19];66:284-90. Available from: https://www.e-ijd.org/text.asp?2021/66/3/284/321324





   Introduction Top


Cutaneous malignancies constitute a significant proportion of all malignancies and there has been an increase in the prevalence of cutaneous malignancies in the past several years.[1] The malignant skin lesions are broadly classified into three groups: basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma (MM), which account for more than 95% of total skin malignancies.[2] Worldwide BCC accounts for major burden, with occurrence up to 60%–70%; however, it carries a better prognosis as it has low propensity to spread. SCC occurs less frequently accounting for 15%–20% but has higher tendency of spreading.[3] Melanomas are seen 5%–10% of the cases and carry poor prognosis.[4] Lymphomas, sarcomas, and metastasis from internal malignancies are very rare forms of cutaneous malignancies.[5] About 90% of these malignancies occur in the age group older than 40 years. Occurrence of NMSCs in children can be seen in the setting of genetic diseases such as Xeroderma pigmentosum (XP), etc. Sun exposure (UVB spectrum [290–320 nm]) is the most important causative factor implicated in NMSCs.[6] Other etiological agents include viral infections, radiation therapy, and chemical exposure.[5] Histopathology is extremely valuable in establishing the diagnosis and identification of the histologic subtypes of different cutaneous malignancies.[7] Recently, dermoscopy has emerged as a valuable noninvasive method of diagnosis of cutaneous malignancies. It is especially useful for the early stage of melanoma.[8]


   Materials and Methods Top


A retrospective study of diagnosed cases of cutaneous malignancies was carried out from January 1, 2017 to December 31, 2018. Institutional ethical committee clearance was obtained (vide no. 1799 EC/Pharmac/GMC/NGP dated 4 May 2019). Medical records of all the patients of cutaneous malignancies attending our outpatient department were retrieved and analyzed with respect to patient's age, sex, occupation, relevant history, clinical features, histopathological, and dermoscopic findings. Relevant history was retrieved including family history, genetic disease, internal malignancy, preexisting dermatosis, trauma or burns at the site of malignancy, history of exposure to known common environmental carcinogens such as prolonged sun exposure evident by occupation of the patient, chemicals (arsenic)/toxin exposure, drug history and viral infections such as human papilloma virus (HPV), etc.

Clinical details were reviewed for duration of onset, site, morphology of lesion in terms of shape, size, surface, color, number, and progression. Assessment for presence of localized or generalized lymphadenopathy was done. Detailed general and systemic examination was done in all cases. Dermoscopic examination was performed in few of the cases. Histopathological examination was done in all cases for confirmation of diagnosis and analysis of subtypes and variants. Clinical, histopathological, and dermoscopic images were also retrieved. Statistical analysis of the data was carried out using mean, proportions, and percentages.


   Results Top


The total number of patients enrolled was 66. Maximum number of patients belonged to the age of 60–70 years (26.5%) followed by age group 51–60 years (20.3%). The youngest patient with malignancy seen was of 18 years, whereas the oldest patient was of 83 years with a mean age of 55.71 ± 3.87 years [Table 1]. Among 66 patients, 26 (39.3%) were men and 40 (60.7%) were women, with a male-to-female ratio of 1:1.53 [Table 1]. Most of the our patients were farmers and laborers by occupation (n = 34, 51%).
Table 1: Age and sex distribution of cutaneous malignancies

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The most common malignancy was BCC (n = 27, 41%) followed by SCC (n = 20,30%) with NMSCs constituting 71% of the total cases. Other malignancies reported were malignant melanoma in six patients (9%), cutaneous lymphomas in seven (11%), and cutaneous metastases in six (9%) patients [Table 1] and [Graph 1].



Head and neck was the most common site of malignancy observed in 34 (51.5%) patients, followed by trunk in 14 patients (21%). Among BCC patients, the most common site involved was forehead in 8 of 27 (29%) patients followed by cheeks in 6 (22.22%) patients. The rare sites of BCC reported were dorsum of hand (n = 1) and popliteal fossa (n = 1) as shown in [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f. In SCC, trunk was the most common site involved in 5 of 20 patients (25%) followed by lower extremities in 3 patients (15%) [Figure 2]a, [Figure 2]b, [Figure 2]c. Malignant melanoma was most commonly seen on lower extremities (soles) in 4 of 6 patients (50%) as shown in [Figure 3]a, [Figure 3]b,[Figure 3]c, [Figure 3]d, whereas lymphomas [Figure 4] and metastases [Figure 5] were collectively common on the trunk in 6 of 13 patients (43%), as depicted in [Graph 2].
Figure 1: Pigmented basal cell carcinoma (BCC) over medial canthus of eye (a), BCC over trunk (b), BCC near outer canthus of left eye (c), Ulcerative BCC over temporal aspect of scalp (d), BCC over popliteal fossa (e), BCC over dorsum of hand (f)

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Figure 2: Squamous cell carcinoma (SCC) secondary to draw string dermatitis over waist (a), Verrucous SCC over back (b), SCC over sole (c), SCC over neck in a patient of albinism (d), SCC over face in a patient of xeroderma pigmentosum (e and f)

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Figure 3: Acral lentigenous melanoma over sole (a), Superficial spreading melanoma over chest (b), Acral lentigenous melanoma with pigmentation & ulceration over sole (c and d)

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Figure 4: Diffuse large B cell lymphoma over legs (a, b), Peripheral T cell lymphoma involving lower abdomen and right thigh (c), Anaplastic T cell lymphoma over lower limb (d)

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Figure 5: Cutaneous metastasis secondary to carcinoma of breast over chest (a), Cutaneous metastasis secondary to carcinoma cervix over vulva (b), Cutaneous metastasis secondary to papillary carcinoma of thyroid over chest (c), Cutaneous metastasis secondary to carcinoma breast over abdomen (d)

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Prolonged sun exposure was found to be the major risk factor (n = 30, 46%), followed by genetic disorders, pre-existing dermatosis and systemic malignancies in 9% cases (n = 6) each. Apart from these, other factors included post-burn scars or ulcers, i.e. marjolin's ulcer (4.5%), previous viral infections i.e HPV (3%), and dysplastic nevi (1.5%). Preexisting dermatosis like drawstring dermatitis was present in six women. Genetic conditions included three cases of XP, two cases of albinism and a single case of multiple familial trichoepithelioma (MFT). SCC was reported in two patients with XP on the cheek and forearm and both patients with albinism on cheek and neck, respectively. [Figure 2]d, [Figure 2]e, [Figure 2]f BCC was seen in one patient with XP on the cheek and one patient with MFT over parotid region. No obvious predisposing factor could be found in 12 (18%) cases, as depicted in [Graph 3].



We performed dermoscopy using 3 Gen Dermlite DL4 (CA, VSA) & eScope 10 x magnification polarized light in three cases of SCC, nine cases Of BCC and three cases of acral lentigenous melanoma (ALM). Dermoscopic features are illustrated in [Figure 6]a, [Figure 6]b, [Figure 6]c, [Figure 6]d, [Figure 6]e, [Figure 6]f.
Figure 6: (a-f). Dermoscopy (10x polarised mode) revealed combination of colours with white shiny streaks, maple leaf like structure (blue arrow) arborizing vessels (green arrow) suggestive of basal cell carcinoma (a), keratinised whitish structure (green arrow, b), polymorphous vascular structure (green arrow) and red dot (black arrow) (c) suggestive of squamous cell carcinoma. Parallel ridge (blue arrow) and lattice pattern (red arrow) (d), brown globules (yellow arrow) (e), white structureless area (blue arrow) (f) suggestive of melanoma

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The most common histopathological variant of BCC observed was nodular type seen (n = 7, 26%) followed by ulcerative and pigmented types in six (22.22%) cases each. Rare histopathological variants of BCC reported were adenoid, basosquamous and fibroepithelial types [Figure 7]a, [Figure 7]b, [Figure 7]c, [Figure 7]d, [Figure 7]e, [Figure 7]f. Of 20 cases of SCC, 12 (60%) were well differentiated and 8 (40%) were poorly differentiated. The most common histopathological variant of SCC was nodular type in 10 cases (50% of SCC) [Figure 8]a and [Figure 8]b. Other types of SCC observed were ulcerative and verrucous. HPV-associated malignancies (SCC) were diagnosed on the presence of koilocytes on histopathology. HPV DNA was not performed because of lack of resources. In melanoma, the most common type was acral lentiginous seen in three (50%) cases followed by superficial spreading in two (33%) cases [Figure 8]c, [Figure 8]d. We reported two cases each of diffuse large B-cell lymphoma, peripheral T-cell lymphoma and anaplastic large cell lymphoma along with a single case of cutaneous T-cell lymphoma. Cutaneous metastasis was seen in three cases of breast carcinomas, single case of cervical, perianal and thyroid carcinoma (papillary type) [Table 2], [Figure 9]a, [Figure 9]b, [Figure 9]c, [Figure 9]d.
Table 2: Histopathology pattern of malignancy

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Figure 7: (a-f). Histopatholgy: nodule over face revealed basaloid cells arranged in nests & cords, nodular BCC (a, nodule over forehead revealed basaloid tumor cells with with squamous differentiation & keratin filled cyst, keratotic BCC (b) nodule over forehead revealed basaloid cells with intra & extracellular brown black coarse pigmentation, pigmented BCC (c) nodule over hand revealed tumor mass in dermis & infiltrating deeper tissues along with desmoplastic stroma, fibro-epithelial BCC (d), mass over forehead revealed basaloid cells arranged in anastomosing cords and trabeculae, adenoid BCC (e and f)

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Figure 8: (a-d). Histopathology from growth over sole revealed hyperplastic epidermis, dermis shows haemorrhage, necrosis & keratin pearl formation with surrounding malignant squamous cells suggestive of squamous cell carcinoma (a and b) histopathology from lesion over sole revealed sheets of tumor cells with large, irretgular pleomorphic, hyperchromatic nuclei & prominent nucleoli, condensation of chromatin & intracytoplasmic melanin pigment suggestive of malignant melanoma

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Figure 9: (a-d). Histopatholgy: nodule over trunk revealed monomorphic population of lymphoid cells in dermis, cutaneous lymphoma(a);plaque over back revealed collection of eosinophil, lymphocyte, large abnormal cells with irregular hyperchromatic multilobulated nuclei, mycosis fungoides (b); lesion over leg revealed tumor cells in cords and nest in dermis; metastasis of malignancy stomach(c); nodule over chest revealed tumor mass arranged in complex branching papillae with central core of occasional Psammoma bodies in dermis; metastasis of papillary carcinoma of thyroid

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   Discussion Top


Cutaneous malignancies account for 1–2% of all the diagnosed cancers in India. Worldwide BCC is the most common cutaneous malignancy, but in India, SCC is reported to be the most common with prevalence of 30–60% followed by BCC with prevalence of 15–25%.[9] However, in this study BCC (41%) was found to be more prevalent than SCC (30%). This is similar to the study conducted by Lal et al. wherein BCC was reported in 54% cases as compared to SCC in 36% cases.[10]

The mean age for diagnosis of malignancy in this study was 55.71 years with a range of 18–83 years, which is similar to study conducted by Azad et al. where the mean age was 55.8 years.[11] There was female preponderance with a male-to-female ratio of 1:1.53. Lal et al. and Pinedo et al. have reported a similar higher proportion of cases in women as compared to men. This could be due to increasing sun exposure among Indian women.[10],[12] However, Azad et al. and Jina et al. have found male predominance in their respective studies.[11],[13]

Head and neck was the most common region involved in all types of malignancies. This result was consistent with studies conducted by Lal et al. and Jina et al., who reported similar results. This head and neck region is under direct effect of prolonged sun exposure.[10],[13] Maximum number of our cases (n = 30, 46%) were farmers and laborers by occupation who worked outdoors for 6-7 hours daily. The rare sites involved in BCC were popliteal fossa and dorsum of hand.

Among 66 patients, 46% patients had a history of prolonged sun exposure pertaining to their outdoor occupations. Lal et al. and Jina et al. have also found sun exposure as the most common risk factor for development of cutaneous malignancies.[10],[13] The role of environmental factors in the causation of skin cancers has been extensively reviewed. UVB radiation is well known as an agent inducing skin cancers in a dose dependent way. Other factors include genetic mutations, immunosuppression and viral infections particularly with HPV. We found six cases of SCC and BCC in exclusive association with genetic disorders like XP, oculocutaneous albinism and MFT. The occurrence of this association is less commonly observed in India as compared to western population.[14] History of chronic frictional dermatitis on waist i.e., drawstring dermatitis was seen in 9% of female patients. Drawstring dermatitis is a type of frictional dermatitis that can result from traditional tightly worn garments like “sari” and “;salwaar-kamiz” and predisposition to SCC. The other rare predisposing factors reported were marjolin's ulcer and HPV infection.

Histopathologically nodular variant was observed as the most common type in BCC and SCC. Well-differentiated types were common in SCC which correlated with the study of Adinarayan et al.[15] Rarely reported histopathological variants were also observed as fibroepithelial, adenoid, basosquamous types in BCC and verrucous type in SCC. In melanoma, acral lentiginous variant was the most common type observed. Panda et al. reported similar observation. However many previous studies report superficial spreading and nodular variants to be more common in India.[16]

Cutaneous T-cell lymphomas are more common than B-cell lymphomas. The most common cause of cutaneous metstasis was breast carcinoma. Similar findings were reported in the studies by El khoury et al. and Khader et al. respectively.[17],[18]

[Table 3] shows comparison of various characteristics between different studies.[10],[11],[13],[16],[17] Small sample size was a major limitation of this study. Immunohistochemistry (IHC) staining and dermoscopy were not performed in all cases due to lack of resources. There is a paucity of studies with regards to dermoscopy and histopathology of cutaneous malignancies. To the best of our knowledge, there is no published data on the clinico-histopathological and dermoscopic pattern of various cutaneous malignancies and metastasis from central India.
Table 3: Comparison between similar studies

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   Conclusion Top


This study emphasizes NMSCs as the cutaneous malignancies with a female predominance. An increased risk of NMSCs is seen with increased sun exposure. These neoplasms along with other rare malignancies like melanoma, cutaneous lymphomas and cutaneous metastases are often associated with increased morbidity. They require increased efforts to assess risk factors in individuals and to encourage periodic self-examination of the skin.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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[PUBMED]  [Full text]  
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[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
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