SPECTRUM OF MALIGNANT SKIN LESION IN PATIENTS ATTENDING NEPALGUNJ MEDICAL COLLEGE AND TEACHING HOSPITAL Affiliation

Results Malignant tumor of skin cons tuted 21.4% of total cases. In malignant tumor, most common sites were head and neck regions followed by lower limb with kera nocy c tumors being in the majority. Most of the specimens (65.7%) were obtained as excisional biopsies. Seven cases diagnosed as benign lesions clinically, turned out to be malignant on histopathological examina on. Out of 13 cases in which clinical diagnosis was of malignancy, only 8 turned out to be malignant, thus for malignant lesions, the clinical diagnosis had a sensi vity of 53.3%, specificity of 90.9% and a posi ve predic ve value of 61.5%.


Objec ve
The aim of this study was to analyze malignant tumor of skin with respect to age, sex, clinical features and histopathological features and to evaluate the accuracy of clinical diagnosis with histopathological correla on.

Methodology
This is hospital based cross-sec onal study conducted at Nepalgunj Medical College and Teaching Hospital, Kohalpur from February 2010 to January 2011.A total of 70 histopathological specimens of skin biopsies were studied and correlated with the clinical diagnosis.The data was entered into Microso office excel and analyzed using sta s cal package for social sciences (SPSS 17.0).

Results
Malignant tumor of skin cons tuted 21.4% of total cases.In malignant tumor, most common sites were head and neck regions followed by lower limb with kera nocy c tumors being in the majority.Most of the specimens (65.7%) were obtained as excisional biopsies.Seven cases diagnosed as benign lesions clinically, turned out to be malignant on histopathological examina on.Out of 13 cases in which clinical diagnosis was of malignancy, only 8 turned out to be malignant, thus for malignant lesions, the clinical diagnosis had a sensi vity of 53.3%, specificity of 90.9% and a posi ve predic ve value of 61.5%.

INTRODUCTION
The skin is affected by both internal and external condi ons and other factors as it is exposed to a range of environmental hazards making it vulnerable to all manner of threats.Various lesions affec ng the skin range from nonspecific inflammatory dermatoses, infec ve disease and neoplasms.This study was conducted in mid-western region of Nepal, which is a very hot and humid tropical region.Skin diseases are the common problems in such region.Among skin diseases, skin cancer if diagnosed in later stages, causes significant morbidity and mortality.Clinical diagnosis of dermatological manifesta on of neoplas c skin lesion can pose diagnos c difficulty at mes.The clinician in many cases suggest differen al diagnosis which forms the basis for The data was entered into Microso office excel and analyzed using sta s cal package for social sciences (SPSS 17.0).

RESULT
Out of 70 cases only 15 cases were malignant skin tumors comprising 6 cases (40%) of SCC, followed by 4 cases of Malignant Melanoma (26.6%) and three cases of BCC (20%).One case each of Dermatofibrosarcoma protuberance (6.6%) and Mucinous Eccrine Carcinoma (6.6%).Benign tumor of the skin were more common than malignant tumor in this study period.The histological categoriza on according to the frequency of the cases are given in table 1 and 2. All the malignant lesions presented clinically as localized lesions and maximum of it were ulcerated followed by nodular lesion.Malignant lesions were more common in the 51 to 60 years age group followed by age group of 21-30 years as shown in table 3. Maximum number of specimens (65.7%) were obtained as excisional biopsies.

Rana R et al
In our study, among the six cases of squamous cell carcinoma, five were well differen ated microscopically and one was of verrucous type (an extremely well-differen ated rare variant of SCC) in a 65 year old female which was present for 6 months on the right foot.The case had clinical diagnosis of pyogenic granuloma which turn out to be malignant in histopathological examina on.The microphotograph of the lesion is shown in figure1.
In this study the malignant lesion were common in head/ neck region and then in lower limbs.Seven cases diagnosed as benign lesions clinically turned out to be malignant on histopathological examina on.Out of 13 cases in which clinical diagnosis was of malignancy, only 8 turned out to be malignant.Thus for malignant lesions, the clinical diagnosis had a sensi vity of 53.3%, specificity of 90.9% and a posi ve predic ve value of 61.5%.Cross tabula on of these cases is shown in table 5.In 15 malignant lesions, from our study (5 were males and 10 females) and SCC was more in number than BCC.Several studies reveal a preponderance of SCC in Africa whereas in North America and Europe, 80% of invasive skin cancers are BCC while 20% are SCC.This reversal of SCC/BCC incidence in Africa could well be due to chronic inflammatory diseases, 4 malnutri on and possibly parasi c infesta ons.

Types of lesion Malignant Benign
In our study, head and neck regions were the most common site of malignant tumor and similar findings were noted in other study and also predicted the sun exposure could be the 4-6 major e ological factor.One of our case of SCC was in a scar ssue in the right knee, pa ent had history of road traffic accident 12 years back (Figure 2a and 2b).One case of SCC was present on the le forearm as ulcerated lesion in pa ent of albinism.These finding were similar to a study reported 7 from Nigeria.
Incidence of SCC were 20% more common than BCC in black pa ent according to the informa on gathered from Tumor registry of Charity Hospital of Louisiana in New Orleans.The most common sites of involvement were face, lower extremi es, non-sun exposed areas, and the most common 8 predisposing condi ons were scarring processes.The incidence of skin tumors varies geographically and is rela vely well documented for melanoma and to a lesser extent for SCC and BCC in different interna onal samples of the general 9-11 popula on.All the four cases of melanoma were present in female in our series and similar sex predilec on was noted in other 12 studies.Three cases presented as nodular swelling and was black in color while other one case was ulcerated type.Lesion was present in foot in two cases and one case each in neck and eyelid margin.Primary melanomas of the eyelid have a nodular pa ern and account for less than 1% of all eyelid 13 malignancies.
Salient morphological features of these four cases are tabulated (Table 4) and microscopic morphology shown in Figure 3a & 3b.
In all the three cases of basal cell carcinoma, lesions were ulcerated, and present on the nose, lateral canthus and post auricular area and in all of them excisional biopsy was done.Two cases were solid type of basal cell carcinoma, with nodular masses of basaloid cells extending into the dermis in rela on to a delicate specialized tumor stroma (Figure 4).One of the case was adenoid basal cell carcinoma which is a rare variant of BCC.Microscopically, it showed kera nized stra fied squamous epithelium with follicular plugging and dermis showing basaloid tumor cells in lobular and glandular pa erns with an edematous loose fibromucinous stroma.Cribriform areas, mucin filled glandular structures and pigment laden macrophages were also seen in the stroma (Figure 5).
Ten cases of skin tumor were arising from adnexal structures comprising 14.2% in which one case was of malignant mucinous eccrine carcinoma and rest were benign tumor.Similar finding was noted by Paudyal Pet al, in which benign appendageal tumor were more common than malignant 14 appendageal tumor.
In this study the eccrine carcinoma was present in 60 years old male pa ent, on right cheek and was clinically diagnosed as pyogenic granuloma.Microscopically, epidermal ulcera on was con nuous with a growth occupying the dermis and ge ng into the subcu s.This growth showed solid as well as a re culate pa ern with mucus lakes in which atypical epithelial cells with moderately acidophilic, finely granular cytoplasm and nucleus with prominent nucleoli were trapped (Figure 6 a and b).A chronic inflammatory response with foreign body giant cells was also seen in the margins to extravasated mucinous material.However, eccrine carcinoma has been reported most frequently in lower extremity (44%), trunk (24%) and head (18%) and only few cases have been 15 reported in the upper extremity (8%) and hand (3%).A case with dermatofibrosarcoma protuberans in our study was present in 11 year old girl on right ankle and was nodular ulcerated type.These are fibrous his ocy c tumors of intermediate (border line) malignant poten al.The tumor is typically centered in the dermis, lacks circumscrip on, and show high cellularity and storiform pa ern of growth (Figure 7a,b).Studies have shown that majority of cases in young 16 adults and presenta on during childhood being rare.
In our study, sensi vity of clinical diagnosis of malignancy was 53.3%, specificity 90.9% and a posi ve predic ve value of 61.5%.Seven cases which were given the clinical diagnosis of benignity turned out to be malignant on histopathological examina on.The cases clinically diagnosed as malignant were also proven benign by histopathological examina on and the specific diagnosis and categoriza on of a par cular malignancy could not be made clinically.One case of DFSP and melanoma were sent for histopathological examina on with the clinical diagnosis of SCC.Histopathological examina on thus remains the mainstay for correct diagnosis categoriza on and for proper management.Sensi vity of clinical diagnosis of malignancy varies widely in the literature with rates ranging from 73 to 91%.Sensi vity for diagnosis of individual malignancies varies with rates of 95.4% for BCC, 68% for SCC, and 67.3% for MM.Clinicians had a tendency to misclassify benign lesions as malignant, but were less likely 17 to do the reverse.

CONCLUSION
This study concludes that histopathological examina on of the skin lesion is extremely important for categoriza on of skin tumor.Squamous cell carcinoma is the most common malignant tumor followed by malignant melanoma.

RECOMMENDATION
This study was conducted in the Mid-Western region of Nepal.It is recommended to conduct such studies throughout the country to have an overall picture and understanding of malignant skin lesions in Nepalese popula on.

LIMITATION OF THE STUDY
This is a hospital-based study conducted during the course of one year, and hence, includes the data collected only during that period.The study is based on the cases that were registered in the Hospital, and does not include other probable cases that never reached the Hospital for treatment or diagnosis.

Figure 2a :
Figure 2a: Squamous cell carcinoma, developing in the scar ssue of the right knee in a 26 year old male.

Figure 7a :
Figure 7a: Dermatofibroscarcoma protuberans Gross: ulceronodular growth (arrow) involving the skin and the subcu s largest organ of the human body making 15% of the total body weight and dermatological manifesta ons are of varied nature.Very few studies have described and correlated the clinical diagnosis and histopathological results in skin diseases in Nepal.The current study describes the pa ern of skin diseases referred for histopathological examina on at Nepalgunj Medical College Teaching Hospital, Kohalpur, Nepalgunj.Out of the 1440 different kinds of surgical specimens submi ed during the study period of one year from February 2010 to January 2011, only 70 cases were of skin biopsies contribu ng 4.86% of total surgical pathology load of the histopathology department.In a similar study performed in a pediatric popula on, skin biopsies cons tuted 7.29% of the total surgical load in a 3 general ter ary care hospital.

and Eosin stain (H&E) was done rou nely for histopathological examina on. The skin tumors were classified according to World Health Organiza on 2 classifica on of skin -2006. Inclusion criteria: Skin biopsies sent to the pathology department. Exclusion criteria: Inadequateskin biopsies without clinical details.
1 the pathologist to evaluate the par cular skin biopsy.Histopathological diagnosis is mandatory for accurate characteriza on of disease en ty for proper and mely management of cases.The aim of this study was to analyze malignant tumor of skin with respect to age, sex, clinical features and histopathological features and to evaluate the accuracy of clinical diagnosis with histopathological correla on.