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Skin Lesions: Evaluation, Diagnosis, and Management : 

Skin Lesions: Evaluation, Diagnosis, and Management Benign Cutaneous Neoplasms

Seborrheic keratoses : 

benign >30 face, trunk, arms Biopsy not necessary. Seborrheic keratoses

Actinic keratoses : 

Actinic keratoses Solar keratoses Risk factors Age Blue eyes Childhood freckling Genetic melanin disorders Immunocompromised Life time risk for conversion to SCC is 6-10% Hypertrophic AK or cutaneous horn. Removal by excision.

Treatment for Actinic keratoses : 

Treatment for Actinic keratoses 5-Fluorouracil Photodynamic therapy

Cutaneous horn : 

Cutaneous horn AK 20% SCC SK Verrucae Sun exposed areas. Excisional biopsy.

Keratoacanthoma : 

Keratoacanthoma Like SCC Can become SCC in 4-6 weeks Early excision.

Dermatofibroma : 

Dermatofibroma Adults Lower extremities Biopsy or excise

Neurofibroma : 

Neurofibroma button-hole sign Solitary or multiple Benign Excise in rapidly growing lesions

Nevus Sebaceous : 

Nevus Sebaceous Hamartoma Scalp or face BCC in 10% of tumors over 10-20 yrs Excision

Bowen’s Disease : 

Bowen’s Disease SCC in situ Head and neck Commonly associated with superficial basal cell carcinoma and actinic keratosis Biopsy Superficial removal

BENIGN MELANOCYTIC NEOPLASMS : 

BENIGN MELANOCYTIC NEOPLASMS Junctional nevus Children Mostly macular Melanocytes at dermoepidermal junction

Intradermal Nevus : 

Intradermal Nevus More elevated skin colored / light brown Melanocytes in papillary and reticular dermis

Compound Nevi : 

Compound Nevi Melanocytes at dermoepidermal junction and dermis Histologic diagnosis

Becker’s nevus : 

Becker’s nevus Males Enlarges Hair can grow Benign but associated with melanoma

Atypical melanocytic nevi : 

Atypical melanocytic nevi Asymmetry Irregular Color variation 5-15mm With or without family H/O of atypical moles / melanoma. Increased risk of melanoma.

Slide 17: 

Follow up every 3-6 months with total body photography and photography of most atypical moles in FAMM syndrome, multiple atypical moles, family h/o melanoma.

Spitz nevus : 

Spitz nevus homogenous, 8mm 50% in <10years 70% in first 2 decades head, neck Epitheloid/ spindle cells Complete excision Atypical- excise with 1cm margins, F/U every 6-12 months, sentinel lymph node biopsy.

Common blue nevus : 

Common blue nevus 50% dorsa of hands, feet Dermal melanocytes

Cellular blue nevus : 

Cellular blue nevus 1-3cm 50% buttocks, sacrococcygeal. Scalp, face, feet Common blue to cellular nevi 5:1

Malignant blue nevi : 

Malignant blue nevi Arise in cellular blue nevi Scalp De novo or in preexisting nevus

Treatment of blue nevi : 

Treatment of blue nevi Common Blue nevi= excision of changing, de novo, multinodular, or plaquelike lesions. Cellular blue nevi= complete excision

Slide 24: 

Congenital melanocytic nevi 3-10% risk for malignant transformation.

Malignant Tumors : 

Malignant Tumors

Basal cell ca : 

Basal cell ca Most common skin ca in whites 20% on occur on non-sun –exposed areas

Slide 27: 

Nodular BCC Telangiectatic surface Less likely to recur Superficial Trunk/ extremities Thin telangiectatic border.

Slide 28: 

5% Head, neck Look like nodular, sometimes like morpheaform Morpheaform/ Sclerosing 3%

Basosquamous Ca : 

Basosquamous Ca BCC with focal areas of individual dyskeratotic cells to keratin pearls. Metastasis like SCC

Slide 30: 

BCC slow growing Local destruction Metastasis rare

Treatment for BCC : 

Treatment for BCC Eliminate primary lesion <2cm-surgical excision with 4 mm margins Large, recurrent, aggressive histologic pattern-Mohs micrographic surgery. Radiation

Squamous cell carcinoma : 

Squamous cell carcinoma Cumulative dosage of Ultraviolet exposure keratinocytes SCC in mucocutaneous interfaces and in non-sun-exposed sites such as legs and areas of chronic ulceration, scarring have higher risk for metastasis. >4mm thick recur >10mm metastasize

Squamous cell ca in situ : 

Squamous cell ca in situ Full thickness epidermal involvement Bowen’s disease Erythroplasia of Queyrat-HPV SCCis resemble superficial BCCs or psoriasis, eczema. Dermal invasion in 26% Metastasis in 16%

Slide 35: 

Lesions on face, near nose or eye-MMS Radiation Intralesional IFN

Treatment of SCCis : 

Treatment of SCCis Electrodessication, curretttage Topical 5-FU Topical Imiquimod PDT under investigation

Adnexal tumors : 

Adnexal tumors Appendageal skin cells of hair follicles, sebaceous glands, apocrine, eccrine glands. Flesh colored/ yellowish papules with hair Histologic diagnosis Benign hamartoma- no treatment

Adnexal Tumors : 

Adnexal Tumors Adnexal adenocarcinoma- de novo or in preexisiting lesions. Microcystic adnexal carcinoma- slow growing, young adults, esp. women. Excise completely. Sebaceous Ca- Ocular and Extraocular, periorbital, complete surgical excision.

Fibrous and Fibrohistiocytic tumors : 

Fibrous and Fibrohistiocytic tumors Atypical Fibroxanthoma Surgical excision

Slide 41: 

Dermatofibrosarcoma protuberans Local invasion Recurs Complete surgical excision

Neuroendocrine ca : 

Merkel Cell ca Aggressive Excise Neuroendocrine ca

Malignant vascular neoplasms : 

Angiosarcomas Associated with lymphedema= 90% is in postmastectomy and lymph node dissection pts Wide excision of 5cm. Multifocal Malignant vascular neoplasms

Cutaneous metastasis : 

Cutaneous metastasis Males= melanoma, lung ca, colon/ rectum, oral cavity, larynx, kidney. Females= Breast Ca, melanoma, ovarian ca. Surgical Excision, radiation, chemotherapy.

Management of skin lesions : 

Management of skin lesions Excisional biopsy Directionality of incision Margins increase in size with the likelihood of later recurrence BCC= 3 mm SCC= 4mm to1 cm

Slide 46: 

Sarcoma= 5cm Melanoma= 2 to 3cm Face= MMS.

Reconstruction and closure : 

Reconstruction and closure Cosmetic

Slide 50: 

Split thickness skin grafts- large areas, cosmetically less important Full thickness- less likelihood of contracture

Slide 52: 

Composite- size limit 1.5cm. Local flaps-

Slide 53: 

The essential difference between the two is that a flap exists on it’s own blood supply. This means that much larger amounts of tissue can be transported, including muscle if required.

Slide 54: 

Tissue expander- Adjacent Non adjacent For more skin for grafting

Slide 56: 

Free flap- anastomose to vascular supply at the defect site Combined approach

Cutaneous Melanoma : 

Cutaneous Melanoma ABCD 5-10% not pigmented Biopsy – deepest portion, excisional Large, distal extremities- punch, incisional Shave biopsy- fail to sample the deepest portion. 4% as m/s without primary site- regression

Types of Melanoma : 

Types of Melanoma Superficial spreading Nodular Lentigo maligna Acral Lentiginous

Slide 59: 

Superficial spreading- not hands , feet Long radial growth phase

Slide 60: 

Nodular 15-30% Vertical growth phase Prognosis same as superficial spreading

Slide 61: 

Lentigo maligna Invasive growth occurs late

Slide 62: 

Acral lentiginous Least common Dark skinned Hutchinson’s Sign

Treatment of primary lesion : 

Treatment of primary lesion Width of margins- characteristics of primary lesion. Adjuvant radiation therapy for desmoplastic lesions

Slide 67: 

Melanoma in situ- 5mm Hand N preoperative margin assessment Melanoma <1mm – 1 cm 1to 4mm – 2 cm >4mm – 2 cm

Reconstruction : 

Reconstruction Local flaps Elliptical Length to width 3:1 Circular Skin grafting- healing takes time Scalp, Face- full thickness Other donor areas- Lateral thigh Lower extremity- C/L Thigh

Slide 69: 

Lesions top of ear – simple wedge excision Lesions of lower portion of ear- flaps/ grafts from post auricular neck.

Indications for lymphatic mapping and sentinel node biopsy : 

Indications for lymphatic mapping and sentinel node biopsy Thin (<1mm)- Young age, >0.75mm, >= Clark’s IV, ulceration, regression, incomplete biopsy, high mitotic rate Intermediate- Prognosis, Overall survival benefit Thick>4mm- Prognosis

Slide 72: 

Radiocolloid, blue dye to mark the sentinel node Popliteal and epitrochlear basins and intramuscular triangle of upper back- 10% Before preparing operative site, blue dye is injected intradermally. Gamma probe preoperative

Slide 73: 

Remove all nodes with 10% of the counts of hottest node in that basin. After surgery- Reexamine potential sentinel node locations with probe. Complete Lymph node dissection if micrometastases in frozen section. Complications of SLNB= Seroma, hematoma, infection, nerve injury, lymphedema.

Complete lymphadenectomy : 

Complete lymphadenectomy Creation of skin flaps Closed suction drains Neck dissection for clinically evident disease differs from that for micrometastasis. Axillary dissection- all 3 levels Inguinal dissection- Deep inguinal area if Cloquet’s node involved, clinically evident disease in superficial basin or >3 superficial nodes involved.

Slide 75: 

Popliteal dissection Positive nodes- dissect superficial inguinal lymph nodes. Interferon

Ectopic nodal sites : 

Ectopic nodal sites Epitrochlear nodes Nodes within intermuscular triangle of back Nodes along flank Positive nodes to be excised along with dissection of adjacent basin.

Adjuvant Radiotherapy : 

Adjuvant Radiotherapy Decrease risk of recurrence in dissected nodal basins- multiple metastasis, extracapsular invasion, >3 tumor involved sites.

In transit metastases : 

In transit metastases Risk depends on primary melanoma Simple excision Isolated limb perfusion Radiation Laser ablation Local immunotherapy- BCG, IFN a, Topical Imiquimod

Distant metastasis : 

Distant metastasis Surgery for solitary distant metastasis M/S to GIT with any frequency- excise for obstruction or bleeding. Isolated Bowel M/S favourable prognosis.

Soft tissue Sarcoma : 

Soft tissue Sarcoma Extremity- 50% Superficial truncal Retroperitoneal/ intra-abdominal- 15% Visceral Head/ neck.

Slide 82: 

Genetic Sydromes Gardner’s Syndrome Li- fraumeni syndrome- mutation of p-53 TSG Nfm-1 Chromosome 12 amplification Translocation TLS-CHOP, SSX-SYT Herbicide Radiation Stewart-Treves syndrome

Treatment : 

Treatment Wide, en-bloc resection Limb preservation by appropriate use of radiotherapy

Extremity Sarcomas : 

Extremity Sarcomas Adults Liposarcoma- 3 types Malignant Fibrous Histiocytoma Children Rhabdomyosarcoma Fibrosarcoma

Slide 86: 

Grading- G1 Well- differentiated G2 moderately diff. G3 poorly diff. G4 undiff. T1 <=5cm T2 >5cm a, b IV- N1 or M1

Slide 87: 

DFSP-Excise with 2-3cm margins, deep fascia Arterial reconstruction Distal tumors= pedicled/free flap Regional therapy/ Palliation for stage IV ILP- Melphalan and TNF alpha or IFN gamma Local recurrence- prognosis depends on time interval

Retroperitoneal and Visceral : 

Retroperitoneal and Visceral Most common retroperitoneal Liposarcoma and leiomyosarcoma 55% low grade 40% high grade Visceral GIST, Leiomyosarcoma, desmoid worse

Presentation : 

Presentation Abd mass LE Neurologic symptoms Pain Hypoglycemia CT Chest, Abd, Pelvis Image guided biopsy- lymphoma/ germ cell tumor

Treatment : 

Treatment Gross resection Bowel Preparartion Evaluate renal function of C/L kidney Renal Capsulectomy Left Retroperitoneum- Spleen, distal pancreas Liposarcoma- Remove Retroperitoneal fat

Slide 91: 

Unresectable- Neoadjuvant radiotherapy/ chemotherapy Local recurrence- resection, COD. Distant M/S= Liver, Lung or both Pulmonary M/S- resect Retroperitoneal recurrence Resectable Palliative Systemic chemotherapy- not curative