skin evaluation

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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 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

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