Skin Lesions: Evaluation, Diagnosis, and Management : Skin Lesions: Evaluation, Diagnosis, and Management Benign Cutaneous Neoplasms Seborrheic keratoses : benign
face, trunk, arms
Biopsy not necessary. Seborrheic keratoses Actinic keratoses : Actinic keratoses Solar keratoses
Genetic melanin disorders
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
Sun exposed areas.
Excisional biopsy. Keratoacanthoma : Keratoacanthoma Like SCC
Can become SCC in 4-6 weeks
Early excision. Dermatofibroma : Dermatofibroma Adults
Biopsy or excise Neurofibroma : Neurofibroma button-hole sign
Solitary or multiple
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
Superficial removal BENIGN MELANOCYTIC NEOPLASMS : BENIGN MELANOCYTIC NEOPLASMS Junctional nevus
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
Hair can grow
Benign but associated with melanoma Atypical melanocytic nevi : Atypical melanocytic nevi Asymmetry
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
Epitheloid/ spindle cells
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
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
Less likely to recur
Thin telangiectatic border. Slide 28: 5%
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
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
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
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
Intralesional IFN Treatment of SCCis : Treatment of SCCis Electrodessication, curretttage
PDT under investigation Adnexal tumors : Adnexal tumors Appendageal skin cells of hair follicles, sebaceous glands, apocrine, eccrine glands.
Flesh colored/ yellowish papules with hair
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
Complete surgical excision Neuroendocrine ca : Merkel Cell ca
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-
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
Acral Lentiginous Slide 59: Superficial spreading- not hands , feet
Long radial growth phase Slide 60: Nodular
Vertical growth phase
Prognosis same as superficial spreading Slide 61: Lentigo maligna
Invasive growth occurs late Slide 62: Acral lentiginous
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
Length to width 3:1
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
Isolated limb perfusion
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%
Retroperitoneal/ intra-abdominal- 15%
Head/ neck. Slide 82: Genetic Sydromes
Li- fraumeni syndrome- mutation of p-53 TSG
Chromosome 12 amplification
Translocation TLS-CHOP, SSX-SYT
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
Fibrosarcoma Slide 86: Grading- G1 Well- differentiated
G2 moderately diff.
G3 poorly diff.
IV- N1 or M1 Slide 87: DFSP-Excise with 2-3cm margins, deep fascia
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
CT Chest, Abd, Pelvis
Image guided biopsy- lymphoma/ germ cell tumor Treatment : Treatment Gross resection
Evaluate renal function of C/L kidney
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
Systemic chemotherapy- not curative