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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 You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.