Management of skin cancers
-
Upload
rex-moulton-barrett -
Category
Health & Medicine
-
view
554 -
download
0
Transcript of Management of skin cancers
![Page 1: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/1.jpg)
Management of Cutaneous Malignancies
Rex Moulton-Barrett, MD
Plastic and Reconstructive Surgery, Otolaryngology Head & Neck Surgery
4th Floor, Doctor’s Offices Alameda Hospital
& 1280 Central Blvd, Suite J-5, Brentwood
Safest is best
Versus: wait and see
![Page 2: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/2.jpg)
The 8 Aspects of Plastic Surgery
• Congenital: clefts, nevi, vascular tumors
ear reconstruction, hand anomalies
• Hand: nerve compression, tumors/soft tissue, trauma
• Burn Reconstruction
• General Reconstruction: truck, abdomen, lower limb
• Breast: reduction, reconstruction
• Cosmetic
• Head and Neck: resection and reconstructive surgery
• Skin cancer: excision and reconstruction
![Page 3: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/3.jpg)
Tumors In Question
• Basal Cell
• Squamous Cell
• Melanoma• The differential diagnosis: non-pigmented benign
pigmented benign
non-pigmented pre-malignant
pigmented pre-malignant
soft tissue tumors
metastatic lesions
![Page 4: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/4.jpg)
Skin Cancer
• Basal (75%) > Squamous (25%) > melanoma
except organ transplant opposite ratio
SCCA 20-65 times more common
• 50% with basal or squamous will develop the other in 5 years
• Intense > prolonged sun exposure: UVB>A, SPF 15, < 20 yrs age
• Genetic predisposition: more pigment is protective
![Page 5: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/5.jpg)
Common Non-pigmented Benign Lesions
• Seborrheic Keratoses
• Syringomas• Xantheloma Palpebrum
• Premalignant Actinic Keratoses
![Page 6: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/6.jpg)
Common non-pigmented benign lesions
• Syringomas: peri-ocular , small, fleshy and nodular
![Page 7: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/7.jpg)
Common non-pigmented benign lesions
• Xantheloma Palpebrum: periocular, drop like & semi-cheezy
rarely associated with hyperlipidaemia
ie planar xanthomatadysbetalipoproteinemia
or hypercholesterolemia
![Page 8: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/8.jpg)
Common non-pigmented benign lesions
• Trichoepitheliomas: periocular, drop like
![Page 9: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/9.jpg)
Common non-pigmented benign lesions
• Milia: periocular, drop like & semi-cheezy
![Page 10: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/10.jpg)
Common non-pigmented Benign/pre-malignant
lesions
• Actinic Keratoses: 20% SCCA, dry, crusty
• really pre-malignant
![Page 11: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/11.jpg)
Pigmented Benign Lesions
• Blue Nevus
• Pigmented Seborrheic Keratosis
• Giant Nevus
![Page 12: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/12.jpg)
Pigmented benign lesions
• Blue Nevus: intradermal and subcutaneous
not pre-malignant
![Page 13: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/13.jpg)
Pigmented benign lesions
• Pigmented Seborrheic Keratosis: waxy, soft
can rub off a little
![Page 14: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/14.jpg)
Non-Pigmented Pre-malignant Lesions
• Bowen’s Disease: red scaly patch of
Squamous Cell Carcinoma in situ
![Page 15: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/15.jpg)
Pigmented Benign & Pre-malignant Lesions
• Giant Nevus: 1-2 % populationRisk of developing melanoma related to size:
> 20cm diameter adult
> 2 palm size / body 5-20 % by 10, peak at 3-5 yrs
> 1 palm size / face 5-20 % by 10, peak at 3-5 yrs
![Page 16: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/16.jpg)
Role for topical anti-mitotic agents
5-fluorouracil imiquimod 5% cream ( Aldara ) aminolevulinic acid photodynamic therapy
![Page 17: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/17.jpg)
Role for topical anti-mitotic agents
0.5% 5-fluorouracil ( 5gram $100 )
effective for actinic keratoses small in-situ lesions: BCCA
not for invasive small = electrodesiccation/curettage
or excision
RNA analogue precursor & progressive DNA labelling
Contraindicated in pregnancy: teratogenic VSD’s
![Page 18: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/18.jpg)
Role for Topical anti-mitotic agents
Imiquimod 5% cream ( Aldara )
Immunomodulator: activates monocytes,macrophages, Langerhan’s cells, T cell infiltrates, cytokines: interferons, interlekins, TNF
effective for: actinic keratoses
superficial basal cell carcinoma*
probably no role for squamous cell ca*
frequency related reactions are common
*3 nights/ week for 6 weeks: 73% clearance rate
at 12 weeks: higher clearance rates
*
![Page 19: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/19.jpg)
Actinic Cheilitis (AC)
Smith et al, 2002: J AM Acad Dermatol 47(4):497-501
• 15 pts with biopsy proven AC
• 3 x weekly for 4-6 weeks
• 4 weeks later all lesions cleared
• Specific Side effects continued in some cases throughout therapy:
• pain, redness, swelling, ulceration
![Page 20: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/20.jpg)
Role for topical anti-mitotic agents
Aminolevulinic acid photodynamic therapy
Levulan Kerastick 20% solution
• 17 minute blue light exposures
• 69% failure for superficial SCCA at 8 months
• 44% failure for superficial BCCA at 8 months Fink-Puches, et al, 1998
Arch Dermatol 134, 821-826.
Category C : unknown side-effects pregnancy or breast feeding
Not if porphyria
Not if taking: oral hypoglycemic agents, sulpha, grseofulvin, phenothiazines, doxycycline, HCTZ diuretics
![Page 21: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/21.jpg)
Basal Cell Carcinoma incisional biopsy
• Basal Cell: elliptical wedge is better than shave
punch biopsies work well if: adequate in width and depth
preferably not from center
nodular
superficial
ulceratedpigmented
morpheiform
![Page 22: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/22.jpg)
Basal cell carcinoma excisional biopsy
• 1 high power field under frozen section/ Moh’s surgery• 3-5 mm margin from the clinical edge: rolled to flat
![Page 23: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/23.jpg)
Squamous cell Biopsy
• Squamous Cell: elliptical wedge:
from periphery towards center better than shave
6-10 mm margin if excisional biopsy
![Page 24: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/24.jpg)
Excisional Biopsy
• Melanoma: closest margin to remove the lesion,
do not shave, or wedge
may use punch if completely excise
• Sarcomas: closest margin to remove the lesion
• Adnexal : closest margin to remove the lesion
• Metastatic: closest margin to remove the lesion
![Page 25: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/25.jpg)
Excisional Biopsy
• Melanoma: closest margin to remove* the lesion,
do not shave, or wedge
may use punch if completely excise
Superficial spreadingLentigo maligna *
nodular
amelanotic
subungal
Acral lentinous
![Page 26: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/26.jpg)
Management of Melanoma
• <0.75 mm deep: 1cm margin
• 0.75cm - 1.25mm deep: 1cm margin & ? sentinel node
• 1.25 mm-4mm deep: 1-2cm margin & sentinel node biopsy
• >4mm deep: 1cm margin and use of lymphadenectomy unproven
![Page 27: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/27.jpg)
S/P Shave of Melanoma
• 2 schools of thought
1. Excisional biopsy and based on depth decide on size of margin using same parameters
2. Excise based at least the depth of the shave
ie 1-2 cm margin, when in doubt take larger margin
![Page 28: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/28.jpg)
Excisional Biopsy
• Kaposi’s Sarcomas: closest margin to remove*
HIV with CD4 <200/mm3
*
![Page 29: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/29.jpg)
Excisional Biopsy
• Adnexal/appendage: ductal or non-ductal
closest margin to remove
hamartoma
hidrocystomamixed tumor
![Page 30: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/30.jpg)
Excisional Biopsy
• Metastatic: closest margin to remove the lesion*
melanoma
breast
adenocarcinoma*
![Page 31: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/31.jpg)
Moh’s Surgery
• Microscopic margin is preferable to macroscopic margin ie face in the ‘H zone’
reduced visible scar may reduce incidence of false negative margin• Recurrent lesions: depth and width defined prior to closure• Availability of service
![Page 32: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/32.jpg)
Dangerous Problems
• Midline LesionsIntranasal: glioma ( 15% CNS communication ) or
encephalocele ( 100% commun )Forehead: dermoid( 15% crista galli communication),
encephalocele gliomas( not lateral brow dermoid- no communication )
• Back: myelocele, meningomyelocele occiput and neck: encephalocele
myelocele meningomyocele
![Page 33: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/33.jpg)
Difficult Problems Problems
• Zygomatic Arch to Angle of the MandibleParotid tumorsLymph nodes: atypical TB
inflammatory-children, metastatic node if > 1.5cm adult
Branchial Cleft Cysts
( < 1-2 yrs: congenital, >2-15 yrs inflammatory, > 15 yrs neoplastic )
![Page 34: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/34.jpg)
Difficult Problems
• Merkel Cell Tumors
• Subungal Pigmentation
• Sebaceous Adenoma
![Page 35: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/35.jpg)
Difficult Problems
• Merkel Cell Tumors: biopsy if excisional will require later larger margin and possible lymph node dissection, may need metastatic work-up and tumor conference presentation
![Page 36: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/36.jpg)
Difficult Problems
• Subungal Pigmentation
Acquired melanocytic nevus melanoma
![Page 37: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/37.jpg)
Difficult Problems
• Sebaceous Adenoma
Warty lesion often in the scalp, can be salmon colored
present at birth,
hamartoma > 10 yrs : will form BCCA and 19% form syringocystadenoma
![Page 38: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/38.jpg)
Surgical Principles
» I. Have a plan:: H & P, iodine allergy, tetanus toxoid, irrigation, instruments, suture and needle, define the defect, method of closure, drain, dressing, antibiotics, post-op wound care and when to remove sutures.
» II. Always have a lifeboat:: If closure does not work out have a second plan in mind, including placing a skin graft
» III. Acknowledge cosmetic units: The face can be divided sub-units. Within each unit there are favorable skin tension lines ( with the pt. in the sitting position and animated ) which form at 90 degrees to the mimetic muscles. Scars are less conspicuous if they lie parallel to these natural creases.
» IV. Control tension: Place all the tension below the epidermis or in the fascia. The majority of the blood supply is in the subdermal plexus ( SDP ): superficial to the subcutaneous fat. Undermine to distribute the tension over a wider area.
![Page 39: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/39.jpg)
Clinical Examples A. 5mm chronic ulcer of the hand in a wrinkled 90 yr man
a. important historyduration, bleeding, numbness, other medical problems,
medications, pacemaker, adenopathy, associated skin lesionsb. important physical characteristics
wipe lesion and look at shape: ulcer with irregular border, little pigmentation
c. type of biopsypunch or wedge using lidocaine with epinephrine. single suture for hemostatis.
d. definitive managementpath: SQ cell ca. If margin clear 6mm ellipse transversely ( using 3 to 1 rule length to width excision ) with local and tag margin for orientation. If final pathology margin positive or close ( < 5MM ) re-excise in
OR with frozen section.
![Page 40: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/40.jpg)
B. 3mm pigmented lesion on the lateral neck of a 33 yr old male Caucasian computer programmer
• a. important history duration, bleeding, numbness, other medical problems, medications, pacemaker
• b. important physical characteristics of lesion to make the diagnosis adenopathy, associated skin lesions, shape, elevation, border, pigmentation and texture: irregular border, irregular pigmentation, not raised and smooth
• c. type of biopsy excise using 4mm punch full thickness into subcutaneous fat or elliptical excision
(using 3 to 1 rule ) with lidocaine with epinephrine. 3 sutures for closure.
• d. definitive management path: Malignant Melanoma depth 0.72 mm no evidence of intra-vascular invasion.
ellipse 1cm margin favorable skin tension lines. check final pathology to confirm clear of tumor. present in tumor board.
![Page 41: Management of skin cancers](https://reader035.fdocuments.us/reader035/viewer/2022062702/554b382eb4c905d3088b5506/html5/thumbnails/41.jpg)
C. 3cm chronic elevated lesion on the cheek of a 55 yr old lady
• a. important historyduration, bleeding, numbness, medical problems, medications, pacemaker
• b. important physical characteristics of lesion to make the diagnosisadenopathy, associated skin lesions, wipe lesion, look at shape, ulcer with irregular border, little pigmentation
c. type of biopsybiopsy punch or wedge using lidocaine with epinephrine. Do not use silver nitrate on face, use battery cautery, hyfercator or a single suture for hemostatis
d. definitive management: in operating room with frozen sectionpath: basal cell ca. Take >3mm margin
and close wound along favorable tension lines with a local flap