15 Skin And Soft Tissue 1

SKIN and SOFT TISSUESKIN and SOFT TISSUE

Celso M. Fidel, MD,FPSGS,FPCSCelso M. Fidel, MD,FPSGS,FPCS

Diplomate Philippine Board of SurgeryDiplomate Philippine Board of Surgery

IntroductionIntroduction SKIN SKIN

Considered as a single anatomic Considered as a single anatomic physiologic physiologic

unitunit

1 to 1.5 sq. m in area1 to 1.5 sq. m in area

Protects the body bearing the brunt of Protects the body bearing the brunt of

injurious effects of external injurious effects of external environmentenvironment

SOFT TISSUESOFT TISSUE

Comprises about 50 % of the total body Comprises about 50 % of the total body bulkbulk

Acts as padding and Shock AbsorberActs as padding and Shock Absorber

SKIN INCISIONSSKIN INCISIONS Choice of known skin lines of relaxed tensionChoice of known skin lines of relaxed tension Applying principles of effective concealment Applying principles of effective concealment and camouflageand camouflage Considers dynamic muscle action and effect of Considers dynamic muscle action and effect of gravity on skin and subcutaneous tissuegravity on skin and subcutaneous tissue Junctions of body planesJunctions of body planes Lines of elevations of facial features Lines of elevations of facial features Lines of Langer’s Lines of Langer’s Contour Lines of junctions of body planes Contour Lines of junctions of body planes Lines of DependencyLines of Dependency Elective Lines that show when patient smiles Elective Lines that show when patient smiles

SkinSkin

SkinSkin

Prevent fluid lossPrevent fluid loss Temperature controlTemperature control Elasticity and supportElasticity and support

LESIONS OF SKIN AND SOFT TISSUELESIONS OF SKIN AND SOFT TISSUE

CONGENITALCONGENITAL TRAUMATICTRAUMATIC INFLAMMATORYINFLAMMATORY NEOPLASTICNEOPLASTIC BENIGNBENIGN MALIGNANT MALIGNANT OTHER LESIONSOTHER LESIONS METASTATIC SKIN LESIONMETASTATIC SKIN LESION FOREICN BODY GRANULOMAFOREICN BODY GRANULOMA


CONGENITALCONGENITAL A. Dermoid CystA. Dermoid Cyst Originate from tissue entrapped during Originate from tissue entrapped during fusion of embryonic processesfusion of embryonic processes Lined by squamous cells and may Lined by squamous cells and may

containcontain Straw colored FluidStraw colored Fluid Cheesy materialCheesy material Lanugo HairLanugo Hair Generally cyst in the head is operated Generally cyst in the head is operated

at OR at OR (Possibility of intracranial extension(Possibility of intracranial extension


DermoidDermoid Frequently occurs in the Frequently occurs in the midline over the :midline over the : OcciputOcciput Nasal dorsumNasal dorsum Mid-frontal region of scalpMid-frontal region of scalp Sacral areaSacral area Abdominal areas Abdominal areas

DermoidDermoid

DermoidDermoid


CONGENITALCONGENITAL

B. Pilonidal Cyst and SinusB. Pilonidal Cyst and Sinus Originate from the NEURENTERIC Originate from the NEURENTERIC

canal canal and appear as dimpling in and appear as dimpling in

sacrococcygeal sacrococcygeal regionregion Due to unidirectional migration of hair Due to unidirectional migration of hair

with micro barbed configurationwith micro barbed configuration When infected cyst becomes an When infected cyst becomes an

abscessabscess mucus and hair maybe discharged mucus and hair maybe discharged

and and branching of the many sinus tracts branching of the many sinus tracts

may may require skin closure by Z or W-plastyrequire skin closure by Z or W-plasty


CONGENITALCONGENITAL C. Branchiogenic sinusesC. Branchiogenic sinuses Are located anterior to medial edge of Are located anterior to medial edge of sternocleidomastoid musclesternocleidomastoid muscle Arise from either Ist,2Arise from either Ist,2ndnd or 3 or 3rdrd branchial branchial archarch Located anterior to ear if coming from Ist Located anterior to ear if coming from Ist TRAUMATICTRAUMATIC A. WoundsA. Wounds Abrasions Abrasions Lacerated wounds Lacerated wounds Punctured wounds Punctured wounds Incised wounds Incised wounds AvulsionAvulsion

AvulsionAvulsion

Incised WoundsIncised Wounds


TRAUMATICTRAUMATIC

B. Pneumatic tire injuryB. Pneumatic tire injury Special type of lacerationSpecial type of laceration Rotating tire “chews up” soft tissue and tears it off from Rotating tire “chews up” soft tissue and tears it off from

underlying deep fascia transecting the investing blood underlying deep fascia transecting the investing blood vessels.vessels.

Common error of Common error of merely suturing the woundmerely suturing the wound and and failing to failing to recognizerecognize massive avulsion of skin and subcutaneous massive avulsion of skin and subcutaneous tissue would result in more extensive necrosis.tissue would result in more extensive necrosis.


TRAUMATICTRAUMATIC

B. B. Pneumatic tire injuryPneumatic tire injury ManagementManagement

Damage area cleaned Damage area cleaned

Divitalized tissue debrided Divitalized tissue debrided

Extremity splintedExtremity splinted

Raw area skin-graftedRaw area skin-grafted


TRAUMATICTRAUMATIC C. BurnsC. Burns ThermalThermal Open flameOpen flame Boiling waterBoiling water Smoke inhalation injuriesSmoke inhalation injuries ChemicalChemical ElectricalElectrical

Partial Thickness BurnsPartial Thickness Burns

Occlusive Dressing w/ DuodermOcclusive Dressing w/ Duoderm

OTHER LESIONSOTHER LESIONS

KELOIDSKELOIDS Fibrous proliferationFibrous proliferation More extensive with insidious spread More extensive with insidious spread into surrounding tissues . into surrounding tissues . Keloid prone areas: sternal, deltoid, Keloid prone areas: sternal, deltoid, and scapular areas.and scapular areas. Most disappointing surgical problem Most disappointing surgical problem because recurrences are frequent. because recurrences are frequent. End results leaves much to be desiredEnd results leaves much to be desired..


KELOIDSKELOIDS Accepted form of treatmentAccepted form of treatment Surgery with post –op radiationSurgery with post –op radiation Surgery with intra –op steroidSurgery with intra –op steroid injectioninjection Triamcinolone>> promising Triamcinolone>> promising steroidsteroid


HematomaHematoma Due to rupture of a blood vesselDue to rupture of a blood vessel Bluish or purplish swelling of skin and Bluish or purplish swelling of skin and subcutaneous tissuesubcutaneous tissue May occur as postoperative complicationMay occur as postoperative complication Treated conservativelyTreated conservatively Surgical evacuation ligate bleedersSurgical evacuation ligate bleeders

INFLAMMATORY CONDITIONSINFLAMMATORY CONDITIONS

--

Virulent or massive Virulent or massive infectioninfection together with low together with low patient resistancepatient resistance, results in skin and soft , results in skin and soft tissue losstissue loss

Skin graftingSkin grafting indicated once infection is indicated once infection is controlled and granulation tissue has controlled and granulation tissue has developeddeveloped

Tissue loss often seen in Tissue loss often seen in malnourishedmalnourished infants infants and children where ordinary pyogenic and children where ordinary pyogenic infection produces massive skin necrosisinfection produces massive skin necrosis

CellulitisCellulitis




FuruncleFuruncle

FuruncleFuruncle

CarbuncleCarbuncle

INFLAMMATORY CONDITIONSINFLAMMATORY CONDITIONS

ManagementManagement

Debridement and delayed skin Debridement and delayed skin graftinggrafting

Biologic dressing such as Biologic dressing such as

HOMOGRAFT, AMNIOTIC HOMOGRAFT, AMNIOTIC membranemembrane

Skin auto graft as soon as patient Skin auto graft as soon as patient is in is in

a better conditiona better condition

NEOPLASTIC CONDITIONSNEOPLASTIC CONDITIONS

Benign conditionsBenign conditions A. Common WartsA. Common Warts Verrucae Vulgaris-Verrucae Vulgaris- Occurs in 2Occurs in 2ndnd decade of life decade of life Maybe transmitted by direct or indirect contact Maybe transmitted by direct or indirect contact Caused by a member of the papovavirus Caused by a member of the papovavirus Invades stratum spinosum epidermidis causing Invades stratum spinosum epidermidis causing papillomatosis papillomatosis Located in hands and feetLocated in hands and feet Rough, grayish papillomatous nodular or Rough, grayish papillomatous nodular or elevated plaques elevated plaques

Verruca VulgarisVerruca Vulgaris




Benign conditions Benign conditions A.Common WartA.Common Wart Verrucae Vulgaris-Verrucae Vulgaris- Can become tenderCan become tender Will resolve spontaneouslyWill resolve spontaneously Problematic lesions can be treated Problematic lesions can be treated by: by: Curettage and electrodessicationCurettage and electrodessication Freezing with liquid nitrogenFreezing with liquid nitrogen Chemotherapy with caustic agentChemotherapy with caustic agent


Benign conditionsBenign conditions B. Cyst-B. Cyst- are fluid filled cavities in are fluid filled cavities in

subcutaneous tissue which may subcutaneous tissue which may resemble solid tumorresemble solid tumor

1. Epidermal inclusion Cyst1. Epidermal inclusion Cyst Epidermal cells are trapped in Epidermal cells are trapped in

subcutaneous subcutaneous tissue. Desquamation leads to the tissue. Desquamation leads to the

creation creation of a cavityof a cavity 2. Sebaceous Cyst2. Sebaceous Cyst 3. Ganglion Cyst3. Ganglion Cyst areas of weakened retinaculum with out areas of weakened retinaculum with out

pouching of underlying synovial pouching of underlying synovial structuresstructures

Sebaceous CystsSebaceous Cysts

Application of AnesthesiaApplication of Anesthesia

Start of ExcisionStart of Excision

The final outcomeThe final outcome

Sebaceous cyst in eyelidsSebaceous cyst in eyelids

Stellate Suturing of Ganglion Stellate Suturing of Ganglion CystCyst

Stellate Suturing of Ganglion Stellate Suturing of Ganglion CystCyst

Lines of LangersLines of Langers


Benign conditionsBenign conditions C. Vascular Tumors C. Vascular Tumors 1. 1. Capillary HemangiomasCapillary Hemangiomas (Port wine- Stain) (Port wine- Stain) found in the found in the face, face, chest, chest, extremitiesextremities


Benign conditionsBenign conditions C. Vascular Tumors C. Vascular Tumors 2.Immature Hemangioma2.Immature Hemangioma Found in the head, neck, chest and Found in the head, neck, chest and extremities of infantsextremities of infants

Elevated, red, soft, compressible tumors; Elevated, red, soft, compressible tumors; frequently enlarges during 1st year of lifefrequently enlarges during 1st year of life

Undergoes spontaneous regression during Undergoes spontaneous regression during the next 2-7 yearsthe next 2-7 years

NEOPLASTIC CONDITIONSNEOPLASTIC CONDITIONS Benign conditionsBenign conditions

C. Vascular Tumors C. Vascular Tumors

3. 3. Cavernous Hemangiomas Cavernous Hemangiomas

Compressible & shows a wide channel Compressible & shows a wide channel

w/ loose connective tissue septae w/ loose connective tissue septae

lined by embryonal endotheliumlined by embryonal endothelium

Lesions maybe nodular, lobular or polypoidLesions maybe nodular, lobular or polypoid

Surgery is the treatment of choiceSurgery is the treatment of choice

NEOPLASTIC CONDITIONSNEOPLASTIC CONDITIONS Benign conditionsBenign conditions

C. Vascular Tumors C. Vascular Tumors

4. Spider Nevi ( Telangiectasia4. Spider Nevi ( Telangiectasia ) )

occur in all age groups & common occur in all age groups & common

in the face, chest & extremities in the face, chest & extremities

Arise during pregnancy & in cirrhosisArise during pregnancy & in cirrhosis

Central arteriole with vessel Central arteriole with vessel

resembling venules radiating from resembling venules radiating from

the center the center


Benign conditionsBenign conditions D. LipomaD. Lipoma Benign encapsulated subcutaneous Benign encapsulated subcutaneous lesion, single but maybe multiplelesion, single but maybe multiple Are most common on the neck, Are most common on the neck, shoulder, back, thighshoulder, back, thigh Occasionally fluctuates under the Occasionally fluctuates under the palpating fingerpalpating finger Visible lobulation upon stretching the Visible lobulation upon stretching the skinskin

LipomaLipoma

Axillary MassAxillary Mass

Mass NapeMass Nape

Another ViewAnother View

Ready for SurgeryReady for Surgery


Benign conditionsBenign conditions

E. Nerve TumorsE. Nerve Tumors

1. Neurilemomas1. Neurilemomas

Originates from Schwann’s cells of Originates from Schwann’s cells of

peripheral nerve sheaths and may peripheral nerve sheaths and may

not adhere to nervenot adhere to nerve

Treatment is by excisionTreatment is by excision


Benign conditionsBenign conditions

E. Nerve TumorsE. Nerve Tumors

2. Neurofibroma:2. Neurofibroma:

May occur as single or multiple as in May occur as single or multiple as in

Von Recklinghausen’s disease Von Recklinghausen’s disease

Fibromas of the dermisFibromas of the dermis

Neurofibromas (multiple)Neurofibromas (multiple)

Widespread skin pigmentation at Widespread skin pigmentation at

back(coffee- colored spots back(coffee- colored spots

(pathognomonic)(pathognomonic)

Neuro FibromaNeuro Fibroma

PREMALIGNANT SKIN LESIONPREMALIGNANT SKIN LESION

1. Actinic Keratosis1. Actinic Keratosis

Rough, scaly epidermal lesion in areas of the Rough, scaly epidermal lesion in areas of the body subjected to chronic sun exposure body subjected to chronic sun exposure

33rdrd and 4 and 4thth decade and 10% to 20% will decade and 10% to 20% will

undergo malignant transformationundergo malignant transformation

If benign, excision or cryotherapyIf benign, excision or cryotherapy

5-fluorouracil for patients with many 5-fluorouracil for patients with many

keratosiskeratosis

Actinic KeratosisActinic Keratosis


2.2. Bowen’s DiseaseBowen’s Disease

Intraepidermal squamous cell carcinoma orIntraepidermal squamous cell carcinoma or

Carcinoma in situ of the skinCarcinoma in situ of the skin

Well defined erythematous plaque covered Well defined erythematous plaque covered

by an adherent scaly yellow crustby an adherent scaly yellow crust

No lymphatics in the layer affected, noNo lymphatics in the layer affected, no

potential for metastasispotential for metastasis

44thth to 6 to 6thth decade of life decade of life

Arsenic ingestion and viruses implicated as Arsenic ingestion and viruses implicated as

etiologic agentsetiologic agents

TreatmentTreatment same as actinic keratosis same as actinic keratosis

Bowen’s DiseaseBowen’s Disease


3.3. KeratoacanthomaKeratoacanthoma

Locally destructive skin lesion found in Locally destructive skin lesion found in

the head, neck, & upper extremitiesthe head, neck, & upper extremities

Fast growing with:Fast growing with:

smooth rounded borders & keratitic smooth rounded borders & keratitic

center plugcenter plug

It may regress within six monthsIt may regress within six months

Excision is treatment of choiceExcision is treatment of choice

Squamous cell cancer is found in ¼ of Squamous cell cancer is found in ¼ of

the lesions biopsiedthe lesions biopsied

NEVI (MOLES)NEVI (MOLES) Pigmented lesions of skin that frequentlyPigmented lesions of skin that frequently concern the patient because of the fear concern the patient because of the fear of malignancyof malignancy

Average white male has 15 to 20 nevi so total Average white male has 15 to 20 nevi so total excision is unreasonableexcision is unreasonable

Clinical diagnosis is of prime importance Clinical diagnosis is of prime importance because malignant transformation can occurbecause malignant transformation can occur

Well circumscribed lesions with uniform color Well circumscribed lesions with uniform color rarely progress to malignancyrarely progress to malignancy

Epidermal NevusEpidermal Nevus

Halo NevusHalo Nevus

BENIGN PIGMENTED LESIONSBENIGN PIGMENTED LESIONS 1. Junctional Nevi1. Junctional Nevi Dark, flat, smooth, lesions about 1mm Dark, flat, smooth, lesions about 1mm to 2cm diameterto 2cm diameter Occasionally hairy and develop from Occasionally hairy and develop from the basal layer of epidermisthe basal layer of epidermis Nevi that are located in the palms and Nevi that are located in the palms and soles are usually junctionalsoles are usually junctional Can develop into malignant melanoma Can develop into malignant melanoma but this rarely occurs before pubertybut this rarely occurs before puberty

BENIGN PIGMENTED LESIONSBENIGN PIGMENTED LESIONS

22. Compound Nevi. Compound Nevi Brown to black, well circumscribed Brown to black, well circumscribed lesionslesions Usually less than 1 cm in diameterUsually less than 1 cm in diameter Maybe elevated and are frequently Maybe elevated and are frequently hairy arising from epidermal- hairy arising from epidermal- dermal interface and within the dermal interface and within the dermisdermis Malignant transformation is rareMalignant transformation is rare --

BENIGN PIGMENTED LESIONSBENIGN PIGMENTED LESIONS 3. Intradermal Nevi3. Intradermal Nevi Are light colored well circumscribed Are light colored well circumscribed lesion less than 1 cm in diameterlesion less than 1 cm in diameter Hairs are usually present and the cell Hairs are usually present and the cell distribution is in the dermisdistribution is in the dermis Malignant transformation is rareMalignant transformation is rare 4. Blue Nevi4. Blue Nevi Smooth, hairless lesion about 1 cm Smooth, hairless lesion about 1 cm Arise from the dermisArise from the dermis Malignant degeneration is rareMalignant degeneration is rare


5. 5. Giant Pigmented NeviGiant Pigmented Nevi

Brown to black, hairy lesions with an Brown to black, hairy lesions with an

irregular nodular surfaceirregular nodular surface

Frequently involve more than 1 sq. inch Frequently involve more than 1 sq. inch

foot of body surface and arise from thefoot of body surface and arise from the

dermis and junctional areasdermis and junctional areas

Frequently described in terms of distribution Frequently described in terms of distribution

as bathing trunk “vest,” sleeve or as bathing trunk “vest,” sleeve or

stockingstocking

Malignant degeneration is 10%Malignant degeneration is 10%

Excision with margin of normal tissueExcision with margin of normal tissue


66.”Spitz Nevi” Benign (juvenile melanoma).”Spitz Nevi” Benign (juvenile melanoma)

Smooth round, pink, to black lesionSmooth round, pink, to black lesion about about

1-2 cm in diameter1-2 cm in diameter

Increased cellularity and occur in vestIncreased cellularity and occur in vest

within the upper dermiswithin the upper dermis

Have no malignant potentialHave no malignant potential

TREATMENTTREATMENT

A. Indicated for junctional & giant pigmented A. Indicated for junctional & giant pigmented

nevi because of their malignant potentialnevi because of their malignant potential

BENIGN PIGMENTED LESIONSBENIGN PIGMENTED LESIONSTREATMENTTREATMENT B. Indications for excision of any B. Indications for excision of any pigmented lesion include:pigmented lesion include: 1. 1. Changes in color, size, shapeChanges in color, size, shape, or , or consistencyconsistency

2. Pain2. Pain 3. Satellite nodules3. Satellite nodules 4. Regional adenopathy4. Regional adenopathy C. Excisional biopsy w/ normal marginsC. Excisional biopsy w/ normal margins D. For large lesions, a full thickness D. For large lesions, a full thickness wedge biopsy including a small area wedge biopsy including a small area of normal skin should be takenof normal skin should be taken

MALIGNANT LESIONSMALIGNANT LESIONSMalignant MelanomaMalignant Melanoma

A. EpidemiologyA. Epidemiology

1. incidence is 13 new cases/ 1. incidence is 13 new cases/ 100,000100,000/year/year

representing an increase of 50%representing an increase of 50%

2. occurs in 52. occurs in 5thth decade, rare in children decade, rare in children

3. some 20% to 30% arise in head & 3. some 20% to 30% arise in head &

neckneck

4. incidence is equal in males and in 4. incidence is equal in males and in

females females

MALIGNANT LESIONSMALIGNANT LESIONSMalignant MelanomaMalignant Melanoma Exposure to sunlight. Fair skinned Exposure to sunlight. Fair skinned whites with frequent direct whites with frequent direct exposure to the sun often affectedexposure to the sun often affected In men chest, back, upper extremitiesIn men chest, back, upper extremities In women affects back upper and In women affects back upper and lower extremitieslower extremities Detection of melanoma is determinedDetection of melanoma is determined by changes in the color, size andby changes in the color, size and shape of a nevusshape of a nevus

MALIGNANT LESIONSMALIGNANT LESIONSMalignant MelanomaMalignant Melanoma C. Classification based on Gross andC. Classification based on Gross and Histologic appearanceHistologic appearance 1. Superficial Spreading Melanoma1. Superficial Spreading Melanoma Accounts for 70% of all melanomaAccounts for 70% of all melanoma Can be present on any part of theCan be present on any part of the body but more at the back & legsbody but more at the back & legs 55thth decade of life decade of life Irregular borders, varied color Irregular borders, varied color UUpperpper dermis w/ lateraldermis w/ lateral junctional spread junctional spread Generally prognosis is goodGenerally prognosis is good

Superficial Spreading MelanomaSuperficial Spreading Melanoma

MALIGNANT LESIONSMALIGNANT LESIONSMalignant MelanomaMalignant Melanoma

2. Nodular Melanoma2. Nodular Melanoma

Accounts for 15% of all melanomaAccounts for 15% of all melanoma

66thth decade of life decade of life

Blue black lesion on any part Blue black lesion on any part

of bodyof body

Vertical spread rapid dermal Vertical spread rapid dermal

invasioninvasion

Prognosis is poorPrognosis is poor

Nodular MelanomaNodular Melanoma

MALIGNANT LESIONSMALIGNANT LESIONSMalignant MelanomaMalignant Melanoma 3. Acrolentiginous & Mucosal Melanoma3. Acrolentiginous & Mucosal Melanoma Comprise 10% of all melanomaComprise 10% of all melanoma 55thth decade of life decade of life mucous membrane, palms and solesmucous membrane, palms and soles Irregular borders; black maybe Irregular borders; black maybe amelanoticamelanotic Slow growth in radial directionSlow growth in radial direction Cells in upper dermis occasional Cells in upper dermis occasional deeper invasiondeeper invasion Prognosis between superficial and Prognosis between superficial and nodular melanomanodular melanoma

MALIGNANT LESIONSMALIGNANT LESIONS

Malignant MelanomaMalignant Melanoma

4. Lentigo Maligna ( Melanotic freckle of 4. Lentigo Maligna ( Melanotic freckle of

Hutchinson)Hutchinson)

The least common; 5The least common; 5thth decade decade

Brown black w/ elevated nodules w/in a Brown black w/ elevated nodules w/in a

smooth frecklesmooth freckle

Frequent in the head, neck, & handFrequent in the head, neck, & hand

Slow growth in radial direction w/ cells inSlow growth in radial direction w/ cells in

the upper dermis the upper dermis

Vertical extension is frequentVertical extension is frequent

Prognosis is excellentPrognosis is excellent

Lentigo MalignaLentigo Maligna

Lentigo MalignaLentigo Maligna


Malignant MelanomaMalignant Melanoma

CLARK’S CLASSIFICATIONCLARK’S CLASSIFICATION

Level 1 Tumor confined to epidermisLevel 1 Tumor confined to epidermis

Level 11 Level 11 Tumor invades papillaryTumor invades papillary dermdermisis Level 111-TLevel 111-Tumorumor fills the papillaryfills the papillary dermdermis is bubut t

ddoes not invadeoes not invade reticu reticularlar dermdermisis

Level 1V-TuLevel 1V-Tumor invades the reticularmor invades the reticular dermis dermis

Level V – Tumor invades subcutaneousLevel V – Tumor invades subcutaneous

tissue ( Fat )tissue ( Fat )

MALIGNANT LESIONSMALIGNANT LESIONSMalignant MelanomaMalignant Melanoma BRESLOW CLASSIFICATIONBRESLOW CLASSIFICATION

Involves measuring the deep invasionInvolves measuring the deep invasion precisely in millimeterprecisely in millimeter Patients with Clark level 1, 11, 111, Patients with Clark level 1, 11, 111, lesion w/a depth of invasion that is lesion w/a depth of invasion that is less than 0.7 are at low risk for less than 0.7 are at low risk for metastasismetastasis Patients w/ level 1V or V and w/ a Patients w/ level 1V or V and w/ a depth of invasion greater than 1.5 mm depth of invasion greater than 1.5 mm are at high risk for distant metastasisare at high risk for distant metastasis

MALIGNANT LESIONSMALIGNANT LESIONSMalignant MelanomaMalignant Melanoma In order to complete the stagingIn order to complete the staging Thorough histological and physical Thorough histological and physical examination are necessaryexamination are necessary Include ancillary work-up likeInclude ancillary work-up like complete blood countcomplete blood count urinalysisurinalysis chest x-raychest x-ray 12 test sequential multiple 12 test sequential multiple analysis ( SMA -12 )analysis ( SMA -12 )


Malignant MelanomaMalignant Melanoma TreatmentTreatment:: A. ExcisionA. Excision B. ResectionB. Resection C. Adjuvant TherapyC. Adjuvant Therapy Regional hyperthermic perfusionRegional hyperthermic perfusion ChemotherapyChemotherapy ImmunotherapyImmunotherapy RadiotherapyRadiotherapy

MALIGNANT LESIONSMALIGNANT LESIONSMalignant MelanomaMalignant Melanoma Prognosis:Prognosis:

Disease confined at primary site 5 Disease confined at primary site 5 yearyear

survival is 80%-90%survival is 80%-90%

If regional lymph nodes are involvedIf regional lymph nodes are involved

survival goes down to 30% to 50%survival goes down to 30% to 50%

Patients who have distant or visceralPatients who have distant or visceral

metastasis are usually dead within metastasis are usually dead within 1212

monthsmonths

BASAL CELL CARCINOMABASAL CELL CARCINOMA

A malignant skin tumor A malignant skin tumor characterized by slow growth characterized by slow growth and very rare distant and very rare distant metastasismetastasis Generally occurs in the head Generally occurs in the head and neckand neck Found most commonly in Found most commonly in individuals of Northern individuals of Northern European Descent European Descent

Basal Cell CarcinomaBasal Cell Carcinoma

BASAL CELL CARCINOMABASAL CELL CARCINOMA EtiologyEtiology

It has been associated with:It has been associated with:

Xeroderma pigmentosumXeroderma pigmentosum

Basal cell nevus syndromeBasal cell nevus syndrome

Nevus sebaceousNevus sebaceous

Unstable burn scarUnstable burn scar

Dermatitis subjected to radiation therapyDermatitis subjected to radiation therapy

Clinical FindingsClinical Findings

Lesion has pearly translucent edgesLesion has pearly translucent edges

Smooth elevation with telangiectatic Smooth elevation with telangiectatic surfacesurface

Present as an ulceration w/ rolled edgesPresent as an ulceration w/ rolled edges


TreatmentTreatment

involves complete removal of the tumor toinvolves complete removal of the tumor to

achieve cure. BIOPSY IS MANDATORYachieve cure. BIOPSY IS MANDATORY

1. Curettage and Electrodessication1. Curettage and Electrodessication

95% cure rate95% cure rate

for lesions less than 0.2cmfor lesions less than 0.2cm

2. Radiation Therapy2. Radiation Therapy

90% cure rate; 90% cure rate;

when tissue preservation is importantwhen tissue preservation is important

depigmentation and atrophy can occurdepigmentation and atrophy can occur


TreatmentTreatment 3. Excision with primary Closure3. Excision with primary Closure A 0.5 cm margin from the grossly detectable A 0.5 cm margin from the grossly detectable

limit of the lesion adequate for curelimit of the lesion adequate for cure 95% cure rate95% cure rate LN should be excised in continuityLN should be excised in continuity if they are clinically positiveif they are clinically positive Reconstruction can be performed Reconstruction can be performed in one setting in one setting

SQUAMOUS CELL CARCINOMASQUAMOUS CELL CARCINOMA

It is more malignant in clinical behavior It is more malignant in clinical behavior

than basal cell carcinomathan basal cell carcinoma

Fast growing and tends to metastasize to Fast growing and tends to metastasize to

regional LN plus wider local spread regional LN plus wider local spread

EtiologyEtiology

Exposure to sunlightExposure to sunlight

From pre-malignant lesionFrom pre-malignant lesion

Old burn scarOld burn scar

Exposure to arsenicals, nitrates andExposure to arsenicals, nitrates and

hydrocarbons hydrocarbons

Squamous Cell CarcinomaSquamous Cell Carcinoma

SQUAMOUS CELL CARCINOMASQUAMOUS CELL CARCINOMA Clinical ManifestationsClinical Manifestations

May appear as a satellite nodule or a central May appear as a satellite nodule or a central area area

of ulceration that may become encrusted of ulceration that may become encrusted obscuringobscuring

deeper invasiondeeper invasion

Common in the lips, paranasal folds and axillaCommon in the lips, paranasal folds and axilla

Treatment:Treatment:

is based upon examination of the biopsy is based upon examination of the biopsy

specimenspecimen

Excision Biopsy for lesion less than 1cmExcision Biopsy for lesion less than 1cm

Incisional Biopsy can be performed forIncisional Biopsy can be performed for

larger lesions and those in the facelarger lesions and those in the face

SQUAMOUS CELL CARCINOMASQUAMOUS CELL CARCINOMA

Treatment MethodsTreatment Methods

1. Electrodessication1. Electrodessication

For lesions less than 1cm in diameterFor lesions less than 1cm in diameter

For older individuals For older individuals

In patients with recurrence of tumorsIn patients with recurrence of tumors

SQUAMOUS CELL CARCINOMASQUAMOUS CELL CARCINOMA Treatment MethodsTreatment Methods 2. Excision with Primary Closure2. Excision with Primary Closure Advantage of available histopath of Advantage of available histopath of

lesionlesion With clinical evidence of nodal disease With clinical evidence of nodal disease

regional LN dissection is performedregional LN dissection is performed Adenopathy accompanying an Adenopathy accompanying an

ulcerated ulcerated lesion is not excised at the same lesion is not excised at the same

time time with the primary tumor because with the primary tumor because

they they will resolve in time if the will resolve in time if the

adenopathy is adenopathy is inflammatoryinflammatory

SQUAMOUS CELL CARCINOMASQUAMOUS CELL CARCINOMA Treatment MethodsTreatment Methods 3. Radiation Therapy3. Radiation Therapy Usually reserved for advanced lesions in Usually reserved for advanced lesions in

areasareas where surgical excision leaves a where surgical excision leaves a

cosmetically cosmetically unacceptable defect the nose, the eyelid, unacceptable defect the nose, the eyelid,

lipslips Not used when bone and cartilage are Not used when bone and cartilage are

involved; involved; these require radical excisionthese require radical excision 4. Moh’s Surgery4. Moh’s Surgery Precise mapping and frozen-section control Precise mapping and frozen-section control

of of the entire resection bedthe entire resection bed Allows early reconstruction because of Allows early reconstruction because of

reliable reliable surgical marginsurgical margin

Sweat Gland Tumors Sweat Gland Tumors Rare lesions arising from the Rare lesions arising from the

eccrine oreccrine or apocrine glandapocrine gland Occur in later life as a soft tissue Occur in later life as a soft tissue

mass mass that has been present for yearsthat has been present for years Metastasis to Metastasis to regional lymphregional lymph nodes arenodes are

commoncommon;; consider dissection at time of initial consider dissection at time of initial

excisionexcision Overall 5 year survival rate Overall 5 year survival rate

approaches approaches 40%40%

Health & Medicine

15 Skin And Soft Tissue 1