Chapter 8 - Skin Surgery

Question 1

Main cause of skin cancers? Typical patient?

Answer 1

Exposure to the sun; fair-skinned person, cumulative damage, repeat sunburn with blistering as a child is likely to develop cancer in later years

Question 2

Cause of 50% of skin cancer? Presentation?

Answer 2

Basal cell carcinoma

Favors the upper part of the face
Timetable measured in years
Does not metastasize
Kills by relentless local invasion

Waxy, raised lesion or ulcer

Question 3

Manage basal cell carcinoma?

Answer 3

If raised lesion -> excise for diagnosis and treatment

If ulcer -> biopsy at the edge

Resection requires only a 1 mm margin all around

Mohs surgery to assure cure and avoid unnecessary mutilation (repeated microscopic sections as excision is being done)

Question 4

Cause of 25% of skin cancer? Presentation?

Answer 4

Squamous cell carcinoma

Prefers the lower lip and the rest of the body
Timetable measured in months
Can metastasize to lymph nodes

Question 5

Manage squamous cell carcinoma?

Answer 5

Surgical margins for the primary lesion should be 0.5-2 cm. Radiation therapy is another option.

Mets to lymph nodes may need to be sampled and removed if involved

Question 6

What is the most lethal skin cancer?

Answer 6

Melanoma

Question 7

Presentation of melanoma?

Answer 7

ABCDE - Asymmetrical, Irregular Borders, Different Colors within the lesion, Diameter >0.5 cm, Evolved (i.e., an existing pigmented lesion has undergone a sudden change in its usual appearance)

Usually originates in a previously benign pigmented lesion

Question 8

What determines prognosis and management of melanoma?

Answer 8

Superficial lesions have good prognosis. Deep ones do not.

<1 mm deep require only local excision

Deeper lesions require wide margins (2 cm) and attention to lymph nodes (biopsy and/or remove as needed)

1-4 mm benefit most from aggressive efforts

Lesions beyond 4 mm have a terrible prognosis regardless of therapy

Question 9

Management of disseminated melanoma?

Answer 9

Cannot be cured

Interferon offers a modest improvement in survival time and thus has been the standard treatment. We now favor targeted therapy. Study tumor genes and choose the best agent.

• Chemo (decarbazine)
• Immunotherapy (pembrolizumab)