Pestana Chap 8 - Skin Surgery Flashcards
Cancer of the skin is most commonly seen in what characteristic individual?
Blonde, blue-eyed, fair-skinned people who live where the sun is fierce, and who by virtue of occupation or hobby are exposed to the rays all day
What percentage of skin cancer is caused by basal cell, squamous cell, or melanoma? Do these cancers often coexist?
1) Basal cell carcinoma accounts for about 50%
2) Squamous cell for about 25%
3) Melanoma for 15% or more (incidence is going up)
4) Because they share etiology, they often coexist, and patients frequently have multiple lesions over the years
How does basal cell carcinoma present? Where does it prefer to grow, how long does it take to form, and does it frequently metastasize to lymph nodes?
1) Basal cell carcinoma may show up as a small, raised waxy lesion or as a nonhealing ulcer
2) In either form it prefers the upper face (above a horizontal line drawn across the lips) and has a timetable measured in years, and it very rarely metastasizes to lymph nodes
If basal cell carcinoma presents as a waxy lesion, how can it be diagnosed? If it presents as a nonhealing ulcer, how can it be diagnosed?
1) The waxy lesion is like no other skin cancer, and it can be simply removed in toto (as a whole), for both diagnosis and therapy
2) The nonhealing ulcer must be differentiated from the next two types of skin cancer, but like them it is diagnosed with a full-thickness biopsy done at the edge of the lesion (The pathologist needs normal skin, ulcer, and the boundary between the two)
Why does basal cell carcinoma need to be removed completely?
Although it grows very slowly, basal cell carcinoma can kill by relentless local invasion (“rodent ulcer”). Thus, it needs to be removed completely. Fortunately, just 1 mm of clear margin is all that is needed
What is a problem with basal cell carcinoma when it is in the form of a very large ulcer in its typical location of the upper face? What was developed to address this issue?
1) Either be conservative and inadvertently leave some cancer behind, or be aggressive and disfigure the patient
2) Mohs surgery is a sophisticated way or performing microscopic sections and tissue diagnosis as the excision is being done
Where does squamous cell carcinoma usually present? How long does it take to form and does it metastasize to regional lymph nodes?
1) Squamous cell carcinoma prefers the lower lip and territories below the horizontal line drawn across the mouth
2) Its timetable is measured in months, and it can metastasize to regional lymph nodes
What is required when taking a biopsy of squamous cell carcinoma? What is done if sentinel nodes need to be biopsied? What is another treatment option?
1) Excision with wider margins is required (0.5 to 2cm)
2) Sentinel nodes may need to be biopsied, and node dissection is done if they are involved
3) Radiation treatment is another option
Where does melanoma usually originate from? How is it identified?
1) Melanoma usually originates in a pigmented lesion
2) Mnemonic ABCDE:
Asymmetric
Irregular Borders
Different Colors within the lesion
Diameter that exceeds 0.5 cm
Evolution, any change that occurs to a longstanding pigmented area
What must the pathology report for melanoma indicate? Why is this?
1) It must indicate not only the presence of melanoma but also the depth of invasion
2) Specifics of how to classify depth keep changing, but the basic idea is that superficial lesions have good prognosis and deep lesions are lethal
At what depth do melanomas require local biopsy vs wide excisional biopsy + attention to lymph nodes? At what depth do lesions have terrible prognosis?
1) Melanomas less than 1mm deep require only local excision
2) Deeper lesions require wide margins (2cm) and attention to lymph nodes (biopsy and/or remove as needed), and those between 1 and 4mm benefit the most from aggressive efforts
3) Lesions beyond 4mm have a terrible prognosis regardless of therapy
What is metastatic malignant melanoma known for in terms of metastasis? Does it have a predictable timetable? How variable is the course of disease?
1) Metastatic malignant melanoma is a bizarre, unpredictable, and fascinating disease
2) It goes to the usual places (lymph nodes, liver, lung, brain, and bone), but it also is the all-time champion for metastasizing to weird places
3) Furthermore, it has no predictable timetable
4) Some patients are full of metastases and dead within a few months of diagnosis and treatment; others go 20 years or more between the original treatment and the sudden explosion of metastases
What is the current preferred adjuvant systemic therapy for metastatic melanoma?
Interferon
