Skin Lesions Flashcards
A 67-year-old man comes to the office with biopsy-proven Merkel cell carcinoma of the forehead. In addition to wide resection, which of the following is the optimal treatment? A) Administration of interferon B) Injection of 5-fluorouracil C) Neoadjuvant chemotherapy D) Radiation therapy
D) Radiation therapy
Merkel cell carcinoma is radiosensitive
Merkel cell carcinoma: General gist
Merkel cell carcinoma is a rare tumor that usually consists of smooth, painless, indurated, solitary dermal nodules approximately 2 to 4 mm in size.
In what population does Merkel cell carcinoma occur?
It occurs more frequently in patients older than age 65 years.
Anatomical site of Merkel cell carcinoma?
Merkel cell carcinoma appears most often at sun-exposed sites on white skin; 50% occur on the head and neck, and 40% on the trunk.
Metastases in Merkel cell carcinoma
Merkel cell carcinoma is an aggressive tumor; metastases to regional lymph nodes are noted on initial diagnosis in 12 to 15% of patients.
Regional metastasis eventually occurs in one half to two thirds of patients.
Distant metastases occur ultimately in one third of patients
Local recurrence of Merkel cell carcinoma occurs in what % of patients?
Local recurrence following primary excision develops in 24 to 44% of patients. Time from diagnosis of the primary tumor to clinically apparent regional nodal metastases is approximately 7 to 8 months. Distant metastases occur ultimately in one third of patients; in order of frequency, metastases occur in the lymph, liver, bone, brain, lung, and skin. The mean time from diagnosis to systemic involvement is 18 months, with death occurring 6 months later. The 5-year survival rate has been reported as 30 to 64%. Two thirds or more of patients with local or regionally recurrent disease ultimately die. Surgical excision is the treatment of choice for primary tumors. The prevailing opinion
Merkel cell carcinoma: time of diagnosis to clinically apparent regional nodal metastases is approximately ________
Time from diagnosis of the primary tumor to clinically apparent regional nodal metastases is approximately 7 to 8 months.
Most frequent sites of distant metastasis of Merkel cell carcinoma
Distant metastases occur ultimately in one third of patients; in order of frequency, metastases occur in the lymph, liver, bone, brain, lung, and skin.
Prognosis/timeline of Merkel cell carcinoma
The mean time from diagnosis to systemic involvement is 18 months, with death occurring 6 months later. The 5-year survival rate has been reported as 30 to 64%.
How should Merkel cell cancers be treated?
- Excised with margins similar to those of melanoma
- SLNB in clinically node negative patients
- RT considered - it is radiosensitive
What determines surgical excision for Merkel cell carcinoma?
Width
A 42-year-old woman comes to the office because of a 1-year history of a mass in the upper abdominal wall that has enlarged gradually. Examination of a specimen obtained on excision biopsy shows a desmoid tumor. Which of the following is the most appropriate next step in management? A) Cryoablation B) Enucleation C) Excision with a 1-mm margin D) Excision with a 1-cm margin E) Observation
D) Excision with a 1-cm margin
Desmoid tumors are relatively rare, technically benign fibrous tumors that may arise in the musculoaponeurotic abdominal wall. These lesions exhibit local invasion and a high rate of recurrence. Wide local excision is regarded as the most effective treatment for these lesions, and intraoperative frozen section is often helpful. Observation will likely result in recurrence, and cryoablation has not been reported as a treatment option for desmoid tumors. Enucleation is not appropriate because the tumor will recur. Excision with a 1-mm margin is not appropriate because wide margins are necessary.
Enucleation
Surgical excision of a mass without cutting or dissecting into it
Desmoid tumor: General gist
Desmoid tumors are relatively rare, technically benign fibrous tumors that may arise in the musculoaponeurotic abdominal wall.
Management of desmoid tumors
These lesions exhibit local invasion and a high rate of recurrence. Wide local excision is regarded as the most effective treatment for these lesions, and intraoperative frozen section is often helpful.
A 79-year-old man has a rapidly growing lesion on the left side of his forehead. Physical examination shows a 2-cm, raised, fungating lesion of the left temple with intact facial nerve function and no lymphadenopathy. Examination of a specimen obtained on biopsy is suspicious for squamous cell carcinoma. Four weeks later, the lesion has disappeared, leaving a small circular scar. Excision is performed, and pathologic study shows no evidence of malignancy. Which of the following is the most likely diagnosis? A) Amelanotic melanoma B) Cutaneous horn C) Keratoacanthoma D) Merkel cell carcinoma E) Squamous cell carcinoma
C) Keratoacanthoma
The most likely diagnosis is keratoacanthoma, a low-grade malignancy that resembles squamous cell carcinoma both clinically and pathologically. The most common natural course of the disease is that of rapid growth followed by spontaneous regression over several months, which is not seen in squamous cell carcinoma.
What is a keratoacanthoma?
A low-grade malignancy that resembles squamous cell carcinoma both clinically and pathologically.
Most common natural course of keratoacanthoma:
The most common natural course of the disease is that of rapid growth followed by spontaneous regression over several months, which is not seen in squamous cell carcinoma.
Keratoacanthoma, clinical course
It CAN progress to squamous cell carcinoma with metastasis, but
The most common natural course of the disease is that of rapid growth followed by spontaneous regression over several months, which is not seen in squamous cell carcinoma.
Amelanotic melanoma makes up ___% of melanoma
5%
Clinical presentation of melanotic melanoma
Nonpigmented lesions that appear pink or tan and can mimic basal cell or squamous cell carcinoma.
It can also occur in the context of cutaneous metastatic melanoma, when cells lack the differentiation required to synthesize melanin. I
What is a cutaneous horn?
A cutaneous horn is a conical projection of hyperkeratosis overlying a hyperproliferative skin lesion such as a seborrheic keratosis or actinic keratosis. Less commonly, it can form from a squamous cell carcinoma or other skin cancer.
A 65-year-old woman is evaluated because of multiple ulcerative, nonhealing wounds on the left shoulder 8 years after undergoing left modified radical mastectomy and subsequent radiation therapy to the chest wall. She has a 5-year history of chronic lymphedema. Which of the following is the most appropriate next step?
A) Brachytherapy
B) Hyperbaric oxygen therapy
C) Incisional biopsy
D) Isolated limb perfusion with chemotherapy
E) Skin resection only with 5-mm margins
C) Incisional biopsy
Stewart-Treves syndrome is an aggressive but rare upper extremity lymphangiosarcoma that occurs in postmastectomy patients.
Stewart-Treves syndrome
Stewart-Treves syndrome is an aggressive but rare upper extremity lymphangiosarcoma that occurs in postmastectomy patients.
Survival rate of Stewart-Treves syndrome
Rare upper extremity lymphangiosarcoma that occurs in post mastectomy patients: historical 5-year survival of less than 1%, but cure rates may be improving, caused in part by refinement of the resection techniques and adjuvant therapies used to treat the original breast cancer.
A 40-year-old man comes to the office because of a 12-year history of recurrent painful nodules in his groin, buttocks, and perineum. Physical examination shows deep subcutaneous abscesses. Some have ruptured and formed multiple discharging sinus tracts. In addition to meticulous hygiene, which of the following is the most appropriate management? A) Antiandrogen therapy B) Anti-tumor necrosis factor-a therapy C) Excision D) Radiotherapy E) Regular chlorhexidine baths
C) Excision
The patient has hidradenitis suppurativa. The disease presents with tender subcutaneous nodules beginning around puberty. The nodules may spontaneously rupture orcoalesce, forming deep, painful dermal abscesses. Eventually, fibrosis and the formation of extensive sinus tracts result.
Due to the multiple interconnected sinus tracts and abscesses throughout an entire region, the patient described has such a debilitating disease that only surgery can adequately address his symptoms. Wide excision of all affected tissue and the underlying sinus tracts is the most effective treatment. It is also advisable to stage the process, preferably with the use of allograft
Hidradenitis suppurativa
Hidradenitis suppurative presents with tender subcutaneous nodules beginning around puberty. The nodules may spontaneously rupture orcoalesce, forming deep, painful dermal abscesses. Eventually, fibrosis and the formation of extensive sinus tracts result.
Management of hidradenitis with abscesses but no cicatrization or sinuses
Hygienic measures and antibiotics are appropriate first line therapy
Hidratenitis primarily involves the ____________, which is __________ by ____________
The disease primarily involves the follicular epithelium, which is colonized secondarily and infected by bacteria.
A 58-year-old man comes to the office because of a 3-month history of multiple light-red, scaly lesions of the scalp and forehead. Physical examination shows extensive sun damage to the face and scalp, including multiple flat lesions measuring between 3 and 10 mm in diameter. Examination of a specimen obtained on shave biopsy shows actinic keratosis without invasive malignancy. In addition to daily application of sunscreen and wearing protective garments, which of the following is the most appropriate management?
A) Application of topical 5-fluorouracil
B) Excision of the lesions with 2-mm margins
C) Repeat biopsy in 6 months
D) Shave excision of the lesions
E) Observation only
A) Application of topical 5-fluorouracil
Ideal treatment involves topical destructive measures, such as application of 5-fluorouracil cream:
Actinic keratosis is a common, premalignant lesion that is a direct result of sun damage. These lesions typically occur in fair-skinned patients who have an extensive history of solar injury. Lesions are flat or slightly raised, red, and scaly. They can be isolated or diffuse. Over time, they can progress to squamous cell carcinoma or other precancer lesions, such as Bowen disease (in situ squamous cell), cutaneous horns, and keratoacanthomas.
Actinic keratosis
Actinic keratosis is a common, premalignant lesion that is a direct result of sun damage.
Who do actinic keratosis lesions occur in?
These lesions typically occur in fair-skinned patients who have an extensive history of solar injury.
Clinical presentation of actinic keratosis
Lesions are flat or slightly raised, red, and scaly. They can be isolated or diffuse.
Natural course of actinic keratosis
Over time, they can progress to squamous cell carcinoma or other precancer lesions, such as Bowen disease (in situ squamous cell), cutaneous horns, and keratoacanthomas.
Treatment of actinic keratosis
Ideally, topical destructive measures such as 5-fluorouracil cream.
A 64-year-old Hispanic woman comes for evaluation of a biopsy-proven basal cell carcinoma on her right cheek. She says that the lesion has been present for 8 months and has grown rapidly during the past 3 months. A photograph is shown (small dome-shaped bump that has a pearly white color). Which of the following is the most appropriate treatment? A ) Cryotherapy B ) Electrodesiccation and curettage C ) Mohs micrographic surgery D ) Radiation therapy E ) Wide local excision
C ) Mohs micrographic surgery
The patient described has a basal cell carcinoma (BCC), which is the most common type of cancer worldwide affecting approximately 1 million people per year. These types of cancers were once more common in people over 40 years of age, but they now are often diagnosed in younger people (85% of lifetime sun exposure occurs before age 18).
__% of lifetime sun exposure occurs before age 18
85%
BCC most often occurs where?
BCC starts in the epidermis and grows slowly and painlessly. It most often appears on areas of skin that are regularly exposed to sunlight or other ultraviolet radiation,such as the face, scalp, ears, chest, back, and legs.
Appearance of basal cell carcinoma
Small dome-shaped bump that has a pearly white color.
Telangiectasias may be seen on the surface.
A common sign of BCC is a sore that bleeds and heals up, only to recur again; oozing or crusting spots within the sore are also common.
5 year recurrence rates for primary BCC by type of treatment
Five-year recurrence rates for primary BCC:
- Mohs micrographic surgery 1%
- Surgical excision 10.1%
- Curettage and desiccation 7.7%
- Radiation therapy 8.7%
- Cryotherapy 7.5%
A 44-year-old woman has a biopsy-proven basal cell carcinoma of the cheek. An indication for resection using conventional excision, over Mohs micrographic surgery, includes which of the following?
A ) Diameter of 1.2 cm
B ) Location next to the alar rim
C ) Morpheaform subtype
D ) Preexisting burn scar surrounding the lesion
E ) Recurrent tumor
A ) Diameter of 1.2 cm
Indications for Mohs micrographic resection of a basal cell carcinoma include morpheaform or other aggressive subtypes, recurrence of a tumor, a previous scar, or locations where the preservation of tissue is critical for final reconstruction.
Indications for Mohs micrographic resection of a basal cell carcinoma
Indications for Mohs micrographic resection of a basal cell carcinoma include
- Morpheaform or other aggressive subtypes
- Recurrence of a tumor
- Previous scar
- Locations where the preservation of tissue is critical for final reconstruction
A 22-year-old woman comes for evaluation of a lesion on her right anterior thigh (shown). She says that the lesion has been present for a number of years and that she frequently nicks it when shaving. She has no other similar lesions, and no family history of similar lesions. Physical examination shows a single, firm lesion. The nodule contracts with lateral compression. No other abnormalities are noted. Which of the following is the most appropriate next step in management? A ) Cryotherapy B ) Excisional biopsy C ) Mohs micrographic surgery D ) Shave biopsy E ) Observation
B ) Excisional biopsy
The lesion is a dermatofibroma, which is a benign nodule derived from mesodermal and dermal cells. They can be found anywhere on the body but most commonly appear on the anterior surface of the lower legs.
Dermatofibroma
Benign nodule derived from mesodermal and dermal cells
Where are dermatofibromas found?
They can be found anywhere on the body but most commonly appear on the anterior surface of the lower legs.
Clinical presentation of dermatofibromas
Dermatofibromas are asymptomatic, firm, raised papules, plaques, or nodules that can vary in size from 3 to 10 mm in diameter. Coloration ranges from brown to purple,red, yellow, and pink. They are diagnosed based on physical examination and commonly display a Fitzpatrick sign, which is the dimpling or retraction of the lesion beneath the skin with lateral compression
Fitzpatrick sign
The dimpling or retraction of the lesion beneath the skin with lateral compression (dermatofibromas)
> ____ dermatofibromas on a patient: May suspect _____________
Underlying autoimmune disorders, such as systemic lupus erythematosus, may be suspected if multiple dermatofibromas (ie, > 15) are found on a patient.
Treatment of dermatofibroma
Treatment is generally performed for cosmetic reasons or histologic diagnosis in case there is any question about the clinical diagnosis. Excisional biopsy is the procedure of choice to ensure clear histology, as well as complete removal of the lesion, as it exists in the dermal plane.
A 38-year-old woman has severe hidradenitis suppurativa of the groin and axillae. Which of the following dermal appendages are located in these areas and implicated in the disease process? A ) Apocrine glands B ) Eccrine glands C ) Glomus bodies D ) Hair follicles E ) Sebaceous glands
A ) Apocrine glands
Apocrine glands are uniquely located in the axillae, groin, and perineum, and they secrete a viscid, milky fluid that becomes malodorous with bacterial colonization. Occlusion of the glands causes inflammation and subcutaneous abscess formation with pain, drainage, and foul odor. This crippling disease can be medically managed with chronic suppressive topical and systemic antibiotics but often requires intermittent incision and drainage, or even surgical resection
Apocrine glands
Apocrine glands are uniquely located in the axillae, groin, and perineum, and they secrete a viscid, milky fluid that becomes malodorous with bacterial colonization.
Occlusion of apocrine glands
Occlusion of the glands causes inflammation and subcutaneous abscess formation with pain, drainage, and foul odor.
Eccrine glands
Eccrine glands are found throughout the skin, secreting a thin, clear, hypotonic fluid ( sweat).
Glomus bodies
Glomus bodies are located in tissues exposed to the cold, such as the fingertips and ears. They form a thickening in the arterial wall before naturally occurring thermoregulatory arteriovenous shunts, and they are thought to control the flow through these shunts.
Sebaceous glands
Sebaceous glands secrete sebum, an oily substance that lubricates hair follicles and surrounding skin. They are found throughout the skin, except for the palms and soles. They are found in abundance in the face and scalp
A 72-year-old man is being evaluated because of a 3-month history of lesions on the nasal dorsum and cheek (shown). He is a poor surgical candidate and is treated with imiquimod (Aldara). Which of the following is the most likely mechanism of action of this treatment?
A ) Inhibition of the cyclooxygenase pathway
B ) Inhibition of DNA synthesis
C ) Modification of gene transcription
D ) Modulation of cell differentiation
E ) Stimulation of proinflammatory cytokine production
E ) Stimulation of proinflammatory cytokine production
Imiquimod (Aldara) is a new immune response enhancer that stimulates host cytokine production and induces apoptosis of tumor cells. It hasbeen used to treat actinic keratoses, viral warts, and nonmelanoma skin malignancy.
Imiquimod
Imiquimod (Aldara) is a immune response enhancer that stimulates host cytokine production and induces apoptosis of tumor cells. It hasbeen used to treat actinic keratoses, viral warts, and nonmelanoma skin malignancy.
Topical 5-fluorouracil
Topical 5-fluorouracil is a topical chemotherapeutic agent that directly inhibits DNA synthesis.
Topical diclofenac
Topical diclofenac is an anti-inflammatory drug that inhibits the cyclooxygenase pathway and has been found useful in the treatment of actinic keratoses.
Interferons vs the skin
Interferons control cell differentiation by modification of gene transcription and have been used in combination with retinoids for advanced squamous cell cancers
An 86-year-old woman comes to the office because of an 18-month history of the isolated, painful lesion shown. History includes CREST (calcinosis cutis, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which of the following is the most appropriate initial management? A ) Debridement B ) Hyperbaric oxygen therapy C ) Injection of corticosteroids D ) Measurement of E ) Measurement of serum uric acid level
A ) Debridement
Calcinosis cutis: The calcific deposits, when symptomatic, can be tender and painful. They can ulcerate, drain a white chalky substance, and become secondarily infected. In scleroderma, calcific deposits are found predominantly in the extremities and around joints and bony prominences. Deposits are typically found in the flexor surfaces of the hands and the extensor surfaces of the forearms and knees. The deposits rest in the dermis but can also be found in deeper periarticular tissues.
Serum calcium, phosphorus, and alkaline phosphatase levels typically are normal; serum measurement does not contribute to management.
Calcinosis cutis
Calcinosis cutis is the pathologic calcification of soft tissues and skin
Where is calcinosis cutis found in scleroderma?
In scleroderma, calcific deposits are found predominantly in the extremities and around joints and bony prominences.
Deposits are typically found in the flexor surfaces of the hands and the extensor surfaces of the forearms and knees. The deposits rest in the dermis but can also be found in deeper periarticular tissues.
Management of scleroderma calcinosis cutis
Surgical excision of localized, painful large deposits can relieve symptoms; recurrence is rare. If calcinosis is diffuse, recurrence is more common.
Calciphylaxis
Calciphylaxis is a poorly understood and highly morbid syndrome of vascular calcification and skin necrosis typically seen in 1 to 4% of patients with end-stage renal disease
Which of the following is the most important management for patients with xeroderma pigmentosum? A ) Cryotherapy B ) Fluorouracil C ) Isotretinoin D ) Minimization of sun exposure E ) Skin grafting
D ) Minimization of sun exposure
Xeroderma pigmentosum (XP) is an autosomal recessive disorder demonstrating defective DNA repair. The ability to repair damage caused by ultraviolet (UV) light is deficient. In severe cases, it is necessary to avoid sunlight completely.
Heredity of xeroderma pigmentosum
Autosomal recessive
What is wrong in xeroderma pigmentosum?
The ability to repair damage caused by ultraviolet (UV) light is deficient.
When are patients with XP usually diagnosed?
1-2 years of age
Clinical manifestations of XP
Development of many freckles at an early age Irregular dark spots on the skin Thin skin Excessive dryness Solar keratoses Skin cancers Premature aging of skin Eyes that are sensitive to the sun
Most important management in xeroderma pigmentosum
Minimizing sun exposure
The number of keratoses in xeroderma pigmentosum can be reduced by:
The number of keratoses can be reduced with isotretinoin (though there are significant side effects).
Keratoses in xeroderma pigmentosum can be treated by:
Existing keratoses can be treated using cryotherapy or fluorouracil.
When are skin cancers detected in xeroderma pigmentosum?
Skin cancers are detected at approximately 8 years of age.
A 52-year-old man is scheduled to undergo a midline laparotomy for colon cancer. History includes cutis laxa. Examination shows hypoelastic skin that does not spring back when stretched. This patient is at increased risk for which of the following complications? A ) Anastomotic dehiscence B ) Hypertrophic scarring C ) Thrombosis D ) Ventral hernia E ) Wound dehiscence
D ) Ventral hernia
Cutis laxa patients are at a higher risk for ventral hernia formation.
Cutis laxa is a rare condition with hypoelasticity of the skin from a defect in elastin fibers.
Wound failure is common in Ehlers Danlos syndrome
Cutis laxa is secondary to:
A defect in elastin fibers
Clinical manifestation of cutis laxa
Skin does not spring back into place immediately upon being stretched
There is an increased risk of _________ formation in cutis laxa
hernia formation
Cutis hyperelastica is also called:
Ehlers-Danlos syndrome
Ehlers-Danlos syndrome
Ehlers-Danlos syndrome (cutis hyperelastica) is characterized by skin hyperextensibility, joint laxity, and tissue friability.
In what cutaneous disorder is wound failure common?
Ehlers-Danlos syndrome
Patients can dehisce their wounds or anastomoses at 1 to 2 weeks. Wound failure is common. Ventral hernias are common and may require closure techniques, such as components separation. Scar formation is wide and extremely thin, and it has been described as papyraceous and cigarette-paper
In what inheritable syndrome is thrombosis common?
Homocystinuria
A 5-year-old girl is brought to the office because of erythema, inflammation, and bullae formation on the face and neck area one day after spending a sunny day in the park with her family
Xeroderma pigmentosum
A 16-year-old boy comes to the office because of a three-year history of dome-shaped, tan papules on the face, neck, and trunk; erythematous pits in the palm of his hand; and swelling and pain in the molar and premolar areas.
Nevoid basal cell carcinoma syndrome
Another name for Gorlin syndrome
Nevoid basal cell carcinoma
Nevoid basal cell carcinoma (Gorlin) syndrome
Physical findings include dome-shaped tan papules on face, neck, and trunk (basal cell carcinoma [BCC]); erythematous pits in the palm of the hand or plantar aspect of the feet;and swelling and pain in molar and premolar areas (odontogenic keratocysts), colobomas, hypertelorism, and fibrosarcomas.
Inheritance of Nevoid basal cell carcinoma (Gorlin) syndrome
Autosomal dominant
Management of Nevoid basal cell carcinoma (Gorlin) syndrome
Surgical excision, application of 5- fluorouracil (5-FU) and imiquimod, and frequent cutaneous examinations. Patients should avoid radiotherapy, radiographs, and sun as these caninduce the formation of new BCCs.
Bazex syndrome inheritance
Bazex syndrome is another autosomally dominant inherited disorder.
Clinical presentation of Bazex syndrome
It is characterized by multiple BCCs of the face, follicular atrophoderma of the extremities, localized or generalized hypohidrosis, and hypotrichosis.
Erythroplasia of Queyrat
Erythroplasia of Queyrat arises from the squamous epithelial cells of the glans penis. It is synonymous with Bowen diseaseof the glans penis, is seen mostly in uncircumcised men, and represents an in situ form of squamous cell carcinoma.
A 60-year-old man is referred to the office by his primary care physician for consultation regarding deformity of the nose caused by rhinophyma. Physical examination shows enlargement of the nasal tip, pitting and scarring of the skin, and several irregular, nodular growths. Which of the following conditions is the most likely cause of these findings? A ) Acne vulgaris B ) Facial dermatitis C ) Hidradenitis suppurativa D ) Rosacea
D ) Rosacea
What is Rhinophyma
Rhinophyma is a condition involving the nose in which the nasal skin is erythematous with telangiectasias and is sometimes purple in color. In severe cases, the skin can have pits, fissures, and scarring. Sebum and bacteria can result in chronically infected skin and often an unpleasant odor.
What is preferentially affected in rhinophyma?
The nasal tip is preferentially enlarged, and as the nasal skin hypertrophies, the aesthetics units of the nose are distorted and obliterated. Tumorous growths can develop late, and a severe aesthetic deformity can result.
Rhinophyma is believed to by the _______ stage of evolving _______
Rhinophyma is believed to be the fourth stage of evolving rosacea.
Patients with rhinophyma may suffer from secondary _________________
Patients may suffer from secondary nasal airway obstruction.
Acne vulgaris
Acne vulgaris is a common, chronic inflammation of the pilosebaceous units of the face and trunk
Facial dermatitis
Facial dermatitis usually occurs in the perioral region, mainly in young women. It results in discrete erythematous micropapules that can become confluent, forming inflammatory plaques.
A 4-year-old boy is brought to the office because of a lump near his right eyebrow. The lesion has been enlarging gradually since it was first noticed by his parents when he was 3 months of age. On physical examination, a 2-cm, firm, mobile mass is palpated at the lateral aspect of the right eyebrow. The lesion has distinct margins and there are no other related symptoms. Which of the following is the most appropriate initial step in management? A ) Angiography B ) CT C ) Needle aspiration D ) Surgical excision E ) Observation only
D ) Surgical excision
The most likely diagnosis in the patient described is a dermoid cyst of the orbital region. Most orbital dermoids manifest as solitary masses with distinct palpable margins and without intracranial extension. These lesions are present in the lateral aspect of the upper orbit and usually do not have any related symptomatology. As a result, these patients do not require preoperative evaluation to exclude the possibility of intracranial involvement. Simple excision of the cyst is appropriate at the time of diagnosis.
Clinical presentation of orbital dermoids
Most orbital dermoids manifest as solitary masses with distinct palpable margins and without intracranial extension. These lesions are present in the lateral aspect of the upper orbit and usually do not have any related symptomatology.
Treatment of orbital dermoids
Do not require preoperative evaluation to exclude the possibility of intracranial involvement.
-> Simple excision
Management of orbital dermoid with indistinct margins
Rarely, a dermoid cyst may present with indistinct margins. During palpation, the lesion may appear to decrease in size and proptosis may occur. These rare patients may have extension of the dermoid cyst throughthe lateral orbital wall. In these cases, further evaluation with CT should occur to determine the extent of intraorbital involvement and determine whether more complex surgery is needed to reconstruct the defect.
Management of orbital vs midline dermoids
Midline dermoid cysts are much more likely to demonstrate intracranial involvement, and, therefore, immediate surgical resection is not recommended
A 65-year-old man comes to the office because he has a painful lesion on the left ear that has been present for the past eight months. Tenderness is noted on palpation of the lesion. A photograph of the ear is shown. Which of the following is the most likely diagnosis? (A)Actinic keratosis (B)Chondrodermatitis nodularis helicis (C)Keratoacanthoma (D)Seborrheic keratosis (E)Tricholemmoma
(B)Chondrodermatitis nodularis helicis
Chondrodermatitis nodularis helicis is a chronic, inflammatory, painful, nodular lesion located primarily on the helix or antihelix of the ear. These lesions often produce exquisite tenderness that interferes with sleep. Histologically, the underlying cartilage demonstrates focal degenerative change and surrounding perichondritis. The cause of this inflammatory process is unknown, but long-term trauma or sun damage may play a role. Surgical excision of the affected cartilage is recommended if conservative therapy with steroid injections is unsuccessful.
Chondrodermatitis nodularis
Chondrodermatitis nodularis helicis is a chronic, inflammatory, painful, nodular lesion located primarily on the helix or antihelix of the ear. These lesions often produce exquisite tenderness that interferes with sleep.
Histology of chondrodermatitis nodularis
Histologically, the underlying cartilage demonstrates focal degenerative change and surrounding perichondritis.
Cause of chondrodermatitis nodularis
The cause of this inflammatory process is unknown, but long-term trauma or sun damage may play a role.
Treatment of chondrodermatitis nodularis
Surgical excision of the affected cartilage is recommended if conservative therapy with steroid injections is unsuccessful.
Symptoms of actinic keratosis
Usually asymptomatic except for possible pruritis
Clinical appearance of actinic keratosis
It is characterized bya discrete, flat, or slightly elevated lesion with surrounding erythema. These lesions are often multiple and appear scaly due to hyperkeratosis and parakeratosis.
Malignant potential of actinic keratosis
Twenty to 25% of lesions progress to squamous cell carcinoma.
Keratoacanthoma clinical presentation
A keratoacanthoma is a round, smooth, pink nodule encircling a large keratinous plug. It enlarges rapidly during a period of weeks and can resolve spontaneously.
Keratoacanthoma histology
Histologically, it can be difficult to distinguish from squamous cell carcinoma.
Keratoacanthoma management
Although it is classified as benign and self-involuting, the treatment of choice is excision.
Seborrheic keratosis clinical presentation
Seborrheic keratosis is a sharply circumscribed, waxy papillomatous lesion with a friable hyperkeratotic surface and a stuck on appearance.
Seborrheic keratosis management
It is an asymptomatic benign lesion and excision is elective.
Tricholemmoma clinical presentation
Tricholemmoma is a benign tumor often found in the scalp and has a clinical appearance similar to an epidermal inclusion cyst.
Tricholemmoma management
Treatment is simple excision.
An otherwise healthy 65-year-old woman comes to the office because she noticed a well-circumscribed 2-cm dark brown lesion with a waxy surface on herback two years ago. On excision of the lesion, which of the following is the most likely pathologic diagnosis? (A)Actinic keratosis (B)Congenital nevus (C)Cutaneous horn (D)Keratoacanthoma (E)Seborrheic keratosis
(E)Seborrheic keratosis
Seborrheic keratosis is commonly excised to prevent potential confusion with malignant melanoma. These lesions are often seen in large numbers on middle-aged and older patients. They are sharply circumscribed, waxy, and friable with a ―stuck on‖ appearance. Pigmentation ranges from tan to deep black. Treatment options include shave excision, electrodesiccation, freezing with liquid nitrogen, or simple excision. These lesions do not undergo malignant degeneration and are not easily confused with squamous cell carcinoma.
Seborrheic keratosis pigmentation
Pigmentation ranges from tan to deep black
Seborrheic keratosis is commonly confused with:
Malignant melanoma
Which of the following treatments for basal cell carcinoma has the lowest recurrence rate? (A)Cryotherapy (B)Electrodesiccation and curettage (C)5-Fluorouracil (D)Mohs surgery (E)Radiation therapy
(D)Mohs surgery
Mohs surgery yields the most favorable recurrence rate of 3.4% to 7.9%, establishing it asthe treatment of choice for recurrent skin tumors.
A 25-year-old woman comes to the office because she has had a raised raw lesion on the dominant right forearm for the past three years since undergoing a cardiac transplantation. The area has slowly increased in size during the past year. She says she has taken oral and topical antibacterial and antifungal agents irregularly for the past year. She currently takes prednisone. Physical examination shows a 3-cm-diameter mass with a raw surface on the dorsal aspect of the right mid forearm. Which of the following is the most appropriate next step in management?
(A)Acticoat dressing
(B)Biopsy for culture and pathology
(C)Contrast and noncontrast MRI
(D)Excision of the lesion followed by skin grafting
(E)Reduction in immunosuppression
(B)Biopsy for culture and pathology
In the scenario described, the most useful intervention is to perform a biopsy of a mass specimen for infection (bacterial, fungal, and atypical pathogen) and histopathology. With this information, the treatment can be cause-specific.
___________ immunosuppression appears to drive the time course of tumor development earlier.
Cyclosporine immunosuppression appears to drive the time course of tumor development earlier.
Acticoat
Silver ion dressing
Origin of congenital melanocytic nevi
Congenital melanocytic nevi, such as this one, are believed to represent an anomaly in embryogenesis and, as such, could be considered a malformation or a hamartoma.
What patient population develops congenital melanocytic nevi
Melanocytic nevi are common in light-or fair-skinned patients and are relatively uncommon lesions in dark-skinned individuals.
Where do keratoacanthomas arise from?
The pilosebaceous glands
Nevus of Ota
A nevus of Ota is a blue-gray lesion occurring on the face in the distribution of the trigeminal nerve (particularly the ophthalmic and maxillary branches—V1 and V2).
Nevus of Ito
A nevus of Ito is similar to the nevus of Ota (a blue-gray lesion) but follows the distribution of the lateral brachial cutaneous and supraclavicular nerves
Nevus sebaceus of Jadassohn
A nevus sebaceus of Jadassohn is a yellow-orange, slightly elevated plaque that usually occurs on the face and scalp. It has the potential for malignant transformation to a basal cell carcinoma.
A 45-year-old woman comes to the office for consultation regarding multiple actinic keratoses on the face. Physical examination shows fair-skinned complexion and small scaly patches on the face and ears. Which of the following interventions will result in the most desirable long-term aesthetic appearance in this patient?
(A)Cryosurgery
(B)Electrodesiccation and curettage
(C)Excision of the lesions with 2-mm margins
(D)Microdermabrasion
(E)Topical application of 0.5% fluorouracil cream
(E)Topical application of 0.5% fluorouracil cream
Several formulations and concentrations of topical fluorouracil have received U.S. Food & Drug Administration (FDA) approval for the treatment of keratotic lesions. Fluorouracil 5% and 0.5% creams have demonstrated, in clinical trials, a marked ability to eradicate keratotic lesions.
Cosmetic result of 5-FU vs surgical excision for keratotic lesions
The cosmetic result of 5-FU is often far better than surgical excision.
0.5% vs 5% FU
0.5% cream is more cost-effective and may be safer, more tolerable, and as effective as fluorouracil 5% cream.
___% of squamous cell carcinoma cases begin as actinic keratosis
Although 60% of squamous cell carcinoma cases begin as actinic keratosis, the risk of progression to squamous cell carcinoma is minimal.
A 17-year-old girl comes to the office because she has had lesions on the upper arms and in the axillary folds for the past eight years. Physical examination shows clusters of white, vesicular lesions ranging from 2 to 5 mm in diameter. The lesions are obliterated with gentle pressure but refill when pressure is removed. Diffuse swelling is palpable in the underlying subcutaneous tissue. Which of the following is the most likely diagnosis? (A)Blue rubber bleb nevus syndrome (B)Lymphangioma circumscriptum (C)Maffucci syndrome (D)Osler-Weber-Rendu syndrome (E)Sebaceous nevus
(B)Lymphangioma circumscriptum
Lymphangioma circumscriptum consists of clusters of small to moderate-sized, clear to whitish-appearing vesicular lesions. These lesions can be obliterated with gentle pressure, but they refill with the lymph when the pressure is removed due to the presence of communications with larger underlying cisterns of lymphatic malformation. Clear vesicles may be present on apparently normal skin or may top small papules. Although the classic lesion can occur anywhere on the body, it is particularly common over proximal parts of limbs and adjacent parts of the limb girdle including the upper arm, axillary, pectoral, and scapular regions. Adequate treatment of lymphangioma circumscriptum usually involves excision of the involved skin as well as the deeper lymphatic components.
Lymphangioma circumscriptum
Lymphangioma circumscriptum consists of clusters of small to moderate-sized, clear to whitish-appearing vesicular lesions. These lesions can be obliterated with gentle pressure, but they refill with the lymph when the pressure is removed due to the presence of communications with larger underlying cisterns of lymphatic malformation. Clear vesicles may be present on apparently normal skin or may top small papules.
Lymphangioma circumscriptum: where does it occur?
Although the classic lesion can occur anywhere on the body, it is particularly common over proximal parts of limbs and adjacent parts of the limb girdle including the upper arm, axillary, pectoral, and scapular regions.
Lymphangioma circumscriptum: Treatment
Adequate treatment of lymphangioma circumscriptum usually involves excision of the involved skin as well as the deeper lymphatic components.
Blue rubber bleb nevi
Blue rubber bleb nevi usually present as raised blue to purple rubbery cutaneous lesions that are easily compressible. This is a rare morphogenetic disorder consisting of malformed vascular channels within the skin and bowel. When blood is expressed from the vesicles, the deflated blister becomes a wrinkled sac. When pressure is released, the deflated blisters refill with blood.
Blue rubber bleb nevi: When do they present?
The lesions sometime present at birth, but more frequently appear throughout adolescence.
Blue rubber bleb nevi: Management
Subtotal excisions of tender or painful skin lesions can be of symptomatic relief.
Maffucci syndrome
Maffucci syndrome classically presents as blood-like, spongy, papular, or pedunculated vascular malformations in association with enchondromas. Visceral vascular malformations may also be present, and the involved bones are usually shortened and deformed.
What is concerning about Maffucci syndrome?
Approximately 20% of the enchondromas can degenerate into chondrosarcoma, which is usually manifest by increasing size and pain of a particular lesion
Osler-Weber-Rendu syndrome
Osler-Weber-Rendu syndrome presents as malformed ectatic vessels in the skin, mucous membranes, and viscera appearing after puberty and multiplying with advancing age. Hemorrhage fromthe lesions presents as epistaxis, hematemesis, hematuria, or melena
When does Osler-Weber-Rendu syndrome present?
Appears after puberty and multiplying with advancing age.
Sebaceous nevi
Sebaceous nevi usually develop as firm, plaque-like, waxy-appearing yellowish lesions developing on the scalp. These are potentially premalignant lesions. Generally, these lesions should be excised, because there is an approximately 5% incidence of malignant degeneration, particularly during adolescence. Hair growth in these lesions is sparse to absent.
What is concerning about sebaceous nevi?
These are potentially premalignant lesions (5%)
Management of sebaceous nevi
Generally, these lesions should be excised, because there is an approximately 5% incidence of malignant degeneration
A 23-year-old woman with neurofibromatosis comes to the office for consultation regarding lesions on the face and trunk that have appeared during the past 10 years. She is dissatisfied with the cosmetic appearance of a lesion on her nose and is concerned about a lesion on the left hip that has been enlarging and is painful on application of pressure. Physical examination shows multiple small, flesh-colored masses on the face and trunk ranging from 5 to 35 mm in diameter. Punch biopsy shows neurofibromas. Which of the following is the most appropriate management of the lesions on the patient’s nose and hip? (A)Injection of a corticosteroid (B)Nd:YAG laser resurfacing (C)Radiation therapy (D)Surgical excision (E)Observation only
(D)Surgical excision
Neurofibromatosis is an autosomal-dominant disorder that can affect the skin, soft tissues, bone, and central nervous system. The treatment of isolated soft tissue and skin nodules is primarily surgical. Lesions are composedof Schwann cells, fibroblasts, and mast cells. Malignant transformation may occur in 3% to 15% of patients over their lifetime. Any lesions that grow rapidly or cause pain should be excised or biopsied to exclude neurofibrosarcoma. Observation is, therefore, not appropriate in this case.
Neurofibromatosis
Neurofibromatosis is an autosomal-dominant disorder that can affect the skin, soft tissues, bone, and central nervous system. The treatment of isolated soft tissue and skin nodules is primarily surgical. Lesions are composedof Schwann cells, fibroblasts, and mast cells. Malignant transformation may occur in 3% to 15% of patients over their lifetime. Any lesions that grow rapidly or cause pain should be excised or biopsied to exclude neurofibrosarcoma. Observation is, therefore, not appropriate in this case.
Heredity of neurofibromatosis
Autosomal dominant
