SKIN ONCOLOGY

Question 1

Melanoma most common sites of recurrence are in order of most to least

Answer 1

skin,
subcutaneous tissues,
distant lymph nodes,

followed by 
visceral sites:
lung, 
liver, 
brain, 
bone, 
gastrointestinal tract
'small bowel'

also goes to adrenal

Question 2

Surgical excision of recurrent melanoma can be effective for palliation in patients with isolated recurrences where

Answer 2

skin, 
central nervous system, 
lung, 
or 
gastrointestinal tract. 

yes we are talking about palliation brain surgery..

Surgical excision of solitary brain metastases has been shown to provide improved palliation and quality of life compared with brain irradiation.

Resection of isolated pulmonary metastases or of subcutaneous recurrences is usually not considered curative but can result in significantly prolonged disease-free survival.

Gastrointestinal lesions causing obstruction or bleeding should be considered for resection or bypass to relieve these symptoms.

Melanoma can respond to radiation therapy. Radiation therapy is commonly used for palliation of bone pain secondary to metastatic disease or brain metastasis.

The average survival after brain irradiation for melanoma is approximately 4 months

Question 3

Fortunately, the American Joint Commission on Cancer (AJCC) has recently recognized the boundry btw the anal margin and the anal canal as

Answer 3

anal verge seperates:

anal margin

versus

anal canal

yep, the rim of the anus

.. most clinicians can readily determine the location of an anal tumor as inside or outside the anal verge using inspection alone—that is, without the aid of an anoscope or proctoscope.

From a practical standpoint, most bulky adenocarcinomas of the distal rectum or proximal anal canal are going to receive the same treatment

and BULKY squamous cancers of the anal canal and margin will be treated in the same way, no matter the precise site of origin (but careful squams less than 2-3 cm anal margin will get the WLE)

“Historically the distinction between anal margin and anal canal was clouded by two different working definitions, one that recognized the dentate line (anatomic canal) and the other that recognized the anal verge (surgical canal) as the key landmark. (see Fig. 53-2).

Question 4

Anal Margin Tumors

Answer 4

Anal Intraepithelial Neoplasia

Accurate lesion mapping

Focal excision or ablation

Imiquimod or 80% trichloroacetic acid

Close observation
Bowen’s Disease

Accurate lesion mapping

Wide local excision for confluent disease, with flap repair as indicated

Exclude presence of locally invasive component or associated gynecologic malignancy
Paget’s Disease

Accurate lesion mapping

Wide local excision with flap repair as indicated

Exclude underlying malignancy

APR and chemotherapy or radiation therapy if invasive adenocarcinoma present
Basal Cell and Anal Margin Squamous Cell Carcinoma

Local excision with clear margins

Radiation therapy for complex primary or recurrent lesions to avoid APR
Verrucous Carcinoma

Wide local excision; APR if extensive

Combined-modality therapy if transformation to squamous cell cancer has occurred
Anal Canal Tumors
Epidermoid Cancer

Local excision if favorable T1

Combined-modality, external beam radiation therapy plus 5-FU plus mitomycin

APR if incontinent or local treatment failure or recurrence after combined chemotherapy and radiation therapy

Triple-modality therapy in bulky T3 and T4 lesions (role of APR controversial)
Adenocarcinoma

APR with 5-FU and radiation therapy as indicated
Melanoma

APR or local excision to achieve an R0 resection