I35 skin

Vesalius SCALpel™ : Skin

Benign

Exfoliative dermatoses

inflammation induced dermal-epidermal separation toxic epidermal necrolysis (TEN)
most severe of the exfoliative dermatoses restore hemodynamics, pulmonary toilette/intubate TF to burn center (equivalent of 2nd degree burn), burn protocol Rx for local no systemic antibiotics, enteral feeding erythema multiforme (EM)
most often associated with herpes simplex Stevens-Johnson syndrome (SJS)
blistering, erosion multiple mucous membranes widespread small blisters on purpuric macules
Pyogenic granuloma

capillary proliferation with or without trauma Hx
Infection

impetigo
superficial ulceration with overlying bulla bullous: staph, non-bullous: staph or strep erysipelas
rapid spread, warmth, erythema, pain, fever, WBC superficial skin and lymphatics (not as deep as celulitis) strep skin infection may lead to glomerulonephritis
Pyoderma gangrenosum

rapid, painful, blue, undermined ulcerations lower extremities and trunk associated with inflammatory bowel disease outside boundary of incision, remains elevated, continues to grow mature keloid: excise plus lo dose adjuvant RT, silicone sheet, TAM (decreases collagen
Hypertrophic scar


Basal cell

30-50% of caucasians in lifetime, locally destructive
30% will develop a 2nd within a year
excise with 4-7mm margin
lymph node concern only for basosquamous and clinically palpable
MOHs (successive margin frozen sections to clear) only for hi risk
Squamous

risk: sun, radiation, chronic skin condition, smoking, immunocompromise (transplant pts. skin lesion =
squamous), arsenic, coal tar, paraffin oil, creosote, fuel oil
poor prognosis: > 2cm, deep, poor differentiation, rapid growth, in scar (burn, Marjolin’s), perineum, positive
nodes (50% 5y)
Rx: excise with 4-7mm margin, down to deep subQ
cryo, curette and electrodessication, laser ablation, topical 5FU recurrence: > 2cm, aggressive histology, poor margins, incomplete excision, perineural, critical location Melanoma

2/3 from pre-existing mole, 1/3 de novo
5% of all skin cancers, increasing at 5%/y, 80% between 25-65, average 53yo
spreads radially first, then deep
risk: Celtic, white (20:1), M>F, 10% familial disposition, dysplastic nevus syndrome, xeroderma pigmentosa,
non-melanotic skin cancer, higher socioeconomic class, urban
characteristics (ABCDE)
Asymmetry
Borders:
lentigo: 10%, older women (70s), superficial, exposed skin superficial spreading: 70%, preexisting nevus, radial growth nodular: 20%, little radial growth phase, don’t follow ABCs, smooth border acral lentiginous: 2%, fingers, palms, soles, toes, 50s, 50% in darker skinned, rare in caucasians T1 < 1mm depth; T2 1-2mm; T3 2-4mm; T4 > 4 N1: 1 node positive, N2: 2-3 nodes, N3: 4 or > c: other viscera (to bone, lung, liver, brain) III: 49% 5y survival (= node involvement) worse: male, trunk, hand, foot, LN invasion, higher number of lymph nodes, satellitosis, ulceration, high mitotic index, nodular, acral lentiginous, ulcerated, male better prognosis: female, extremities, presence of tumor-infiltrating lymphocytes > 1mm: 2cm (all depths > 1mm) + SLN face 1cm, MOHs surgery for clear margin, cosmetic concerns depth > 1mm, Clark’s level IV or V, or ulcerated do sentinel lymph node (SLN)(gamma count chance of LN met 5% if lesion is < 1mm SLN should be done before wide excision for accuracy (no more discussion of elective node dissection, before SLN were 80% negative) node +: interferon increases disease-free interval and survival search for primary: ocular, mucosal, anus, pelvis anterior scalp, forehead and face can go to parotid as well as levels I, II and III ocular melanoma has a propensity to go to liver I & II, > 4mm, ulcerated, desmoplastic flat: 25% recurrence excise (small margin) local or nodal, if no distant disease, 25% long term survival isolation/perfusion: melphalan & TNF 80% response recurrence too big to resect, distal extremity
Merkel cell carcinoma:

mechanoreceptor cells at base of epidermis neuroendocrine, aggressive, 20% lymph node involvement (v 10% melanoma), 11% satellitosis @ Dx, hi local recurrence, 55% 3y survival (v 80% 5y melanoma) wide and deep (cells extend to subQ fat) excision, adjuvant XRT to tumor site and nodal painless, solitary violaceous dermal nodule or plaque sun-exposed areas 50% head and neck, 40% extremities, 10% trunk histo: cytokeratin IHC (CK20), conspicuous paranuclear dots neuroendocrine markers: neuron specific enolase, chromogranin, synaptophysin differentiate from small cell lung (CK7), melanoma, keratoacnthoma 70% recurrence after wide local excision
Other skin cancers

angiosarcoma: rare, malignant, combo Rx, 33% overall survival
atypical fibroxanthoma: spindle cell, elderly male, locally aggressive, wide excision
dermatofibrosarcoma: from fibroblasts, locally aggressive
extramammary Pagets: adenocarcinoma, apocrine origin, F>M, 24% associated adenocarcinoma
Kaposi’s sarcome: indolent vascular, no Rx if asymptomatic, cryo or RT if symptomatic
microcystic adnexal carcinoma: sweat ducts, MOHs
sebaceous gland carcinoma: eyelids, frequent local recurrence, 25% mets, XRT > 6mm

Source: http://www.vesalius.com/graphics/cf_quicknotes/sc_skin.pdf