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SKIN AND SUBCUTANEOUS TISSUE

BACKGROUND
Skin
Protective barrier
Bodys primary thermoregulatory organ

ANATOMY & PHYSIOLOGY


Layers of the Skin

Rate of melanin production


Transfer to keratinocytes
Melanosome degradation

Melanin Production
Genetically activate factors
UV
o UV A (315 to 400 nm) majority of skin
damage
o UV B (240 to 315 nm) sunburn injury &
melanoma development
Hormones estrogen, ACTH, MSH

EPIDERMIS
Functions
Semipermeable barrier to chemical absorption
Prevents fluid loss
Protects against penetration of solar radiation
Rebuffs infectious agents
Composition
Very little ECM
Keratinocytes
o Transit time: 40-56 days
Layers of epidermis
Stratum germinatum
o Basal cells mitotically active, single layer of
least differentiated keratinocytes
Stratum spinosium
o Keratinocytes linked together Keratin
Keratin intermediate filaments, flexible
scaffolding resist external stress
Keratin 5 & 14
o Point mutations blistering
diseases (Epidermolysis bullosa)
o No mitotic activity
Stratum granulosum
o Cells accumulate keratohyalin granules
Stratum lucidum
Stratum corneum horny layer
o Keratinocytes age, lose intercellular connections
& shed

Melanocytes deter absorption of harmful radiation


o 1:35 keratinocytes
o Melanin from tyrosine & cysteine; packaged
into melanosomes within cell body
Apocopation as dendritic processes
sheared off, transferred to keratinocytes via
phagocytosis

Determinants of Degree of Skin Pigmentation

Langerhans cells skin macrophages


o Expresses Class II MHA
o Antigen presenting capabilities
o Immunosurveillance against viral infections &
neoplasms of the skin

DERMIS
resist physical forces
soft tissue durability
Blood Supply: Vertical vascular channels interconnect
2 horizontal plexuses papillary dermis & dermalsubcutaneous junction
Glomus bodies tortuous arteriovenous shunts that
allow a substancial increase in superficial blood flow
when stimulated to open
Meissners, Ruffinis & Pacinis corpuscles transmit
info on local pressur, vibration & touch
Free nerve endings temperature, touch, pain & itch
sensations
Composition
ECM collection of fibrous proteins & associated
glycoproteins embedded in glycosaminoglycans &
proteoglycans
o architectural framework mechanical support
(nerves, vasculature and adnexal structures) &
viscoelasticity
o regulate neighboring cells (migration,
proliferation & survival)
Collagen main functional protein within
o 70% of dermal dry weight
o Remarkable tensible strength
o Tropocollagen collagen precursor
3 polypeptide chains: hydroxyproline,
hydroxylysine & glycine wrapped in
helix
o Type I collagen skin

Type III collagen (reticulin fibers) fetal


dermis
Elastic fibers highly branched proteins capable of
stretching to twice their resting length
o Allow return to baseline form after the skin
responds to deforming stress
Grounds substance glycosaminoglycans
o Amorphous material that occupies the remaining
spaces secreted by fibroblasts
o Constitute most of dermal volume
o

Basement Membrane - anchors the epidermis to the


dermis
Biologic Functions
o tissue organization
o GF reservoir
o Support cell monolayers during tissue
development
o Semipermeable selective barrier
Cutaneous Adnexal Structures
Eccrine glands entire body, concentrated on
palms, soles, axillae & forehead
Pilosebaceous units hair follicles + sebaceous
glands
Apocrine glands primarily in axillae & anogenital
region (suppurative hydroadenitis)
Hair follicles mitotically active germinal centers that
produce hair
Hair cylinder of tightly packed cornified epithelial
cells
Functions
o Reservoir of pluripotential stem cells
epidermal reproductivity

INJURIES TO THE SKIN AND


SUBCUTANEOUS TISSUE
TRAUMATIC INJURIES
Clean Lacerations
Irrigation, debridement, careful evaluation
PRIMARY CLOSURE
Contaminated/Infected Wounds healing by
secondary intention or delayed wound closure
- skin loss: skin grafting
Tangential Wounds similar to second degree burns
Degloved wounds considered third degree burns
Partial salvage: place it back on the wound like a
skin graft

Replacement of clean avulsed tissue


Remove necrotic debris
Areas of uncovered bed Delayed primary closure
or definitive reconstruction

Bite wounds
Etiology: Viridans streptococci, S. aureus, Eikenella
corrodens, H. influenza & -lactamase producing
bacteria
Dog bites most frequent animal related wound
o Pasteurella multocida, Staphylococcus species,
-hemolytic streptococci, E. corrodens,
Actinomyces, Fusobacterium
Contaminated wounds
Treatments: drainage, copious irrigation,
debridement of necrotic material, antibiotic therapy,
extremity immobilization & elevation
EXPOSURE TO CAUSTIC SUBSTANCES
Acidic Agents deep tissue coagulative injury
nerves, blood vessels, tendons & bone injury
Initial treatment: copious irrigation with water or
normal saline for 15-30 mins
Hydroflouric Acid cardiac arrhythmia
o Topical calcium carbonate gel
Alkaline agents fat saponifications tissue
penetration tissue damage
Liquifactive injury
Treatment: Immediate irrigation with continuous
flow of water for > 2 hours
IVF extravasation leakage of injectable fluids into
interstitial space --- Chemical burn
Produces injury via chemical toxicity, osmotic
toxicity or pressure effects in a closed environment
Associated Substances
o Cationic solutions K, Ca, HCO3
o Osmotically active chemicals TPN,
o Antibiotics or cytotoxic drugs
Dorsum of the hand most common site
Risk Factors
o undergoing chemotherapy
o newborn fragility, small caliber veins, poor
ability to verbalize pain, frequent use of
pressurized IVF
high concentration dextrose solutions,
calcium, bicarbonate, parenteral nutrition
o adults
chemotherapeutic agents: doxorubicin &
paclitaxel
Treatment: conservative

o
o

Severe infusion injury vigorous liposuction


with a small cannula to introduce saline flush
into injured area
Necrotic pain, damage to underlying structures
surgery

HYPER/HYPOTHERMIC INJURY
Skin exposed to temperature extremes
Hyperthermic Burns
Factors Affecting Degree of Tissue Injury
Temperature
Period
Method of exposure

Zone of Coagulation central area of injury,


necrotic
o Exposedto the most direct heat transfer
Zone of Stasis marginal tissue perfusion &
questionable viability
Zone of Hyperemia most similar to uninjured
tissue
o blood flow

Hypothermic Injury/Frostbite - acute freezing of


tissues
20% Skin tensile strength
Factors Affecting Degree of Tissue Injury
o Duration of exposure
o Temperature gradient at the skin surface
Severe Hypothermia direct cellular injury to
blood vessel walls & microvascular thrombosis
Treatment Protocol
o Rapid rewarming
o Close observation
o Elevation & splinting
o Daily hydrotherapy
o Serial debridements
PRESSURE INJURY
Pressure Ulcers/ Decubitus Ulcers
Prolonged excessive pressure
o As little as 1 hr of 60 mmHg pressure
Normal Pressures
o Arteriole 32 mmHg
o Capillary 20 mmHg
o Venule 12 mmHg
Sitting at ischial tuberosities 300 mmHg
Sacral pressure at standard hospital mattress 150
mmHg
Risk Factors: paraplegics & bedridden individuals
o Muscle tissue more sensitive to tissue pressure

Commonly Affected Areas


o Lying - sacrum, occiput, heels
o Sitting ischia
Pressure Sore Treatment
o Relief of pressure air flotation mattresses &
gel seat cushions
o Wound care
o Systemic enhancement optimize nutrition
Surgical Management
o Debridement, then irrigation
Shallow ulcers secondary intention closure
Deeper wounds with bone involvement
debridement

RADIATION EXPOSURE

UV radiation
o UV A 400 to 315 nm
o UV B 315 to 290 nm
Acute sunburns, chronic skin damage
malignant degeneration
o UV C 290 to 200 nm
Absorbed by ozone layer
iatrogenic management
industrial/occupational applications

Ionizing radiation blocks mitosis in rapidly dividing


cell types
mainstay treatment of various malignancies
Factors affecting cellular damage
o Radiation dose
o Exposure period
o Cell types
Acute Radiation
Erythema & basal epithelial cellular death
permanent hyperpigmentation
skin lesions, GI hemorrhage, bone marrow
suppression, multiorgan system failure
Chronic Radiation (4 6 months)
loss of capillaries 2o thrombosis & fibrinoid
progressive fibrosis & hypovascularity necrosis
of vessel walls poor vascular inflow poor
tissue perfusion ulceration
Hypertrophic Scars raised, red, nodular but remain
within the limits of the original incision or trauma
Keloids- much bulkier and their nodularity and
firmness extend beyond the wound
Susceptible: dark-skinned individuals, genetic
component

Location: Across a joint, on the sternum

INFECTIONS OF THE SKIN &


SUBCUTANEOUS TISSUE
Heralded by erythema, warmth, tenderness &
edema

Necrotizing Myositis primarily involves muscles and


spreads to adjacent soft tissues

Cellulitis superficial spreading infection of the skin &


subcutaneous tissue
Etiology: Group A Stretococcus & S. aureus
Treatment: Oral antibiotics

Etiology: Commonly Polymicrobial


o Gram (+) Group A streptocci, enterococci
coagulase (-) staphylococci, S. aureus, S.
epidermidis, Clostridium spp.
o Gram ( - ): E. coli, Enterobacter, Pseudomonas
spp, Proteus spp, Serratia spp &Bacteroides
Note: incidence of MRSA

Follicullitis infection & inflammation of the hair


follicle
Etiology: Staphylococcus, gram(-) organism

Risk Factors: DM, CLL, malnutrition, steroid use,


obesity, RF, chronic alcoholism, cirrhosis, peripheral
vascular disease, autoimmune deficiency syndrome

Furuncle (boil) folliculitis fluctuant nodule


Treatment: adequate hygiene, soaking in warm water

Management
Prompt Recognition
Broad spectrum IV antibiotics
Aggressive surgical debridement
ICU support
Aggressive fluid replacement - offset acute RF

Carbuncles deep seated infections multiple draining


sinuses
Treatment: incision & drainage
Abscess localized accumulation of pus with an
associated cellulitis
Treatment
o hot/warm compresses
o Antibiotics
o Incision & drainage
o Wide excision of infected tissue
& sinuses
NECROTIZING SOFT TISSUE INFECTION
Rapid, necrotizing spread & septic shock
Basis of Classification
Tissue plane affected & extent of invasion
Anatomic site
Causative pathogen
Fourniers Gangrene an abrupt, rapidly progressive,
gangrenous infection of the external genitalia, perineum
or abdominal wall
Meleneys gangrene a lethal and rapidly soft-tissue
infection caused by a microaerophilic streptococcus
Synergistic gangrene characterized by symbiosis of
anaerobic streptococci and staphylococci
DEEP SOFT-TISSUE NECROTIZING
INFECTIONS
Necrotizing Fasciitis rapid extensive infection of the
fascia deep to the adipose tissue

HIDRADENITIS SUPPURATIVA defect of the


terminal follicular epithelium apocrine blockage,
obstructed infection, abscess formation (axillae,
inguinal & perianal regions) spontaneous rupture
sinus formation
prone to repeated infections wider area of
infection
Treatment
o Acute infection
warm compresses
antibiotics
excision
o Chronic Hidradenitis
Wide excision
Skin graft oor local flap placement
Prevention: Proper hygiene & discontinue deodorant
ACTINOMYCOSIS granulomatous suppurative
bacterial disease
Etiology: Actinomyces face /head
o *Nocardia, *Actinomadura & *Streptomyces deep cutaneous infections (nodules) draining
tracts within surrounding tissue
*Mycetomas deep cutaneous infections that
present as nodules and spread to form draining tracts
to the skin and surrounding soft tissue
o fibrosis and contractures
Common site: foot (Madura foot)
Actinomycotic infections tooth infection,
odontogenic infection & facial traumas

Histologic Diagnosis: Presence of Sulfur Granules


(Pathognomic)
Treatment
o Penicillin & Sulfonamides
o Deep seated infection, abscess & chronic
scarring surgery

PILONIDAL DISEASE - infected pilonidal cysts of the


sacrococcygeal region
primarily in young male adults
Pathogenesis: Sweaty activity & buttock friction
o Squamous cell CA is a rare complication
Treatment
o Acute abscesses drainage
o Chronic sinus tract
tract curettage
local excision and closure
wide excision and marsupialization
wide excision and flap closure
fistulotomy and marsupialization

VIRAL INFECTIONS OF THE SKIN AND


SUBCUTANEOUS TISSUE
HUMAN PAPILLOMAVIRUS
Warts epidermal growths from HPV infection
Common wart (verruca vulgaris) fingers & toes
o Rough & bulbous
Plantar warts (verruca plantaris) soles & palms
o Resemble common callus
Flat warts (verruca plana) - face, legs &hands
o Slightly raised & flat
Treatments
Chemicals formalin, podophyllum, phenol-nitric
acid
curettage with electrodessication scattered lesions
surgical excision extensive areas
o recurrences are common
HPV types 5, 8 &10 associated with SCC

Venereal warts (condylomata acuminata) moist


area around vulva, anus & scrotum
o Most common STD
o Etiology: HPV Type 6 & 11
o BuschkeLowenstein Tumor concomitant
growth facilitated by HIV
o Histological Findings
Hyperkeratosis hypertrophy of the horny
layer

Acanthosis hypertrophy of the spinous


layer
Papillomatosis
o Treatment
Local destruction/excision
Adjuvant therapy: IFN, isoretinoin or
autologous tumor vaccine
Imiquimod
Small lesions podophyllotoxin cream
Larger lesions Risk of malignant
transformation

HUMAN IMMUNODEFICIENCY VIRUS


Delayed Wound healing
o T-cell count
o Opportunistic infection
o serum albumin
o Poor nutrition
poor collagen cross-linking & deposition
LYMPHOGRANULOMA VENEREUM
Etiology: Chlamydia trachomatis
STD, gram (-) bacterial infection
Incubation period: 2 weeks
Clinical Findings:
o Penile/ labial ulcer
o Inflammation & tenderness of inguinal lymph
nodes suppuration & rupture
Treatment
o Doxycycline /Azithromycin
*Surgery for Unruptured Abscesses Not
recommended

INFLAMMATORY DISEASES OF THE SKIN


& SUBCUTANEOUS TISSUE
PYODERMA GANGRENOSUM uncommon
destructive disorder
Rapidly enlarging, necrotic lesion with undermined
border & surrounding erythema
Associate with IBD, RA, hematologic malignancy &
monoclonal Ig A gammapathy
Management
o Systemic steroids or cyclosporine
o Chemotherapy with aggressive wound care
TOXIC EPIDERMAL NECROLYSIS (TEN) &
STAPHYLOCOCCAL SCALDED SKIN
SYNDROME (SSSS) similar clinical findings
erythema of the skin
bullae formation
wide areas of tissue loss

SSSS - caused by exotoxin produced during a


staphylococcal nasopharyngeal or middle ear infection
TEN immunologic reaction to certain drugs:
sulfonamides, phenytoin, barbiturates, tetracycline

Diagnosis: skin biopsy


o SSSS: cleavage plane in the granular layer of the
epidermis
o TEN: structural defects at the dermoepidermal
junction
Similar to second degree burn
Treatment
o Fluid and electrolyte replacement
o Wound care
porcine or cadaveric skin or semi-synthetic
biologic dressings
o *Steroids not effective

> 30% TBSA TEN


<10% of epidermal detachment Steven-Johnson
Syndrome respiratory & alimentary tract epithelial
sloughing intestinal malabsorption & pulmonary
failure

BENIGN TUMORS OF THE SKIN &


SUBCUTANEOUS TISSUE
CUTANEOUS CYSTS contains Keratin
Epidermal cysts - most common
o Single firm nodule anywhere
o completely mature epidermis with a granular
layer
Dermoid cysts congenital lesions that result when
epithelium is trapped during fetal midline closure
o Most frequent sites: eyebrow, from nasal tip to
forehead
Trichilemmal (pilar cysts) - 2nd most common
cutaneous cysts
o Often on the scalp of females
o Ruptured cysts intense, characteristic odor
Histologic Findings
Cyst walls epidermal layer oriented with the basal
layer superficial & more mature layers deep
o Desquamated cells (keratin) collect in the
center
Epidermal cysts mature epidermis complete with
granular layer
Dermoid cysts squamous epithelium, eccrine
glands & pilosebaceous units
Trichelimmal cysts no granular layer, however
contain distinctive outer layer resembling the roor
sheath of a hair follicle

Treatment
Excision
o Remove the entirety of cyst wall after resolution
of inflammation
Infected incision & drainage
KERATOSES (SEBORRHEIC, SOLAR)
Seborrheic Keratoses sun-exposed areas of the
body: face, forearms, back of hands
o Old age groups most notableon the chest, back
and abdomen
o Light brown/yellow lesions, velvety, grease
texture
o Premalignant lesions SCC
sudden eruption of multiple lesions
o Histological Findings: lesions contain atypical
appearing- keratinocytes & evidence of solar
damage
o Treatment:
Lesion destruction
Topical 5-FU
Surgical excision
Electrodessication
Dermabrasion
NEVI (ACQUIRED & CONGENITAL)
Acquired Melanocytic Nevi
Junctional nevus cells accumulate in the
epidermis
Compound mature nevus cells migrate partially
into the dermis
Dermal finally rest in dermal tissues
most undergo involution
Congenital Nevi rare
larger lesions with hair
Giant congenital lesions (giant hairy nevi) swim
trunk distribution, chest or back
May develop to malignant melanoma
Treatment
Total excision
Serial excisions with local tissue
expansion/advancement
VASCULAR TUMORS OF THE SKIN &
SUBCUTANEOUS TISSUES
Hemangiomas benign
Initially undergo rapid cellular proliferation over 1st
year of life & slowly involute throughout

Histological Findings: Mitotically active endothelial


cells surrounding several, confluent blood-filled
spaces
Acute Treatment hemangiomata that interfere with
function (airway,vision & feeding)
o Prompt Resection systemic problems
(thrombocytopenia or high-output cardiac
failure)
o Systemic prednisone or IFN -2a rapidly
enlarging lesions
o Surgical excision hemangiomata

Vascular Malformations result of structural


abnormalities formed during fetal development
Grow in proportion to the body & never involute
Histological Findings: enlarged vascular spaces
lined by nonproliferating endothelium
o Arteriovenous malformations high flow
lesions that often present as subscutaneous
masses associated with locallyelevated
temperature, dermal stain, thrill & bruit
Overlying ischemic ulcers,adjacent bone
destruction or local hypertrophy
Very large malformations cardiac
enlargement & CHF
Complications: Pain, Hemorrhage,
Ulceration, Cardiac effects &local tissue
destruction
Treatment: Surgical resection, angiography
with selective embolization
o Capillary malformation/ Port wine stain-flat,
dull redlesion often located on CN V
(Trigeminal N.) on face, trunk & extremities
Stuge-Weber syndrome V1 or V2 facial
regions
Leptomeningeal angiomatosis, epilepsy
& glaucoma
Histological Findings: ectatic capillaries
lined by mature endothelium
Treatment
Pulsed dye laser covered with cosmetics
Surgical excision
o Glomus tumor uncommon, benign tumor of
the extremity
Common site: hand, subungual region of
toe
Clinical Findings: severe pain, point
tenderness & cold sensitivity
Blue subungual discoloration of 1 to
2mm
Treatment: Tumor excision

SOFT TISSUE TUMORS (ACROCHORDONS,


DERMATOFIBROMAS, LIPOMAS)
Lipomas benign, no risk of malignancy
most common subcutaneous neoplasm
Common site: trunk
Clinical Findings: soft & fleshy
Histological Findings: lobulated tumor composed of
normal fat cells
Treatment: excision
Acrochordons (skin tags) fleshy, pedunculated
masses
Common site: preauricular areas, axillae, trunk,
eyelids
Histological Findings: hyperplastic epidermis overa
fibrous connective tissue stalk
Treatment: tying-off or resection
Dermatofibromas - solitary nodules, 1 to 2 cm in
diameter on
Common site: legs & flank
Histological Findings: unencapsulated connective
tissue whorls containing fibroblasts
Excisional biopsy
Treatment: operative removal
NEURAL TUMORS ( NEUROFIBROMAS,
NEURILEMOMAS, GRANULAR CELL TUMORS)
benign cutaneous tumors that arise from nerve
sheath
Neurofibromas sporadic & solitary
associated with caf-au-lait spots , Lisch nodules &
von Recklinghausens disease
firm, discrete nodules attachedto a nerve
Histological Findings: proliferation of perineurial &
endoneurial fibroblasts with Schwann cells
embedded in collagen
Neurilemmomas - solitary tumors arising from of
peripheral nerve sheath
Local or radiating painalong the distribution of the
nerve
Histologic Findings: Schwann cells with nuclei
packed in palisading rows
Treatment: Surgical resection
Granular Cell Tumors solitary tumors of the skin or
more commonly the tongue
Granular cells derived from schwann cells that often
infiltrated the surrounding striated muscle
Treatment: Operative resection

MALIGNANT TUMORS OF THE SKIN

most arise from the epidermis


1. Basal cell CA
2. Squamous cell CA
3. Melanoma

Key Factors
exposure to UV radiation
Melanin
Chemicals carcinogens: tar, arsenic & nitrogen
mustard
Radiation therapy
HPV
Chronic irritation/Nonhealing areas burnscars,
sites of repeated bullous skin sloughing, decubitus
ulcers
Systemic immunologic dysfunction on
chemotherapy, with advanced HIV/AIDS,Transplant
patients
BASAL CELL CARCINOMA most common type of
skin cancer
Subtypes
Nodulocystic or noduloucerative waxy&
frequently cream colored
o Rolled pearly borderssurrounding a central ulcer
Superficial basal cell cancers red scaling lesion
on trunk
Micronodular
Infiltrative
Pigmented tan to black
Morpheaform flat, plaquelike lesion
o Relatively aggressive prompt excision
Basosquamous metastasize similar to SCC

slow growing
extremely rare metastasis
can cause local destruction

Treatment of small nodular lesions (<2mm)


curettage
electrodessication
laser vaporization

surgical excision 0.5 cm to 1cm margins


morpheaform, infiltrative & basosquamous
Mohs surgery aesthetic areas

SQUAMOUS CELL CARCINOMA


arise from the keratinocytes of the epidermis
less common but more devastating

Bowens disease - in situ SCC lesions


Erythroplasia of Queyrat SCC tumors to the
penis
Tumor thickness correlates with malignant behavior
o >4 mm thick recur locally
o At least 10 mm metastasize
Lesions arising in burn scars (Marjolins ulcer),
chronic osteomyelitis, and areas of previos injury
metastasize early

Treatment:
Small areas of cumulative damage excision
Small lesions curettage & electrodissection
Recommended: surgical excision with 1-cm margin
& histologic confirmation that margins are tumor
free
Tumors with aesthetic value Mohs Surgery
Palpable nodes Regional lymph nodes excision
Lesions arising in chronic wounds prophylactic
lymphadenectomy

Treatment:
o Radiation therapy
o Topical 5-FU
o Mohs micrographic surgery
o intralesional interferon injection
o retinoids + interferon

MOHS TECHNIQUE serial excisionin small


increments coupled with immediate microscopic
analysis
Advantage: All specimen margins are evaluated
Major Benefit:Ability to remove tumor with
minimal sacrifice of uninvolved tissue
Major Drawback: Procedure length
MALIGNANT MELANOMA arises from
transformed melanocytes and anywhere that these cells
have migrated during embryogenesis
Nevi/Freckles benign melanocytic neoplasms
found of the skin
Dysplastic Nevi intermediate stage between
benign nevus & true malignant melanoma
90 % on skin; eyes, anus
Clinical Features: pigmented lesion with an irregular
border, darkening coloration,ulceration & raised
surface
4 Common Types of Melanoma
Superficial spreading 70% of melanomas
o Common site: Except hands and feet
o flat &measure 1 to 2 cm in diameter
o prolonged radial growth phase

Nodular 15 to 20 % of melanomas
o Vertical growth phase during diagnosis
o Darker & raised
o aggressive lesion but similar prognosis with
superficial spreading
Lentigo maligna 4 to 15% of melanomas
o Common site: neck, face and back of hands of
elderly
o tend to become large but best prognosis because
invasive growth occurs late
Acral lentiginous type rare
o Most common sites: palms, soles
Subungual regions (great toe or thumb)
blue-black discooration of posterior nail fold
Diagnosis: Hutchinsons sign
pigmentation in the proximal or lateral
nail folds

How to spot malignant melanoma


A Assymetric mole or lesion
B Irregular borders.
C irregular colors: light brown to dark brown, black,
red, blue or white
D diameter: > 5 mm in diameter
E Elevation of a mole or lesion m
Prognosis
Lesions of extremities > melanomas of head, neck
or trunk
Lesion ulceration worse prognosis
Gender: female > male
Nodular melanomas = superficial spreading
Lentigo maligna better prognosis
Acral lentiginous lesions worse prognosis
Staging System
AJCC TNM, best method
Clark anatomic depth of invasion
o Level I superficial to basement membrane
o LevelI papillary dermis
o Level III papillary/reticular dermaljunction
o Level IV reticular dermis
o Level V subcutaneous fat
Breslow thickness vertical thicknessof 1otumor
o I 0.75mm or less
o II 0.76 to 1.5 mm
o III 1.51to 4.0 mm
o IV 4.0 mm ormore
Diagnosis of Melanoma Excisional Biopsy
1o wound closure 1 mm margin of normal skin

Removal creates too large defect Incisional


Biopsy

Surgical excision management of choice


Lesions <1mm or less thick 1 cm margin
Lesions 1 mm to 4 mm thick 2 cm margin
Lesions > 4 mm 3 cm margin
Sentinel Lymph Node Determination
Sentinel Lymphadenectomy sentinel node may
be preoperativelylocated using gamma
camera,which identifies the radioisotope injected
into the primary lesion
Intraoperative mapping with 1% isosulfan blue
dye injection
Micrometastasis Complete Lymph Node Dissection
Regional Nodal Dissection
Groin LN deep (iliac) nodes superficial inguinal
nodes
Axillary dissections nodes medialto pectoralis
minor muscle
Lesions on face, anterior scalp& ear superficial
parotidectomy- parotid nodes modified neck
dissection
Solitary lesions in the brain, GIT or skin that are
symptomatic excision

Hyperthermic regional perfusion with a


chemotherapeutic agent (Melphalan)
TNF or IFN- with melphalan

Investigational Adjuvant Therapies


Radiation therapy
Regional & systemic chemotherapy
immunotherapy
Vaccines
Gangliosides

IFN -2b only FDA approved adjuvant treatment


for AJCC stages IIB/III melanoma

ADDITIONAL MALIGNANCIES OF THE


SKIN
MERKEL CELL CARCINOMA
Primary Neuroendocrine Carcinoma of the Skin
Aggressive in nature, high local recurrence
Treatment: Wide local resection with 3 cm margin
o Prophylactic regional lymph node dissection
o Adjuvant radiation therapy

KAPOSIS SARCOMA rubbery bluish nodules that


occur primarily on the extremities but may occur
anywhere on the skin & viscera
Histological Findings: capillaries lined by atypical
endothelial cells
o Early lesions: Resemble hemangiomas
o Older lesion: Resemble sarcomas (more spindle
cells)
Locally aggressive but undergo remission periods
AIDS related KS male homosexuals
o Rapid spread to lymph nodes GI &
respiratory tract
Treatment
o Radiation
o Combination chemotherapy
o Surgery bowel obstruction or airway
compromise
EXTRAMAMMARY PAGETS DISEASE
cutaneous lesion that appears as pruritic red patch that
does not resolve
Biopsy: Paget cells
ANGIOSARCOMA bruise that spontaneously bleeds
or enlarges without trauma
Common sites: Scalp, face & neck
Risk Factors
o radiation therapy,
o chronic lymphedema of arm
Histological Findings: anaplastic endothelialcells
surrounding vascular channels
Poor prognosis
Treatment
o Total excision
o Chemotherapy & Radiation therapy palliation
DERMATOFIBROSARCOMA PROTUBERANS
Most frequent in persons aged 20 to50 years &
males
Common site: trunk, proximal extremities, head &
neck
Pink nodular lesion that may ulcerate & become
infected
Histological Findings: atypical spindle cells,
probably fibroblasts origin, located around
corecollagen tissue
High recurrence rates
Radiosensitive
Treatment
o 3D margin of 2 to 3 cm with resection of
skin,subcutaneous tissue & underlying investing
fascia
o Resection of periosteum & portion of bone

o
o

Radiation therapy
Imatinib(?)

FIBROSARCOMA hard, irregular masses found in


the subcutaneous fat
Histologic findings: fibroblasts appear markedly
anaplastic with disorganized growth
Treatment: Complete excision
LIPOSARCOMA arise in deep muscle planes, rarely
from subcutaneous tissue
Common site: thigh
Treatment: wide excision
o Radiation therapy

SYNDROMIC SKIN MALIGNANCIES

Other prognostic factors:


- number of positive lymph nodes
- anatomic location
- ulceration
- sex
- histologic type
Treatment:
- primarily surgical
- radiation
- regional and systemic chemotherapy
- immunotherapy
SOFT TISSUE SARCOMAS
Rare
1% of adult cancers
15% of pediatric cancers
Sites: 43% extremities (2/3 lower limb)
19% visceral
15% retroperitoneal
10% trunk/ thoracic
13% other sites
Genetic syndromes:
neurofibromatosis
familial adenomatous polyposis
Li-Fraumeni syndrome
Ionizing radiation
Lymphedema
Trauma?
Chemical carcinogens?
Genetic alterations:
KIT mutations GIST
APC/-catenin mutations desmoid tumors
Most common:
Liposarcoma
Malignant fibrous histiocytoma
Leiomyosarcoma
Histopathology is dependent on anatomic site:
extremity - liposarcoma, MFH
retroperitoneal intra-abdominal - liposarcoma
- leiomyosarcoma
visceral GIST, leiomyosarcoma
Histopathology is dependent on age:

Embryonal rhabdomyosarcoma childhood


Synovial sarcoma young adults (<35 years)
Liposarcoma, MFH older population
Extremity sarcoma - painless mass (33% have pain)
Any enlarging soft tissue mass in an adult
Any mass >5 cm
Any mass > 4 weeks
Perform an INCISIONAL or CORE BIOPSY
Small cutaneous o subcutaneous lesions (<3cm)
excisional biopsy
Intra-abdominal/ Retroperitoneal sarcomas
abdominal discomfort
non specific gastrointestinal symptoms
CT scan/ MRI of the abdomen
Abdominal lymphoma needle biopsy
Exploratory laparotomy
Metastases: extremity LUNG
visceral - LIVER
STAGING: TNM - histologic grading
Extremity - if possible, function- and limb-sparing
procedures
Objective: complete removal of tumor
negative margins (1-2 cm of normal tissue)
maximal preservation of function
5 cm, low-grade, subcutaneous/intramuscular
- surgery alone with 1-2 cm cuff
Margin? adjuvant radiation (MFH)
Neoadjuvant therapy (doxorubicin/Adriamycin and
ifosfamide)
Ewings sarcoma
rhabdomyosarcoma
Retroperitoneal and Visceral Sarcoma
abdominal mass obstruction
GI bleeding neurologic symptoms
CT scan
Surgery completeness of resection
histologic grade
Recurrent disease
Metastatic disease palliative treatment
GIST - imatinib

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