Management of Cutaneous Malignancies

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Management of Cutaneous Malignancies
Safest is best

• Rex Moulton-Barrett, MD
• Plastic and Reconstructive Surgery,
  Otolaryngology Head Neck Surgery
• 4th Floor, Doctors Offices Alameda Hospital
• 1280 Central Blvd, Suite J-5, Brentwood

Wait and see
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The 8 Aspects of Plastic Surgery

• Congenital clefts, nevi, vascular tumors
• ear reconstruction, hand
  anomalies
• Hand nerve compression, tumors/soft tissue,
  trauma
• Burn Reconstruction
• General Reconstruction truck, abdomen, lower
  limb
• Breast reduction, reconstruction
• Cosmetic
• Head and Neck resection and reconstructive
  surgery
• Skin cancer excision and reconstruction

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Tumors In Question

• Basal Cell
• Squamous Cell
• Melanoma
• The differential diagnosis non-pigmented benign
• 
  pigmented benign
• non-pigmented pre-malignant
• pigmented pre-malignant
• 
  soft tissue tumors
• 
  metastatic lesions

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Skin Cancer

• Basal (75) gt Squamous (25) gt melanoma
• except organ transplant opposite ratio
• SCCA 20-65 times more common
• 50 with basal or squamous will develop the other
  in 5 years
• Intense gt prolonged sun exposure UVBgtA, SPF 15,
  lt 20 yrs age
• Genetic predisposition more pigment is protective

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Common Non-pigmented Benign Lesions

• Seborrheic Keratoses
• Syringomas
• Xantheloma Palpebrum
• Premalignant Actinic Keratoses

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Common non-pigmented benign lesions

• Syringomas peri-ocular , small, fleshy and
  nodular

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Common non-pigmented benign lesions

• Xantheloma Palpebrum periocular, drop like
  semi-cheezy
• 
  rarely associated with hyperlipidaemia
• ie planar xanthomatadysbetalipoproteinemia
• or hypercholesterolemia

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Common non-pigmented benign lesions

• Trichoepitheliomas periocular, drop like

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Common non-pigmented benign lesions

• Milia periocular, drop like semi-cheezy

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Common non-pigmented Benign/pre-malignant lesions

• Actinic Keratoses 20 SCCA, dry, crusty
• really pre-malignant

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Pigmented Benign Lesions

• Blue Nevus
• Pigmented Seborrheic Keratosis
• Giant Nevus

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Pigmented benign lesions

• Blue Nevus intradermal and subcutaneous
• not pre-malignant

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Pigmented benign lesions

• Pigmented Seborrheic Keratosis waxy, soft
• 
  can rub off a little

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Non-Pigmented Pre-malignant Lesions

• Bowens Disease red scaly patch of
• Squamous Cell
  Carcinoma in situ

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Pigmented Benign Pre-malignant Lesions

• Giant Nevus 1-2 population
• Risk of developing melanoma related to size
• gt 20cm diameter adult
• gt 2 palm size / body 5-20 by 10, peak
  at 3-5 yrs
• gt 1 palm size / face 5-20 by 10, peak
  at 3-5 yrs

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Role for topical anti-mitotic agents

• 5-fluorouracil
• imiquimod 5 cream ( Aldara )
• aminolevulinic acid photodynamic therapy

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Role for topical anti-mitotic agents

• 0.5 5-fluorouracil ( 5gram 100 )
• effective for actinic keratoses
• small in-situ lesions BCCA
• not for invasive small electrodesiccation/curett
  age
• or
  excision
• RNA analogue precursor progressive DNA
  labelling
• Contraindicated in pregnancy teratogenic VSDs

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Role for Topical anti-mitotic agents

• Imiquimod 5 cream ( Aldara
  )
• Immunomodulator activates
  monocytes,macrophages, Langerhans cells,
  T cell infiltrates, cytokines interferons,
  interlekins, TNF
• effective for actinic keratoses
• superficial basal cell
  carcinoma
• probably no role for squamous cell ca
• frequency related reactions are common
• 3 nights/ week for 6 weeks 73 clearance rate
• at 12 weeks higher
  clearance rates

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Actinic Cheilitis (AC)

• Smith et al, 2002 J AM Acad Dermatol
  47(4)497-501
• 15 pts with biopsy proven AC
• 3 x weekly for 4-6 weeks
• 4 weeks later all lesions cleared
• Specific Side effects continued in some cases
  throughout therapy
• pain, redness, swelling, ulceration

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Role for topical anti-mitotic agents

• Aminolevulinic acid photodynamic therapy
• Levulan Kerastick 20 solution
• 17 minute blue light exposures
• 69 failure for superficial SCCA at 8 months
• 44 failure for superficial BCCA at 8 months
• Fink-Puches, et al,
  1998
• Arch Dermatol 134,
  821-826.
• Category C unknown side-effects pregnancy or
  breast feeding
• Not if porphyria
• Not if taking oral hypoglycemic agents, sulpha,
  grseofulvin, phenothiazines,
  doxycycline, HCTZ diuretics

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Basal Cell Carcinoma incisional biopsy

• Basal Cell elliptical wedge is better than
  shave
• punch biopsies work well if adequate in width
  and depth
• preferably not from center

nodular
superficial
ulcerated
pigmented
morpheiform
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Basal cell carcinoma excisional biopsy

• 1 high power field under frozen section/ Mohs
  surgery
• 3-5 mm margin from the clinical edge rolled to
  flat

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Squamous cell Biopsy

• Squamous Cell elliptical wedge
• from periphery towards center better
  than shave
• 6-10 mm margin
  if excisional biopsy

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Excisional Biopsy

• Melanoma closest margin to remove the lesion,
  
• do not shave, or wedge
• may use punch if completely excise
• Sarcomas closest margin to remove the lesion
• Adnexal closest margin to remove the lesion
• Metastatic closest margin to remove the lesion

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Excisional Biopsy

• Melanoma closest margin to remove the
  lesion,
• do not shave, or wedge
• may use punch if completely excise

Superficial spreading
Lentigo maligna
nodular
amelanotic
subungal
Acral lentinous
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Management of Melanoma

• lt0.75 mm deep 1cm margin
• 0.75cm - 1.25mm deep 1cm margin ? sentinel
  node
• 1.25 mm-4mm deep 1-2cm margin sentinel node
  biopsy
• gt4mm deep 1cm margin and use of lymphadenectomy
  unproven

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S/P Shave of Melanoma

• 2 schools of thought
• Excisional biopsy and based on depth decide on
  size of margin using same
  parameters
• Excise based at least the depth of the shave
• ie 1-2 cm margin, when in doubt take larger
  margin

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Excisional Biopsy

• Kaposis Sarcomas closest margin to remove
• HIV with CD4 lt200/mm3

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Excisional Biopsy

• Adnexal/appendage ductal or non-ductal
• closest margin to remove

hamartoma
hidrocystoma
mixed tumor
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Excisional Biopsy

• Metastatic closest margin to remove the lesion

melanoma
breast
adenocarcinoma
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Mohs Surgery

• Microscopic margin is preferable to macroscopic
  margin
• ie face in the H zone
• reduced visible scar
• may reduce incidence of false negative
  margin
• Recurrent lesions depth and width defined prior
  to closure
• Availability of service

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Dangerous Problems

• Midline Lesions
• Intranasal glioma ( 15 CNS communication )
  or encephalocele ( 100 commun )
• Forehead dermoid( 15 crista galli
  communication), encephalocele
• gliomas
• ( not lateral brow dermoid- no communication )
• Back myelocele, meningomyelocele
• occiput and neck encephalocele
• 
  myelocele
• 
  meningomyocele

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Difficult Problems Problems

• Zygomatic Arch to Angle of the Mandible
• Parotid tumors
• Lymph nodes atypical TB inflammatory-ch
  ildren,
• metastatic node if gt 1.5cm adult
• Branchial Cleft Cysts
• ( lt 1-2 yrs congenital, gt2-15 yrs inflammatory,
  gt 15 yrs neoplastic )

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Difficult Problems

• Merkel Cell Tumors
• Subungal Pigmentation
• Sebaceous Adenoma

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Difficult Problems

• Merkel Cell Tumors biopsy if excisional will
  require later larger margin and possible lymph
  node dissection, may need metastatic work-up and
  tumor conference presentation

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Difficult Problems

• Subungal Pigmentation

Acquired melanocytic nevus
melanoma
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Difficult Problems

• Sebaceous Adenoma
• Warty lesion often in the scalp, can be salmon
  colored
• present at birth,
• hamartoma
• gt 10 yrs will form BCCA and 19 form
  syringocystadenoma

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Surgical Principles

• I. Have a plan H P, iodine allergy, tetanus
  toxoid, irrigation, instruments, suture and
  needle, define the defect, method of closure,
  drain, dressing, antibiotics, post-op wound care
  and when to remove sutures.
• II. Always have a lifeboat If closure does not
  work out have a second plan in mind, including
  placing a skin graft
• III. Acknowledge cosmetic units The face can be
  divided sub-units. Within each unit there are
  favorable skin tension lines ( with the pt. in
  the sitting position and animated ) which form at
  90 degrees to the mimetic muscles. Scars are
  less conspicuous if they lie parallel to these
  natural creases.
• IV. Control tension Place all the tension below
  the epidermis or in the fascia. The majority of
  the blood supply is in the subdermal plexus ( SDP
  ) superficial to the subcutaneous fat. Undermine
  to distribute the tension over a wider area.

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Clinical Examples

• A. 5mm chronic ulcer of the hand in a
  wrinkled 90 yr man
• a. important history
• duration, bleeding, numbness, other medical
  problems, medications, pacemaker, adenopathy,
  associated skin lesions
• b. important physical characteristics
• wipe lesion and look at shape ulcer with
  irregular border,
• little pigmentation
• c. type of biopsy
• punch or wedge using lidocaine with
  epinephrine.
• single suture for hemostatis.
• d. definitive management
• path SQ cell ca. If margin clear 6mm ellipse
  transversely
• ( using 3 to 1 rule length to width excision )
  with local
• and tag margin for orientation.
• If final pathology margin positive or close ( lt
  5MM ) re-excise in OR with frozen section.

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B. 3mm pigmented lesion on the lateral
neck of a 33 yr old male
Caucasian computer programmer

• a. important history
• duration, bleeding, numbness, other
  medical problems, medications, pacemaker
• b. important physical characteristics of lesion
  to make the diagnosis
• adenopathy, associated skin lesions, shape,
  elevation, border, pigmentation and
  texture irregular
  border, irregular pigmentation, not raised and
  smooth
• c. type of biopsy
• excise using 4mm punch full thickness into
  subcutaneous fat or elliptical excision
• (using 3 to 1 rule ) with lidocaine
  with epinephrine.
• 3 sutures for closure.
• d. definitive management
• path Malignant Melanoma depth 0.72 mm no
  evidence of intra-vascular invasion.
• ellipse 1cm margin favorable skin tension
  lines.
• check final pathology to confirm clear of
  tumor.
• present in tumor board.

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C. 3cm chronic elevated lesion on the
cheek of a 55 yr old lady

• a. important history
• duration, bleeding, numbness, medical problems,
  medications, pacemaker
• b. important physical characteristics of lesion
  to make the diagnosis
• adenopathy, associated skin lesions, wipe
  lesion, look at shape, ulcer with irregular
  border, little pigmentation
• c. type of biopsy
• biopsy punch or wedge using lidocaine with
  epinephrine. Do not use silver nitrate on face,
  use battery cautery, hyfercator or a single
  suture for hemostatis
• d. definitive management in operating room with
  frozen section
• path basal cell ca. Take gt3mm margin
• and close wound along favorable tension lines
  with a local flap