DERM—-DANIEL TODD, MD

EXANTHEMS/SKIN CA

RASHES

EXANTHEM = A CUTANEOUS ERUPTION(RASH)

ENANTHEM = A MUCOSAL ERUPTION

ERYTHISM=EXCESSIVE SENSITIVITY TO STIMULATION AND HIGH LOCAL REACTIVITY

ERYTHRASMA=CHRONIC SKIN INFXN IN MAJOR SKIN FOLDS (CORYNEBACTERIUM MINUTISSIMUM)

AN EPITHELIAL MANIFESTATION OF AN INFXOUS Dz

USUALLY AN IMMUNOLOGIC PHENOM TO A VIRAL OR BACTERIAL AG

DERMATITIS (LATIN) = EXCZEMA (GREEK)

FIRST Dz = MEASELS = RUBEOLLA = MORBILLI

DUE TO A PARAMYXOVIRUS

SPREAD BY RESP DROPLETS

10 DAY INCUBATION

PRIMARY VIREMIA

PRODROME OF FEVER, CORYZA, CONJUNCTIVITIS

3-5 DAYS–SECONDARY VIREMIA

KOPLIK SPOTS (ENANTHEM) = PATHOGNEUMONIC

MORBILLIFORM RASH—CELL MEDIATED IMMUNE RXN—COMMENCING ON FACE AND SPREADING DOWN

ALSO RESOLVES HEAD DOWN

MICRO: WARTHIN FINKELDAY GIANT CELLS

COMPLICATIONS: GIANT CELL BRONCHOPNEUMONIA, (SSPE)ENCEPHALOMYELITIS, O.M., ATYPICAL MEASELS

SECOND Dz = SCARLET FEVER

FOLLOWS GABHS INFXN BY 3-5 DAYS

FLUSHED FACE

CIRCUMORAL PALLOR

PASTIAS LINES (INCREASED ERYTHEMA IN ANTECUBITAL FLEXOR CREASES)

WHITE STRAWBERRY TONGUE

BRANNY FINE SAND PAPER RASH—-LATER DESQUAMATES

HIGH ASO AND DNASE B TITERS

Rx PCN TO AVOID RARE GABHS SEQUELAE (PSGN/RHEUMATIC HEART Dz)

THIRD Dz = RUBELLA (GERMAN MEASELS)

TOGAVIRUS

INCUBATION = 18 DAYS

NO PRODROME IN CHILDREN

LASTS 3 DAYS

URT Sx

DISCRETE GENERALIZED MACULOPAPULAR RASH

CONG. RUBELLA (CLASSICALLY CALLED THE MOST COMMON CAUSE OF AQUIRED SNHL—-PROBABLY SECOND TO CMV)

SCHEIBES APLASIA ASSOC.

PATENT DUCTUS ARTERIOSUS

CONG CATARACT/MICROPHTHALMIA/RETINITIS

AGENESIS OF THE ORGAN OF CORTI—SNHL

JAUNDICE

FOURTH Dz = DUKE’S Dz

SCARLITINOFORM RUBELLA

NO LONGER USED

FIFTH Dz = ERYTHEMA INFECTIOSUM (SLAPPED CHEEK Dz)

PARVOVIRUS B-19

USUALLY AGE 4-15

NO PRODROME

IMMUNE MEDIATED FEVER

SLAPPED FACE RASH

MACULOPAPULAR TRUNCAL RASH–SPREADS TO EXTREMITIES—FADES CENTRALLY

POSSOBLE LYTIC APLASTIC CRISIS—HIGHER IN SSA PTS

PERSISTENT INFXN-ANEMIA IN IMMUNOCOMPROMISED HOST

POSSIBLE HYDROPS FETALIS

SIXTH Dz = ROSEOLA SUBITUM = EXANTHEM SUBITUM

HSV 6

 

PRIMARILY IN INFANTS

ABRUPT HIGH FEVER (103-106)

3-4 DAYS THEN

MACULO-PAPULAR RASH (PRIMARILY ON TORSO)

DESQUAMATES AS FEVER ABATES

KAWASAKI (MUCOCUTANEOUS LYMPH NODE) SYNDROME—-1974

PRESUMED INFECTIOUS/TRANSMISSABLE BASED ON EPIDEMIOLOGY

ASIANS AND BLACKS MORE SUSCEPTIBLE

PREUSMED TO BE AN IMMUNOLOGIC RXN TO AN INFXOUS AGENT WHICH EVOKES AN AUTOIMMUNE RESPONSE

SINE QUA NON = ACUTE FEBRILE PHASE LASTING > 5 D (7-10)

CONJUNCTIVITIS, MUSOSAL INJECTION, STRAWBERRY TONGUE

ERYTHEMATOUS DRY FISSURED LIPS

EXTREMITY SWELLING AND ERYTHEMA–REFUSAL TO WALK= MOST SPECIFIC FINDING

RASH

CERVICAL LAD

PROLONGED COURSE CAN LEAD TO CADz

HIGH WBC, ESR, IgE, AND PLTS(THROMBOCYTOSIS)

Rx: ASA 80MG/KG/DAY AND IgG 400MG/KG/DAY

STEROIDS ARE CONTRAINDICATED

SYPHILIS

Secondary Stage: “Mucocutaneous Sx”

Extremely contagious, rash, LAD, loss of eyelashes and alopecia. Constitutional Sx. Snail Track Ulcers in the OP. “RULE OF 1/3RDS”— 1/3 RESOLVE, 1/3 Indefinite Latency, 1/3 Progress to Tertiary Syphilis.

VARICELLA (CHICKEN POX)

2 WK INCUBATION

MILD PRODROME

MUCOSAL ENANTHEM

PRURITIC TEARDROP VESCICULAR RASH IN ASYNCHRONOUS CROPS

CAN EVENTUALLY LEAD TO HERPES ZOSTER—RAMSEY HUNT—SHINGLES

IS ALWAYS DERMATOMAL IN DISTRIBUTION

RMSF

PETICHIAL RAXH ON WRISTS AND ANKLES

ROSE COLORED BLANCHING MACULES ON HANDS AND FEET, WRISTS AND ANKLES

Rx: CHLORAMPHENICOL TO KIDS/ TETRACYCLINE TO ADULTS

HERPANGINA

COX A 1-6,8,10

FEVER, ULCERATIVE PHARYNGITIS—PRIMARILY ON ANT PILLARS

HERPES SIMPLEX CUTANEOUS ERUPTIONS (HSV I AND II)–VESCICULAR

COMMON TO GET HERPETIC GINGIVOSTOMATITIS

HAND FOOT AND MOUTH Dz

BUCCAL ENANTHEMS

COX A16, A5, A10—EV71

INC 3-7 DAYS

ULCERATE AND HEAL 7-10 DAYS

ERYTHEMA NODOSUM

PRODROMAL F/C, MYALGIAS,

TENDER, NODULAR, CIRCUMSCRIBED, ERYTHEMATOUS SKIN LESIONS PRIMARILY ANT LEGSBELOW THE KNEES,ALSO EXTENSOR ARMS, ANDFACE—1-4 CM-RESEMBLE ECCYMOSIS

MULT ETIOLOGIES: SARCOID, TB, STREP, YERSINIA, INFLAMMATORY BOWEL Dz, ORAL CONTRACEPTIVES

ERYTHEMA CHRONICUM MIGANS

STAGE I LYME DISEASE (RED SPREADING RING LESION WITH FLU LIKE SYMPTOMS)

RING WORM/TINEA CORPORIS

TOPICAL ANTIFUNGAL ALONG WITH AN ANTI PRURITIC USUALLY CURATIVE

MENINGOCOCCUS

 

WATERHOUSE-FREIDRICHSON SYNDROME

ERYTHEMA TOXICUM(URTICARIA NEONATORUM)

ANTIBIOTIC RASHES

7% AFTER AMINO-PCN (50% WITH ASSOC. EBV)

5% SULFA

2% PCN

1-2% CEPHALOSPORIN

USUALLY ABOUT 3 DAYS AFTER ONSET OF DRUG

MORBILLIFORM, ERYTHEMATOUS, PAPULAR, SYMMETRIC RASH PRIMARILY TRUNCAL ON TORSO

URTICARIA = IGE

RASH = IGG

ERYTHEMA MULTIFORME = COMMON FINAL PATHWAY

CIRCULAR BLOTCHES ON SKIN AND MUCOUS MEMBRANES

IRIS OR TARGET LESIONS

FIXED DRUG RXN—–THINK SULFA

STEVENS JOHNSON SYNDROME—-WHEN ERYTHEMA MULTIFORME GETS AWAY FROM YOU

EMERGENCY

STOP OR TREAT THE ETIOLOGY—-DRUGS, HERPES, MYCOPLASMA, STREP

STEROIDS?—-CAN EASILY BLIND THE PATIENT

CLOX (ANTI STAPH)–TO TREAT SECONDARY SKIN INFXNS

HIVES = NETTLE RASH = URTICARIA (70% IDIOPATHIC)

> 6 WEEKS = CHRONIC URTICARIA

A SUPERFICIAL DERMIS PHENOM (VS QUINKES ANGIOEDEMA = DEEP DERMAL)

ZYRTEC AND ZANTEC WORK WELL

NEED TO BE OFF ZYRTEC ONLY 5 DAYS FOR SKIN TESTING WHERE AS HISMANAL CAN TAKE 6 WEEKS

PITYRIASIS ROSEA—”ROSE COLORED SCALE”

BEGINS AS A HERALD PATCH 1-10 CM IN DIAMETER

LATER DEV “CHRISTMAS TREE” LIKE LESION USUALLY ON BACK

REMAINS IDIOPATHIC HOWEVER–VIRAL AGENT SUSPECTED

ROSACEA—–”REDNESS”—–CAN LEAD TO PERMANENT CHANGES—ACNE ROSACEA—-TELANGIECTASIA AND—-RHYNOPHYMIA

RHINOPHYMA “POTATO NOSE”

A BENIGN OVERGROWTH OF THE SEBCEOUS GLANDS OF THE NOSE

THE END STAGE OF ACNE ROSECEA—CHRONIC HYPERPLASTIC RESPONSE TO DERMODEX FOLLICULORUM COLONATION/ INFXN

USUALLY WHITE MEN (MEN 3:1)—-MEAN AGE 50

PRIMARILY AFFECTS INF HALF OF NOSE

ETOH—CHRONIC VASODILATION OF THE SKIN

REMOVE VIA DERMABRASION, LASER OR HOT KNIFE—-WILL RE-EPITHELIALIZE WITHOUT A GRAFT IN ABOUT 6 WEEKS

MAY TRY TOPICAL ABX (METROGEL/METROCREAM 0.75% BID FOR A LONG TIME)—SUNSCREEN AND MOISTURIZERS AND BLEACHING AGENTS

MISC.

LIPOMA = MOST COMMON S.Q. TUMOR

NEVUS = EPIDERMAL, JUNCTIONAL, COMPOUND, DERMAL

HAIR ON A NEVUS HAS NO PROGNOSTIC VALUE

S.K. =NOT PREMALIGNANT—-WAXY—”PEEL OFF”, –OILY, RAISED, “CAN PICK IT OFF”–CAN HAVE A CUTANEOUS HORN

TAN, DISCRETE, RAISED, RUGOSE, CEREBRIFORM

SQUARED SHOULDERS, STUCK ON APPEARANCE, WELL DEMARKATED BORDERS

SUPERFICIAL—NON-INVASIVE

HIGHEST CONCENTRATION ON BACK AND SHOULDERS

IS MOST COMMON SKIN TUMOR OF OLDER PATIENTS—USUALLY BEGIN IN 4TH DECADE

NO MALIGANT POTENTIAL

 

AK = MOST COMMON PREMALIGNANT CONDITION=SOLAR/SENILE KERATOSIS—-RELATED TO SUN EXPOSURE

YELLOW, BROWN, GREY, OR BLACK

VERY COMMON (> 50% OF PEOPLE WITH SUN EXPOSURE)

60% OF CUTANEOUS SCCA ARISE IN AK’S

5-20% OF THESE CAN TRANSFORM INTO SCCA IF LEFT UNTREATED

SCALEY WELL CIRCUMSCRIBED “SAND PAPER” LESION

KERATIN CORE/CUTANEOUS HORN CAN BE RELATED TO ANY PROCESS

Rx: FREEZE , EXCISION, OR SHAVE BIOPSY AND 5-FU (EFUDEX)

CIS = BOWEN’S Dz = BOWENOID KERATOSIS–INTRADERMAL SCCA THAT SPREADS ALONG THE EPIDERMAL PLANE–30% DEVELOPE INVASIVE SCCA

MARJOLIN’S ULCER = SCCA IN A BURN SITE

KA = KERATOACANTHOMA (PSEUDOMALIGNANCY)- -RAPID GROWTREACH FULL SIZE IN 2 MONTHS, THEN INVOLUTE IN 2-6 MONTHS – KERATIN CORE (SK CAN HAVE A KERATIN CORE)

MALE>FEMALE

USUALLY CALLED WELL DIFF SCCA—CAN BE CONSIDERED A LOW GRADE MALIGNANCY

Rx : EXCISION WITH CLEAR MARGINS

BENIGN LENTIGO = LIVER SPOTS = MELANOCYTIC HYPERPLASIA “OLD AGE SPOTS”—-80% ON SCALP

TELANGIECTASIA = BENIGN DERMAL ANGIOPLASIA

NEVUS SEBACEUS OF JADASSOHN

CONG LESION LOCATED ON THE FACE OR SCALP—-APPROX 15% WILL DEV A BCCA

PROPHYLACTIC EXCISION IS RECOMMENDED

SKIN CANCER

70-80% BCCA (4MM MARGINS)

20% SCCA (1 CM MARGINS)——–IF NOT SURE MIGH BE OK TO DO 5-8MM MARGINS

3% MELANOMA (2 CM MARGINS-ONLY DO EXCISIONAL BIOPSY FOR Dx)

7-10% OTHERS

DIVORCE THE EXCISION FROM THE RECONSTRUCION–DRAW IT FIRST—-CIRCULAR EXCISION WITH MARGINS–CUT ON THE VERY OUTSIDE EDGE OF THE MARKINGS–”LAST AST OF AGGRESSION”—MARK THE SPECIMEN ACCURATELY(ONLAT SPECIMEN)—DO NOT PLACE SUTURE THROUGH MARGIN— TO SEND TO PATH–MAY WANT TO TO TAKE A DEEP MARGIN–MARK THEM VERY ACCURATELY—–THEN LATER CONSIDER THE RECONSTRUCTION—ELLIPSE 3:1

BCCA AND SCCA STAGING:

T1 < 2 CM

T2 = 2-5 CM

T3 > 5 CM

T4 INVADING DEEP EXTRADERMAL STRUCTURES (CARTILAGE, MUSCLE, BONE)

N0 NO REGIONAL METS

N1 REGIONAL LYMPH NODE MET

BCCA

PRIMARY SKIN CA (60-80%)

86% OF THEM HAPPEN IN THE H&N—RELATED TO SUN EXPOSURE

60% OF ALL H & N CANCER

RARELY METASTATIC

BEHAVE MORE AGGRESSIVELY ONCE IT HITS BONE OR CARTILAGE

4 BASIC HISTOLOGIC PATTERNS: SOLID, KERATOTIC, CYSTIC, ADENOID

CELLULAR CLEFTING ON H & E IS PATHOGNEUMONIC

2-3MM MARGINS ADEQUATE

< 1% METASTASIZE

SUBTYPES (CAN FIND ALMOST 30)

NODULAR (NODULO-ULCERATIVE)

MOST COMMON

MOST INDOLENT

DISCRETE

RAISED

“RODENT ULCER”

 

ROLLED “HEAPED UP” BORDER

PINKISH

PEARRLY

WAXY

TELANGIECTATIC

SMOOTH

CENTRAL DEPRESSED ULCERATION

SUPERFICIAL MULTICENTRIC BCCA

RESEMBLING PATCHES OF ECZEMA, TINEA, OR PSORIASIS

INSIDIOUS THIN THREADY BORDER

MORE COMMON ON TRUNK AND EXTREMITIES

MORPHEAFORM (MORPHEIC)

MOST DANGEROUS FORM

ALMOST EXCLUSIVELY ON FACE

FEMALE>MALE

ILL DEFINED MARGINS

LOOKS LIKE SCAR

INSIDIOUS-DIFFICULT TO EXCISE

CYSTIC NODULAR, FIBROEPITHELIOMATOUS, ADENOID CYSTIC, PIGMENTED BCCA

BASOSQUAMOUS CELL CARCIMOMA = METATYPICAL CA OF THE SKIN

MAY BE AN AGGRESSIVE BCCA WITH A SQUAMOUS LIKE DESMOPLASTIC RESPONSE

Rx: CURRETTAGE EXCISION WITH ELECTRO SURGERY FOR LESIONS <2CM

EXCISIONAL BIOPSY WITH 2-4MM MARGINS

TOPICAL 5 FU

MOHS

CRYOSURGERY

BASAL CELL NEVUS SYNDROME=NEVOID BCCA SYNDROME

GORLIN’S SYNDROME

AUTO D

AFFECTS PTS AT A YOUNG AGE(PUBERTY-30’S)

CUTANEOUS:

MULTIPLE BCCA(FEW TO THOUSANDS)-NEED EVAL Q 3 MONTHS

NEVOID PHASE(CHILDHOOD)–NEOPLASTIC PHASE(ADULTHOOD)

PALMAR AND PLANTAR KERATOTIC PITTING(65%)

MULT. MILIA(SMALL EPIDERMAL INCLUSION CYSTS) AND DERMAL CALCINOSIS

SKELETAL:

MULTIPLE OKC’S-+KERATIN FORMATION (Rx: COMPLETE EXCISION)

HIGH RECURRENCE RATE 10-60%

RADIOGRAPHICALLY UNILOCULAR/WELL CIRCUMSCRIBED WITH THIN RADIO-OPAQUE BORDERS

MAXILLA>MANDIBLE

BIFID RIBS AND OTHER RIB ABNL’S

PROGNATHISM

HYPERTELORISM/TELECANTHUS

FRONTAL BOSSING

SCOLIOSIS

SHORT 4TH METACARPAL(LIKE TURNER’S)

NEURO:

CALCIFICATION OF FALX CEREBRI(85%)

+MEDULLOBLASTOMA

DYSGENESIS OF CORPUS CALLOSUM

MR

SCCA

20% OF ALL SKIN CA

95% IN THE H & N —-RELATED TO SUN EXPOSURE

ETIOLOGY—RADIATION, IMMUNOSUPPRESION (RENAL FAILURE), HPV, CHEMICAL, AGING

MICROSCOPIC VARIATION—SOLAR KERATOSIS, ACANTHOLYTIC DYSKERATOTIC CELLS, DE NOVO SCCA, SPINDLE CELL CA

METASTATIC RATE OF 2% ASSOC WITH LARGE TUMOR SIZE, UNDIFFERENTIATED HISTOLOGY, AND LOCATION ON HAND, LIP OR EAR

POOR Px:

.>6MM DEPTH, >2 CM DIAMETER

POOR GRADE, IMMUNOCOMP. HOST(RENAL FAILURE)

SITE – EAR, TEMPLE, LIP, DORSUM OF HAND, SCALP

PERNEURAL INVASION

 

RAPIDITY OF GROWTH

SUBTYPES DE NOVO AND SPINDLE CELL CA

KETATIN PEARLS, INTERCELLULAR BRIDGES ON H & E

KERATIN CORE/CUTANEOUS HORN CAN BE RELATED TO ANY PROCESS

CIS = BOWEN’S Dz = BOWENOID KERATOSIS-BOWENOID PAPULOSIS—INTRADERMAL SCCA THAT SPREADS ALONG THE EPIDERMAL PLANE–30% DEVELOPE INVASIVE SCCA—-CALLED ERYTHROPLASIA OF QUEYRAT IF IT INVOLVES THE MUCOUS MEMBRANES

MARJOLIN’S ULCER = BURNS

KA = KERATOACANTHOMA (PSEUDOMALIGNANCY)–RAPID GROWTREACH FOLL SIZE IN 2 MONTHS, THEN INVOLUTE IN 2-6 MONTHS – KERATIN CORE (SK CAN HAVE A KERATIN CORE)

MALE>FEMALE

USUALLY CALLED WELL DIFF SCCA—PROBABLY BEST TO TREAT LIKE SCCA

BASOSQUAMOUS CELL CARCIMOMA = METATYPICAL CA OF THE SKIN

MAY BE AN AGGRESSIVE BCCA WITH A SQUAMOUS LIKE DESMOPLASTIC RESPONSE

XERODERMA PIGMENTOSA–AUTO R–INABILITY TO REPAIR

MELANOMA (OF SKIN AND MUCOUS MEMBRANES)

1% OF ALL CA, 12.5/100,00,—–15% OF IT IS IN THE H & N

SEEMS TO BE MORE AGGRESSIVE IN THE H&N

3-5% OF ALL CUTANEOUS MALIGNANCY

65-75% OF ALL CUTANEOUS MALIGNANCY DEATHS

PRIMARILY A Dz OF CAUCASIONS

MALES OFTEN TRUNCAL Dz

FEMALES OFTEN LOWER EXTREMITY Dz

JAPANESE OFTEN O.C. MELANOSIS THEN O.C. MELANOMA

BLACKS OFTEN ACRAL LENTIGINOUS MELANOMA (PALMS, SOLES, AND SUB-UNGUAL LESIONS–BAD Px)

RISK FACTORS:FAIR SKIN, EPISODIC SEVERE SUN EXPOSURE, DYSPLASTIC NEVI, FHx, XERODERMA PIGMENTOSA-7%, IMMUNO-SUPPRESSION, AGE, PRE-EXISTING MOLES (THE SOURCE IN >70%)

CONGENITAL GIANT NEVI (>20 CM IN GREATEST DIAMETER)= 6-12% RISK OF LIFETIME MELANOMA

POOR PROGNOSTIC INDICATORS: BRESLOW’S LEVEL(DEPTH IN MM)=PRIMARY INDICATOR, ULCERATION = SECOND MOST COMMON INDICATOR, CLARKS LEVEL(TISSUE PLANE)–CLARK’S LEVEL I = IN SITU (LENTIGO MALIGNA)—LEVEL V = INTO S.Q. TISSUE, MALE GENDER, BANS(BACK, ARMS, NECK, SCALP), HIGH ANTI-MELANOMA AND ANTI-TYROSINASE LEVELS, NODULAR SUBTYPE, , SHAVE OR INCISIONAL BIOPSY

FELT TO BE IMMUNE MEDIATED TO SOME EXTENT—-SPONT. REGRESSION, ASSOC. LARGE IMMUNE CELL INFILTRATES, VITILIGO APPEARS WITH ANTI MELANOTIC RESPONSES, SERA FROM PATIENTS WITH MELANOMA CONTAINS MELANOMA BINDING ANTIBODY, AUTOLOGOUS MELANOMA SPECIFIC LYMPHOCYTE T-CELLS, PT RESPONSE TO IL-2 AND INF, IMMUNE RESPONSES ARE DEMONSTRATABLE IN VITRO

STAGE I = LOCAL

STAGE II = REGIONAL

STAGE III = DISTANT

Tx, T0 = CIS = LENTIGO MALIGNA, MELANOMA IN SITU, HUTCHINSON’S FRECKEL, CLARK LEVEL I—->99% SURVIVAL

T1 = CLARK LEVEL II = BASAL CELL LAYER OF EPIDERMIS/PAPILLARY DERMIS, < 0.75 MM BRESLOWS LEVEL—-80% SURVIVIAL

T2 = CLARK LEVEL III = SUPERFICIAL RETICULAR DERMIS, O.76 – 1.5 MM BRESLOWS LEVEL—-50% SURVIVAL(15-20% INCIDENCE OF REGIONAL METS)

T3 = CLARK LEVEL IV = DEEP RETICULAR DERMIS = 1.51 – 4.0 MM BRESLOWS LEVEL—-30% SURVIVAL

T4 = CLARK LEVEL V = S.Q. TISSUE, OR SATALLITOSIS WITHIN 2 CM, > 4.0 MM IN DEPTH

NO

N1 = < 5 CM, SATALLITOSIS > 2 CM AWAY

TEND TO MET TO LUNG, BONE, LIVER, SKIN, AND HEART

SPECIAL STAINS = S-100, HMB-45 (ALSO GOOD FOR PYCOMYCETES(MUCOR)), +/- VIMENTIN

SUBTYPES:

50-70% -SUPERFICIAL SPREADING: PRIMARILY ON LOWER EXTREMITIES—- PAGETOID EPIDERMAL SPREADING

25-30%- NODULAR: PRIMARILY ON TRUNK(MOST AGRESSIVE)-BLUE AND BLACK NODULE WITH NL APPEARING SKIN

5-15% -LENTIGO MALIGNA(MELANOMA IN SITU- HUTCHINSON’S FRECKLE-CLARKS LEVEL I)-(PRIMARILY OLDER PTS(MOSTLY ON HEAD AND NECK-90%)

 

5%- ACRAL LENTIGINOUS MELANOMA-PALMS AND SOLES(SUBUNGUAL) OF BLACK PTS

2%- AMELANOTIC MELANOMA AND OTHER UNCLASSIFIED

EXCISION MARGINS:

CONTROVERSIAL

1977 BRESLOW—2 CM FOR LESIONS < 0.76mm

1983 AITKEN—-3 CM FOR LESIONS > 0.76mm

1984 KELLY—1 CM FOR LESIONS <1mm, 3 CM FOR OTHERS

1985 URIST—–1-2 CM FOR LESIONS <1mm, 2-3 CM FOR OTHERS

1990 HO—-1 CM FOR LESIONS < 1mm, 1.5 CM FOR LESIONS 1.0-1.5mm, 3 CM FOR GREATER THAN 1.5mm

WHO/NIH CONCESUS—JESUS E MEDINA, MD

< 1 MM = 1 CM

1-4 MM = 2 CM (SOME SAY 4 CM)

>4 MM = 2 CM—-SURGEONS JUDGEMENT IS PARAMOUNT

MOH’S—STILL CONTROVERSIAL AND NOT ENOUGH DATA TO RECOMMEND IT AS A STANDARD OF CARE

NEGATIVE RESULTS ON FROZEN SECTION ARE RELIABLE

POSITIVE RESULTS ON FROZEN MUST BE INTERPRETED WITH SUSPICION AS INFLAMATORY CHANGES CAN BE MISTAKEN FOR CANCER

PROPHYLACTIC REGIONAL NODE DISSECTION:

< 1.5 MM = NO BENEFIT PROVEN(EXCEPT IN HIGH RISK SITES, ULCERATED, NODULAR MELANOMAS, OR WHEN INADEQUATE PT F/U IS EXPECTED))

1.5 – 4.0 MM= PROBABLE BENEFIT

WOULD CONSIDER ADDRESSING THE REGIONAL LYMPHATICS WITH ANY LESION .75-4 MM—-(T2, T3)—-LYMPHOSCINTIGRAPHY

> 4.0 MM = NO BENEFIT BECAUSE PTS DIE OF METASTATIC Dz (HOWEVER, MAY OFFER LOCAL AND REGIONAL CONTROL)

QUESTIONABLE WHETHER YOU SHOULD PERFORM A SUPERFICIAL OR TOTAL PAROTIDECTOMY

HIGH RT DOSES WITH HYPERFRACTIONATION MAY IMPROVE SURVIVAL, CERTAINLY OFFERS PALLIATION

ADJUVANT RT FOLLOWING SURGERY DOES IMPROVE REGIONAL CONTROL—IT HAS NOT BEEN SH0OWN TO IMPROVE SURVIVAL

DACARBAZINE HAS AN OVERALL 20% RESPONSE RATE

IFN ALPHA 2B HAS SOME THERAPEUTIC BENEFIT—ALSO TOXIC—4 WEEKS OF IV—FEVER, MYALGIAS, ARTHRALGIAS AND 11 MONTHS OF CHRONIC FATIGUE

IL-2 HAS BEEN USED

POLY-VALENT VACCINE SHOWS PROMISE (ACTIVE IMMUNOTHERAPY—STIM PT TO FIGHT Dz)

ANTI MELANOMA ANTIBODIES (PASSIVE) ATTACHED TO CYTOTOXIC AGENTS OR ANTIBODIES MY BE IN THE FUTURE

FOR PRIMARY MELANOMA- METASTATIC WORK UP =CBC, LFT’S, CXR

FOR REGIONAL RECURRENT MELANOMA = CT(HEAD, NECK, CHEST, ABD), SMAC

ADNEXAL TUMORS

SEBACEOUS GLAND=MOST COMMON

—-OF THE MEIBOMIAN GLAND—USUALLY PRESENT AS ULCERATED NODULAR LESOIN OF THE PALPEBRAE

SWEAT GLAND

APOCRINE OR ECCRINE GLAND CA—PROPENSITY FOR UPPER FACE—PROPENSITY FOR PERINEURAL INVOLVEMENT—CAN BE MISREAD AS BCCA—MOHS IS BEST—CONSIDER POST OP RT

HAIR FOLLICLES

TRICHOLEMMAL CA OR MALIGNANT TRICHOLFOLLICULOMA

PILOMATRIXOMA—”OF MALHERBE”

A CALCIFYING EPITHELIOMA OF MALHERBE (CALCIUM DEPOSITS IN 75%/0SSIFICATION IN 15-20%)

RARE—A BENIGN TUMOR OF HAIR CELL ORIGIN

50% IN THE H&N

PRIMARILY 8-13 YEARS OLD

FEMALE > MALE

ASSOC. WITH MYOTONIC MUSCULAR DYSTROPHY, GARDNER’S SYNDROME, AND CRANIAL DYSOSTOSIS

Rx: WLE—-RECURRENCE IS RARE(AFTER EXCISIONAL BIOPSY—CAN PROBABLY OBSERVE

MESENCHYMAL TUMORS(VIMENTIN +)

ATYPICAL FIBROXANTHOMA

MFH(MALIGNANT FIBROUS HISTIOCYTOMA)

DFSP (DERMATO FIBRO SARCOMA PROTUBERANS) (DARIER AND FERRAND–1924)

A DERMAL LAYER NODULAR SARCOMA WITH A HIGH PROPENSITY FOR LOCAL RECURRENCE AFTER SIMPLE EXCISION

A MALIGNANT MESENCHYMAL SPINDLE CELL NEOPLASM

15% OCCUR IN THE H&N

 

OFTEN PRESENT MANY YEARS BEFORE DIAGNOSED

RARE-SARCOMAS ACCOUNT FOR LESS THAN 1 % OF HEAD AND NECK MALIGNANCIES

MEN > WOMEN

SMALL, UNIFORM, FIBROCYSTIC CELLS IN “CARTWHEEL” PATTERNS

NEED > 2 CM MARGIN AS THEY USUALLY EXTEND A LONG WAY–OPTIMALLY– 3 CM OF NL TISSUE SHOULD BE TAKEN–<10% RECURRENCE!

RARELY METASTASIZE

MOH’S IS THE BEST TREATMENT OPTION–POSSIBLY—<3% RECURRENCE—MAX TISSUE CONSERVATION

RT IS PROBABLY BETTER THAN PREVIOUSLY THOUGHT (50% CURE) -8% RECURRENCE WITH QUESTIONABLE MARGINS

CUTANEOUS TUMORS OF NERVES AND NEUROENDOCRINE CELLS

NEUROFIBROSARCOMA

MERKEL CELL CARCINOMA (TOKER 1972-ENDOCRINE CA OF THE SKIN)

RARE, AGGRESSIVE — BEHAVE LIKE AN AGGRESSIVE AMELANOTIC MELANOMA

OF THE EPIDERMAL (TACTILE) MERKEL CELL IN THE STRATUM BASALE OF THE EPIDERMIS (SITS ON THE B.M.)RESPONSIBLE FOR TACTILE SENSATION

OR OF PLURIPOTENTIAL, UNDIFFERENTIATED CELLS OF NEURAL CREST ORIGIN, S-100 +, CYTOKERITIN +

HISTOLOGICALLY – DENSE COHESIVE SHEETS OF HIGHLY MITOTIC CELLS NOT INVOLVING THE DERMIS (SEEMS TO SIT IN THE S.Q. TISSUE, CELLS HAVE SCANT CYTOPLASM (LOOKS LIKE SMALL CELL CA OF THE LUNG)

E.M. PERINUCLEAR FILAMENTS, DENSE CORE GRANULES

55% IN H&N

20% IN THE PERIORBITAL REGION

PRIMARILY IN 6TH DECADE

FEMALES DO BETTER

FLESH COLORED, SMALL, PAINLESS

PRIMARILY ON H & N OR EXTREMITIES

SMALL SOLITARY NODULE

PRIMARILY OLDER INDIVIDUALS

> 50% REGIONAL METS(OFTEN OCCULT)

> 20 % DISTANT METS

DESCRIBED IN 1972, NOW ABOUT 250-300 REPORTED CASES

35% MORTALITY

Rx: WLE (3CM) WITH REGIONAL LYMPHADENECTOMY FOR STAGE I, PLUS POST OP RT(40 Gy) FOR STAGE II

INDUCTION CHEMO (CARBOPLATIN AND ETOPOSIDE) FOR STAGE III

PROBABLY RADIOSENSITIVE

GLOMUS CELL TUMOR

SYMPATHETIC INNERVATION

REGULATES THE SUEQUET HOYER CANAL

CUTANEOUS TUMORS OF VESSELS

MALIGNANT ANGIOENDOTHELIOMA

KAPOSIS SARCOMA(SHOULD BE CALLED KAPOSIS ANGIOSARCOMA)

HEMANGIOPERICYTOMA

FROM THE CAPILLARY PERICYTE(EPITHELIAL ORIGIN) OF ZIMMERMAN

RARE, 20% IN THE H&N

HIGH INCIDENCE ON NASAL SEPTUM

CAN BE BENIGN OR MALIGNANT

IF MALIGNANT 50% METS TO BONE OR LUNG

MALE = FEMALE, USUALLY IN 4TH, 5TH, AND 6TH DECADES

STAINS + VIMENTIN, FACTOR 8, FACTOR 13

CHARACTERISTIC SILVER STAIN

PRIMARILY PRESENTS AS A SLOW GROWING PAINLESS MASS

Rx–SURGERY (WLE) IS BEST—TREAT LIKE IT IS MALIGNANT, RELATIVELY RADIORESISTANT

CANCER METASTATIC TO SKIN

SCALP IS PRIMARY LOCAL

MEN PRIMARY IN LUNG OR KIDNEY

WOMENT PRIMARY IN BREAST

CUTANEOUS METS TO NECK—FROM OC OR BREAST

TO FACE—-OC, RENAL OR LUNG

 

NEUROECTODERMAL—NEURAL CREST CELL TUMORS

NOTOCHORD= STRUCTURAL VESTIGE FORMED FROM MESODERM

EVENTUALLY BECOMES THE NUCLEUS PALPOSUS—VERTEBLRAL COLUM FORMS AROUND IT

STIMULATES NEURULATION PROCESS IN THE OVERLYING NEUROECTODERM

NEURULATION—-SOME OF THE NEUROECTODERM SEPERATES AN MIGRATES OUT TO FORM PERIPHERAL NEURAL STRUCTURES:

AFFERENT–DORSAL ROOT GANGLION

AUTONOMIC GANGLION—-SYMPATHETIC TRUNK, CN 3, 7, 9, AND 10 ( GLOMUS CELL TUMORS—PARAGANGLIOMAS)

ADRENAL MEDULLA (CHROMAFFIN CELLS)– -PHEOCHROMOCYTOMA

CELIAC,RENAL, INTESTINAL PLEXUS

SCHWANN CELLS— -SCHWANNOMA

MENINGES—PIA AND ARACHNOID (MENINGIOMA)

PIGMENT CELLS— -MELANOMA

IRIS CHROMATOPHORES

ULTIMOBRANCHIAL BODY—-PARAFOLLICULAR C-CELLS OF THE THYROID— -MEDULLARY CA OF THE THYROID

GRANULAR CELL TUMOR (DORSAL TONGUE)

NEUROBLASTOMA

ESTHESIONEUROBLASTOMA (OLFACTORY NEUROBLASTOMA)

NEUROECTODERMAL TUMOR OF INFANCY

CUTANEOUS TUMORS OF NERVES AND NEUROENDOCRINE CELLS

NEUROFIBROSARCOMA

MERKEL CELL CARCINOMA (TOKER 1972-ENDOCRINE CA OF THE SKIN)

GLOMUS CELL TUMOR—SYMPATHETIC INNERVATION—–REGULATES THE SUEQUET HOYER CANAL

CUTANEOUS TUMORS OF VESSELS

MALIGNANT ANGIOENDOTHELIOMA

KAPOSIS SARCOMA(SHOULD BE CALLED KAPOSIS ANGIOSARCOMA)

HEMANGIOPERICYTOMA —FROM THE CAPILLARY PERICYTE(EPITHELIAL ORIGIN) OF ZIMMERMAN