Cutaneous malignancies

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Cutaneous malignancies
2013-03-03 21:34:03
head neck

head and neck
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  1. Hereditary disorders associated with melanoma
    • familial dysplastic nevus syndrome, AKA FAMMM (familial atypical mulitple mole melanoma). AD inheritance and 10% risk of melanoma in 10 years.
    • xeroderma pigmentosa. AR inheritence, cancer diagnosis by age 10.
  2. Describe Clark staging of melanoma
    • Not commonly used anymore. Breslow is more predictive.
    • Level I - Confined to epidermis, also called “in situ” melanoma
    • Level II - Invasion of the papillary dermis (upper)
    • Level III - Filling of the papillary dermis (lower)
    • Level IV - Extending into the reticular dermis
    • Level V - Invasion of the subcutaneous tissue
  3. Describe Breslow staging and 5 year survival rates for each
    • <1mm: 5-year survival is 95-100%
    • 1-2mm: 5-year survival is 80-96%
    • 2.1-4mm: 5-year survival is 60-75%
    • >4mm: 5-year survival is 37-50%
  4. Describe the T staging for melanoma
    • Tis: Melanoma in situ
    • T1: ≤ 1.0 mm in thickness
    • T2: 1.01-2.0 mm 
    • T3: 2-4 mm
    • T4: >4 mm
    • T1 suffixes: "a" Without ulceration and mitoses < 1/mm2; "b" With ulceration or mitoses ≥ 1/mm2
    • Suffixes T2-T4: "a" means no ulceration (eg T2a), "b" means ulceration present
  5. Describe N staging for melanoma
    • N1: 1 lymph node
    • N2: 2 or 3 lymph nodes
    • N3: ≥ 4 metastatic lymph nodes, or matted lymph nodes, or in-transit met(s)/satellite(s) with metastatic lymph node(s)
    • Suffices: (For N1, N2) "a" micrometastases; "b" macrometastases; (For N2) "c" in-transit met(s)/satellite lesion(s) without metastatic nodes
  6. M classification in melanoma
    • M0: No detectable evidence of distant metastases
    • M1a: Metastases to skin, subcutaneous, or distant lymph nodes, normal serum lactate dehydrogenase (LDH) level
    • M1b: Lung metastases, normal LDH level
    • M1c: Metastases to all other visceral sites or distant metastases to any site combined with an elevated serum LDH level
  7. Most common site for mucosal melanoma?
    • Hard palate
    • mucosal melanoma is about <10% of head and neck melanoma
    • low rate of mets
  8. Common immunohistochemical markers for melanoma
    • S-100 (high sensitivity, low specificity)
    • HMB-45 (sensitive and specific, doesn't stain spindle cell type)
    • MART-1 and melan A (sensitive and specific for melanocytes)
  9. Differential for small, blue, round cell tumors?
    • MR SLEEP
    • Melanoma, Merkel cell
    • Rhabdomyosarcoma
    • SNUC, Small cell cancer, Sarcoma
    • Lymphoma
    • Ewing's sarcoma
    • Esthesioneuroblastoma
    • PNET (Primitive neuroectodermal tumor)
  10. Describe superficial spreading melanoma
    • 70% arise from preexisting junctional nevi
    • radial phase predominates
    • ulceration suggests vertical growth
  11. Describe nodular melanoma
    • very aggressive, rapid vertical phase
    • may present de novo on non-sun-exposed areas
    • worst prognosis
  12. Describe lentigo maligna
    • irregularly hypopigmented macule on sun-exposed skin
    • more common in the elderly
    • confined to epidermis, spreads laterally
    • lentigo maligna is carcinoma in situ, lentigo maligna melanoma is invasive carcinoma
  13. Margins needed for surgical resection of melanoma
    • Tis: 2-5 mm
    • T1: 1 cm
    • T2: 1-2 cm
    • T3 and T4: 2 cm margins
  14. Treatment of superficial melanomas
    • superficial, <1mm
    • excision with 1 cm margin down to fascia
    • Elective neck dissection not indicated for N0
  15. Treatment of intermediate melanomas
    • Intermediate 1-4 mm thick
    • excision with up to 2 cm margin down to fascia
    • may consider interferon alpha-2b
    • N0 neck: consider sentinal LN bx with complete neck for positive nodes
    • survival benefit for elective ND in patients less than 60 years old with 1-2 mm thick melanomas
    • N1-N3: neck dissection (posterolateral for scalp, parotid for anything anterior to EAC), consider chemo (dacarbazine)
  16. Treatment of deep melanomas
    • Deep, >4 mm thick
    • excision with up to 2 cm margin down to fascia
    • may consider interferon alpha-2b
    • N0 neck: no treatment
    • N1-N3: neck dissection (posterolateral for scalp, parotid for anything anterior to EAC), consider chemo (dacarbazine)
  17. Staging for mucosal melanoma
    • T3 Any mucosal disease
    • T4a Moderately advanced disease, tumor involving deep soft tissue, cartilage, bone, or overlying skin
    • T4b Very advanced disease, tumor involving brain, dura, skull base, lower cranial nerves (IX, X, XI, XII), masticator space,carotid artery, prevertebral space, or mediastinal structures
    • N and M staging: 0 for no, 1 for yes
  18. What is desmoplastic melanoma? How is it different from other types of melanoma?
    • Desmoplastic melanoma is a subtype with spindle cells, abundant collagen and fibroma resembling features.
    • neurotropic variant
    • rare (1% of all melanomas) with 75% manifesting in the head and neck (vs 25% of all cutaneous melanomas).
    • 73% are amelanotic (vs 4-5% of all cutaneous melanomas) and often lack typical ABCD criteria.
    • Locally aggressive and highly infiltrative, often with CN and skull base involvement.
    • Local recurrence ~50%.
    • Lower rate of regional LN metastasis(12.5%)
  19. Cutaneous lesions of these regions may be more aggressive and require closer follow-up
    • Embryonic fusion plates, H-zone of the face
    • nasolabial folds, floor of the nose, columella, preauricular regions, inner and outer canthus of the eye
  20. describe nodular basal cell carcinoma
    • most common type
    • pearly, telangiectatic papule
    • central ulceration and rolled base
  21. Describe superficial basal cell carcinoma
    • found in the trunk and extremities
    • scaly, waxy, indurated, irregular shapes
  22. Describe morphea BCC (sclerosing or fibrosing)
    • common on the face
    • flat or depressed
    • indurated, yellow, indistinct borders
    • aggressive with higher rate of recurrence
    • poor prognosis
  23. Describe pigmented BCC
    • similar to nodular type, but pigmented
    • resembles a melanoma or benign nevus
  24. Describe fibroepithelioma BCC
    • raised, firm, pedunculated, or sessile
    • red with smooth skin surface
  25. Describe Gorlin's syndrome (nevoid basal cell carcinoma syndrome)
    • autosomal dominant
    • multiple BCC at early age
    • odontogenic keratocyst
    • rib abnormalities and scoliosis
    • mental retardation and frontal bossing
    • malignant lesions should be excised, follow up every 3-6 months
  26. Management options for BCC.  Describe excisional curettage w electrodesiccation, cryosurgery, scalpel excision, and RT
    • Curettage/electrodesiccation: most common, ideal for <2 cm lesion.  Contraindicated in morphea
    • Cryosurgery: requires 5 mm margin, consider for <1 cm lesion
    • Scalpel: 4 mm margin with primary reconstruction
    • RT: where cosmetic outcome is important or for non-operative candidates.  Use electron beam (not traditional photon treatment) because lesion is so superficial
  27. Indications for Moh's surgery
    • Morphea type
    • recurrence
    • high risk of recurrence (H-zone of the face)
    • cosmetically sensitive regions
  28. Metastatic potential of cutaneous SCC?
  29. Signs of more aggressive cutaneous SCC lesions
    • site of previous scar or wound
    • located on embyronic fusion plates (nasolabial folds, floor of the nose, columella, preauricular regions, inner and outer canthus of the eye)
    • lesions arising de novo on non-sun-exposed skin
    • deep (>6mm)
    • large (>2 cm)
  30. Symptoms of cutaneous SCC
    erythematous, hyperkeratotic, opaque nodule, ulcerative, granular base, bleeds easily
  31. What type of SCC is more likely to occur at the site of a scar, trauma, or burn?
    Spindle cell. More aggressive.
  32. What is the name of SCC in situ that presents as erythematous plaques or patches, +/- scaly changes.
    Bowen's disease.
  33. Margins for surgical excision of early SCC?  Late SCC?
    • early: 4-6 mm
    • late: 1-2 cm
  34. Is there a role for RT in cutaneous SCC?
    • cosmetically sensitive sites
    • nonoperative candidates
    • advanced disease followed by surgical salvage
    • post-op for positive or close margins, positive nodes, extracapsular spread, perineural or intravascular invasion, recurrence, or bone/cartilage invasion