Management of Cutaneous Malignancies

Rex Moulton-Barrett, MD

Plastic and Reconstructive Surgery, Otolaryngology Head & Neck Surgery

4th Floor, Doctor’s Offices Alameda Hospital

& 1280 Central Blvd, Suite J-5, Brentwood

Safest is best

Wait and see

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

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

Skin Cancer

• Basal (75%) > Squamous (25%) > 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 > prolonged sun exposure: UVB>A, SPF 15, < 20 yrs age

• Genetic predisposition: more pigment is protective

Common Non-pigmented Benign Lesions

• Seborrheic Keratoses

• Syringomas• Xantheloma Palpebrum

• Premalignant Actinic Keratoses

Common non-pigmented benign lesions

• Syringomas: peri-ocular , small, fleshy and nodular

Common non-pigmented benign lesions

• Xantheloma Palpebrum: periocular, drop like & semi-cheezy

rarely associated with hyperlipidaemia

ie planar xanthomatadysbetalipoproteinemia

or hypercholesterolemia

Common non-pigmented benign lesions

• Trichoepitheliomas: periocular, drop like

Common non-pigmented benign lesions

• Milia: periocular, drop like & semi-cheezy

Common non-pigmented Benign/pre-malignant

lesions

• Actinic Keratoses: 20% SCCA, dry, crusty

• really pre-malignant

Pigmented Benign Lesions

• Blue Nevus

• Pigmented Seborrheic Keratosis

• Giant Nevus

Pigmented benign lesions

• Blue Nevus: intradermal and subcutaneous

not pre-malignant

Pigmented benign lesions

• Pigmented Seborrheic Keratosis: waxy, soft

can rub off a little

Non-Pigmented Pre-malignant Lesions

• Bowen’s Disease: red scaly patch of

Squamous Cell Carcinoma in situ

Pigmented Benign & Pre-malignant Lesions

• Giant Nevus: 1-2 % populationRisk of developing melanoma related to size:

> 20cm diameter adult

> 2 palm size / body 5-20 % by 10, peak at 3-5 yrs

> 1 palm size / face 5-20 % by 10, peak at 3-5 yrs

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/curettage

or excision

RNA analogue precursor & progressive DNA labelling

Contraindicated in pregnancy: teratogenic VSD’s

Role for Topical anti-mitotic agents

Imiquimod 5% cream ( Aldara )

Immunomodulator: activates monocytes,macrophages, Langerhan’s 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

*

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

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

ulceratedpigmented

morpheiform

Basal cell carcinoma excisional biopsy

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

Squamous cell Biopsy

• Squamous Cell: elliptical wedge:

from periphery towards center better than shave

6-10 mm margin if excisional biopsy

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

Excisional Biopsy

• Melanoma: closest margin to remove* the lesion,

do not shave, or wedge

may use punch if completely excise

Superficial spreadingLentigo maligna *

nodular

amelanotic

subungal

Acral lentinous

Management of Melanoma

• <0.75 mm deep: 1cm margin

• 0.75cm - 1.25mm deep: 1cm margin & ? sentinel node

• 1.25 mm-4mm deep: 1-2cm margin & sentinel node biopsy

• >4mm deep: 1cm margin and use of lymphadenectomy unproven

S/P Shave of Melanoma

• 2 schools of thought

1. Excisional biopsy and based on depth decide on size of margin using same parameters

2. Excise based at least the depth of the shave

ie 1-2 cm margin, when in doubt take larger margin

Excisional Biopsy

• Kaposi’s Sarcomas: closest margin to remove*

HIV with CD4 <200/mm3

*

Excisional Biopsy

• Adnexal/appendage: ductal or non-ductal

closest margin to remove

hamartoma

hidrocystoma

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mixed tumor

Excisional Biopsy

• Metastatic: closest margin to remove the lesion*

melanoma

breast

adenocarcinoma*

Moh’s 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

Dangerous Problems

• Midline LesionsIntranasal: 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

Difficult Problems Problems

• Zygomatic Arch to Angle of the MandibleParotid tumorsLymph nodes: atypical TB

inflammatory-children, metastatic node if > 1.5cm adult

Branchial Cleft Cysts

( < 1-2 yrs: congenital, >2-15 yrs inflammatory, > 15 yrs neoplastic )

Difficult Problems

• Merkel Cell Tumors

• Subungal Pigmentation

• Sebaceous Adenoma

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

Difficult Problems

• Subungal Pigmentation

Acquired melanocytic nevus melanoma

Difficult Problems

• Sebaceous Adenoma

Warty lesion often in the scalp, can be salmon colored

present at birth,

hamartoma > 10 yrs : will form BCCA and 19% form syringocystadenoma

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.

Clinical Examples A. 5mm chronic ulcer of the hand in a wrinkled 90 yr man

a. important historyduration, bleeding, numbness, other medical problems,

medications, pacemaker, adenopathy, associated skin lesionsb. important physical characteristics

wipe lesion and look at shape: ulcer with irregular border, little pigmentation

c. type of biopsypunch or wedge using lidocaine with epinephrine. single suture for hemostatis.

d. definitive managementpath: 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 ( < 5MM ) re-excise in

OR with frozen section.

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.

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

• a. important historyduration, bleeding, numbness, medical problems, medications, pacemaker

• b. important physical characteristics of lesion to make the diagnosisadenopathy, associated skin lesions, wipe lesion, look at shape, ulcer with irregular border, little pigmentation

c. type of biopsybiopsy 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 sectionpath: basal cell ca. Take >3mm margin

and close wound along favorable tension lines with a local flap