Skin and Soft Tissue—Skin Cancer
(Other than Melanoma)
Concept
Usually we are talking here about squamous cell cancer or basal cell cancer. Can consider other types of benign skin lesions in your differential, but question will be how to manage the malignant type. Basal cell is most common and may present as nodular, superficial, or ulcerating lesion.
Way Question May be Asked ?
“66 y/o male presents to office with bleeding scalp lesion.
Fungating large mass on physical exam. When patient’s hat is removed. What do you want to do?”
How to Answer?
Brief H+P
Risk factors:
(Excessive) Sun exposure Radiation
Inherited skin disorders
Physical Exam
Characteristics of lesion (size, shape, color) Full skin survey (include axillae, groin, scalp) Examine lymph node basins related to lesion
Treatment
Briefly consider DDx and then proceed to Surgical excision
Review pathology
For Squamous cell → want 5 mm margins for lesions <
2 cm in size
→ want 1 cm margin for lesions
> 2 cm in size node dissection if palpable nodes or if Margolin’s ulcer
For Basal cell → want 2 mm margins
For lesion on head/neck → would want to resect and close defect with:
(1) Free full thickness skin graft from behind ear or base of the neck
(2) Rotation flap
Mohs Surgery Indications
Recurrent basal/squamous cell CAs
Tumors of face, invasive into nasal, periorbital, periau- ricular structures
Adjuvant Treatment (XRT)
Close margins of resection (< 1 mm) Neuro/vascular invasion
BCC/SCC in medial canthus of eye/nose
Lymph Node Dissection
Only for clinically involved nodes (modified radical neck+ suparotidectomy if tumor invading parotid)
Common Curveballs
Path will come back melanoma (change scenario) Lymph nodes will be palpable
Excised lesion will recur
Lesion will be on face and needs full thickness skin graft Tumor will be large and ulcerating
There will be palpable nodes
Tumor will be preauricular invading parotid gland 107 Part 2.qxd 10/19/05 2:52 AM Page 107
Treating a lesion that develops in chronic wound (Margolin’s ulcer)
Strikeouts
Discussing electrodessication and curettage Discussing Mohs surgery when not indicated
Discussing simply treating with radiation/chemo- therapy
Talking about SLN bxs or elective lymph node dissec- tion
108 Skin and Soft Tissue—Skin Cancer (Other than Melanoma)
Part 2.qxd 10/19/05 2:52 AM Page 108