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04 Malignant Skin Lesions - 2006 WebMD Inc All rights...

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Jennifer A.Wargo, M.D. , and Kenneth Tanabe, M.D ., F.A.C.S. 4 MALIGNANT SKIN LESIONS Given the variable natural history and prognosis of skin malignan- cies, clinical assessment and management of these lesions can be challenging.Malignant skin lesions have become increasingly preva- lent over the past several years.In the United States,approximately 1.2 million cases of nonmelanoma skin cancer are diagnosed annu- ally. 1 More alarming is the observation that approximately 80,000 cases of melanoma are now diagnosed each year 2 —a figure that that has been steadily rising, 3 to the point where the current lifetime risk for the development of melanoma is 1 in 75. 2 This disturbing in- crease in the incidence of both nonmelanoma skin cancer and melanoma can largely be attributed to prevailing social attitudes to- ward sun exposure. 4 Given the increasing prevalence of skin cancers and the pivotal role surgeons play in their treatment, it is critical that surgeons be well informed about the recognition, workup, and manage- ment of these conditions.Accordingly, in what follows, we address evaluation and management of malignant skin lesions in detail; management of benign skin lesions is beyond the scope of this chapter. Assessment of Potentially Malignant Skin Lesions CLINICAL EVALUATION History A careful history should be obtained, with particular attention paid to the extent of previous sun exposure.A history of blistering sunburn in childhood or adolescence is a significant risk factor and is reported by virtually all white persons with melanomas. 5 A per- sonal or family history of skin cancer is also a risk factor: the likeli- hood that melanoma will develop is increased eight- to 12-fold when a first-degree relative has a history of melanoma. 6 Previous immunosuppression or transplantation should be inquired about as well;both place the patient at higher risk for the development of skin cancer. A detailed history of the lesion’s development, starting with the time when it was first noted and including any changes in its size or appearance,should be elicited.Such a history will help the clinician make the initial judgment regarding whether the lesion is suspicious or nonsuspicious. Generally speaking, lesions are considered non- suspicious if they remain stable and uniform in terms of their physi- cal characteristics (e.g., size, shape, color, profile, and texture). An example of a nonsuspicious lesion is a simple nevus,which typically becomes apparent at 4 to 5 years of age, darkens with puberty, and fades in the seventh to eighth decades of life.Pigmented lesions that have an irregular border or demonstrate a change in size, color, or texture are considered suspicious. Careful attention should also be paid to constitutional symptoms. Patients who present with metastatic disease may have systemic or focal complaints, such as headaches or, in the case of melanoma that has metastasized to the brain,visual changes.
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