04 Malignant Skin Lesions

Physical examination physical examination should

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Unformatted text preview: n, visual changes. Physical Examination Physical examination should include a complete skin examination, as well as examination of mucosal membranes. In the case of a possible melanoma, particular attention should be paid to the presence or absence of surrounding nodules or nodules between the skin lesion and the closest nodal basins that may represent in-transit metastases. Attention should be paid to the draining nodal basins because lymph node metastases are known to occur in both squamous cell carcinoma (SCC) and melanoma. If the lesion is not clinically suspicious, conservative monitoring through patient self-examination and regular follow-up with a healthcare provider is appropriate. INVESTIGATIVE STUDIES Biopsy Any clinically suspicious lesion should undergo either excisional biopsy (if the lesion is small) or incisional biopsy (if the lesion is large). Excisional biopsy typically incorporates a 1 to 4 mm margin of normal skin, depending on the clinical characteristics of the lesion.With some types of lesions (e.g., a dysplastic nevus), the use of this margin may eliminate the need for subsequent reexcision if the lesion proves to contain high-grade cytologic atypia. In any case, no attempt should be made to perform a definitive radical excision until a diagnosis is established by means of biopsy. A full-thickness excision that extends into the subcutaneous fat should be performed, and the specimen should be marked for orientation to help the pathologist evaluate the margins for possible microscopic involvement with tumor cells. As a rule, electrocauterization should not be employed to remove the specimen, because it creates artifacts that can substantially distort cells at the margins. Shave biopsy is discouraged for evaluation of pigmented lesions because it may create a positive deep margin, thereby compromising determination of the true depth of penetration of a melanoma. In the case of an elliptically shaped excisional biopsy on an extremity, the long axis of the specimen should be oriented along the long axis of the extremity to facilitate subsequent reexcision if necessary. EXCISION OF MALIGNANCY If the lesion proves to be benign, no further treatment is usually required. If it proves to be malignant, further excision with appropriate margins is usually necessary, and tumor staging becomes an important concern. Appropriate excision margins for different skin cancers are discussed in more detail elsewhere [see Management of Specific Types of Skin Cancer, below]. For lesions excised in an ellipse of skin and fat, the length of the ellipse should be approximately 3.5 to 4 times the width to allow tension-free closure without dog-ears. If an area cannot be closed primarily, skin grafting may be necessary [see 3:7 Surface Reconstruction Procedures]. For very large lesions or lesions in difficult areas (e.g., the face), specialized flaps may be required. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 3 BREAST, SKIN, AND SOFT TISSUE Management of Specific Types of Skin Cancer BASAL CELL CARCINOMA 4 Malignant Skin Lesions — 2 often turn out to be larger than they appear clinically, and they generally have a more aggressive natural history than other BCCs; as a result, complete exci...
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This note was uploaded on 03/21/2011 for the course ONC 01 taught by Professor Dzodic during the Spring '11 term at Multimedia University, Cyberjaya.

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