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21 Cards in this Set
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- 3rd side (hint)
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Margin for dermatofibrosarcoma protuberans? |
2 cm |
Use Mohs if possible |
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Which malignancy is most likely to arise from sebaceous nevus? |
Basal cell carcinoma |
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Mohs surgery indications: Which part of the face? Which cancers & subtypes? Types of margins? Size of tumor? |
Indications for Mohs surgery include recurrent basal cell carcinomas (BCC) and squamous cell carcinomas (SCC), locations prone to recurrence ("H-zone" of the face: inner canthus, nasolabial fold, nose, periorbital, temple, upper lip and periauricular regions, retroauricular, and chin), at/near critical structures (e.g., eye, lip), large tumors (>2 cm), ill-defined tumor margins, aggressive histology (BCC - morpheaform infiltrative, basosquamous, perineural; SCC - poorly differentiated, invasive, perineural), and special hosts (immunosuppressed, basal cell nevus syndrome, xeroderma pigmentosum). |
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Treatment of the Merkel cell should be wide local excision or Mohs micrographic surgery. For wide local excision of tumors smaller than 2 cm, the recommended surgical margin should be ___ cm. As there is a high rate of occult nodal metastasis, and nodal status is associated with mortality rates, biopsy of the sentinel node is recommended for all cases regardless of primary tumor size. What else should be done for treatment? |
Treatment of the primary tumor should be wide local excision or Mohs micrographic surgery. For wide local excision of tumors smaller than 2 cm, the recommended surgical margin should be 1 cm. As there is a high rate of occult nodal metastasis, and nodal status is associated with mortality rates, biopsy of the sentinel node is recommended for all cases regardless of primary tumor size. Merkel cell carcinoma is a radiosensitive tumor, and postoperative adjuvant radiation therapy has been shown to decrease local recurrence. |
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62-year-old woman with biopsy-proven basal cell carcinoma of left mid cheek presents for consultation for surgical treatment. On physical examination, the lesion is 0.6 cm in diameter and has indistinct borders. Which of the following criteria is the most likely indication for Mohs micrographic surgery in this patient? A) Anatomical location of the cancer B) Diagnosis of basal cell carcinoma C) Indistinct borders D) Patient age E) Size of the carcinoma
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Indistinct border - The correct response is Option C. |
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Squamous cell carcinoma margins: What types of lesions would get 4mm? 6mm? |
Cutaneous squamous cell carcinoma (cSCC) is the second most common skin cancer after basal cell carcinomas. They are broadly categorized into low- and high-risk lesions depending on size, location, depth of invA 4-mm margin of healthy tissue is recommended for lower-risk lesions. This category includes well-differentiated tumors smaller than 2 cm in diameter that do not occur on the scalp, ears, eyelids, lips, or nose, and do not involve subcutaneous fat. A 6-mm margin of healthy tissue is recommended for lesions that are larger than 2 cm, invasive to fat, or in high-risk locations (i.e., central face, ears, scalp, genitalia, hands, feet). Given the cosmetic and functional impact of these wider margins, tumors in this latter category are often removed via Mohs micrographic surgery to achieve high cure rates while sparing healthy tissue. The depth of an excision should always include a portion of the subcutaneous fat. |
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A 24-year-old woman is evaluated because of a slow-growing subcutaneous mass of the scalp. An excisional biopsy is performed, and pathologic examination shows keratin and its breakdown products. What type of cyst? |
Pilar cyst, also known as trichilemmal cysts, originate from the outer root sheath of the hair shaft. |
Most common tumor of scalp. |
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Main treatment for cutaneous angiosarcomas of the face and scalp? |
Wide local excision. Angiosarcoma is a rare (2% of all soft-tissue sarcomas) but highly aggressive tumor that is most commonly found in the face and scalp in older Caucasian men. |
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A 39-year-old woman is evaluated because of a 6-month history of a growth on the face. A biopsy is planned. Which of the following findings on pathology can be safely treated with observation only in this patient? A) Cylindroma B) Eccrine poroma C) Nevus sebaceous D) Trichoepithelioma |
Trichoepitheliomas are neoplasms of follicular differentiation. Trichoepithelioma usually presents as multiple, yellowish-pink, translucent papules distributed symmetrically on the cheeks, eyelids, and nasolabial area. |
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A 47-year-old man comes to the office because of an asymptomatic lesion of the anterior abdominal wall that has been enlarging gradually for the past 10 years. The lesion has accelerated in growth during the past several months and recently ulcerated. Examination shows a 6-cm, raised, indurated, and irregularly shaped violaceous plaque consisting of firm, irregular nodules. Examination of a specimen obtained on incisional biopsy shows a soft-tissue malignancy arising from mesenchymal cells in the dermis. Which lesion is being described? Treatment? |
Dermatofibrosarcoma. Treatment primarily consists of wide surgical excision to include margins of 2 to 3 cm beyond the clinical tumor border if possible. Mohs micrographic surgery has been used with good outcomes in aesthetically sensitive areas such as the head and neck where tissue sparing is important. |
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Margin for desmoid tumor? |
1 cm |
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Treatment for cylindroma? |
Cylindromas are benign adnexal tumors showing an eccrine and an apocrine differentiation. They are found most commonly on the scalp and face, and are more common in women. Solitary cylindromas are generally sporadic in nature. Multiple cylindromas can be seen in patients with Brooke-Spiegler syndrome as an autosomal dominant trait with variable penetrance.
Cylindromas may undergo malignant transformation, and therefore surgical excision is typically recommended, with close postoperative follow-up given high recurrence rates. |
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Which 2 zones or areas of the face are almost always good places to perform Mohs for BCC? |
Area H: "Mask areas" of face (central face, eyelids [including inner/outer canthi], eyebrows, nose, lips [cutaneous/mucosal/vermilion], chin, ear and periauricular skin /sulci, temple), genitalia (including perineal and perianal), hands, feet, nail units, ankles, and nipples/areola. Area M: Cheeks, forehead, scalp, neck, jawline, and pretibial surface. |
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A 60-year-old man presents with a 6-mm lesion of the forehead. The patient states that it has enlarged over a period of 2 years. Examination of a biopsy specimen shows squamous cell carcinoma (adenoid subtype) with a 1.5-mm depth of involvement. Which of the following is the most likely risk factor for recurrence of this patient's lesion after surgical excision? A) Anatomic location B) Depth of involvement C) Growth rate D) Histologic subtype E) Size |
D) Histologic subtype Adenoid, adenosquamous, and desmoplastic subtypes are considered high risk for recurrence.
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What is the most appropriate surgical treatment recommendation for a 4-cm round sebaceous nevus of the scalp in a child? |
Serial monitoring and selective excision Historically, there has been a 10 to 15% reported malignant degeneration in nevus sebaceous in children and the recommendation had been for all lesions to be removed before puberty. More recent studies have shown malignant transformation of these lesions to be less than 1%. Although serial excision is an alternative reconstructive option, it is recommended only for larger lesions that can be excised in three stages or less. |
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There is no history of trauma. On examination, the finger appears normal with no visible swelling or discoloration. The pain is exacerbated by local pressure when the patient writes and during her weekly swimming lessons. MRI (T2-weighted) image is shown. What is the most likely diagnosis? |
This lesion is a glomus tumor. Glomus tumors are benign hamartomas originating from the glomus body, a structure comprised of vascular and neural elements that is responsible for thermoregulation in the skin. These often inconspicuous tumors present with pain, point tenderness, and sensitivity to cold. X-ray studies may show cortical erosion of the bone adjacent to the lesion, and ultrasonography can provide confirmation. MRI is the most accurate imaging modality and the tumor appears as a bright, discrete mass on T2-weighted images. |
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An 85-year-old man who takes an anticoagulant medication comes to the office for evaluation of a recurrent 1-cm nodular basal cell carcinoma at his nasal tip that has started to bleed intermittently. Medical history includes placement of a cardiac stent 1 month ago, after myocardial infarction. What is the most appropriate treatment for this patient? |
With a 5-year recurrence rate of about 3% for nodular basal cell carcinomas (BCC), superficial radiation therapy has become a viable alternative to Mohs micrographic surgery, which remains the gold standard for treatment of nonmelanomatous skin cancers. |
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12-year-old girl develops a 12-mm nodule on her right cheek that grows slowly over 2 months. It is firm to the touch, mildly tender, and slightly bluish. There is no redness, ulceration, or visible punctum. Which is the most likely diagnosis? |
Pilomatricoma (also known as pilomatrixoma or calcifying epithelioma of Malherbe) is a common, benign calcifying tumor of the hair appendages that mostly occur under the age of 20. Most occur in the head and neck, but the extremities and trunk are also affected. Surgical excision is the treatment of choice. Malignancy is very rare. Intraoperative findings show a calcific, friable mass adherent to the undersurface of the skin. Unlike a keratinous or sebaceous cyst, there is no discrete capsule or punctum (plugged pore). Recurrence is reported in the 1 to 2% range. This benign growth is related to a somatic (non-inherited) gene mutation CTNNB-1, that is involved in cell replication of the hair matrix. |
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Rate of malignant transformation for AKs? |
AKs are common in in people with significant sun exposure and are a response to ultraviolet radiation. The likelihood of malignant transformation to squamous cell carcinoma (SCC) is approximately 10%. |
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Treatment for dermatofibrosarcoma protuberans of the face? |
Mohs micrographic surgery has demonstrated to have a much lower recurrence rate, with multiple studies demonstrating less than 10%. Subsequently, Mohs micrographic surgery is the best initial treatment plan for complete resection of DFSP. |
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An otherwise healthy 30-year-old woman is diagnosed with dermatofibrosarcoma protuberans (DFSP) of the upper back. A wide excision is performed, and a local flap is used to reconstruct her back. On follow-up evaluation, CT scan shows multiple pulmonary metastases. Which of the following is the most appropriate next step in management? A) Chemotherapy B) Hormone therapy C) Immunotherapy D) Radiation therapy E) Surgical excision |
The most appropriate next step in management is chemotherapy. Patients with inoperable, recurrent, or metastatic disease may benefit from imatinib which is a tyrosine kinase inhibitor and acts as a molecularly targeted drug. It acts by inhibiting the platelet-derived growth factor receptor tyrosine kinase. |
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