جامعة المعرفة ALMAAREFA UNIVERSITY

Skin, & Subcutaneous Tumors

Dr. Ahmed khan MBBS, FCPS

Assoc. Professor, Dept. Surgery

Leenah Turjoman ♥

2/3/2024

Dr. M. Almadani

Objectives

Skin structure & functions
Type of skin wounds & its management
Different methods to provide skin coverage
Diagnosis & management of common lesions

2/3/2024

Dr. M. Almadani

Skin consists of:

Skin structure, & function

① Epidermis: → Thin layer consists of keratinocytes (keratinized layer)

The epidermis is derived primarily from surface ectoderm
Keratinized stratified squamous epithelium.
Basal germinal layer generates:

a. Keratinocytes- migrates superficially to form keratinized SE and finally shed. → form keratin b. Pigment cells (Melanocytes)- melanin passed to keratinocytes. → form melanin

2/3/2024

Dr. M. Almadani

Skin structure, & function

②. Dermis: → Thicker part

Derived primarily from mesoderm
Collagen, elastic fibers & fat, thus to sustain and support the epidermis
Supports blood vessels, nerves, lymphatics and epidermal appendages.
Has appendages (hair follicles, sweat & sebaceous glands)
Sweat glands:
- Eccrine: Major glands, (excessive sweating → loss of salt and water). Mostly in palms, & soles
- Apocrine: Musty smelling fluid in the axilla, perineum, ears & areola
Composed of 2 layers: - the more superficial papillary dermis and
- the deeper reticular dermis

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Dr. M. Almadani

the hair follicle, and the external surface

2/3/2024

Dr. M. Almadani

2/3/2024

Dr. M. Almadani

2/3/2024

Dr. M. Almadani

Skin function

The skin covers the entire external surface of the human body and is the principal site of interaction with the surroundings.
It serves as:
- Protective barrier (anatomical)
  - Prevents internal tissues from exposure to trauma, ultraviolet (UV) radiation, temperature extremes, toxins, and bacteria.
- Sensory perception
- Immunologic surveillance
- Thermoregulation
- Control of insensible fluid loss → incase of burns → lose skin → lose fluid

2/3/2024

Dr. M. Almadani

Wounds

Disruption of normal continuity of bodily structures due to trauma.
Types:

Incised (Tidy): Clean cut, inflicted by sharp object (knife, glass), no devitalized tissue. eg. Surgical wound

Lacerated (Untidy): Irregular margin. Caused by crushing, tearing, blunt knife contains devitalized tissue. → main source of wound infection

Abrasions: Friction damage. Superficial bruising & loss of varying skin thickness. → depending on the force applied

2/3/2024

Dr. M. Almadani

Wounds

For TTT: Cut the skin because it will not survive, there will be necrosis within 24-48 hours and there will be gangrene of affected part.

Degloving: Shearing forces, extensive section of skin is completely torn off the underlying tissue, severing its blood supply. Skin remain intact but deprived of blood supply (Skin may be attached by the edges but its blood supply is severed)

Fenetrating Knife and gun shots. High velocity wounds are associated with extensive deeper tissue injuries.

Leg, intra abdominal organs

2/3/2024

Dr. M. Almadani

AEC (DEH)

Types of wound healing

Primary (First intention)

best type of healing approximation of skin, using sutures or clips bring 2 edges together

Wounds are sealed immediately, may done for wounds <24 h
Clean type → neat and clean wounds (no devitalized tissue)
Simple suturing & Skin graft /flap

Secondary (Second intention)

No closure
Highly contaminated wounds
Re-epithelialization > Wound contracture

leave area to heal, do dressings slowly and gradually, treat infection and healing occurs by 2ry intention There will be a scar, because no approximation of skin occurs.

Tertiary (Third intention)

Delayed primary closure (use Closure Suture)
Contaminated wounds treated first, once the wound is clean then closed → done after debridement and cleaning of wound

2/3/2024

Dr. M. Almadani

Wounds managements

→ for larger wound or cosmetically exposed

▲ mostly

▲ Small wounds esp. for non cosmetically exposed

2/3/2024

Dr. M. Almadani

Wounds managements

Incised wound:
Primary closure
Lacerated wound:
Wound debridement.
Primary or Tertiary.
Grossly contaminated/infected:
left to heal by secondary intention.
Degloving injury: → (devitalized hanging skin) (can reach extent of bones being visible)
Excision of devascularized skin, skin grafting/flap.

later do

2/3/2024

Dr. M. Almadani

difference between graft and first

Wounds managements

Thin slice of epidermis and part of dermis taken from donor area and transplanted to recipient area

Grafts: are the tissues that are completely detached from the body before it is transplanted to other host bed.

recipient area

DONOR AREA → eg. from thigh
RECIPIENT AREA → eg. to arm
not contain blood supply (blood supply is not transferred)
graft depend on blood supply of recipient area
grafts applied to wound that is healed and red, and granulation tissue appear on the floor

2/3/2024

Dr. M. Almadani

Wounds with skin loss

Small skin defect:
- Aesthetically or functionally unimportant
- Allowed to heal by secondary intention.
Large skin defects:
- Skin “graft”:
  - All vessels nourishing the graft are cut
  - Types: Full thickness, Partial thickness → both are detached from blood supply
- Skin “flap”:
  - Some aspect of the blood supply to the segment of tissue has remained intact during transfer. → blood supply remain attached until revascularization occurs

2/3/2024

Dr. M. Almadani

grafts:

Split skin (Thiersch) graft (Partial thickness)

Epidermis with a portion of the dermis
Graft taken by electric dermatome → an instrument
Donor site: Heal by epithelialization from skin appendages → so epithelium grows from inside and covers it by itself
Graft can be expanded by ‘meshing’ to cover larger area.
Thinner graft take more easily on imperfect vascular bed.
Used for covering granulating areas and burns.
Do not take on bare bone, cartilage and tendons → only put it on granulation tissue not on bare areas
Appearance not as good as full thickness graft. (because bare areas not have blood supply) because its a very thin layer

2/3/2024

Dr. M. Almadani

Split skin (Thiersch) graft

There should be no infection and area should be healing and presence of granulation tissue

↓

ready recipient area to receive graft

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Dr. M. Almadani

Dermatomes

epithelium will grow in those holes

→ used to take Skin so it can be applied on recipient area

②

Full thickness graft

Full portion of the dermis with the epidermis.
Grafts survival:
- Absorption of nutrients from recipient area capillary beds & angiogenesis.
5 days are required for definitive vascular ingrowth to occur.
Dressings left on the recipient site for this period of time.

more time because it is full thickness

So good healing occurs and it develops its blood supply

2/3/2024

Dr. M. Almadani

Full thickness graft

Do not shrink, looks better and stronger than partial thickness
Graft retain functional hair follicles and sweat glands.
Commonly used in “reconstructive surgery.”
Donor area covered by suture or graft.
Chosen sites has “spare skin” - groin, behind the ear So its better than partial thickness graft because there will be no appendages left so no epithilization occurs
areas where there is naturally extra loose skin

2/3/2024

Dr. M. Almadani

Flaps

and this blood supply is cut once the recipient area makes its own blood supply

DEF: Flap is a tissue with its original blood supply (bring their own blood supply)
Thicker and stronger than graft. → because they contain skin, subcutaneous tissue and even sometimes muscles.
Can be applied to avascular surfaces – bone, tendon, or joints.
Commonly used in “reconstructive surgery” → esp. breast reconstruction surgery after mastectomy (basic difference between flaps and grafts)

2/3/2024

Dr. M. Almadani

Flaps

How the diffuses

Types:

Local flaps used for covering small defects after surgical excision of small tumors (v-y advancement, rotation flap, rectangle advancement) To eg. BCC by taking skin locally (use skin beside the defect)

Types based on how its taken geometrically

2/3/2024

Dr. M. Almadani

Flaps

Distant flaps: Remains attached to its original blood supply until new one developed locally (2-3 weeks), Then pedicle is divided.
Free flaps: Grafts blood supply is restored locally by microsurgery.
Composition: Cutaneous, fasciocutaneous, myocutaneous, osteo-myocutaneous Include many things: Skin, fascia, muscle, osteomyocutaneous tissue

2/3/2024

Dr. M. Almadani

Pedicle flap

Distant flap

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Dr. M. Almadani

Skin, & soft tissue lesions

→ Superficial

Skin lesions are attached to skin → eg. sebaceous cyst, epidermal cyst → skin can’t be pinched
Epidermal lesions cause surface irregularity
Dermal lesions do not
Pigmented lesions indicate melanocytic lesions
Subcutaneous lesions: → eg. lipoma, Dermoid cyst → below epidermis and dermis
skin can be pinched up or moved independently over swelling

2/3/2024

Dr. M. Almadani

Skin infections

become Folliculitis (infection of hair follicle)

Boil (Fruncle) → involve Skin, surrounding hair follicle and surrounding subcutaneous tissue

Carbuncle → when may Boils join together and there are multiple openings → most severe form → may cause toxemia

Stages of some infection

Erysipelas
Impetigo
Cellulitis
Necrotizing soft tissue infection (Necrotizing fasciitis)

2/3/2024

Dr. M. Almadani

Skin infections

Folliculitis is a tender pustule that involves the hair follicle
Furuncle involves both the skin and the subcutaneous tissues in areas with hair follicles
A carbuncle is an aggregate of connected furuncles and has several pustular openings

2/3/2024

Dr. M. Almadani

Skin infections

2 • Boil

2/3/2024

Dr. M. Almasani

Skin infections

Carbuncle: is an aggregate of connected furuncles and has several pustular openings

TTT:

incision and drainage and send for culture and sensitivity, do dressing, and give antibiotic

2/3/2024

Dr. M. Almadani

Skin infections

• Erysipelas: Erysipelas is a skin infection, well demarcated involving the upper dermis extends

into the superficial cutaneous lymphatics.

Surgical emergency
Swelling, red, hot, edematous appearance over skin
usually involve the legs
more common in diabetic patients
Superficial infection, involve epidermis, and may extend to superficial lymphatics
non-necrotizing inflammation
well²/³ demarcated

Dr. M. Almadani

TTT for both Erysipelas and Cellulitis:

rest
antibiotics
debride pustule if Present

Skin infections

Cellulitis: Non-necrotizing inflammation of the skin and subcutaneous tissues, usually from acute infection

acute
more common in diabetic patients
non necrotizing inflammation
deeper than erysipelas
ill defined margins
red, hot, tender

2/3/2024

Dr. M. Almadani

Skin infections

below skin

Necrotizing fasciitis: is a rapidly progressive inflammatory infection of the fascia, with secondary necrosis of the subcutaneous tissues

Usually poly microbial →
Risk factors
DM · Trauma
Obesity
Malnutrition
Immunocompromised

so antibiotics given should cover gram the and -ve. anaerobic (metronidazole)

according to region

Fournier’s (scrotum; penis perineal)
Meleney’s (abdominal wall gangrene)

2/3/2024

TTI: aggressive debridment, antibiotic, later repair with graft

% of the recosed tissue and normal tissue till it starts to bleed

Sebaceous gland produce sebum and gland becomes blocked forming cyst

Sebaceous cyst

“Epidermal” Cyst
Dermal swelling covered by epidermis
Thin wall
Filled with sebum
Typical punctum
Blocked sebaceous glands
Treatment: excision

2/3/2024

Dr. M. Almadani

Dermoid cyst

midline swelling

It is growth of normal tissue enclosed in a pocket called a sac
Congenital vs acquired
A cyst is a lump that may contain fluid or other material
Most often greasy yellow material but may be other

like skin appendages

TTT: excision

2/3/2024

Dr. M. Almadani

Tumors of the skin, & subcutaneous

• Benign:

Papilloma
Dermatofibroma
Keratoacanthoma
Benign pigmented moles
Haemangioma
Neurofibroma
Lipoma

• Premalignant lesions: → if left untreated become malignant

Actinic (solar) keratosis
Bowen’s disease
Marjolin’s ulcer

• Malignant:

Squamous cell carcinoma
Basal cell carcinoma
Malignant melanoma
Dermatofibrosarcoma protruberans
Liposarcoma
Fibrosarcoma
Kaposi’s sarcoma

2/3/2024

Dr. M. Almadani

1. Benign lesions

1. Papilloma: → most common one

Finger like projection from skin.
Covered by normal skin. usually Pedunculated
Treatment : Excision looks benign, not hot or red

2/3/2024

Dr. M. Almadani

Benign lesions

2. Keratoacanthoma:

Hemispherical nodule → (like BCC or SCC)
Friable center covered with keratin
Common site - face
Age - over 50 → elderly
Heals spontaneously after shedding central core.
Confused with squamous cell carcinoma.

2/3/2024

Dr. M. Almadani

Benign lesions

3. Dermatofibroma:

Brownish, firm to hard, nodular, single/ multiple
Commonly over hand or feet
Freely mobile over deeper structures
Treatment: Excision

2/3/2024

Dr. M. Almadani

4. Benign pigmented moles

A developmental abnormality due to aggregation of melanocytes (naevus or moles)
Types: (by histopathology)
Junctional moles: Melanocyte activity is at the junction of epidermis and dermis- moles of palm and sole.
Dermal naevus: Migration of sheets of melanocytes to dermis.
Compound naevus: Migration of sheets of melanocytes to dermis & epidermis.

usually congenital or from childhood, but may appear later on.

2/3/2024

Dr. M. Almadani

Benign pigmented moles

Common moles:
- Flat or raised brown-black lesion covered by normal epidermis.
- May show some activity in childhood.
- Becomes quiescent after puberty.
Alert: Increased pigmentation, itching, scaliness or bleeding- suggest malignant change.

2/3/2024

Dr. M. Almadani

Benign pigmented moles

Giant hairy naevus: → has least malignant potential
- Present at birth,
- Over trunk, face.
- Low risk of malignant change
- Excision: Cosmetic → if its on areas where its cosmetically visible

2/3/2024

Dr. M. Almadani

5. Hemangioma

A- Involuting type: → meaning: they regress with time

True neoplasms arising from endothelial cells.
Present at birth or appear within weeks
Predominantly affect head & neck.
Types:

Superficial lesions (strawberry)

bright-red, raised, irregular, & bosselated.

Deeper lesion :- blue-black tumor covered by normal skin.

more likely to develop complications of ulceration, bleeding.

once ulcerated may lead to infections

2/3/2024

Dr. M. Almadani

Hemangioma

Involuting type:
Grows for first 6 months, static until 2-3-years age.
Usually disappear before child is 7 years of age.
Complications: Ulceration, bleeding, coagulopathy

if complications Treatment: Laser photocoagulation or intra-lesional steroid help early involution

*if no complications → don’t treat, it will resolve on its own

2/3/2024

Dr. M. Almadani

Hemangioma

B. Non-Involuting type:

Hamartoma of abnormal blood vessel formation
- Bright-red patchy lesion on face or scalp.
- Often overlies a peripheral nerve distribution.
- No spontaneous regression or growth.
- Good result with CO above the scan.

2/3/2024

Dr. M. Almadani

Types of noninvoluting:

Hemangioma

Cavernous haemangioma: →venous origin
“Bluish-purple elevated mass” appearing in early childhood
Composed of mature vein like structures.
Positive sign of emptying. (compressibility) → (compressed and when release my finger they are filled up again)
Treated by excision. → and feeding vessels are ligated
Cirsoid aneurysm:
Lesion is fed by arterial blood → (arterial origin) → So may bleed alot So embolize it before excision
Tortuous, and pulsating
Treatment: Angiographic embolization prior to excision.

2/3/2024

Dr. M. Almadani

6. Neurofibroma

Commonly seen in Surgical OPDs having nodularity along

Hamartoma of peripheral nerve sheath.
Neurilemmoma (schwannoma)
solitary
No malignant potential.
Neurofibroma (peripheral nerve tumor)
solitary or multiple (von Recklinghausen’s disease)
Autosomal disorder, present at birth or early childhood
Patches of skin pigmentation (café au lait’ spots)
Increase in size or new swelling suggest malignant transformation

become painful

nerve distribution along the body. usually they are non tender and freely mobile

if not complicated → leave it alone don’t treat (because can’t cut all the nerves) 2/3/2024 Dr. M. Almadani

2. Premalignant lesions → all are due to UV rays

• Actinic keratosis (solar keratoses):

Small, single or multiple warty spots on the face, back of neck or hands of fair skinned
dry scaly patches of skin that have been damaged by the sun
Elderly
Biopsy for diagnosis.
Treated by cryosurgery.

2/3/2024

Dr. M. Almadani

Premalignant lesions

2. Bowen’s disease: (SCC in situ)

very early form of skin cancer
Cause: long-term exposure to the sun – especially in people with fair skin
It affects the squamous cells, which are in the outer layer of skin (epidermis)
‘Elevated red scaly plaque’ on the exposed area of body.
Gradually enlarge & thickens.
Transform into SCC.
Biopsy for diagnosis
Treatment: excision, cryosurgery or topical 5-fluorouracil.

depend on stage

best one

in early stages

(anti cancer element)

2/3/2024

Dr. M. Almadani

Premalignant lesions

3. Marjolin’s ulcer:

Cutaneous malignancy that arises in the setting of :
- chronic wounds
- longstanding scars
- previously injured skin
- Chronic non-healing burn scars (due to chronic inflammation and cellular proliferation)
Turn into SCC.
Grows slowly.
Lymphatic metastasis unusual- less vascularity & lymphatics in the scar.
Treatment: excision with wide margin.

2/3/2024

Dr. M. Almadani

3. Carcinoma of epidermis

Occurs primarily on exposed areas → due to UV rays
Albinos, xeroderma pigmentosa (undue sensitivity to sunlight).
Chronic irritation: chemicals, chronic ulcer, radiation exposure, exposure to sunlight.
Age: > 50 elderly
Pathological types: Basal cell (80%) & Squamous cell carcinoma (16%)
- more common
- more aggressive
- less common

2/3/2024

Dr. M. Almadani

I - Basal cell cancer (BCC)

BCC arises from basal layer of epidermis
Common in Elderly, commonest skin malignancy (80%)
Slow growing, locally invasive (rodent ulcer).
Rarely metastasize (malignant cells larger than the size of lymphatics) (<0.1%).
Site: Middle third of the face- nose, inner canthus of eye, forehead & eyelids.
Earliest lesion- hard pearly nodule, dimpled in Centre

2/3/2024

Dr. M. Almadani

Basal cell cancer (BCC)

Degeneration makes the lesion translucent and raised.
Ulcerated lesions - rolled edges. → Typical finding → due to dimpled center
Repeatedly scales over and breaks down.
Aggressive tumors burrows deeply and destructive to skin and bone.
Extremely radiosensitive (when surgery is contraindicated or very difficult e.g. near the eye)

2/3/2024

Dr. M. Almadani

Basal cell cancer (BCC)

→rolled edges • dimpled center

2/3/2024

Dr. M. Almadani

Basal cell cancer (BCC)

Diagnosis: Biopsy (Bx):
- excisional (small lesions) → Diagnostic and therapeutic → Send Srecimin to histopathology
- incisional or punch bx (large lesions)
Management:
- Surgical excision with adequate margins or radiotherapy (RT)
- Small lesion-: cryosurgery, curettage and cautery
- Late presentation- reconstructive surgery to restore appearance & function.
Contraindications of RT: if lesions are close to eye or over the cartilage.
- if Surgery is contraindicated

2/3/2024

Dr. M. Almadani

2. Squamous cell cancer (SCC)

Less common, more aggressive (16%)
Arise from keratinocytes of the epidermis
Common sites: Ear, lips, back of hand. Any other area. back of scalp & common site
Early lesion - hard erythematous nodule

Cauliflower like ulcer, with raised everted edge. → Typical finding

Metastasis: Regional lymph nodes (≥ 10 mm thick)

very common to lymphatics and to blood poor prognosis

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Dr. M. Almadani

back of scalp

Squamous cell cancer (SCC)

ideal treatment

Treatment: Excision with a 1-cm margin.
Histologic confirmation of tumor-free margin. → this is necessary
Regional lymph node excision- if clinically palpable.
Lesions on the face, nose or eye.
cosmetically imp area
not have much tissue to be excised

Excision by Mohs’ technique

Serially excise a tumor by taking small increments of tissue until the entire tumor is removed.
Clear margin confirmed by frozen sections.

(excision with tumor free margins) (normal tissue)

if metastasize to regional LNs

if its in foot or leg, it will go to inguinal LN
if its in arm, it will go to cervical LN

2/3/2024

Dr. M. Almadani

other options for treatment: Squamous cell cancer (SCC)

Radiation therapy:

Small and superficial lesions
Adjuvant therapy (along with surgery)
Cure rates are less comparable to surgical excision
Metastatic disease:
- Poor prognostic sign
- 13% patients surviving after 10 years

2/3/2024

Dr. M. Almadani

Malignant melanoma

malignant form of nevus/mole

Malignant transformation of melanocytes
Most deadly skin cancer. high mortality and morbidity
Comprises 4-8% of skin cancers less common than SCC
Predominantly affect fair-skinned people
More common in females
Major cause- exposure to sunlight
Half of malignant melanoma arises in pre-existing naevi.
Any new nevi after 40 years old- should be dealt as melanoma

warning sign

2/3/2024

Dr. M. Almadani

Malignant melanoma

Types:

Superficial spreading melanoma
Hutchison’s melanotic freckle (lentigo maligna)
Nodular melanoma
Amelanotic melanoma
Acral lentiginous melanoma
Subungual melanoma

2/3/2024

Dr. M. Almadani

Malignant melanoma

Superficial spreading melanoma

Commonest type.

Commonly affects middle aged.
Common site: trunk or exposed areas.
Premalignant phase:- malignant cells spread outwards, surface slightly raised, pigmentation patchy and outline indistinct.
Invasive phase:- spreads down into dermis while lesion still small.
Indurated nodule.
Soon ulcerates or bleeds.

2/3/2024

Dr. M. Almadani

Malignant melanoma

2. Nodular melanoma:

Elevated, deeply pigmented lesions.
2nd most common type & most aggressive form.
May develop in a pre-existing benign naevus.
No initial intraepithelial spread.
Nodule enlarges steadily in all direction.
Darkens progressively, active area is jet black.
Typical findings: itching, ulceration, bleeding, crusting, scab formation.
Appearance of satellite nodules- metastasis

→ (alerting signs in benign conditions)

sign of

2/3/2024

Dr. M. Almadani

Malignant melanoma

3. Hutchison’s melanotic freckle (lentigo maligna)

light brown colored areas

Brownish-red patch
On the face of elderly
Grows slowly over years.
Least aggressive
Serrated margin.
Premalignant phase- lasts for 10-15 years.
Malignant change- brownish red papule, develop eccentrically within freckle.

2/3/2024

Dr. M. Almadani

Other types of melanoma

4. Amelanotic melanoma:

Rare, pale pink lesion (less pigmented)
Grows rapidly
Histology demonstrates pigment

5. Subungual melanoma:

Nail bed of thumb or big toe
Pigmentation not visible in early stage
Misdiagnosed as paronychia (nail infection) or ingrowing toenail

if there is no history of trauma and something appears on nail, be alerted.

2/3/2024

Dr. M. Almadani

Other types of melanoma

6. • Acral lentiginous melanoma:

Site: Over sole and palm.

So may be ignored or misdiagnosed • Thick skin masks some features. • Presents late with nodularity and ulceration.

Fig. 18.24 Acral lentiginous melanoma arising on the sole of the foot.

2/3/2024

Dr. M. Almadani

Malignant melanoma

Spread: → (like SCC)
Lymphatics: - regional nodes.
In transit metastasis along lymphatics- satellite nodule.
Blood-borne: Brain, liver, lungs, skin subcutaneous.
Staging:
Clinical stage
TNM stage

(histological) Mitotic activity & lymphocytic infiltration- influences prognosis

2/3/2024

Dr. M. Almadani

Malignant melanoma

Table 18.6 Prognosis in relation to the stage and depth of malignant melanoma
Clinical stage	5-year survival rate (%)
I Primary lesion only → Breslow depth (mm)	The more thickness of the less survival rate
<1.5	(due to longer duration and more advanced)
1.5–3.5	about its still curable because its stage 1
>3.5
II Primary lesion + regional lymph node or satellite deposit	30
III Metastatic disease	0

Classification	Thickness (mm)	Ulceration Status/Mitoses
T
Tis	NA	NA
T1	( \leq 1.00 )	a: Without ulceration and mitosis ( < 1/mm^{2} )b: With ulceration or mitoses ( \geq 1/mm^{2} )
T2	1.01-2.00	a: Without ulcerationb: With ulceration
T3	2.01-4.00	a: Without ulcerationb: With ulceration
T4	>4.00	a: Without ulcerationb: With ulceration
N	No. of Metastatic Nodes	Nodal Metastatic Burden
N0	0	NA
N1	1	a: Micrometastasis* b: Macrometastasis†
N2	2-3	a: Micrometastasis* b: Macrometastasis†c: In transit metastases/satellites without metastatic nodes
N3	4+ metastatic nodes, or matted nodes, or in transit metastases/satellites with metastatic nodes
M	Site	Serum LDH
M0	No distant metastases	NA
M1a	Distant skin, subcutaneous, or nodal metastases	Normal
M1b	Lung metastases	Normal
M1c	All other visceral metastases	Normal
	Any distant metastasis	Elevated

Abbreviations: NA, not applicable; LDH, lactate dehydrogenase.

*Micrometastases are diagnosed after sentinel lymph node biopsy.

†Macrometastases are defined as clinically detectable nodal metastases confirmed pathologically.

2/3/2024

Dr. M. Almadani

Malignant melanoma

Treatment:

→ excision with tumor free margins → not only surroundings but also in the depth

Excision biopsy to determine the depth of tumor.
Healthy tissue margin depends on tumor thickness.
Small lesion:
Excision with a clear margin of 3 mm down to deep fascia.
Smaller defects closed by primary suture.
Larger defects closed by skin graft or flap.
SLNB: Sentinel LN is the 1st node that drain the lesion.
LND: Stage II or primary lesion overlies LN

(LN dissection) nodes are enlarged

Adjuvant therapy:

Immunotherapy, molecular therapy, isolated limb perfusion

To get the tumor free margin of deeper tissues

2/3/2024

Dr. M. Almadani

Uncommon malignant lesions

Dermatofibrosarcoma protruberans:

Rare invasive tumor of the dermis
Presenting as red or bluish firm painless mass.
Rarely metastasize.
Treatment: wide surgical excision, RT reduce risk of recurrence.

Liposarcoma:

Arise from any fatty tissue.
Treatment: Wide surgical excision.

*malignant transformation from long standing or larger lipomas

2/3/2024

Dr. M. Almadani

Uncommon malignant lesions

Kaposi’s sarcoma:
Neoplasm of capillaries and perivascular connective tissue.
Multifocal in presentation.
May be associated with AIDS or other immunocompromised state.
Lesions appear as purplish nodule.
Legs most commonly involved.
Treatment: unsatisfactory.
RT or
immunotherapy may help. not sufficient and cure rates are low

2/3/2024

Dr. M. Almadani

Thanks

2/3/2024

Dr. M. Almadani

🩺 MedAtlax

Explorer

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Skin, & Subcutaneous Tumors

Objectives

Skin structure, & function

Skin structure, & function

②. Dermis: → Thicker part

Skin function

Wounds

Wounds

Types of wound healing

Primary (First intention)

Secondary (Second intention)

Tertiary (Third intention)

Wounds managements

Wounds managements

Wounds managements

Wounds with skin loss

Split skin (Thiersch) graft (Partial thickness)

Split skin (Thiersch) graft

Dermatomes

②

Full thickness graft

Full thickness graft

Flaps

Flaps

Flaps

Pedicle flap

Skin, & soft tissue lesions

Skin infections

Skin infections

Skin infections

Skin infections

Skin infections

Skin infections

Skin infections

Sebaceous cyst

Dermoid cyst

Tumors of the skin, & subcutaneous

• Benign:

• Premalignant lesions: → if left untreated become malignant

• Malignant:

1. Benign lesions

1. Papilloma: → most common one

Benign lesions

2. Keratoacanthoma:

Benign lesions

3. Dermatofibroma:

4. Benign pigmented moles

Benign pigmented moles

Benign pigmented moles

5. Hemangioma

Hemangioma

Hemangioma

B. Non-Involuting type:

Hemangioma

6. Neurofibroma

2. Premalignant lesions → all are due to UV rays

• Actinic keratosis (solar keratoses):

Premalignant lesions

2. Bowen’s disease: (SCC in situ)

Premalignant lesions

3. Marjolin’s ulcer:

3. Carcinoma of epidermis

I - Basal cell cancer (BCC)

Basal cell cancer (BCC)

Basal cell cancer (BCC)

Basal cell cancer (BCC)

2. Squamous cell cancer (SCC)

Squamous cell cancer (SCC)

other options for treatment: Squamous cell cancer (SCC)

Radiation therapy:

Malignant melanoma

Malignant melanoma

Malignant melanoma

Superficial spreading melanoma

Commonest type.

Malignant melanoma

2. Nodular melanoma: