All right, so I'm going to start with skin cancer and related lesions, and then my second talk is going to be on amputations and prosthetics. So just a reminder, the layers of the skin, although the thicker skin is overall thicker, it's got less dermis to it and also has fewer appendages. The thin skin has hair appendages and more dermis to it. This affects both how we may treat primary lesions and things we may do to reconstruct it. I'm going to start with the things that actually aren't yet cancers but may look like them, some of which have been mentioned in other talks, but just to briefly go through them. There are a lot of questions on these every year in the self-assessment, typically three to six every year, so I'd expect at least a couple of these. I know we'll have more questions at the end, so I won't spend too much time on these. But these are priable, shiny lesions that can occur on a finger or they can occur more proximally. If you knock them off, they will grow back. And what is it? And then what do you do for it? It's a pyogenic granuloma, and the answer is you need to get just beyond it. So marginal incision won't do. It's not truly a cancer, but these are stubbornly recurrent if you don't get healthy tissue back to healthy tissue. These are typically associated with trauma, which can include surgical trauma. So sometimes your non-healing wounds will develop these, as John mentioned earlier. Silver nitrate is a good initial treatment, especially if it's a smaller lesion, but sometimes that will not work. Other non-invasive treatments have been tried. In my hands, I'll give them one or two tries with silver nitrate, and if it doesn't go away, a simple incision with a one-millimeter margin is usually enough for them. Another self-assessment exam, we see a lesion on the dorsum of the hand in a guy we know has a lot of sun exposure, and it's been growing actually very quickly. That's one of the hallmarks of this is it actually grows much faster than we would expect a cancer to do. So this is actually a non-malignant keratoacanthoma. It grows, again, it can grow faster than you would expect a cancer to grow. The scale in the middle can look a little bit like an ulceration of a cancer. While it may regress spontaneously, most of the time we treat these to make sure that they are not cancer. And again, histologically, warn your pathologist or ideally get a dermatopathologist just because they can look a little bit like swain, and that would affect the margins that you need and what else you might need to do. Solar lentigo, sun-exposed areas, older patients, unlike freckles, these do not change their intensity of brown based on sun exposure. As patients get older, they get more of them. If there's any suspicion of this from melanoma, a biopsy will be able to distinguish them, as I'll get to later in the talk. These need to be full-thickness biopsies. They can be incisional, they can be punched, but anything that is brown needs a full-thickness biopsy. Surgical incision for cornucutanium, so this is actually on last year's exam and why they went with the Latin rather than the English. Cutaneous horn, which we do see these, and the main reason we worry about these, other than the fact that they're ugly, is there some association with squamous cell carcinoma at the base. Actinic keratosis, now moving into the premalignant lesions. These are hyperkeratonic. There's more superficial layers of the epidermis, scales adhering to a pink base. These are in sun-exposed areas. Hands and forearms face other areas like that. While they can convert to malignancy, that's not all that common. The problem with these, typically, these are very broad areas. You'll see an entire dorsum of the hand or an entire forearm that's affected by this. Because these are usually field effects, usually we'll let the dermatologist treat these and they'll use things like cryotherapy, 5-fluorouracil. And then only if they have a focal area that they're worried about malignant transformation will I take care of them and do an excision. And many times you will find squamous in situ or other things that did need surgery. Speaking of which, Bowen's disease, which is the eponym for squamous in situ. Now we have actual malignant cells, but they have not yet violated the dermis. These can look like warts, crusty, scaly. They are typically in the non-glabrous skin. A little bit higher rate of conversion to squamous cell, about 1 in 30 of these. And you can do kind of any of the range of what the dermatologist would do for actinic keratosis all the way to what we would do for squamous. And a lot of it kind of depends on who sees them. The dermatologist will do non-invasive. I will typically excise them. Melanoma skin cancer in general is very dependent on where you live and how dark or not dark your skin is. So if you are in sunnier areas and your skin is lighter, you're going to get more of it. So Australia, 1,000 per 100,000 person years of basal cell carcinoma. Africa, less than 1 per 100,000. England a little bit in the middle, 76. And then U.S., I think these are 2013 statistics, 1.2 million cases of non-melanoma skin cancer per year at the expense of half a billion dollars. Moving on to treatment of these. When we treat things surgically, most of the time we're going to get standard bread loafing. And what that means is we hand our pathologist a chunk of something, they cut a couple of representative cross-sectional slices, and then they look at those on their microscope slide. And as the drawing on the right shows, depending on exactly how they do it, they in theory could have a positive deep margin that was not seen on their section. And I'll talk a little bit later about what are the things that can be done with that. Obviously for any tumors, we want to maximize our likelihood of surgical clearance and lack of recurrence, but we don't want to make a bigger hole and require a bigger reconstruction than we would otherwise need to. So getting to the specific tumor types. Now for plastic surgeons like me in the audience, we all learned that basal cell to squamous cell most places on the body is 3 to 1 basal cell. On the hand, it's reversed. Squamous cell is the most common skin cancer on the hand, about 3 to 1 to basal cell. Basal cell is actually fairly rare in the upper extremities. Very common on the face, clavicles, but not as much on the hands. Plastic appearance, primarily borders, telangiectasias, multiple subtypes, which will have some effect on how we might choose to treat them. Rather nodular, pigmented, and then the sclerosing morphioform, which is a little bit more stubborn. In general, we want to get 5 millimeter margins of normal tissue. Now again, those guidelines are if you're going to do this in a setting where PATH is not immediately available, so you do your 5 millimeter margins and close, that's one acceptable way to do it. If you are going to get margins at the time of, I have a lot of older, sicker patients who may need platelet transfusions or things like that where we really want to get them done in one stage. If you get frozen section analysis, you can have a more definitive answer if your margin is clear and you may not have to go all the way out to 5 millimeters. Destructive techniques, these are something the dermatologist will typically do or not do before they send them to me. I don't do them, but just be aware that these are within the broad medical literature of treatment. Electrodesiccation and curatage, cryosurgery, laser, and the major downside of any of these is there's no specimen to look at. So you don't know your margins, and in theory, an enterprising lawyer could even say you didn't really know that it was basal cell carcinoma. Intralesional and furon injection, chemotherapy, radiation therapy, charitably I put only for poor surgical candidates, really radiation therapy has no role in the treatment of primary cancers of the skin, but again, you will see this in some corners of the medical literature. So a question from the self-assessment exam, a lady who had a finger fungal infection a few years ago hasn't gone away, and as Jonathan mentioned earlier, culture what you biopsy and biopsy what you culture, and this would ultimately come back as a squamous cell carcinoma. So also this one, hopefully this would not just get cultured but also get a biopsy. And then as mentioned earlier, where do these most commonly go to? Regional lymph nodes are where they're going to go to first, and then lung would be second once they get out of the regional lymph nodes. And I'll get into what do we do about patients with metastatic or suspicion of metastatic disease in just a minute. So speaking of squamous cell carcinoma, it is the most common skin cancer of the hand. Again, unlike other areas of the body where it's basal cell, for the hand it is by far a squamous cell. Risk factors are all those things we would expect, radiation exposure, sun exposure, subungual warts, and then chronic wounds, marginal insulcer. As an aside, that is a very aggressive squamous cell carcinoma. It does not behave like the primary idiopathic squamous cells. So this is a patient, hopefully everybody can see the image on the top well enough. With a biopsy-proven squamous cell, you can see erosion of the top of the distal phalanx. That means we're in the bone and simple soft tissue treatment is not going to be enough. But a single joint disarticulation is going to be enough for tumor clearance. Now this one from the 2011 self-assessment exam, the important point of this one is now it's recurrent squamous cell carcinoma. You can see it looks a little bit different than your normal treatment. And so for this one, the right answer is Mohs micrographic surgery. And some of you might say, what is that? I'll tell you. So the original surgery described by Mohs at the University of Wisconsin was actually you put the chemical in situ on the patient and then cut the whole thing out and looked at the edge of the specimen. Fairly morbid to do to the patient. What it has done now is the modified technique is you cut out your specimen and then freeze it in a manner that your entire deep and circumferential margin is flat. And so unlike the risk of bread loafing that I mentioned earlier, where you're only going to see portions of your deep margin, you see the entire deep margin. Very good for tumor clearance. Very appropriate for areas where you're worried about that. Those include recurrent basal and squamous cell, the morpheiform basal cell type, and actually dermatofibrosarcoma. This may be a way where you may not have to do quite 2.5 centimeter margins, which you can imagine on a hand would be pretty destructive. You'll find in the derm surgery literature that they use this for melanoma. The surgical oncology literature is pretty consistent that you should not do that. I would not do Mohs for melanoma. It does work. However, it's expensive and it's time consuming. Generally, this is done over a half a day or sometimes even a full day where the patient is just sitting there in the derm surgeon's office getting an excision. They look at it. It's not clear. They get another specimen. But it is very good for tissue preservation and it's very good for margin clearance. So speaking of squamous cell carcinoma in general, if you're going to do the margins themselves and not get immediate frozen section analysis, 5 to 10 millimeters is your guideline. Obstructive techniques have very high recurrence rates. Again, you'll find these in the literature, but I don't recommend them. And generally, on a surgical exam, they will not be the right answer. Radiation therapy, five floor uracil, again, patients refusing surgery, you will see articles if you look for them in the radiation oncology literature where they quote relatively high cure rates. The problem is in a surgeon's practice, you're going to see stuff that looks like this. This is a late 70s guy who had multifocal squamous cell carcinoma and somebody told him that radiation therapy was a good idea. It did cure his cancer and instead gave him osteonecrosis of his carpal bones. And so to spare him multiple local anesthetic procedures, he instead needed a free flap to treat his disease. So we should not be recommending that. Other types of non-melanoma skin cancers, just for completeness sake, dermatofibrosarcoma protuberans. Again, that sort of is the border of skin versus deeper than skin. It is technically a malignancy, but mostly it is locally stubborn and either very wide margins if you're going to do them yourself or Mohs surgery are going to be appropriate for tumor clearance. Merkel cell carcinoma, sweat gland carcinoma, these are fortunately very rare because these are really bad actors. Unfortunately, fairly high mortality rates for both of them. These are just photographs of them. Moving on to pigmented things. So the nevus is the standard pigmented lesion. All of us have them somewhere. They're in two major types. The acquired type occurs at greater than six months of age. There are various subtypes based on are they in the epidermis, epidermis and dermis or just in the dermis. And then finally, acral or if they're in the glabrous skin or subungual or other areas that have different epithelial tissue. Congenital nevi are present at birth. They grow proportionally with the child. Giant nevi, there's a little bit of disagreement on what counts, whether it's 10 centimeters, 20 centimeters or an estimated 1% or more of the surface area of the child. Certainly higher than general nevi risk of malignant degeneration, although that number you'll notice is pretty broad, anywhere from 0 to 9%, 9%, 1 in 11, that'd be pretty high. For those children who are going to get malignant degeneration, 70% of those occur by the time they hit puberty. The ABCDs of melanoma, this is very fair game for a test. Asymmetry of the border, or excuse me, asymmetry of the mass itself, irregularity of the border, variability of the color, again, a nice even brown tone is less dangerous. And then finally, diameter. We used to say the back of a pencil eraser, which is six millimeters, but not many of us are walking around with those anymore. So a disposable pen is a reasonable estimate. That's about a six, seven millimeter diameter. A typical nevi, or sometimes called this plastic nevi, and these have ranges of severity, typically they have one or more of the ABCDs that make us nervous. If they're symmetric in growth and if they're uniform in how they are getting dark, that's less worrisome than if they're doing more in some areas of the nevus and less than in others. Change in an existing nevus is rare. If it is changing, that's a reason to get a biopsy. If it is just an atypical nevus, a one to two millimeter margin is curative. Now if it comes back as melanoma, you will then have to go back and do more, but at least as an initial treatment, that is appropriate. Again, these are all pretty fair game questions for the test. Melanoma in situ. Now we have malignant melanocytes, but they have not invaded yet. Sometimes called lentigo maligna or Hutchinson's freckles. These do have a higher incidence in sun damaged skin, particularly in areas where we have epidermal atrophy or other things that show you this is skin that has seen a lot of sunlight. And it can occur within a pigmented actinic keratosis or seborrheic keratosis. So again, if something is brown and worrisome, your technique of biopsy needs to be the same, full thickness, so that you can, in the event it is a melanoma, you can get a proper diagnosis and get the patient a proper treatment. So peri-angular extension of melanonechia. So again, we have something brown, and it is changing. This was on last year's self-assessment exam. What are we worried about? We're worried about melanoma. We're going to get a full thickness biopsy. Melanoma is becoming more frequent, fortunately, though the proportions of types are staying the same. Superficial spreading is the least aggressive of the melanomas. The melanomas are still the bad actors of skin cancer. And what that means is it's going to spread radially before deep. The more dangerous cancers are as they get deep. Nodulars about 20%. And then acral antigenous are the very tough ones, because they're on the palms, on the soles, places we're not looking at very frequently. They're also often in darker skinned individuals. People were less suspicious, in general, of getting melanomas. So these are just representative photographs of each of these. And acral antigenous, palms, soles, nail beds. So melanoma, its dangerousness depends first on how thick it is in a vertical dimension. And this is a simple ruler measurement on the microscope slide. If it's ulcerated, you don't try to estimate where the top of it would have been. It is a simple linear measurement, top to bottom. We used to talk about Clark's levels, which talked about the anatomic layers of the dermis. It doesn't correlate well with disease survival. So it may be mentioned as an aside, but it does not affect what we do for them. Sorry, this is a very busy slide talking about the AJCC staging of this. Simple versions. Stages 1 and 2 are local tumor only. The thicker it is, the worse it is. Stage 3, now you have nodal disease. Stage 4, now you have metastatic disease. And as with any other tumor, as your stage goes up, survival goes down. Surgical treatment for a thumb-suggung malignant melanoma in a 62-year-old, unfortunately, they don't give us a thickness measurement. And so that would actually affect how wide a margin you would want. But typically, your initial treatment would be at the interphalangeal joint, because remember, there is a fair amount of distance between when the nail bed ends and when the interphalangeal joint is. Also, you have bolder skin that you can bring up for reconstruction. Thirteen-month history, pigment and lesion, right thumb nail bed. We do a biopsy. It's an intermediate thickness melanoma, intermediate meaning between 1 and 4 millimeters. Mitotic rate doesn't affect staging, but just generally speaking, the more mitosis you see, the worse it is. It means it's a more aggressively dividing tumor. What do we do for this? This is where we get into some of the adjuvant treatments, including sentinel lymph node biopsy. So first, talking about the tumor itself, again, this is something where you'll see in derm surgery, most micrographic surgery, surgical oncology says absolutely not. We should be taking these with a margin directly based on the thickness of the tumor. So if you have a thin melanoma, I'm sorry, if you have an in situ melanoma, 5 millimeters radially from the visible tumor is sufficient. Thin melanomas, which is to say less than a millimeter thick, 1 centimeter is enough. Intermediate melanomas, you will go up to 2 centimeters. The rule once upon a time of you had to take 5 centimeters in all directions was based on a single case report of a cadaver. And it turned out that, yes, you'd get great clearance, but you would create a horribly morbid hole on your patient, and you don't need to do that. It doesn't help their survival. So both the American and the European trials came out very conclusively on that about 10 years ago. Lymphatic mapping for axillary lymph nodes has been shown too. So what's the benefit we get out of sentinel nodes as opposed to elective lymph node dissection? Not as many people need elective lymph node dissection. So speaking about that, if you don't do this often, let your Surgeron colleagues do it. It will be done faster. You will have less worry about if it's being done right. It will be done in a less morbid way for those of us who don't dive into the axilla very often. So again, based on both the American and the European trials, there is no benefit of an elective, meaning cleaning out the lymph node basin dissection in the absence of either a positive sentinel lymph node or palpable lymph nodes. So in summary, for the non-pigmented lesions, there are unfortunately a lot of precursor lesions and a lot of things that look like cancer but aren't. Squamous is about three times more common than basal. For excision, simple surgical excision with margins is accessible. If it is recurrent, if it's one of the more pesky types, like morphia form, Mohs surgery may be valuable to maximize your rate of tumor clearance. Non-surgical treatment is referred for people who are poor surgical candidates or who are absolutely refusing surgery. But unfortunately, sometimes that cure is worse than the disease. For pigmented lesions, full thickness biopsies. Please, please don't shave a pigmented lesion. Full thickness biopsy. They are staged by thickness. Margin will be up to two centimeters, but not beyond that because there's no survival benefit beyond that. If you have a greater than one millimeter thick, and some people will say three quarters of a millimeter, but with ulceration or a high mitotic rate, a sentinel lymph node biopsy is appropriate. If you don't do these often, involve somebody who does.

skin cancer

lesions

treatment options

melanoma

surgical excision

biopsies