All right, so we're going to move on from the benign lesions to the malignant lesions, and again, here's Mark Rekamp from Philadelphia. Thank you, Josh. So some disclosures, nothing really that has any application today. I think we've heard sort of the benign side, so just moving into some malignant cases. You can see here that there's an increasing incidence of skin-related cancers across the U.S., and you can sort of see the numbers here, attributes to 1% of our cancer deaths. Some etiologic factors, certainly sun exposure or UV exposure is tops, perhaps radiation exposure, chemical carcinogens, viral. Moving into basal cell carcinoma, certainly there is the – let me see if I can get this arrow out of the way. Mainly affects Caucasians, it's typically sporadic, it doesn't metastasize quite often, so it's really a local annoying problem. It's the immature cells of the basal layer, as the name would connotate, and you can kind of see these clusters of cells here on this slide. Treatment generally, excision is the best option. Certainly there are alternatives for nonoperative patients, such as curatage and cautery, the topical creams, photodynamic therapy, and perhaps radiotherapy for areas that cannot be surgically addressed. Just a quick example, I don't know if it projected terribly well, but kind of lesions right in here, and this is small enough that it was excised and allowed for secondary healing in this area, since it was basically too small for a skin graft. You could also move forward with full-thickness skin grafting. As you can see in this example, rotational flaps have been described for this, but it's basically a fairly benign malignant type of cancer, if you can say that as an oxymoron, and quite readily be treatable with excision. So this is a busy slide, so I kind of dumbed this down with what do we do for different margins, and in essence, if the lesion's under two centimeters, generally speaking, we're going to shoot for a five-millimeter margin. If it's larger than two centimeters, then you try to get a one-centimeter margin. And then, obviously, certainly, there are certain areas that it just doesn't play out to get five millimeters, and in those cases, maybe we're going to call it cheating a little bit in these critical areas, where we'll get a two-millimeter margin, get a frozen section, and confirm if there's no tumor in that, then move forward, rather than take a large amount of skin that may require further reconstruction or alter the joint mechanics, such as in a web space or the tip of a finger. Moving into squamous cell, generally affects older men, again, more so in Caucasians. There's a whole host of differential diagnoses, some of which we've just seen. So some of these squamous cells, their cousins are going to be benign lesions, and there's some differential diagnoses I'll discuss. But generally, again, these are going to have an elevated border. There'll be a neurothematous plaque, and they originate from the spindle cells. So I think this was sort of brought out in the last talk, like the game show, Figure It Out, tissue biopsy, tissue biopsy and tissue biopsy. This was brought out by my father over the dinner table, I think, since I was five. So I think that can't be overemphasized. If you have any questions or concerns, as we just heard, to get a biopsy really can't be faulted. So again, some case examples, here's a lesion that I was able to obtain margins and allow for primary closure, because the skin on the dorsum of the hand had some mobility and ended up healing quite well. Again, this could be treated with a rotational flap if it was larger or in a different location. So again, this is another lesion that came to the office. Anyone want to venture a guess? Obviously, we're in the squamous cell section of the talk. And how would this be treated? And this is a little bit more difficult than the one on the dorsum of the hand. And I think to get adequate margins, a fairer section is taken here. And then you could argue or debate whether this was worthwhile to salvage the fingertip. And I think that's a discussion you have with the patient. You can do this and do a skin graft over some integral, perhaps, rather than do a disarticulation and shorten the finger as an alternative. Another lesion here, again, what could this possibly be? And again, this is a variant of a squamous cell carcinoma. Certainly we wonder what took the patient so long to get to the office. I'm sure Dr. Koh has had some similar experiences here in the city. I'm sure it's not isolated to Philly. And again, how could this be treated? Again, with a wide resection and ultimate skin graft coverage. The lookalikes I was mentioning, certainly up here on the top left, you see simple keloids. I think this was discussed, pyogenic granuloma. And then looking at the cousins here. So, you know, to an untrained eye, and I think this is a value of having these lectures today, is it's helpful to differentiate one versus the other. And certainly from a squamous cell perspective, a basal cell perspective, these two will bleed if the patient hits them and rubs them. So it's one of these things you just sort of recognize. And again, certainly have a low threshold to incisionally biopsy it or incisionally biopsy it before telling the patient it's a simple nothing. Another presentation here. As you can see, a 67-year-old took his time coming to the doctor, and then all of a sudden it was an emergency, as I'm sure you've all had in your practice. The differential diagnosis is sort of these things here that we've discussed. And this also was a squamous cell carcinoma. And again, history is very, very helpful. Got a lot of some exposure as a farmer to his hands. And it turned out it actually was growing for many, many years. Surgical excision with grafting. And initially a drain was placed just because of the size of it. And I don't think there was a way to salvage the radial border digit in this particular lesion. So in essence, what are treatment options for squamous cell? Certainly surgical excision, if done well, is simple, versatile, meaning you have lots of ways to get these things out, whether it's skin grafting or amputation. Elliptical incisions tend to work best. Delayed closure, obviously if you're not sure if you've got your margins, you can't get a frozen section. Perhaps the patient is only amenable to a surgery center because their insurance doesn't pay for a hospital, as we're seeing. You leave it open, get your biopsy results, and then move forward with treatment. Skin grafts, local flaps, we've discussed. Moving on to maybe a lesion that's not quite as simple to treat. The melanoma, which you can see here, comes in all sizes, shapes, colors, can be found really anywhere on the body. It doesn't necessarily have to be on a sun-exposed area. Seventy percent are new. Thirty percent can exist in preexisting moles, as was discussed in our earlier talk. Second most common killer in males arises from the neural crest cells. Some risk factors, certainly I don't think it's any of these, but again, Caucasians, a previous melanoma, a previous skin cancer, whether basal cell or squamous cell, increases their risk. Certainly if the patient has a large number of moles, that potentially will degenerate into a melanoma. Skin that tans poorly or burns easily, and obviously a patient whose family member has had a melanoma. And lastly, the immunosuppressed. So again, typically the deal here is that these are asymmetrical, which is contrary to the benign lesions we just heard about that tend to be more symmetric. And again, I was taught this, even though I didn't necessarily end up going into dermatology. My dad gave one last push my fourth year of medical school. The A and the B is asymmetry, and then biopsy, anything that's asymmetrical, it can never go wrong. I must have heard that 17,000 times. So again, here's kind of the concept. Really, you just sort of draw this mental line, or you can take your goniometer out and kind of go over the center of the lesion. And if one side doesn't look like the other, then it's probably worth a biopsy, or at least a dermatological consultation. By comparison, we saw a blue nevus earlier, and that certainly has a symmetrical look to it. It's certainly bluish, but melanoma can look blue in some patients. Here you see something that's asymmetric. It's thinner, so really take a close look at the shape and coloring. Again, that was drawn into me. Here's some more examples of a symmetrical pear-shaped mole type of lesion versus something that's asymmetric. And sometimes they don't necessarily occur in isolation. So here you can see a melanoma and a seborrheic keratosis, as we saw earlier. So I think these are somewhat tricky at times. Thank God we have the smart dermatologist here. So from a prognostic perspective, like everything else, thickness and ulceration. So here you can see this hopefully projects. It's quite thick. There's an ulcer in the center, which tends to lead to a poorer prognosis. There's the band here, excision. Again, that's the mainstay of treatment. Excise with a 2-millimeter margin at minimum. Wait for your pathology report. And if it obviously comes back as a melanoma, then do a wider resection. Melanoma in situ, you're going to see maybe more with the nail beds. Certainly you should get a 5-millimeter margin at minimum. And then you can see here the guidelines for melanoma with a millimeter thickness, 10-millimeter margin, more than a millimeter, 20-millimeter margins. And certainly there's some Mohs surgeons out there that can also help us out with these lesions. I don't know how well this projecto. It did pretty good up there. So this is a case example. And again, this is your classic patient that has a one-year history of this painless lesion. Perhaps there's a history of trauma. She's not quite sure. Maybe a sewing needle. Maybe this is a subungual hematoma. But in essence, it gets passed around for quite some time. Here's some more views. There's no bone involvement, if it doesn't project well. So this was biopsied with immunohistochemistry staining. There were some ulcerations, mitotic figures. So this staining is going to show more of those melanocytes. They're going to be mitotic rather than the simple ones we saw earlier today. Again, here's sort of the melanin that's been stained. Looking for sentinel nodes is important, depending on the size of these lesions. And you can see here that these do have a high tendency relative to the other skin cancers of metastasis. These are ones that I think really should be caught quickly and jumped on quickly. And you can see, obviously, the thicker they get, the higher the risk of metastasis. And generally, when they're over 0.7 millimeters in thickness, the sentinel lymph node biopsy is indicated. As certainly you would imagine in this case, that was pretty thick. So another thing using the TEC99 scan to sort of localize potential metastasis, that was carried out. We did some localizing dye to help with the general surgeon who did the lymph node biopsy. And again, you can see that there is some staining in the lymph nodes, which again sort of indicates that there's been some metastasis there. So any thoughts for treatment? We now know it's melanoma. And went on to PIP disarticulation with the nerves being anastomosed there to try to minimize neuroma formation. So this was sort of the final pathology here with a depth of 11 millimeters, as one might suspect. So just in closing, some more weird and wacky. That's pretty weird, isn't it, Josh? Kaposi's sarcoma, which I can barely say is a lesion that's seen primarily in the immunosuppressed, associated often with HIV. And it was described by a Hungarian dermatologist as the name would connotate. This is another thing that can be confused with some of the skin cancers, and certainly this is something that should be managed surgically. Maybe not a malignancy, but bastillary angiomatosis. Again, looks like some of the lesions that we've seen earlier, and certainly requires, I think, at the most or at least a biopsy. And generally it's associated with the Bartonella bacteria, whether it's a cat scratch. Again, here's where history is helpful. And I thought this would be a nice segment into the next discussion with Dr. Osterman and his ticks and sheaths and all kinds of issues. And lastly, the pyrodermocangrinosum, which is sort of, I think, the lesion that looks like everything else. And it's uncommon, it's ulcerative, uncertain etiology. I've tried to treat this all different types of ways. The slippery slope for me early in my career was to try to excise these, and they always come back. So basically, I think the key to this is just to get tissue biopsy to exclude some of the other lesions, and this thing tends to be self-limiting. Like some of the other things we've heard of, you can try these topical corticosteroids, anti-inflammatory agents, things of that nature. Again, Wegner's grain litosis looks a lot like what Josh showed earlier, so I thought I'd put this slide up there just to confuse everyone a little bit more with the tests coming up. And I think in summary, a safe margin is necessary. Generally, a four-millimeter margin for normal-looking tissue when you're talking about a basal cell or a squamous cell. And generally, you have a 95% chance of removing the tumor. Thank you.

malignant lesions

basal cell carcinoma

squamous cell carcinoma

melanoma

skin-related cancers