Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_4518_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

30 Мб

Скачать

☆

<<< < Предыдущая 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 4445 / 5045 46 47 48 49 50 > Следующая >>>

448

https://t.me/medicina_free

• Cryotherapy (liquid nitrogen)

– Not recommended rst line, poor cosmesis, high recurrence rate (2-year esti-

mated recurrence rate 20.6%)

– Other topical agents include 5-FU and imiquimod

• Laser

– Carbon dioxide or Erb:YAG – Limited data, potential need for subsequent surgery

• Chemotherapy

– Vismodegib – Sonidegib – Reserved for metastatic and locally advanced BCC

K. Wong et al.

Cutaneous Squamous Cell Carcinoma (cSCC) oftheHead andNeck

Epidemiology

• 25% of all nonmelanotic skin cancers

• Second most common cutaneous cancer of the head and neck

• Average age at diagnosis=75.2years old

• Increasing incidence worldwide

• 60–80% of temporal bone malignancies

Presentation

• History

– Presents in the middle- and older-aged individual with change to pre-existing

lesion, nonhealing ulcer, or abnormal growth in sun-exposed area

– 60% arise from actinic keratosis, though <1% of actinic keratosis lesions

progress to cSCC annually (40% de novo)

– Medical conditions: xeroderma pigmentosum, previous cutaneous nonmela-

noma malignancies, and lymphocytic leukemia

• Signs and symptoms

– Reddish-brown or erythematous papule or nodule with hyperkeratotic center,

borders may be diffuse or distinct based on the degree of differentiation – Cutaneous horn, ulceration, or erosion may be present – Metastasis to the parotid and upper cervical chain may be palpable

24 Cutaneous andTemporal Bone Malignancies

https://t.me/medicina_free

449

Etiology/Pathogenesis

• Ultraviolet radiation

– Sunlight (most frequently associated with cSCC), tanning booths, UV

light therapy – UV radiation→modify nucleic acids→ mutations leading to activation of

oncogenes or inactivation of tumor suppressor genes

• Gene mutations

– Telomerase gene – p53 tumor suppressor – p16 tumor suppressor

• Immunosuppression

– Allogenic transplant patients most at risk

• Infection

– HPV, EBV – Polyomavirus (Merkel cell carcinoma)

• Occupational exposures (insecticides, herbicides, cleaning agents),

• Dermatoses (genodermatoses, scarring dermatoses, chronic wounds, burn scars)

Diagnosis

• Excisional biopsy with 1- to 3-mm margins

• Punch or incisional biopsy for large lesions

• Fine-needle aspiration (FNA) can uncover metastasis

• High-risk features

– Anatomic sites: lip (vermilion and hair-bearing), ears, temple, pre- and post-

auricular region, central face, eyelids, nose, lips, chin, mandible – Depth ≥2mm – Recurrence – History of immunosuppression or radiation – Ill-dened borders – PNI or perivascular invasion (PVI) – High-risk histologic types (see below)

• Types

– Adenoid: high risk, glandular, more common in elderly, periauricular – Adenosquamous: high risk, uncommon, mixed glandular and squamous dif-

ferentiation on histology

450

https://t.me/medicina_free

– Bowen’s disease: in situ cSCC presenting as erythematous scaly plaque with

well-dened edges, may progress to invasive cSCC if untreated – Desmoplastic: high risk, increased risk of local recurrence and metastasis,

sun-exposed skin in the elderly – Solar keratosis: atypical squamous cells inltrating papillary dermis – Spindle cell: arises from previous wound, burn, or trauma as whorled cluster

of cells with stretched nuclei – Verrucous: wart-like, lower malignant potential

K. Wong et al.

Treatment Recommendations

• Overview

– Good prognosis, 95% cure rate with complete excision – Recurrence risk 5%, distant metastasis risk 5%, disease-specic death 1%

Lip (vermilion and hair-bearing), ear, temple, and cheek have an increased risk of local recurrence and metastatic potential

• Surgery with wide local excision

– Gold standard – 4-mm margins for well-dened lesions – 6-mm margins for poorly dened lesions

• Cryotherapy, curettage, and electrodessication

– For isolated, low-grade, primary lesions

• Mohs

– High-risk disease (i.e., recurrent disease, PNI/PVI, large size, cosmetically

sensitive location, ill-dened borders) Mohs with histologically clear bor-

ders=97% cure rate

• Radiotherapy

– Indications: adjuvant or preoperative for metastatic disease, unresectable dis-

ease, limited nodal metastasis, extracapsular extension, and PNI

• Sentinel lymph node biopsy for high-risk disease

• Cervical lymphadenectomy

– Indicated for nodal metastasis – Include parotidectomy and levels I-IV for temple, cheek, and forehead

involvement – Posterolateral neck dissection for posterior scalp and neck

24 Cutaneous andTemporal Bone Malignancies

https://t.me/medicina_free

• Role for chemotherapy not well established

– Generally used for unresectable disease, nodal metastasis, and distant

metastasis – Agents: 5-FU, carboplatin, cisplatin, EGFR inhibitors

451

Malignant Melanoma

Epidemiology

• 5% all skin cancers, 3× as many deaths as nonmelanotic skin cancer

• Male:female ratio=1.2:1

• 25% of cutaneous melanomas arise in head and neck region

• Average age at diagnosis: 55years old

Presentation

• History: changes in color/size/shape, bleeding, ulceration, pain, or pruritus; family or personal h/o skin cancer, h/o excessive tanning and blistering sunburns

• ABCDE: asymmetry, border irregularity, color variation, diameter >6 mm, evolution

• Risk factors:

– Fair skin (Fitzpatrick scale type 1), freckling, h/o sunburning, immunosup-

pression, tanning booth exposure, prior h/o melanoma (8% concurrent multiple melanomas, 5–10% develop second primary)

• Unknown primary

– 2–8% of melanoma cases – 2/3 with regional metastasis in the absence of primary lesion or h/o melanoma – 1/3 distant mets

Etiology/Pathogenesis

• Gene mutations

– p16 most common mutation in general, however only seen in 0.2% of mela-

noma cases,

– Ras–Raf–Mek-Erk: pathway in cell proliferation, gain-of-function mutations

in BRAF (50–70% of melanomas)

452

https://t.me/medicina_free

K. Wong et al.

– PI3K/PTEN: activating mutation PI3K, loss of PTEN, amplication of AKT – c-kit (tyrosine kinase receptor): activating mutations→constitutive activation

of proliferation pathways

• Hereditary causes

– B-K mole syndrome

Autosomal dominant Multiple dysplastic nevi, melanoma in >2 family members Increased risk for developing melanoma

– Xeroderma pigmentosa (see above) – Familial atypical multiple mole melanoma syndrome (FAMMM syndrome)

Autosomal dominant mutation in CDKN2a gene ≥1 rst- or second-degree relatives with melanoma Multiple atypical moles of different colors and sizes Risk for melanoma approaches 100% the age of 75

– BRCA2

Autosomal dominant Hereditary breast cancer gene associated with slightly increased risk of melanoma

• Premalignant lesions

– Congenital melanocytic nevi: appear between birth and 6 months; 5–20%

increased risk for melanoma – Dysplastic nevus/atypical mole: irregular/indistinct borders, color variation – Lentigo maligna (Hutchinson’s melanotic freckle): In situ melanoma, precur-

sor to lentigo malignant melanoma

• Growth phases: radial (outward spread, through epidermis), vertical (invasion deep into dermis, risk for metastasis)

• Types

– Acral lentiginous

Less than 5% of melanomas Dark skin (African, Asian, Hispanic) No relationship to sun exposure (palms, soles, underneath nails) Flat dark brown or black lesion

– Desmoplastic

Rare Presents as a lump the same color as surrounding skin (nonpigmented)

– Lentigo maligna

About 10–15% of melanomas Older individuals

24 Cutaneous andTemporal Bone Malignancies

https://t.me/medicina_free

Large, at, tan patches with uneven borders Years of radial growth prior to vertical growth

– Mucosal lentiginous

Rare No relationship to sun exposure Diagnosed at later stages, distant metastasis more common Most commonly found in the nasal cavity

– Nodular

Second most common melanoma (20%) Tendency toward vertical growth Pedunculated, black, red, or esh-colored lesions

– Supercial spreading

Most common melanoma (70%) Flat, thin (often <1mm thick), uneven border Color variability (red, blue, brown, black, grey) Tendency toward radial growth May arise from dysplastic nevus

• Diagnosis

453

– Excisional biopsy with 1- to 2-mm margin, including dermis and subcuta-

neous fat

– Consider incisional or punch biopsy in case of large lesions or those in cos-

metically important areas (e.g., face)

• Histopathology

– Thickness (see Breslow and Clark classications below), ulceration, mitotic

rate, margin status, depth of invasion, microsatellites

– Angiolymphatic invasion, neurotropism, regression, vertical growth phase,

lymphocytic inltration

• Imaging

– CXR

High false-positive rate Cost ineffective

– CT with contrast

Head and neck: evaluate local disease Chest: obtain in patient with known metastatic disease (stage IV) Abdomen: obtain in patients with stage III, locally recurrent or in-transit disease; low yield but provides baseline Pelvis: obtain in patients with history of primary tumors below the waist or local recurrence below the waist

454

https://t.me/medicina_free

K. Wong et al.

• Ultrasound

– Surveillance for asymptomatic patients – Low yield; high false-positive rates

• PET

– Gold standard for detecting distant metastasis – Low sensitivity for detecting occult regional nodal metastasis – Monitoring tool for metastatic disease during therapy – Not indicated in early-stage disease (stage I and II)

• Sentinel lymph node biopsy (SLNB)

– Most sensitive and specic staging test – Important prognosticator for disease-specic survival (melanomas >1 mm

thick)

Staging

• Breslow Thickness Classication

– ≤0.75mm – 0.76–1.5mm – 1.51–4mm – ≥4mm

• Clark Levels Classication

– Level I: All tumor cells above basement membrane (in situ) – Level II: Tumor extends into papillary dermis – Level III: Tumor extends to junction between papillary and reticular dermis – Level IV: Tumor extends into reticular dermis – Level V: Tumor invasion into subcutaneous tissue

American Joint Committee onCancer (AJCC) Eighth Edition Guidelines

Primary tumor (T) T Thickness Ulceration

TX – – T0 – – Tis – – T1a <0.8mm No T1b <0.8mm OR 0.8–1.0mm Yes (<0.mm),

T2a >1.0–2.0mm No

Either (0.8-1.0mm)

24 Cutaneous andTemporal Bone Malignancies

https://t.me/medicina_free

Primary tumor (T) T Thickness Ulceration

T2b >1.0–2.0mm Yes T3a >2.0–4.0mm No T3b >2.0–4.0mm Yes T4a >4.0mm No T4b >4.0mm Ye s

Regional lymph (N)

In-transit, satellite, or

N Number of tumor-involved lymph nodes

NX Regional nodes not assessed

microsatellite metastasis

No N0 No regional metastases detected No N1a One clinically occult (detected via biopsy) No N1b One clinically detected No N1c No regional lymph nodes Ye s N2a 2–3 clinically occult No N2b 2–3, at least one clinically detected No N2c One clinically occult or detected Yes N3a ≥4 clinically occult No N3b ≥4 of which at least one clinically detected OR

Any number of matted nodes

N3c ≥2 clinically occult or detected AND/OR any

Yes

number of matted nodes

Exception: pathological N category is not required for T1 melanomas, use cN

455

Distant metastasis (M) M Anatomic site LDH level

M0 No distant metastasis Not

M1a(0) Distant metastasis to skin, muscle, or nonregional lymph node Not elevated M1a(1) Elevated M1b(0) Distant metastasis to lung with or without M1a sites of disease Not elevated M1b(1) Elevated M1c(0) Distant metastasis to non-CNS visceral sites with or without M1a M1c(1) Elevated

or M1b sites of disease

M1d(0) Distant metastasis to CNS with or without M1a, M1b, or M1c sites M1d(1) Elevated

of disease

Final staging (clinical) T N M Stage

Tis N0 M0 0 T1a N0 M0 IA

applicable

Not elevated

Normal

456

https://t.me/medicina_free

Final staging (clinical) T N M Stage

T1b N0 M0 IB T2a N0 M0 IB T2b N0 M0 IIA T3a N0 M0 IIA T3b N0 M0 IIB T4a N0 M0 IIB T4b N0 M0 IIC Any T, tis ≥N1 M0 III Any T Any N M1 IV

Final staging (pathological) T N M Stage

Tis N0 M0 0 T1a N0 M0 IA T1b N0 M0 IA T2a N0 M0 IB T2b N0 M0 IIA T3a N0 M0 IIA T3b N0 M0 IIB T4a N0 M0 IIB T4b N0 M0 IIC T0 N1b, N1c M0 IIIB T0 N2b/c, N3b/c M0 IIIC T1a/b, T2a N1a, N2a M0 IIIA T1a/b, T2a N1b/c, N2b M0 IIIB T2b, T3a N1a/b/c, N2a/b M0 IIIB T1a/b, T2a/b, T3a N2c, N3a/b/c M0 IIIC T3b, T4a Any N≥N1 M0 IIIC T4b N1a/b/c, N2a/b/c M0 IIIC T4b N3a/b/c M0 IIID Any T, tis Any N M1 IV

K. Wong et al.

Staging

• Surgery with wide local excision

– Gold standard – 1–2cm margins around primary tumor – 2cm margins for tumors >2mm in thickness or with ulceration – Mixed evidence regarding improved survival with margins >2cm – Lentigo maligna subtype associated with broader supercial subclinical

extension, requiring wider surgical margins

24 Cutaneous andTemporal Bone Malignancies

https://t.me/medicina_free

• Radiation

– RT is not indicated as initial therapy for localized disease – Adjuvant radiation indications:

Local recurrence Positive surgical margins not amenable to re-resection Desmoplastic melanoma with risk for recurrence

– For mucosal melanoma either with surgery or as primary modality if

unresectable

– Palliation for metastasis

• Sentinel lymph node biopsy

– Replaced elective neck dissection – Indicated for T2 and T3 tumors and no proven neck disease

• Cervical lymphadenectomy

– Therapeutic dissection acceptable for proven neck disease

Level I–IV: disease involving ear, temple, scalp, face Level II–V with retroauricular/suboccipital nodes: posterior scalp and retroauricular disease

– Prophylactic neck dissection does not demonstrate overall survival benet

457

• Supercial parotidectomy for ear, temple, and scalp melanomas with evidence of regional disease

• Adjuvant therapy

– Interferon alpha-2b

Immunomodulatory cytokine → increase phagocyte and lymphocyte activity Efcacy based on large multicenter study showing improved disease-free survival using high-dose IFN, delayed time to progression (8months), and 1-year survival benet Subsequent prospective randomized trials have not shown signicant differences in overall survival or relapse-free survival One-year treatment regimen, signicant toxicity

– Vemurafenib

Inhibits mutated forms of BRAF serine–threonine kinase Indications: unresectable or metastatic melanoma with BRAF-V600 mutation

• Stage IV melanoma

– Poor therapeutic options, no signicant prolongation of survival – Dacarbazine (DTIC): 10–15% response rate

<<< < Предыдущая 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 4445 / 5045 46 47 48 49 50 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
31.08.202634 Мб0Книга_4506_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202634 Мб0Книга_4507_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202632 Мб0Книга_4510_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202631 Мб0Книга_4512_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202631 Мб0Книга_4517_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4518_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4520_Библиотеки_им_академика_М_И_Перельмана.djvu
#
31.08.202630 Мб0Книга_4522_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4523_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4524_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202630 Мб0Книга_4525_Библиотеки_им_академика_М_И_Перельмана.pdf