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The skin’s outer layer and variable amounts of deeper skin are removed using a carbon dioxide or erbium YAG laser. Lasers give the doctor good control over the depth of tissue removed, and are sometimes used as a secondary therapy when other techniques are unsuccessful

MEDICATIONS. Imiquimod is FDA-approved only for superficial BCCs, with cure rates generally between 80 and 90 percent. The 5% cream is rubbed gently into the tumor five times a week for up to six weeks or longer. It is the first in a new class of drugs that work by stimulating the immune system.

5-Fluorouracil (5-FU) also has been FDA-approved for superficial BCCs. The 5% liquid or ointment is gently rubbed into the tumor twice a day for three to six weeks.

Trials with more invasive BCCs are under way for both imiquimod and 5-FU. Side effects are variable, and some patients do not experience any discomfort, but redness, irritation, and inflammation are predictable.

Melanoma. The most dangerous form of skin cancer, these cancerous growths develop when unrepaired DNA damage to skin cells (most often caused by ultraviolet radiation from sunshine or tanning beds) triggers mutations (genetic defects) that lead the skin cells to multiply rapidly and form malignant tumors. These tumors originate in the pigment-producing melanocytes in the basal layer of the epidermis. Melanomas often resemble moles; some develop from moles. The majority of melanomas are black or brown, but they can also be skin-colored, pink, red, purple, blue or white. Melanoma is caused mainly by intense, occasional UV exposure (frequently leading to sunburn), especially in those who are genetically predisposed to the disease. Melanoma kills an estimated 8,790 people in the US annually.

If melanoma is recognized and treated early, it is almost always curable, but if it is not, the cancer can advance and spread to other parts of the body, where it becomes hard to treat and can be fatal. While it is not the most common of the skin cancers, it causes the most deaths. The American Cancer Society estimates that at present, about 120,000 new cases of melanoma in the US are diagnosed in a year. In 2010, about 68,130 of these were invasive melanomas, with about 38,870 in males and 29,260 in women.

Even if you have carefully practiced sun safety all summer, it's important to continue being vigilant about your skin in fall, winter, and beyond. Throughout the year, you should examine your skin head to toe once a month, looking for any suspicious lesions. Self-exams can help you identify potential skin cancers early, when they can almost always be completely cured.

First, for a successful self-exam, you obviously need to know what you're looking for. As a general rule, to spot either melanomas or non-melanoma skin cancers (such as basal cell carcinoma and squamous cell carcinoma), take note of any new moles or growths, and any existing growths that begin to grow or change significantly in any other way. Lesions that change, itch, bleed, or don't heal are also alarm signals.

What causes melanoma? The most important preventable cause is exposure to too much ultraviolet light in sunlight, especially during the first 20 years of life. There is lots of evidence linking melanoma to this, and melanomas are especially common in white-skinned people who live in sunny countries. The use of artificial sources of ultraviolet light, such as sun beds, also raises the risk of getting a melanoma.

Some people are more likely to get a melanoma than others:

People who burn easily in the sun are particularly at risk. Melanoma occurs most often in fair-skinned people who tan poorly. Often they have blond or red hair, blue or green eyes, and freckle easily. Melanomas are less common in dark-skinned people.

Past episodes of severe sunburn, often with blisters, and particularly in childhood, increase the risk of developing a melanoma. However, not all melanomas are due to sun exposure, and some appear in areas that are normally kept covered.

People with many (more than 50) ordinary moles, or with a very large dark hairy birthmark, have a higher than average chance of getting a melanoma.

Some people have many unusual (atypical) moles (known as ‗dysplastic naevi‘). They tend to be larger than ordinary moles, to be present in large numbers, and to have irregular edges or colour patterns. The tendency to have these ‗dysplastic naevi‘ can run in families and carries an increased risk of getting a melanoma.

The risk is raised if another family member has had a melanoma. People who have already had one melanoma are at an increased risk of getting another one.

People with a damaged immune system (e.g. as a result of an HIV infection or taking immunosuppressive drugs, perhaps after an organ transplant) have an increased chance of getting a melanoma.

Are melanomas hereditary? About 1 in 10 of people with a melanoma have family members who have also had one. There are several reasons for this. Fair skin is inherited; dysplastic naevi can run in families, as can a tendency to have large numbers of ordinary moles.

What are the symptoms of melanoma? Melanomas may not cause any symptoms at all, but tingling or itching may occur at an early stage. Some melanomas start as minor changes in the size, shape or colour of an existing mole: others begin as a dark area that can look like a new mole. Later on a melanoma may feel hard and lumpy, and bleed, ooze or crust up.

What does a melanoma look like? All melanomas do not look the same, and there are several different types. The ABCD system (below) tells you some of the things to look out for.

A melanoma may show one or more of the following features:

A symmetry – the two halves of the area differ in their shape.

B order – the edges of the area may be irregular or blurred, and sometimes show notches.

C olour – this may be uneven. Different shades of black, brown and pink may be seen.

D iameter - most melanomas are at least 6 mm. in diameter.

Melanomas can appear on any part of the skin but they are most common in men on the body, and in women on the legs.

How is a melanoma diagnosed? If you are at all worried about changes in a mole, or about a new area of pigmentation appearing on your skin, you should see your family doctor. The ABCD changes listed above can sometimes be found in completely harmless conditions, and doctor will often be able to put your mind at rest quickly. However, if there is still any doubt, doctor will usually refer you to a specialist (a dermatologist or a surgeon with a special interest in pigmented lesions) who will examine the area, perhaps with a special instrument (a dermatoscope), and decide whether it needs to be removed. The only way in which the diagnosis of a melanoma can be made firmly is by looking at the suspected area under microscope in the laboratory.

If the mole needs to be examined further, the whole of the suspicious area will then be removed under a local anaesthetic (an excision biopsy) and sent to the laboratory to be examined. If the area is too large to remove easily, a sample of it (a biopsy) will be taken. If a melanoma is found, the biopsy specimen will provide valuable information about its type and depth that will help to plan the next step in treatment.

Can a melanoma be cured? Yes: three quarters of the people who have a melanoma removed will have no further problems. However it is crucial for a melanoma to be removed as early as possible - before it has had time to spread deep into the skin or to other parts of the body. The thinner the melanoma is when it is removed; the better is the survival rate. This is why a doctor should examine anyone with a suspicious mole or blemish as soon as possible. In a small minority of people the melanoma may have spread but further surgery or chemotherapy can often help to control this.

How can a melanoma be treated? At present, the treatment for melanoma is surgical. There is no other treatment of proven benefit, and usually no other tests are needed. Radiotherapy is of little benefit, and various drugs have been tried, but with limited success only.

Most people who have had a melanoma removed will need another operation to try to prevent the melanoma from coming back at the original site. During the operation, some healthy skin will be removed from around the original scar to make absolutely sure that all of the melanoma has been taken away, and this makes the scar larger than before. Occasionally a skin graft will be needed.

―Sentinel node biopsy‖ may be discussed with some people. In this, a small sample of the nearest lymph node is taken as an additional procedure when the melanoma is being removed. However sentinel node biopsy is not used routinely, and is usually performed only as part of a research study: it is not an essential part of treatment.

After your operation you will be followed up regularly in the outpatient clinic. There are three main reasons for this:

To make sure the tumour has not come back or spread. To detect any other skin cancers.

To provide you with support and information.

At the clinic your scar will be checked, and your neck, groin and armpits will also be examined for lumps to detect any spread to the lymph nodes there. Any other moles that you are concerned about will be examined and, if you have large numbers of moles, an eye will be kept on these too. Photographs of these moles may be taken and kept in your hospital notes. When you come back to the clinic, they will allow your doctors to compare the way your moles look now with how they looked before.

If your melanoma was at a very early stage when it was removed, you may need to be seen only once more in the follow-up clinic. Otherwise you will be reviewed 3-monthly for at least 3 years. If you develop problems between clinic appointments, you should consult your family doctor who will arrange for an earlier hospital appointment if this is necessary.

Top sun safety tips:

Protect the skin with clothing, including a hat, T shirt and UV protective sunglasses

Seek shade between 11am and 3pm when it‘s sunny

Use a sunscreen of at least SPF 30 which also has high UVA protection

Keep babies and young children out of direct sunlight

The British Association of Dermatologists recommends that you tell your doctor about any changes to a mole.

Sunscreens should not be used as an alternative to clothing and shade, rather they

offer additional protection. No sunscreen will provide 100% protection.

Lymphoepithelioma - A cancer of the epithelium and lymphoid tissue of the nasopharynx. Lymphoepithelioma is a type of poorly differentiated nasopharyngeal carcinoma characterized by prominent infiltration of lymphocytes in the area involved by tumor. Lymphoepithelioma is also known as "class III nasopharyngeal carcinoma" in the WHO classification system.It has high tendency to metastasize and is exquisitely radio sensitive tumour. Most cases are associated with Epstein-Barr virus infection.

Lymphoepithelioma may also be referred to as Schmincke-Regaud tumor, after the German pathologist Alexander Schminke and French radiologist Claude Regaud.

6. MATERIALS FOR SELF-CHECKING:

A. Tasks for self-checking (tables, scheme, pictures, graphics):

Benign epithelial tumours of soft tissues in maxillofacial areas.

B. Test tasks for self checking:

1.The old man with complains of presence on the lower lip of a painless, firm new growth which some months exist, slowly increasing. Objectively: on the skin of a lower lip cone-shaped formation up to 1 sm in length, firm, painless, dark brown color on a wide basis is defined.

What diagnosis is most possible? (The answer: a skin horn).

2.The patient complains of presence of a painless new growth on the skin of a cheek which quickly grows. Objectively: on the skin of the left cheek of a new growth 1 х 1,5 sm, saucer visible forms with a smooth surface and cavity in the center as a crater that is filled with horn weight.

What diagnosis is most possible? (The answer: keratoacanthoma).

3. Having removed a papilloma of tongue, the doctor has directed a material on histologic research, having placed it to 70 % ethyl spirit.

Whether actions of the doctor true are?

(The answer: no, a spirit sharply changes a histologic picture of a material).

C Materials for test control. Test tasks with the individual right answer (α=2):

1. Find the description of a nevus of a skin:

A.Above a surface of a skin, painless growths. Are covered with hair, dark brown color, there are some cracks, do not bleed, borders are not precise.

B.Single, dense, painless formation in the size in some millimeters of the brown color, covered with a wrinkled skin, on the leg.

C.Single, painless formation in the size up to 0,5 sm, bright red color with the smooth surface, located on a leg.

D.The flat papule brown color in the size up to several millimeters, roundish forms, painless, with a smooth surface.

E.Tumour-like formation of black color, the size up to 0,5 sm, motionless, painless, quickly increases. (The right answer: D).

2.When navus is malignant it is no looks so:

A.Acute increase in its sizes.

B.Change of a degree of pigmentation.

C.Occurrence of the stagnant incendiary phenomena on periphery невуса.

D.Occurrence of the ulcer.

E.Occurrence of a hair on the nevus.

(The right answer: Е).

3.Trichoepithelioma is:

A. A benign tumour that develops from hair follicles and that contains ferriferous cysts.

B.A benign tumour of hair follicles which consist of highly differentiated cellular elements.

C.The benign tumour which genetically is connected with a hair follicle.

D.A benign tumour which arises from epithelium of sebaceous glands and that keeps structural similarities with initial glands.

E.Benign formation that develops from excretory ducts of sweat glands.

(The right answer: А).

D.Educational problems of the 3rd level (atypical tasks):

1.The ulcer in a cavity at the review of the patient has such appearance: edges dense, turned out in a look

to a crater, a basis condensing, the bottom is covered with a fine-grained tissue which easily bleeds at palpation. The ulcer is painless.

What diagnosis is more authentic? (Answer: cancer ulcer)

2.On skin in a site of the left cheek half a year ago there was a small knot reminding the grain acting over a surface of skin. The tumor of a dense consistence, deadwhite color, is located on a plaque. After removal of a tumor it is revealed that structural unit of a tumor is bazalioma.

What diagnosis is more authentic? (Answer: bazalioma)

3.The patient has on a mucous membrane of a lower lip has tumour-like formation of a spherical form, the size to 0,5 cm, a soft consistence, with accurate contours, mobile, painless; a mucous membrane over education without pathological changes.

It is possible to think of what disease? (Answer: papilloma)

7. Literature:

7.1. Basic literature:

1.Пачес А.И. Опухоли головы и шеи. - М.: Медицина, 1983.

2.Дунаевский В.А., Шеломенцев Ю.А. Предопухолевые заболевания и злокачественные опухоли слизистых оболочек полости рта. - М.: Медицина, 1986.

3.Колесов А.А., Воробьев Ю.И., Каспарова Н.Н. Новообразования мягких тканей и костищ лица в детей и подростков. - М.: Медицина, 1989.

4.Blot, W.J., J.K. McLaughlin, D.M. Winn, D.F. Austin, R.S. Greenberg, S. Preston-Martin, L. Bernstein, J.B. Schoenberg, A. Stemhagen, and J.F. Fraumeni. 1988. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Research 48:3282-3287.

5.Bricker, S.L., R.P. Langlais and C.S. Miller. 1994. Oral Diagnosis, Oral Medicine, and Treatment Planning, Second Edition. Philadelphia, Lea and Febiger Publishing.

6.Greenblatt, M.S., W.P. Bennett, M. Hollstein, C.C. Harris. 1994. Mutations in the p53 tumor suppressor gene: clues to cancer etiology and molecular pathogenesis. Cancer Research 54(18):48554878.

7.Lidral, A.C., J.C. Murray, K.H. Buetow, A.M. Basart, H. Schearer, R. Schiang, A. Naval, E. Layda, K. Magee, W. Magee. 1997. Studies of the candidate genes TGFB2, MSX1, TGFA, and TGFB3 in the etiology of cleft lip and palate in the Philippines. Cleft Palate - Craniofacial Journal 34(1):1-6.

7.2. Additional literature: http://www.skincancer.org/content/view/17/79/ www.wessexcancer.org

Ministry of health Ukraine

Higher state educational establishment of Ukraine

«Ukrainian medical stomatological academy»

It is «ratified» at meeting of chair of surgical stomatology and maxillofacial surgery with plastic and reconstructive surgery of the head and neck

The Head of the chair

doctor of medicine Aveticov D. S.

METHODICAL INSTRUCTION

FOR INDEPENDENT WORK OF STUDENTS DURING PREPARATION FOR PRACTICAL

(SEMINAR) LESSON

Poltava – 2012

1. ACTUALITY OF THEME.

Tumor-like new formations of the soft tissues, especially such, as atheroma, are often observed at practice of surgeon-stomatologist. Usually they do not make a threat to life and health of patient, but at certain terms some of them, for example keratoacanthoma, can become malignant tumor. Clear knowledge of clinical displays of this group of new formations will help a doctor to set a faithful diagnosis and avoid flagrant errors.

2.SPECIFIC GOALS:

2.1.To analyze the clinical symptoms of atheroma, rhinophyma, keratoacanthoma, keratolytic papilloma (warty (skin) horn).

2.2.To explain the etiologic and pathogenetic factors of development of tumor-like formations of

soft tissues.

2.3.To offer the plan of examination of patient with a diagnosis atheroma, rhinophyma, keratoacanthoma, keratolytic papilloma (warty (skin) horn).

2.4.To classify tumor-like formations of soft tissues.

2.5.To interpret principles of diagnostics and treatment of tumor-like formations of soft

tissues.

2.6.To draw the graphology chart of lesson.

2.7.To analyze the results of laboratory and instrumental examination.

2.8.To diagrammatize treatment of patients with atheroma, rhinophyma, keratoacanthoma, keratolytic papilloma (warty (skin) horn).

3.BASIC LEVEL OF PREPARATION

4. TASKS FOR INDEPENDENT WORK DURING PREPARATION FOR LESSON.

4.1. The list of the main terms, parameters, characteristics which the student should know during preparation for lesson:

4.2.Theoretical questions for lesson:

1.To transfer factors which are provoke to neoplasm of soft tissues.

2.To describe the clinical picture of atheroma.

3.To describe the clinical picture of rhinophyma.

4.To describe the clinical picture of keratoacanthoma.

5.To describe the clinical picture of skin horn.

6.Methods of diagnostics and additional methods of research of patients.

7.Differential diagnostics of tumors of soft tissues.

8.Prophylaxis of origin of neoplasms of soft tissues.

9.Clinical displays of malignization of tumor-like formations of soft tissues.

10.Methods of treatment of neoplasm of soft tissues.

4.3. Practical works (tasks) which are carried out on lesson:

It is not foreseen by the program.

5. ORGANIZATION OF THE MAINTENANCE OF THE TRAINING MATERIAL.

Classification

Tumor-like lesions of soft tissues

Clinic, diagnostics, treatment

Atheroma («athere» - porridge) is a retentional cyst of sebaceous gland, which appears after corking of conclusion channel of gland of skin. More frequent it has place at the traumatic damage of skin during shaving and other. Atheromas are more frequent singl, but can be and plural (atheromatosis). Atheroma grows slowly and painlessly, localized in any area of skin of face and head. Objectively: atheroma has a spherical form, a skin is not changed in a color, mobile. Skin is adhes with the membrane of cyst in one place (in the area of entrance of duct of sebaceous gland). There is contraction of skin in this place. As skin is folded there, there is a symptom of «lemon crust». Atheroma is mobile, painless at palpation, it has densely elastic consistency, the surface is smooth, borders are clear. It has size from a few millimeters to a few centimeters in a diameter. In some cases at the pressure on atheroma from depression porridge-like mass with unpleasant smell is discharged.

Atheromas can purulented. In such cases it loses mobile, a skin is red, there is an edema of surrounding tissues, an abscess is formed. The capsule of atheroma is formed from connecting tissues, inwardly covered a flat epithelium.

Treatment of atheroma is surgical – delete of capsule together with the region of skin which is accrete with the overhead pole of cyst. In the case of suppuration of atheroma it treat as an ordinary abscess, and a capsule of atheroma is deleted after complete liquidation of inflammation‘s symptoms.

Rhinophyma is chronic inflammation of skin of nose with the lesion of all its elements and hyperplasia of sebaceous glands and vessels. More frequent meets for old men, that has problem with an alcohol.

A disease develops slowly. Objectively: painless nodosal purple-blue color neoplasm in the area of tip and wings of nose. On the skin‘s surface there is extended vessels – telangioectasies. Rhinophima results to deformations of nose and distortion of face.

Disease is divided into two forms – fibrotic and glandular (nodosal, knotted). A fibrotic form is characterized by the increase of nose and it does not lose the form. At a glandular form knots are formed on wings and tag of nose which in future meet between itself.

Treatment of rhinophima is surgical. Pathological vegetations must be removed with direct skin transplantation.

Keratoacanthoma is a tumor-like epithelial formation, that clinically and histologically resemble epidermoid carcinoma but it heals spontaneously without treatment (self limiting lesion) It is of unknown etiology. Clinical features: common age – over 50 years of age, common sex: males more than females, common site: sun exposed skin, including the lip, rarely intraorally. Keratoacanthoma appears as an elevated dome-shaped nodule with a depressed central keratinfilled core giving it a crater-like appearance. It does not exceed 1 to 1,5 cm in diameter, it reaches its maximum size within 4-8 weeks, persists static for another 4-8 weeks, then regresses spontaneously within another 6-8 weeks. Histologically keratoacanthoma is characterized by a central keratin formation, surrounded by hyperplastic epithelium (pseudoepitheliomatous hyperplasia), with mixed inflammatory cells infiltration.

It simulates the histological features of a welldifferentiated squamous cell carcinoma but with absence of deep invasion. Keratoacanthoma is a self limiting lesion, but careful follow up is required.

Warty (skin) horn (keratolytic papilloma) has appearance of formation conic form as a horn, on wide basis, grey or umber color. It can has the appearance of hemisphere. Neoplasm is painless, has a smooth or layer surface, hard, as a horn. Size of skin horn is from a few millimeters till a few centimeters in length. Formation has clear borders. Treatment is surgical excision till the unchanged (normal) tissues.

Differential diagnostics of tumor-like formations of soft tissues