Excision of Skin Tumors


Cutaneous tumor cells are defined as a conglomerate without functionality. The tumors can be benign or malignant.

Benign tumors (BT) are defined as a new unstable cellular formation with a tendency to grow slowly. Tumors may originate in any structure of the skin. They grow slowly and do not metastasize.

Malignant tumors ( MT) are anarchic cell proliferations that are able to invade nearby tissues and also spread to distant areas (metastasis).

The major risk factor for skin cancer is excessive sun exposure, especially in childhood.

Benign skin tumors can be:

Epithelial tumors (seborrheic keratosis, clear cell acantoma, keratoacanthoma, polyp, actinic keratoses)

  • Tumors of the connective tissue (keloid, histiocytoma, glom tumor, leiomyoma, neurofibromas, xantelasmele, dermatofibroamele, lipomas)
  • Cystic tumors (epidermoid cyst, trichilemal, milia, dermoid cyst)
  • Vascular tumors (hemangioma)
  • Pigmented tumors (pigmented nevi)

Premalignant lesions are defined as benign proliferations of skin structures with increased malignant potential. These are:

  • actinic keratosis
  • Bowen 's disease
  • Eritroplazia 's Queyrat
  • leukoplakia
  • keratoacanthoma
  • dermatitis irradiation
  • Xeroderma pigmentosum
  • Chronic ulcerative lesions

The malignant skin tumors are:

  • Basal cell carcinoma (squamous)
  • squamous cell carcinoma
  • Malignant melanoma.
  • Dermatofibrosarcoma.

Basal Cell Carcinoma

Basal cell carcinoma is the most common form of skin cancer (65-80 %). It originates in the basal cells of the epidermis, slowly invading the area. It rarely metastasizes. It occurs more frequently in subjects that are:

  • white skin, European race
  • males
  • adults
  • location: foto-exposed areas: most commonly the cephalic extremity (head and neck - 85%)

It commonly occurs on the face (nose, lips, forehead, ear flag), chest and appears at first as small, round, translucent nodules, covered with thin telangiectasia epidermis. Subsequently it evolves into ulcers of different sizes, covered or not with crust.

The prophylactic treatment consists in avoiding sun exposure and using sunscreen creams.

The curative treatment is represented by:

  • surgical excision, recurrence being common. 
  • Mohs surgery:
    • ensures the extemporaneous microscopic control of the excision's margins, thus eliminating the risk of recurrence.
    • the cure rate is above 99% for primary lapses and 96 % for relapses, but it is a costly method.

The excision of skin tumors creates defects. These, depending on the size, depth and location can be:

  • primary sutured
  • grafted with PLD
  • covered with local or neighborhood flaps
  • covered by distance flaps or microsurgical free transfer

Squamous Cell Carcinoma

Squamous cell carcinoma is a more aggressive skin cancer. It originates in the keratinocytes. Characteristic of squamous cell carcinoma is that it has a rapid growth rate, invading the area, and that it has an increased metastatic capacity. It predominates in men, especially in smokers and immunosuppressed. It usually locates in modified skin (actinic radiation, scarring, trauma).

Predisposing factors:

  • genetic - skin type I, II;
  • X radiation,
  • trauma,
  • degenerative and inflammatory changes
  • chemical factors (keratosis, tar, arsenic)
  • inf virus (papillomavirus)
  • immunosuppression

From a clinical point of view, there are two types:              

  1. slow-growing: squamous papillary nodular corneum (cutaneous horn)
  2. fast-growing: node endured, red-purple, firm ulceration that occurs early, combined with a local invasion

The treatment is surgical and consists of the aggressive excision with higher limits both in surface and in depth.

Mohs technique is beneficial in this type of lesion. Defects should be sutured directly if possible or closes by using grafts, or locoregional or free transferred flaps.

Malignant Melanoma

It is defined as an extremely aggressive malignant melanocytic, which appears in any cell capable of forming melanin. Represents 1-2% of the total number of malignant tumors and 2-5% of all cutaneous malignant tumors. Occurs more frequently in 35-50 years old men, especially on the chest, and in women especially on the legs.

The etiology is unknown. The predisposing factors are:

  • genetic phenotype I, II (very rare in people with dark colored skin)
  • preexisting melanoma lesions (30 % )
  • local trauma
  • UV radiation
  • immunosuppression

Clinically, the malignant melanoma appears as a hyper lesion, slightly inflamed, with poor demarcation and irregular edges, itchy and full color (from dark brown to light, erythematous). The treatment consists of a complete surgical excision which is a fundamental therapeutic approach . If the tumor is

  • < 1 mm – the excision around the tumor must be 1 cm
  • 1 – 4 mm – the excision around the tumor must be 2 cm
  • > 4 mm – the excision around the tumor should be 3 cm

The Mohs Excision

The slow Mohs excision allows for the cancer margins to be verified, being widely accepted as an extremely valuable method in this type of lesions. Undergoing an elective lymphadenectomy is not recommended, but the biopsy of the sentinel node is performed in patients with malignant melanoma > 1 mm. If micrometastases are detected, then the complete neck dissection is performed.

Results depend largely on the type of injury, its severity and the time since its appearance.

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