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SKIN CANCERS
The skin is the largest and most vulnerable organ of the body. It is involved in a number
of important jobs; these include providing a protective surface for the contents of the
body, helping with thermoregulation, sensation and the storage of vitamin D, water and
fat. It is made up of a number of layers, each of which has its own functions.
superficial
epidermis
papillary
dermis
reticular
dermis
subcutaneous
tissue
deep
Within the field of surgery you are often presented with a skin lesion that has been
referred for excision or an excision biopsy, so it is important you know what you are
presented with before you excise the lesion. Accurate diagnosis starts with a good history,
and although the examination is of primary importance here, histology will confirm
your diagnosis. Of course in finals, you will have to work without histology and therefore should be able to come up with a reasonable list of differential diagnoses of any skin
lesion presented to you. Even if you are unsure of the diagnosis, being able to examine
and describe the lesion competently will have scored you most, if not all of the marks.
In some cases, the examiner may give you the opportunity to take a brief history;
usually this is in the form of the examiner saying Would you like to ask the patient any
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questions? Remember to keep your questions focused; you will not have time to take a
full history. Features in the history of particular interest with skin lesions are:
Duration: The length of time the lesion has been present for.
Changing lesion: Have the lesion(s) changed, increased or decreased in size, disappeared then reappeared? If this is the case how many times has this happened, and is
there any relationship to the season? Or any other identifying features, e.g. bleeding,
itching?
Environmental influence: Occupation and hobbies; e.g. does the patient spend a
significant time out in the sun? Does he or she use sun beds frequently?
Patient history: Has he or she had anything like this before, and if so how was it
treated?
When examining a lesion the same basic principles apply as to any other systems exam.
There is an emphasis on general inspection of the body surface first before moving on
to a more focused assessment of the lesion identified. In actual clinical practice it is
important to ask patients to remove any make-up, as this may distort the lesion. There
are various associated features that you could look for on systems examination as part of
your skin lesion examination; however, as the emphasis is on surgical finals, we suggest
you refer to a good dermatology textbook because this will be an invaluable resource
for your medical finals.
Clinical examination
Introduction
As for any clinical encounter (see Chapter 1, Section 1.3).
Inspection
Describe general characteristics of lesion
Site: The site will help you in part to decide the possible diagnoses; e.g. is the
lesion on a sun-exposed area, raising the possibility of a malignancy, or present
on the palms and soles? Is there a special predilection for the flexor or extensor
surfaces or is there sparing of certain areas?
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Colour
Possible pathology
Hypopigmentation/paler
skin
Loss of melanocytes
Red
Yellow
Orange
Purple
Purple/grey
Ischaemic skin
Tanned
Haemochromatosis
Black
Blue
Discoloured fingernails
Palpation
Describe the texture
This may be palpable or visible and helps in the diagnosis of the lesion, e.g. in
lichenification, where there is thickening of the skin following repeated rubbing,
and the skin markings become more obvious.
Is the surface smooth, scaly, crusty or rough? Can you remove the crust or
scales?
On deeper palpation using the pulps of your thumb and index finger, is the lesion
soft, firm or hard?
This describes the physical changes in the skin and helps you to describe the type
of lesion.
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Lesion
Morphology
Macules
Papules
This is also <10 mm in diameter, but this lesion is solid and palpable with
distinct borders, e.g. a naevus, seborrhoeic and actinic keratosis.
Plaques
Palpable lesions that are raised or depressed compared to the skin surface;
these are >10 mm in diameter, e.g. the plaque of psoriasis.
Nodules
Vesicles
These are clear, fluid filled lesions measuring <10 mm in diameter. Seen in
dermatitis herpetiformis.
Bullae
Clear, fluid-filled blisters that are >10 mm in diameter, e.g. seen following
bites or burns and in pemphigus vulgaris and bullous pemphigoid.
Pustules
Petechiae
Purpura
Urticaria (wheals/
hives)
This appears as pink, raised lesions secondary to localised oedema and can
occur following hypersensitivity drug reactions, a reaction to temperature or
sunlight, or following local pressure. This lesion is normally transient, lasting
less than 24 hours.
Ulcers
Here some or all of the dermis is lost, including the epidermis (see
Chapter 9, Ulcers).
Erosions
This is an area of skin that has lost its epidermal layer; seen commonly after
trauma.
Tumours
Scars
Areas of the skin that have undergone fibrosis as a result of injury. This can
sometimes become thickened and enlarged. For instance, a keloid scar is
seen when the original scar has hypertrophied and extended beyond the
initial scar margin.
Is there crust on the surface where the exudate has dried up?
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Lesion
Clinical features
Seborrhoeic keratosis
(Seborrhoeic wart/
senile wart/ basal cell
papilloma)
Cutaneous horn
Lesion
Clinical features
Keratoacanthoma
(Molluscum sebaceum)
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Lesion
Clinical features
Actinic keratosis
(Solar keratosis/senile
keratoses)
Bowens disease
(Carcinoma in
situ/squamous
intraepidermoid
neoplasia)
Viva questions
Q1
These are lesions that occur secondary to an exaggerated tissue response during
the healing process, leading to excessive fibrous tissue deposition. Both also
appear in wounds.
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Clinical features
Keloid
Hypertrophic
Relationship to wound
edge
Onset
Epidemiology
Common in children
Special features
Usually recurs
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Viva questions
Q1
Q2
SCC is the second most common non-melanoma skin cancer (NMSC) after
BCC, occurring from the squamous cells in the epidermis.
Risk factors: Incidence increases with increasing age (especially >70 years) and
is more common in males.
Clinical features: Occurs on sun-exposed areas and is slow growing. It usually
metastasises to the surrounding structures, with distant metastases a rare
occurrence.
Morphology: Appears as a scaly lesion with an erythematous base or as a firm
red papule. The lesion fails to heal and may bleed easily.
Special features: SCC in situ is also known as Bowens disease. It appears as
large erythematous or brown plaques that are slightly raised with scaling on
the surface. The SCC that is associated with Bowens disease metastasises in as
many as 33% of cases.
Treatment for both BCC and SCC requires an MDT approach, but typically
involves:
Excision of the lesion with a pre-defined margin of clearance.
Usage of topical 5FU or curettage and electrocautery if the lesion is small.
Radiotherapy if the lesion is too large for surgical excision or if operative
management will be associated with disfiguration.
Radiotherapy following surgical excision to minimise recurrence risk.
Chemotherapy if metastases present.
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To complete my exam I would like to examine the regional lymphatic chains, the
liver and listen to the chest.
Thank the patient
Wash your hands
Present your findings
Summarise as above and then say:
I am concerned that this may be a suspicious lesion and I would like to exclude
malignant melanoma.
Melanoma is a form of skin cancer with an annual incidence of >10 000 people in
the United Kingdom. Over the past 10 years, incidence has doubled in the United
Kingdom and has become the most common cancer in those aged 1534 years
(although it is more common in the older age group). It is frequently seen in fairskinned people as a result of increased growth of melanocytes in the epidermis.
It can occur as a dark macule/papule in a pre-existing naevi in half of all cases;
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typically in women, this is seen on the legs; and in men, on the chest or back. This
is more progressive than NMSC and will metastasise, making it the commonest
cause of death from skin disease. Diagnosis involves excision biopsy and in some
cases a sentinel node biopsy is also performed.
Viva questions
Q1
Type
Features
Superficial
spreading
Most common (65%) form, occurs on any body site, looks like a flat,
irregularly shaped and coloured lesion.
Nodular melanoma
Twenty per cent of cases and is polypoid in shape; colour can range
from dark black/blue to blue/red to normal skin colour.
Lentigo maligna
Acral lentiginous
An uncommon form; occurs on the palms, soles and nail base; common
in Africans.
Amelanotic
A rare form where the lesion is not pigmented; patients often present
with metastatic spread to the lymph nodes and consequently have a
poor prognosis.
Q2
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There are two commonly used: Clarks Levels and Breslows Thickness; a
combination of the two increases prognostic accuracy.
Both assess depth of tumour invasion with respect to the epidermis.
Clarks Levels
Breslows Thickness
Tumour invasion thickness versus approximate 10-year survival rates:
3.2
SURGICAL SCARS
Although this is unlikely to be an OSCE station in its own right, students may be asked
in an abdominal examination station what the name of a particular scar is and what
they think the underlying operation was. We find many students struggle on this unnecessarily; therefore, we provide you with an outline of the most common scars you are
likely to come across in finals and how to approach them in a logical manner.
Clinical examination
Identify scar
If you do not know the names, then describe the scars anatomically, e.g. a 2-cm
scar in the right groin.
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2
1
6
8
Key
Scar name
Possible operation
Reversed Kochers
3
2+3 Double Kochers or
rooftop scar
Open splenectomy
Ivor Lewis (oesophagectomy), complex pancreatic/gastric
surgery
Mercedes scar or
2
3+4 extended rooftop
Left nephrectomy
5
scar or loin incision
Gridiron or
6
McBurneys
Pfannenstiel
7
Appendicectomy
Pelvic surgery: Bladder resection, prostatectomy, bilateral
hernia repairs
Gynaecological: Caesarean section, cystectomy,
hysterectomy
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Viva questions
Q1
Q2
Q3
What are the advantages and disadvantages of the midline laparotomy scar?
(Honours Question)
Advantages
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Disadvantages
(Difficult Case)
laparoscopic
ports
laparoscopic
ports
target organ
e.g. appendix
(a)
(b)
Completion
Laparoscopic scars are difficult to see by their very nature, but increasingly laparoscopic surgery is becoming commonplace. It is important to bear in mind that even
though there may be smaller individual scars in terms of size, collectively they may
equal or even be greater than the original size of a single open-access incision.
Viva questions
Q1
In general, ports should be placed away from areas of high risk, such as:
Previous scars, adhesions and known organomegaly.
The vessels of the anterior abdominal wall should be avoided, particularly
the inferior epigastric artery.
The minimum number of ports possible should used; typically three ports.
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Q2
The positioning of these three ports should then allow for the target organ to
be at the apex of an imaginary diamond formed by the various ports as well as
the target organ itself.
The 10-mm port is for the camera and is useful for the removal of organs such as
the gallbladder in a cholecystectomy. All other ports are typically 5 mm in size.
Variable
Description
Advantages
Disadvantages
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