-Skin closure stepladder?

-Matis Triangle?

-Skin graft

-Wound Healing (stage= HIPR)

-Flap and Graft

Kuliah dr Sjaifuddin SpBP UNAIR

Guna flap
1 Menutup luka yang bed lukanya miskin vaskuler - Luka dengan
dasar tulang, tendo dan syaraf - Luka ulkus
2. Rekonstruksi muka
3. Sebagai bantalan diatas penonjolan tulang
4. Memperbaiki sensibilitas suatu area

KLASIFIKASI I. Berdasarkan Vaskularisasinya :

1. Random Flaps
2. Axial Flaps

1. Random Flaps - Jika flap diperdarahi oleh pembuluh darah

yang tidak mempunyai nama - Sebagian besar flap adalah
random - Diperdarahi oleh pleksus dermal sub dermal

2. Axial Flaps - Disuplai oleh vaskuler yang bisa diidentifikasi

(punya nama)
II. Berdasarkan cara memindahkannya
1. Local Flaps
A. Rotation Flap
B. Transposition Flap
C. Interpolation Flap
D. Advancement Flap
2. Distant Flap (Flap Jauh)
A. Direct
B. Indirect
3. Free Flap
D. Advancement flap di dorong kedepan
• Single pedicle advancement flap A rectangular or square flap that
is stretched forward
• Bipedicle advancement flap
• V – Y advancement flap V shape incision is made and closed as a Y
• Y – V advancement flap The opposite to the V – Y advancement
flap
3.Free Flap

Melanoma Maligna
MM < 5% of skin cancer cases diagnosed
But >70% of the deaths attributable to skin cancer per year

Asal: pigment-producing epidermal melanocytes

Epidemiologic studies: strong link between the risk of cutaneous
melanoma and exposure to ultraviolet (UV)
Radiation  UV radiation (UVR)–induced DNA damage

Mutations in three genes in this pathway: BRAF, RAS, and NF1 (The
cancer genome atlas)

Molecular signaling pathways in melanoma. (Reprinted from

Sullivan RJ, Lorusso
PM, Flaherty KT. The intersection of immune-directed and
molecularly targeted therapy inadvanced melanoma: where we
have been, are, and will be.
91.2% of melanomas were cutaneous, 5.3% ocular, 1.3% mucosal,
and 2.2% metastases from unknown primary site.

Site:
-Male: most common back and head-neck
-Female: lower extremities (below knee)

Lentigo maligna melanoma (LMM) most commonly arises on sun-

damaged surfaces of the head and neck in older patients.
Acral lentiginous melanoma (ALM) is most common on subungual
and other acral locations.

Etiology and Risk factor

-UV exposure  a combination of DNA damage, inflammation,
immune suppression, and induction of tissue proteases
UVC radiation  absorbed by the ozone layer
UVB radiation (290 to 320 nm)  sunburn and induction of
tanning by melanin pigment production
UVA radiation (320 to 400 nm) is more associated with chronic sun
damage changes but is also implicated in melanoma induction 
UVA can induce matrix metalloproteinase expression in melanoma
cells, and it may also support invasiveness by inducing cathepsin K.

UVA and UVB have immunosuppressive effects on the skin, which

are implicated in melanoma induction

Fisik
blond or red hair, green or blue eyes, presence of multiple (>100)
melanocytic nevi, and five or more atypical nevi.

Familial
The most frequent and highest penetrance melanoma susceptibility
gene is a germline mutation in CDKN2A, a tumor suppressor gene
that encodes for two different proteins, p16INK4A and p14ARF.
These proteins control cell cycle progression and apoptosis and
have roles in correcting DNA damage and cellular senescence.

Pregnancy and estrogen use  sebelumnya dikatakan berpengaruh

tapi penelitian yg multisystematic and larger mengatakan tidak
berhubungan.

Prevention
-sunblock
-self examination

Klinis
Biopsy  full-thickness biopsy of the entire lesion, with a narrow (1
to 2 mm) margin of grossly normal skin. Sampai batas
dermis/subkutis. Tujuannya untuk dd/ melanoma dengan Spitz
nevus, and it permits an accurate measure of tumor thickness,
which is critical for prognosis and affects the surgical treatment
recommendations.

Nail  proximal ends

Histologic patterns
Yg utama ada 4

Superficial Spreading Melanoma

Most common = 70% of primary cutaneous melanomas
It is typical for the trunk and extremities, except on acral sites.
Commonly associated with sun exposure.

Nodular Melanoma
-lack an RGP (radial growth phase), may be nonpigmented, and
commonly are diagnosed when relatively thick. Usuallly in VGP
(vertical growth phase) when recognized.
-Worst prognosis
-20% of cutaneous melanomas.

Acral Lentiginous Melanoma

- <5% of melanomas
- typically found on acral sites (subungual, palmar, plantar) and on
mucosal surfaces (anorectal, nasopharyngeal, female genital tract)
- independent of UV light exposure
-African, Asian ethnic  more common than fair skin
- prolonged RGP before vertical growth; however, its locations
make it harder to diagnose than other forms of melanoma.
-Subungual lesions can be detected by linear pigment streaks
arising from the base of the nail (dd/ hematoma biasa 3 weeks
hilang)

Lentigo Maligna Melanoma

-older individuals, in chronically sun-damaged skin, and commonly
on the face
- have shades of brown or black
- 10% to 20% of melanomas
- usually have an extensive RGP that extends for many years before
developing invasion
-When melanoma is just in situ, this RGP portion is called lentigo
maligna or Hutchinson freckle, as opposed to LMM
Dd/ benign pigmented macule= lentigo
Lentigo malignas evolve a VGP to become invasive LMMs at a rate
estimated to be between 5% and 33%
Lentiginous Melanoma
- Early RGP melanomas sometimes are difficult to classify into the
typical patterns of lentigo maligna, superficial
spreading melanoma, or ALM
-Lentiginous melanoma features include
diameter ≥1 cm, elongated and irregular rete ridges, confluent
melanocytic nests and single cells over a broad areaof the
dermal/epidermal junction, focal pagetoid spread, cytologic atypia,
and possible focal dermal fibrosis.

Desmoplastic Melanoma
-uncommon form of melanoma
-histologically manifest by a superficial lentiginous proliferation of
melanocytes at the base of the epidermis, spindled melanocytes in
dense desmoplastic stroma, and
intratumoral aggregates of lymphocytes.
-These lesions are usually nonpigmented and usually have lost the
melanin production pathway

Prognostic Factors for Primary Melanomas

-The best predictor of metastatic risk is the depth of invasion,
originally described by Breslow and
remains an important factor in staging and prognostic stratification.
-Breslow thickness is the depth of invasion measured from the
granular layer of the epidermis to the base of the
Lesion
- (AJCC) identifies tumor (T) stage based on Breslow thickness:
- T1 lesions are ≤1 mm thick,
- T2 lesions are 1.1 to 2 mm thick
- T3 lesions are 2.1 to 4 mm thick
- T4 lesions are >4 mm thick

-Clark et aldefined depth based on the layer of skin to which the

melanoma has invaded
- Clark level I= melanomas in situ, limited to the epidermis
or dermal/epidermal junction
- Clark level II = invade into the superficial (papillary)
dermis, and these are usually RGP lesions
- Clark level III = fill the papillary dermis
- Clark level IV = invade into the deep (reticular) dermis and
have significant metastatic risk
- Clark level V melanomas are uncommon and contain
invasion into the subcutaneous fat.

Clark level was removed from the seventh and eighth versions of
the AJCC staging system karena tidak terlalu beda dengan Breslow

- Ulceration of the primary lesion has been identified as an

important negative prognostic feature. Pada T sistem TNM,
a=nonulcerated, b = ulcerated.
T1
-ada perdebatan margin
- evolusi dari th 1900an melanoma penyakit jarang dan biasa
ditemukan sudah locally advanced. Surgical resection was often
associated with recurrent disease. Guideline belum ada.
-1907, Handley reported a study of primary melanoma in a human
tissue specimen that he obtained from a patient with a large
primary melanoma. In that study, he found microscopic evidence of
melanoma cells as far as 5 cm from the primary tumor. He
recommended wide reexcision of melanomas with a measured
margin of 5 cm from the
primary lesion. This recommendation became standard
management for melanoma for many decades. Saat ini sudah lebih
sering terdiagnosis earlier and thinner  safety margin <<.
-WHO: There were no local recurrences for melanomas <1 mm
thick treated with 1-cm margins.
-French and Swedish: Both of these studies support 2-cm margins
asadequate for melanomas up to 2 mm thick and find no added
benefit to 5-cm margins.

Lymph Node
-In the past, the standard recommendation was to perform ELND
(elective LN dissection) for melanomas of intermediate thickness
(1to 4 mm).
- The concept and method for SNBx were originally developed by
Cabanas for penile carcinoma
- Lymphoscintigraphy has been coupled with the blue dye injection
to support identification of the sentinel
node(s), using handheld probes for detection of γ radiation emitted
by technetium-99m (99mTc)
- Lymphatic mapping and SNBx using both blue dye and radiocolloid
increase sentinel lymph node
identification rates to 99% compared with 87% with blue dye alone
- SNBx is generally recommended for patients with melanomas at
least 1 mm thick. For thinner melanomas, there isdebate about the
appropriate criteria for performing SNBx
Surgical Methods in Wide Local Excision (Applies for All
Primary Melanoma Thicknesses)
- For melanomas of the trunk and proximal extremities, wide local
excisions should involve measuring the
appropriate margin (usually 1 to 2 cm) around the entire scar from
the biopsy
- The excision should include all skin and subcutaneous tissue to
the deep fascia but not including the fascia.

THICK MELANOMAS (T4A, T4B, >4 mm Thick)

-associated with a risk of metastasis and mortality in the range of
50% over 5 to 10 years.
- have a high risk of sentinel node positivity (approximately 35% to
40%), there is a high chance of regional nodal recurrence, and
SNBx, followed by CLND, offers the prospect of increasing the
chance of regional control.

Special consideration
-subungual melanomas of any finger or toe, the appropriate
management is amputation at the interphalangeal joint. Even for
subungual melanomas in situ, such an amputation is indicated.
Radiation Therapy
-The general management of primary melanoma lesions is surgical
resection.
-definitive or adjuvant radiation therapy in certain histologic
variants including lentigo maligna, desmoplastic melanoma, or
neurotropic melanoma, and for palliation of bulky unresectable
primary disease.

Metastasis Regional
- high propensity to regional metastasis
- all presumably via intralymphatic dissemination
- Regional metastases are defined as follows:
Local recurrence = recurrence of melanoma in the scar from the
original excision
Satellites metastases may occur either simultaneously with the
original diagnosis or arise subsequent to
original excision. Typically, are separate from the scar but within 2
to 5 cm
-Regional recurrences beyond 5 cm of the scar but proximal to
regional nodes are considered in-transit
metastases
-Regional node metastases are typically in a draining nodal basin
that is near the lesion.

Management of Satellite and In-Transit Metastases

-th/= perform excision of these metastases sampai free
Margins yaitu sampai 5- to 10-mm margin. Repeat SNBx
from the site of recurrence may also be considered
- multiple in-transit metastases  no ideal management for such
patients because the natural history almost always involves
systemic dissemination of disease

Lymphadenectomy
- Axillary dissection should include all node-bearing tissue in levels
I, II, and III. The long thoracic nerve and
thoracodorsal neurovascular bundle should be identified and
preserved unless involved with tumor
-kena vena axillary  sacrifice/boleh buang, tdk ada morbiditas
berarti karena ada anastomose
-kena brachial plexus  forequarter amputation
-Inguinal dan iliac  metastatic melanoma to inguinal nodes,
complete groin dissection is indicated
- As described by Spratt  the inguinal region including the
superficial ( superficial to the fascia that lies immediately
superficial to the femoral vessels), and the deep inguinal region
(deep to that fascia and includes the femoral vessels). Cloquet
node is the deep inguinal node that is classically considered to be
the transitional node between the inguinal region and the iliac
region. If that node contains metastatic melanoma, an iliac and
obturator dissection may be indicated.
-When patients have extensive nodal disease in the inguinal region,
a complete inguinal dissection is
appropriate, with skeletonization of the femoral artery and vein,
often with a sartorius flap to cover these vessels.
-Jika SNBx (+)  completion node dissection dengan superficial
inguinal dissection with excision of Cloquet node  provides
excellent regional control
-Cloquet node is accessible through the foramen in which the
saphenous bulb is found and is located lateral to the saphenous
bulb.
-iliac region tidak sama dengan the deep groin (bbrp ahli bedah
ambiguity dg term ini)
-An iliac node dissection involves skeletonizing the external iliac
vessels and is generally combined with removal of the
iliac node-bearing tissue and obturator fat pad (obturator
dissection). This dissection extends from the inguinal
ligament to the takeoff of the internal iliac vessels and can be
performed in continuity with the inguinal dissection
or through a separate lower quadrant abdominal wall incision and a
retroperitoneal approach.

Cervical Dissection
Metastatic melanoma to a cervical node is appropriately managed
by complete neck dissection. A modified radical
neck dissection should be performed, with preservation of the
internal jugular vein, sternocleidomastoid muscle,
and spinal accessory nerve. However, if these structures are
invaded by tumor or involved with tumor, they can be
resected. Sacrifice of the spinal accessory nerve can cause
significant morbidity but is occasionally necessary.

Terapi tambahan
-radioterapi
adjuvant radiation to reduce primary and regional nodal
recurrences in selected patient populations and for its use for
palliation of unresectable primary and nodal recurrences or distant
metastases.
-systemic therapy
These include HDI-α for 1 month followed by 1 year
of intermediate dosing, pegylated IFN administered for a target
period of 5 years, and high-dose ipilimumab at 10
mg/kg. Two randomized trials suggest that further benefit could be
achieved with the use of anti–PD-1 and with
BRAF and MEK inhibitors for patients with resected BRAF-mutated
melanoma, and these treatments are likely to
be approved by regulatory bodies soon and become the new
preferred adjuvant treatment for resected melanomas
at high risk of relapse.

Distant Metastases (Stage IV)

Surgery
Cases in Which the Benefit of Surgery Is Clear
- Anemia due to occult bleeding from intestinal metastasis
- Bowel obstruction due to small bowel metastasis
- Cutaneous or subcutaneous metastasis with ulceration, pain,
or impending ulceration
- Lymph node metastasis with neurologic symptoms
- Symptomatic brain metastasis
- Life-threatening hemorrhage from metastasis
Immunoterapi

IL2, BRAF inhibitor (Vemurafenib)

Chemotherapy
Single
Dacarbazine (antialkylating agent), Temozolomide,
Fotemustine, nab-paclitaxel
Combination
-dikatakan benefit lebih tinggi
-regimens: -cisplatin, vinblastine, and dacarbazine (CVD)
-Dartmouth regimen (cisplatin,carmustine,
dacarbazine, and tamoxifen).
- The Dartmouth regimen was associated with significantly more
severe neutropenia, anemia, nausea, and vomiting. In addition,
several randomized trials refuted the concept that tamoxifen
substantially modulates the efficacy of chemotherapy in metastatic
melanoma

Non Melanoma Skin Cancer

Biopsy
- based on the morphology of the primary lesion and clinical
differential diagnosis.
-A shave biopsy  for raised lesions such as nodular basal cell
carcinoma (BCC) and squamous cell carcinoma (SCC) or flat,
superficial lesions such as SCC in situ (SCCIS).
-A punch biopsy is appropriate for lesions with a deeper dermal or
subcutaneous extension such as dermatofibrosarcoma protuberans
(DFSP).
-An excisional biopsy  for diagnosis of a dermal nodule when
morphologic assessment of overall tumor architecture is crucial for
proper diagnostic assessment, such as distinguishing between a
benign dermatofibroma and a malignant fibrous tumor
-anestesi lokal dengan lidocaine atau pehacain

Operasi
-The management of skin cancer is guided by the histologic and
biologic nature of the tumor, the anatomic site, the
underlying medical status of the patient, and whether the tumor is
primary or recurrent.
-Perlu accurate interpretation of the diagnostic biopsy
-Depending on the biologic aggressiveness of the tumor, cancers of
the skin may be excised or, in some cases of superficial tumors or
precancerous lesions, eliminated in a less invasive fashion.
-Surgical options include conventional excision and Mohs
micrographic surgery (MMS).  provide information about the
histologic completeness of the cancer ablation
-Destructive modalities include curettage and cautery or
electrodessication (C&D), cryosurgery, photodynamic therapy
(PDT), and laser surgery.
-Other techniques are topical therapy (e.g., imiquimod, 5-
fluorouracil [5-FU]), intralesional interferon (IFN), chemotherapy,
and radiation therapy (RT).

Eksisi
-kalau office procedure, batas sayatan bebas tumor/tidak, tifak bisa
lgsg diketahui
Mohs Microsurgery (MMS)
- MMS is a staged excision with intraoperative microscopic analysis
that facilitates optimal margin control and
conservation of normal tissue.  standard of care in a variety of
skin cancer subtypes, bisa lokal anestesia
- After gentle curettage to define the clinical gross margin of the
cancer, a 45-degree tangential specimen of tumor with a minimal
margin of clinically normal-appearing tissue is excised, precisely
mapped, and immediately processed
with tangential, or en face, frozen sections for microscopic
examination.
- A key defining feature of MMS is that the surgeon excises, maps,
and reviews the specimen personally
- Because clear surgical margins are confirmed intraoperatively,
reconstruction with tissue rearrangement may be performed
immediately

Radiation
RT is a treatment option for several types of NMSC, including BCC
and SCC, Merkel cell carcinoma (MCC),
angiosarcoma (AS), cutaneous lymphomas, some adnexal
carcinomas, and other primary and metastatic cutaneous
neoplasms.
RT, in properly fractionated doses, is indicated for patients whose
overall health status precludes surgery, for patients who are
unwilling or unable to undergo surgery, or when the size of the
tumor precludes
surgical extirpation.
RT is also used as an adjuvant treatment for patients with positive
surgical margins, perineural invasion (PNI), or local regional nodal
metastasis  ??? vs reeksisi

BCC
-BCC is a slow-growing neoplasm of nonkeratinizing cells originating
from the basal cell layer of the epidermis.
-BCC = most common human cancer = ½ dari keseluruhan human
cancer dan 75% dari keganasan kulit
-Typically, BCC develops on sun-exposed areas of lighter skinned
individuals  ada primary role of UV radiation
- rarely metastasizes BUT it is locally invasive and can result in
extensive morbidity through local recurrence and tissue destruction
-With appropriate local treatment, the prognosis for primary BCC is
excellent

Clinical and Pathological Features

- slowly growing solitary lesion on sun-exposed, jarang lesi multiple
-50% di face and ear, 30% nose, bisa juga di sun-protected areas
(vulva, penis, scrotum, and perianal area)
-keluhan pasien: minor skin trauma that fails to heal over
several months
-Pathology
-indolent-growth:
-Superficial
-nodular
-aggressive-growth
-infiltrative BCC
-metatypical BCC
-morpheiform or sclerosing BCC
-micro-nodular
-basosquamous  paling agresif

Indolent Nodular -Common

>60% of all tumor
BCC
- raised, translucent, pearly, skin-
toned to pink papule or nodule
with prominent telangiectasias
- Occasionally, the center of the
tumor appears depressed or
sunken, leaving a rolled, raised
border with the classic
pearly appearance so-called
 rodent ulcer.
- Not infrequently, history of easy
bleeding and/or crusting is
obtained

Super- -2nd most common, 15% BCC

-younger px <50y.o
ficial BCC
- well-defined, pink to
erythematous,
scaly or eroded macule or plaque
commonly with a thin pearly
border
-in trunk
-dd/ aktinik keratosis, SCCIS, or
an inflammatory lesion
- lateral extension of the cancer
within the dermis
may be prominent, and local
recurrence can be observed with
incomplete treatment. A small
proportion of lesions
may also progress to more
invasive subtypes of BCC.
Aggresive Infiltra- -5 sampai 15% all BCC
-sering di head&neck
tive
- Morpheaform or sclerosing BCC
adalah variant of infiltrative BCC
with prominent
fibrosis of the surrounding
dermis
- Any of these subtypes may
present as a flat or indurated,
slightly firm lesion, subtle atrophic plaque
without well-demarcated extending broadly over
borders, with a white to the cheek with
yellowish hue, and may be focal scale and crust.
difficult to differentiate from a
scar
- Traction on the skin often
highlights the clinical extent of
the lesion.
-Jarang bleeding,
crusting, and ulceration
 - actual size >>
greater than the clinical
appearance of the tumor
Microno
dular

Basosqu -atau Metatypical ca

-sifat jadi mirip scc
amous
-paling agresif

Jarang Fibroepit - typically presents on the torso

and extremities but
helioma
also has been noted on the
of Pinkus genitalia, groin, and sole of the
(FEP) foot
- a pink, smooth,
dome-shaped, or pedunculated
papule, plaque, or nodule.
- indolent prognosis similar to
superficial BCC
BCC Management
- Low-risk tumors  treated with excisional surgery or C&D (C&D
frequently used by dermatologists For selected low-risk BCCs (<2
cm in diameter and not on the central face))

-Surgical excision  higher cure rates than C&D for typical BCC
-4-mm peripheral margins of surrounding normal skin (excised to a
depth of the subcutaneous adipose) are adequate for removal
nonmorpheaform BCC of dia <2 cm
- Infiltrative or micronodular subtypes  require surgical margins
of 5 to 10 mm for complete clearance, and more effectively treated
with MMS (MMS permits superior histologic verification of
complete tumor extirpation, allows maximum conservation of
tissue, and remains cost effective as compared with traditional
excisional surgery)
Data from a randomized clinical trial have provided high-level
evidence that MMS is superior to standard excision for high-risk
BCC. MMS is the preferred treatment for morpheaform, recurrent,
poorly delineated,
high-risk, and incompletely removed BCCs and for those sites in
which tissue conservation for function and
cosmesis is imperative.

-surgical contraindicates  radiotherapy is a valid option for

management of primary BCC. Disadvantages of RT include lack of
margin control, possible poor cosmesis over time, a drawn out
course of therapy, and increased risk of future skin cancers
SCC

Intro
-From keratinizing (squamous) cells of the epidermis
-found in elderly patients, is associated with chronic UV exposure
-SCC has the potential for rapid growth and a low but significant
risk of metastasis and death
-SCC is frequently associated with precursor lesions of benign AK
(actinic keratosis)

Clinical
- AKs = benign precursors of SCC. AKs are red, pink, or
brown papules with a scaly (hyperkeratotic) surface. They occur on
sun-exposed areas and are especially common
on the balding scalp, forehead, face, dorsal forearms, and hands

AK on forehead

-SCC is often more clinically distinct than AK

-SCCIS appears as a discrete, solitary, sharply demarcated, scaly
pink to red papule or thin plaque

-Erythroplasia of Queyrat (SCCIS on the glans of penis of

uncircumcised male related to HPV infection) presents as a
verrucous or polypoid papule or plaque that is often
eroded.
-Invasive SCC may present as a slightly raised papule plaque or
nodule that is skin-colored, pink, or red

A B

A: SCC on the temple

presenting as a cutaneous horn within a scaly pink plaque. B: SCC on the chest
presenting as a firm,
tender, keratotic nodule with central ulceration and scale crust.

-The surface of the tumor may be smooth, keratotic, or ulcerated.

More advanced lesions may be nodular, exophytic, or indurated.
Kadang ada pain or pruritus. Bleeding with minimal trauma is
common

Histopathology

Squamous cell carcinoma (SCC) histologic features. A: Well-differentiated SCC with

large, well-defined aggregates of squamous cells with modest cytologic atypia and
central keratin
pearls. B: Poorly differentiated SCC, with subtle histologic presentation of spindle
cells with
nuclear atypia infiltrating through dermal collagen (red arrows).
Terapi
-AK  cryotherapy (most common), imiquimod/5fu topical
-Local SCC  There are three general approaches to management
of earlystage,localized SCC: (1) destruction by C&D, (2) removal by
excisional surgery or MMS, and (3) RT.
- SCCIS may be treated by cryotherapy destruction
- Surgical excision, including margin-controlled excision with MMS,
is the most common and effective
treatment modality for SCC.
-Brodland and Zitelli  low-risk lesions of dia <2 cm  95%
pathologic clearance rate using clinical surgical margins of 4 mm.
-Higher risk lesions  diameter ≥2 cm, histologic grade >2, invasion
of the subcutaneous tissue, and location in high-risk areas
(primarily periorificial central face), required greater surgical
margins of 6 mm.
- MMS is indicated for high-risk SCCs
-High risk SCC = including recurrent lesions, large or deeply invasive
lesions, poorly differentiated SCCs, and lesions occurring in high-
risk anatomic sites or sites in which conservation of normal tissue is
essential for preservation of function and/or cosmesis, perineural
involvement, recurrence, multiple cSCC tumors, and
immunosuppression.
- Locally advanced cutaneous SCC may be treated with surgery and
adjuvant RT. Adjuvant postoperative RT is
added in situations in which the possibility of residual disease is
high
- Advanced SCC Treatment of SCC with nodal metastasis may
involve local RT, lymph node dissection, or a combination of both.

MERKEL CELL CARCINOMA

-MCC is a rare and aggressive tumor of neuroendocrine cell origin
that is associated with frequent metastasis and
poor overall prognosis
-insiden men =2x women, white=20xblack, elderly people >75yo
- role of chronic UV exposure in pathogenesis
- Clinically, MCC usually presents as a rapidly growing, firm, flesh-
colored or red-violaceous, dome-shaped papule
or plaque on sun-exposed skin. Most lesions are <2 cm in diameter
at the time of diagnosis. Dd/ BCC, SCC
-th/ complete surgical excision when possible.
WLE with 1- to 2-cm margins is generally recommended. The
optimal width and depth of normal tissue margin
that should be excised around the primary tumor are not well
defined, but clear surgical margins appear to be
associated with improved local control