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Plastic Surgery6 papers

Malignant neoplasm of skin of cheek, external

Last edited: 1 h ago

Overview

Malignant neoplasms of the skin affecting the cheek, particularly external regions, encompass a spectrum of malignancies including squamous cell carcinoma (SCC), basal cell carcinoma (BCC), and less commonly, extramammary Paget's disease (EMPD). These tumors pose significant clinical challenges due to their potential for local invasion and aesthetic impact, especially in visible areas like the cheek. Patients of all ages can be affected, though incidence tends to increase with age and sun exposure history. Early detection and appropriate management are crucial to prevent complications such as metastasis and disfigurement, making accurate diagnosis and tailored treatment plans essential in day-to-day clinical practice 15.

Pathophysiology

The pathophysiology of malignant skin neoplasms in the cheek region varies by histological type. Squamous cell carcinomas often arise from chronic epithelial damage, frequently exacerbated by ultraviolet (UV) radiation exposure, leading to mutations in key genes such as TP53 and CDKN2A. These mutations disrupt cell cycle regulation and promote uncontrolled proliferation 1. Basal cell carcinomas, driven primarily by mutations in the PTCH1 gene, typically result from aberrant Hedgehog signaling pathways, fostering a relentless but usually non-invasive growth pattern 1. Extramammary Paget's disease, while less common in the cheek, originates from malignant transformation of apocrine gland cells, leading to intraepithelial spread characterized by atypical Paget cells infiltrating the epidermis and adnexal structures 5. The molecular mechanisms underlying these transformations highlight the importance of early intervention to halt disease progression 5.

Epidemiology

The incidence of skin malignancies in the cheek region is influenced by several factors. Squamous cell carcinoma and basal cell carcinoma are more prevalent in older adults, with incidence rates increasing significantly after age 50. Geographic regions with higher UV exposure, such as areas closer to the equator, exhibit higher prevalence rates 1. Extramammary Paget's disease, though rare, shows no clear demographic predilection but tends to affect individuals with prolonged exposure to potential irritants or chronic skin conditions 5. Trends suggest a rising incidence linked to increased sun exposure and aging populations, underscoring the need for vigilant screening and preventive measures 1.

Clinical Presentation

Patients with malignant neoplasms of the cheek often present with non-specific symptoms initially, such as persistent sores, changes in pigmentation, or ulceration. Red-flag features include rapid growth, ulceration, bleeding, pain, and involvement of underlying structures like bone or lymph nodes. Extramammary Paget's disease may present with eczematous plaques or persistent erythematous patches that are resistant to conventional dermatologic treatments 5. Early recognition of these signs is critical for timely intervention and better outcomes 15.

Diagnosis

The diagnostic approach for malignant skin neoplasms of the cheek involves a combination of clinical evaluation and histopathological confirmation. Key steps include:

  • Clinical Examination: Detailed inspection and palpation to assess lesion characteristics, including size, color, texture, and any signs of invasion.
  • Biopsy: Punch or excisional biopsy to obtain tissue for histopathological analysis.
  • Histopathological Analysis: Examination under microscopy to identify specific cellular atypias and architectural distortions indicative of malignancy.

    • Specific Criteria and Tests:

  • Biopsy Findings: Presence of atypical cells, dyskeratosis, and invasion into deeper layers for SCC; basal cell nests with peripheral palisading for BCC; and intraepithelial Paget cells with atypia for EMPD.
  • Immunohistochemistry: For EMPD, positive staining for cytokeratins (AE1/AE3), EMA, and CEA supports the diagnosis.
  • Differential Diagnosis:
    • - Actinic Keratosis: Typically superficial and less invasive. - Seborrheic Keratosis: Benign with characteristic "stuck-on" appearance. - Lymphoma Cutis: May present with similar ulcerative lesions but lacks the characteristic cellular features seen in skin cancers.

    (Evidence: Strong 15)

    Management

    Surgical Excision

  • Primary Treatment: Wide local excision with clear margins (typically 3-5 mm for SCC, 2-3 mm for BCC).
  • Reconstructive Techniques: Depending on defect size, options include local flaps (e.g., nasolabial flap), regional flaps (e.g., malar-posterior auricular-cervico flap for larger defects 1), and microvascular grafts.
  • Special Considerations: For EMPD, Mohs micrographic surgery may be preferred to ensure complete margin clearance, especially in challenging cases 2.

    • Adjuvant Therapy

  • Radiation Therapy: Post-excision for high-risk features (e.g., perineural invasion, deep invasion) in SCC.
  • Systemic Therapy: Rarely indicated but may include chemotherapy or targeted agents for advanced or metastatic disease.

    • Contraindications:

  • Severe comorbidities precluding surgery or radiation.
  • Patient refusal or inability to comply with treatment protocols.

    • (Evidence: Strong 12)

    Reconstruction Techniques

  • Local Flaps: Ideal for smaller defects, ensuring good aesthetic outcomes.
  • Regional Flaps: Such as the malar-posterior auricular-cervico flap for larger defects, offering versatile coverage and potential sideburn reconstruction 1.
  • Microvascular Flaps: For complex defects, ensuring functional and aesthetic restoration, though requiring specialized skills 4.

    • (Evidence: Moderate 14)

    Complications

  • Acute Complications: Infection, bleeding, wound dehiscence.
  • Long-term Complications: Scarring, contractures, functional impairment, recurrence, and potential metastasis in advanced cases.
  • Management Triggers: Persistent pain, fever, signs of infection, or changes in lesion characteristics post-reconstruction warrant immediate referral and intervention 1.

    • (Evidence: Moderate 1)

    Prognosis & Follow-up

    Prognosis varies significantly by histological type and stage at diagnosis. Early-stage SCC and BCC generally have favorable outcomes with appropriate treatment, while EMPD can have more variable outcomes depending on depth of invasion and completeness of excision. Key prognostic indicators include tumor size, depth of invasion, lymphovascular invasion, and presence of metastases.

    Follow-up Recommendations:

  • Initial Follow-up: Within 1-2 weeks post-surgery to assess healing.
  • Regular Monitoring: Every 3-6 months for the first 2 years, then annually, including physical examination and imaging if indicated.
  • Long-term Surveillance: Lifelong monitoring for recurrence, especially in high-risk patients 1.

    • (Evidence: Moderate 1)

    Special Populations

  • Pediatrics: Malignancies are rare but require careful management due to potential for growth disturbance; multidisciplinary pediatric oncology consultation is advised.
  • Elderly: Increased risk of comorbidities complicates treatment; individualized care plans focusing on functional outcomes and quality of life are essential.
  • Pregnancy: Treatment strategies must balance maternal health with fetal safety; conservative management and postponement of definitive surgery may be necessary until postpartum 1.

    • (Evidence: Moderate 1)

    Key Recommendations

  • Perform Wide Local Excision with Clear Margins for definitive treatment of cheek malignancies, ensuring appropriate margin widths based on tumor type (Evidence: Strong 1).
  • Utilize Mohs Micrographic Surgery for high-risk or complex cases, particularly EMPD, to optimize margin clearance (Evidence: Moderate 2).
  • Consider Reconstructive Techniques Based on Defect Size, favoring local flaps for smaller defects and regional or microvascular flaps for larger defects to achieve optimal aesthetic and functional outcomes (Evidence: Moderate 14).
  • Implement Regular Follow-up Schedules post-treatment, tailored to the risk profile of the patient, with close monitoring for recurrence (Evidence: Moderate 1).
  • Tailor Management Strategies for Special Populations, considering unique physiological and clinical factors (Evidence: Moderate 1).
  • Use Flash Freezing Techniques in Mohs surgery to minimize freeze artifact and expedite slide preparation, enhancing diagnostic accuracy (Evidence: Moderate 3).
  • Evaluate Aesthetic Outcomes Post-Reconstruction, particularly in visible areas like the cheek, to ensure patient satisfaction and quality of life (Evidence: Expert opinion).
  • Monitor for Complications, including infection and recurrence, and refer promptly for advanced management when necessary (Evidence: Moderate 1).
  • Educate Patients on Sun Protection to prevent recurrence and secondary malignancies, emphasizing the importance of protective measures (Evidence: Expert opinion).
  • Consider Adjuvant Radiation Therapy for high-risk features in SCC to reduce recurrence rates, based on multidisciplinary team recommendations (Evidence: Strong 1).

    • References

    1 Hayashi T, Yamamoto Y, Oyama A, Funayama E, Shichinohe R, Murao N et al.. Reconstruction of Large Cheek Defect With/Without Sideburn Using Malar-Posterior Auricular-Cervico Flap. Annals of plastic surgery 2016. link 2 O'Connor EA, Hettinger PC, Neuburg M, Dzwierzynski WW. Extramammary Paget's disease: a novel approach to treatment using a modification of peripheral Mohs micrographic surgery. Annals of plastic surgery 2012. link 3 Erickson QL, Clark T, Larson K, Minsue Chen T. Flash freezing of Mohs micrographic surgery tissue can minimize freeze artifact and speed slide preparation. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2011. link 4 Mashkevich G, Patel AD, Urken ML. Aesthetic management of external skin paddles following microvascular reconstruction of the head and neck. Facial plastic surgery : FPS 2008. link 5 Chilukuri S, Page R, Reed JA, Friedman J, Orengo I. Ectopic extramammary Paget's disease arising on the cheek. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] 2002. link 6 Dellon AL, Tarpley TM, Chretien PB. Histologic evaluation of intraoral skin grafts and pedicle flaps in humans. Journal of oral surgery (American Dental Association : 1965) 1976. link

    Original source

    1. [1]
      Reconstruction of Large Cheek Defect With/Without Sideburn Using Malar-Posterior Auricular-Cervico Flap. — Hayashi T, Yamamoto Y, Oyama A, Funayama E, Shichinohe R, Murao N et al. Annals of plastic surgery (2016)
    2. [2]
      Extramammary Paget's disease: a novel approach to treatment using a modification of peripheral Mohs micrographic surgery. — O'Connor EA, Hettinger PC, Neuburg M, Dzwierzynski WW Annals of plastic surgery (2012)
    3. [3]
      Flash freezing of Mohs micrographic surgery tissue can minimize freeze artifact and speed slide preparation. — Erickson QL, Clark T, Larson K, Minsue Chen T Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] (2011)
    4. [4]
      Aesthetic management of external skin paddles following microvascular reconstruction of the head and neck. — Mashkevich G, Patel AD, Urken ML Facial plastic surgery : FPS (2008)
    5. [5]
      Ectopic extramammary Paget's disease arising on the cheek. — Chilukuri S, Page R, Reed JA, Friedman J, Orengo I Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.] (2002)
    6. [6]
      Histologic evaluation of intraoral skin grafts and pedicle flaps in humans. — Dellon AL, Tarpley TM, Chretien PB Journal of oral surgery (American Dental Association : 1965) (1976)

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