Health-Process-Evidence-based Clinical Practice Guidelines for Skin & Soft Tissue Tumors

1. Health-Process-Evidence-based Clinical Practice Guidelines forSkin & Soft Tissue Tumors Redomir Roque, M.D. Derrick K.Chua, M.D. Maria Cecilia T. Leyson, M.D. Nolan O. Aludino, M.D. Jeffy Guerra, M.D.

2. Clinical Question • What is the OMMC Surgery’s operational concept of skin & soft tissue tumors? • Definition Tumors- Masses, lumps, “bukol” Skin- epidermis & dermis Soft tissue- connective tissues, tendon, ligament, muscle, nerves, vessels (exclusive of skin, breast, blood, viscera and bone)

3. Clinical Question • What are typicaloperational concepts of skin & soft tissue tumors by other people? Latin = a swelling (primarily infectious) Some MDs = Neoplasm [neo+ Greek plasma, thing formed] = an abnormal tissue that grows by cellular proliferation more rapidly than normal, continues to grow after the stimuli that initiated the new growth cease Most lay people = malignancy* * cyst = benign

4. Clinical Question 2. How are skin and soft tissue tumors classified in terms of of pathology? Inflammatory/ infectious Traumatic Malignant [L. maligno, to do any thing maliciously] locally invasive & destructive, or metastatic Benign/ non-malignant [Latin benignus, kind]

5. Clinical Question 3. What are the hypothesized causes of malignant skin & soft tissue tumors? Ans: Genetic- race, premalignant lesions, gender Environmental- UV(B), radiation, soot, burn scars, arsenic, asbestos?, dioxin?, viral? immunologic? trauma?

6. 4. What are common types of skin & soft tissue tumors?

7. Skin and Soft tissue Tumors General Management Guidelines Clinical Diagnosis Paraclinical Diagnosis Staging and Prognostication Treatment

8. Skin & Soft Tissue Tumors Skin Soft Tissue Inflammatory Noninflammatory inflammatory Noninflammatory Erythema malignant nonmalignant erythema malignant nonmalignant Swelling swelling Warm to flat/raised warm to mass touch white/pink- EIC touch large Tender brown-black nevus tender deep non-tender dermoid immobile irregular borders nontender non-healing sore basal cell carcinoma Sarcoma squamous cell carcinoma melanoma

9. Clinical Question 5. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient has a benign skin or soft tissue tumor? Ans: • Soft, small, movable/ not fixed to adjacent structures, no metastasis OR • Recent mass and onset of prominent signs of inflammation such as redness, pain, warmth, purulent discharge

10. Clinical Question 6. What are reliable signs and symptoms (more than 90% certainty) that will indicate that a patient has a malignant skin or soft tissue tumor? Ans: • Rapidly growing mass without prominent signs of inflammation, hard and fixed to the underlying structures, or with metastasis

11. Clinical Question 7. What are reliable signs and symptoms (more than 90% certainty) that a patient needs operation? Ans: Functional- e.g. near orifices, joints Pain Cosmetic- to restore normal skin contour Psychological- fear of malignancy

12. Inflammatory lesions not included • For the diagnosis and treatment of inflammatory/ infectious tumors, the user of the CPG is directed to the departmental protocol on skin and soft tissue infections.

13. Clinical Question 8. What are conditions that a patient with skin and soft tissue tumors do not need surgery? Ans: • Reasonable amount of certainty that lesion is benign • No functional or cosmetically unacceptable disfigurement

14. Clinical Question 9. If a paraclinical diagnostic procedure is needed in a patient with skin and soft tissue mass, what is the most cost-effective procedure to differentiate benign from malignant? Ans: Tissue biopsy

15. Paraclinicals

16. 10. In a patient with skin and soft tissue malignancy, are further paraclinical diagnostic procedures needed for determination of matastasis? Ans:

17. 11. What are the treatment goals? • Benign skin tumor • Skin tumor of uncertain behavior • Malignant skin tumor • Benign soft tissue tumor • Soft tissue tumor of uncertain behavior • Malignant soft tissue tumor

18. TREATMENT GOALS Benign skin tumor • Resolve functional or cosmetically unacceptable disfigurement

19. TREATMENT GOALS Skin tumor of uncertain behavior • Ascertain that lesion is not malignant • Resolve functional or cosmetically unacceptable disfigurement

20. TREATMENT GOALS Malignant skin tumor • Resolve lesion • Preserve function and cosmesis

21. TREATMENT GOALS Benign soft tissue tumor • Resolve functional or cosmetically unacceptable disfigurement

22. TREATMENT GOALS Soft tissue tumor of uncertain behavior • Ascertain that lesion is not malignant • Resolve functional or cosmetically unacceptable disfigurement

23. TREATMENT GOALS Malignant soft tissue tumor • Resolve lesion • Preserve function and cosmesis

24. 12. What is the best treatment? • Benign skin tumor • Skin tumor of uncertain behavior • Malignant skin tumor • Benign soft tissue tumor • Soft tissue tumor of uncertain behavior • Malignant soft tissue tumor

25. Benign Skin Lesion

26. Skin Lesion of Uncertain Behavior

27. Malignant Skin Lesion

28. Benign Soft-Tissue Lesion

29. Soft-Tissue Lesion of Uncertain Behavior

30. Malignant Soft-Tissue Lesion

31. 13. What is the best timing for surgery? Ans: • Benign skin tumor >6wk • Skin tumor of uncertain behavior • Malignant skin tumor <3-6wk • Benign soft tissue tumor >6wk • STT of uncertain behavior • Malignant soft tissue tumor <<18mo

32. 14. What is the role of chemotherapy?

33. 15. What is the role of radiotherapy?

34. 16. What is the role of immunotherapy?

35. 17. What is/are the most cost-effective procedure in preventing postop complications?

36. 18. What is/are the parameters to use in adequate margin of resection? Ans: Benign- complete capsule removal 1cm for MM<1mm 2cm for nMSC<2cm, MM1-4mm 2-5cm for nMSC>2cm, sarcomas nMSC non-melanoma skin cancer