لمشاهدة الفلم اضغط علي الاعلان

Internal fixation for treatment bone fractures

Fixation of bone fractures can be divided into external and internal fixations

Internal fix­ation

Definition
Are implants that are fitted directly on to or put down the inside of the bone and are then covered with soft tissues and skin ,Internal fixation can allow accurate reduction of fractures, and allows strong and stable fixation, so that the patient can rapidly return to everyday activities, with the minimum of inconvenience
Internal fixation is best performed under a tourniquet, if possible in order to obtain a blood-free view
Internal fixation requires careful preplanning and the best surgery is performed if the fractures are drawn out on stencils first, and the problems of reduction and obtaining mechanical stability planned in advance

Soft-tissue dissection should be kept to a minimum but must be adequate to obtain a clear view and access

External fixation
 Are those where the mechanical strength of the construct is outside the skin or fixation of fracture outside the skin

There are two main ways in which a fracture can be held which make a profound difference to the way in which the fracture heals

  

Rigid fixation blocks the normal callus formation of bone healing.The bone appears to be unaware that there is a frac­ture if there is no movement at the fracture site

As the bone undergoes normal physiological remodelling. the fracture cleft is gradually obliterated by new bone

This takes about a year During that time the fixation must share the loads normally taken by the bone

Most implants fatigue under the repetitive load imposed by the human body and will soon fail if the bone does not heal and take over its original function

Fracture healing is therefore a race against time: the bone must unite before the implant fails or the construct will col­lapse

• Non-rigid means of fixing (such as plaster of Paris) allow limited movement and loading of the fracture site

 The aim is to allow movement and load to stimulate callus formation without allowing the fracture to redisplace

This delicate bal­ancing act depends on the quality of the fixation the type of fracture and the compliance of the patient

Rigid versus non-rigid fixation

• Rigid fixation allows immediate loading but does not stimulate callous formation
• Non rigid fixation risks loss of reduction but stimulates rapid callus formation

Semi-rigid fixation

If the fixation of the fracture is not completely rigid then some callus will form rapidly. but the patient may be able to resume near-normal function because the fracture is held stable if not immobile by the fixation

 This partial rigidity therefore offers the best of both worlds with rapid biological healing combined with the benefits of early mobilisation of the patient

Types of Internal fixation

Screws

  

 Can be used to hold plates on to bone or can he used in their own right to hold bone fragments together

In orthopaedics, screws have been standardised to an agreed set of diameters

The threads of the screws also come in two standard forms. one for cortical and the other for cancellous bone

The size of these thread, and their pitch (the distance between each thread) are specifically designed to give the best possible grip in healthy human bone

The drills which create the holes for these screws are also standerdised allow as snug a fit of the screws as possi­ble without putting under load on the bone Taps are also sup­plied which cut the grooves in the bone to take the threads of the screws tables are available in every orthopaedic theatre to show which drill should be used for which screw

Plates and screws

• Sizes of screw and plates are now standardised

• Maximum grip is obtained without risking crocking the bone

• Nevertheless, plates must be plated on the tension side of the bone

Lagging

 
If a screw is to be used to compress two bone fragments together it is important that the thread of the screw should grip only the distal fragment in which the tip of the screw is embedded. as the screw is tightened the shoulder of the screw (the part that tapers in under the head) presses down on the proximal fragment and compresses the two fragments together. If the thread of the screw engages with the proximal fragment the screw can actually hold the fragment apart

There are techniques used to ensure that the fragments are drawn together as the screw is tightened

First a screw can be used which has no proximal thread. just a smooth shaft this known as lag screw

An alternative strategy is to use a fully threaded screw but to drill the hole in the proximal fragment to a slightly larger size so that the screw threads cannot engage with the wall of the hole

This is called lagging the drill hole and serves the same purpose as using a lag screw

Lagging

• Ensures that bone fragments are drown together as the screw is tightened

Plates

Plate, come in several sizes. each designed to be used with a stan­dard set of screws

 They are designed to fit on to the curved sur­face of bone and to be held there by screws

 The plates can be used in several ways and there are specific plate designed for each function

Use of plates

 
• They can butress,compress or neutralise plates

• In all cases their strength is in tension

• They are not good at resisting bending

Buttress plates: Buttress plates prevent one fragment of bone slip­ ping on another

They are especially useful in oblique fractures in load bearing bones, when they will stabilise what is a very unstable­ fracture configuration

Dynamic compression plates :(DCP) Dynamic compression plates have oval screw holes in them with tapered walls

If the screw holes are drilled into the bone at one end of these holes (there are drill guides to assist in doing this) then the plate slides along the bone as the screw is tightened home

If the plate has already been firmly fixed to the other fragment then the slip can be used to compress the fragments of bone tightly together

This has the ben­efit of stabilising the construct by increasing the area of contact. it also appears to stimulate healing by putting the bone edges in close apposition

Neutralisation plates :Neutralisation plates are used to prevent bone ends from being distracted

They can be used to resist angular forces by being placed on the side of a bone that goes into tension when load is applied the side that opens when the fracture bends

Plates with screws are excellent at resisting tension

 and this is how they are used in neutralisation

Plates have very little resistance to bending and so should never be put on the side of the bone that is in compression and which will go into concave angulation when load is applied

Wires

Wires are much less traumatic than plates and screws

 They can be used temporarily to hold fragments reduced while plates and screws are applied

They can also be used to resist shear where loads are not great. They are especially useful m children's frac­tures, when plates and screws could damage the epiphyseal plate

Wires can cross the growth plate without causing long-term effects and if left protruding from the skin can be removed when the fracture is secure without the need for a further surgery

The value of wires

• Can be introduced and removed percutaneously

• Safe to cross an epiphyseal plate

• Can be used as a guide for cannulated screws
Kapanji wires These are a technique which can be used in fractures in which Impaction may have left a defect that leaves the fracture unstable when reduced

After the fracture has been dis­impacted and reduced, wires are introduced into the fracture cleft on the side of the defect

 As soon as the tip of the wire is in the medulla the wire is tilted so that its tip travels proximally and embeds on the Inside of the far cortex

 One or more wires placed in this way substitute for the missing cortex and work with the intact periosteum on the other side to create a stable reduction

Figure-of-eight wiring This allows a strong wire suture to be woven over the cortex of bone which is held in tension
The device is not prominent and so fits well subcutaneously and is commonly used on the olecranon and on the patella 

Intramedullary nails

Implants driven down the medulla of a long bone sutter from a significant mechanical disadvantage because they must be narrower than the bone into which they are introduced, The resistance of an implant to bending and twisting proportional to the square of its diameter, Nevertheless, the medulla can provide a natural guide for the implant, and introducing the nail into one end of the bone (under image intensifier control) minimizes the risk of infection from opening the fracture, .and preserves the periosteal blood supply

 Nails are now available for the humerus and tibia as well as the femur

 In recent years the scope of intramedullary nails has been increased by the introduction of the locking nail
 
This system has hole through the nail at each end. using jigs or an image intensifier screw can be passed through the bone, the hole in the nail and out through the opposite cortex of the bone. This produces a construction that holds the bone rigidly,and is especially resistant to twisting it follow an intramedullary nail to be used for a far greater range of long bone fractures including those in the metaphysis some of the newer nails can now be passed down the medulla without requiring any reaming in advance the unreamed nails this makes the operation quicker and reduces the trauma to the patient

Advantages of intramedullary nails

• Now available for all major long bones

• Can be put in closed and unreamed

• Locking screws gives great stability

• Periosteal blood supply is preserved

• Patient can be mobilised early

Disadvantages and complications of internal fixation

The disadvantages of internal fixation are those of damage to soft tissues, especially blood supply

The rigidity of fixation slows the natural healing process, even though it allows earlier mobilisation of the patient

Internal fixation is technically demanding, requires a large range of implants and instruments, and is best performed in ultra clean theatres as infection is a disaster
 
This includes size and type of plates and position of screws. Only in this way can the operation be performed quickly and cleanly (minimising the risk of tissue damage and infection) so that the strongest fixation is obtained.
 There are complications inherent in using a tourniquet such as cuff damage to nerves as a result of inflation to an excessive pressure and problems of reper­fusion injury if the cuff is left inflated for too long.

Exposure of the fracture may damage the soft-tissue attachments to the bone and produce avascular fragments, which will delay or even prevent fracture union

The risk of infection can be minimised by cleaning out open
fractures and leaving them open with the fractures stabilised until it is certain that all dead and contaminated tissue has been removed

Only when they are clean should they be closed delayed primary closure

When internal fixation is used, infection is min­imised by performing quick, tidy and well-planned surgery, and by adhering to strict theatre discipline on theatre sterility
. Surgery should be covered by three doses of a broad-spectrum antibiotic which has good activity against Staphylococcus (the most common infective organism) and Streptococcus (the second most common

Internal fixation can also leave unsightly scars, and should be planned to minimise cosmetic deformity without compromising­ access

Drills and screws can damage nerves and vessels

 Drill guards should always be used to prevent soft tissues being inadvertently dragged into a spinning drill

When the drill is cutting into the far cortex, the hand that the surgeon is using to hold the drill should have a straight finger resting on the limb through which the drill is passing

Only light pressure should be applied to the drill so that when the drill then comes out through the far cortex it will not suddenly penetrate deep in the soft tissues on the far side of the bone where it might perforate a nerve or vessel .

Complications of Internal fixation

• Damage to soft tissues and blood supply

• Risk of introducing infection

•Callus formation is inhibited

Indications for removal of internal fixation

Implants for internal fixation are made of surgical-grade stainless steel and should not corrode

Nevertheless, the alloys con­tain transitional metal such as chromium and vanadium, whose salts are allergenic toxic and may even be carcinogenic

Despite this, there is little evidence that metalware left in patients for long periods causes any chemical or even allergic problems

Children should have metalware removed if it is likely to compromise growth

It should be removed as early as possible because periosteal bone grows rapidly over the plates and makes their removal difficult

 Internal fixation also shields the bone around it from load and so may cause local osteoporosis

The load passing down the bone may then peak at the end of a plate (a stress raiser) and cause a fracture

 Internal fix­ation of a fracture next to an old plate already embedded in the bone is very difficult to manage

Despite this, it is now normal practice to leave plates and even intramedullary nails in the patient unless they are causing pain or there is another specific reason for the patient to receive another general anaesthetic for another procedure
in which case plates can be removed at the same time

Reasons for removing metalwork

• Plates may load shield, producing osteoporosis

• Salts of stainless steel may be toxic in long term


tags:fixation,internal,bone,fractures,plate

Pig or swine influenza causes types diagnosis and treatment

Pig or swine influenza causes types diagnosis and treatment

Introduction

Pig or swine influenza it is a viral infection which affect human and can produce mild to severe disease and the disease is transmitted from people to other people

Transmission of virus from pigs to human is not common and rare to causes human flu

Pig or swine influenza also known as 2009 virus which caused by influenza A serotype  H1N1

HA means haemagglutinin and NA means neuraminidase which they are the viral proteins that determine the subtype of influenza virus for example A|H1N1 and H3N2 v
The HA and NA are important in the immune response against virus antibodies the NA protein is the target of the antiviral drugs such as relenza and tamiflu

The pig or swine virus are more common and more dangerous in those with low immunity from any causes such as extreme of age eg infants, child and old age also in pregnant woman ,immune-compermized patient such as AIDS,diabetic patient ,cancer or patient with malignancy or on chemotherapy ,patient with chronic pulmonary air way diseases and cardiovascular diseases or blood diseases such as leukemia, renal and hepatic diseases and neurological diseases
What are the classification of virus influenza
There are three known types of virus influenza type A,B and C that can causes human flu but in pigs there is two types influenza A which is common and influenza C which is rare

Influenza A
Pig or swine influenza is known to be caused by influenza type A subtypes H1N1,H1N2,H2N3,H3N1,and H3N2 in 2012 the center for disease control and prevention CDC confirmed the presence H3N2 v
What are the methods of transmission in human
People in direct contact or exposure to poultry and swine are more liable for infection with influenza virus endemic in these animals such as farm worker
In human influenza spread between humans when infected people cough and sneeze ,then other people breathe in the virus or touch something with the virus on it such as tables or glasses and then people touch their own face such as eye ,nose and mouth

What are the symptoms and signs in human

• The patient may complaining from symptoms similar to those of usual influenza 
• The patient may complaining from high grade body temperature fever
• The patient may complaining from sore throat 
• The patient may complaining from cough and increased nasal secretion
• The patient may complaining from body ache or generalized skeletal pain
• The patient may complaining from severe headache
• The patient may complaining from lethargy and fatigue and loss of appetite
• The patient may complaining from diarrhea and vomiting which important
• The patient may complaining from chills and shivering
• These are symptoms not specific to swine flu so that the CDC advise the doctors to consider swine influenza infection in the differential diagnosis of patients with acute febrile  respiratory illness who have either  been in contact with person with confirmed swine flu
• To confirm the diagnosis that need for laboratory testing by taken simple swab from the nose and throat
• Best method of diagnosis recommended by CDC it is real time polymerase chain reaction( PCR )as the method of choice to diagnosis H1N1
• The patient may complaining from the virus complications such as respiratory failure and pneumonia

What are the complications of swine virus

There are some complications which can be associated with swine virus which may be the causes of death such as respiratory failure ,pneumonia ,renal failure,  dehydration and electrolytes imbalance due to excessive vomiting and diarrhea ,high fever can affect the brain and lead to neurological manifestations

 

What are the methods of human transmission prevention

There are two methods that can prevent transmission of the virus as follow

Prevention OF transmission from pigs to human

• The transmission of swine virus to human occur mainly in swine farms because they are in direct contact with living pigs ,although strains of swine influenza are usually not able to causes human infections so to prevent this transmission the farm workers and veterinarians or other people with direct contact with infected pigs should be use face masks when they deal with these animals
• There are risk factors which can increased transmission of the disease from swine to human such as smoking and people not wear gloves in his hands when working with these infected pigs so these leads to increased risk of  hand to eye,hand to nose or hand to mouth transmission
• Vaccination against swine virus to prevent their infection is consider a major method to limit swine to human transmission

Prevention OF transmission from human to human

• There are recommendation to prevent spread of infection between human such as
• Frequent washing of the hand with soap and water or with alcohol based hand sanitizers especially after being out in public also washing the face
• Using disinfecting materials such as diluted chlorine bleach solution for household surface more effective to decreased incidence of transmission
• Avoid touching your own eye ,nose and mouth by your hand
• As influenza can spread in cough and sneezes so small droplets of containing the virus can linger on tabletops telephones and other surface which transferred by the fingers to the eye ,nose and mouth but using alcohol based gel or foam hand sanitizers reduce the risk of transmission
• Any person with flu like symptoms such as sudden fever, muscle pain and cough should be stay away from work or public transportation and should contact a doctor for advise
• Social distancing is staying away from other people who might be infected and can include avoiding large gatherings,spreading out a little at work or may be stay in the home and lying low if an infection is spreading in community
• The patient should use a tissue to cover his mouth and nose when he get cough or sneeze and put them in a waste basket
• Follow your doctors instructions

What are the vaccination against swine virus

The Food and Drug Administration FDA approved that the new swine flu vaccine for use in United State on 2009  ,studies by the national institutes of health show a single dose  of the vaccine can created enough antibodies to protect against the virus within about 10 days

What are the treatment of pig or swine virus in human

Treatment can be including the following items

Antiviral drugs

  These drugs make the disease mild and make the patient feel better faster

These drugs also can reduce or prevent  the risk of the complications

These drugs give better result when they start early within first two days of the symptoms

The U.S.Centers for disease Control and Prevention recommends the use of oseltamivir (Tamiflu) or zanamivir (Relenza) for the treatment and or prevention of infection with swine influenza virus

It is important to know that most of people infected with virus make a full recovery without requiring medical attention or antiviral drugs

It was found that the virus isolated in the 2009 outbreak have been found resistant to other antiviral drugs such as amantadine and rimantadine

Beside antiviral drugs the patient need supportive care either at home or better at hospital for controlling of their symptoms such as fever and to relieve pain and maintaining fluid balance also for treatment any associated complications or other medical problems

Don not take aspirin because it may lead to reyes syndrome

tags:pig,influenza,swine,H1N1,tamiflu

Carcinoma of thyroid gland types causes diagnosis and treatment

Carcinoma of thyroid gland types causes diagnosis and treatment

Introduction

Thyroid gland is that gland which present in front of the neck which has two lobes one on each side connected together by an isthmus taken butter fly appearance

Thyroid gland is responsible for release of thyroid hormones such as tri-iodothyronine T3 tetra-iodiothyronine T4 and thyroid stimulating hormones TSH ,these hormones are responsible for the process of metabolism in the body if there is any disorders affect the release of these hormones are associated with diseases either in the form of increased secretion of thyroid hormones causing hyperthyroidism or decreased secretion of thyroid hormones causing hypothyroidism 

 

Thyroid cancer is a malignant tumor or neoplasm which arise from either follicular or parafollicular cells of the thyroid gland it is uncommon cancer which affect women more than men ,there are several types of thyroid cancer and different methods of treatment

 

What are the causes of cancer thyroid 

 There are certain factors which may associated with cancer thyroid such as

• Exposure to irradiation head and neck exposure to irradiation such as X rays during childhood for treated other diseases such as tuberculosis or TB of the lymph nodes which was done in the past these patients are more liable for development of cancer thyroid
• Endemic cancer such as the incidence of follicular carcinoma  is high in endemic areas possibly due to TSH stimulation
• Presence of benign thyroid lesions which may transformed to malignancy such as adenoma of the thyroid gland especially in male ,nodular goitre and Hashimotos thyroiditis
• Cancer thyroid may occur alone without previous causes DE Novo such as anaplastic carcinoma
• Hereditary causes may be found

What are the types of  thyroid cancer

 

There are several types of thyroid cancer as follow

• Papillary:it is the most common type of thyroid cancer account for more than 60% which can occur in young age begins in the follicular cells characterized by localized slowly growing nodule,can spread through lymphatic vessels to lymph nodes which is the main route of spread  it is hormonal dependency tumor and if diagnosed early and treated give good result and best prognosis
• Follicular : it is the second most common causes account for about 17% which also begins in the follicular cell of the thyroid gland can occur in young and old age characterized by slow rate of growth but more than papillary type ,can spread to through the blood to the lung and bones which is the main route of spread it is Iodine uptake tumor and if diagnosed early and treated can give better result but less than papillary type
• Anaplastic :it is least common type account for about 13% of thyroid cancer common in old age patient above 60 years ,begins also in follicular cells of thyroid gland , characterized by large rapid growing highly infiltrating mass ,can spread either by direct spread to surrounding organs which is the main route of spread or to the lymph nodes through lymphatic spread or to the lung bones liver and brain through blood spread,give temporary response to external irradiation has poor prognosis
• Medullary :less common type of thyroid cancer which arise from parafollicular cells called C- cells of thyroid gland which secreted calcitonin characterized by some tumors are familial runs in family and form part on multiple endocrine syndrome type II MEN type II or Sipples syndrome which has two forms MEN type IIa which consists of medullary carcinoma pheochromocytoma and hyerparathyyroidism ,MEN type IIb when the familial form is associated with prominent mucosal neuromas involving lips , tongue and eyelids can spread through lymphatic to the lymph nodes or through the blood to the lungs bone brain and liver which is the main route of spread the disease common associated with diarrhea due to 5 -hydroxy traptophan 5HT or prostaglandins produced by the tumor cells,calcitonin is a biomarker  it is non hormonal dependent can give good result after treatment without blood spread or metastases

What are the symptoms and signs of thyroid cancer

• The patient may complaining from mass or swelling in front of the neck
• The patient may not complaining and the thyroid mass or swelling is discovered incidentally by the physician during routine examination
• The patient may complaining from thyroid swelling of recent onset with rapid increased in size 
• The patient may complaining from pain either in front of the neck or in the ear earache due to Arnolds nerve infiltration by cancer cells this nerve is the auricular branch of the vagus nerve
• The patient may complaining from difficulty in swallowing dysphagia due to swelling compression on the esophagus
• The patient may complaining from change in his voice in the form hoarseness of voice due to recurrent laryngeal nerve infiltration by cancer cells
• The patient may complaining from shortening or difficulty in breathing dypsnea and cough either due to swelling compression effect or due to spread of cancer cells to the lungs
•    The doctor may showing by examination thyroid swelling which it is hard ,tender,irregular and fixed
• The doctor may show enlarged lymph nodes which hard and  mobile then become fixed
• The doctor may showing other signs of distant metastases or cancer spread such as loos of weight and jaundice in case of liver affection

When we can suspected thyroid cancer

 

Thyroid cancer can be suspected to be malignant in the following cases

• When there is thyroid swelling or goitre with previous history of head and neck exposure to irradiation
• When thyroid swelling present either in young or very old ages
• When thyroid swelling become increased in size and rapid growth
• When thyroid swelling associated with pain 
• When thyroid swelling become hard ,irregular and fixed or with limitation of it is mobility
• When there is blood or lymphatic metastases 

What are the investigations of cancer thyroid

 

Laboratory

 

Complete blood count

For anemia and fitness

   Liver function test

For elevation of liver enzymes in case of liver metasteses

Tumor markers

For detection of of thyrogobulin for differentiated carcinoma or calcitonin for medullary carcinoma

Tumor markers definition types and its aims

Thyroid function test

For T3,T4,TSH hormones of thyroid gland either elevated or decreased

Other according to the case

 

Radiological

 

Thyroid ultrasound

 

To differentiated between cystic from solid swelling

 

Thyroid scanning

 

By radioactive iodine to show the thyroid nodule which appear as

 

Cold nodule (inactive nodule)  a cold nodule it is the nodule which takes up no isotope such as in case of cancer  thyroid or common in cystic nodule

 

  Hot nodule or overactive nodule which takes up isotope while the surrounding thyroid tissue is inactive because the nodule is producing such high levels of thyroid hormones that TSH secretion is suppressed such as in case of hyperthyroidism

 

 Warm nodule or active nodule in which the warm nodule take isotope like normal thyroid tissue

 

X rays

For the neck ,chest,skull,spine and pelvis for detection cancer metastases

 

Laryngoscopy and bronchoscopy

For detection of recurrent laryngeal nerve or tracheal invasion by cancer cells

 

CT scanning of the head neck and chest and brain

MRI scanning of the head neck chest and brain

 

Whole body scanning

 

By using radioactive iodine which go through circulation to different body organs to detect cancer metastases

Other according to the case

 

Thyroid biopsy

 

Biopsy of thyroid gland it is essential for diagnosis of thyroid cancer which may be done by an open operation by surgical removal of the swelling or by needle fine needle aspiration cytology FNAC or by true cut needle biopsy which taken for histological examination under microscope for detection of cancer cells

If an enlarged lymph node is present it may be removed through a small incision directly over it and taken for microscopic examination for detection of cancer cells

 

What are the treatment of thyroid cancer

Treatment of thyroid cancer depend on many factors such as the type of the cancer the size of the cancer ,the age of the patient , there is distant metastases to other organs such as to the liver lungs bone brain lymph nodes or no the patient fit for operation or no

Treatment of thyroid cancer can be done by the following methods

Surgical

 

Surgical removal of thyroid gland by an operation called thyroidectomy

 

Radiotherapy

External irradiation indicated in case of some thyroid cancer which can not be treated by surgery or for recurrent cancer after it is removal or as palliative treatment to relieve pain or ulceration can be used in anaplastic cancer

 radiotherapy how it is work types and its complications

 

Hormonal therapy

 

    Some thyroid cancers are hormonal dependent and can respond to thyroid hormones like L-thyroxine such as papillary and follicular carcinoma

  Hormonal therapy how it is work types and its complications

Chemotherapy

 

Can be used in some thyroid cancer such as medullary carcinoma and analpastic cancer can be used also to relieve pain

Chemotherapy how it is work types and its complications

 

Radioactive iodine

 

Can be used in some thyroid cancer which its can uptake iodine such as follicular carcinoma by using sodium Iodide 131 which given by oral route then absorbed into the body and reach thyroid gland which trapped inside it which causes irradiation to the thyroid tissue and causing its damage so reduced secretion of thyroid hormones from thyroid gland  the half life of sodium Iodide 131 is eight days and can be retained in the body for several week and the excess Sodium Iodide are eliminated from the body through the kidney passing to the urine

tags:thyroid,cancer,malignancy,papillary,madullary

Precancerous or malignant skin diseases

Precancerous or malignant skin diseases

Introduction

Precancerous or premalignant skin diseases there are some skin condition in which under certain circumstances can be changed or transformed into skin cancer such as squamous cell carcinoma , basal cell carcinoma and malignant melanoma if they left without any treatment

These skin condition include the following

• Keratocanthoma
• Bowen,s disease
• Solar or senile keratosis
•  Chronic radiodermatitis
• Xeroderma pigmentosa
• Carcinogens agents
• Leukoplakia
• Chronic scars Marjolin,s ulcer
• Lupus vulgaris or Tuberculosis of skin T.B of skin
• Moles or naevi

Each disease will be discussed separately as follow

Keratocanthoma

• Others names adenoma sebaceum ,molluscum pseudocarcinomatosum or molluscum sebaceum
• It is means overgrowth of hair follicle cells with producing central plug of keratin with subsequent regression
• May be self limiting benign tumor or neoplasm or may due to an unusual response to infection
• Certain causes unknown
• Common in  male adults
• It take from 2-4 weeks to grow and from 2-3 months to regress normally single lesion
• Common site on the face
• Appear as hard separated central core then the lump collapses leaving a deep indrawn scar
• May mistake for squamous cell carcinoma  but it differs from it by it is has slow rate of growth does not have a central dead core and gradually become an ulcer
• Rare under change to squamous cell carcinoma
• Treatment by surgical removal or excision to confirm the diagnosis and prevent depressed scar formation and its changes to malignancy

Bowen,s disease

• Pre-malignant intra-epidermal carcinoma or carcinoma in situ
• Slow growing lesion and common in old age
• May look like as eczema
• Can occur on any part of the body especially the trunk
•  Appear as thickened brown or pink colour with well defined plaque
• Appear also as flat papular clusters covered with crusts
• Causes may be associated with sun damage ,arsenic exposure,viral infection such as human paplilloma virus and immune-suppression such as AIDS 
• Can be changed into squamous cell carcinoma
• Appear under microscope as full thickness dysplasia of the epidermis
• Erythroplasia of Queyrat is bowen,s disease of the glans of the pens or prepuce in male and also same in  female
• Treatment by surgical removal or excision with safety margin about 0.5 cm or cryotherapy  cauterization or diathermy coagulation

Solar or senile keratosis

• Exposure to sun is the important predisposing factor
• Resulting from solar damage to the skin and hyperkeratosis of the skin
• Common found in old weather-beaten man eg farmers  on the backs of fingers and hands, face and helix of the ears and in fair- skinned
• Skin appear as yellow, grey, or has brown crusty patches from which arise prodtruding plaques of horny skin and have dry hard scale
• Common changes to squamous cell carcinoma if not treated
• Appear under microscope as hyperkeratosis and epidermal dysplasia
• Can develop tethering ,fixity, or regional enlarged are worrying features
• Treatment Surgical removal,shaving,cryotherapy or topical or local appilcation of 5- fluorouracil chemotherapy drug

Chronic radiodermatitis

• Result from prolonged exposure of skin to ionized irradiation which result in  varying degree of skin damage after several months to several years irradiation known as carcinogens which can causes damage DNA cells and transformed it into cancer cells
• Common in those handling radioactive materials or delivering X rays
• Usually affects face and hands
• Skin appear as chronic inflammation from prolonged irradiation irritation and the skin appear as atrophic indurated plaques with yellowish or whitish colour with telangiectasia ,radionecrosis and ulceration can occur especially in moist areas
• Can be changes to squamous cell carcinoma and basal cell carcinoma

Xeroderma pigmentosa

•  Xeroderma mean skin dryness  and change in the color (pigment) of the skin pigmentosum

• Also called XP disease
• Causes it is an autosomal recessive genetic disorders of DNA repair
• The patient have no any ability to repair damage caused by ultraviolet rays of the sun
• Rare disease which characterized by an extreme abnormal sensitivity to sunlight
• Common site affection are the eye and any areas of the skin exposed to the sun
• The symptoms and signs appear commonly during infancy or early childhood
• Many children develop a severe sunburn on exposure to sunlight even for just few minutes causing redness and blistering which may  persist for weeks
• The child develop freckling in the skin exposed areas to the sun such as in the arms ,face and eyelids and lips the skin become scaly and dry with irregular dark spot on the skin
•    Can be changed to malignancy or skin cancer such as squamous cell carcinoma at early age during childhood especially in those does not protect from the sun
• Most people develop multiple skin cancer during their life which can develop in the lips , tongue,face,eyelids and also on the scalp
• The eyes become so sensitive to the ultraviolet of the sun may become painful irritated with blood shot with clouding in front of the cornea and corneal ulceration the patient can not see clear and the eyelashes fall out and the eyelids become atrophic and thin and may turn abnormally inside called entropion or turn outside called ectropion which associated with impair vision field
• Some patient may develop progressive neurological disorders such as hearing loss inability to walking difficulty in swallowing which called dysphagia difficulty in speech and fits or seizures
• Poor prognosis few patient may survive up to their adolescence
• Treatment by surgical removal with grafting and protective measures against sunlight eg sun - screen ointments

Carcinogenic agents

These are substance when become in contact with skin for prolonged period can develop skin cancer these substance acts as carcinogens which can produce DNA  damage of the normal cells and transformed it into cancer cells such as exposure to pitch,tar and soot  for more see here

Leukoplakia

• Leukoplakia means white patches it is also called leukokeratosis or idiopathic keratosis or idiopathic white patches
• Appears as adherent white patches on the mucous membrane of the oral cavity and lips also can occur in other mucous membrane such as gastrointestinal tract , urinary tracts and genitals
• Leukoplakia may confused with other lesion causes white patches  in the mouth such as oral candidiasis or fungal infection and lichen planus
• Common occur in smoking and chewing tobacco but other causes may unknown
• Precancerous or malignant lesion which can be changed into squamous cell carcinoma eg cancer lips or esophagus
• Patient may complaining from nothing or from pain or discomfort and presence of white or grey patches
• Treatment by surgical removal , electrocautery and cryotherapy

Chronic scar or marjolin,s ulcer

• The name is applied to malignant change in a scar ,ulcer or sinus such as chronic varicose ulcer , an unhealed burn, the sinus of chronic esteomyelitis and chronic wounds
• It has the following criteria slow rate of growth because the lesion is relatively avascular  has no pain or painless ulcer because the tissue does not contain cutaneous nerves secondary metastases do not occur in the regional lymph nodes because the lymphatic vessels have been destroyed but if the ulcer invades normal tissue surrounding the scar then the ulcer take rapid rate of growth and become painful and can give lymphatic metasese
• Common change to malignancy such as squamous cell carcinoma later may develop to basal cell carcinoma
• Treatment by  wide surgical removal with safety margin about 1 cm or radiotherapy

Lupus vulgaris

• Also called tuberculosis of the skin or T.B of the skin
• Caused by mycobacterium tuberculosis which it is the micro-organism of TB
• Has the following criteria painful cutaneous lesion with nodular appearance common seen in the face around the nose,lips ,cheeks,ears and neck may develop into disfiguring skin ulcer and deformity , lesion may persist for many years
• Has progressive and persistent form of skin T.B
• Appear as small reddish or brownish small nodules with gelatinous consistency called apple -jelly nodules
• Can be changed into malignancy or skin cancer such as squamous cell carcinoma
• Treatment by anti-tubercolsis drugs such as rifampicin , isoniazid,pyrazinamide,streptomycin and ethambutol

Moles or navei

• Common precancerous skin lesion
• Mainly junctional naevus and compound naevs can change or transformed into skin cancer
• Junctional naevus appear as tiny dark points they are not raised above the skin the melanocytes lie in the deeper layers of the epidermis
• Compound naevus the melanocytes are present in both the dermis and epidermis
• They can changed into malignant melanoma
• There are warring criteria with moles which if present so it is need for immediate investigations and deal with it to exclude the malignant changes these criteria are

The mole become increased in size

The mole become change in its colour either increased or decreased in pigmentation

The mole become have fissuring and ulceration

The mole become painful and itching

The mole become indurated and bleeding

There is spread of pigment as sattelite nodules around it due to lymphatic permeation

 

 

tags:skin,precancerous,premalignant,lupus,vulgaris,xeroderma,leukoplakia,marjolin

Malignant melanoma and Amelonatic

Malignant melanoma and Amelonatic

Introduction

Malignant melanoma it is a type from skin cancer which arise from epidermal skin layer  from melanocyte cells or pigment cells which responsible for release of melanin pigment which give the skin it is colour malignant melanoma can arise in any part in the body which containing melanocyte cells such as in the skin of the head and neck, trunk , lower and upper limbs

 There are special site of malignant melanoma  which can be arise such as mucosal as mucous membrane of the nose or the mouth( sublingual), eye as conjunctiva , choroid and pigmented layer of the retina and genitalia

 Also there are hidden area of malignant melanoma which can be found such as pia and arachnoid matter which they are  the layer of brain covering and adrenal medulla
 Malignant melanoma it is the most aggressive type of skin cancer which it is more common in Caucasian than black

Melanocytes produce melanin pigment during exposure to the sun to protect us from the burning effect of the sun

Skin cancer when arise from the basal layer of the epidermis is called basal cell carcinoma see here
When arise from squamous cell layer is called squamous cell carcinoma see here

When arise from the melanocytes cell producing pigment is called malignant melanoma
 

What are the causes of malignant melanoma

There are predisposing factors which associated with malignant melanoma formation such as

• Exposure to the sunlight in which the ultraviolet rays cause damage to the DNA nucleous especially intermittent exposure is more closely associated with melanoma than regular exposure
• Sunbeds and tanning lamps carry a potential risk
• Albinism and xeroderma pigmentosum have higher risk
• Red fair haired skin
• Hereditary or genetic inheritance
• Gaint congenital naevi of more than 20 cm in diameter have increased risk of malignant change which may occur in the first 10 years of life

What are premalignant condition of melanoma

• Congenital gaint or bathing trunk naevus or mole
• Melanosis of the eye conjunctiva
• Hutchinson,s freckle or lentigo which mean presence of large area of pigmentation in old age patient more than 60 years on the face and is slow growing mainly smooth but may developed rough ares of junctional activity which are at increased risk of malignant change
• Junction melanoma in which the melanocytes lies in the deep layers of the epidermis they appear as tiny dark points and look as if paint is sprinkled on the skin
• Compound melanoma in which the melanocytes are present both in the dermis and epidermis

What are symptoms and signs of malignant melanoma

Any individual with mole or naevi in his skin body should be aware about the warring signs which if present this may indicated of malignant transformation  these warring signs such as

• If the mole become increased in size
• If the mole colour changed either decreased or increased pigment
• If the mole become has fissuring 
• If the mole become ulcerated
• If the mole become painful
• If the mole become bleeding
• If the mole become indurated
• If the mole become itchy
• If the mole pigment spread as satellite nodules around it due to lymphatic permeation

The physician should be asked about

• If there is family history of previous malignant melanoma
• If there is family history of multiple melanoma syndrome
• If there is recent history of mole changes in its colour size shape or become painful or ulcerated or itching or bleeding
• If there is previous history of intermittent sun exposure
• If there previous history of pancreatic cancer or astrocytoma
• If there is previous history of skin cancer

The physician should be examined the whole body skin to detect any suspected lesion to deal with it also if the individual notice any abnormalities in the mole or naevi such as warring signs he should be immediately investigated by the physician to excluded any malignant transformation

   

What are the types of malignant melanoma

There are many types of malignant melanoma such as

Superficial spreading malignant melanoma

• Account for about 65%
• Commonest types
• Can occur on any part of the body
• Usually palpable but thin with irregular edge
• Has variable colour but common black  with satellites
• Occur on the leg of female and back of male also present in the palm of the hand and sole of the foot

Nodular melanoma

• Account for about 27%
• Thick protruding with a smooth surface and regular outline
• May become bleeding and ulcerated
• Commonly black lump with rapid growth
• Most dangerous

 Lentigo maligna melanoma

• Account for about 7%
• Malignant melanoma arsing in Hutchinson melanotic freckle
• Malignant areas are thicker than the surrounding pigmented skin
• Usually dark in colour
• Very rare to be ulcerated
• Irregular common present in the face
• Best prognosis

Acral lentiginous melanoma

• Account for about 1%
• Rare type
• Can be present in the palm of the hand and sole of the foot
• Can also present as a chronic paronychia or sub-ungual  haematoma
• Has irregular expanding area of brown or black pigmentation on the palm ,sole or beneath a nail as sub-ungual melanoma
• Poor prognosis

Amelanotic melanoma

• Account for about 1%
• May be pink with some pigmentation at the base
• Presents with lymph nodes involvement
• Worse prognosis

What are the classification and staging of malignant melanoma

The malignant melanoma can be classified and staged as follow

Histological classification

Clark-McGovern Level

Level 1 : In situ melanoma - melanoma confined to the basal epidermis with no dermal invasion

Level 2 : Invasion of the subepidermal and connective tissue known as the papillary dermis

Level 3 : Invasion of the level of the junction between the papillary and reticular dermis

Level 4 : Invasion of the reticular dermis

Level 5 : Invasion of the subcutaneous tissues

Breslow Tumor Thickness Measurement TTM

The thickness is measured by an optical micrometer from the top of the granular layer of the epidermis to the deepest melanoma cells in the dermis

A modified version of the American Joint C omittee on Cancer|Union Internationale Contre le Cancer AJCC|UICC staging system is the most widely used

AJCC staging

pTx  Primary tumor cannot be assessed

pT0  No evidence of primary tumor

Clark level  I    pTis : Melanoma in situ intra-epidermal

Clark level  II   pT1 :Less than 0.75 mm thick and invades the papillary dermis

Clark level  lII  pT2 :0.75-1.5 mm thick with or without invades to papillary -reticular dermis interface

Clark level IV pT3 : 1.5-4 mm thick with or without invades reticular dermis

pT3a  1.5- 3 mm thick

pT3b  3-4 mm thick

pT4  more than 4 mm thick

TNM system T means tumor N mean lymph nodes M means distant metastases

Stage I       pT1|2 :N0.M0

 Stage II      pT3|4 : N0 ,M 0

 Stage III     Any pT:N1-2 ,M0

Stage IV   Any pT: any N,M1

Investigations of malignant melanoma

Laboratory

Complete blood count for surgical fitness

Lactic dehydrogenase may be raised

Other according to the case

Radiological

Chest X rays and CT scanning

Utrasound and CT scanning of the abdomen and pelvis

MRI scanning of the brain

PTE scanning for detection of metastases

Other investigations according to the case

Biopsy

Biopsy taken either from the primary tumor or from the regional lymph nodes

  Biopsy from the tumor

Either by removal part from the tumor called incisional biopsy or removal the whole tumor called excisional biopsy then the biopsy taken for histopathological examination under microscope for detection of cancer cells

Biopsy from the lymph nodes

Fine needle aspiration cytology FNAC

 For detection cytology of cancer cells such as loss of cellular cohesiveness : nuclei oriented in different directions and irregularly spaced cells become detached from one another

pleomorphism : variation in size ,shape and number of nucleoli

nuclear to cytoplasmic ratio increased abnormal mitoses and so on

Sentinal lymph nodes biopsy

Sentinal node means its the first lymph nodes received the cancer metastases and taken the dye in this technique the tumor is injected by special dye called patent blue dye around it then wait about 5-10 minute untill the dye can reach the regional lymph nodes then the sentinal nodes can by identified by gamma prob which appear as a hot spot  or by incision over the regional lymph nodes in which the sentinal nodes appear taken the blue dye and can be seen easily then taken for microscopic examination for detection of cancer cells in such case immunohistochemical staining can be used which give best result than cytological one

The aim from these sentinal nodes may to avoid complete removal of the regional lymph nodes but remove only the node taken the dye and have cancer cells to prevent the complications of removal of the all regional nodes such as lymph-edema

Treatment of the malignant melanoma

Treatment of malignant melanoma can be divided into treatment of the primary tumor ,treatment of the regional lymph nodes and treatment of inoperable case and distant metastases

Treatment of the primary tumor

Surgical removal or excision

Surgical removal of the tumor with safety margin which depend on the maximum tumor thickness according to Breslow method such as 

Melanoma in situ remove 5 mm margin , tumor thickness from 0,1-1.5 pT1-2 remove 10 mm margin

Thickness from 1.6-4 mm pT3 remove 10-20 mm margin

Thickness more than 4 mm pT4 remove 20-30 mm margin

Some prefer to remove 5 cm as safety margin including the deep fascia followed by plastic reconstruction of the defect left 

In case of melanoma of the eye treated by removal of the whole eye by operation called eye enucleation

In case of melanoma of digit or finger treated by removal of that affected digit or finger by operation called amputation

Treatment of regional lymph nodes

Prophylactic block dissection of the nodes in case of stage 1 or if there is no clinical lymph nodes are detectable surgical clearance after FNAC confirmation is indicated

Therapeutic block dissection of the lymph nodes as in case of stage 2

Sentinal lymph biopsy see above

Treatment of inoperable cases such as in case of stage 3 and 4 and recurrent melanoma and in transit metastases

Palliative surgical removal

Surgical removal or excision  of the tumor to relieve the pain itching ulceration or bleeding

Chemotherapy

Vincrestine - DTIC which can be given by intravenous infusion then reach the tumor throgh systemic circulation

Melphanan phenyl alanine mustard  it is most effective line of treatment for in transit metastases can be given by intra-arterial perfusion using special pump

For more details see here

 

Radiotherapy
  

Can be used for bone and brain metastases

For more details see here

 

Fast neutrons

Using high energy cyclotron better than irradiation

Immunotherapy

USING Interleukin 2 which responsible for induction cytotoxic T- cells

Interferon- beta has been used in the past for node positive patients but its benefit is unclear

Prognosis of malignant melanoma

This depend on the tumor thickness lymph nodes involvement metastases also depend on the anatomical site of the melanoma such as trunk and scalp melanoma have bad prognosis than peripheral lesion and type of the growth superficial spreading melanoma better than penetrating ulcerating lesion

tags:skin,cancer,malignant,melanoma,amelonatic,acral,hutchinson,frekle,lentigo

Epithelioma or squamous cell carcinoma

Epithelioma or squamous cell carcinoma

Introduction

Epithelioma or squamous cell carcinoma it is a malignant tumor or neoplasm which arise from squamous cell layer of the epidermis of the skin  so epithelioma it is a type from skin cancer

Skin cancer can be divided into main types non melanoma skin cancer type which include squamous cell carcinoma SCC and basal cell carcinoma BCC  and melanoma skin cancer type which include malignant melanoma

What are the causes of squamous cell carcinoma

• Exposure to sunshine
• Exposure to irradation
• Exposure to carcinogenic agents such as pitch ,tar, betel nuts
• Human papilloma virus
• Immunosuppressive drugs
• Chronic ulceration such as marjolin,s ulcer is malignant change in a longstanding scar , ulcer or sinus which typically seen in chronic varicose ulcer unhealed burn, sinus of chronic esteomyelitis
• Lupus valgaris and warts

Marjolin,s ulcer has the following criteria

• Slowly growing ulcer
• Painless ulcer
• Transformed into squamous cell carcinoma
• Spread to lymphatic late
• The edge of the ulcer not always raised and everted such as in SCC
• Unusual nodules or changes in a chronic non healing ulcer or scar should be viewed with suspicion and take biopsy from that lesion early
• Other features may be masked by the presence of previous ulcer or scar
• Need vigorous treatment

What are the premalignant condition of the skin

• Senile or solar keratosis  which usually multiple lesion on the face and backs of the hands in patient past middle life fair skinned appear as dry hard scaly
• Seborrhoeic keratosis
• Chronic radiodermatitis
• Xeroderma pigmentosa
• Bown,s disease
• Leukoplakia

Any changes in the pre-exsiting skin lesions such as warts or mole should be rise suspicion of malignant changes such as

If the patient has mole or warts and he notice that

• It become increased in size
• It colour become changed either increased or decreased in pigmentation
• The lesion become itchy
• The lesion become bleeding
• The lesion become swollen
• The lesion become painful
• The lesion become has fissuring or ulceration
• The lesion become indurated
• Spread of pigment as sattelite nodules around it due to lymphatic permeation

Symptoms signs and pathology of squamous cell carcinoma

Squamous cell carcinoma is a common invasive malignant epidermal tumor which can spread to the lymphatic and may give metastasis first lymph node become hard and mobile but later become fixed to deeper structures but rare to give blood metastasis

Very common skin cancer which occur commonly in older aged patient

More common in male than female

Common site at sun exposed areas such as face back of the hands also can occurs in lips gums tongue esophagus genitals and anal margins

Squamous cell carcinoma can be appear as

Hyperkeratotic and crusty on sun damaged skin eg ear pinna

Friable or papilliferous varities

Malignant ulcer or squamous cell carcinoma ulcer which have the following criteria

• Size small or moderate or large size
• Edge of the ulcer raised everted nodular edges
• Base of the ulcer hard indurated and is often fixed to the deeper structures
• Floor of the ulcer irregular composed of necrotic material scab or haemorrhagic tumor tissue

Pathology of squamous cell carcinoma

Malignant or carcinomatous ulcer as above when see by the eye

Solid columns of epithelial cells growing into the dermis with epithelial pearls or nest of central keratin surrounded by prickle cells this is see under microscope

Treatment of squamous cell carcinoma

There are different ways to treated squamous cell carcinoma such as

Surgical removal or excision

Surgical removal of the lesion with safety margins to avoid it is recurrence and the defect left is closed by plastic skin flap or grafts

Irradiation therapy

Which can be used in multiple session

  

contraindication

 Very small ulcer because it is better to surgical removal

Ulcer near the eye to protect eye against irradiation effect  but this can be protected by using a lead shield

Ulcer infiltrating the bone or cartilage because the cancer cells become hidden and efficient dose will causes irradiation bone or cartilage necrosis and if small dose it will be carry the risk of recurrence

 Recurrent ulcer

Cases resistant to irradiation

For more about cancer treatment by radiotherapy see here

 

Currettage and cautery

In this methods the lesion is currette by using spoon like called currette followed by using electric current called cautery to kill or destroyed malignant cells

Cryosurgery

In this method a cryo device is used to freeze the lesion and kills the cancer cells using nitrogen liquid

Topical chemotherapy

Local treatment by using 5- flurouracil in small and superficial lesions but recurrent rate is high than with other forms of treatment

Treatment of the regional lymph nodes

If the lymph nodes are involved the block lymph nodes dissection is indicated

How cancer skin can be prevented see here

 For basal cell carcinoma or rodent ulcer see here
For malignant melanoma see here
 

tags:epithelioma,cancer,squamous,carcinoma,skin,nest,keratin,margolins,ulcer