curss 13 carcinom bazocelular
DESCRIPTION
dermatoTRANSCRIPT
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Tumori cutanate maligne
Conf.dr. LAURA GHEUCA SOLOVASTRU
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Tumorile cutanate maligne reprezintă aproximativ 20-25% din totalul cancerelor şi au următoarele particularităţi:
se dezvoltă pe leziuni precanceroase, sunt bine conturate clinic şi histopatologic; sunt localizate superficial; au un polimorfism clinic accentuat ceea ce
face ca examenul histopatologic să fie indispensabil.
INTRODUCERE
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Tumorile cutanate maligne sunt clasificate după criteriul histogenezei în:
carcinoame cutanate (cu origine epitelială);
melanoame maligne (tumori ale sistemului pigmentar);
sarcoame cutanate (cu origine mezenchimatoasă).
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Factori implicaţi
I. Factori genetici
II. Factori imunologici
III. Factorii extrinseci (Radiaţiile ultraviolete
)
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I. Factori genetici
Studiile recente au subliniat rolul a trei mari tipuri de gene implicate în procesul de carcinogeneză: oncogenele (Bcl-2), antioncogenele (gena RB-situată pe cromozomul
13q14), metastogenele (gena nm23 – gena supresoare de
metastazare). Toate aceste mutaţii genetice determină
alterarea ritmului de diviziune celulară şi măresc capacitatea de invazie şi metastazare a celulelor neoplazice.
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II. Factori imunologici
Imunodepresia este o condiţie ce favorizează dezvoltarea neoplaziilor cutanate (infecţiile HIV, tulburări metabolice, afecţiuni virale - virusul HPV – are mare potenţial oncogen).
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III. Factorii extrinseci
Radiaţiile ultraviolete
au acţiune carcinogenă, ele acţionează prin efect cumulativ, datorat expunerilor excesive la lumina solară sau artificială;
risc crescut pentru dezvoltarea tumorilor cutanate au persoanele cu fenotip I şi care locuiesc în zone geografice însorite.
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CARCINOMUL BAZOCELULAR
Conf.dr. LAURA GHEUCA SOLOVASTRU
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CARCINOMUL BAZOCELULAR
INTRODUCERE EPIDEMIOLOGIE ŞI ETIOPATOGENIE CLASIFICARE MANIFESTĂRI CLINICE ASPECTE DERMATOSCOPICE ASPECTE HISTOPATOLOGICE DIAGNOSTIC POZITIV ŞI DIFERENŢIAL TRATAMENT
CHIRURGIA MOHS IN CBC EVOLUŢIE ŞI PROGNOSTIC
CUPRINS
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Caracteristici generale:
sunt formaţiuni tumorale care se dezvoltă lent
pe tegumentul indemn sau pe alte leziuni
preexistente;
au malignitate „in situ”- manifestată prin
caracterul invadant şi recidivant;
nu metastazează;
nu se însoţesc de simptomatologie subiectivă;
nu au tendinţă spontană spre vindecare.
CARCINOMUL BAZOCELULAR
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CARCINOMUL BAZOCELULAR
cel mai frecvent “cancer de piele”
tumora maligna – datorită potentialului
distructiv local
in popululaţia tanara – incidenta este in crestere
INTRODUCERE
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CARCINOMUL BAZOCELULAR
neoplazie maligna derivata din celule nekeratinizate ale stratului bazal al EPIDERMULUI
fara tratament – evoluţie lentă, cu invazie locala – poate produce leziuni tisulare import., cu implicatii functionale si estetice
nu afecteaza mucoasele
INTRODUCERE
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EPIDEMIOLOGIE ŞI ETIOPATOGENIE
CARCINOMUL BAZOCELULAR
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CARCINOMUL BAZOCELULAR
75% din cancerele cutanate nemelanocitare
mai frecvent la bărbaţi si la varstnici, dar si incidenta la cei sub 50 de ani e in crestere
clasic – indivizi cu fototip I sau II, pe tegument expus la soare, 20% din cazuri – pe nas
pacientii cu CBC – risc de 3x mai mare de a dezvolta melanom, dar Nu si alte tipuri de cancer
EPIDEMIOLOGIE
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CARCINOMUL BAZOCELULAR
EPIDEMIOLOGIE
CBC – localizari de electie.
Punctele reprez. CBC superficial multicentric.
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CBC poate apare : la vârstnici, bărbaţi (formele nodulare
localizate pe cap) dar şi
la tineri, la femei (forme superficiale pe
trunchi)
alcoolicii cr. – incidenta crescuta a CBC, cu forme profunde, infiltrative
CARCINOMUL BAZOCELULAR
EPIDEMIOLOGIE
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CARCINOMUL BAZOCELULAR
se dezvoltă de multe ori pe leziuni preexistente – keratoze actinice, radiodermite, cicatrici dupa arsuri sau vaccinari, keratoze arsenicale etc.
patogenia CBC presupune expunerea la lumina UV, in special UVB – lungime de unda 290-320 nm – mutatii in genele supresoare de tumori
risc mai mare – expunerile intense, in vacante (intermitente), fata de expunerea profesionala, cronica
ETIOPATOGENIE
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CARCINOMUL BAZOCELULAR
alti factori implicati – mutatii genetice transmise ereditar (PTCH1 de pe cromozomul 9), expunere la radiatii ionizante, alterari ale sist. imun etc.
sindroame transmise ereditar, cu risc de a dezv. CBC multiple – sdr. Gorlin (sdr. CBC nevoide)
implicarea sist. imun – pacientii imunodeprimati au risc doar usor crescut de a dezv. CBC (fata de risc foarte mare de a dezv. CSC)
ETIOPATOGENIE
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CLASIFICARE
CARCINOMUL BAZOCELULAR
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CARCINOMUL BAZOCELULAR
CLASIFICARE
Carcinoame bazocelulare
endofitice: Carcinom bazocelular perlat Carcinom bazocelular perlat ulcerat Carcinom plan perlat ulcero-cicatricial Ulcus rodens
Carcinom bazocelular terebrant
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Carcinoame bazocelulare exofitice: Carcinom bazocelular globulos Carcinom bazocelular nodular Carcinom vegetant sau burjonat
Carcinoame bazocelulare superficiale
Carcinomul bazocelular pagetoid
Carcinom bazocelular sclerodermiform
Carcinom bazocelular pigmentat
CARCINOMUL BAZOCELULAR
CLASIFICARE
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MANIFESTĂRI CLINICE
CARCINOMUL BAZOCELULAR
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CARCINOMUL BAZOCELULAR
ASPECTUL LEZIUNILOR DE DEBUT
Un mic grăunte emisferic de dimensiunea unui
grăunte de ac, albcenuşiu, translucid, “perlă”
epiteliomatoasă
Mic nodul semidur de 2-3 mm roz roşiatic
O mică eroziune rotund ovalară de 2/5 mm
O mică pată eritematoasă sau
eritematoscuamoasă
O placă alb gălbui palidă
MANIFESTARI CLINICE
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CARCINOMUL BAZOCELULAR
ASPECT
lez. friabila, fara tendinta la vindecare, asimptomatica
caracteristic – leziune translucenta, prezenta de ulceratii sau telangiectazii, margine rulata (“perlata”)
de multe ori pacientul declara ca leziunea “a sangerat putin, s-a vindecat, dar a aparut din nou”
MANIFESTARI CLINICE
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CARCINOMUL BAZOCELULAR
SUBTIPURI CLINICE DE CBC
MANIFESTARI CLINICE
5. plan cicatriceal6. sclerodermiform7. superficial8. pigmentat
1. nodular2. ulcerat3. terebrant4. chistic
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CARCINOMUL BAZOCELULAR
cel mai frecvent subtip clinic de CBC
papula sau nodul dur, proeminent, localizat pe fata
telangiectazii, uneori keratozic
margine rulata, formata prin confluarea unor perle epiteliomatoase, translucide
evol. lenta – creste incet, pe parcursul mai multor ani
are tendinta de a ulcera
1. CBC NODULAR
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CARCINOMUL BAZOCELULAR
CBC nodulare incipiente: - papula mica, perlata, langa narina
- alta si mai mica in pliul nazolabial.
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CARCINOMUL BAZOCELULAR
CBC nodular ceva mai avansat. Nodul unic, lucios, cu vase telangiectazice, dezvoltat pe tegument expus cronic la soare.
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CARCINOMUL BAZOCELULAR
CBC nodular, cu telangiectazii.
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CARCINOMUL BAZOCELULAR
CBC nodular – placa lucioasa pe varful nasului, cu multiple telangiectazii.
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CARCINOMUL BAZOCELULAR
CBC nodular – tumora neteda, perlata, cu telangiectazii. Tumora este dura, bine definita, asimptomatica.
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CARCINOMUL BAZOCELULAR
uneori – prin ulcerarea unui CBC nodular sau morfeiform
alteori – debut cu aspect ulcerativ, “in zgarietura de unghie”
marginea ulceratiei – reliefata, perlata
suprafata – rosie, curata sau acoperita de sfaceluri si secretii purulente
2. CBC ULCERAT – ULCUS RODENS
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CARCINOMUL BAZOCELULAR
CBC nodular ulcerat – nodul oval, perlat, pe pleoapa inf., cu aparitia unei mici ulceratii.
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CARCINOMUL BAZOCELULAR
CBC ulcerat, cu telangiectazii.
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CARCINOMUL BAZOCELULAR
CBC nodular ulcerat – nodul translucid, cu ulceratie centrala.
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CARCINOMUL BAZOCELULAR
CBC ulcerat.
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CARCINOMUL BAZOCELULAR
forma avansata a CBC ulcerat
distructie tisulara import., extinsa la structurile prof. cartilaginoase sau osoase
in evolutie – complicatii:- hg – prin erodarea unor vase de sange- afectare meningeala – prin erodarea cutiei craniene- deschiderea sinusurilor paranazale
3. CBC TEREBRANT
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CARCINOMUL BAZOCELULAR
CBC neglijat, care invadeaza osul subiacent.
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CARCINOMUL BAZOCELULAR
CBC recurent, terebrant – distructie tisulara locala masiva.
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CARCINOMUL BAZOCELULAR
nodul proeminent, hemisferic, dar cu aspect chistic – moale, cu o zona centrala depresibila
localizare – frecvent la niv. pleoapelor si in reg. sup. a obrazului
4. CBC CHISTIC
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CARCINOMUL BAZOCELULAR
CBC chistic.
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CARCINOMUL BAZOCELULAR
CBC chistic, cu telangiectazii.
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CARCINOMUL BAZOCELULAR
CBC chistic pleoapa inferioara.
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CARCINOMUL BAZOCELULAR
in centru – placa atrofo-cicatriceala, cu mici ulceratii superficiale, acoperite de cruste
la periferia leziunii – burelet perlat, translucid sau pigmentat
localizare – frecvent temporo-frontal
5. CBC PLAN CICATRICEAL
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CARCINOMUL BAZOCELULAR
CBC plan cicatriceal.
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CARCINOMUL BAZOCELULAR
CBC incipient – margine rulata, opalescenta, centru acoperit de o crusta.
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CARCINOMUL BAZOCELULAR
CBC plan cicatriceal – atrofie centrala, cu perle epiteliomatoase, pigmentate si telangiectazii la periferie.
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CARCINOMUL BAZOCELULAR
CBC plan cicatriceal.
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CARCINOMUL BAZOCELULAR
sinonim – CBC morfeiform
forma ceva mai rara
placa ingrosata, scleroasa, NU este bine delimitata – fara perle la periferie
la palpare – induratie ce depaseste marginile vizibile clinic, tegumentul este dificil de pliat
suprafata neteda, usor reliefata sau subdenivelata, de culoare galbuie sau sidefie
6. CBC SCLERODERMIFORM
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CARCINOMUL BAZOCELULAR
CBC sclerodermiform in unghiul intern al ochiului.
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CARCINOMUL BAZOCELULAR
CBC morfeiform – asemanator unei cicatrici, si fara margine perlata.
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CARCINOMUL BAZOCELULAR
CBC morfeiform – zona mica, neuniforma, rau definita, asemanatoare unei cicatrici. Prezinta 2 mici eroziuni acoperite de cruste. La palpare – leziunea este indurata dincolo de limitele vizibile clinic – necesita excizie cu margini largi de siguranta.
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CARCINOMUL BAZOCELULAR
CBC sclerodermiform – leziune mare, asemanatoare unei cicatrici subdenivelate, cu numeroase arii de pigmentare si telangiectazii, dara fara chenar perlat.
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CARCINOMUL BAZOCELULAR
sinonime – pagetoid, eczematoid, multicentric
localizare – frecvent pe trunchi
placa eritematoasa / eritemato-scuamoasa, diametru – cativa cm
eroziuni, cruste sau pigmentare pe suprafata
7. CBC SUPERFICIAL
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CARCINOMUL BAZOCELULAR
margine discret reliefata, cu perle mici
uneori – zone cicatriceale atrofice, ca rezultat al vindecarii, dar leziunea se extinde centrifug
tendinta redusa la extindere sau ulcerare
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CARCINOMUL BAZOCELULAR
Placa eritemato-scuamoasa persistenta. Marginea rulata, translucida sugereaza un CBC superficial.
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CARCINOMUL BAZOCELULAR
CBC supeficial – leziune cu aspect pagetoid.
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CARCINOMUL BAZOCELULAR
CBC superficial, cu aspect de leziune izolata, inflamatorie - eczematoid.
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CARCINOMUL BAZOCELULAR
CBC superficial – leziune unica, lucioasa, eritematoasa. Marginea este rulata, usor elevata si se observa mai bine prin iluminare laterala.
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CARCINOMUL BAZOCELULAR
la niv. oricarei forme de CBC, la un moment dat in evolutie poate sa apara pigment melanic, negru-maroniu → CBC pigmentat
se pigmenteaza mai frecvent CBC nodular si cel superficial
aparitia de pigment nu influenteaza evolutia leziunii
8. CBC PIGMENTAT
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CARCINOMUL BAZOCELULAR
Tumora pigmentata. Marginile translucide indica dg. de CBC.
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CARCINOMUL BAZOCELULAR
CBC pigmentat – varianta de CBC nodular ulcerat.
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CARCINOMUL BAZOCELULAR
CBC pigmentat.
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ASPECTE DERMATOSCOPICE
CARCINOMUL BAZOCELULAR
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CARCINOMUL BAZOCELULAR
Carcinom bazocelular Keratoza seboreica Angioame Dermatofibrom Dermatoze lichen plan-
like Acantom cu celule clare Lentigo solar Porocarcinom ecrin Boala Bowen Carcinom
scuamocelular Porom ecrin pigmentat
ASPECTE DERMATOSCOPICE
Indicatiile dermatoscopiei:- tumori melanocitare, benigne sau
maligne- tumori nemelanocitare, intre care:pt. aceste tumori
exista criterii bine stabilite, raportate de studii multicentrice
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CARCINOMUL BAZOCELULAR
leziunea va fi evaluata pt. prezenta de: arborizatii vasculare (telangiectazii) arii in forma de “frunza de artar” cuiburi mari ovalare gri-albastrui multipli globuli gri-albastrui arii “in roata cu spite” sau ulceratii
daca acestea sunt prezente - leziunea este sugestiva pentru un CBC
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CARCINOMUL BAZOCELULAR
Dermatoscopia arata telangiectazii arborescente, un cuib ovalar si multipli globuli si puncte gri-albastrui.
Imagine clinica a unui carcinom bazocelular partial pigmentat.
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CARCINOMUL BAZOCELULAR
Dermatoscopie - puncte si globuli multipli, gri-albastrui.
Imagine clinica a unui carcinom bazocelular pigmentat.
arii “in roata cu spite”
mica zona de ulcerare
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CARCINOMUL BAZOCELULAR
CBC - aspecte dermatoscopice - vase arborescente.
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ASPECTE HISTOPATOLOGICE
CARCINOMUL BAZOCELULAR
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CARCINOMUL BAZOCELULAR
initial – in DERM – mase tumorale care se desprind din EPIDERM
ulterior – DERMUL este invadat de mase tumorale mari, bine delimitate, de forme variate
ASPECTE HISTOPATOLOGICE
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CARCINOMUL BAZOCELULAR
pe alocuri, plajele tumorale se afla in prelungirea stratului bazal
stratul bazal
plaje de celule bazaloide
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CARCINOMUL BAZOCELULAR
masele tumorale au aspect monomorf – un singur tip de celule, asemanatoare celulelor bazale (cel. bazale atipice), care la periferia maselor sunt dispuse in palisada, iar in centru - dezordonat
atipiile celulare si mitozele sunt rare
stroma conjunctiva din jurul maselor tumorale – infiltrata cu limfocite si retractata, formind lacune peritumorale
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CARCINOMUL BAZOCELULAR
Plaje de celule tumorale maligne (asemanatoare celulelor stratului bazal al epidermului), cu caracter infiltrativ in derm. Dispozitia celulelor tumorale este caracteristica: la periferia plajelor celulele se dispun "in palisada" (nucleii perpendiculari pe conturul plajei) si dezordonat in centrul plajelor tumorale. Stroma conjunctiva este redusa, infiltrata cu limfocite.
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CARCINOMUL BAZOCELULAR
Detaliu.
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CARCINOMUL BAZOCELULAR
forme histopatologice:- nediferentiate – CBC solid, chistic sau superficial- cu diferentiere - pilara (CBC keratozic)
- sebacee (CBC sebaceu) - glandulara CBC adenoid) - calcificat Malherbe
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CARCINOMUL BAZOCELULAR
DIAGNOSTIC POZITIV ŞI DIFERENŢIAL
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CARCINOMUL BAZOCELULAR
in general clinic
examinare atenta, in lumina potrivita, eventual cu ajutorul unei lentile simple sau a dermatoscopului
palpare
diagnosticul trebuie confirmat histologic - biopsie excizionala
DIAGNOSTIC POZITIV
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CARCINOMUL BAZOCELULAR
CBC NODULAR- nev melanocitar dermic- tricoepiteliom- dermatofibrom- CSC la debut- keloizi- keratoze seboreice- molluscum
contagiosum
DIAGNOSTIC DIFERENTIAL CLINIC
CBC ULCERAT- CSC nodular ulcerat- sancru sifilitic primar extragenital- keratoacantom- melanom ulcerat
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CARCINOMUL BAZOCELULAR
CBC PIGMENTAT- melanom nodular,
cu dezvoltare in suprafata sau pe lentigo malign
- nevi compusi- nev albastru- tumori ale
anexelor- keratoza seboreica
exofitica- angiokeratom
CBC SUPERFICIAL- boala Bowen- boala Paget- psoriazis- eczema numulara- melanom amelanoticCBC
MORFEIFORM- morfee- lichen scleroatrofic- cicatrici atrofice
DIAGNOSTIC DIFERENTIAL CLINIC
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CARCINOMUL BAZOCELULAR
TRATAMENT
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CARCINOMUL BAZOCELULAR
fctie de localizarea anatomica, aspectul clinic, dimesiunea leziunii, varsta pacientului
pt. a obtine vindecarea este necesat trat. adecvat al tumorii primare - tumorile recurente au probabilitate mare de recurenta in continuare si de distructie locala importanta
obiectivele tratamentului - vindecarea, dar si un aspect estetic satisfacator (majoritatea CBC sunt localizate la niv. extremitatii cefalice!!!)
TRATAMENT
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CARCINOMUL BAZOCELULAR
Excizia chirurgicala clasica- avantaj - rezultat cosmetic bun, vindecare
rapida, control histologic al piesei excizate- dezav. - excizia incompleta determina
recidive
- sunt necesare margini de siguranta de 3-5 mm (5 mm pt CBC morfeiform sau recurent)
- excizie - pana in tesutul subcutanat
- pt. tumorile mici - sutura plagii- pt. tumori mari - excizie larga, urmata de
grefa libera sau cu pedicul vascular
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CARCINOMUL BAZOCELULAR
Chirurgia Mohs (chirurgie controlata microscopic)
- excizie conservatoare, cu economie de tesut, dar totusi sigura
- control microscopic riguros al piesei - elimina riscul de recidiva
- in CBC recurente, cele cu localizare centrofaciala, CBC morfeiform
- scumpa ?!
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CARCINOMUL BAZOCELULAR
Electrocauterizarea- indicatii - leziuni mari, multiple (CBC
superficial) pe torace, sau leziuni mici (chistice sau nodulare) pe fata
- NU periorificial - cicatrici fibroase, retractile- NU pt. CBC extensiv, morfeiform, recurent
- dezav. - vindecare mai indelungata, fara control histologic
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CARCINOMUL BAZOCELULAR
Chiuretarea- la pacientii varstnici, cu leziuni bine
delimitate, nodulare sau superficiale
- este urmata de electrocauterizare pt. indepartarea eventualelor resturi tumorale
- vindecare cu cicatrici minime
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CARCINOMUL BAZOCELULAR
Fotocauterizare cu laser- laser CO2
- rezultate comparabile cu ale electrocauterizarii
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CARCINOMUL BAZOCELULAR
Criochirurgia- metoda rapida, putin dureroasa, nu necesita
anestezie (suficient EMLA)
- distrugerea tumorii prin temperatura scazuta - azot lichid la -50-60°C
- profunzimea distructiei este de max. 5 mm - pt. tumori mici, incipiente, mai ales superficiale
- tehnica este “oarba” (fara control histologic) - indicata doar in cazurile in care alte metode sunt contraindicate
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CARCINOMUL BAZOCELULAR
Substantele citoxice topice- 5-fluorouracil, imiquimod 5% etc
- pt. CBC superficiale
- pt. alte forme - asociate cu chiuretare sau electrocauterizare
- recurente frecvente - metoda rezervata pacientilor imobilizati, cu speranta mica de viata
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CARCINOMUL BAZOCELULAR
Radioterapia- la cei care au contraindicatii pt. excizie
chirurgicala (varstnici, afectiuni generale severe)
- pt. tumori excizate incomplet
- doza de radiatii - fctie de suprafata si profunzimea tumorii
- trat. dureaza mult, risc de recidive
- NU periocular - recidive imposibil de tratat- NU la tineri - risc de radiodermite tardive
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CARCINOMUL BAZOCELULAR
Alte metode de tratament terapia fotodinamica (PUVA)
tratament sistemic cu retinoizi aromatici pt. CBC la pacienti cu sindrom nevoid bazocelular sau xeroderma pigmentosum
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CHIRURGIA MOHS IN CBC
Conf.dr. LAURA GHEUCA SOLOVASTRU
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CARCINOMUL BAZOCELULAR
sinonime - chemochirurgie - chirurgie micrografica - excizie controlata microscopic - chirurgie histografica orientata
microscopic (= Microscopically Oriented Histographic
Surgery)
dezvoltata de dr. Frederic Mohs - metoda precisa de trat. al tumorilor cutanate maligne, cu cele mai mari rate de vindecare (99%) si cu maxima economie de tesut sanatos
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CARCINOMUL BAZOCELULAR
initial - anestezie locala
apoi - chiuretarea sau excizia tangentiala a tumorii, pt. a evidentia mai bine marginile ei anatomice in plan transversal - se apreciaza intinderea tumorii in suprafata
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CARCINOMUL BAZOCELULAR
dupa chiuretare - desenarea conturului care va fi excizat - 2-3 mm inafara marginilor leziunii
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CARCINOMUL BAZOCELULAR
excizia chirurgicala - cu bisturiul inclinat la 45°
piesa rezultata are forma unei farfurii
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CARCINOMUL BAZOCELULAR
piesa in forma de farfurie se sectioneaza in 4 sferturi
fiecare sfert este numerotat si marcat cu 2 culori pt. identificare
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CARCINOMUL BAZOCELULAR
realizarea unei harti a piesei excizate - se deseneaza cele 4 sferturi, fiecare cu numarul si cu orientarea sa (in fctie de culori)
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CARCINOMUL BAZOCELULAR
procesarea celor 4 sferturi separat : inghetare la criostat - sectionare cu criotomul - sectiuni transversale de 5-10 μ grosime - sectiunile obtinute se intind pe lama si se coloreaza HE sau albastru de toluidina - pt. CBC
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Harti ale tumorii, la diferite niveluri de profunzime.
Realizarea de sectiuni transversale ale tumorii - imagine din lateral a tumorii.
Sectiuni transversale (orizontale) la diferite niveluri de profunzime ale tumorii.
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CARCINOMUL BAZOCELULAR
separat pt. fiecare sfert - se examineaza sectiunile transversale de pe lama la microscop - de catre chirurg!!
acolo unde este identificat tesut tumoral - se deseneaza pe harta pt. a obtine harta exacta a tumorii - corelarea aspectului microscopic cu localizarea anatomica
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CARCINOMUL BAZOCELULAR
pt. a nu exista recidive - excizia trebuie sa fie facuta in tesut sanatos - sa nu existe celule tumorale in marginile piesei
daca se identifica celule tumorale in una din marginile piesei - se deseneaza pe harta si se reintervine, dar numai in zona respectiva - excizia tangentiala a restului de tumora
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CARCINOMUL BAZOCELULAR
procedura se repeta pana cand marginile tesutului excizat sunt 100% fara celule tumorale - s-a realizat excizia tumorii in totalitate, dar fara risipa de tesut sanatos - rezultat cosmetic maxim posibil
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CARCINOMUL BAZOCELULAR
dupa excizia primara a tumorii, cat timp sunt realizate si examinate lamele - plaga este acoperita cu un pansament temporar, iar pacientul asteapta
interventia dureaza destul de mult, mai ales daca se reintervine de mai multe ori - de la 30 min la cateva ore - contribuie astfel la costul crescut al chirurgiei Mohs
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CARCINOMUL BAZOCELULAR
cel care realiz. excizia si cel care citeste lamele la microscop - obligatoriu una si aceeasi persoana - chirurg dermato-patolog - pt. optimizarea corelatiilor clinico-patologice
in plus este nevoie de asistenta in timpul interventiei si de un tehnician pt. procesarea piesei excizate - de aici o parte din costurile mari ale procedeului
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CARCINOMUL BAZOCELULAR
dupa realizarea exciziei complete - defectul tegumentar ramas trebuie inchis - fctie de dimensiuni - cu sutura sau cu grefa/lambou de piele
inchiderea plagii - acelasi chirurg sau altul, specializat in chirurgie reconstructiva
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CARCINOMUL BAZOCELULAR
De ce chirurgie Mohs?
pentru ca…
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CARCINOMUL BAZOCELULAR
in chirurgia clasica - piesa obtinuta este sectionata in ”felii de paine” - doar 1% din marginile tumorii sunt examinate - risc mare de celule tumorale restante - recidiva
daca se largesc limitele exciziei - defect tegumentar mare, cu rezultate estetice mai reduse
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CARCINOMUL BAZOCELULAR
EVOLUŢIE ŞI PROGNOSTIC
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CARCINOMUL BAZOCELULAR
Evolutie naturala- cele mai import. complicatii apar prin
invazie locala
- tumora creste lent, timpul de dedublare a leziunii - 6 luni-1an
- netratata, leziunea invadeaza tesutul subcut., muschiul si chiar osul
- tumorile situate la niv. unor santuri anatomice sunt de obicei extensive
EVOLUTIE SI PROGNOSTIC
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CARCINOMUL BAZOCELULAR
- rar, tumorile foarte agresive sau cele recurente pot evolua cu invazie perineurala - durere, parestezii, pareze (in specialCBC la niv. periocular)
- mts. - doar foarte rar - in ggl. limf. si pulmon
- factori de risc pt. mts. - CBC morfeiform, prezenta invaziei perineurale
EVOLUTIE SI PROGNOSTIC
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CARCINOMUL BAZOCELULAR
Cu tratament corect- pt. majoritatea pacientilor tratati corect,
progn. este excelent - vindecare pana la 99%
- totusi, pacientii trebuie supravegheati pt. recurente sau pt. aparitia unui nou CBC - riscul de a dezv. un al doilea CBC primar este de 36-50%
EVOLUTIE SI PROGNOSTIC
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CARCINOMUL BAZOCELULAR
- pacientul cu istoric de CBC - examinare periodica a intregului tegument (la 2, 6, 12 luni, apoi anual) + consiliere pt. fotoprotectie (risc crescut de melanom!!!)
- pt. CBC recurente - progn. este favorabil, desi astfel de tumori sunt de obicei mai agresive
- CBC cu mts. - progn. rezervat, supravietuire 8-10 luni de la dg.
EVOLUTIE SI PROGNOSTIC
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CARCINOMUL BAZOCELULAR
Prin urmare, in fata unui CBC…
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CARCINOMUL BAZOCELULAR
CBC
“H” zone - regiunea centrofaciala, in care economia de tesut sanatos este foarte importanta
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Atât deocamdată
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CARCINOMUL BAZOCELULAR