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Chapter 16 Flashcards

1
Q

What is the 5th most common cancer type?

A

Melanoma

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2
Q

What is the most common cause of melanoma?

A

BRAF mutation (60% of melanomas)

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3
Q

Age of melanoma

A

Wide range, often in women 20-30 yrs

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4
Q

Race predilection of melanoma

A

White 30x more likely

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5
Q

Hx of melanoma lesion

A

Recently developed or changing OR

FHx of CDKN2A or CDK4

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6
Q

Environmental factors of melanoma

A

UV radiation

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7
Q

Presentation of melanoma

A 
Asymmetry
Irregular borders
Color
Diameter >6 mm
Elevated surface
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8
Q

What is the most suspicious melanoma?

A

Superficial spreading > nodular melanoma > lentigo maligna > acral lentiginous

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9
Q

What is the MC noncutaneous melanoma?

A

Ocular melanoma

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10
Q

What is associated with a worse prognosis in pts with disseminated melanoma?

A

Elevated LDH

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11
Q

What type of margins should be achieved with less than or equal to 1 mm thickness melanoma?

A

1 cm margin

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12
Q

What type of margins should be achieved with 1-2 mm thickness melanoma?

A

1-2 cm

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13
Q

What type of margins should be achieved with >2 cm thickness melanoma?

A

2 cm

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14
Q

What is the MC site for the first metastasis of melanoma?

A

Regional LNs

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15
Q

What is now the standard procedure for detecting subclinical metastatic to the regional nodes?

A

Sentinel LN bx

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16
Q

When is surgical resection recommended for melanoma?

A

Pts with primary tumors >1 mm, with tumor thickness of 0.76 to 1 mm who have T1b lesions, and tumor thickness of 0.76 to 1 mm who have T1a lesions

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17
Q

When is resection not recommended in melanoma?

A

Pt with tumor thickness <0.76 mm

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18
Q

What high-risk features are rare in thin lesions but when present may warrant sentinel LN bx in selected individuals in whom it is not otherwise recommended? (melanoma)

A 
High mitotic rate
Lymphovascular invasion
Microsatellites
Clark level IV
Ulceration
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19
Q

What is the single strongest prognostic factor for pts with clinically localized melanoma?

A

The status of the sentinel node

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20
Q

How is a melanoma lesion identified?

A

Tech-99m labeled sulfur colloid
-Accuracy of the procedure is maximized by the additional intraoperative injection of isosulfan blue dye into the tumor site, which allows both visualization of the blue sentinel node and detection with a handheld gamma probe

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21
Q

What is recommended in stage II melanoma, in the absence of distant metastases

A

Therapeutic lymph node dissection

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22
Q

What is located in the inguinal region?

A

The superficial femoral nodes, which reside in the triangle between the sartorius muscle laterally; the adductor muscles medially; and the inguinal ligament superiorly

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23
Q

Where do the parotid, submandibular, submental, jugular, and posterior triangle lymph nodes drain?

A

Anterior to the ear and superior to the mouth

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24
Q

Where do anterior lesions inferior to the mouth drain?

A

To cervical nodes

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25
Where do posterior lesions drain?
To occipital, postauricular, posterior triangle, and jugular nodes
26
What are complications of lymph node dissection?
Infection Wound dehiscence Seroma Lymphedema
27
Who is at a high risk for local recurrence despite therapeutic lymph node dissection?
Pts with lymph node metastases that grow through the capsule of the lymph node (extracapsular extension) and those with extensive tumor burden in multiple nodes -Consider adjuvant radiation therapy
28
In-transit metastases- lymphatic
Tumor deposits along the path of lymphatic drainage from the primary tumor to the regional lymph node basin
29
Prognosis of in-transit metastases- lymphatic
Worsens with increasing number
30
Tx of in-transit metastases- lymphatic
Excision and sentinel lymph node bx or dissection | Additionally, isolate limb perfusion (ILP) and isolated limb infusion (ILI) have also been used
31
Local recurrence of advanced lymphatic metastases
Regrowth of tumor within 5 cm of the primary resection site 4% rate of recurrence Occurs more frequently in pts with thick (>4 mm) primary lesions and ulcerated tumors and in lesions of the foot, hand, scalp, and face
32
Distant metastases lymphatic
To the lung, liver, brain, and bone are most common
33
Tx options for distant lymphatic metastases
Observation- often warranted for asymptomatic pts in poor medical condition Surgical resection of metastases- resection can provide effective palliation and a 5-yr survival of up to 29% Radiation therapy- Palliative tx for symptomatic lesions and brain metastases Chemo- combo regimens include dacarbazine are used predominantly but are now reserved for pts failing other options
34
Target therapy for distant metastases- lymphatic
``` BRAF inhibitors (vemurafenib, dafrafenib) target the activating mutation in BRAF (present in 60% of melanomas). Response rates of 50% but resistance develops after a median of 9 mos MEK inhibitor (trametinib) often in combo with BRAF inhibition ```
35
Biologic therapy for distant metastases- lymphatic
IL-2 results in 10-20% response rate (some responses are dramatic) but largely supplanted by ipilimumab Anti-CTLA-4 antibody (ipilimumab) is associated with modest response rates but substantially improves overall survival Anti-PD-1 antibody (pembrolizumab) recently demonstrated improved response rates and overall survival compared to ipilimunab in a phase II trial
36
Soft tissue sarcoma
Malignant tumors of the mesenchymal origin (fat, muscle, connective tissue) Most occur on the LEs and retroperitoneum is 2nd MC
37
Genetic syndromes associated with soft tissue sarcoma
Gardner syndrome Retinoblastoma Neurofibromatosis I
38
Types of soft tissue sarcoma
Leiomyosarcoma MC | Rhabdomyosarcoma (MC childhood sarcoma)
39
What is the mainstay of therapy for soft tissue sarcoma?
Surgical resection
40
What is the prognosis of retroperitoneal sarcoma?
15%, poor prognosis
41
GIST
GI stromal tumor, rare, from interstitial cells of Cajal, receptor KIT (CD117), surgical resection is the mainstay of therapy if localized
42
What percentage of lymphomas does Hodgkin lymphoma constitute?
10%
43
Characteristics of Hodgkin lymphoma
A malignancy of B cells and can be characterized pathologically by the presence of Reed-Sternberg cells Bimodal age distribution with first peak at ~20 yoa and a second peak at age 65
44
What is the most common presentation of Hodgkin lymphoma?
Painless LAD
45
What are the most commonly involved sites in Hodgkin lymphoma?
Cervical/supraclavicular lymph node basins followed by the axillary and inguinal node basins
46
Alternate presentation of Hodgkin lymphoma
Incidentally discovered mass on imaging- most commonly a mediastinal mass with retroperitoneal adenopathy seen less frequently
47
Other sx in Hodgkin lymphoma
Fever >38 degrees Celsius Night sweats Wt loss of more than 10% body weight over a 6-mo period AKA B sx
48
What does an eval of pts referred for lymph node bx for Hodgkin lymphoma include?
PE with detailed evaluation of all accessible lymphatic tissue -Palpation of all superficial lymph node basins and abdominal palpation for hepatic or splenic enlargement
49
Diagnostic laboratory studies for Hodgkin lymphoma
CBC with diff | Peripheral blood smear
50
What is staging in Hodgkin lymphoma based on?
The extent of disease and the present or absence of B sx
51
Staging workup for Hodgkin lymphoma
Liver function LDH ESR CXR CT scan (typically neck, chest, abdomen, and pelvis) PET scan Bone marrow bx recommended for stage IB, IIB and III-IV
52
What is the tx modality of choice Hodgkin lymphoma?
Chemoradiation for all pts with stage I-II | Chemo , with or without radiation for more advanced stages
53
Presentation of NHL
Can vary widely from an indolent course over yrs to an acute presentation that can be fatal within wks
54
How are NHL tumors classified?
By their cell of origin (B cell, T cell, or rarely NK cells) with most cases of B-cell descent (80%)
55
Presentation of NHL
More than 2/3 of pts with NHL present with LAD
56
What is the surgeon's role in NHL?
Obtain tissue for dx | Treat extranodal lymphomas in the GI tract
57
What is one of the few indications for urgent performance of a LN bx in NHL?
Suspicion of an aggressive NHL lymphoma
58
Gastric MALT
A clonal B-cell neoplasm typically associated with an indolent course but prone to local recurrence and occasionally capable of distant metastatic spread or degeneration into a high-grade B-cell lymphoma
59
What is MALT lymphoma classically associated with?
H. pylori present in >90% of cases
60
Tx of MALT lymphoma
For early dz, tx of H. pylori alone serves as a highly effective tx For those with advanced dz or in whom H. pylori therapy fails, radiation therapy is typically highly effective with surgical resection reserved for cases in which radiation is contraindicated
61
What is the MC site of involvement for extranodal NHL?
GI tract
62
From where do the majority of GI lymphomas arise?
In the stomach (75%)
63
Presentation of gastric lymphomas
``` Abd pain Wt loss N/V Bleeding Rarely, perforation ```
64
Tx for gastric lymphoma
Surgical resection is rarely employed Chemo is the therapy of choice Surgery is now reserved for those rare pts who develop complications from the dz or during therapy
65
What are uncommon in the US but are the most common extranodal lymphoma in the Middle East?
Lymphomas of the small bowel
66
When are there higher incidences of small bowel lymphomas?
In pts with celiac dz
67
Where are lymphomas of the small bowel most often found?
Proximal jejunum
68
Presentation of small bowel lymphomas
Obstruction Intussusception Bleeding
69
Tx of small bowel lymphomas
Chemo is the mainstay However, resection needs to be done to obtain a dx Then, adjuvant chemo
70
What are the MC noncarcinomatous tumors of the large bowel?
Colonic lymphomas

Surgery (30 decks)

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