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Comprehensive Prep > Chapter 18: Plastics, Skin, and Soft Tissues > Flashcards

Chapter 18: Plastics, Skin, and Soft Tissues Flashcards

1
Q

Skin: primarily cellular

A

Epidermis

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2
Q

Main cell type in epidermis; originate from basal layer; provide mechanical barrier

A

Keratinocytes

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3
Q

Neuroectodermal origin (neural crest cells); in basal cell layer of epidermis

A

Melanocytes

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4
Q

Have dendritic processes that transfer melanin to neighboring keratinocytes via melanosomes

A

Melanocytes

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5
Q

How do melanocytes differ among races?

A

Density of melanocytes is the same among races; difference is in melanin production

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6
Q

Skin: primarily structural proteins (collagen) for the epidermis

A

Dermis

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7
Q
  • Acts as antigen-presenting cells (MHC Class II)
  • Originate form bone marrow
  • Have a role in contact hypersensitivity reactions (type 4)
A

Melanocytes

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8
Q

Sensory nerves: pressure

A

Pacinian corpuscles

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9
Q

Sensory nerves: warmth

A

Ruffini’s endings

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10
Q

Sensory nerves: cold

A

Krause’s end-bulbs

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11
Q

Sensory nerves: Meissner’s corpuscles

A

Tactile sense

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12
Q

Aqueous sweat (thermal regulation, usually hypotonic)

A

Eccrine sweat glands

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13
Q

Milky sweat

- highest concentration of glands in palms and soles

A

Apocrine sweat glands

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14
Q

What autonomic is in control of sweat production?

A

Most sweat is the result of sympathetic nervous system via acetylcholine

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15
Q

Drug type: increased skin absorption

A

Lipid-soluble drugs

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16
Q

Predominate collage type in skin; 70% of dermis; gives tensile strength

A

Type 1 Collagen

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17
Q

Resistance to stretching (collagen)

A

Tension

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18
Q

Ability to regain shape (branching proteins that can stretch to 2x normal length)

A

Elasticity

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19
Q

What causes Cushing’s striae?

A

Caused by loss of tensile strength and elasticity

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20
Q

MCC of pedicled or anastomosed free flap necrosis

A

Venous thrombosis

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21
Q

Flaps: what causes tissue expansion?

A

Occurs by local recruitment, thinning of the dermis and epidermis, mitosis

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22
Q

TRAM flaps: complications

A

Flap necrosis, ventral hernia, bleeding, infection, abdominal wall weakness

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23
Q

TRAM flaps: rely on what vessel?

A

Superior epigastric vessels

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24
Q

Most important determinant of TRAM flap viability?

A

Periumbilical perforators

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25
Q

What is a TRAM flap?

A

Transversus rectus abdominis flap

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26
Q

Stage I Pressure ulcer

A

Erythema and pain; no skin loss

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27
Q

Stage 2 Pressure Ulcer

- Treatment?

A

Partial skin loss with yellow debris

- Tx: local treatment, keep pressure off

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28
Q

Stage 3 Pressure Ulcer

- Treatment?

A

Full-thickness skin loss; subcutaneous fat exposure

- Tx: sharp debridement; likely need myocutaneous flap

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29
Q

Stage 4 Pressure Ulcer

- Treatment?

A

Involves bony cortex, muscle

- Tx: myocutaneous flap

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30
Q
  • Damages DNA and repair mechanisms

- Both a promoter and initiator

A

UV radiation

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31
Q

Single best factor for protecting skin from UV radiation

A

Melanin

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32
Q

Responsible for chronic sun damage

A

UV-B

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33
Q

Represents only 5% of skin CA but accounts for 65% of the deaths

A

Melanoma

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34
Q

Risk factors for melanoma

A
  • Dysplastic, atypical or large congenital nevi
  • Familial BK mole syndrome
  • Xeroderma pigmentosum
  • Fair complexion, easy sunburn, intermittent sunburns, previous skin CA, previous XRT
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35
Q

10% lifetime risk for melanoma

A

Dysplastic, atypical, or large congenital nevi

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36
Q

Almost 100% risk of melanoma

A

Familial BK mole syndrome

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37
Q

% melanomas that are familial

A

10%

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38
Q

MC melanoma site on skin

A

Back in men, legs in women

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39
Q

What carries a worse prognosis in melanoma?

A

Men, ulcerated lesions, ocular and mucosal lesions

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40
Q

Signs of melanoma

A
  • Asymmetry (angulations, indentation, notching, ulceration, bleeding)
  • Borders that are irregular
  • Color change (darkening)
  • Diameter increase
  • Evolving over time
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41
Q

Where does melanoma originate?

A

Originates from neural crest cells (melanocytes) in basal layer epidermis

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42
Q

Color: most ominous sign of melanoma

A

Blue color

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43
Q

MC location for distant melanoma metastases

A

Lung

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44
Q

Diagnosis melanoma:

- 2 cm lesion or cosmetically sensitive area

A
  • 2cm or cosmetically sensitive area: incisional biopsy (or punch biopsy), will need to resect with margins if path shows melanoma
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45
Q

Five types of melanoma

A
  • Melanoma in situ or thin lentigo maligna (Hutchinson’s freckle)
  • Lentigo maligna melanoma
  • Superficial spreading melanoma
  • Nodular
  • Acral lentiginous
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46
Q

Components of melanoma staging workup

A

Chest/abd/pelvic CT, LFTs, and LDH for all melanoma > 1mm; examine all possible draining lymph nodes

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47
Q

Melanoma: treatment for all stages

A

1) Resection of primary tumor with appropriate margins
- AND -
2) Management of lymph nodes

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48
Q

Surgical margins for melanoma excision:

  • In situ (mm)
  • 1.0 (mm)
  • 1.1 - 2.0 (mm)
  • > 2.0 (mm)
A
  • In situ (mm): 0.5 - 1.0 cm
  • 1.0 (mm): 1.0 cm
  • 1.1 - 2.0 (mm): 1.0 - 2.0 cm
  • > 2.0 (mm): 2.0 cm
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49
Q

Surgical margins for melanoma excision:

- In situ (mm)

A
  • In situ (mm): 0.5 - 1.0 cm
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50
Q

Surgical margins for melanoma excision:

- 1.0 (mm)

A
  • 1.0 (mm): 1.0 cm
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51
Q

Surgical margins for melanoma excision:

- 1.1 - 2.0 (mm)

A
  • 1.1 - 2.0 (mm): 1.0 - 2.0 cm
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52
Q

Surgical margins for melanoma excision:

- > 2.0 (mm)

A
  • > 2.0 (mm): 2.0 cm
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53
Q

Melanoma: what nodes do you need to resect?

A

Always need to resect clinically positive nodes

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54
Q

Melanoma: when do you perform sentinel lymph node biopsy?

A

If nodes clinically negative and tumor >/ 1 mm deep

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55
Q

Characteristic of involved nodes in melanoma

A

Involved nodes usually nontender, round, hard 1-2 cm

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56
Q

What do you need to include for all anterior head / neck melanomas >/ 1mm deep?

A

Superficial parotidectomy (20% metastasis rate to parotid)

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57
Q

Tx: axillary node melanoma with no other primary

A

Complete axillary node dissection (remove Level 1, 2 , and 3 nodes - unlike breast CA)

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58
Q

Melanoma: has provided some patients with long disease-free interval and is the best chance for cure

A

Resection of metastases
- Isolated metastases (ie lung or liver) that can be resected with a low-risk procedure should probably undergo resection

59
Q

Melanoma: can be used for systemic disease

A

IL-2 and tumor vaccines

60
Q

Most common malignancy in US

A

Basal cell carcinoma

  • 4x more common than squamous cell skin cancer
  • 80% on head and neck
61
Q

What does basal cell carcinoma originate from?

A

Epidermis - basal epithelial cells and hair follicles

62
Q

-Pearly appearance, rolled borders, slow and indolent growth

A

Basal cell carcinoma

63
Q

Path: basal cell carcinoma

A

Peripheral palisading of nuclei and stromal retraction

64
Q

Basal cell carcinoma: what do you do for clinically positive nodes

A

Regional adenectomy

65
Q

Basal cell carcinoma: most aggressive, has collegians production

A

Morpheaform type

66
Q

Basal cell carcinoma:

- Treatment: 0.3 - 0.5 cm margins

A

XRT and chemotherapy: may be of limited benefit for inoperable disease, mets or neuro/lymphatic/vessel invasion

67
Q
  • Overlying erythema, papulonodular with crust and ulceration; usually red-brown
  • May have surrounding induration and satellite nodules
  • Can develop in post-XRT areas or in old burn scars
A

Squamous cell carcinoma

68
Q

Incidence of metastasis: squamous cell vs basal cell vs melanoma

A

Melanoma > squamous cell carcinoma > basal cell carcinoma

69
Q

Risk factors for squamous cell carcinoma

A

Actinic keratoses, xeroderma pigmentosum, Bowen’s disease, atrophic epidermis, arsenics, hydrocarbons (coal tar), chlorophenols, HPV, immunosuppression, sun exposure, fair skin, previous XRT, previous skin cancer

70
Q

Risk factors for metastasis in squamous cell carcinoma

A

Poorly differentiated, greater depth, recurrent lesions, immunosuppression

71
Q

Squamous cell carcinoma - tx: 0.5 - 1.0 cm margins for low risk

A
  • Can treat high risk with Mohs surgery when trying to minimize area of resection (i.e., lesions on facE)
  • Regional adenectomy for clinically positive nodes
  • XRT and chemotherapy - may be of limited benefit for inoperable disease, mets, or neuo/lymphatic/vessel invasion
72
Q

Margin mapping using conservative slices; not used for melanoma

A

Mohs surgery

73
Q

MC soft tissue sarcomas

A
  1. Malignant fibrous histiosarcoma

2. Liposarcoma

74
Q

MC location / age of soft tissue sarcoma

A

50% arise from extremities; 50% in children (arise from embryonic mesoderm)

75
Q
  • Most are large, grow rapidly, painless

- Symptoms: asymptomatic mass (MC presentation), GIB, bowel obstruction, neurologic deficit

A

Soft tissue sarcoma

76
Q

Imaging studies necessary for soft tissue sarcomas

A
  • CXR: to r/o lung mets

- MRI before biopsy: to r/o vascular, neuro, or bone invasion

77
Q

Soft tissue sarcoma: excisional biopsy vs longitudinal incisonal biopsy

A
  • Excisional biopsy: mass 4cm

- Need to eventually resect biopsy skin site if biopsy shows sarcoma

78
Q

MC site for mets of soft tissue sarcoma

A

Lung

79
Q

How do mets spread in soft tissue sarcoma?

A

Hematogenous spread, not to lymphatics -> mets to nodes is rare

80
Q

What is staging based on in soft tissue sarcoma?

A

Staging based on grade, not size

81
Q

Tx: soft tissue sarcoma

A

Want at least 3-cm margins and at least 1 uninvolved fascial plane -> try to perform limb-sparing operating.
- Place clips to mark site of likely recurrence -> will XRT these later

82
Q

Post op XRT: soft tissue sarcomas

A

For high-grade tumors, close margins, or tumors > 5 cm

83
Q

Chemotherapy: soft tissue sarcoma

A

Chemotherapy is doxorubicin based

84
Q

What to think about with soft tissue sarcomas and tumors > 10 cm?

A

Tumors > 10 cm may benefit from pre op chemo XRT -> may allow limb-sparing resection

85
Q

Tx: isolated sarcoma metastases

A

Isolated sarcoma mets without other evidence of systemic disease can be resected and are the best chance for survival; otherwise can palliate with XRT

86
Q

Incision favored for pelvic and retroperitoneal sarcomas

A

Midline incision

87
Q

What do you try to preserve in resection of soft tissue sarcoma?

A

Try to preserve motor nerves and retain or reconstruct vessels.

88
Q

Poor prognosis overall: soft tissue sarcoma

A
  • Delay in diagnosis
  • Difficulty with total resection
  • Difficulty getting XRT to pelvic tumors
89
Q

Survival rate with complete resection of soft tissue sarcoma

A

40% 5-year survival rate

90
Q

Can occur in pediatric population (usually rhabdomyosarcoma)

A

Head and neck sarcomas

91
Q

Why are head and neck sarcomas difficult to get margins?

A

Because of proximity to vital structures. Post op XRT for positive or close margins as negative margins may be impossible to obtain

92
Q

Most commonly are leiomyosarcomas and liposarcomas

A

Visceral and retroperitoneal sarcoma

93
Q

What is the most important prognostic factor in visceral and retroperitoneal sarcomas?

A

The ability to completely remove the tumor

94
Q

Risk factors for soft tissue sarcoma

A
  • Asbestos: mesothelioma
  • PVC and arsenic: angiosarcoma
  • Chronic lymphedema: lymphangiosarcoma
95
Q
  • Vascular sarcoma

- a/w immunocompromised state

A

Kaposi’s sarcoma

96
Q

MC malignancy in AIDS

A

Kaposi’s sarcoma

- Rarely a cause of death in AIDS

97
Q

MC site Kaposi’s sarcoma (vascular sarcoma)

A

Oral and pharyngeal mucosa (s/s: bleeding, dysphagia)

98
Q

Tx: Kaposi’s sarcoma

A
  • AIDS tx (HAART) shrinks AIDS-related KS (best tx)
  • Consider XRT or intra-lesional vinblastine for local disease
  • Interferon-alpha for disseminated disease
  • Surgery for severe intestinal hemorrhage
99
Q

Best treatment AIDS-related Kaposi sarcoma

A

AIDS Tx (HAART) shrinks it

100
Q

Tx: local disease - Kaposi’s sarcoma

A

Consider XRT or intra-lesional vinblastine

101
Q

Tx: disseminated disease - Kaposi’s sarcoma

A

Interferon-alpha

102
Q

Tx: severe intestinal hemorrhage - Kaposi’s sarcoma

A

Surgery

103
Q

1 soft tissue sarcoma in kids

A

Childhood rhabdomyosarcoma

104
Q

Poorest prognosis in childhood rhabdomyosarcoma

A

Head/neck, genitourinary, extremities, and trunk

105
Q

MC subtype childhood rhabdomyosarcoma

A

Embryonal

106
Q

Worst prognosis childhood rhabdomyosarcoma

A

Alveolar

107
Q

Tx: childhood rhabdomyosarcoma

A

Surgery; doxorubicin-based chemotherapy

108
Q

Most are metastatic at the time of diagnosis

A

Osteosarcoma

109
Q
  • Increased incidence around the knee
  • Originates from metaphyseal cells
  • Usually in children
A

Osteosarcoma

110
Q

CNS tumors
Peripheral sheath tumors
Pheochromocytoma

A

Neurofibromatosis

111
Q

Childhood rhabdomyosarcoma, many others

A

Li-fraumeni syndrome

112
Q

Also includes other sarcomas

A

Hereditary retinoblastoma

113
Q

Angiomyolipoma is associated with what?

A

Tuberous sclerosis

114
Q

Familial adenomatous polyposis and intra-abdominal desmoid tumors

A

Gardner’s syndrome

115
Q

What is important in lip lacerations?

A

Lip lacerations: important to line up vermillion border

116
Q

Yellow, contains histiocytes

- Tx: excision

A

Xanthoma

117
Q

Viral origin, contagious, autoinoculable, can be painful

- Tx: liquid nitrogen initially

A

Warts (verruca vulgaris)

118
Q

Can be associated with neurofibromatosis and von Recklinghausen’s disease (cafe-au-lait spots, axillary freckling, peripheral nerve and CNS tumors)

A

Neuromas

119
Q

Café-Au-Lait spots, axillary freckling, peripheral nerve and CNS tumors

A

von Recklinghausen’s disease

120
Q

Keratoses: Premalignant in sun-damaged areas; need excisional biopsy if suspicious

A

Actinic keratosis

121
Q

Keratoses: Not premalignant; trunk on elderly, can be dark

A

Seborrheic keratosis

122
Q

Keratoses: associated with squamous cell carcinoma

A

Arsenical keratoses

123
Q
  • Very aggressive malignant tumor with early regional and systemic spread
  • Red to purple papulonodule or indurated plaque
A

Merkel cell carcinoma (are neuroendocrine)

124
Q

Have neuron-specific enolase (NSE), cytokeratin, and neurofilamint protein

A

Merkel cell carcinoma (are neuroendocrine)

125
Q
  • Painful tumor composed of blood vessels and nerves

- Benign; most common in the terminal aspect of the digit

A

Glomus tumor

- Tx: tumor excision

126
Q

Benign but locally very invasive; occur in fascial planes

A

Desmoid tumors

127
Q

Most common location of desmoid tumors

A

Anterior abdominal wall

128
Q

When can anterior abdominal wall desmoid tumors happen?

A

Can occur during or following pregnancy; can also occur after trauma or surgery

129
Q

Associated with gardner’s syndrome and retroperitoneal fibrosis; often encases bowel, making it hard to get en bloc resection

A

Intra-abdominal desmoids

130
Q

High risk of local recurrences; no distant spread

A

Desmoid tumor

131
Q

Tx: desmoid tumors

A

Surgery if possible; chemotherapy (sulindac, tamoxifen) if vital structure involved or too much bowel would be taken (high risk of short bowel syndrome with surgery)

132
Q

SCCA in situ; 10% turn into invasive SCCA; associated with HPV

A

Bowen’s disease

133
Q

Tx: Bowen’s disease

A

Imiquimod, cautery ablation, topical 5-FU, avoid wide local excision if possible (high recurrence rate with HPV), regular biopsies to rule out cancer

134
Q
  • Rapid growth, rolled edges, crater filled with keratin
  • is not malignant but can be confused with SCCA
  • involutes spontaneously over months
A

Keratoacanthoma

135
Q

Tx: keratoacanthoma

A
  • Always biopsy these to be sure

- If small, excise; if large, biopsy and observe

136
Q

Increased sweating, especially noticeable in the palms.

- Tx?

A

Hyperhidrosis

Tx: thoracic sympathectomy if refractory to variety of antiperspirants

137
Q

Infection of apocrine sweat glands, usually in axilla and groin regions
- Staph / strep most common organisms

A

Hidradenitis

138
Q

Tx: hidradenitis

A

Antibiotics, improved hygiene first; may need surgery to remove skin and associated sweat glands

139
Q

Most common benign cysts

A

Epidermal inclusion cyst

- Have completely mature epidermis with creamy keratin material

140
Q

Benign cyst: in scalp, no epidermis

A

Trichilemmal cyst

141
Q

Benign cyst: over tendons, usually over wrist; filled with collagen material

A

Ganglion cyst

142
Q

Benign cyst: midline intra-abdominal and sacral lesions usual; need resection due to malignancy risk

A

Dermoid cyst

143
Q

Benign cyst: congenital coccygeal sinus with ingrown hair; gets infected and needs to be excised

A

Pilnoidal cyst

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