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Cameron Skin & Soft Tissue > Cutaneous Melanoma > Flashcards

Cutaneous Melanoma Flashcards

1
Q

What are the ABCDs of diagnosing melanomas?

A

Asymmetric, (irregular) Border, (variegated) Color, or (large) Diameter

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2
Q

What is the ideal biopsy for suspected melanoma

A

Excisional biopsy including the deepest portion of the melanoma, when possible - depth affects staging and treatment

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3
Q

When lesions are too large to excise for biopsy, what portion should be biopsied?

A

The darkest or the thickest (by palpation)

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4
Q

What are the depth to margin recommendations in melanoma?

A

In situ - 5mm, 4mm - 3cm

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5
Q

What mechanisms exist for local recurrence of melanoma after excision?

A

Radial extension, local dissemination through lymphatics, or neurotropic (along nerves)

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6
Q

True/False: Margins of excision may be modified in subungal lesions.

A

False - it often requires amputation at midproximal phalanx and replantation of tendons

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7
Q

What is the ideal resection length to width ratio for primary closure with advancement flaps?

A

3 to 1

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8
Q

What is the most likely first site of melanoma metastasis?

A

Regional lymph nodes

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9
Q

What pathological findings dictate lymph node biopsy in melanoma

A

1mm in depth OR, to a lesser extent, ulceration, young age, regression, incomplete biopsy, and high mitotic rate

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10
Q

What is the most important prognostic factor with localized melanoma?

A

Lymph node status

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11
Q

Why does lymphoscintigraphy imaging have to include the entire body?

A

Risk of occult sites that could represent the site of the sentinel node - found in 10% of cases

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12
Q

Along with radionucleotide lymphoscintigraphy, what measures are used to identify sentinel nodes?

A

Injection of blue dye, to visually identify sentinel node

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13
Q

At what level is the blue dye injected to identify melanoma sentinel nodes?

A

Intradermal - there are relatively few subcutaneous lymphatic channels

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14
Q

In melanoma, the nodal basin is dissected until what is achieved?

A

The radioactivity count falls below 10 of the hottest node

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15
Q

True/False: All proposed sentinel nodes should be sent for frozen section in melanoma?

A

False - there is limited accuracy and loss of diagnostic material during cryostat processing

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16
Q

What are the potential complications of sentinel node biopsy?

A

Wound seroma, hematoma, and infection - nerve injury and lymphedema are also possible, in certain sites.

17
Q

What is the standard of care in nodal metastasis associated with melanoma?

A

Complete lymphadenectomy

18
Q

What are the recommended number of nodes in lymphadenectomy?

A

Axillary/Cervical - 15, Inguinal - 8 (sup) and 6 (deep), SC- 6, Suprahyoid - 4, Parotid - 3 , Popliteal - 2 to 3

19
Q

What is the primary determinant in the thickness of skin flaps during lymphadenectomy?

A

Achieving the thinnest possible flaps WITHOUT compromising perfusion

20
Q

What modalities are recommended for dissecting visible lymphatics?

A

Clips, ties, ligating energy sources - NOT electrocautery

21
Q

True/False: In melanoma, only axillary nodes of levels 1 and 2 need to be dissected.

A

False - all 3 levels are included.

22
Q

What are the borders of axillary node dissection for melanoma?

A

(S) axillary vein from thoracic inlet to latissimus dorsi, (M) serratus anterior and intercostals, including interpectoral (Rotter’s) nodes, (L) latissimus dorsi, (I) Fourth Intercostal space, (P) subscapularis.

23
Q

What nerves are encountered (and should be spared) during axillary node dissection?

A

The lateral thoracic and thoracodorsal nerves (do not preserve if involved with tumor)

24
Q

What muscle is encountered (and sometimes transected or removed) during level 3 axillary node dissection?

A

Pectoralis minor

25
Q

What are the borders of a superficial inguinal node dissection?

A

(S) 5-6 cm superior to inguinal ligament, to abdominal fascia, (M) adductor magnus, (L) Sartorius), (I) Bottom of muscular triangle formed by adductor magnus and Sartorius, (Deep) to femoral vessels

26
Q

What findings mandate deep inguinal node dissection?

A

Presence of tumor in Cloquet’s node (highest superficial node) or palpable inguinal nodal metastasis

27
Q

What is the most common way to protect the exposed femoral vessels following superficial nodal dissection?

A

A Sartorius flap, secured to the inguinal ligament

28
Q

What nodal regions are dissected in a deep inguinal node dissection?

A

Iliac, hypogastric, and obturator

29
Q

True/False: It is not necessary to violate the peritoneum in a deep inguinal resection.

A

True: The retroperitoneum can be entered while sweeping the peritoneum superiorly

30
Q

What are the borders of the popliteal nodal basin?

A

(S/L) Biceps femoris, (S/M) semimebranosus and semitendinosus, (I) gastrocnemius, (Deep) Popliteus

31
Q

What vessel is often ligated in a popliteal nodal dissection?

A

Lesser saphenous

32
Q

If there are positive nodes in the popliteal basin, what other remote site needs complete lymph node dissection as well?

A

The superficial inguinal nodal basin

33
Q

When is radiotherapy indicated in melanoma, an otherwise “radioresistant” disease?

A

Dissected nodal basins with high risk features (gross disease, extracapsular extension, or >3 diseased lymph nodes

34
Q

What is the major risk associated with radiotherapy in a nodal basin?

A

Markedly increased risk of lymphedema

35
Q

What is “In-transit Metastasis”?

A

A metastatic presentation unique to melanoma where tumor cells have spread through lymphatics without reaching a lymph node and present as dermal or subcutaneous lesions

36
Q

What are the risk factors for in-situ metastasis?

A

Characteristics of the primary disease, not extent of excision or management or regional nodes

37
Q

What are the possible treatments of in transit metastasis?

A

Simple excision, isolated limb perfusion, radiation, laser ablation, local immunotherapy

38
Q

True/False: Surgical resection of distant melanoma metastases are never indicated.

A

False - there are indications in carefully selected groups with soft tissue, lung, and other visceral mets - bowel mets have shown the best results

39
Q

What are the pre-operative requirement before resection of melanoma mets?

A

CT of chest, abdomen, pelvis. PET of whole body. MRI of brain.

Cameron Skin & Soft Tissue (13 decks)

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