Melanoma

Question 1

A 60-year-old man comes to the office because of a 2-cm pigmented lesion on the right lower back that has enlarged progressively for 3 years. No lymph nodes are palpable. Examination of a specimen obtained on punch biopsy shows a Clark Level IV malignant melanoma with a Breslow thickness of 1.2 mm and ulceration. Which of the following is the most appropriate management?
A) Excision with 2-cm margins
B) Preoperative lymphoscintigraphy, sentinel lymph node biopsy, and excision with 1-cm margins
C) Preoperative lymphoscintigraphy, sentinel lymph node biopsy, and excision with 2-cm margins
D) Excision with 1-cm margins, followed by lymphoscintigraphy and sentinel lymph node biopsy at a later date
E) Excision with 3-cm margins, split-thickness skin grafting, and right axillary lymph node dissection

Answer 1

C) Preoperative lymphoscintigraphy, sentinel lymph node biopsy, and excision with 2-cm margins

A melanoma 1.2 mm in thickness on the lower back would best be excisedwith 2-cm margins and a concurrent sentinel lymph node biopsy. Although a few studies cite the adequacy of a 1-cm margin for tumors less than 2 mm in thickness, a punch biopsy was performed in he scenario described, and the final pathology of the complete lesion could show a thicker lesion. In a location where there is sufficient tissue, a 2-cm margin is more appropriate for a lesion that is over 1 mm in thickness. Most authors cite resection margins of 5 mm for melanoma in situ, 1 cm for melanoma less than 0.8 mm, and 2 cm for melanoma between 0.8 and 4 mm.

Question 2

Most authors cite resection margins of _____ for melanoma in situ

Answer 2

Most authors cite resection margins of 5 mm for melanoma in situ, 1 cm for melanoma less than 0.8 mm, and 2 cm for melanoma between 0.8 and 4 mm.

Question 3

Most authors cite resection margins of _____ for melanoma less than 0.8 mm

Answer 3

1 cm for melanoma less than 0.8 mm

Question 4

Most authors cite resection margins of _____ for melanoma between 0.8 and 4 mm

Answer 4

2 cm for melanoma between 0.8 and 4 mm.

Question 5

Margins cited for melanoma sizes

Answer 5

Most authors cite resection margins of 5 mm for melanoma in situ, 1 cm for melanoma less than 0.8 mm, and 2 cm for melanoma between 0.8 and 4 mm.

Question 6

Patients with intermediate thickness lesions of 0.8 mm to 4 mm have a ______% incidence of microscopic regional disease.

Answer 6

Patients with intermediate thickness lesions of 0.8 mm to 4 mm have a 20 to 25% incidence of microscopic regional disease. S

Question 7

Sentinal lymphadenectomy for melanoma

Answer 7

In patients with melanomas greater than or equal to 1 mm in thickness and no clinical evidence of regional lymph node metastases, lymphoscintigraphy is performed preoperatively to define the lymphatic drainage and demonstrate sentinel lymph node location. Sentinel lymphadenectomy is performed most accurately at the time of wide and deep excision of the primary lesion. Later,sentinel lymph node localization may be impaired if the primary lesion has been excised deeply, as the drainage patterns may have been altered by the previous procedure.

Question 8

When should preoperative lymphoscintigraphy be performed for melanoma?

Answer 8

It is imperative to obtain preoperative lymphoscintigraphy in areas with a high likelihood of aberrant drainage patterns. In the trunk, unpredictable drainage patterns can occur in 20 to 35% of cases.

Question 9

A 65-year-old Caucasian man comes to the office because of a dark, pigmented lesion on the thumb that he first noticed 3 months ago. There is no history of trauma to the digit. Physical examination shows a variegated lesion with asymmetrical borders in the germinal matrix of the nail bed of the right thumb. Which of the following is the most appropriate first step in management?
A ) Amputation to next joint
B ) Radiation therapy
C ) Shave biopsy
D ) Wide excision
E ) Observation

Answer 9

C ) Shave biopsy

This pigmented lesion in the patient described could be a post-traumatic subungual hematoma, benign nevus, or subungual melanoma, or benign melanonychia striata longitudinalis. Evaluation of a suspiciously pigmented lesion in the nail bed should commence with a shave biopsy of the lesion. The lesion has been present for 3 months and has not grown out to the sterile matrix; because the patient says there has been no previous trauma, further observation would be inappropriate.

Wide excision or amputation is not warranted until an attempt at diagnosis has been completed. T

Question 10

Evaluation of a suspiciously pigmented lesion in the nail bed should commence with:

Answer 10

Evaluation of a suspiciously pigmented lesion in the nail bed should commence with a shave biopsy of the lesion.

Question 11

Melanonychia striata longitudinalis

Answer 11

Benign streaks in the nail plate (melanonychia striata longitudinalis) are extremely common in African American patients and often occur spontaneously with advancing age.

Question 12

Core biopsy to evaluate nail bed lesion

Answer 12

Evaluation of a suspiciously pigmented lesion in the nail bed should commence with a shave biopsy of the lesion. A core biopsy of the germinal matrix could produce a nail bed and plate abnormality.
Furthermore, there is no need for a core biopsy to determine the depth of the lesion, as the histology and staging of the nail bed are different from the skin.

Question 13

How long does it take for the nail plate/matrix to grow to the tip after an injury?

Answer 13

After an injury, the nail plate and corresponding matrix grow to tip by 3 to 4 months.

Question 14

Nailbed: treatment for melanocytic hyperplasia without atypia

Answer 14

Melanocytic hyperplasia without atypia is considered benign and can be observed.

Question 15

Nailbed: atypia or melanoma in situ

Answer 15

The presence of atypia or melanoma in situ requires complete excision with clear margins. The wound is closed with a full-or split-thickness nail bed graft.

Question 16

Acral-lentiginous melanoma represent ___ of all cutaneous melanomas

Answer 16

Acral-lentiginous melanoma is found beneath the nail, on the palm of the hand, or on the sole of the foot. These lesions represent approximately 3% of all cutaneous melanomas.

Question 17

Prognosis of acral-lentiginous melanoma vs others

Answer 17

The prognosis for subungual melanomas is worse than for other cutaneous melanomas, probably because of delayin diagnosis.

Question 18

When symptoms occur with acral lentiginous melanoma, _____% have metastases

Answer 18

When symptoms occur, 25 to 30% of patients have metastases.

Question 19

Treatment of subungual hand melanomas

Answer 19

Treatment of subungual hand melanomas consists of amputation through the joint, just proximal to the lesion. Volar flaps are used for the closure of the defect.

Question 20

Special consideration when amputating for thumb - subungual hand melanoma

Answer 20

For lesions of the thumb, deepening the first space with local z-plasty is recommended to improve function.

Question 21

Which of the following additional findings in the patient shown is indicative of the most life-threatening syndrome? 
A ) Hydrocephalus 
B ) Large or multiple axial nevi 
C ) Posterior midline nevi
D ) “Satellite” nevi 
E ) Underdevelopment of a limb

Answer 21

A ) Hydrocephalus

Neurocutaneous melanosis connotes the association of a large axial CMN with the CNS involvement.

At least two thirds of those who present with or develop symptomatic CNS disease succumb to the disease process, either because of inexorable “benign” proliferation of melanocytes in the leptomeninges and brain or as a result of malignant degeneration.
Symptomatic hydrocephalus may necessitate the placement of a ventriculoperitoneal or ventriculojugular shunt. Unfortunately, following malignant transformation in the CNS, such shunts afford the malignant melanocytes ready access to the systemic circulation, leading to a rapid demise

Question 22

Congenital melanocytic nevi (CMN)

Answer 22

Congenital melanocytic nevi (CMN) are birthmarks that are present at birth or become apparent within the first year of life. They are found in 1% to 2% of the general population. CMN are one of several known risk factors for development of melanoma.

Question 23

Where do melanomas associated with congenital melanocytic nevus occur?

Answer 23

Interestingly, 50% of the melanomas that develop occur within the nevi, but the other 50% occur within the central nervous system (CNS) or within normal skin.

Question 24

What % of pediatric melanomas are associated with giant congenital melanocytic nevi

Answer 24

Despite significant increase in risk, giant CMN-associated melanomas still account for less than 3% of all pediatric melanomas

Question 25

Neurocutaneous melanosis

Answer 25

NCM connotes the association of a large axial CMN with the CNS involvement. CNS manifestations may present as hydrocephalus, seizures, focal deficits, or partial paresis. The majority of those children with NCM who manifest such problems do so before 2 years of age.

Question 26

Prognosis of neurocutaneous melanosis (displaying neurologic symptoms)

Answer 26

At least two thirds of those who present with or develop symptomatic CNS disease succumb to the disease process, either because of inexorable “benign” proliferation of melanocytes in the leptomeninges and brain or as a result of malignant degeneration.
Symptomatic hydrocephalus may necessitate the placement of a ventriculoperitoneal or ventriculojugular shunt. Unfortunately, following malignant transformation in the CNS, such shunts afford the malignant melanocytes ready access to the systemic circulation, leading to a rapid demise

Question 27

To identify which patients with congenital melanocytic nevi may have CNS involvement, a number of risk factors have been identified:

Answer 27

Presence of large or multiple axial CMN or both
Nevi on the posterior midline
Presence of multiple satellite nevi

MRI with gadolinium contrast has proved to be a particularly sensitive method for detecting the presence of CNS involvement by melanocytes in such patients. MRI can detect occult neurologic involvement even in infants who are clinically normal.

Question 28

A 42-year-old man has Clark Level III melanoma with a Breslow thickness of 1.5 mm in the concha of the right ear. Physical examination shows no other palpable masses. In addition to wide excision of the lesion, which of the following is the most appropriate step in management?
A ) Infraclavicular lymph node dissection
B ) Posterior neck dissection
C ) Sentinel lymph node biopsy
D ) Superficial parotidectomy
E ) Total parotidectomy with radical neck dissection

Answer 28

C ) Sentinel lymph node biopsy

Sentinel lymph node biopsy, which also serves to stage the extent of disease, is the most appropriate management after wide excision of the lesion. It is the most specific means of identifying regional lymph node spread. The sentinel node may be located in the parotid gland, the infraclavicular node, or some other part of the cervical chain of lymph nodes.

Question 29

A 9-month-old female infant has an 11-cm congenital melanocytic nevus. The patient is at greatest risk for malignant transformation of which of the following systems?
(A)Central nervous
(B)Endocrine
(C)Gastrointestinal
(D)Skeletal
(E)Urologic

Answer 29

(A)Central nervous

In addition to melanoma, patients with large, congenital melanocytic nevi are at increased risk for developing neurocutaneous melanocytosis, in which collections of melanocytes are present in the leptomeninges. Malignant transformation also can occur in neurocutaneous melanosis and result in primarycentral nervous system (CNS) melanoma. Even without malignant transformation, neurocutaneous melanosis can carry significant morbidity and mortality, often from seizures, hydrocephalus, and other signs of CNS irritation.

Question 30

Other than CNS melanoma, the incidence of _____________ is also increased in patients with large, congenital melanocytic nevi.

Answer 30

The incidence of rhabdomyosarcoma is also increased in patients with large, congenital melanocytic nevi.

Question 31

A 45-year-old man comes to the office because he has a one-year history of a dark streak on the nail of the thumb of the nondominant left hand. Biopsy of the specimen of involved nail bed tissue shows 1-mm-thick malignant melanoma. Which of the following is the most appropriate surgical intervention?
(A)Mohs micrographic surgery
(B)Wide soft-tissue excision
(C)Amputation at the interphalangeal joint
(D)Amputation at the mid metacarpal joint
(E)Ray amputation

Answer 31

(C)Amputation at the interphalangeal joint

The nail bed is unique because it is directly adherent to the underlying distal phalanx periosteum. Early studies recommended metacarpal or metacarpal ray amputations for invasive melanoma; however, recent studies have shown the efficacy of more conservative amputations without altering survival rate or local recurrence rate. Treatment goals are eradication of the tumor and preservation of function. Therefore, amputation at the level just proximal to the disease is recommended.

Question 32

Why is the nail bed unique for melanoma / aggressive treatment?

Answer 32

The nail bed is unique because it is directly adherent to the underlying distal phalanx periosteum.

Question 33

Which of the following percentages best represents the risk of transformation of a congenital giant nevus to malignant melanoma?
(A)10%
(B)20%
(C)30%
(D)40%
(E)50%

Answer 33

(A)10%

Although it is generally accepted that giant congenital nevi may undergo transformation to malignant melanoma, the exact incidence is difficult to determine, due in part to limitations in methodology of the available studies. Recent reports cite an incidence ranging from 2.9% to 12.2%

Question 34

Which giant congenital nevi are at greatest risk for malignant transformation?

Answer 34

Giant congenital nevi at greatest risk for transformation to melanoma are those lesions that have a predicted largest diameter of 20 cm in adulthood.

Question 35

What are the precursor lesions for malignant melanoma?

Answer 35

Congenital melanocytic nevi
Common acquired melanocytic nevi
Dysplastic nevi
Melanoma in situ

Question 36

Which of the following skin lesions meets criteria for sentinel lymph node biopsy (SLNBx)?
(A)Basal cell carcinoma (8 cm wide) on the anterior chest
(B)Melanoma (1.6 mm thick) of the breast with bulky axillary adenopathy
(C)Melanoma-in-situ on the shoulder
(D)Squamous cell carcinoma (1.8 cm wide) on the dorsum of the hand
(E)Squamous cell carcinoma (2 cm wide) in a 26-year-old burn scar of the foot

Answer 36

(E)Squamous cell carcinoma (2 cm wide) in a 26-year-old burn scar of the foot

Sentinel lymph node biopsy (SLNBx) is a well-established staging procedure for melanoma and breast cancer. A patient with melanoma in situ, by definition, does not have invasion and, therefore, would not benefit from SLNBx. Conversely, the patient with bulky adenopathy most likely has regional metastatic disease and requires formal lymphadenectomy. Indications for SLNBx in non-melanoma skin cancers are evolving and currently include squamous cell carcinoma greater than 2 cm in diameter, Merkel cell carcinoma, and Marjolin ulcer (burn scar carcinoma). Basal cell carcinomas almost never demonstrate lymphatic spread; therefore, SLNBx would not add any diagnostic information

Question 37

Basal cell carcinomas and SLNBx

Answer 37

Basal cell carcinomas almost never demonstrate lymphatic spread; therefore, SLNBx would not add any diagnostic information

Question 38

Non-melanoma skin cancers and SLNBx

Answer 38

Indications for SLNBx in non-melanoma skin cancers are evolving and currently include squamous cell carcinoma greater than 2 cm in diameter, Merkel cell carcinoma, and Marjolin ulcer (burn scar carcinoma)

Question 39

Melanoma in situ and SLNBx

Answer 39

A patient with melanoma in situ, by definition, does not have invasion and, therefore, would not benefit from SLNBx

Question 40

A 73-year-old man is referred to the office by his primary care physician for evaluation of discoloration of the nail of the left thumb, which has been present for the past seven years. The patient says the appearance of the nail has not changed recently. Biopsyof the nail matrix shows malignant melanoma of indeterminate depth. Which of the following surgical procedures is the most appropriate management?
(A)Elective lymph node dissection and amputation at the metacarpophalangeal joint
(B)Elective lymph node dissection and nail ablation
(C)Sentinel node biopsy and amputation at the level of the interphalangeal joint
(D)Sentinel node biopsy and excision of skin with 1-cm margins
(E)Sentinel node biopsy and ray amputation of the carpometacarpal joint

Answer 40

(C)Sentinel node biopsy and amputation at the level of the interphalangeal joint

Because of the proximity of the nail matrix to the periosteum and bone, adequate resection margins are not achieved with standard wide excision of 1 to 2 cm, and recommendation for excision is at the distal interphalangeal joint of the finger or interphalangeal joint of the thumb. Melanoma can track along the neurovascular bundles.
Sentinel node biopsy has become the standard of care, and since its advent, elective lymph node dissection is no longer recommended.

Question 41

Approximately _____% of subungual melanomas may be amelanotic.

Answer 41

Approximately 20% to 25% of subungual melanomas may be amelanotic.

Question 42

Amputation more proximal than the proximal joint for subungual melanoma

Answer 42

Amputation at a more proximal level is not needed and does not improve prognosis. Moreproximal amputation also results in a critical loss of function, particularly concerning the thumb.

Question 43

An area of pigmentation in the ________ is almost pathognomonic for subungual malignant melanoma.

Answer 43

An area of pigmentation in the eponychium is almost pathognomonic for subungual malignant melanoma.

Question 44

A 60-year-old man is diagnosed with melanoma of the forehead. In addition to wide local excision, in which of the following tumor stages is sentinel lymph node biopsy indicated?
(A)Tis N0 M0
(B)T2a N1 M0
(C)T2b N0 M0
(D)T3b N1 M0
(E)T4a N0 M1

Answer 44

(C)T2b N0 M0

Sentinel lymph node biopsy (SLNB) is the standard of care for intermediate-thickness melanoma, with clinically negative nodes.
T4 is a deep melanoma and is not appropriate for SLNBx.

Question 45

Importance of SLNB for melanoma

Answer 45

Guides adjuvant systemic protocols

Question 46

Sentinel lymph node biopsy (SLNB) is the standard of care for _______-thickness melanoma, with clinically negative lymph nodes

Answer 46

Sentinel lymph node biopsy (SLNB) is the standard of care for intermediate-thickness melanoma of the trunk and extremities and is recommended when possible for intermediate melanoma of the head and neck. SLNB is indicated in intermediate melanoma with lymph nodes that are clinically negative.

Question 47

Intermediate melanoma in the head and neck include stages _______:

Answer 47

Intermediate melanoma in the head and neck includes stages IB and II. In these stages, tumor characteristics include
T1b (Breslow thickness of less than 1 mm with ulceration, or Clark level of IV or V),
T2 (Breslow thickness of 1.01 to 2 mm)
T3 (Breslow thickness of 2.01 to 4 mm)

Question 48

T1b melanoma

Answer 48

T1b (Breslow thickness of less than 1 mm with ulceration, or Clark level of IV or V)

Question 49

T2 melanoma

Answer 49

T2 (Breslow thickness of 1.01 to 2 mm)

Question 50

T3 melanoma

Answer 50

T3 (Breslow thickness of 2.01 to 4 mm)

Question 51

T1a melanoma

Answer 51

A T1a tumor is a thin, less aggressive melanoma with a Breslow thickness of less than 1 mm without ulceration or a Clark level below III.

Because it is not yet intermediate, this tumor is not appropriate for SLNB.

Question 52

T4 melanoma

Answer 52

T4 tumor is a deep melanoma, with a Breslow thickness of more than 4 mm.

Question 53

A 6-month-old girl is brought to the office by her parents for consultation regarding a congenital melanocytic nevus covering one third of the back. Which of the following best represents the risk of malignant transformation of this nevus?
(A) 0% to 10%
(B) 30% to 40%
(C) 60% to 70%
(D) 90% to 100%

Answer 53

(A) 0% to 10%

Difficulty arises in assigning risk because the definition of these lesions is not standardized (large versus giant) and true long-term prospective studies are lacking.

Question 54

A 44-year-old woman undergoes narrow-margin, complete excision of a 1-cm lesion on the right forearm that has been present for several years and has only recently begun to change in color and appearance. The pathologist reports that the central portion of the lesion contains malignant melanoma with a depth of invasion of 2.2 mm with a clear margin. Patient history, physical examination, and laboratory studies are otherwise unremarkable. In addition to reexcision, which of the following is the most appropriate management?
(A) Observation
(B) Interferon therapy
(C) Sentinel lymph node biopsy
(D) Isolated limb perfusion
(E) Axillary lymphadenectomy

Answer 54

(C) Sentinel lymph node biopsy

This patient has malignant melanoma of intermediate thickness, which requires excision with a 2-cm margin and sentinel lymph node biopsy.

Question 55

What is the most important determinant of a melanoma’s clinical behavior?

Answer 55

Thickness, or depth of invasion

Question 56

Sentinel lymph node biopsy is advocated for lesions ______ mm

Answer 56

Sentinel lymph node biopsy is advocated for intermediate thickness lesions (1 to 4 mm).

Question 57

Positive SLN biopsies portend a worse diagnosis, warrenting ________

Answer 57

Positive biopsies portend a worse prognosis, warranting complete lymphadenectomy.

Question 58

Adjuvant therapy and increased melanoma survival

Answer 58

To date, no standard adjuvanttherapy has clearly increased overall survival in patients with malignant melanoma.

Question 59

Sentinel lymph node biopsy and patients with thick melanoma (>4 mm)

Answer 59

Sentinel lymph node biopsy has not been shown to improve survival in patients with thick melanoma (>4 mm); these patients have high rates of local and distant metastases.

Question 60

Management of patients with melanoma who have clinically palpable disease

Answer 60

Lymph node dissection is reserved for patients with clinically palpable disease.

Question 61

A 70-year-old man is referred for evaluation of a 2.2 x 1.3-cm pigmented lesion on the right side of the neck over the midsection of the sternocleidomastoid muscle. Punch biopsy shows lentigo maligna melanoma with a Breslow thickness of 0.6 mm. Wide surgical excision with a 1-cm margin is performed. A photograph is shown above. The specimen report upgrades the Breslow thickness to 1.2 mm. Further evaluation, including CT scan of the head, neck, chest, and abdomen, shows no associated metastases. Which of the following represents the amount of additional margin of excision that is needed for adequate local management of this lesion?
(A) No additional margin is necessary
(B) 0.5 cm
(C) 2 cm
(D) 3 cm
(E) 5 cm

Answer 61

(A) No additional margin is necessary

Question 62

Breslow thickness is measured from where to where?

Answer 62

Breslow thickness measured from the top of the granular layer to the deepest level of tumor is the single most important factor in the prognosis of melanoma.

Question 63

A study performed by the World Health Organization has shown that for melanomas less than 2 mm, a surgical margin of 1 cm is just as effective as a _____-cm margin

Answer 63

A study performed by the World Health Organization has shown that for melanomas less than 2 mm, a surgical margin of 1 cm is just as effective as a 3-cm margin

Question 64

A 70-year-old man has a T3 N0 M0 melanoma involving the skin of the preparotid region. In addition to wide local excision and superficial parotidectomy, which of the following is the most appropriate next step in the management of the regional lymph nodes? 
(A) Observation
(B) Prophylactic radiation therapy
(C) Sentinel node biopsy
(D) Modified radical neck dissection
(E) Radical neck dissection

Answer 64

(C) Sentinel node biopsy

Because this melanoma is of intermediate thickness and there are no palpable regional lymph nodes, it is classified as Stage II. In addition to local excision and superficial parotidectomy, sentinel node biopsy is currently recommended to rule out the presence of micrometastases in patients with these lesions.

Question 65

Approximately _______% of patients with melanomas of intermediate thickness and no palpable lymph nodes in the neck have subclinical nodal micrometastases

Answer 65

Approximately 30% to 40% of patients with melanomas of intermediate thickness and no palpable lymph nodes in the neck have subclinical nodal micrometastases.

(Performing elective lymph node dissection in all of these patients, without identifying those who would benefit most, would subject the remaining 60% to 70% who do not have demonstrable micrometastases to unnecessary morbidity without increasing survival advantage. Sentinel lymphadenectomy using vital blue dye and radiocolloid for mapping can be performed to identify the subgroup in which regional lymphadenectomy should be performed.

Although prophylactic radiation therapy has been shown to produce benefits similar to elective lymph node dissection in patients with tumors of intermediate thickness, it subjects approximately 66% of patients to unnecessary morbidity.)

Question 66

When is neck dissection for melanoma indicated?

Answer 66

Neck dissection is indicated for patients with stage II tumors who have micrometastases identified via sentinel lymphadenectomy and in patients who have stage III melanoma. The dissection should include levels I through V as well as any other nodal groups that may be at risk.

Question 67

A 68-year-old man has the lesion shown in the photographs above. A satellite lesion is noted 2 cm from the primary lesion. Findings on laboratory studies and radiographs of the chest are normal. Histologic examination of a biopsy specimen of the primary tumor shows findings consistent with Clark's level IV melanoma. The tumor has a Breslow's thickness of 2.8 mm. There is no palpable adenopathy or distant metastases. According to the American Joint Committee on Cancer, which of the following is the correct clinical classification stage of this tumor?
(A) Stage 0
(B) Stage I
(C) Stage II
(D) Stage III
(E) Stage IV

Answer 67

(D) Stage III

This patient’s tumor is classified as T4 N0 M0, or Stage III.

Breslow’s thickness typically takes precedence over Clark’s level in the classification of melanoma; however, because this patient has a satellite lesion, which represents a more advanced level of disease, the tumor is classified as T4.

Question 68

How are satellite lesions defined in melanoma? versus farther lesions?

Answer 68

Satellite lesions, defined as those lesions located within 2 cm of the primary tumor, affect tumor classification.
In contrast, secondary lesions farther than 2 cm from the primary tumor are considered in-transit metastases, which influence nodal classification.

Question 69

Which of the following is associated with invasive malignant melanoma?
(A) Actinic keratosis
(B) Bazex syndrome
(C) Erythroplasia of Queyrat
(D) Nevus sebaceus of Jadassohn
(E) Xeroderma pigmentosum

Answer 69

(E) Xeroderma pigmentosum

Although all of the lesions listed are premalignant, only xeroderma pigmentosum is likely to develop into invasive malignant melanoma. In patients who have this autosomal recessive condition, the skin is intolerant to ultraviolet light. Pigmentary changes result from absence of DNA repair mechanisms; affected patients develop freckling and thickening of the skin, with atrophy of the subcutaneous tissues. Malignant tumors, including melanoma, frequently develop in patients younger than 10 years. Appropriate management includes minimal sun exposure and topical sun protection

Question 70

Heredity of xeroderma pigmentosum

Answer 70

Autosomal recessive

Question 71

Actinic keratoses

Answer 71

Actinic keratoses are common premalignant lesions that occur following excessive exposure to sunlight. These lesions appear flesh colored to brown and are rough and scaly with discrete erythematous borders. If untreated, 10% of patients will develop squamous cell carcinoma.

Question 72

Treatment of actinic keratoses

Answer 72

5-fu or surgical excision

Question 73

Bazex syndrome

Answer 73

Bazex syndrome is an X-linked, autosomal dominant condition that manifests as follicular atrophoderma with multiple basal cell carcinomas. Hypotrichosis and hypohidrosis are associated.

Question 74

Bazex syndrome heredity

Answer 74

X-linked autosomal dominant

Question 75

Erythroplasia of Queyrat

Answer 75

Erythroplasia of Queyrat is also known as Bowen’s disease of the mucous membranes, or squamous cell carcinoma in situ. These bright red, velvety lesions affect the glans penis and prepuce, and occur less often on the vulva.

Question 76

Erythroplasia of Queyrat treatment

Answer 76

Conservative excision is recommended.

Question 77

Nevus sebaceus of Jadassohn

Answer 77

Nevus sebaceus of Jadassohn is a lesion affecting the head and neck region that is present at birth and enlarges gradually. Because 10% to 15% of patients with this condition will eventually develop basal cell carcinoma, excision should be performed before the patient reaches puberty.Malignant adnexal tumors such as apocrine carcinoma occur infrequently.

Question 78

Treatment of Nevus sebaceus of Jadassohn

Answer 78

Because 10% to 15% of patients with this condition will eventually develop basal cell carcinoma, excision should be performed before the patient reaches puberty.
(Malignant adnexal tumors such as apocrine carcinoma occur infrequently.)

Question 79

An 18-month-old boy has a 25-cm pigmented lesion on his back. Which of the following is the most appropriate management?
(A) Observation with photographic mapping
(B) Intralesional injection of interferon gamma
(C) Dermabrasion
(D) Tunable dye laser ablation
(E) Excision

Answer 79

(E) Excision

Because of the potential for malignant transformation, surgical excision of the entire lesion is recommended.

Question 80

Hutchinson's freckle is another name for which of the following types of melanoma? 
(A) Acral-lentiginous
(B) Lentigo maligna
(C) Mucosal
(D) Nodular
(E) Superficial spreading

Answer 80

(B) Lentigo maligna

Hutchinson’s freckle is a misleading term for lentigo maligna melanoma, a melanoma in situ that is found within the layers of the epidermis only. This lesion typically occurs in fair-skinned, elderly persons and manifests as a macule or patch of darkened skin on the face or other sun-exposed areas.

Question 81

Natural history of lentigo melanoma

Answer 81

The risk for development of invasive melanoma in affected patients has been shown to range from 5% to 30% in various studies. Slow growth, often for a period of 10 to 20 years, is common initially and is then followed by an aggressive, invasive phase

Question 82

What percent of melanoma is lentigo?

Answer 82

5% to 10% of all melanomas can be classified as lentigo maligna

Question 83

Hutchinson’s freckle

Answer 83

Hutchinson’s freckle is a misleading term for lentigo maligna melanoma, a melanoma in situ that is found within the layers of the epidermis only. This lesion typically occurs in fair-skinned, elderly persons and manifests as a macule or patch of darkened skin on the face or other sun-exposed areas.

Question 84

A 42-year-old woman has a pigmented matrix lesion on the index finger. Biopsy of the lesion shows a subungual melanoma. Which of the following is the most appropriate management?
(A) Ablation of the nailbed and matrix resurfacing with skin grafting
(B) Amputation at the distal interphalangeal joint
(C) Amputation at the proximal interphalangeal joint
(D) Ray amputation

Answer 84

(B) Amputation at the distal interphalangeal joint

Question 85

Survivor rate for subungual melanoma

Answer 85

Studies have reported a five-year survival rate of 66% in patients diagnosed with subungual melanoma

Question 86

A 13-year-old boy has a pigmented, slightly raised nevus on the thigh. He has no history of malignant tumors and there is no family history of melanoma. Histologic examination of an excisional biopsy specimen of the lesion shows findings consistent with juvenile melanoma; the surgical margins are free of tumor. Which of the following is the most appropriate next step?
(A) No additional treatment
(B) Referral to an oncologist for chemotherapy
(C) Interferon therapy
(D) Isolated limb perfusion
(E) Wide local excision

Answer 86

(A) No additional treatment

Benign juvenile melanoma is referred to by many terms, including Spitz nevus, spindle cell nevus, and epithelioid nevus. This solitary tumor istypically pink to red in color and is most likely to appear on the face in childhood. Although it can be initially mistaken for melanoma, histologic examination of a biopsy specimen will show giant spindle cells; it is believed to be a histologic variant of the compound nevus. Because it is benign, conservative treatment or complete excision is recommended.

Question 87

Benign juvenile melanoma

Answer 87

Benign juvenile melanoma is referred to by many terms, including Spitz nevus, spindle cell nevus, and epithelioid nevus. This solitary tumor istypically pink to red in color and is most likely to appear on the face in childhood. Although it can be initially mistaken for melanoma, histologic examination of a biopsy specimen will show giant spindle cells; it is believed to be a histologic variant of the compound nevus. Because it is benign, conservative treatment or complete excision is recommended.

Question 88

Presentation of benign juvenile melanoma

Answer 88

This solitary tumor istypically pink to red in color and is most likely to appear on the face in childhood.

Question 89

Histology of benign juvenile melanoma

Answer 89

Although it can be initially mistaken for melanoma, histologic examination of a biopsy specimen will show giant spindle cells; it is believed to be a histologic variant of the compound nevus

Question 90

The above photograph is of a 75-year-old woman who has a discolored 4-mm lesion of the nail bed of the nondominant left thumb after undergoing removal of the nail plate for management of chronic paronychia. A biopsy specimen of the lesion shows subungual melanoma with a thickness of 3 mm. The above MRI shows possible tumor tracking along the ulnar neurovascular bundle. Lymphoscintigraphy shows two positive nodes in the axilla. Which of the following is the most appropriate level of amputation?
(A) Carpometacarpal joint
(B) Metacarpal diaphysis
(C) Metacarpophalangeal joint
(D) Proximal phalanx diaphysis
(E) Interphalangeal joint

Answer 90

(D) Proximal phalanx diaphysis

xcisional biopsy should be performed immediately to distinguish this type of tumor from squamous cell carcinoma, basal cell carcinoma, pyogenic granuloma, glomus tumor, or giant cell tumor.

Question 91

Clark’s level for subungual melanoma

Answer 91

A Clark’s level cannot be determined in patients with subungual melanoma because of theabsence of subcutaneous tissue within the nail matrix.

Question 92

A 67-year-old man with a large lentigo maligna on the left cheek comes to the office for closure after undergoing excision. Which of the following steps is most appropriate for the surgeon prior to performing a cervical-facial rotation flap?
A) Await permanent pathology results
B) Confirm negative margins by Mohs micrographic surgery
C) Evaluate the margins clinically with a Wood lamp
D) Perform confocal microscopy
E) Refer the patient for sentinel node biopsy

Answer 92

A) Await permanent pathology results

Lentigo maligna is a slow-growing lesion with a substantial radial growth pattern before progressing to invasion in most cases. These lesions often occur in the head and neck region of older patients with a history of sun exposure. Clinical occurrence is variable, but many appear as irregular, sometimes extensive, pigmented patches on the face. Staging of these lesions follows the American Joint Committee on Cancer guidelines, and prognosis is based on depth of invasion. Need for sentinel node biopsy is based on staging and is independent of resection size.

Wide local excision of the lesion is the current standard of care, but the surgical margin for successful excision remains controversial. Alternative techniques have been investigated to improve the 8 to 20% recurrence rates associated with standard excision with 5-mm margins. Mohs micrographic surgery shows promise in the treatment of this disease, but there remains difficulty in interpretation of melanocyte proliferation on frozen section, leading to the proposal of modifications of the procedure, including sending the final Mohs margins for rush permanent section evaluation for verification of clear margins, the so-called “slow Mohs.”

Clinical evaluation of margins with Wood lamp may be useful in evaluating the clinical extent of the lesion but is not adequate for determination of surgical margins. Confocal microscopy is a new technique that allows examination of melanocytes without biopsy. This modality may be useful in diagnosis of lentigo maligna, but availability is currently limited and requires training in interpretation of images.

Question 93

An 89-year-old man comes to the office because of a 2-year history of a pigmented lesion of the left cheek. The patient has an extensive history of sun exposure but no history of skin malignancy. On examination, the lesion is flat and light brown with irregular borders, but has no nodularity or ulceration. Examination of a specimen obtained on punch biopsy shows lentigo maligna. Which of the following is the most appropriate treatment?
A) Cryotherapy with liquid nitrogen
B) External beam radiation
C) Laser ablation
D) Resection with 1-cm margins
E) Topical treatment with imiquimod

Answer 93

D) Resection with 1-cm margins

Lentigo maligna is melanoma in situ that primarily occurs in elderly patients with a history of extensive sun exposure. It represents 4 to 15% of all melanomas and is slow-growing in a radial phase, but can progress to lentigo maligna melanoma with invasion and metastatic potential.

Surgical resection remains the standard of care for treatment of lentigo maligna. In 1992, the National Institutes of Health Consensus Conference on Melanoma recommended a 5-mm margin for excision of lentigo maligna. However, the use of 5-mm margins has been associated with recurrence rates of 8 to 20%. In 2008, the National Cancer Comprehensive Network released guidelines indicating that 5-mm margins may be inadequate for treatment of lentigo maligna. The use of a staged excision technique has shown that 10-mm margins or greater were required in a majority of patients and resulted in low (1.7%) recurrence rates at 2 years.

Nonsurgical modalities have been investigated in the treatment of this lesion, as they tend to occur in elderly patients who may not be surgical candidates. Nonsurgical treatments are associated with recurrence rates of 20 to 100%, with laser ablation associated with the highest recurrence rates. Topical imiquimod has shown promise, but data is limited, and long-term cure rates are unknown at this point.

Question 94

An 88-year-old woman comes to the office because of the 2-cm pigmented lesion on the vertex of the scalp shown. There is no evidence of cervical or suboccipital lymphadenopathy. Examination of a specimen obtained on punch biopsy shows a Breslow thickness of 2.1 mm, Clark Level IV, two mitotic figures per high-power field, and no evidence of ulceration. Which of the following is the most appropriate management?
A) Excision with 1-cm margins and bilateral cervical lymphadenectomy
B) Excision with 2-cm margins and delayed sentinel lymph node biopsy
C) Excision with 3-cm margins and bilateral cervical lymphadenectomy
D) Preoperative lymphoscintigraphy, excision with 1-cm margins, and immediate sentinel lymph node biopsy
E) Preoperative lymphoscintigraphy, excision with 2-cm margins, and immediate sentinel lymph node biopsy

Answer 94

E) Preoperative lymphoscintigraphy, excision with 2-cm margins, and immediate sentinel lymph node biopsy

In the patient described with an intermediate thickness tumor (1–4 mm) and clinically negative neck, the most appropriate treatment is wide excision with 2-cm margins (shown) and a concurrent sentinel lymph node biopsy. The defect may be reconstructed with a local flap or skin graft depending on patient and surgeon preference. In Stage I and II melanomas (localized disease T1-4, and no evidence of regional lymphadenopathy, N0), Breslow tumor thickness is the most important predictor of local recurrence, regional/distant metastases, and overall survival.

Current recommended excisional margins are 0.5 to 1.0 cm for melanoma in situ/lentigo maligna. For invasive lesions less than 1 mm thick, a 1-cm margin is adequate. Lesions with Breslow thickness of 1 to 2 mm should be resected with a 1- to 2-cm margin, using closer to 2 cm when the anatomical area is more forgiving (scalp/trunk), the thickness approaches 2 mm, or the lesion displays more aggressive histopathologic features, such as ulceration, lymphovascular invasion, tumor regression, or a mitotic index greater than one figure per high-power field. Lesions between 2 to 4 mm are adequately treated with 2-cm margins. Balch, et al., have shown that 2-cm margins are safe for lesions of intermediate thickness with equivalent survival rates, less use of skin grafting, shorter hospital stays, and lower medical costs when compared with more aggressive peripheral margins. When possible, 3-cm margins should be used for tumors greater than 4 mm thick because of their high local recurrence rate (greater than 20%).

Patients with intermediate-thickness melanomas have a 20 to 25% chance of microscopic regional disease. Before the advent of sentinel lymph node biopsy, elective lymphadenectomy (ELD) was advocated for patients with intermediate-thickness melanoma because of a significant improvement in overall survival at 10 years. The primary disadvantage of routine ELD, however, was that approximately 75 to 80% of patients underwent an unnecessary procedure.

The status of the sentinel lymph node is a powerful predictor of survival in melanoma because it identifies (1) those patients with a relatively favorable prognosis requiring no further therapy; and (2) high-risk patients who might benefit from additional surgery (completion lymphadenectomy) and interferon. Current indications for sentinel lymph node biopsy include all of the following: male patients with truncal melanoma less than 0.76 mm thick (9% incidence of nodal metastasis); all patients with melanoma thickness 0.76 to 1.0 mm (5% incidence of nodal metastasis); male patients with “thin” melanomas with aggressive features (Clark Level III or greater, ulcerated, evidence of regression, or axial location; these patients have a 10% risk of metastasis); and all melanomas greater than 1 mm in thickness.

In the scenario described, 1-cm margins would be too narrow. A 3-cm margin is excessive for the lesion described. As noted, elective lymphadenectomy has been replaced with sentinel lymph node biopsy in a clinically negative neck. Finally, sentinel lymph node biopsy should be performed at the time of the primary tumor resection if possible due to variations in the lymphatic drainage that may occur after wide excision, skin grafting, or flap closure.

Question 95

A 40-year-old, right-hand-dominant man comes to the office because of a 2-mm pigmented lesion beneath the thumbnail of the left hand. He says that he first noticed the lesion within the last week. The patient recalls no trauma to the thumb. He has no other fingernails or toenails with similar streaking. Biopsy of a subungual lesion is most appropriate after which of the following periods of time has passed without change?
A) 0 to 3 Weeks
B) 4 to 6 Weeks
C) 7 to 9 Weeks
D) 10 to 12 Weeks
E) 13 to 15 Weeks

Answer 95

B) 4 to 6 Weeks

The prognosis for a subungual melanoma is worse than that of cutaneous melanoma. Often, there is a delay in the diagnosis of subungual melanomas; in practice, it is better to be highly suspicious of any pigmented lesion beneath the nail and perform a biopsy. According to recent research, the 5-year survival rate for a patient with a subungual melanoma ranges from 28 to 30%. The 10-year survival rate drops to 0 to 13%. Clearly, this is a devastating disease, and over-vigilance regarding diagnosis is recommended. The current recommendation is to perform a biopsy of any subungual lesion after 4 to 6 weeks without significant change.

Question 96

A healthy 8-year-old girl is brought to the office because of a 15-cm congenital nevus of the buttock and thigh. Which of the following is the most appropriate recommendation to the parents for management?
A ) Alexandrite laser treatment
B ) Punch biopsy
C ) Serial excision starting at age 21 years
D ) Tissue expansion and excision
E ) Observation for 3 to 6 months

Answer 96

D ) Tissue expansion and excision

While the overall lifetime risk of congenital nevomelanocytic lesions is estimated in the 5 to 12% range, giant nevi tend to transform earlier. Some studies suggest that 50% of the malignancies that do develop in large nevi do so by age 3 years, and 70% occur by puberty. Giant nevi are classified as lesions over 20 cm in adults, or lesions in children that are estimated to reach 20 cm by full growth (9 cm on the head, 6 cm on the body). Patients with giant congenital nevi are estimated to have a 51% increased risk of developing melanoma. Another study showed a 5-year malignant melanoma transformation rate of 5.1%.

Given this propensity for malignant transformation, many authors advocate early aggressive treatment of giant nevi, starting at age 6 months. Serial excision, skin grafting, cultured epidermal autografts, and dermal regeneration templates (Integra) have all been described as treatments. In older patients, rotation and free flaps can be incorporated as needed.

Alexandrite lasers have not been advocated for nevi. Studies of ruby and carbon dioxide lasers have mixed results, some showing adequate lesion destruction and cosmesis, others with high rates of hypertrophic scarring.

Observation may be appropriate for smaller congenital nevi, though in this patient, at this age, the melanoma risk is sufficient to warrant intervention. Over 3 to 6 months, one would not expect clinically significant changes. Indeed, many would have urged earlier treatment. Waiting until age 21 years would also be inadvisable.

Punch biopsy is useful for surveillance of smaller lesions, though it may not be representative of a large lesion, and could possibly yield false-negative results.

Question 97

A 45-year-old woman comes to the office with a history of a 4.1-mm irregular black lesion of the left leg. Excisional biopsy was performed by her primary physician with a 1-mm margin. The pathology result reveals a 1.8-mm thick ulcerated malignant melanoma. A wide local excision is planned. Which of the following is the most appropriate excision margin for this lesion?
A ) 0.5-cm margin
B ) 1-cm margin
C ) 2-cm margin
D ) 3-cm margin
E ) 5-cm margin

Answer 97

C ) 2-cm margin

The diameter of the melanoma described is not taken into account for the wide local excision that is to be performed. Wide local excision surgical margins are determined by the thickness of the tumor, not the diameter. An in situ melanoma would require a 0.5-cm margin. Melanomas with a depth of less than 1 mm (thin) require a 1-cm margin. Lesions between 1 and 4 mm (intermediate thickness) require a 2-cm margin. If the depth is greater than 4 mm (thick), a 2- to 3-cm margin is necessary. Intermediate melanomas (those of a 1- to 4-mm depth) had previously required a 4-cm margin of resection. In a landmark article in 1993, Balch, et al. recommended a 2-cm margin for intermediate-depth melanomas. Another landmark article in 1998 by Heaton, et al. advocated surgical margins of 2 cm for patients with thick melanoma.

Question 98

A 32-year-old man with a history of self-inflicted gunshot wound is evaluated because of significant facial deformity despite multiple complex reconstructive procedures. Composite tissue allotransplantation is performed. One episode of rejection is successfully treated 4 weeks postoperatively. Three months postoperatively, the patient develops recurrent swelling and hyperemia of the facial skin. Which of the following is the most likely cause of this condition?
A) ABO incompatibility
B) Acute rejection
C) Antibody incompatibility
D) Chronic rejection
E) Hyperacute rejection

Answer 98

B) Acute rejection

The most likely diagnosis is acute rejection, because this patient is still in the early postoperative period when acute rejection is most likely to occur (0 to 3 months). ABO incompatibility and antibody incompatibility would result in hyperacute rejection, which is mediated by the humoral immune system and occurs within minutes of transplantation. Chronic rejection occurs after years and is characterized by vasculopathy and fibrosis.

Question 99

A 36-year-old man with traumatic injuries, who is intubated and sedated in the intensive care unit, is noted to have extravasation of concentrated calcium solution from a peripheral access intravenous line. The consult is made immediately after extravasation. Which of the following is the most appropriate management of this injury?
A) Intravenous administration of dexrazoxane
B) Local injection of hyaluronidase
C) Phentolamine infiltration
D) Topical application of dimethyl sulfoxide
E) Topical application of heat

Answer 99

B) Local injection of hyaluronidase

Hyaluronidase is an enzyme that breaks down hyaluronic acid, a mucopolysaccharide that is a normal component of the interstitial fluid barrier. It has been shown to increase the rate of absorption of an injected substance by facilitating diffusion of the substance over a large area. When injected locally within 1 hour of extravasation, it breaks down hyaluronic acid and decreases the viscosity of the extracellular matrix, and facilitates absorption and dispersal of the extravasated chemical.

The ischemic effects of extravasated vasoconstrictive agents such as norepinephrine and dopamine may be reversed with local infiltration of phentolamine, which is an alpha-blocking agent. Topical heat application has been recommended in vinca alkaloid extravasation to promote local circulation and speed up clearance of the extravasated agent. Topical cooling in animal models has been demonstrated to increase ulcer formation.

Dexrazoxane has been shown to antagonize the effects of several topoisomerase II poisons such as anthracycline agents, including doxorubicin. Recent clinical trials in Europe have demonstrated its efficacy in minimizing tissue damage from anthracycline extravasation if administered intravenously within 6 hours of extravasation. It is now the recommended initial treatment of anthracycline extravasation, especially in light of its FDA approval in 2007.

Dimethyl sulfoxide (DMSO) is a free radical scavenger and an effective solvent. It may also have antibacterial, anti-inflammatory, and vasodilatory properties. Its topical application is effective in preventing ulcerations caused by doxorubicin extravasation.

Question 100

A 30-year-old woman who underwent uneventful abdominoplasty is evaluated 2 weeks postoperatively because of midline wound dehiscence with tissue necrosis. She reports that she did not stop smoking before surgery as instructed. A photograph is shown. Which of the following mechanisms is the most likely cause of the delayed wound healing?

A) Decreased catecholamine production
B) Decreased hemoglobin concentration
C) Decreased leukocyte function
D) Increased fibrinogen production
E) Increased microvascular vasoconstriction

Answer 100

E) Increased microvascular vasoconstriction

Cigarette smoking is a leading cause of preventable death and disability in the United States. Over the past 20 years, several studies have demonstrated an increased risk of postoperative complications following plastic surgical procedures, including rhytidectomy, breast reconstruction, digital replantation, muscle flaps, and body-contouring procedures. Tobacco smoke is a complex mix of particulate matter, volatile acids, and gases. There are over 4000 different compounds in cigarette smoke, many of which are toxic, mutagenic, and carcinogenic. Tobacco-induced vasoconstriction is mediated directly and indirectly by nicotine, a colorless, odorless, and poisonous alkaloid.

Increased cellular levels of nicotine cause direct microvascular vasoconstriction. Indirect pathways of vasoconstriction include the enhancement of thromboxane A2 and stimulation of catecholamine release. Random skin flaps such as abdominoplasty, rhytidectomy, and mastectomy flaps are predominantly supplied by the subdermal plexus, which is very sensitive to sympathomimetic agonists such as catecholamines.

Smoking also increases carboxyhemoglobin levels, which shifts the oxygen-hemoglobin saturation curve to the left. The net result is decreased oxygen-carrying capacity by direct competitive inhibition from carbon monoxide. Other effects caused by smoking include decreased prostaglandin I2 (prostacyclin) production, increased platelet aggregation and blood viscosity, decreased collagen production, decreased red blood cell deformability, increased fibrinogen production, and decreased leukocyte function (mediated by hydrogen cyanide). The net effect is a prothrombogenic state with impaired inflammation that also contributes to slow wound healing. Although fibrinogen production is increased and leukocyte function is decreased, the primary mechanism by which wound healing is impaired is related to the nicotine-induced vasoconstriction of the subdermal plexus.

Rhytidectomy patients who smoke are 12.5 times more likely to develop skin necrosis compared with patients who do not smoke. One study showed a 47.9% rate of wound-healing problems in abdominoplasty patients who smoked compared with 14.8% in those who did not smoke. Another large study of patients undergoing breast reconstruction using a free transverse rectus abdominis musculocutaneous (TRAM) flap showed no difference in free flap survival in those patients who smoked, but the smoking population had a significantly higher rate of mastectomy skin flap loss, abdominal donor-site complications, and hernias. Current recommendations for smokers who desire elective cosmetic surgery are to avoid smoking and all nicotine products for 4 weeks before and after surgery.

Question 101

A 45-year-old man sustains a facial laceration and develops a keloid scar. Compared with a hypertrophic scar, this patient’s scar is most likely to have which of the following characteristics?
A) Decreased fibroblast density
B) Increased fibroblast proliferation rates
C) Increased ratio of type III to type I collagen
D) Regression of the scar over time
E) Smaller and thinner collagen fibers

Answer 101

B) Increased fibroblast proliferation rates

Hypertrophic scars generally arise during the first few weeks following the initial scar, grow rapidly, and then regress. On the other hand, keloid scars appear later following the initial scar, and then gradually proliferate, often indefinitely.

Both keloid and hypertrophic scars demonstrate increased fibroblast density.

Keloid scars demonstrate increased fibroblast proliferation rates compared with hypertrophic scars.

Keloid scars demonstrate a decreased ratio of type III to type I collagen. This is not observed in hypertrophic scars.

Keloid scars demonstrate thicker, larger, and more randomly oriented collagen fibers compared with hypertrophic scars.

Question 102

A 10-year-old boy underwent removal of a pigmented nevus from his scalp 2 weeks ago with suture closure. The tensile strength of the incision line today is most likely which of the following percentages of its final strength?
A) 10%
B) 20%
C) 40%
D) 60%
E) 80%

Answer 102

A) 10%

The tensile strength of a skin incision 2 weeks following repair is approximately 10%. Classic studies by Madden and Peacock showed that a cutaneous wound achieves 5% of its ultimate strength after 1 week, 10% after 2 weeks, 20% after 3 weeks, 40% after 4 weeks, and 80% after 6 weeks. The scar has its full strength 12 weeks after repair.

Question 103

An 87-year-old woman with a history of squamous cell carcinoma on the left lower extremity comes for evaluation because of the ulcer shown in the photograph. When the tumor did not resolve 9 months ago, she underwent radiation therapy for 4 weeks followed by excision. All margins were negative. Coverage of the wound with a split-thickness skin graft 6 months ago was not successful. Physical examination shows an ulcerated area over the anterior compartment. There is moderate fibrinous debris within the ulcer. Which of the following is the most likely underlying cause of the impeded wound healing?

A) Decreased vascularity
B) Elevated oxygen tension
C) Enhanced angiogenesis
D) Fibroblast hyperplasia
E) Peripheral margin hypokeratosis

Answer 103

A) Decreased vascularity

Radiation therapy produces many changes in the skin, whether it is directed at the skin, such as for skin cancer, or directed at deeper structures. Direct damage to blood vessels in the wound bed (obliterative endarteritis) produces decreased oxygen tension. Unlike nonirradiated wounds, radiated wounds do not respond with increased angiogenesis. Decreased breaking strength of radiated wounds is caused by both edema of collagen bundles and direct injury to the fibroblasts that would otherwise repair them. Radiated wounds have hyperkeratotic edges, which impair both contraction and keratinocyte migration.

Question 104

A 60-year-old woman is seen in the hospital for a pressure ulcer in the lumbar region. A photograph is shown (ischial with necrotic fat base). A sponge for negative pressure wound therapy is about to be applied directly to the wound. Which of the following is the most likely complication of this therapy in this patient?
A) Enterocutaneous fistula
B) Excessive bleeding
C) Excessive wound drainage
D) Infection
E) Retained sponge in wound

Answer 104

D) Infection

Infection due to retained necrotic tissue would be the most likely complication in this patient. The vacuum-assisted negative pressure wound closure device should not be used in place of good wound care principles such as debridement.

Use of negative pressure wound therapy has been used for pressure ulcers, open abdomen, traumatic extremity wounds, chest wounds, burns, and skin grafts. Negative pressure wound therapy works through mechanisms that include fluid removal, drawing the wound together, microdeformation, and moist wound healing. Several randomized clinical trials support the use of negative pressure wound therapy in certain wound types. Serious complications include bleeding and infection.

Negative pressure wound therapy devices should be used with caution in infected wounds. They should not be used until the wounds are adequately debrided. This wound has not been adequately debrided and negative pressure wound therapy should not be used until necrotic tissue has been removed.

Bleeding is the next most common complication, but is usually seen in anticoagulated patients and after debridement. Use of a conventional gauze dressing for several hours after a debridement before placing a sponge-based negative-pressure wound therapy device may decrease the risk of excessive bleeding. Most significant bleeding has occurred secondary to disruption of major vessel grafts, cardiac bypass grafts, or the ventricle itself when sponges are placed directly on the structures. This wound is not near any major blood vessels.

Use of a single sponge or a long roll of gauze within any deep wounds is recommended to avoid retained foreign bodies.

Negative pressure wound therapy has been used to control wound drainage. Increased drainage would be caused by the lack of debridement and infection.
Even in clean wounds, a recent report on abdominal wound closure found the most likely complication to be infection rather than recurrent hernia or enterocutaneous fistula. This wound is on the back and would not be likely to have an enterocutaneous fistula. Although initially contraindicated for use with enterocutaneous fistula, recent reports have shown its use to be safe and effective in selected cases.

Question 105

A 56-year-old woman who has been undergoing treatment for breast cancer has pain around the port site 6 hours after the extravasation of paclitaxel from a subcutaneous tunneled subclavian vein catheter. The patient is hemodynamically stable and breathing comfortably. Moderate swelling and tenderness are observed between the port and clavicle. Which of the following is the most effective management?
A) Application of calcium gluconate gel
B) Application of topical collagenase
C) Line change over a wire
D) Line removal and observation
E) Operative debridement

Answer 105

D) Line removal and observation

This patient has paclitaxel extravasation due to a malpositioned or leaking catheter with minimal symptoms; therefore, removal of the line and observation is warranted. Calcium gluconate gel is indicated after generously washing areas exposed to hydrofluoric acid as it neutralizes the fluoride ion. Topical collagenase is indicated in wounds with limited tissue necrosis and thus has no role in this patient. Changing this patient’s line over a wire is contraindicated as the catheter is either malpositioned or broken. Although operative debridement is sometimes indicated in extravasation injuries, it is unusual, and expectant management is the norm. As this patient has no acute signs of compartment syndrome or tissue necrosis, line removal and observation are indicated.

The incidence of extravasation is 0.01 to 6%. Chemotherapeutic agents that cause reactions are classified as irritants or vesicants. Irritants cause immediate and typically limited local reactions such as erythema, warmth, and tenderness. Common irritants are: bleomycin, carboplatin, carmustine, cisplatin, dacarbazine, etoposide, ifosfamide, and thiotepa. Vesicants can cause erythema, blistering, and skin necrosis. Itching in the absence of pain is common. In addition, vesicants can cause delayed ulceration that is self-perpetuated when the vesicant is rereleased upon lysis of affected cells. Common vesicants are: dactinomycin, daunorubicin, epirubicin, idarubicin, mechlorethamine, mitomycin, mitoxantrone, paclitaxel, vinblastine, vincristine. Paclitaxel is derived from the bark of the Pacific yew tree and induces microtubular assembly and stabilization, which leads to cell death. It is a vesicant, and if extravasation occurs, symptoms can range from localized pain, swelling, and erythema to severe skin necrosis and ulceration requiring surgical debridement. The vast majority of extravasations are managed non-operatively.

Question 106

A 55-year-old woman who is wheelchair-bound has a stage IV ischial pressure ulcer. She has a history of systemic lupus erythematosus and multiple sclerosis. Medications include prednisone and gabapentin. BMI is 21 kg/m2 and has been stable for the past year. White blood cell count is 10.5 × 109/L, hematocrit is 30%, and serum albumin concentration is 3.6 mg/dL. After debridement of nonviable tissue, wound care is instituted. Supplementation with which of the following is most likely to promote wound healing?
A) Echinacea
B) Ferrous gluconate
C) Glutamine
D) Lipid emulsion
E) Vitamin A

Answer 106

E) Vitamin A

Vitamin A is essential because it promotes epithelialization in collagen synthesis for wound healing, and supplementation is advocated in patients on chronic corticosteroid immunosuppressive medications such as prednisone. A 20,000-IU daily dosage can be useful for wound healing in immunosuppressed or irradiated patients and appears to reverse the wound healing–suppressive effects of the medication.

Patients with chronic wounds frequently have some form of malnutrition that can impede the wound-healing process. In this case, the patient has a serum albumin concentration within the reference ranges, and a stable BMI, signifying adequate protein. In protein-deprived patients, supplementing amino acids that serve as the building blocks of protein synthesis is vital. L-arginine, in particular, has been shown to augment wound healing and collagen production. One study in elderly human subjects found that daily supplementation of 30 g of arginine aspartate for 14 days resulted in markedly enhanced collagen production and total protein.

Ferrous gluconate is a useful supplement in iron deficiency anemia. This patient has borderline anemia, though not of a severity likely to be the central impediment to wound healing. Echinacea is a common herbal supplement used as an immunostimulant but has also been shown to have immunosuppressive effects. Lipid emulsion would be useful in a severely malnourished patient, though in this case, the patient’s BMI is stable in the normal range. Of note, omega-3 fatty acids appear to inhibit the quality of collagen strength, and avoiding this common supplement during healing may be advisable.

Question 107

A 73-year-old man is evaluated for a non-healing wound on the medial aspect of the calf. The wound has been present for 8 months, and he has undergone several months of serial debridements and moist wound care without improvement. A photograph is shown. Ten years ago, he was diagnosed with squamous cell carcinoma of the medial calf skin, and the condition was managed solely with radiation therapy. Which of the following is the most appropriate next step in management?
A) Hyperbaric oxygen therapy
B) Negative pressure wound therapy
C) Wound biopsy and culture
D) Wound debridement and skin graft
E) Continued observation and wound care

Answer 107

C) Wound biopsy and culture

Based on the clinical scenario described, wound biopsy and culture is the most appropriate management option. Despite wound debridement and moist wound care, the wound has not improved and is in the region of a previous malignancy. Wound biopsy would allow the diagnosis of recurrent malignancy and aid in the determination of further surgical intervention. Wound culture would allow the diagnosis of soft-tissue infection contributing to the wound’s persistence.

Although wound debridement would be beneficial in this case, application of a skin graft in the face of possible recurrent malignancy and probable marked radiation injury would be associated with increased risk of delayed wound healing and may delay management of recurrent malignancy. If the wound was attributed only to radiation therapy, a better strategy would be to excise the irradiated soft tissues and cover the whole defect with a well-vascularized flap.

Hyperbaric oxygen therapy has been shown to be beneficial for the management of radiation soft-tissue injury. This therapeutic modality should only be instituted after a complete evaluation of the patient’s wound, which would include soft-tissue biopsy because the patient previously had a malignancy in the region.

Complete evaluation of the wound would include pertinent history and physical examination, evaluation of the patient’s nutritional status, examination of extremity vascular inflow and outflow, diagnosis and treatment of wound infection, and optimization of wound characteristics.
The patient has already undergone debridement and wound care for several months; therefore, continued observation and wound care would be an inadequate management option.

It is inappropriate to perform negative pressure wound therapy in an irradiated wound without diagnosis by tissue biopsy.

Question 108

A 29-year-old man comes to the office because of scarring 12 weeks after he sustained extensive chemical burns to 30% of the total body surface area. Examination shows thick hypertrophic scarring of the upper extremities and anterior torso. Which of the following is the most appropriate management?
A) Injection of a corticosteroid
B) Scar band revision
C) Serial casting
D) Topical application of vitamin E
E) Use of pressure garments

Answer 108

E) Use of pressure garments

Compression decreases blood flow to active scars, leading to decreased production of collagen fibers. This results in a balance of collagen synthesis and lysis that produces a flatter, softer, less vascularized scar. Clinically, burn scar hypertrophy is managed by use of pressure garments and inserts that must be worn almost 24 hours per day. They should be initiated as soon as all burn wounds have closed enough to tolerate wear and continued until the burn scar has matured. Initially, the pressure applied is low (15 to 17 mmHg). Then, as the scar progresses in maturation, custom-made pressure garments that provide 24 to 28 mmHg of pressure may be fabricated for the patient.

The prompt institution of splinting techniques after the acute phase of burn injury can limit the development of long-term deformities. Splinting can combat edema, protect exposed structures and balance soft-tissue lengths to prevent contracture formation and compensate for functional deficits. Later, during the remodeling phase, serial casting can be a great adjunct to a therapeutic exercise program to restore normal range of motion. Surgical lengthening and scar band revision are options that are evaluated if hypertrophic scarring and contractures still develop after appropriate rehabilitation and management.

Although the depth and distribution of the injury factor into the development of scars, the patient’s own genetic predisposition also plays a role in scar formation and maturation.

Injection of a corticosteroid can improve hypertrophic scars, but its use is limited to small, focused areas. Metabolic effects can be considerable. Due to the extent of scarring in this patient, corticosteroids are not an appropriate option.
Although other topically applied therapies, such as creams containing vitamin E, have been widely used with the intent to improve wound healing, there is not substantial evidence to support regular use. Thirty-three percent delayed hypersensitivity reaction can be seen with topical vitamin E.

Question 109

A 33-year-old African American woman has a large recurrent keloid of the left earlobe. Reexcision with postoperative radiation therapy is planned. Which of the following is the most likely long-term complication of this therapeutic plan?
A) Altered pigmentation
B) Desquamation
C) Itching
D) Skin cancer
E) Telangiectasia

Answer 109

A) Altered pigmentation

The patient described has a recurrent keloid after previous excision. Surgery alone has recurrence rates of over 50%, and combination therapies including injection of a corticosteroid, pressure earrings, and surgery can have marked recurrence rates.

For recurrent keloids, post-excision radiation therapy, usually given in one to three fractions, has efficacy rates between 6 and 98%. The most common long-term complications of radiation therapy include hypo- or hyperpigmentation (62%) and telangiectasias (27%). Skin desquamation is an acute reaction to radiation therapy and occurs in 24% of patients. Secondary malignancies after radiation therapy for keloids are very rare. Itching from keloids is usually improved with treatment.

Question 110

A male newborn is evaluated because of the scalp anomaly shown in the photograph. Which of the following is the most appropriate initial management of the affected area? (Cutis aplasia)
A) Application of a skin substitute
B) Local wound care with antibiotic ointment
C) Primary closure
D) Skin grafting
E) Tissue expansion

Answer 110

B) Local wound care with antibiotic ointment

This child has aplasia cutis congenita, or cutis aplasia, of the scalp. First described in 1767 by Cordon, cutis aplasia is the congenital absence of all skin layers including the epidermis, dermis, and subcutaneous fat. This process most commonly affects only focal areas of tissue but involvement can be extensive. The majority of cases involve the scalp, but this process can occur in any cutaneous area of the body. Cutis aplasia can occur in isolation or as part of a syndrome, the most common being Adams-Oliver syndrome. Cutis aplasia of the scalp can range from small areas of involvement that often heal in utero and appear at birth as a “congenital scar” to massive defects that are devoid of scalp and cranium. Most small- or intermediate-sized full-thickness defects heal quickly (as in the patient described) if kept moist and the resultant scar can be excised secondarily. Bone healing is often complete in small lesions, and residual defects can be reconstructed when the child is older if needed. Large areas are more problematic and extensive scalp defects that threaten dural integrity may require early operative intervention. Cutis aplasia involving large areas of the scalp has a reported mortality ranging from 20 to 55%, typically as a result of sagittal sinus hemorrhage or associated congenital defects. In such cases, coverage of the dura can be life-saving. Described methods of soft-tissue coverage include skin graft, cultured allograft, acellular dermis, and immediate or delayed reconstruction with a flap. Tissue expansion of the scalp in a newborn presents many challenges and is not recommended.

Question 111

A 12-year-old boy is brought to the emergency department with a soft-tissue injury to the left knee after falling while playing football. Which of the following types of cells is most likely to appear first at the wound site?
A ) Fibroblast
B ) Lymphocyte
C ) Macrophage
D ) Neutrophil
E ) Platelet

Answer 111

E ) Platelet

The process of wound healing occurs as a sequence of overlapping processes. The appearance of cell types in an acute wound occurs in the following order: platelets, neutrophils, macrophages, lymphocytes, and fibroblasts, during the inflammatory phase.

Tissue injury causes injured vessels to constrict rapidly, with primary hemostasis being a platelet-mediated process. Platelets trapped in the clot contain growth factors that initiate the coagulation and wound-healing cascade.

The ensuing phases of wound healing consist of inflammation, collagen synthesis, angiogenesis, epithelialization, and remodeling.

During the inflammatory phase, after platelet aggregation and degranulation, chemoattractants, activation factors, and vasoconstrictors are released. An efflux of neutrophils occurs at the wound site to primarily sterilize the wound. Within 2 to 3 days, the inflammatory cell population shifts to monocytes that differentiate into macrophages, which orchestrate the repair process. Collagen synthesis occurs as circulating bone marrow-derived cells migrate into the wound and develop a fibroblastic cell function. These cells and local, activated fibroblasts synthesize and secrete the replacement collagen scar. Fibroblasts become the predominant cell type by 3 to 5 days in clean, noninfected wounds. As fibroplasia progresses, granulation tissue forms as a consequence of neoangiogenesis and the directed growth of vascular endothelial cells stimulated by platelet and activated macrophage and fibroblast products. Wound reepithelialization occurs as keratinocytes at the wound margins migrate and proliferate once epidermal continuity is reestablished. Remodeling of the resultant scar is a dynamic process that occurs slowly over months to years. Collagen deposition and degradation occur to yield a mature scar; however, maximum tensile strength of a wound reaches only approximately 80% of noninjured skin.

Question 112

A 50-year-old man with a history of organ transplantation is scheduled to undergo resection of a squamous cell carcinoma of the scalp followed by reconstruction with a flap. This patient is most likely to avoid postoperative wound-healing complications if he is currently undergoing which of the following immunosuppressive therapies?
A ) Antilymphocyte antibody (basiliximab)
B ) Antimetabolite (azathioprine)
C ) Calcineurin inhibitor (cyclosporine)
D ) Glucocorticosteroid (prednisone)

Answer 112

A ) Antilymphocyte antibody (basiliximab)

Many immunosuppressive agents used in organ transplantation have been shown to impair wound healing. Thus, free tissue transfer or major reconstructive surgery has been associated with higher complication rates. Immunosuppressive agents can be categorized as antilymphocytes (lymphocyte immune globulin [Atgam], thymoglobulin, basiliximab), antimetabolites (azathioprine, mycophenolate mofetil), calcineurin inhibitors (cyclosporine, FK-506), and glucocorticosteroids. Only antilymphocyte therapy has been shown not to impair wound repair.

Question 113

Which of the following characteristics best distinguishes keloid scar tissue from hypertrophic scar tissue?
A ) Collagen fibers parallel to the direction of wounding
B ) Extension beyond original scar
C ) Improved by surgical excision alone
D ) Increased fibroblast density
E ) Location on flexor surfaces and areas of motion

Answer 113

B ) Extension beyond original scar

Keloid scars differ from hypertrophic scars in that they can extend beyond the original scar, whereas hypertrophic scars are confined to the original boundary.

Collagen fibers are wavier in keloids and more parallel in hypertrophic scars. Light and electron microscopic studies demonstrate that collagen in keloids is disorganized compared with normal skin. The collagen bundles are thicker and wavier, and the keloids contain hallmark ?collagen nodules? at the microstructural level.

Surgical excision alone has a high rate of recurrence for keloids.

Increased fibroblast density occurs in both hypertrophic scars and keloid scars and cannot be used to differentiate between the two. Keloids have increased fibroblast proliferation rates.

Hypertrophic scars commonly occur on flexor surfaces and joints. Keloids have a high predilection for the sternum and earlobe.

Question 114

A 41-year-old man undergoes an elective transplantation of the right hand 2 years after traumatic amputation in a machine accident. Postoperatively, the patient takes immunosuppressive medications to minimize the chance of rejection. To monitor for cellular rejection, observation and biopsy of which of the following tissue types in the postoperative period is most appropriate?
A ) Blood vessel
B ) Bone
C ) Muscle
D ) Skin
E ) Tendon

Answer 114

D ) Skin

Composite tissue allotransplantation (CTA) has been performed on a host of tissues, though more recently in plastic surgery; this has largely been in the field of hand or upper extremity and facial transplantation. This requires immunosuppressive regimens which have had varying degrees of success, as well as issues with patient compliance, especially as these medications are expensive and, at least at this time, necessary for the rest of the patient’s life. Skin is thought to be the most antigenic and immunoreactive tissue in CTA. Experience from China in hand transplantation demonstrated that cellular rejection in these patients was largely limited to the skin, with relative sparing of the underlying blood vessels, bone, muscle, nerve, and tendon. However, as the skin is an easily monitored tissue (versus solid organs), it is the most sensitive indicator of acute rejection in that it is clearly visible and can be easily evaluated by both patient and physician. Therefore, this tissue type is most appropriate to be monitored and biopsied.