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Plastics, Skin and Soft Tissues > Plastics, Skin and Soft Tissues > Flashcards

Plastics, Skin and Soft Tissues Flashcards

1
Q

Epidermis

A

primarily cellular

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2
Q

Keratinocytes

A

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

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3
Q

melanocytes

A

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

  • have dendritic processes that transfer melanin to neighboring keratinocytes via melanosomes
  • density of melanocytes is the same among races; difference is in production
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4
Q

Dermis

A

primarily structural proteins for the epidermis

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5
Q

Langerhans cells

A

act as antigen presenting cells (MHC class II)

  • originate from bone marrow
  • have a role in contact hypersensitivity reactions (type IV)
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6
Q

Pacinian corpuscles

A

pressure

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7
Q

Ruffini’s endings

A

warmth

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8
Q

Krause’s end bulbs

A

cold

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9
Q

Meissner’s corpuscles

A

tactile sense

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10
Q

Eccrine sweat glands

A

aqueous sweat (thermal regulation, usually hypotonic)

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11
Q

Apocrine sweat glands

A

milky sweat
*highest concentration of glands in palms and soles; most sweat is the result of sympathetic nervous system via acetylcholine

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12
Q

Lipid soluble drugs

A

increase skin absorption

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13
Q

type I collagen

A

predominant type; 70% weight of dermis; gives tensile strength

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14
Q

Tension

A

resistance to stretching (collagen)

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15
Q

Elasticity

A

ability to regain shape (branching proteins that can stretch to 2X normal length)

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16
Q

Cushing’s striae

A

caused by loss of tensile strength and elasticity

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17
Q

Split thickness skin grafts

A

include all of the epidermis and part of the dermis

  • donor site skin regenerated from hair follicles and skin edges on split-thickness grafts
  • more likely to survive; graft not as thick so easier fro imbibition and subsequent revascularization to occur
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18
Q

Full thickness skin grafts

A

have less wound contraction; good for areas such as palms and back of hands

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19
Q

imbibition

A

osmotic; blood supply to skin graft for days 0-3

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20
Q

neovascularization

A

starts around day 3

*poorly vascularized beds are unlikely to support skin grafting (tendon, bone without periosteum, XRT areas)

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21
Q

Pedicled or anastomosed free flap necrosis

A

venous thrombosis most common cause Ti

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22
Q

Tissue expansion

A

occurs by local recruitment, thinning of dermis and epidermis, mitosis

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23
Q

TRAM flaps complications

A

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

  • rely on superior epigastric vessels
  • periumbilical perforators most important determinant of TRAM flap viability
  • transverse rectus abdominus myocutaneous flap
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24
Q

Pressure sores

A

stage I - erythema and pain, no skin loss
stage II - partial skin loss with yellow debris
stage III - full thickness skin loss, subcutaneous tissue exposure
stage IV - usually involves bony cortex

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25
Q

UV radiation

A

damages DNA and repair mechanisms

  • both an promoter and initiator
  • melanin single best factor for protecting skin from UV radiation
  • UV-B - responsible for chronic sun damage
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26
Q

Melanoma

A
  • represents only 3% - 5% of skin CA but accounts for 65% of the deaths
  • Risk factors for melanoma
  • dysplastic, atypical or large congenital nevi (10% lifetime risk for melanoma)
  • Familial BK mole syndrome (almost 100% risk of melanoma)
  • xeroderma pigmentosum
  • fair complexion, easy sunburn, intermittent sunburns, previous skin CA, previous XRT
  • 10% familial
  • most common melanoma site on skin - back in men, legs in women
  • Prognosis worse for men, ulcerated lesions, ocular and mucosal lesions
  • Signs of transformation - color change, angulations, indentation / notching, enlargement, darkening, bleeding, ulceration
  • originates from neural crest cells (melanocytes) in basal layer epidermis
  • blue color - most ominous
  • Dx:
  • < 2cm lesion –> excisional biopsy unless cosmetically sensitive area; need resection with margins if pathology comes back as melanoma
  • > 2 cm lesions or cosmetically sensitive area –> incisional biopsy (or punch biopsy), will need to resect with margins if pathology shows melanoma
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27
Q

Most common location for distant melanoma mets

A

Lung

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28
Q

Most common metastasis to small bowel

A

melanoma

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29
Q

Lentigo maligna

A

least aggressive, minimal invasion, radial growth 1st usual; elevated nodules

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30
Q

Superficial spreading melanoma

A

most common; intermediate malignancy; originates from nevus/sun-exposed areas

31
Q

Nodular melanoma

A

most aggressive; most likely to have metastasized at time of dx; deepest growth at time of dx; vertical growth 1st; bluish black with smooth borders; occurs anywhere on the body

32
Q

Acral lentiginous

A

very aggressive; palms/soles of African Americans

33
Q

Melanoma in situ or thin lentigo maligna

A

0.5 cm margins OK

34
Q

Melanoma staging

A

need chest xray, LFTs; examine all possible draining lymph nodes

35
Q

Nodes (melanoma)

A

always need to resect clinically positive nodes with melanoma

  • perform SLN biopsy if nodes clinically negative and tumor > 0.9 mm deep
  • involved nodes usually nontender, round, hard 1-2cm
  • all stage III tumors need full LN dissection
  • need to include superficial parotidectomy for anterior head and neck melanomas
36
Q

Axillary node melanoma with no other primary

A

complete axillary node dissection

37
Q

resection of melanoma mets

A

has provided some patients with long disease-free interval and is the best chance for cure
*isolated mets (i.e., lung or liver) that can be resected with low risk procedure should probably undergo resection

38
Q

Clarks Levels for Melanoma

A

I - epidermis basement membrane intact
II - papillary dermis through basement membrane
III - junctional dermis between papillary and reticular dermis
IV - reticular dermis
V - fat

39
Q

Melanoma margins

A

Depth Margin Needed
< 1mm 2 cm
1-4 mm 2 cm
> 4 mm 2-3 cm

40
Q

Basal Cell Carcinoma

A
  • most common malignancy in US; 4X more common than squamous cell skin CA
  • 80% on head and neck
  • originates from epidermis - basal epithelial cells and hair follicles
  • pearly appearance, rolled borders
  • pathology - peripheral palisading of nuclei and stromal retraction
  • slow, indolent growth
  • ulcerative, rare metastases, deep invasion, occasionally dark
  • regional adenectomy for clinically positive nodes
  • morpheaform type - most aggressive, has collagenase production
  • tx: 0.3 - 0.5 cm margins
  • XRT and chemo - may be limited benefit for inoperable disease or mets; neuro, lymphatic, or vessels invasion
41
Q

Squamous Cell Carcinoma

A
  • overlying erythema, papulonodular with crust and ulceration
  • may have surrounding induration and satellite nodules
  • usually red-brown; can have pearly appearance
  • mets more frequently than basal cell CA but less common than melanoma
  • can develop in postradiation areas or in old burn scars
  • Risk factors: actinic keratoses, xeroderma pigmentosum, Bowen’s disease, atrophic epidermis, arsenics, hydrocarbons (coal tar), chlorophenols, nitrates, HPV, immunosuppression, sun exposure, fair skin, XRT exposure, previous skin CA
  • Risk factors for mets: poorly differentiated, greater depth, recurrent lesions, immunosuppression
  • Tx: 0.5-1.0 cm margins for low risk
  • can treat high risk with Mohs surgery (margin mapping using conservative slices; not used for melanoma) when trying to minimize area of resection
  • regional adenectomy for clinically positive nodes
  • XRT and chemotherapy - may be of limited benefit for inoperable disease or mets; neuro, lymphatic or vessels invasion
42
Q

Most common soft tissue sarcoma

A 
#1 malignant fibrous histiosarcoma
#2 liposarcoma
43
Q

Soft tissue sarcomas

A

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

  • most sarcomas are large, grow rapidly and are painless
  • asymptomatic mass most common presentation, GI bleeding, bowel obstruction, neuro deficit
  • CXR to r/o lung mets
  • MRI before biopsy to r/o vascular, neuro, or bone invasion
  • hematogenous spread, not to lymphatics; mets to nodes is rare
  • lung most common site for metastasis
  • staging based on grade, not size or nodes
  • tx: want at least 3 cm margins and at least one uninvolved fascial plane
  • place clips to mark site of likely recurrence; will XRT these later
  • post op XRT for high grade tumors, close margins, or tumors > 5 cm
  • chemo is doxorubicin based
  • tumors > 10 cm may benefit from preop XRT and chemo
  • midline incision favored for pelvic and RP sarcomas
  • 40% 5YSR with complete resection
44
Q

Biopsy soft tissue mass

A

excisional biopsy if mass < 4cm

longitudinal incisional biopsy for masses > 4 cm

45
Q

Head and neck sarcomas

A

can occur in peds (usually rhabdomyosardcoma)

46
Q

Sarcoma risk factors

A

Asbestos - mesothelioma
PVC and Arsenic - angiosarcoma
Chronic lymphedema - lymphangiosarcoma

47
Q

Kaposi’s sarcoma

A

vascular sarcoma

  • can involve skin, mucous membranes or GI tract
  • assoc with immunocompromised state
  • rarely a cause of death in AIDS; 15-20 year survival; slow growing
  • tx: XRT or intralesional vinblastine for local disease; systemic chemotherapy for disseminated disease; surgery for intestinal hemorrhage
48
Q

Childhodd rhabdomyosarcoma

A
  • # 1 soft tissue sarcoma in kids
  • head/neck, GU, extremities and trunk (poorest prognosis)
  • Embryonal - most common
  • Alveolar - worst prognosis
  • Tx: surgery; doxorubicin based chemotherapy
49
Q

Bone sarcomas

A
  • most are metastatic at time of dx
  • osteosarcoma –> increased incidence around the knee; originates from metaphyseal cells; usually in children
  • usually need to take the joint, followed by reconstruction; may require amputation
50
Q

Neurofibromatosis

A

CNS tumors, peripheral sheath tumors, pheochromocytoma

51
Q

Li-Fraumeni syndrome

A

childhood rhabdomyosarcoma, many others

52
Q

Hereditary retinoblastoma

A

also includes other sarcoma

53
Q

Tuberous sclerosis

A

angiomyolipoma

54
Q

Gardner’s syndrome

A

familial adenomatous polyposis and intra-abdominal desmoids

55
Q

Xanthoma

A

yellow, contains histiocytes; tx: excision

56
Q

Actinic keratosis

A

premalignant, in sun damaged areas, need excisional biopsy if suspicious

57
Q

Seborrheic keratosis

A

not premalignant; trunk on elderly; can be dark

58
Q

Arsenical keratosis

A

associated with squamous cell carcinoma

59
Q

Merkel cell carcinoma

A

neuroendocrine

  • aggressive regional and systemic spread; patients have red to purple papulonodule / indurated plaque
  • have neuron-specific enolase (NSE), cytokeratin, and neurofilament protein
60
Q

Glomus cell tumor

A

painful tumor composed of blood vessels and nerves

  • benign, most common in terminal aspect of digit
  • tx: tumor excision
61
Q

Hutchinson’s freckle

A

in elderly, often on face; premalignant, not aggressive

62
Q

Lip laceration

A

important to line up vermillion border

63
Q

desmoid tumors

A

usually benign; occur in fascial planes

  • anterior abdominal wall (most common location)
  • high risk of local recurrences; no distant spread
  • tx: surgery or chemotherapy / XRT if vital structure involved
64
Q

Bowen’s disease

A

SCCA in situ; 10% turn into invasive SCCA

tx: excision with negative margins usual

65
Q

Keratoacanthoma

A

rapid growth, rolled edges, crater filled with keratin

  • is not malignant but can be confused with SCCA
  • involutes spontaneously over months
  • always biopsy these to be sure
  • if small, excise; if large, biopsy and observe
66
Q

Hyperhydrosis

A

increase sweating, especially noticeable in palms; tx: sympathectomy if refractory

67
Q

Hidradenitis

A

infection of apocrine sweat glands, usually in axilla and groin regions

  • staph / strep most common organisms
  • tx: antibiotics, improved hygiene 1st; may need surgery
68
Q

Epidermal inclusion cyst

A

most common; have completely mature epidermis with creamy keratin material

69
Q

Trichilemmal cyst

A

in scalp; no epidermis

70
Q

ganglion cyst

A

over tendons; usually over wrists; filled with collagenous material

71
Q

dermoid cyst

A

midline abdominal and sacral lesions, occiput and nose; found along body fusion planes

72
Q

pilonidal cyst

A

congenital coccygeal sinus with ingrown hair; gets infected and need to be excided

73
Q

keloids

A

autosomal dominant; dark skin

  • collagen goes beyond original scar
  • tx: XRT, steroids, silicone, pressure garments
74
Q

Hypertrophic scar tissue

A

dark skin; flexor surfaces of upper torso

  • collagen stays within confines of scar
  • often occurs in burns or wounds that take long time to heal
  • tx: steroids, silicone, pressure garments

Plastics, Skin and Soft Tissues (1 decks)

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