Score - Skin and Soft tissue Flashcards
A 42-year-old man who has been on oral antibiotics and retinoids to treat hidradenitis suppurativa develops multiple new lesions across many areas of his body. The patient does not desire ablative surgical therapy and has no actively infected areas. What is the best therapy to offer this patient?
D. TNF-alpha inhibitor.
Two randomized, phase 3 trials (PIONEER I and PIONEER II) showed that TNF-alpha inhibitors, specifically adalimumab, benefit patients with moderate to severe hidradenitis suppurativa. Other treatment modalities such as radiation, laser therapy, hormone therapy, and systemic glucocorticoids have a varied efficacy that has not been as well established.
A 32-year-old man presents to the emergency department with a gunshot wound to the back. Following a complete trauma workup, the man is found to be paraplegic. He remains in the intensive care unit for 2 weeks. On physical examination, his sacrum begins to undergo erythematous changes. Which of the following is a recommended method of prevention for pressure ulcers?
Nutrition supplementation and optimization.
Nutritional supplementation to optimize patient nutritional status is a key component of pressure ulcer prevention and treatment. Similarly, more frequent turning (typically every 2 hours, not every once per nursing shift [every 8-12 hours]), using air-fluidized mattresses (foam mattresses cause significant pressure), and applying pressure bandages have all been shown to prevent pressure ulcers. Empiric antibiotics have no role in the prevention of pressure ulcers.
An 18-year-old woman presents to the emergency room with complaints of creamy discharge from both axillae. Her primary care physician placed her on oral clindamycin a few days ago. Upon examination, she has multiple sinuses in the axilla spontaneously draining purulent material with chronic scarring in the groins. Her temperature is 37.2°C, and white blood cell count is 7.4. What is the next best step in management?
Local wound care and completion of oral antibiotics with outpatient follow-up.
Hidradenitis suppurativa is a chronic acneiform infection of the cutaneous apocrine glands that also can involve adjacent subcutaneous tissue and fascia of the axilla, groin, or wherever apocrine glands are concentrated. The incidence of hidradenitis suppurativa is greater in females. The condition may be observed in patients of any age after puberty, and symptoms may be affected by the menstrual cycle. Hidradenitis suppurativa occurs when apocrine gland secretion becomes obstructed by perspiration or glands are unable to drain normally because of structural abnormality. Trapped secretions and bacteria extravasate bacteria into surrounding tissue, causing subcutaneous inflammation and infection. The nodules may open and drain pus spontaneously, then heal slowly, with or without drainage, over a 2- to 4-week period. Remissions may last months or years, but recurrences are frequent. Patients with chronic affliction may present with multiple nodules that have coalesced and are associated with a fibrotic reaction that results in scarring. Most nodules will resolve without surgical drainage. Incision and drainage may be helpful for fluctuant nodules that have not opened spontaneously. Antibiotics are indicated if cellulitis or fever is present, and hospitalization should be considered if the patient has systemic toxicity. In severe or intractable cases, excision of the pathologic tissue with split-thickness skin grafting offers the best chance for cure.
A 30-year-old man presents to the office for evaluation of recurrent, chronic pilonidal disease. He has undergone multiple incision and drainage procedures of pilonidal abscesses in the ED and an attempted excision with primary repair about 1 year ago. He now has recurrence of clear fluid draining from sinus pits. What is the best treatment option at this time?
Excision of the diseased area with flap-based coverage.
After multiple previous surgical treatments, it is recommended that one of several flap-based treatment strategies be used to provide healthy tissue coverage of the excised tissue defect. Flap-based procedures include the rhomboid (Limberg flap), Karydakis flap, and cleft-lift technique.
While performing a sentinel lymph node biopsy for melanoma using technetium-99m and isosulfan blue, you remove a single “hot” and blue node with a gamma count of 1000. On further examination of the nodal basin, there is some gamma activity, with the highest count being 25. No blue nodes are visible, but there is a single, firm, palpable node remaining that is not “hot” or blue. What is your next step?
Remove the single firm node.
Any firm node that is encountered during a sentinel lymph node biopsy should be removed and evaluated, regardless of gamma count or blue dye. There is no need to remove the node with the count of 25. Once the sentinel node has been identified and removed, the node is examined with a gamma probe ex vivo and given a count (in this case, 1000). Further nodal exploration is warranted, and sentinel lymph nodes are identified using gamma counts greater than 10% (in this case, 100) of the highest sentinel lymph node count and/or if they are blue in color. This is often called the 10% rule. Because the highest gamma count in the nodal basin is 25, no other “hot” nodes should be removed.
A 28-year-old man with familial adenomatous polyposis syndrome who is status–post total proctocolectomy and ileoanal pouch creation presents with a 10-cm mass in the root of his small bowel mesentery. He is asymptomatic. The mass abuts but does not encase the superior mesenteric vessels. A percutaneous biopsy confirms a desmoid tumor. Which of the following is the best first option in the treatment of this man?
Watchful waiting and reimaging in 3 months
Watchful waiting with reimaging in 3 months is the best choice. As with extra-abdominal desmoid tumors, intra-abdominal desmoids often remain stable in size for many years or even spontaneously regress. Radiation therapy, chemotherapy, and cryoablation are associated with known toxicities and may engender greater morbidity than the tumor itself. Surgical resection of this tumor is likely to be challenging because of the tumor’s location in the root of the mesentery and the fact that the resection will likely entail a fairly lengthy small bowel resection. Thus, surgical resection is not the best first treatment option in this case.
A 32-year-old woman presents with a 1-week history of a painful right index fingertip. She has no significant medical history, and she states that she works as a dental hygienist. She reports that first her finger developed severe pain and redness and then clear blisters developed. On examination, the fingertip appears abscessed with surrounding local erythema and tenderness. What is the appropriate management of this patient?
Observation
The patient presents with a history typical for herpetic whitlow caused by herpes simplex infection. Observation and avoidance of contact with the contagious lesion is the indicated treatment. While the current examination is consistent with an abscess, the abscessed blisters of a whitlow are superinfected, and the bed of the ulcer must not be debrided to avoid systemic spread of the virus. Amputation is not indicated because this infection is self-limited.
A 58-year-old woman undergoes resection of a large, dedifferentiated liposarcoma of her retroperitoneum. Postoperatively she returns to see you; she is recovering well. Pathology shows that all margins are negative microscopically. In addition to cross-sectional imaging of her retroperitoneum at regular intervals, which dedicated staging imaging and interval is most appropriate?
Chest computed tomography (CT) every 4 months
According to National Comprehensive Cancer Network (NCCN) guidelines, dedicated chest imaging is recommended every 3 to 6 months for the first 2 years. Noncontrast imaging is acceptable and is preferred over chest x-ray for histologies that have a relatively high likelihood of recurrence in a distant site, such as lung metastasis with dedifferentiated liposarcoma.
Ultrasound of the lymph node basin every 6 months is incorrect because liposarcoma is extremely unlikely to spread to lymph nodes. It is well known to spread hematogenously. Magnetic resonance imaging of the liver every 12 months is incorrect because (1) the liver is a rare site of metastases of liposarcoma and (2) the interval proposed is outside the NCCN guidelines for interval imaging for either primary or metastatic evaluation. Positron emission tomography–computed tomography is not recommended by the NCCN for retroperitoneal liposarcoma, although it may be used for the surveillance of other sarcoma histologies. In addition, this response indicates a longer interval between staging studies than is currently recommended.
A 45-year-old man with a 1.6-mm melanoma of the right calf recently underwent wide excision and sentinel lymph node biopsy. Final pathology reveals no further disease at the primary site and one of three right groin sentinel lymph nodes positive for metastatic melanoma (<10% nodal involvement, 1 mm largest metastatic focus). Whole body PET/CT imaging and brain MRI are negative for disease. What is the next best step in the management of this patient?
Observation with ultrasounds of the right groin nodal basin every 4 months and referral to medical oncology for discussion of adjuvant systemic therapy
The Multicenter Selective Lymphadenectomy Trial 2 (MSLT-2), published in June 2017, evaluated completion lymphadenectomy versus observation following positive sentinel lymph node biopsies for metastatic melanoma. There was no significant difference in disease-specific survival between the two treatment groups. A key limitation of the study was that it mostly included patients with a low burden of disease (percent nodal involvement, small metastatic focus, and number of positive nodes) in their sentinel lymph nodes. Debate remains regarding which subset of patients with a positive sentinel node would benefit most from completion lymphadenectomy; however, it is reasonable for most of these patients to be observed closely with nodal ultrasounds every 4 months for the first 2 years, every 6 months for years 3 through 5, and then annually. Sentinel lymph node biopsy remains an important procedure for prognostication and determining eligibility for adjuvant therapies and surveillance follow-up intervals.
A 22-year-old man with diabetes comes to your clinic with an infected index finger. Your examination reveals fluctuance at the pulp with no focal point of the index finger. How should treatment proceed?
Incision and drainage of the felon using a longitudinal ulnar incision
When possible, the incision is made on the ulnar side of the second to fourth digits and on the radial side of the thumb and small finger. The incision is started dorsal to and 0.5 cm distal to the distal interphalangeal joint flexion crease. It is continued distally in line with the volar margin of the distal phalanx, but it does not cross over the fingertip. The incision is deepened along a plane just volar to the palmar cortex of the phalanx until the abscess is entered. The opening in the cavity is enlarged until adequate evacuation is achieved. Incision and drainage of a paronychia involves lifting up the nail bed to evacuate the purulence, but this patient has a felon, not a paronychia. Antibiotic therapy would be an adjunct to treatment but is not the proper first-line treatment for this patient.
A 25-year-old obese, African-American woman presents to clinic for evaluation of persistently painful, foul-smelling lumps in her left armpit. She reports recurrence despite consulting multiple physicians and following their prescribed medication regimens. She recently attempted a trial of oral doxycycline therapy without success. Her social history is positive for smoking two packs of cigarettes per day. A focused physical examination reveals diffuse scarring and abscesses encompassing the entire left axillary region. There is involvement of interconnected sinus tracts. No healthy skin is observed in between any of the largely affected area. A malodorous, purulent discharge is also present. What is the most appropriate next step in management?
Complete surgical excision of the entire affected area
Surgical excision of the entire affected area is the best answer. Female sex, obesity, smoking history, physical examination findings, and history of failed trials with medical therapy all support the diagnosis of hidradenitis suppurativa (HS), Hurley stage 3. Complete ablation of the affected area via excision of all skin and subcutaneous tissues involved in fibrosis, sinus, and fistulas is critical for the treatment of recurrent or chronic HS refractory to nonsurgical therapy.
Twice-daily oral acetaminophen is not a recommended treatment for HS. Topical clindamycin gel therapy daily may be appropriate for HS Hurley stage 1 but not for HS Hurley stage 3. Oral doxycycline therapy for several months may be appropriate to treat HS Hurley stage 2 but not HS Hurley stage 3. Furthermore, this medication trial was already attempted without success. Surgical excision of the entire affected area, not only of selective portions, is recommended for treating recurrent or chronic HS refractory to nonsurgical therapy.
A review of Hurley staging is included below.
Hurley stage 1: Involves a localized abscess that may be described as a painful lump or inflammatory nodule. There is no sinus tract involvement or scarring.
Hurley stage 2: Involves recurrent abscesses. It includes sinus tract involvement and scarring. There is also separation of areas by skin that appear normal/healthy.
Hurley stage 3: Involves diffuse disease. Multiple interconnected sinus tracts are involved. Abscesses that involve an entire area with scarring is also present. Purulent drainage may occur. A foul smell may also be present.
A 65-year-old man is referred to you for inguinal hernia repair from a urology colleague after a procedure for presumed hydrocele. Intraoperatively, the urologist found no hydrocele but instead a large lipoma, measuring 15 cm in size. Examination reveals fullness within the inguinal canal but no palpable hernia, and the man is asymptomatic. What is the most appropriate next step?
Obtain computed tomography of the abdomen and pelvis to evaluate the extent of the large lipoma.
Retroperitoneal liposarcoma can present as an apparently benign fatty lesion within the inguinal canal and scrotum. Surgical intervention directed toward the inguinal canal and/or scrotum without evaluation of the retroperitoneum can significantly affect the oncologic outcome for the man in a negative way. Prior to intervention, imaging in the form of computed tomography of the abdomen and pelvis with intravenous contrast should be performed to ensure that the fat-containing inguinal hernia is not, in fact, the distal extent of a retroperitoneal liposarcoma. A minimally invasive approach is not indicated in the surgical management of retroperitoneal sarcoma, and an open inguinal hernia repair alone does not address the potential proximal extent of disease. Even when asymptomatic, a 15-cm fatty tumor in the scrotum should result in further evaluation and potential surgical intervention.
A 26-year-old woman with past medical history of hidradenitis suppurativa treated with surgical unroofing and oral doxycycline presents to your clinic with a recurrent abscess with bridged scars overlying a sinus tract. The scars are widely separated by normal skin. In addition to unroofing the abscess, what is the best treatment for this patient?
Oral clindamycin and rifampin
The Hurley clinical staging system is commonly utilized to describe the severity of hidradenitis suppurativa (HS). In accordance with this system, HS is categorized into three stages: Stage I- abscess formation (single or multiple) without sinus tract formation and cicatrization/scarring; Stage II- recurrent abscesses with one or more sinus tracts and scarring, widely separated by normal skin, and Stage III- diffuse involvement with multiple interconnected tracts and abscesses across the entire area with no intervening normal skin.
Therapy is based upon the clinical severity of disease as well as an assessment of the patient’s treatment history. This patient has stage II disease. The two major forms of pharmacologic therapy utilized in the management of Hurley stage II are systemic antibiotics (usually given for several weeks or longer) and long-term hormonal therapy. Tetracyclines are well-tolerated and are the most common antibiotic agents prescribed for HS. Combination therapy with clindamycin and rifampin is an option for patients who have not responded to conventional antibiotic therapy. Surgery can be used for the treatment of individual nodules and sinus tracts that occur in any stage of disease. Punch debridement (mini-unroofing) of fresh lesions or unroofing of single nodules and extensive sinuses is usually sufficient. Topical therapy and intralesional injections of corticosteroids are usually used for Hurley Stage I. Wide excision is typically reserved for Stage III disease.
What are the appropriate steps in a sentinel lymph node biopsy for melanoma?
Inject technetium, perform lymphoscintigraphy, and then proceed to the operating room, and inject blue dye intradermally at the site of the lesion prior to resecting it.
Formal lymphoscintigraphy is required for sentinel lymph node biopsy in melanoma prior to proceeding to the operating room, and blue dye is injected intradermally at the time of the operation prior to resection.
Lymphoscintigraphy with technetium may be performed the day of surgery or the day before. Injecting the dye should occur in the operating room before resecting the lesion. The injection should be intradermal (not subcutaneous).
Unlike with breast cancer, formal lymphoscintigraphy is required for sentinel lymph node biopsy in melanoma prior to proceeding to the operating room.
A 45-year-old African-American woman presents with a raised nodular lesion on her flank. She undergoes a biopsy, and pathology shows dermatofibrosarcoma protuberans. She is treated with wide local excision, and margins are negative on surgical pathology. Which of the following additional findings on the pathology report would be most concerning for metastatic potential?
Fibrosarcomatous change
Dermatofibrosarcoma protuberans without fibrosarcomatous change rarely metastasizes, and instead usually recurs locally because of its spreading nature. All other answer choices listed (tumor size, chromosomal translocation, irregularly whorled spindle-type cells, and tumor cell invasion) are typical features of this tumor. Dermatofibrosarcoma protuberans with fibrosarcomatous change increases the risk of metastasis, which usually occurs in the lung.
