Skin and Soft Tissue Disorders and Hernias

Question 0

Is excision of the lesion warranted?

Answer 0

larger lesions (>2-3 cm) or lesions that are contiguous with important structures such as on the face, incisional biopsy of full-thickness skin at the border of the lesion is war­ranted

Question 1

What aspects of the history and physical are important when evaluating a skin lesion?

Answer 1

– Family history of melanoma increases risk
– Exposure To the sun
–previous dysplastic nevi or atypical moles.
ABC DE rules, alteration, recent change

Question 2

Treatment for basal cell carcinoma

Answer 2

rarely metastasize, but they require adequate local excision because recur­ rent lesions may be locally invasive.

May also require topical 5-fluorouracil or radiation.

Question 3

What margins are required for more aggressive lesions?

Answer 3

margins are positive, it is essential to reexcise the node to dear margins. The margin for large or more aggressive lesions should be 2-4 mm.

Question 4

Which is more dangerous squamous cell carcinoma, or basal cell carcinoma?

Answer 4

Squamous cell carcinoma is more dangerous than basal cell carcinoma because of its locally aggressive behavior and its propensity to metastasize to local lymph nodes.

Question 5

What margins are required for removal of squamous cell carcinoma?

Answer 5

Local recurrence is more com­mon with lesions 4 mm or greater in thickness, which necessitate excision with a 1-cm tumor-free margin

Question 6

what is the treatment for In situ melanoma?

Answer 6

It is necessary to reexcise the lesion to a 0.5-1-cm margin of normal tissue. This approach
should result in a cure.

Question 7

Treatment for dysplastic nevus?

Answer 7

Local excision only with surveillance

Question 8

A malignant melanoma is diagnosed; how is the lesion staged?

Answer 8

two commonly used classifications are the Clark level and Breslow thickness. The tumor-node-metastasis (TNM) stages correlate highly with patient survival

Question 9

What factors in addition to histological type and TNM stage affect survival?

Answer 9

presence of ulceration in the primary lesion.

Even in stage I lesions, ulcerated lesions have about a one-third reduction in survival.

Question 10

How do you manage the following findings:Malignant melanoma of 0.7 mm depth

Answer 10

With local control the prognosis is good. Re-excise the lesion lesion with 1 cm margins.

Question 11

How do you manage the following histological findings:Malignant melanoma of 1 . 6-mm depth

– With palpable nodes?
– No nodes are palpable?

Answer 11

excision with a larger, 2-cm margin. The risk of regional lymph node metastasis is approximately 40%.

–If palpable nodes are present, therapeutic lymphadenectomy should be performed

–If no nodes are palpable, a sentinel lymph node biopsy is warranted. If the biopsy
is positive, elective lymph node dissection is indicated, even in the case of nonpalpable nodes.

Question 12

How would you manage a patient with the following histological findings:Malignant melanoma of 4.5-mm depth.

Do you think that lymph nodes will be palpable?

Answer 12

poor prognosis, will most likely die from metastatic disease. Re­-excision of the lesion with a 2-3-cm margin is appropriate.

In such a case, it is more likely that lymph nodes are palpable; if so, excision of the nodes is warranted, because they have a tendency to erode the skin and become infected and painful. It is unlikely that an elec­tive, or prophylactic, node dissection will be beneficial.

–CT abdomen and MRI of brain to evaluate for distant metastasis
–Begin treatment with interferon, which has proven benefit for patients with T4 primary tumors or stage III disease.

Question 13

Skin lesion with palpable axillary lymph node

Answer 13

– Regional lymphadenectomy: Recurrence rate is 75% at five years
– Full staging for distant metastasis : chest x-ray, CBC, liver function tests, Brain MRI
– Treatment with interferon improves survival by 40%

Question 14

Malignant melanoma with a new long nodule observed on chest x-ray. What is the best treatment?

Answer 14

systemic therapy with combination drugs or dacarbazine may produce a response in up to one-third of patients.

Question 15

A 5-cm irregular lentigo maligna (Hutchinson freckle) of the cheek is found on exam. What do you advise?

Answer 15

precursor of lentigo malignant melanoma. Management involves close ob­ servation, looking for changes.

Question 16

Treatment for subungual melanoma? What is the prognosis?

Answer 16

amputation at the distal interpha­ langeal joint. Affected patients have a survival rate of 60%.

Question 17

What type of biopsy is done for a sarcoma?

Answer 17

Excisional biopsy is indicated for masses less than3cm.
Incisional biopsy is the initial step for sarcomas 3 cm or more. The biopsy incision should parallel the subsequent surgical incision for a definitive resection

Question 18

How can sarcomas be divided?

Answer 18

low-grade and high-grade malignancy
based on the number of mitotic figures and the degree of necrosis (not the cell type of origin). Gross size greater than 15 cm and a symptomatic lesion have been associated with poor outcome

Question 19

What tests are necessary to characterize and stage sarcoma?

Answer 19

Sarcomas have a high rate of metastasis on presentation (22%); the most common sites for metastasis are the liver, lung, bone, and brain. Patients should have a metastatic workup prior to resection. A CT scan is very useful for detection of bony involvement, and an MRI scan detects involvement of adjacent soft tissue structures

Question 20

Treatment for Sarcoma

Answer 20

Total Compartmental resection

Question 21

Sarcoma with a mass 15 cm in diameter. What is the treatment?

Answer 21

Radical amputation or limb salvage. Neoadjuvamt chemotherapy and radiation.

Question 22

What is the treatment for metastatic sarcoma to the lung?

What is the prognosis?

Answer 22

A thoracic wedge resection

recurrence of sarcoma is one of the few tumors in which excision of the
pulmonary metastasis may result in a significant long-term disease-free interval (years).

Question 23

Patient with previous sarcoma is now found to have a 3 cm mass on the liver from CT scan. What is the next step in management?

Answer 23

Biopsy of the new liver lesion is warranted. If pathologic studies indicate that it is a sar­coma, resection with a hepatic wedge resection with a 1-cm margin or formal lobectomy is necessary.

Question 24

Severall-cm tender lymph nodes in the groin

Answer 24

infection causing lymphadenitis in the groin, leg,
or foot. Malignancy is a less likely cause.

Question 25

A firm, tender mass in the medial portion of the groin.

Answer 25

Direct inguinal hernia

Question 26

A tender area in the lateral portion of the groin and an impulse that travels down the inguinal canal when he coughs

Answer 26

Indirect inguinal hernia

Question 27

firm, tender mass below the inguinal ligament

Answer 27

Femoral hernia

Question 28

firm, tender mass with fever, leukocytosis, and acidosis

Answer 28

Segment of bowel is strangulated

Question 29

Which type of hernia most commonly results in strangulation?

Answer 29

Strangulation is most common in femoral hernias, followed by indirect hernias.

Question 30

What is the difference between a direct hernia and an indirect hernia?

Answer 30

indirect hernia, which usually has an intact posterior surface, called the floor of the canal, originates at the internal ring and traverses down the inguinal canal. A direct hernia, a weakness in the floor of the canal, originates medially to the inferior epigas­ tric vessels.