Skin and Soft Tissue Disorders and Hernias Flashcards
Is excision of the lesion warranted?
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
What aspects of the history and physical are important when evaluating a skin lesion?
– Family history of melanoma increases risk
– Exposure To the sun
–previous dysplastic nevi or atypical moles.
ABC DE rules, alteration, recent change
Treatment for basal cell carcinoma
rarely metastasize, but they require adequate local excision because recur rent lesions may be locally invasive.
May also require topical 5-fluorouracil or radiation.
What margins are required for more aggressive lesions?
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.
Which is more dangerous squamous cell carcinoma, or basal cell carcinoma?
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.
What margins are required for removal of squamous cell carcinoma?
Local recurrence is more common with lesions 4 mm or greater in thickness, which necessitate excision with a 1-cm tumor-free margin
what is the treatment for In situ melanoma?
It is necessary to reexcise the lesion to a 0.5-1-cm margin of normal tissue. This approach
should result in a cure.
Treatment for dysplastic nevus?
Local excision only with surveillance
A malignant melanoma is diagnosed; how is the lesion staged?
two commonly used classifications are the Clark level and Breslow thickness. The tumor-node-metastasis (TNM) stages correlate highly with patient survival
What factors in addition to histological type and TNM stage affect survival?
presence of ulceration in the primary lesion.
Even in stage I lesions, ulcerated lesions have about a one-third reduction in survival.
How do you manage the following findings:Malignant melanoma of 0.7 mm depth
With local control the prognosis is good. Re-excise the lesion lesion with 1 cm margins.
How do you manage the following histological findings:Malignant melanoma of 1 . 6-mm depth
– With palpable nodes?
– No nodes are palpable?
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.
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?
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.
Skin lesion with palpable axillary lymph node
– 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%
Malignant melanoma with a new long nodule observed on chest x-ray. What is the best treatment?
systemic therapy with combination drugs or dacarbazine may produce a response in up to one-third of patients.
A 5-cm irregular lentigo maligna (Hutchinson freckle) of the cheek is found on exam. What do you advise?
precursor of lentigo malignant melanoma. Management involves close ob servation, looking for changes.
Treatment for subungual melanoma? What is the prognosis?
amputation at the distal interpha langeal joint. Affected patients have a survival rate of 60%.
What type of biopsy is done for a sarcoma?
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
How can sarcomas be divided?
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
What tests are necessary to characterize and stage sarcoma?
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
Treatment for Sarcoma
Total Compartmental resection
Sarcoma with a mass 15 cm in diameter. What is the treatment?
Radical amputation or limb salvage. Neoadjuvamt chemotherapy and radiation.
What is the treatment for metastatic sarcoma to the lung?
What is the prognosis?
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).
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?
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.
Severall-cm tender lymph nodes in the groin
infection causing lymphadenitis in the groin, leg,
or foot. Malignancy is a less likely cause.
A firm, tender mass in the medial portion of the groin.
Direct inguinal hernia
A tender area in the lateral portion of the groin and an impulse that travels down the inguinal canal when he coughs
Indirect inguinal hernia
firm, tender mass below the inguinal ligament
Femoral hernia
firm, tender mass with fever, leukocytosis, and acidosis
Segment of bowel is strangulated
Which type of hernia most commonly results in strangulation?
Strangulation is most common in femoral hernias, followed by indirect hernias.
What is the difference between a direct hernia and an indirect hernia?
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.
