Skin/Soft Tissue

Question 1

When to consider BRAF testing in melanoma

Answer 1

stage III at high risk for recurrence

Question 2

1 microscopically positive SLN in melanoma

Answer 2

MSLT II trial
No ALND necessary. Decreased local recurrence but no survival benefit.
Surveillance q6mo US of LN basins at risk
Present case at tumor board
Strongly consider full body staging including CT C/A/P + MR brain OR full body PET

Question 3

Additionally lab testing for melanoma

Answer 3

BRAF
KRAS
NRAS

Question 4

BRAF + melanoma

Answer 4

60%
Dabrafenib + tarafenib
Pembro
At least 1 year

Question 5

Extremity sarcoma - staging

Answer 5

CT chest + MRI of affected extremity

Question 6

Indications for pre op RT for extremity sarcoma

Answer 6

Intermediate or high grade, most recommend pre op RT

Question 7

How to make tissue dx for sarcoma

Answer 7

Incisional or core biopsy

Question 8

Any time when chemo recommended adjuvantly for sarcoma

Answer 8

If mets (unlikely, poorly responsive) or margin + and resection causes a lot of morbidity

Question 9

Metastatic sarcoma to lung - adjuvant therapy?

Answer 9

Maybe chemo, immunotherapy regimen

Question 10

Borders of deep inguinal lymphadenectomy

Answer 10

Inguinal ligament
Adductor magnus
Sartorius

Question 11

RP sarcoma - XRT?

Answer 11

Not typically. Neither is chemo

Question 12

RP sarcoma - preoperative testing

Answer 12

Consider split function scans to assess if other kidney is functional incase removal is necessary

Question 13

Inguinal lymphadenectomy - OR

Answer 13

Curvilinear incision from ASIS down medially
ID inguinal ligament and trace down to vessels and identify vessels (NAVL) and come right along artery/vein and lift mass up
Take saphenous v. at femoral origin and ligate
Take down to Hunters canal and take saphenous again there
Take out Cloquet’s node - if positive, consider going further up and split inguinal ligament and at least up to bifurcation of iliac
Sartorious muscle transposition

Question 14

Margins for melanoma in situ

Answer 14

0.5 cm

Question 15

Indications for SLNB in melanoma

Answer 15

> 1 mm thickness or 0.8 mm + ulceration

Question 16

SLN for melanoma - OR

Answer 16

Inject isosulfan blue and radiotracer around lesion 1-2 hours prior
After excision of primary, use gamma probe to ID node
Make incision that takes possibility of future complete LND into account
Excise all nodes with blue dye or radioactivity