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Lachie FRACS - Brainscape Not Good > Skin & soft tissue > Flashcards

Skin & soft tissue Flashcards

1
Q

Melanoma TNM

A

T:

  • Breslow depth
  • Presence of ulceration

N:

  • Number of LN
  • Mode of detection (sentinel node -micro, clinical - macro)
  • Intransit/satellite lesions

M:

Site of metastasis, LDH level

Stage:

  1. T1-T2a
  2. t2b-t4
  3. N+ (note 4 subgroups A-D)
  4. M+
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2
Q

MSLT-1

A

Randomised to WLE +/- SLNBx

In SLNBx group

  • If positive then immediate complete lymphadenectomy
  • If negative then nodal observation and salvage lymphadectomy

In WLE alone group

  • Nodal observation and salvage lymphadenectomy

Intermediate thickness melanomas (MSLT-1)

  • Of all comers over time 1:5 (20%) will have or develop nodal disease
  • 15% of SLNBx patients will be positive – 80% would have no residual disease on CLNDx
  • 95% of negative SLNBx will not develop nodal disease by 10 years
  • If negative SLNBx 1:20 (5%) chance of developing nodal disease (false-negative)
  • Overall, no difference in survival @ 10 years, but worse survival if node positive disease without SLNBx (1:5 chance of being in this group if SLNBx not done  HR 0.56 of death – proportion alive at 10yrs = 62 vs 41%)

So; do SLNBx because better melanoma specific survival for those that have positive nodes

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3
Q

Care pathway for melanoma 2021

A
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4
Q

Layers of skin

A

But mate, Britney Spears Grows Like Cancer

Subcutaneous fatty tissue

Dermis

  • Reticular
  • Papillary

Epidermis

  • Basement membrane
  • Stratum basale
  • Stratum spinosum
  • Stratum granulosum
  • Stratum lucidum
  • Stratum corneum
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5
Q

What layer do melanocytes and merkel cells live?

A

Melanoma stratum basale epidermis (if in the dermis then a melanoma)

Merkel cells also stratum basale

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6
Q

Fitzpatrick skin types

A

1-6

Lowest are whitest

Easy to burn

Never tan

Red hair

Blue eyes

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7
Q

Subtypes of melanoma

A
  • Lentigo maligna
  • Superficial spreading
  • Nodular
  • Acral including subungal
  • Desmoplastic
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8
Q

Stains suggestive of melanoma

A
  • S100
  • SOX10
  • MelanA
  • HMB45
  • (BRAF PCR)
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9
Q

MSLT2

A
  • MSLT2 trial showed no survival benefit from immediate CLNDx for positive SLNBx, also lymphoedema rate of 25 vs 5%
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10
Q

Tumour marker used in melanoma

A

LDH

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11
Q

Clinical appearance of Merkel Cell?

A

AEIOU Asymptomatic Expanding Immunosuppressed Older UV rays

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12
Q

What causes Merkel cell carcinoma

A

UV rays Merkel cell polyomavirus Age and immunosuppression

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13
Q

High risk features SCC

A
  • Large >2cm
  • >4mm thick
  • Poorly differentiated
  • Near major nerves of head or neck
  • Infiltrative growth
  • Extracutaneous growth
  • Immunosuppressed
  • Histology
    • Perineual
    • Lymphovascular invasion
    • Desmoplasia
      • Clinical features
        • Rapid growth
        • Ears/lips/hands/feet/pretibial/anogenital
        • Multiple cancers
        • Immunosuppression
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14
Q

What is innervated by the median nerve?

A

Motor:

  • All the muscles of the FLEXOR forearm except (FCU, ulnar half of FDP)
  • The LOAF (lumbricals 1-2, oppenens pollicis, abductor policis brevis, flexor pollicis brevis) of the hand

Sensory:

  • The radial half of the palm and palmar surface of radial digits 1-3.5
  • Extensor surface of radial digits 1-3/5 from the PIPJ distally
  • The palm is innervated by the palmar branch of median which doesn’t pass through the carpal tunnel
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15
Q

Describe the course of the median nerve and where it can be compressed

A
  • Medial and lateral cords embrace the brachial artery in proximal arm
  • Overlies the artery, runs deep to biceps and superficial to brachialis in medial arm
  • Lies medial to artery in the cubital fossa
  • Enters the forearm between the head of pronator teres*
  • Passes deep to the fibrous arch* of FDS, runs between FDS and FDP
  • Emerges at the wrist, to the radial side of the FDS tendons, its crossed by PL and FCR tendons
  • Passes through the carpal tunnel* to reach the hand

Branches

  • Anterior interosseous branch
  • Palmar cutaneous branch
  • Recurrent motor branch to the thenar muscles
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16
Q

Describe the course of the ulna nerve

A

Arises from C7-C8-T1 as continuation of the medial cord

Runs medial to the brachial artery

Mid humerus it pierces the intermuscular septum to enter the extensor/posterior compartment

Passes posterolateral behind the medial epicondyle (where it is palpable) through the ulnar tunnel (between medial epicondyle and the olecranon)

Pierces between the two heads of the FCU to travel deep alongside the bone

At the wrist, the ulnar nerve travels superficially to the flexor retinaculum, and is medial to the ulnar artery. It enters the hand via the ulnar canal (Guyon’s canal). In the hand, the nerve terminates by giving rise to superficial and deep branches.

17
Q

What is supplied by the ulna nerve

A

Sensory:

  • Ulna half of the hand (including digits 4-5)

Motor:

  • Anterior forearm FCU and ulna half of FDS
  • Hand muscles except palmaris brevis and LOAF
18
Q

What is Guyons canal

A

Guyon’s canal

  • Fibro-osseous tunnel located at the level of the palm, transmits the ulnar neuromuscular bundle from the forearm into the hand
  • Borders
    • Floor: Transverse carpal ligament, pisohamate ligament, hypothenar muscles
    • Roof: Palmar fascia and the palmaris brevis muscle
    • Lateral: hook of hamete
    • Medial: pisiform
  • Contents
    • Ulnar nerve; bifurcating into deep motor and superficial sensory branches
    • Ulnar artery
    • Venae comitantes of the ulnar artery
    • Lymphatics
19
Q

Peripheral nerve injury pathophysiology

A
  • Degree of injury:
    • Neuropraxia:
      • Myelin injured, causes conduction block.
      • Heals fast, full recovery (eg. Saturday night radial palsy)
    • Axonotmesis:
      • Axon injured, a portion remains proximally attached to the cell body, distal portion undergoes “Wallerian degeneration”.
      • Proximal portion will attempt to grow at 1mm/day.
      • Recovery achievable if supporting tissues (endo, peri, epineurium) intact and <18-24/12 (after which neuromuscular junction irreversibly damaged).
    • Neurotmesis:
      • Myelin, axon and supporting structures injured.
      • No recovery, need surgery.
  • Management:
    • Observation
    • Surgery:
      • Neurolysis
      • Direct repair
      • Nerve graft
      • Nerve transfer
    • Timing of surgery:
      • Early (3 days): lacerations; neurotmesis
      • Subacute (3 weeks): blunt / ragged transections; neurotmesis
      • Delayed (3 months): lesions-in-continuity; axonotmesis
      • Late (>1y): salvage procedures
20
Q

explain ulnar paradox

A

The ulnar paradox describes the counter-intuitive situation of a distal ulnar lesion causing a worse claw-hand deformity. If the ulnar nerve lesion occurs more proximally (closer to the elbow), the flexor digitorum profundus muscle may also be denervated. As a result, flexion of the IP joints is weakened, which reduces the claw-like appearance of the hand. With more distal lesions, the FDP maintains the flexion of the IP joints and the affected lumbricals cannot oppose the flexion. (JB)

21
Q

What cancers are common in Li fraumeni?

A

SLAB

Sarcoma

Leukaemia

Adrenal adrenocortical carcinoma

Breast/Brain

22
Q

What cancers are common in NF1?

A
  • Neurofibromas – cutaneous, plexiform, nodular
  • Optic pathway gliomas and CNS tumours – astrocytomas, brainstem gliomas
  • Soft tissue sarcomas
    • Malignant peripheral nerve sheath tumours
      • Arise from pre-existing neurofibromas that have under gone malignant transformation
      • 5-13% lifetime risk
    • Rhabdomyosarcomas
      • Early age, GU site
    • GIST
      • Usually small bowel (70%), often multiple
    • Glomus tumours
  • Other tumours
    • Juvenile myelomonocytic leukaemia of childhood
    • Phaeochromocytoma
22
Q

What cancers are common in NF1?

A
  • Neurofibromas – cutaneous, plexiform, nodular
  • Optic pathway gliomas and CNS tumours – astrocytomas, brainstem gliomas
  • Soft tissue sarcomas
    • Malignant peripheral nerve sheath tumours
      • Arise from pre-existing neurofibromas that have under gone malignant transformation
      • 5-13% lifetime risk
    • Rhabdomyosarcomas
      • Early age, GU site
    • GIST
      • Usually small bowel (70%), often multiple
    • Glomus tumours
  • Other tumours
    • Juvenile myelomonocytic leukaemia of childhood
    • Phaeochromocytoma
23
Q

Sarcoma grading and staging

A
  • Grading
    • Classified as low (grade I), intermediate (grade II) or high (grade III)
    • Depends on
      • Differentiation
      • Necrosis
      • Mitotic count
  • Staging
    • Size – T1_<_5, T2 >5
    • Depth related to fascia – superficial T1a or 2a, deep T1b or 2b
    • Nodal spread is rare
24
Q

Synoptic report melanoma

A

Lachie FRACS - Brainscape Not Good (15 decks)

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