Skin, Soft Tissue

Question 0

Patient has skin lesions suspicious of melanoma – next step?

Answer 0

Excisional biopsy unless contiguous with important structures (then incisional biopsy)

Question 1

Findings suggestive of melanoma?

Answer 1

ABCD

Asymmetry
Border irregularity
Color variation
Diameter over .6 cm

Question 2

Patient presents with lesion on forearm. Management if biopsy shows:

1. Basal cell carcinoma
2. Squamous cell carcinoma
3. In situ melanoma
4. Dysplastic Nevus

Answer 2

1. Excise
#If histologic margins of free of tumor, no additional treatment. 
#If margins are positive, reexcise. 
#Can also use topical 5-FU or radiation. 

2. #If 4 mm or greater, need 1 cm margins
#If 10 mm or greater, likely metastases to lymph nodes – However do not excise lymph notes unless clinically palpable. 
#Also use 5-FU or radiation

3. Excise lesion to 1 cm margins
4. Excision and routine surveillance

Question 3

Four important findings regarding melanoma that affect prognosis?

Answer 3

1. Histologic classification
2. TNM stage
3. Presence of ulceration (worse prognosis)
4. Lesions on the Face or truck (worse prognosis)

Question 4

Patient with MELANOMA – management if:

1. 0.7 mm depth
2. 1.6 mm depth
3. 4.5 mm depth

Answer 4

1. Excision with 1 cm margin down to deep fascial plane followed by CXR, CBC, LFTs

C. Excision with 2 cm margins. 
#If palpable lymph nodes, therapeutic lymphadenopathy
#if no palpable lymph nodes, sentinel node biopsy

3. Patient will most likely die of metastatic disease
#Excision with 2-3 cm margins
#Excision of palpable lymph nodes
#CT of abdomen, CXR, MRI of brain
#Treatment with interferon

Question 5

All patients with stage IV melanoma should enter trial of what drugs?

Management if lung/brain metastases? If bone metastases?

Answer 5

Immunotherapy (interferon)
+ Combination drugs/dacarbazine

If solitary long/brain metastases – resection

It’s bone metastases – radiation

Question 6

Clark levels of melanoma?

Answer 6

1 – confined to epidermis
2 – invades papillary dermis
3 – invades entire length of papillary dermis
4 – invades reticular dermis
5 – invades subcutis

Question 7

Lentigo maligna melanoma – Age group? description? Prognosis? Management?

Answer 7

Elderly; superficial and spreading (not invasive)

Favorable prognosis (versus melanoma) because of superficiality

Excision with a narrow margin

Question 8

Hutchinson freckle – aka? description? Prognosis? Management?

Answer 8

Lentigo maligna

Brown lesion on the cheek – not inherently malignant but precursor of lentigo malignant melanoma.

Close observation

Question 9

Management (and any differences in prognosis) of melanoma if:

1. 4.2 mm depth close to nasolabial fold
2. On sole of foot
3. On subungal area of index finger
4. On anus

Answer 9

1. Margins of excision maybe smaller on the face
2. Thicker and associated with poorer prognosis
3. Excision involves amputation at distal interphalangeal joint (survival rate of 60%)
4. Usually on dentate line; usually require abdominoperineal resection of the anorectum; mortality near 100% in 5 years

Question 10

Patient with stage I malignant melanoma removed five years ago presents with abdominal distention, nausea, vomiting. X-ray shows evidence of small bowel obstruction. Suspected diagnosis? Management? Prognosis?

Answer 10

Melanoma metastasis to peritoneal cavity

Exploration; poor prognosis

Question 11

50-year-old man presents with painless 5cm mass on anterior thigh which has been present for months. Suspected diagnosis? Neoplasm of what tissue? Specific types (and which are associated with)?

Answer 11

Soft tissue sarcoma; connective tissue

Fibrosarcoma (history of therapeutic radiation) and Lymphangiosarcoma (history of axillary lymphadenectomy)

Question 12

50-year-old man presents with painless 5cm mass on anterior thigh which has been present for months. Likely diagnosis? Management? Associated with poor outcome?

Answer 12

Sarcoma
#Incisional Biopsy (Excisional if under 3 cm, incisional if over)
#CT scan for staging and metastases (liver, lungs, bone, brain)
#Total compartmental resection (limb sparing and provides local control)

Size greater than 15 cm or symptomatic

Question 13

Total compartmental resection – Indications? Involves? Benefits?

Answer 13

Sarcomas

Remove entire tumor plus all enclosing tissue (if myosarcoma, entire length of muscle, origin, insertion, investing fascia)

1. Limb-sparing
2. Excellent local control

Question 14

Difference in treatment between low-grade and high-grade 15 cm sarcoma?

Answer 14

Total compartmental resection versus

1. radical amputation
2. radical compartmental resection with neoadjuvant chemoradiation

Question 15

Patients with high-grade sarcoma will likely develop metastasis where? Only type of Sacoma that responds well to chemotherapy?

Answer 15

Lung (50% of patients)

Childhood retroperitoneal pelvic rhabdomyosarcoma

Question 16

52-year-old man with history of low grades sarcoma s/p excision presents for one year follow-up. CXR shows 1.5 cm mass in the right upper lobe of lung. Management?

Management if bilateral lesions are found?

Answer 16

1. CT with contrast
2. Percutaneous needle biopsy or PET scan
3. If either positive, thoracic wedge resection

Median sternotomy parentheses allows multiple which resections simultaneously)

Question 17

Tumor in which excision of pulmonary metastases may result in significant long-term disease-free interval?

Answer 17

Sacoma