SKIN / SOFT TISSUE

Question 1

Most common soft tissue sarcoma

Answer 1

Malignant fibrohystiosarcoma

also called
pleomorphic sarcoms

Question 2

Malignant fibrohystiosarcoma with multiple metastases - what is the management

Answer 2

Can do multiple metasectomy

Question 3

Soft tissue sarcomas most important predictors of prognosis are

Answer 3

mitotic index

and

amount of necrosis.

Question 4

Chemotherapy is effective with what type of sarcoma

Answer 4

CAREFUL radiation therapy most effective for sarcomas overall

Ewing’s Sarcoma, that show survival benefits with neoadjuvant chemotherapy. (KIDS, ONION PEAL)

Question 5

staging of sarcoma

Answer 5

High-grade histologic findings
I-III

deep Fascia

> 5 cm

CAREFUL - nodes considered advanced disease

Staging classifies lesions as:
-T1 - 5 cm
-N1 - regional node involvement
-G1 - well-differentiated -G2 - moderately differentiated -G3 - poorly differentiated -G4 - undifferentiated.
Staging is based on T, N, M and G classification.

Stage IV disease is classified as any G or T with regional nodal involvement (N1) OR evidence of metastatic disease (M1).

Question 6

Li-Fraumeni syndrome associated cancer

Answer 6

Colon cancer

colonoscopy every 2-3 years beginning

breast pre-menopausal

annual breast MRI and twice annual clinical breast examination beginning at age 20-25 years.

adrenocortical carcinoma (ACC)

soft tissue sarcoma,

osteosarcoma,

brain tumors,

leukemias.

Question 7

most common site of metastasis of sarcomas.

Answer 7

The lung is the most common

hematogenous metastasis

Question 8

Staging of sarcoma should include

Answer 8

CHEST CT - rule out lung metastasis, especially for high grade, large (> 5 cm) sarcomas.

NOT mandatory to do CT of the abdomen and pelvis with extremity sarcoma,

MAY consider CT abd/pelv if:
myxoid liposarcoma, 
epitheliod, 
angiosarcoma 
synovial sarcoma, 
which commonly metastasize to the abdomen...

Question 9

when would Imaging alone be considered diagnostic (without bx)

Answer 9

well-differentiated liposarcoma

(also known as atypical lipomatous tumors).

Question 10

what sarcoma need adjuvant

Answer 10

almost all need xrt

may not need radiation therapy, provided that they can be reliably followed:

small (1 cm)

nonneoplastic tissue or biologic barrier (fascia)

Question 11

breast sarcoma

Answer 11

Primary angiosarcoma

breast parenchyma young women.

The only potentially curative therapy is surgery.

patients should be offered a simple mastectomy instead of lumpectomy (don’t need nodes in sarcoma)

Partial resection of pectoralis major may be necessary to achieve negative margins!

The skin may be closed primarily.

staging with:
CT chest, abdomen, and pelvic

MRI of the breast!

contralateral breast may be a site for metastatic disease, but to date, a contralateral prophylactic mastectomy has no proven benefit.

in general responsive to systemic chemotherapy - unlike other sarcomas (besides Eweing)

However, once chemotherapy is stopped, the disease tends to regrow.

AND NO proven survival benefit from systemic therapy.

Question 12

non-op tx of desmodis tumors

Answer 12

first choice

NSAIDS

Tomxafen

maybe: cytotoxic intravenous chemotherapy with different agents and schedules, oral tyrosine kinase inhibitors, GLEVAC?

Question 13

Dermatofibrosarcoma protuberans

Answer 13

locally aggressive

slow, infiltrative growth.

low to intermediate grade.

minimal metastatic potential

tends to recur locally after surgical excision.

appear range from plaque-like to elephant nose

commonly on the trunk and proximal extremities.

Diagnosis punch biopsy.

Excisional biopsy should be avoided because reexcision will be required to obtain wide negative margins.

Other than routine chest x-ray, no preoperative metastatic work-up is indicated.

node exam on physical only

wide, pathologically negative margins as the optimal treatment for primary or recurrent DFSP.

For tumors occurring on the head, face, or other areas where wide local excision is not cosmetically acceptable, Mohs micrographic surgery may be a reasonable alternative.

Radiation therapy is typically provided as adjuvant treatment.

Question 14

What lab do you need with every melanoma workup

Answer 14

LDH

Question 15

When do you give interferon

Answer 15

Positive lymph node

Locally advanced disease

Metastatic disease

Question 16

What are the adjuvant therapy options for melanoma

Answer 16

Yervoy

Zelb B-raf - targets B-raf
must have b - raf pos

Question 17

Merkel cell

Presentation and treatment

Answer 17

This can be deep sub-cu and mimic a lipoma!

2 cm margin

Sentinel lymph node

If node pos:
XRT!
And
chemo (Cis-Platnum)

If node neg:
Chemo
Cis-platinum

Platinum treatment for a special non lipoma lesion

Question 18

Tumor markers for melanoma

and path fetures to request

Answer 18

LDH

Other histopathologic features have prognostic implications and should be routinely described on the pathology report:

regression, 
microsatellitosis, 
vertical growth phase, 
angiolymphatic invasion, 
tumor-infiltrating lymphocytes

(b-raf if considering brafanimb)

“Duh” B-raf enib

mitoses/ mm2.

Removed nodes are then carefully evaluated using hematoxylin and eosin staining and immunohistochemistry techniques with antibodies to one or more melanoma marker epitopes such as:
S100,
HMB45,
MART-1/ Melan-A.

Question 19

Chemotherapy for melanoma

Answer 19

Interferon

“Duh” B-raf enib
(if B-raf pos marker)

yervoy

Question 20

Treatment of melanoma by thickness

Answer 20

Less than one mm
And no ulceration

1 cm wide local excision
No sentinel left on biopsy

1 cm or greater
2 cm wide local excision
Sentinel lymph node biopsy

Satellite lesions

In transit lesions

Question 21

Node stage for melanoma

Answer 21

N1 1

a: micrometastases*
b: macrometastases¶

N2 2-3

a: micrometastases*
b: macrometastases¶
c: in-transit met(s)/satellite(s) without metastatic lymph nodes

N3 4 or greater
or
matted lymph nodes, or in-transit met(s)/satellite(s) with metastatic lymph node(s)

Question 22

T stage melanoma

Answer 22

T1 ≤1.0 mm

a: without ulceration and mitoses 4.0 mm
a: without ulceration
b: with ulceration

Question 23

Patients with clinical stage I and II (localized) melanoma are those with

Answer 23

no clinical or radiologic evidence of regional or distant metastases.

Stage I and II are node negative just like colon

Clinical stage III patients are those with regional metastases, manifesting as enlarged lymph nodes or satellite or in-transit disease or both.

Question 24

Current guidelines recommend sentinel lymph node biopsy for patients with

Answer 24

clinically node-negative melanomas

at least 1 mm in thickness.

If the primary melanoma is

Question 25

Regardless of the stage of the original melanoma, patients with suspected recurrence should be worked up how

Answer 25

complete physical examination
assessment of all lymph node groups.

In patients with prior surgery, the status of the scars at the primary and lymph node resection sites as well as the presence of lymphedema should be documented.

When a melanoma patient presents with an enlarged lymph node, the preferred diagnostic modality is

fine needle aspiration (FNA) of the node.

If this cannot be performed or if the FNA is nondiagnostic,

open biopsy is the next step, orienting the incision so as to facilitate a subsequent lymph node dissection.

The use of imaging studies in the initial staging of the patient with advanced or recurrent disease includes

computed tomography and

positron emission tomography (PET) scans.

PET/ CT fusion scans provides improved anatomic definition but does not eliminate false-positive results.

Pelvic CT scans are often recommended in the setting of inguinofemoral lymphadenopathy to evaluate for the presence of intrapelvic disease.

when patients have neurologic symptoms and for patients with palpable nodes or distant disease:

Brain magnetic resonance imaging (MRI) is recommended .

Question 26

en bloc resection of all inguinal lymphatic

Answer 26

This technique involves tissue contained within the
femoral triangle,
node-bearing tissue superior to the inguinal ligament but superficial to the external abdominal oblique aponeurosis.

The decision making about adding a pelvic node dissection, that is, performing a superficial and deep inguinal node dissection (ilioinguinal lymphadenectomy), remains controversial.

Some authors recommend routine biopsy of Cloquet’s node to predict involvement of pelvic lymph nodes. In our experience, we have found this approach to be of very limited value.

Radiographic evidence of pelvic nodal metastasis is an absolute indication for ilioinguinal lymphadenectomy, but we tend to perform this in most patients with palpable inguinal nodes.

The most common complications following inguinofemoral and ilioinguinal lymphadenectomy include wound infections and seroma, lymphedema, and deep vein thrombosis.

To prevent the femoral vessels from being exposed in the event of a wound disruption, the sartorius muscle is often detached from its origin on the anterior superior iliac spine and transposed, suturing it to the inguinal ligament to cover the femoral vessels.

Typically, inguinal lymphadenectomy patients are kept on bed rest overnight but are asked to ambulate starting on postoperative day 1.

Low molecular weight heparin administration and early ambulation may decrease the rate of postoperative DVT.

Question 27

Current recommendations for adjuvant therapy

Answer 27

stage IIB or III melanoma

interferon alpha therapy

improve relapse-free survival by approximately 20% to 30%, and in some analyses overall survival by a smaller amount.

Adjuvant radiation therapy can be considered in certain situations.

For desmoplastic melanoma with neurotropic spread, radiation to the primary site is often used.

Radiation to the regional node basin is also often recommended in the face of risk factors for postlymphadenectomy regional recurrence, which include

extracapsular extension,

four or more involved lymph nodes,

maximum nodal metastasis size ≥ 3 cm, or

recurrent disease in the nodal basin after complete lymphadenectomy.

Radiation therapy is also used in the treatment of

brain metastases

Ipilimumab, an antibody directed against cytotoxic T-lymphocyte

T-lymphocyte antigen 4 (CTLA4), has been shown to improve overall survival for patients with unresectable metastatic melanoma when given alone or combined with dacarbazine.

More recently, selective inhibition of the mutant BRAF V600E protein with vemurafenib was shown in a phase III study to dramatically prolong progression-free and overall survival compared to dacarbazine. About 50% of patients with metastatic melanoma have tumors that harbor the BRAF V600E gene mutation, so patients with metastatic disease should routinely have their tumors undergo mutational analysis to determine if targeted therapy is an appropriate consideration. Patients treated with vemurafenib or other selective BRAF inhibitors such as dabrafenib develop cutaneous squamous cell carcinomas, particularly keratoacanthoma-type lesions, at a greatly increased frequency.

Question 28

biopsy-proven palpable nodal involvement, should undergo

Answer 28

if there is no radiologic evidence of distant metastases.

wide local excision of the primary tumor

complete lymph node dissection

Question 29

metastatic workup for melanoma should be done when and how

Answer 29

presenting with clinical stage III disease.

history and physical examination. any neurologic symptoms from possible brain metastases.

serum lactate dehydrogenase (LDH) level

at minimum a chest x-ray.

Many surgeons, however, would recommend staging of these patients with a CT scan of the

chest/ abdomen/ pelvis,

PET scan, or PET/ CT.

CT scan or MRI of the brain is not routinely necessary in asymptomatic patients.

histologic confirmation of an abnormal lesion should be obtained whenever feasible before concluding a patient has stage IV disease and abandoning a potentially curable surgical approach.

Question 30

Ax dissection

Answer 30

I, II, and III to provide the best regional control. In a very thin person, anterior retraction of the pectoralis major and minor muscle may allow for adequate dissection of the level III nodes. However, in most individuals, it may be necessary to divide the pectoralis minor. To do so, the pectoralis major is retracted anteriorly and the fascia on either side of the tendon of the pectoralis minor is incised. With a finger behind the muscle to protect the axillary artery and vein, the insertion of the

pectoralis minor is divided with electrocautery.

Question 31

For patients with palpable disease in the groin,

Answer 31

the extent of lymphadenectomy (“ superficial” vs. “superficial and deep”) is controversial. Some surgeons advocate complete superficial and deep inguinal lymph node dissections in all patients with palpable adenopathy. Others reserve deep dissection to those patients with a positive Cloquet’s node, or three or more involved nodes. Still others only perform deep groin dissections when there is radiographic evidence of pelvic adenopathy. If a deep groin dissection is to be performed together with a superficial dissection, this can be accomplished through one skin incision by obliquely dividing the external and internal oblique muscles to expose the pelvic retroperitoneum, or alternatively by dividing the inguinal ligament. Dividing the ligament is particularly useful in cases of extensive disease low in the pelvis along the distal external iliac vessels. Although it is simpler to divide the ligament over the femoral vessels, wound healing may be improved if the inguinal ligament is detached from the anterior superior iliac spine (Table 1).

Dimick, Justin B.; Upchurch, Gilbert R.; Sonnenday, Christopher J. (2012-06-18). Clinical Scenarios in Surgery: Decision Making and Operative Technique: 1 (Clinical Scenarios in Surgery Series) (Kindle Locations 14423-14431). Lippincot (Wolters Kluwer Health). Kindle Edition.

Question 32

A recently completed prospective randomized trial demonstrated that radiation to the basin after radical lymph node dissection

Answer 32

does decrease regional recurrence rates, although this does not appear to impact overall survival. Therefore, it is reasonable to consider postoperative radiation in patients with extracapsular extension, multiple involved lymph nodes (≥ 2 cervical or axillary nodes or ≥ 3 inguinal nodes), or large nodes (≥ 3 cm in the neck or axilla or ≥ 4 cm in the groin), but the risks and benefits of adjuvant radiation must be carefully weighed. Given the higher risk of recurrence and lower morbidity of radiation after a neck dissection, the threshold for adjuvant radiation for cervical metastases is lower. On the other hand, adjuvant radiation after an inguinal node dissection is associated with significant morbidity and should be reserved for patients with a very high risk of relapse. Patients with clinically evident regional metastases are also at a high risk of distant metastases, and most patients in this situation will ultimately die of their disease. Therefore, adjuvant therapy should be considered. Although multiple systemic therapies have been studied, none had demonstrated a benefit in reducing the risk of relapse or death for high-risk melanoma patients until the introduction of high-dose interferon alpha-2b (IFNα-2b). Three randomized studies have demonstrated an improvement in disease-free survival with high-dose interferon (HDI), while two of the three demonstrated an improvement in overall survival. However, significant toxicities of HDI and the equivocal results of some of the trials have made the use of IFNα-2b controversial. Serious side effects include flu-like symptoms (malaise, fevers,

Dimick, Justin B.; Upchurch, Gilbert R.; Sonnenday, Christopher J. (2012-06-18). Clinical Scenarios in Surgery: Decision Making and Operative Technique: 1 (Clinical Scenarios in Surgery Series) (Kindle Locations 14438-14450). Lippincot (Wolters Kluwer Health). Kindle Edition.

Question 33

Adjuvant for melanoma after sentinel lymph node

Answer 33

Some have advocated the use of adjuvant radiation to the dissected nodal basin.

reasonable to consider postoperative radiation in patients with :
extracapsular extension,
 multiple involved lymph nodes 
≥ 2 cervical / axillary nodes 
or 
≥ 3 inguinal nodes), 
or 
large nodes (≥ 3 cm in the neck or axilla or ≥ 4 cm in the groin), 

but the risks and benefits of adjuvant radiation must be carefully weighed.

Given the higher risk of recurrence and lower morbidity of radiation after a neck dissection, the threshold for adjuvant radiation for cervical metastases is lower.

adjuvant radiation after an inguinal node dissection is associated with significant morbidity and should be reserved for patients with a very high risk of relapse.

Patients with clinically evident regional metastases are also at a high risk of distant metastases, and most patients in this situation will ultimately die of their disease.

Therefore, adjuvant therapy should be considered.

introduction of high-dose interferon alpha-2b (IFNα-2b).

Question 34

side effects of IFNa

Answer 34

liver function abnormalities,
neutropenia
infectious complications.

Question 35

MCC other names and presentation

Answer 35

MCC 
 aggressive skin cancer,
also called neuroendocrine carcinoma of the skin 
or 
small cell carcinoma of the skin.

appearence:
flesh-colored, red, or purple.
sometime ulcerates, the overlying skin is frequently intact.

They are most common on sun-exposed areas,

differential includes lipoma, keratoacanthoma, epidermal cysts, pyogenic granuloma, basal cell carcinoma, squamous cell carcinoma, amelanotic melanoma, lymphoma cutis, and metastatic carcinoma of the skin.

Question 36

Workup merkel cell

Answer 36

The diagnosis is made on excisional biopsy.

25% will have palpable regional lymphadenopathy at presentation

5% present with distant metastases.

MCC tumors arise in the dermis and frequently extend into the subcutaneous fat. The tumor is composed of small blue cells with round-to-oval, hyperchromatic nuclei and minimal cytoplasm.

There are three variants: 
intermediate (the most common), 
small cell, 
and 
trabecular. 

The small cell variant is identical to other small cell carcinomas and must be distinguished from metastatic small cell carcinoma.

This can be accomplished through immunohistochemistry.

Merkel cell tumors express CAM 5.2 and cytokeratin (CK) 20. CK7 and thyroid transcription factor-1 (TTF-1), which is typically found on bronchial small cell carcinomas, are absent on MCC.

The intermediate type can often be confused for melanoma or lymphoma.

MCC is invariably negative for S-100 and leukocyte-common antigen, which distinguishes it from these.

MCC typically metastasizes to the regional lymph nodes, skin, lung, brain, bone, and liver.
(same as melanoma)

Question 37

Merkel cell Patients with clinically involved lymph nodes or symptoms suggestive of distant metastases should be staged how

Answer 37

computed tomography (CT) scan of the
chest,
abdomen,
pelvis.

CT scan of the chest should also be considered in patients with the small cell variant to exclude the presence of a lung mass suspicious for small cell lung cancer.

Otherwise, for patients who have clinically localized disease, a chest x-ray alone is reasonable.

Question 38

tx of merkel

Answer 38

BOTH radiosensitive and chemosensitive (BUT chemo NO DIFINITIVE RECS!!)

margins of 2 to 3 cm have historically been recommended.

For lesions 2 cm,
2-cm margin is recommended when feasible.

For patients with MCC in cosmetically sensitive areas, where even 1-cm margins would be difficult, Mohs micrographic surgery has been reported

Question 39

ALL patients with clinically localized MCC should undergo

Answer 39

sentinel lymph node biopsy (SLNB) in conjunction with wide excision REGARDLESS OF SIZE

Approximately 20% to 30% of clinically node-negative MCC patients are SLNB positive, and the pathologic lymph node status is the most consistent predictor of survival.

After changing gowns, gloves, and instruments, the SLNB is performed.

Preoperative planning is critical to determine whether the patient will be able to be closed primarily. If not, then reconstruction with either a split-thickness skin graft or a rotational flap should be considered.

The likelihood of postoperative radiation to the primary site should be taken into account when deciding the optimal method for reconstruction.

Question 40

ratio of skin taken if tyring to elpise out a lesion and get primary closure

Answer 40

3.5 to 1 ratio of length to width.

After excision, the skin flaps are elevated to allow primary wound closure.

Question 41

If primary closure is not likely, then

Answer 41

preoperatively:

either a rotational flap is marked out
or
a donor site for a split-thickness skin graft is prepped out.

If there is any concern regarding the margin status, it may be preferable to place a temporary graft, such as Integra, until the final pathology results are known.

The patient can then return to the operating room for a skin graft or rotational flap once it is known that negative margins have been attained

Question 42

For merkel patients who have clinically involved lymph nodes and no evidence of distant metastasis

Answer 42

complete lymph node dissection (CLND) should be performed at the time of wide resection.

Question 43

For merkel patients with positive SLN biopsy

Answer 43

CT scan may be considered to rule out distant disease.

If negative,

CLND is typically.

Question 44

adjuvant for for merkel

Answer 44

radiosensitive tumor,

radiation therapy to the regional basin alone can be considered in cases where CLND may be excessively morbid or for patients with minimal tumor burden in the SLN.

Failure to treat the lymph node basin after a positive SLN has been associated with high recurrence rates, although the impact on overall survival is unknown.

Presentation to a multidisciplinary tumor board on a case-by-case basis is recommended.

Adjuvant radiation may be omitted for small primary tumors (

Question 45

Adjuvant radiation therapy should be considered for what squamous cell CA

Answer 45

perineural invasion.

Question 46

The mainstay of treatment for squamous cell carcinoma is

Answer 46

excision with histopathologic confirmation of clear or negative margins.

no standardized excisional margins

typically range from 4 to 10 mm.

Mohs micrographic surgery should be considered for squamous cell carcinomas on the face, especially those involving the H-zone (temple, midface, perioral, periorbital and periauricular regions) and neoplasms on the trunk and the extremities, which are larger than 2 cm.

Mohs micrographic surgery usually results in the lowest risk of recurrence.

Recurrent squamous cell carcinomas should be referred for Mohs micrographic surgery.

Question 47

Treatment of basal cell carcinoma

Answer 47

Treatment of basal cell carcinoma is similar to squamous cell carcinoma.

But can also do:
electrodesiccation and curettage for small (

Question 48

His laboratory values that prognosticate NEC fasc include

Answer 48

white blood cell (WBC) count of 18,000 with 23% bands,

serum sodium concentration of 130 mmol/ L,

creatinine of 2.1,

glucose of 300 mg/ dL,

base deficit of 6 mEq/ L.

The laboratory risk indicator for necrotizing fasciitis (LRINEC) score measures nonspecific biochemical and inflammatory markers and can aid in the early recognition of necrotizing infections

A numerical score is assigned based on six laboratory parameters: 
C-reactive protein, 
total WBC count, 
hemoglobin concentration, 
sodium level, 
creatinine, 
glucose. 

A score of ≥ 6 should raise the suspicion of necrotizing fasciitis (positive predictive value, 92% and negative predictive value, 96%),

score of ≥ 8 is strongly predictive of the disease.

The LRINEC score was derived from a single-center retrospective study and requires further validation with prospective studies. Despite this limitation, the LRINEC score remains a useful tool for the early detection of NSTI, and an elevated score should alert the

Question 49

There are three clinical subtypes of nec fasc

Answer 49

Type I infections are the most common form of disease and are polymicrobial in nature. The causative microbes are a combination of gram-positive aerobes (Staphylococcus, Streptococcus, Enterococcus), gram-negative aerobes (Pseudomonas, Escherichia coli, Enterobacter, Klebsiella, etc.), anaerobes (Bacteroides, Clostridium), and fungi (Candida, mucormycoses). These organisms not only act synergistically but can also produce virulence toxins that increase tissue destruction. Type II, or monobacterial, NSTIs are frequently caused by β– hemolytic streptococci, Clostridium perfringens, and Staphylococcus aureus. Salt-water acquired NSTIs occur when a skin wound is infected with Vibrio vulnificus and are referred to as type III NSTIs. While type III infections are uncommon, these may progress rapidly to MOF and cardiovascular collapse within 24 hours and must be recognized and treated quickly. Workup The most important components in the diagnostic evaluation of NSTIs are a high index of suspicion and a thorough physical exam. Findings suspicious for

Dimick, Justin B.; Upchurch, Gilbert R.; Sonnenday, Christopher J. (2012-06-18). Clinical Scenarios in Surgery: Decision Making and Operative Technique: 1 (Clinical Scenarios in Surgery Series) (Kindle Locations 14624-14632). Lippincot (Wolters Kluwer Health). Kindle Edition.

Question 50

buzz words for nec fasc on exam

Answer 50

erythema, 
tense edema, 
vesicles or bullae, 
necrosis, 
grayish wound drainage, 
crepitus, 
ulcers, 
cutaneous anesthesia, 
 pain disproportionate to physical exam findings. 

By the time cutaneous manifestations such as blisters, bullae, crepitus, or skin necrosis are present, there may have been a significant delay in diagnosis and operative debridement.

Question 51

risk factors of NEC fasc

Answer 51

comorbidities:
chronic renal insufficiency, 
diabetes, 
coronary artery disease, 
peripheral vascular disease, 
immunosuppressive 

traumatic injury,
intravenous drug use,
prior surgery.

Question 52

Laboratory evaluation nec fasc

Answer 52

The triad of crepitus, skin blistering, and radiographic evidence of soft tissue gas has a sensitivity of over 80% for the diagnosis of NSTI; thus, these three signs serve as a helpful screening tool.

electrolyte panel,
complete blood cell count with differential,
blood gas analysis.

NO Superficial wound cultures

Laboratory findings associated nec:
 azotemia, 
hypocalcemia, 
hyponatremia, 
leukocytosis, 
thrombocytopenia, 
metabolic acidosis. 

A serum lactate level above 54.1 mg/ dL and a serum sodium level

Question 53

Intraoperative findings suggestive of nec fasc

Answer 53

thrombosis of small blood vessels (obliterative endarteritis),

swollen gray fascia (liquefactive necrosis),

ability to easily dissect fascia away from normally adherent tissue (loss of tissue planes).

If the diagnosis is still uncertain, deep tissue fascial biopsy with frozen section analysis may be confirmatory.

Histologic changes consistent with NSTIs include tissue necrosis:

fibrinous vascular thrombosis,
polymorphonuclear infiltration,
microorganisms within destroyed tissue.

Question 54

treatment of nec fasc

Answer 54

Operative exploration should not be delayed in the unstable patient. A diagnostic incision and even therapeutic exploration can be performed at the bedside in the unstable patient.

use of one initial antibiotic regimen over another; however, most combinations include

High does Vanc, levafloxacin, clinda

penicillins or cephalosporins
with
either an aminoglycoside or a fluoroquinolone,

plus

antianaerobic agent, such as clindamycin or metronidazole.

As the incidence of methicillin-resistant S. aureus NSTIs is increasing, vancomycin or linezolid may be used empirically until culture results are available.

Aminoglycosides and vancomycin should be appropriately dosed and monitored in patients with renal insufficiency.

Question 55

risk factors for vibrio nec vasc and abx choice

Answer 55

cirrhosis
or
saltwater / seafood exposure

Vibrio:
gram-negative bacillus

susceptible to doxycycline,

as well as other antibiotics, with gram-negative activity.

Question 56

Surgical Approach nec fasc

Answer 56

requires prompt surgical debridement and excision of all infected tissue to a margin of normal healthy tissue.

Excision of all infected and necrotic tissue is necessary.

Margins of excision should be carried out to grossly normal tissue, characterized by the lack of inflammation and purulence and the presence of normal bleeding.

A tissue biopsy should be sent to pathology to confirm the diagnosis and help tailor the antibiotic regimen postoperatively.

After irrigation and surgical hemostasis, the wound should be packed open with Kerlix or gauze, or, alternatively, a negative pressure wound therapy system may be used for temporary soft tissue coverage.

reexpl 24h or earlier

Question 57

Fournier’s gangrene,

Answer 57

In a colostomy may be considered if fecal soilage is contaminating the open wound. This can be accomplished with either open or laparoscopic techniques with diverting transverse or sigmoid colostomy.

Question 58

ggressive infections involving the extremities,

Answer 58

With a a damage-control guillotine
amputation or disarticulation may be indicated in the setting of systemic toxicity and hemodynamic instability to control the infection.

have been identified as three independent predictors of limb loss with NSTIs:

Heart disease,
shock (systolic blood pressure