Soft Tissue Flashcards
hurley stages of HS
I. localized abscesses
II. sinus tracts
III. interconnected tracts
tx HS
I: topical clinda, benzoyl wash
II: PO doxy + rifampin + antiandrogenic, adalimumab refractory
+ III: wide excision with healing by secondary intention (no graft)
acute abscess HS
deroof (not “I&D”)
LRINEC
for NSTI; Na<135, Cr >1.6, glucose, Hgb<13.5, WBC>15000, CRP>150
6+ = NSTI sus
8 = dx
how long to observe for rabies?
10 days
erysipelas vs cellulitis
differentiated from cellulitis by its raised lesions with sharply demarcated borders between infected and normal skin
also GAS
merkel cell carcinoma
skin neuroendocrine cells > purplish nodule/plaque
test positive for neuron specific enolase, cytokeratin, neurofilmanet protein
resection with 1- to 2-cm margins and ***sentinel lymph node biopsy in clinically localized cases
metastatic workup before surgery for high-risk tumors should be considered. Positron emission tomography/computed tomography and magnetic resonance imaging would be appropriate choices for an initial staging approach.
melanoma dx
<2 cm: excisional Bx Tru Cut CNBx unless cosmetically sensitive (just then curative excision with margins)
> 2cm or cosmetically: incisioanl Bx w
stains for melanoma
S100 and HMB-45
melanoma scary depth?
6mm
melanoma clinically node positive
need FNA of node.
if positive, can do therapeutic dissection or neoadjuvant therapy
melanoma mgmt margins
5-mm margins for melanoma in situ
1-cm margins for invasive melanoma <1mm depth
1- to 2-cm margins for invasive melanoma 1 to 2 mm depth
2-cm margins for invasive melanoma depth > or equal to 2 mm.
Sentinel lymph node biopsy should be done for patients with melanoma of Breslow depth greater than or equal to 0.8 mm or less than 0.8 mm but with high-risk features such as ulceration or increased mitotic 2+, <42YO, lymphovascular invasion, head or neck region
Head and neck melanomas anterior to ear and above lip needs this in addition to SLNBx
superifical parotidectomy
postop melanoma surveillance MSLT2 trial
The Multicenter Selective Lymphadenectomy Trial 2 (MSLT-2),positive SLNBx followed by nodal ultrasounds every 4 months for the first 2 years, every 6 months for years 3 through 5, and then annually
ax node positive in melanoma?
need level I, II, and III nodes*****
worst prognosis for melanoma?
nodular type; bluish black
desmoplastic melanoma subtype; postop radiation?
Desmoplastic melanoma is the one subtype where radiation to the primary site has been shown to increase local control rates.
melanoma in situ or “thin lentigo maligna” mgmt
0.5 cm margins is OK
melanoma metastatic disease mgmt
First line: dacarbazine (first line)
also
Pembrolizumab PD-1 with ipilimumab (chemotherapy)
MC type of melanoma
superficial spreading (sun exposed)
where does acral lentiginous melanoma present?
African Americans; soles/palms/below fingernails
dermatofibrosarcoma protuberans (reddish firm nodule) factor that increases metastatic risk?
fibrosarcomatous change
(look for mets to LUNG if seen) – get CT chest
just resect and resect and resect if recurs locally (wide local excision)
pilonidal disease dx?
clinical alone.
sarcoma mgmt
NEOADJ or ADV RADIATION
+
RESECTION to microscopically negative margins and preservation of extremity function
preoperative radiation should be considered for larger tumors (more than 5 cm) and high-grade tumors to increase the chances of complete tumor resection, preservation of critical neurovascular structures, and limb salvage, and to improve margin negativity rates
no SNLBx (heme spread only)
sarcomas are chemosensitive typically. Chemotherapy (DOXORUBICIN) is typically reserved for certain and select cases of unresectable tumors, metastasis, or particularly chemosensitive subtypes
