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
mgmt of sarcoma isolated mets
resect if palliative not indicatd
MC sarcoma
malignant fibrous histiosarcoma > liposarcoma
chronic paronychia mgmt
topical steroids > nail plate removal.
melanoma prognosis based on? recurrence base on?
prognosis based on Breslow
recurrence based on nodal disease (off SNLBx)
I&D recurrence in pilonidal disease?
I&D 40% recurrence
sarcoma initial diagnostic step?
IMAGING VIA MRI (because heterogenous and need to aim biopsy at most high grade spot; also r/o vascular/neuro/bone invasion)
then, Core Needle Bx > FNA (only use for recurrence)
excisional Bx if < 4 cm
sarcoma staging based off of? AKA most important prognostic factor
GRADE.
where does sarcoma met to? HEME
lungs
NSTI type I
and type II
Type I: polymicrobial
Type II: mono microbial (S. pyogenes, C. perfrigens > Vibrio (eating touching oysters)
Clostridium septicums association
colon cancer
postop seroma prevention; vacuum closed drains; when to DC drain?
<30cc/day.
pilonidal disease surgical management
only after I&Ds have failed
excision with primary repair
if still fails, needs flap: rhomboid (Limberg flap), Karydakis flap, and cleft-lift technique.
mgmt of herpetic whitlow
observation and avoid contact; don’t incise the bed of the ulcer (systemic spread)
decubitus staging
Stage 1: intact skin characterized by non-blanching erythema
Stage 2: partial thickness injury with loss of dermis. This may present as a shallow ulcer with (1) red or pink wound bed or (2) intact blister or bullae.
Stage 3: full-thickness skin loss with exposure of subcutaneous fat or tissue but no exposed muscle, tendon, or bone.
Stage 4: full-thickness skin loss with exposed muscle, tendon, or bone
Unstageable: lesions with overlying eschar or slough with indeterminable depth
desmoid tumor (aggressive fibromatosis from fibroblasts)
get MRI first to characterize and need to STAGE it and biopsy.
small, asymptomatic: surveillance
if bigger, sx: surgical resection is indicated (high rate of recurrence)
If cannot resect: NSAIDs, tyrosine kinase inhibitors, hormonal therapy, or chemotherapy
suspected basal cell carcinoma?
excisional biopsy
Dysplastic nevus syndrome = familial atypical multiple mole melanoma FAMM:
AD disease >50 dysplastic nevi and family hx
MC malignancy in US
BCC (4x SCC)
pathology of basal cell carcinoma
peripheral palisading of nucleia nd stromal retraction
basal cell carcinoma tx
resect with 0.3 to 0.5 cm margins or MOHS if high risk
morpheaform type of basal cell carcinoma
most aggressive; produces COLLAGENASE
squamous cell ca tx
5-10mm resection
bowens disease
SCC in situ ass’d HPV
mgmt: imiquimod, cautery, topic 5-FU, avoid wide local excision
CTM with frequent bx to r/o cancer
exceptions to margins for SCC
penile, vulvar, and Marjolin’s (burn) need 2 cm margins
liposarcoma surveillance
stage I disease: physical exam every 3 to 6 months for 2 to 3 years and then annually. A CT chest>chest x-ray should be considered every 6 to 12 months.
stage II or stage III disease: seen every 3 to 6 months for clinical assessment for 2 to 3 years, then every 6 months for the next 2 years, and then annually. Imaging of the tumor site and chest is routinely performed.
pilonidal disease abx indication
if cellulitis or immunocompromised (because otherwise just drain acutely)
leiomyosarcoma mgmt
chemotherapy for metastatic
no radiation
surgical resection for R0
what happens when scintigraphy identifies 2 nodal basins?
dissect both.
superificial inguinal lymphadenectomy
= femoral triangle plut 5-7 cm above inguinal ligament
the adductor longus muscle medially
sartorius muscle laterally.
superior boundary is the inguinal ligament (need to clear above this)
burn energy needs equation?
indirect calorimetry; determining resting energy requirements in complex patients
kaposi sarcoma mgmt
HAART shrinks it
radiation or intralesional vinblastine for local
IFN-a for dissmeinated
surgery if intraabdominal bleeding
rhabdomyosarcoma (vagina= botryoides tumor) is MC sarcoma in kids
embryonal more common; alveolar type worst prognosis]
think: Li Fraumeni syndrome
rhabdomyosarcoma has whwat in path?
desmin
rhabodmyoarcoma mgmt
surgery or doxorubicin chemotherapy
neuromas association
think NF or von REcklinghausen dz (cafe au lait, axillary freckling, peripheral and CNS tumors)
mgmt actinic keratosis
get an excisional bx to confirm then use diclofenac sodium and liquid nitrogen
suppurative thrombophlebitis
IV abx x 4-6 wks
