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CGSO oral boards > soft tissue > Flashcards

soft tissue Flashcards

1
Q

Lesions you can treat with photodynamic therapy?

A

Aktinic Keratosis
Superficial BCCs
SCC in situ

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2
Q

Sarcoma T staging

A

T1: <5cm
T2: 5-10 cm
T3: 10-15 cm
T4: >15 cm

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3
Q

Major contraindication to limb sparring surgery for STS?

A

If nerve function is already gone then no point in limb sparring

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4
Q

STS involvement of aorta and IVC

A

Sideclamp IVC, fix hole with a bovine pericardial patch

resect segment of aorta, do an interposition graft

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5
Q

Chemical risk factor for SCC?

A

Arsenic

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6
Q

Topical interferon response rate?

A

50-80% regression in non-melanoma skin cancer.

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7
Q

Preop RT for extremity sarcoma?

A

yes for all G2-G3 [nccn catagory 1]

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8
Q

Other flaps for closure of melanoma defect

A

Keystone flap - limbs

hatchet flap - large areas with a lot of tension

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9
Q

vemurafenib/trametinib during pregnancy?

A

class D

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10
Q

penile radiation?

A

outcomes are generally non-functional. Would not reccomend

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11
Q

How do you do an ILP of the lower extremity?

A

cannulation of the external iliac vessels via a hockey stick incision for thigh sarcoma

connect cannula to the inflow and outflow lines of an extracorporeal bypass circuit. (prevents hypoxia, allows longer run time)

A tourniquet is applied around the root of the extremity

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12
Q

SLNB for MCC?

A

guides RT

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13
Q

Rate of SLN positivity for T1b melanoma?

A

8%

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14
Q

Differences between ILI and ILP

A

ILI circulates blood in the isolated extremity at a much slower rate than ILP and for only 30 minutes.

During ILI, the extremity is hypoxic, which leads to marked acidosis.

ILI uses standard chemotherapy drugs and not TNF.

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15
Q

S100 and Sox10 in a retroperitoneal mass

A

Malignant PEripheral Nerve Sheath Tumor

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16
Q

NCI 1998 EBRT RCT for extremity sarcoma?

A

High grade had 0 v 22% LR at 10 yrs (p = 0.003)

Low grade had 4% v 33% LR at 10 yrs (p = 0.016)

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17
Q

Supplement to reduce risk of BCC/SCC?

A

Vitamin A

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18
Q

adjuvant therapies for desmoplastic melanoma?

A

Generally a lower threshold for RT but no prospective data.

66% improved local control with RT; have a higher local recurrence rate via retrospective data.

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19
Q

IS there a specific biomarker for olaratumab?

A

no

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20
Q

When do you do SLNB for desmoplastic melanoma?

A

Same for regular melanoma, no randomized data, but no evidence of greater LN mets.

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21
Q

Melanoma on plantar surface of foot?

A

let granulate from below

do a STSG from other part of the plantar surface of the foot. (glabrous skin)

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22
Q

High risk subtypes of BCC?

A

Infiltrative

Morpheoform

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23
Q

Radiation margin for EBRT for soft tissue sarcoma

A

5cm

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24
Q

High risk BCC with nerve involvement?

A

spare nerve and add RT

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25
Q

Neoadjuvant chemo for extremity STS?

A

would heavily emphasize tumor board and clinical trial enrollment.

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26
Q

Risk factors to add RT for desmoplastic melanoma?

A

Logical to recommend for most, but especially:
T3 or higher
perineural invasion
Head and Neck

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27
Q

Radiation margin for MCC

A

5cm

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28
Q

additional test for sarcomatous transformation of a DFSP?

A

send FISH for a translocational fusion gene

collagen to PDGFbeta

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29
Q

Treatment for cutaneous horn?

A

excise to subdermal fat to remove the base.

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30
Q

Agents used in isolated limb infusion for STS

A

TNF alpha - only available in Europe, or a trial
melphan
interferon

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31
Q

two radiosensitive STS

A

synovial cell sarcoma

myxoid sarcoma

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32
Q

Actinic Keratosis cancer risk?

A

10% become SCC

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33
Q

Radiation dosing for MCC primary

A

R0: 50-56 Gy
R1: 56-60 Gy
R2/definitive: 60-66 Gy

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34
Q

Sarcoma near the popliteal fossa

A

find the nerves proximal and trace them inferiorly

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35
Q

Merkel Cell Polyomavirus

A

DNA virus
almost all humans get at some point
mild respiratory symptoms in adolescence/late childhood
only causes cancer in very small % of those infected
virus is permanently integrated into the cancer cells, so not infectious.

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36
Q

What margin is most important for BCC?

A

deep

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37
Q

Olaratumab and OS of sarcoma

A

1 year improvement

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38
Q

Metastatic MCC

A

No big NCCN reccomendation, would present at tumor board, try aggressive surgery and radiation for a fit patient.

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39
Q

Any increased toxicity by adding Doxorubicin or Ifosfamide to RT for STS?

A

No

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40
Q

Medical treatment for desmoid after delivery?

A

tamoxifen and NSAIDs

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41
Q

hibernoma

A

benign retroperitoneal tumor

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42
Q

Radiation dosing for MCC nodal basin

A

high risk but SLN not done: still do 46-50 Gy
SLN- : no RT
SLN+: 50-56 Gy

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43
Q

cystic lymphangioma

A

benign retroperitoneal tumor

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44
Q

High risk pathology for BCC

A

subtypes other than nodular or superficial

perineural involvement

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45
Q

Do margins ever impact OS in any of the margin trials for melanoma?

A

No

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46
Q

What to add for epitheliod sarcoma and clear cell sarcoma?

A

Consider adding PET or other modality to look for lymph node metastasis.

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47
Q

Imatinib dosing

A

400mg for exon 11

400mg bid for exon 9

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48
Q

When to do neoadjuvant RT for RP sarcoma?

A

when an R2 resection is otherwise expected.

Always better to do RT upfront

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49
Q

Non-surgical considerations for patient with Li Fraumeni syndrome?

A

radiation causes secondary tumors consider avoiding radiation therapy;
get a surveillance MRI instead of surveillance CT scan

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50
Q

Original RCT showing equivalent OS between amputation and limb sparring surgery with adjuvant RT.

A

Steven Rosenberg at NCI, published in 1982

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51
Q

Treatment for Actinic Keratosis?

A

topical 5-fu

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52
Q

Things to add at the end of an inguinal lymph node dissection?

A

preserve the saphenous

do a sartorius transposition flap

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53
Q

Most common retroperitoneal sarcomas?

A

liposarcoma

leiomyosarcoma

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54
Q

Incidence of metastatic disease with a Marjolin’s Ulcer?

A

20-30%; Would get systemic staging for all.

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55
Q

What is “image guided therapy” RT for sarcomas?

A

re-image during therapy to reduce dosage as tumor shrinks.

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56
Q

Response rate to ILI

A

85-90%

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57
Q

Surgical approach to retrohepatic sarcoma

A

hockey stick Makuuchi incision
Mobilize the liver
dissect out the hepatic veins and control
Be prepared to take right kidney.
Can take left renal vein and let left kidney drain via the gonadal. (test clamp)

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58
Q

Preop workup for DFSP?

A

consider MRI if big.

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59
Q

Sox 10

A

immunostain for desmoplastic melanoma

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60
Q

OB/GYN asks you to resect a desmoid at the time of cesarian section?

A

No; tumor will regress (see above)

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61
Q

Is estimated tumor necrosis standardized by pathologists in STS?

A

no (but it is in osteosarcoma and Ewings…)

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62
Q

ILI response rate

A

about 40%

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63
Q

MDM2 amplification

A

Liposarcoma

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64
Q

Two STS that can go to lymph nodes?

A

Epitheliod sarcoma

Clear Cell sarcoma

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65
Q

smooth muscle actin and desmin

A

Leiomyosarcoma

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66
Q

isolated limb infusion

A

vessels accessed by VIR, Tourniquet is applied

No ECMO, so is acidotic/hypoxic

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67
Q

Sarcoma grading

A 
2-8 point scale based on
tumor differentiation (1-3)
mitotic count (1-3)
tumor necrosis (0-2)
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68
Q

5 year survival extremity sarcoma all comers?

A

50-60%

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69
Q

High risk tumor factors for BCC/SCC

A

any H area of central face, genitals, hands or feet
>1cm HEENT
>2cm Trunk/limbs

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70
Q

Which is more cosmetically acceptable for NMSC treatment, RT or surgery?

A

surgery!

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71
Q

Risk of SCC after organ transplant?

A

50% at 20 years.

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72
Q

Theoretical arguments for neoadjuvant RT for STS?

A 
RT works better due to less hypoxia
smaller field (Rad/Onc can aim)
no delays due to surgical complications
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73
Q

Most common location of desmoplastic melanoma?

A

Head and neck

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74
Q

Prognosis of desmoplastic v mixed desmoplastic melanoma?

A

pure desmoplastic has better prognosis than mixed desmoplastic.

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75
Q

Radiation dosing for SCC

A

can go up to 70 Gy for macroscopic disease.

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76
Q

Basal Cell Nevus Syndrome

A

multiple BCC
Skeletal abnormalities
1st BCC in 20s
average life expectancy with strict sun avoidance

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77
Q

Merkel Cell management?

A

do the SLNB

can choose to irradiate the draining bed instead of CLND

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78
Q

adrenal angiomyelolipoma

A

benign retroperitoneal tumor

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79
Q

EORTC 62961

A

better local control for regional hyperthermia plus chemotherapy than for chemotherapy alone for those patients with the highest risk of local recurrence

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80
Q

Desmoid first step?

A

repeat CT scan in 3 months unless exceedingly symptomatic

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81
Q

Isolated Limb Infusion

A

surgical isolation of the vascular inflow and outflow of an extremity to separate the circulation of the affected limb from that of the remainder of the body

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82
Q

Sarcoma staging

A

Stage I - any G1
Stage II - T1 G2-3
Stage III T2+ G2-3
Stage IV any nodes or distant mets

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83
Q

Recurrent BCC

A

refer for Mohs surgery

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84
Q

How do you do an ILP of the upper extremity?

A

Cannulate axillary artery and vein

connect cannula to the inflow and outflow lines of an extracorporeal bypass circuit.

A tourniquet is applied around the root of the extremity

85
Q

Non-surgical option for problematic desmoid during pregnancy?

A

low dose doxorubicin (established as safe from breast cancer series)

86
Q

myxoid liposarcoma staging

A

needs full body CT scan

87
Q

Stage IV recurrence of BCC

A

clinical trial or Vismodegib (hedgehog inhibitor)

88
Q

immunotherapy during pregnancy?

A 
not recommended on basis of mechanism; no data yet
class D
89
Q

Rate of compartment syndrome after ILP?

A

3% -

90
Q

bad histologies for SCC

A

acanthotic
adenosquamous
desmoplastic
metaplastic

91
Q

Mechanism of Imiquod

A

topical modulator of immune response

92
Q

SMAC Metanalysis of RCTs for adjuvant chemo after resection of STS?

A

doxorubicin ifosfamide had improved OS with p = 0.01

93
Q

Melanoma during pregnancy?

A

Be aggressive

transplacental metastasis of melanoma to baby has been reported.

94
Q

RT for gorlins syndrome?

A

contraindicated

95
Q

preventative drugs for SCC

A 
oral retinoids (Vit A) - teratogenic
nicotinamide (Vit D3)
96
Q

Survival after metastasectomy for stage IV sarcoma?

A

40-50% 3 year survival

97
Q

Unresectable RP sarcoma

A

Bilateral Renal artery involvement
Portal Vein/SMA encasement
Aortic encasement without reconstruction option
IVC encasement without reconstruction option

98
Q

larotrectinib?

A

FDA approved TRK Inhibitor, for Patients with Advanced Solid Tumors Harboring an NTRK Gene fusion

99
Q

Response rate for desmoids for most systemic therapies?

A

20%

100
Q

Stage IV/unresectable Merkel Cell Carcinoma

A

Pembolizumab

101
Q

first line systemic agent for disseminated MCC?

A

clinical trial

avelumab/pembrolizumab (combined PD-1 PDL-1 blockade) (better PFS than chemo in early trials)

102
Q

Recurrent abdominal liposarcoma in 3 locations, what next?

A

re-resect

[TARPS study, Cancer 2017]

103
Q

Time frame to regression of desmoid after delivery?

A

1-2 years

104
Q

Is there a definitive RCT for melanomas between 1 and 2 mm for margin?

A

No

105
Q

Where is RT contraindicated for NMSC?

A

Hands, feet and genitals

106
Q

high risk pathology for SCC

A

poorly differentiated
bad histologies
>6mm deep
perineural invasion

107
Q

SMI 2008 ILI series for extremity sarcoma?

A

ILI with melphan/actinomycin D

similar outcomes to ILP in europe

108
Q

What percent of melanoma patients get in transit disease?

A

3-10%

109
Q

score for a G2 sarcoma

A

4-5

110
Q

4 most common extremity sarcomas?

A

undifferentiated pleomorphic
liposarcoma
synovial sarcoma
fibrosarcoma

111
Q

retroperitoneal sarcoma with hepatic vein involvement?

A

Be prepared to go on ECMO

112
Q

FDA approved targeted therapies for metastatic sarcomas?

A

trabectedin - intercalating agent
eribulin - microtubule inhibitor
olaratumab - PDGFR blocker
pazopanib - dirty TKI

113
Q

pattern of metastasis for myxoid liposarcoma?

A

liver instead of lung

114
Q

Leiomyosarcoma recurrence pattern?

A

highest risk of metastatic over local recurrence.

use to support systemic chemo in adjuvant setting.

115
Q

SCC when to do lymphnode dissection

A

selective dissection if solitary node <3 cm

comprehensive nodal dissection if >3 cm or multiple

116
Q

metastatic pattern of pleomorphic sarcoma?

A

can met outside the lung, get full body CT

117
Q

Mitotic count sarcoma grade score:

A

1 - <10 mitosis/10hpf
2 - 10-20 mitosis/10hpf
3 - > 20 mitosis/10hpf

118
Q

Gorlin syndrome synonym

A

Basal Cell Nevus Syndrome

119
Q

Skin biopsy - spindle cells with storiform or fascicular pattern. Bland with minimal cytologic atypia.

A

dermatofibrosarcoma protuberans

120
Q

AIM chemotherapy

A

doxorubicin, ifosfamide, and mesna

121
Q

biopsy of extremity sarcoma

A

plan with incision

122
Q

Time to recurrence after ILI

A

about 2 years

123
Q

staging for a well differentiated liposarcoma

A

CXR

124
Q

Local control rate/cure for definitive radiation for BCC/SCC?

A

> 90%

125
Q

When to biopsy RP mass

A

after you ruled out pheochromocytoma

before you plan non-surgical therapy

126
Q

response to HILP for melanoma?

A

50% will have a complete response

50% of the responses will eventually recur

127
Q

When to consider observation for a GIST?

A

if <2cm and no suspicious features on EUS or other imaging

128
Q

Small leiomyosarcoma encircling the left renal artery, what next?

A

Neoadjuvant radiation since high risk of positive margins.

129
Q

chemo agent for ILI

A

only melphan used in any country

130
Q

Stat6

A

Solitary Fibrous Tumor

131
Q

Immunostains for MCC

A

positive for CK20
negative for TTF1
Merkel cell polyomavirus T antigen

132
Q

Chemo used in ILI

A

doxorubicin

133
Q

RP Sarcoma staging

A

CT chest (add belly for some)
No PET
do Renal Scan if near kidney
Get multidisciplinary review

134
Q

Adjuvant RT for MCC after completion LND?

A

only for multiple involved nodes and or the presence of extra-capsular extension.

135
Q

Send sarcoma to look for MSI?

A

yes, FDA approval includes sarcomas; would probably also consider clinical trials and only do when in disseminated StageIV

136
Q

When to get nodal RT for SCC

A

could give to all, but consider observation for single node < 3cm with no ECE

137
Q

Size cutoff for biopsy of lung nodules for STS?

A

1 cm

138
Q

Cutaneous horn cancer risk?

A

10% have an SCC at the base

139
Q

schwannoma

A

benign retroperitoneal tumor

140
Q

Risk of metastasis with G2-3 extremity sarcoma?

A

40-50% of all patients will eventually develop

141
Q

Utility of imaging for staging imaging during pregnancy?

A

12% of MRIs done during pregnancy have incidental findings

142
Q

5 prognostic variables for STS

A 
Size >5 cm
Deep to fascia
High grade tumor
location (trunk higher risk)
local invasion
143
Q

Suspect retroperitoneal lymphoma, what to check for?

A

additional lymphadenopathy

144
Q

First lab test when working up a desmoid tumor

A

pregnancy test

145
Q

SLN+ on an MCC

A

look for a clinical trial and consult tumor board

can do RT, completion LND or both.

146
Q

Mechanism of topical interferon?

A

Stimulates a T-cell response.

147
Q

Isolated Limb Perfusion agent

A

melphan in US, reached 20x systemic doses with minimal systemic toxicity

148
Q

How do you do a Stage I sarcoma operation?

A

include biopsy site with incision
2cm margins if within compartment and not taking neurovascular tissue
Place clips
place drain near incision in case needs RT
Ink margins with pathologist

149
Q

ILI v ILP mnemonic

A

isoloated limb INfusion is minimally INvasive

150
Q

IMRT v conventional radiaiton for sarcomas?

A

can reduce dose of radiation

151
Q

Do SLNB for BCC or SCC?

A

Just don’t do it on oral boards, no evidence to establish it as helpful.

152
Q

typical pigmentation of desmoplastic melanoma?

A

amelanotic - possibly explains why presents at later stages

153
Q

RT to primary site for MCC

A

do for all except tumor <1cm with no high risk features (LVI, immunosuppression)

154
Q

PET avid liposarcoma?

A

More likely to be high grade and therefore chemo/radiosensitive.

155
Q

Indications for CLND?

A

> 3 positive SLN
ECE
immunosuppressed patient
poor compliance/access to ultrasound surveilance

156
Q

metastatic pattern of epithelial sarcoma?

A

can metastasize to nodes

157
Q

T1a SCC of the penis

A

Tumor invades subepithelial connective tissue without lymph vascular invasion and is not poorly differentiated (ie, NOT grade 3-4)

158
Q

ILP technique

A

cutdown on inflow and outflow to limb
hook up to ECMO machine
perfuse 1-1.5 hrs at 39 C

159
Q

Surgery for Stage II/II (G2/G3) extremity sarcoma?

A

wide excision with limb sparing en bloc R0 resection

160
Q

Fibrosarcomatous transformation of a DFSP?

A

cytologic atypia
mitotic activity >5/HPF
negative CD34 staining

161
Q

How do you do an ILI of the lower extremity?

A

cannulation of the external iliac vessels via a hockey stick incision for thigh sarcoma

connect cannula to the inflow and outflow lines of an extracorporeal bypass circuit.

A tourniquet is applied around the root of the extremity

162
Q

SLNB for SCC of penis?

A

Yes for T1b or higher. do the completion LND

163
Q

High risk patient factors for BCC/SCC

A

immunosuppresion

previous RT

164
Q

Radiation margin for brachytherapy for soft tissue sarcoma

A

2 cm

165
Q

Recurrence rates afte Mohs
BCC
SCC

A

BCC 1%

SCC 3%

166
Q

which limb chemotherapy technique can be repeated?

A

ILI

167
Q

Imaging for Merkel Cell Carcinoma?

A

only for clinical suspicion or SLNB+ (then get PET)

168
Q

T staging for MCC

A

same as SCC!

T1 < 2cm
T2 2-5 cm
T3 >5 cm no invasion
T4 invades other structure

169
Q

Preop chemo/chemoradiation for sarcoma

A

consider for all stage III (G2-3 T2+)

170
Q

genetic syndrome associated with leiomyosarcoma?

A

hereditary retinoblastoma

171
Q

CD99, EWSR-1

A

Ewing Sarcoma

172
Q

R2 resection of RP sarcoma?

A

try to re-resect
Radiation
AIM is most common chemo

173
Q

Recurrent retroperitoneal liposarcoma?

A

Consider aggressive compartmental surgery skelotonizing the ureter and vessels down to IVC/Aorta.

Only evidence for this is high risk of additional recurrence and getting back into the retroperitoneum is going to be hard.

174
Q

metastatic/unresectable DFSP?

A

basically nothing in NCCN guidelines. Keep cutting, consider imatinib.

175
Q

60% of non-melanoma skin cancers occur where?

A

H&N

176
Q

Where do you inject blue dye?

A

subdermally

177
Q

Melanoma incidence is?

A

increasing

178
Q

sarcoma tumor differentiation score:

A

1 - normal mesenchymal tissue
2 - myxoid indeterminate structure
3 - embryonal undifferentiated

179
Q

Treatment of SCC of the penis

A

T1a - local skin excision or Mohs and grafting

T1b or worse - partial or complete amputation

180
Q

2011 Dutch series ILP for extremity sarcoma?

A

ILP with TNFalpha and Melphan
71% response
81 % limb salvage
40% overall survival

181
Q

SCC with rapid growth or neurologic symptoms?

A

automatic high risk. make sure it goes to resection (Mohs v 1 cm margins)

182
Q

Modifiable risk factor for melanoma?

A

ask about tanning bed use.

183
Q

Desmoid growing during pregnancy

A

still watch, this is typical

184
Q

How do you do an ILI of the upper extremity?

A

Cannulate axillary artery and vein

connect cannula to the inflow and outflow lines of an extracorporeal bypass circuit.

A tourniquet is applied around the root of the extremity

185
Q

How do you do photo-dynamic therapy?

A 
Apply photosensitizer (Photofrin -Porfimer sodium)
Shine UV light
186
Q

Isolated Limb Perfusion

A

surgical isolation of the vascular inflow and outflow of an extremity to separate the circulation of the affected limb from that of the remainder of the body

187
Q

Surveillance after BCC?

A

Complete skin exam q6 months.

188
Q

medicine for risk reduction of BCC in gorlins syndrome

A

Nicotinamide

189
Q

Nx for technically unsuccessful SLNB for MCC?

A

would radiate primary draining basin anyway

190
Q

Agent with highest response rate for desmoid tumors?

A

sorafenib

191
Q

renal angiomyolipoma

A

benign retroperitoneal tumor

192
Q

retroperitoenal mass and scrotal mass

A

lost likely metastatic testicular cancer

193
Q

Clinically positive node for MCC

A

do IR biopsy, then manage as per SLN+
look for a clinical trial and consult tumor board
can do RT, completion LND or both.

194
Q

Best lesions to treat with topical 5FU

A

multiple superficial Basal cell carcinomas

multiple aktinic keratosis

195
Q

curretage for BCC?

A

low risk only, never on hair bearing area

if adipose is reached then just do surgical excision with primary closure.

196
Q

What to do for an infiltrative or morpheoform BCC?

A

Consider wider margin (1 cm) if cosmetically acceptable

197
Q

Treatment for recurrent STS

A

If resectable -> resect

If no prior RT -> radiation (before or after)

198
Q

sarcoma v renal mass, tests to get?

A

plasma and urine catacholamines
steroid hormones
DHEA

199
Q

sarcoma tumor necrosis score:

A

0 - no necrosis
1 - <50% necrosis
2 - >50% necrosis

200
Q

Surgical options for DFSP?

A

Mohs v WLE with 2-cm margins.
delayed closure
do STSG if margin is close/equivocal.

201
Q

Surgery for G1 (Stage I) sarcoma

A

Limb sparing function preserving en bloc R0 resection

202
Q

subungual melanoma?

A

distal phalanx amputation

203
Q

Margin for a DFSP?

A

NCCN rx - 2-4 cm

some retrospective evidence that >3 is better than <4cm

204
Q

pink/violet slowly growing lesion?

A

dermatofibrosarcoma protuberans

205
Q

unresectable DFSP?

A

consider gleevec, has a characteristic PDGFR gene fusion

206
Q

Anal mass S-100, HMB-45 and Melan-A positive?

A

anal melanoma

207
Q

BRAF/MEK inhibition?

A

dabrafenib and trametinib

208
Q

heterogenously enhancing retroperitoneal nodules

A

dedifferentiated liposarcoma

CGSO oral boards (7 decks)

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