Nms Skin And Soft Tissue Disorders

Front 1

How can you tell if pigmented lesion is a melanoma?

Back 1

ABCD rule:
Asymmetry, Border irregularity, Color variation, Diameter >.6cm, Dark black color.
Also ulceration, nodularity, regional lymphadenopathy

Front 2

When should skin lesions be excised?

Back 2

Any characteristics of ABCD or has changed recently.

Front 3

When a lesion is on the face, what kind of excision do you perform?

Back 3

full thickness Incisional biopsy

Front 4

Which type of skin lesions can be dangerous?

Back 4

Basal cell carcinoma: maybe locally invasive. Reexcise if margins positive
Squamous cell carcinoma: more dangerous than BCC because its' locally aggressive and mets to local LNs. >4mm in thickness? 1cm margin. Topical 5FU or radiation is common.

Front 5

What type of skin lesion is most dangerous?

Back 5

Melanoma. If it's in situ, .5-1 cm margin needed.

Front 6

What type of skin lesion is benign?

Back 6

Dysplastic nevus. Transition between benign and melanoma. Excise and routine surveillance.

Front 7

What factor determines staging of melanoma? What else is important?

Back 7

thickness, histology, ulcerations becauae they have 1/3 reduction in survival

Front 8

What locations on the body of skin lesions do worse?

Back 8

Face or trunk worse prog than extremities. Women do better than men.

Front 9

What to do for Clark Levels I and II?

Back 9

Depth up to .75mm: reexcise with 1cm margin down to fascial plane.

Front 10

Post excision for melanomas?

Back 10

CXR, CBC, LFTs, warrant f/u only if abnormal

Front 11

What to do for Clark level IV?

Back 11

1.5-2.5mm, Reexcise with 2cm margin, lymphadenectomy only if nodes palpable

Front 12

What to do for Clark level V?

Back 12

>4mm: reexcision with 2-3cm margin, excision of palpable nodes, CTabd, MRI of brain, start tx w/ Interferon

Front 13

What do palpable nodes mean?

Back 13

Possible mets.

Front 14

What's metastatic workup?

Back 14

CXR, LFTs, CBC, CTabd, MRI brain, Interferons

Front 15

With mets what are the chances of recurrence of melanoma?

Back 15

75%

Front 16

What specialized tx for stage IV?

Back 16

Immunotx: Polyvalent vaccine vs tumor cells

Front 17

What to do with melanoma and mets on CXR?

Back 17

percutaneous lung biopsy, systemic tx with (chemo) Dacarbazine and immunotx. Resection of solitary lesions. Radiation if bone pain.

Front 18

What's the benefit of immunotx?

Back 18

In people with bone mets, complete resection with vaccine increases 5 year survival by 35%

Front 19

What is irregular discoloaration on face?Tx?

Back 19

lentigo maligna melanoma. It's superficial and spreading, favorable prog cause it's not thick. Excise with narrow margin.

Front 20

What's the precursor to lentigo melagna melanoma? Tx?

Back 20

Hutchinson's freckle. Observe for changes.

Front 21

What are melanomas on the foot called? Who does it happen to? Tx?

Back 21

acral-lentiginous lesion. happens to darker skinned people. Poorer prog. Excise according to thickness

Front 22

What's a tumor under the nail called?

Back 22

Subungual melanoma. After biopsy with portion of the nail, reexcision is amputation at the DIP.

Front 23

Survival rate of subungual melanoma?

Back 23

60%

Front 24

Mortality of anal melanomas?

Back 24

almost 100% at 5 years

Front 25

Tx of anal melanomas?

Back 25

Thin lesions can be excised, Thick lesions need abdominoperineal resection of anorectum. Regional LN resection for positive inguinal nodes.

Front 26

Where does melanoma usually met to?

Back 26

Small bowel. Explore, resent for palliation for obstruction.

Front 27

What are sarcomas?

Back 27

Rare neoplasms of connective tissue

Front 28

What is assoc with sacromas?

Back 28

Hx of therapeutic radiation or axillary lymphadenopathy (lymphangiosarcoma) 1-2 decades earlier

Front 29

What can mimic sarcoma?

Back 29

trauma and subsequent hematoma

Front 30

How do sarcomas present?

Back 30

firm, painless masses

Front 31

How do you biopsy sarcomas?

Back 31

<3cm: excisional biopsy
>3cm: incisional biopsy. larger defects make primary closure complex and potentially contaminates additional compartments with tumor

Front 32

What determines low grade and high grade sarcomas?

Back 32

# of mitotic figures and degree of necrosis

Front 33

Rate of mets on presentation?

Back 33

22%

Front 34

Most common site of sarcomas mets?

Back 34

liver, lung, bone, brain

Front 35

What should you always do before resection of sarcoma?

Back 35

met workup

Front 36

How should you treat sarcoma?

Back 36

Total compartmental resection, including muscle, origin and insertion, and investing fascia

Front 37

What's the recurrence rate for sarcomas when it's a less than total compartmental resection?

Back 37

15-50%

Front 38

What do you do with a large high grade sarcoma?

Back 38

Radical amputation or compartmental resection with neoadjuvant chemoradiation, and postop radiation

Front 39

What type of sarcomas have been shown to be the only types to respond to chemo?

Back 39

childhood retroperitoneal pelvic rhabdomyosarcomas

Front 40

What type of imaging can detect mets?

Back 40

CT/PET

Front 41

When it is warranted to resect a met?

Back 41

When it's same as the primary tumor, resectable, solitary. Do a thoracic wedge resection(s) for lung mets, it improves survival. Liver mets too.

Front 42

Differential for tender lymph nodes in groin?

Back 42

Lymphadenitis, malignancy, STDs, chancroid

Front 43

Diff for tender testicle?

Back 43

torsion, vircal orchitis, epididymitis

Front 44

What's suspected diag when impulse travels down inguinal canal when cough?

Back 44

indirect hernia

Front 45

What's diag when firm tender mass below inguinal ligament?

Back 45

Femoral hernia

Front 46

What's diag when firm tender mass with nausea, vomiting, abd distension?

Back 46

loop of intestine incarcerated or strangulated

Front 47

What vessels determine direct or indirect?

Back 47

Inferior epigastrics

Front 48

What are signs of a strangulated hernia?

Back 48

fever, leukocytosis, acidosis with hernia

Front 49

Incidence of strangulation for patient with a known hernia?

Back 49

1-3% per year

Front 50

What type of hernias is strangulation most common for?

Back 50

Femoral

Front 51

Most common type of hernia?

Back 51

Indirect. Then direct, then femoral

Front 52

Conditions associated with hernia?

Back 52

obesity, COPD, ascites, BPH, colorectal obstruction, constipation, anything that increases abdominal pressure

Front 53

What should you do with a hernia?

Back 53

Repair it cause it can get encarcerated and strangulated

Front 54

What is Bassini repair?

Back 54

weakness in transversalis fascia fixed by suturing Transversalis fascia, TA fascia and internal oblique fascia to inguinal ligament

Front 55

Weakness of Bassini repair?

Back 55

tension on tissues, likely to fail with poor tissues

Front 56

McVay's repair?

Back 56

Same as Bassini but structures are sutured to Cooper's ligament at periosteum of the pubic ramus. Then you make an incision in the anterior rectus sheath to relieve tension. Good for femoral hernias and attenuated inguinal ligaments

Front 57

Shouldice repair?

Back 57

Similar to Bassini except suture placed in multiple layers to redistribute tension

Front 58

Dangers of Shouldice repair?

Back 58

lose scrotal sensation b/c routine division of genital branch of genitofemoral nerve. but decreased recurrence rates

Front 59

Lichtenstein repair?

Back 59

uses prosthetic mesh to cover superior structures to inguinal ligament. no tension.

Front 60

Nerves to watch out for in hernia repair?

Back 60

Genital branch of genitofemoral, ilioinguinal, iliohypogastric, lateral femoral cutaneous.

Front 61

Recurrence rate of hernia after repair?

Back 61

1-10%

Front 62

Complications of hernia repair?

Back 62

Would infection, graft infection, testicular atrophy, edema, sensory defects, hematoma

Front 63

F/u after hernia repair?

Back 63

No lifting for 6 weeks, office visit 1 week and 6 weeks post surg to monitor healing, return if healing poor or hernia recurs

Front 64

What is difference b/w pediatric and adult inguinal hernias?

Back 64

Pediatric represent persistent processus vaginalis and have no defect in the floor or the inguinal canal. So, they're indirect hernias. High incidence of b/l.

Front 65

How do you repair pediatric inguinal hernia?

Back 65

high ligation and excision of the processus vaginalis, maybe need to plicate floor of canal (transversalis fascia) when internal inguinal ring is enlarged, reconstruction of the floor of the canal if large hernia

Front 66

When do you want to surgically repair pediatric inguinal hernia?

Back 66

manually or sugicaly reduce it first, then after 24-48 hours operate.

Front 67

What are posterior and anterior structures of inguinal canal?

Back 67

EO anterior, Transversalis and transversus abdominis posterior

Front 68

What type of hernia more common in women?

Back 68

Femoral

Front 69

Procedure for femoral hernia?

Back 69

McVay (Cooper's)

Front 70

What other structures can get injured in hernia repair?

Back 70

If it's a sliding hernia it involves bladder, cecum, sigmoid, can get injured

Front 71

What's a Richter's hernia?

Back 71

When only 1 sidewall of the bowel get herniated, can result in necrosis and perf w/o signs of obstruction

Front 72

What is Littre's hernia?

Back 72

Protrusion of Meckel's diverticulum (remnant of the yolk stalk) through hernia

Front 73

Who get sliding hernias?

Back 73

Males on the left side

Front 74

How to repair sliding hernias?

Back 74

LaRoque technique with entering peritoneum above internal ring to recognize pathological anatomy then reducing hernia. Don't try to dissect away from posterior wall of sac, just dissect cord away cause the bowel IS the posterior wall of the sac

Front 75

Why should a ventral hernia be repaired?

Back 75

Risk of incarceration and strangulation