Skin/soft Tissue

Front 1

42 yo man visit for a lesion on left forearm - believes it may be enlarging. You suspect melanoma. Name some important items on history and exam that would raise suspicion for melanoma. Name 5-6.

Back 1

1. previous dysplasia / melanoma
2. family hx melanoma
3. exposure to sunlight
4. ABCD = assymetry, irregular borders, color variation, diameter > 0.6 cm)
5. regional lymphadenopathy
6. recent change in size (spreading)

Front 2

what is indicated for large (>2-3cm) skin lesion that is suspicious for melanoma?

Back 2

incisional biopsy (gets full thickness skin to establish lesion depth)

Front 3

excisional versus incisional biopsy - difference?

Back 3

excisional - excises w/ rim of normal tissue VS incisional - portion of the margin of the lesion w/ segment of normal tissue

Front 4

management of basal cell carcinoma?

Back 4

local excision with clear margins; no further treatment necessary

Front 5

management of sq cell carcinoma? In addition to primary tumor, is any treatment appropriate?

Back 5

excision with 1cm tumor free margins; if palpable lymph nodes, need to be excised, and radiation or 5-FU following excision is appropriate

Front 6

dysplastic nevus (areas of atypia) management? follow up?

Back 6

excision; routine surveillence

Front 7

What are three components that go into prognosis of diagnosed melanoma?

Back 7

1. depth by mm (Breslow)
2. Clark level layer of dermis penetrate (epi, papillary, reticular, subcutis)
3. ulceration (1/3 reduction in survival)

Front 8

malignant melanoma of 1.6 mm depth (Clark IV) - no palpable lymph nodes- management?

Back 8

resection with good margins (2cm); sentinel lymph node biopsy (with dissection if positive)

Front 9

patient with 4.5 mm malignant melanoma (Clark V), 25% survival at 5 years - management (4 parts)?

Back 9

1. excision with wide margins (2-3cm),
2. regional lymphadenectomy (for palpable lymph nodes)
3. abdomen CT, MRI brain
4. treatment with interferon (improves survival)

Front 10

Stage IV melanoma (usually not curable)- management (medical and surgical (2))?

Back 10

medical: combination chemo
surgical: excision of solitary lung/brain nodules

Front 11

type of melanoma that carries more favorable prognosis due to its superficial spreading nature as opposed to invasive nature? usually occurs in what populations and where?

Back 11

lentigo melanoma; typically occurs in elderly on face

Front 12

precursor of lentigo melanoma? management?

Back 12

Hutchinson freckle; close observation for changes

Front 13

Anal melanomas are associated with ___ prognosis; most occur at ____; thicker lesions usually require what?

Back 13

poor prognosis (mortality near 100% at 5 years); dentate line; abdominoperineal rsx of anorectum

Front 14

melanoma has propensity to metastasize to peritoneal cavity, often presenting how?

Back 14

SBO

Front 15

45 yo man with painless mass on anterior thigh - slow growing, present for several months? differential (name 3-4)

Back 15

hematoma, lipoma, hemangioma, sarcoma

Front 16

45 yo man with 5 cm mass on anterior thigh - slow growing, firm and painless, and present for several months; what needs to be ruled out and how is this accomplished? what methods of diagnosis are discourage due to poor reliability (2)?

Back 16

sarcomal incision biopsy (>3cm) versus excisional biopsy (<3cm);
FNA and frozen biopsy not reliable

Front 17

1. what features of sarcomas associated with poorer outcomes (4 important ones)?
2. What are preferred methods imaging to look for bone and adjacent soft tissue involvement of sarcoma?

Back 17

increased mitotic figures, degree of necrosis, symptomatic (e.g. pain), lesions > 15 cm;
2. CT scan (to look at bony involvement) and MRI (to look at soft tissue involvement)

Front 18

What is the principle of sarcoma surgery?

Back 18

extensive initial resection is necessary (e.g. total rsx of compartment or even amputation)

Front 19

Assume sarcoma of quadriceps - what would be included in total compartmental resection?

Back 19

rsxn of entire quadriceps muscle (origin/insertion) and investing fascia

Front 20

1. T1 versus T2 sarcoma
2. T1a versus T1b sarcoma?
3. G1-G5?

Back 20

1. T1<5cm AND limited to tissue of origin, T2>5cm
2. T1a=superficial, T1b=deep
3. G1=well differentiated, G5=poorly differentiated

Front 21

52 yo male with hx of excision of low grade sarcoma on thigh in for 1 yr follow up. CXR reveals new 1.5 cm mass (most recurrences occur within 2 yrs). Needle biopsy reveals malignant sarcoma to lung. What is management, and why?

Back 21

thoracic wedge resection (one of few pulmonary metastases that excision can lead to long-term dz survival)

Front 22

post-op adjuvant therapies to reduce recurrence / metastasis (e.g. lung primarily) in sarcoma? 2 answers.

Back 22

postoperative radiation, brachytherapy (seeding of radiation seeds to surgical field)

Front 23

acute versus gradual onset of tender testicle/scrotal region - what is on differential (1-2 for each)?

Back 23

acute: torsion, epidydimitis. trauma
gradual: orchitis, epidydimitis, hernia

Front 24

relationship to inferior epigastric vessels - indirect versus direct inguinal hernia?

Back 24

direct: medial to vessels
indirect: lateral to vessels

Front 25

tender area in lateral portion of groin with impulse traveling down inguinal canal with cough?

Back 25

indirect inguinal hernia

Front 26

firm tender mass below inguinal ligament?

Back 26

femoral hernia

Front 27

firm, tender mass with nausea, vomiting and abdominal distension?

Back 27

incarcerated or strangulated hernia --> SBO

Front 28

large, soft mass in scrotum separate from testicle with fullness in inguinal canal, and reducible. diagnosis?

Back 28

indirect inguinal hernia extending to scrotum

Front 29

firm tender mass below inguinal ligament with leukocytosis, fever and acidosis -
1. Diagnosis?
2. Management?
3. most common hernia with strangulation?

Back 29

1. strangulated bowel
2. to OR (surgical emergency)
3. femoral (30-50%)

Front 30

conditions that are assciated with hernias due to increase abdominal pressure. name 4-5

Back 30

obesity, COPD, constipationm BPH, ascites

Front 31

weakness of open Bassini repair of hernia?

Back 31

tension it places on struture --> higher rate of recurrence

Front 32

1. 7 layers of midline incision (superficial to deep)?
2. 5 layers of inguinal hernia repair incision? hernia is defect in which layer?

Back 32

1. skin, superficial fascia, linea alba, transversalis fascia, extraperitoneal connective tissue, median umbilical ligament, parietal peritoneum
2. skin, superficial fascia (Campers and Scarpas), external oblique, internal oblique, tranversalis fascia; defect usually transversalis fascia

Front 33

principle complication in hernia repair? post-op hernia repiar instructions?

Back 33

neuralgia due to many nerves in area (sensory defects); no heavy lifting for 6 weeks`