Chapter 18: Plastics, skin, and soft tissues. Flashcards Preview

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1

Skin: primarily cellular

Epidermis

2

Main cell type in epidermis; originate from basal layer; provide mechanical barrier

Keratinocytes

3

Neuroectodermal origin (neural crest cells); in basal cell layer of epidermis

Melanocytes

4

Have dendritic processes that transfer melanin to neighboring keratinocytes via melanosomes

Melanocytes

5

How do melanocytes differ among races?

Density of melanocytes is the same among races; difference is in melanin production

6

Skin: primarily structural proteins (collagen) for the epidermis

Dermis

7

- Acts as antigen-presenting cells (MHC Class II)
- Originate form bone marrow
- Have a role in contact hypersensitivity reactions (type 4)

Melanocytes

8

Sensory nerves: pressure

Pacinian corpuscles

9

Sensory nerves: warmth

Ruffini's endings

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Sensory nerves: cold

Krause's end-bulbs

11

Sensory nerves: Meissner's corpuscles

Tactile sense

12

Aqueous sweat (thermal regulation, usually hypotonic)

Eccrine sweat glands

13

Milky sweat
- highest concentration of glands in palms and soles

Apocrine sweat glands

14

What autonomic is in control of sweat production?

Most sweat is the result of sympathetic nervous system via acetylcholine

15

Drug type: increased skin absorption

Lipid-soluble drugs

16

Predominate collage type in skin; 70% of dermis; gives tensile strength

Type 1 Collagen

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Resistance to stretching (collagen)

Tension

18

Ability to regain shape (branching proteins that can stretch to 2x normal length)

Elasticity

19

What causes Cushing's striae?

Caused by loss of tensile strength and elasticity

20

MCC of pedicled or anastomosed free flap necrosis

Venous thrombosis

21

Flaps: what causes tissue expansion?

Occurs by local recruitment, thinning of the dermis and epidermis, mitosis

22

TRAM flaps: complications

Flap necrosis, ventral hernia, bleeding, infection, abdominal wall weakness

23

TRAM flaps: rely on what vessel?

Superior epigastric vessels

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Most important determinant of TRAM flap viability?

Periumbilical perforators

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What is a TRAM flap?

Transversus rectus abdominis flap

26

Stage I Pressure ulcer

Erythema and pain; no skin loss

27

Stage 2 Pressure Ulcer
- Treatment?

Partial skin loss with yellow debris
- Tx: local treatment, keep pressure off

28

Stage 3 Pressure Ulcer
- Treatment?

Full-thickness skin loss; subcutaneous fat exposure
- Tx: sharp debridement; likely need myocutaneous flap

29

Stage 4 Pressure Ulcer
- Treatment?

Involves bony cortex, muscle
- Tx: myocutaneous flap

30

- Damages DNA and repair mechanisms
- Both a promoter and initiator

UV radiation

31

Single best factor for protecting skin from UV radiation

Melanin

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Responsible for chronic sun damage

UV-B

33

Represents only 5% of skin CA but accounts for 65% of the deaths

Melanoma

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Risk factors for melanoma

- Dysplastic, atypical or large congenital nevi
- Familial BK mole syndrome
- Xeroderma pigmentosum
- Fair complexion, easy sunburn, intermittent sunburns, previous skin CA, previous XRT

35

10% lifetime risk for melanoma

Dysplastic, atypical, or large congenital nevi

36

Almost 100% risk of melanoma

Familial BK mole syndrome

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% melanomas that are familial

10%

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MC melanoma site on skin

Back in men, legs in women

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What carries a worse prognosis in melanoma?

Men, ulcerated lesions, ocular and mucosal lesions

40

Signs of melanoma

- Asymmetry (angulations, indentation, notching, ulceration, bleeding)
- Borders that are irregular
- Color change (darkening)
- Diameter increase
- Evolving over time

41

Where does melanoma originate?

Originates from neural crest cells (melanocytes) in basal layer epidermis

42

Color: most ominous sign of melanoma

Blue color

43

MC location for distant melanoma metastases

Lung

44

Diagnosis melanoma:
- 2 cm lesion or cosmetically sensitive area

- 2cm or cosmetically sensitive area: incisional biopsy (or punch biopsy), will need to resect with margins if path shows melanoma

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Five types of melanoma

- Melanoma in situ or thin lentigo maligna (Hutchinson's freckle)
- Lentigo maligna melanoma
- Superficial spreading melanoma
- Nodular
- Acral lentiginous

46

Components of melanoma staging workup

Chest/abd/pelvic CT, LFTs, and LDH for all melanoma > 1mm; examine all possible draining lymph nodes

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Melanoma: treatment for all stages

1) Resection of primary tumor with appropriate margins
- AND -
2) Management of lymph nodes

48

Surgical margins for melanoma excision:
- In situ (mm)
- 1.0 (mm)
- 1.1 - 2.0 (mm)
- > 2.0 (mm)

- In situ (mm): 0.5 - 1.0 cm
- 1.0 (mm): 1.0 cm
- 1.1 - 2.0 (mm): 1.0 - 2.0 cm
- > 2.0 (mm): 2.0 cm

49

Surgical margins for melanoma excision:
- In situ (mm)

- In situ (mm): 0.5 - 1.0 cm

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Surgical margins for melanoma excision:
- 1.0 (mm)

- 1.0 (mm): 1.0 cm

51

Surgical margins for melanoma excision:
- 1.1 - 2.0 (mm)

- 1.1 - 2.0 (mm): 1.0 - 2.0 cm

52

Surgical margins for melanoma excision:
- > 2.0 (mm)

- > 2.0 (mm): 2.0 cm

53

Melanoma: what nodes do you need to resect?

Always need to resect clinically positive nodes

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Melanoma: when do you perform sentinel lymph node biopsy?

If nodes clinically negative and tumor >/ 1 mm deep

55

Characteristic of involved nodes in melanoma

Involved nodes usually nontender, round, hard 1-2 cm

56

What do you need to include for all anterior head / neck melanomas >/ 1mm deep?

Superficial parotidectomy (20% metastasis rate to parotid)

57

Tx: axillary node melanoma with no other primary

Complete axillary node dissection (remove Level 1, 2 , and 3 nodes - unlike breast CA)

58

Melanoma: has provided some patients with long disease-free interval and is the best chance for cure

Resection of metastases
- Isolated metastases (ie lung or liver) that can be resected with a low-risk procedure should probably undergo resection

59

Melanoma: can be used for systemic disease

IL-2 and tumor vaccines

60

Most common malignancy in US

Basal cell carcinoma
- 4x more common than squamous cell skin cancer
- 80% on head and neck

61

What does basal cell carcinoma originate from?

Epidermis - basal epithelial cells and hair follicles

62

-Pearly appearance, rolled borders, slow and indolent growth

Basal cell carcinoma

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Path: basal cell carcinoma

Peripheral palisading of nuclei and stromal retraction

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Basal cell carcinoma: what do you do for clinically positive nodes

Regional adenectomy

65

Basal cell carcinoma: most aggressive, has collegians production

Morpheaform type

66

Basal cell carcinoma:
- Treatment: 0.3 - 0.5 cm margins

XRT and chemotherapy: may be of limited benefit for inoperable disease, mets or neuro/lymphatic/vessel invasion

67

- Overlying erythema, papulonodular with crust and ulceration; usually red-brown
- May have surrounding induration and satellite nodules
- Can develop in post-XRT areas or in old burn scars

Squamous cell carcinoma

68

Incidence of metastasis: squamous cell vs basal cell vs melanoma

Melanoma > squamous cell carcinoma > basal cell carcinoma

69

Risk factors for squamous cell carcinoma

Actinic keratoses, xeroderma pigmentosum, Bowen's disease, atrophic epidermis, arsenics, hydrocarbons (coal tar), chlorophenols, HPV, immunosuppression, sun exposure, fair skin, previous XRT, previous skin cancer

70

Risk factors for metastasis in squamous cell carcinoma

Poorly differentiated, greater depth, recurrent lesions, immunosuppression

71

Squamous cell carcinoma - tx: 0.5 - 1.0 cm margins for low risk

- Can treat high risk with Mohs surgery when trying to minimize area of resection (i.e., lesions on facE)
- Regional adenectomy for clinically positive nodes
- XRT and chemotherapy - may be of limited benefit for inoperable disease, mets, or neuo/lymphatic/vessel invasion

72

Margin mapping using conservative slices; not used for melanoma

Mohs surgery

73

MC soft tissue sarcomas

1. Malignant fibrous histiosarcoma
2. Liposarcoma

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MC location / age of soft tissue sarcoma

50% arise from extremities; 50% in children (arise from embryonic mesoderm)

75

- Most are large, grow rapidly, painless
- Symptoms: asymptomatic mass (MC presentation), GIB, bowel obstruction, neurologic deficit

Soft tissue sarcoma

76

Imaging studies necessary for soft tissue sarcomas

- CXR: to r/o lung mets
- MRI before biopsy: to r/o vascular, neuro, or bone invasion

77

Soft tissue sarcoma: excisional biopsy vs longitudinal incisonal biopsy

- Excisional biopsy: mass 4cm
- Need to eventually resect biopsy skin site if biopsy shows sarcoma

78

MC site for mets of soft tissue sarcoma

Lung

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How do mets spread in soft tissue sarcoma?

Hematogenous spread, not to lymphatics -> mets to nodes is rare

80

What is staging based on in soft tissue sarcoma?

Staging based on grade, not size

81

Tx: soft tissue sarcoma

Want at least 3-cm margins and at least 1 uninvolved fascial plane -> try to perform limb-sparing operating.
- Place clips to mark site of likely recurrence -> will XRT these later

82

Post op XRT: soft tissue sarcomas

For high-grade tumors, close margins, or tumors > 5 cm

83

Chemotherapy: soft tissue sarcoma

Chemotherapy is doxorubicin based

84

What to think about with soft tissue sarcomas and tumors > 10 cm?

Tumors > 10 cm may benefit from pre op chemo XRT -> may allow limb-sparing resection

85

Tx: isolated sarcoma metastases

Isolated sarcoma mets without other evidence of systemic disease can be resected and are the best chance for survival; otherwise can palliate with XRT

86

Incision favored for pelvic and retroperitoneal sarcomas

Midline incision

87

What do you try to preserve in resection of soft tissue sarcoma?

Try to preserve motor nerves and retain or reconstruct vessels.

88

Poor prognosis overall: soft tissue sarcoma

- Delay in diagnosis
- Difficulty with total resection
- Difficulty getting XRT to pelvic tumors

89

Survival rate with complete resection of soft tissue sarcoma

40% 5-year survival rate

90

Can occur in pediatric population (usually rhabdomyosarcoma)

Head and neck sarcomas

91

Why are head and neck sarcomas difficult to get margins?

Because of proximity to vital structures. Post op XRT for positive or close margins as negative margins may be impossible to obtain

92

Most commonly are leiomyosarcomas and liposarcomas

Visceral and retroperitoneal sarcoma

93

What is the most important prognostic factor in visceral and retroperitoneal sarcomas?

The ability to completely remove the tumor

94

Risk factors for soft tissue sarcoma

- Asbestos: mesothelioma
- PVC and arsenic: angiosarcoma
- Chronic lymphedema: lymphangiosarcoma

95

- Vascular sarcoma
- a/w immunocompromised state

Kaposi's sarcoma

96

MC malignancy in AIDS

Kaposi's sarcoma
- Rarely a cause of death in AIDS

97

MC site Kaposi's sarcoma (vascular sarcoma)

Oral and pharyngeal mucosa (s/s: bleeding, dysphagia)

98

Tx: Kaposi's sarcoma

- AIDS tx (HAART) shrinks AIDS-related KS (best tx)
- Consider XRT or intra-lesional vinblastine for local disease
- Interferon-alpha for disseminated disease
- Surgery for severe intestinal hemorrhage

99

Best treatment AIDS-related Kaposi sarcoma

AIDS Tx (HAART) shrinks it

100

Tx: local disease - Kaposi's sarcoma

Consider XRT or intra-lesional vinblastine

101

Tx: disseminated disease - Kaposi's sarcoma

Interferon-alpha

102

Tx: severe intestinal hemorrhage - Kaposi's sarcoma

Surgery

103

#1 soft tissue sarcoma in kids

Childhood rhabdomyosarcoma

104

Poorest prognosis in childhood rhabdomyosarcoma

Head/neck, genitourinary, extremities, and trunk

105

MC subtype childhood rhabdomyosarcoma

Embryonal

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Worst prognosis childhood rhabdomyosarcoma

Alveolar

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Tx: childhood rhabdomyosarcoma

Surgery; doxorubicin-based chemotherapy

108

Most are metastatic at the time of diagnosis

Osteosarcoma

109

- Increased incidence around the knee
- Originates from metaphyseal cells
- Usually in children

Osteosarcoma

110

CNS tumors
Peripheral sheath tumors
Pheochromocytoma

Neurofibromatosis

111

Childhood rhabdomyosarcoma, many others

Li-fraumeni syndrome

112

Also includes other sarcomas

Hereditary retinoblastoma

113

Angiomyolipoma is associated with what?

Tuberous sclerosis

114

Familial adenomatous polyposis and intra-abdominal desmoid tumors

Gardner's syndrome

115

What is important in lip lacerations?

Lip lacerations: important to line up vermillion border

116

Yellow, contains histiocytes
- Tx: excision

Xanthoma

117

Viral origin, contagious, autoinoculable, can be painful
- Tx: liquid nitrogen initially

Warts (verruca vulgaris)

118

Can be associated with neurofibromatosis and von Recklinghausen's disease (cafe-au-lait spots, axillary freckling, peripheral nerve and CNS tumors)

Neuromas

119

Café-Au-Lait spots, axillary freckling, peripheral nerve and CNS tumors

von Recklinghausen's disease

120

Keratoses: Premalignant in sun-damaged areas; need excisional biopsy if suspicious

Actinic keratosis

121

Keratoses: Not premalignant; trunk on elderly, can be dark

Seborrheic keratosis

122

Keratoses: associated with squamous cell carcinoma

Arsenical keratoses

123

- Very aggressive malignant tumor with early regional and systemic spread
- Red to purple papulonodule or indurated plaque

Merkel cell carcinoma (are neuroendocrine)

124

Have neuron-specific enolase (NSE), cytokeratin, and neurofilamint protein

Merkel cell carcinoma (are neuroendocrine)

125

- Painful tumor composed of blood vessels and nerves
- Benign; most common in the terminal aspect of the digit

Glomus tumor
- Tx: tumor excision

126

Benign but locally very invasive; occur in fascial planes

Desmoid tumors

127

Most common location of desmoid tumors

Anterior abdominal wall

128

When can anterior abdominal wall desmoid tumors happen?

Can occur during or following pregnancy; can also occur after trauma or surgery

129

Associated with gardner's syndrome and retroperitoneal fibrosis; often encases bowel, making it hard to get en bloc resection

Intra-abdominal desmoids

130

High risk of local recurrences; no distant spread

Desmoid tumor

131

Tx: desmoid tumors

Surgery if possible; chemotherapy (sulindac, tamoxifen) if vital structure involved or too much bowel would be taken (high risk of short bowel syndrome with surgery)

132

SCCA in situ; 10% turn into invasive SCCA; associated with HPV

Bowen's disease

133

Tx: Bowen's disease

Imiquimod, cautery ablation, topical 5-FU, avoid wide local excision if possible (high recurrence rate with HPV), regular biopsies to rule out cancer

134

- Rapid growth, rolled edges, crater filled with keratin
- is not malignant but can be confused with SCCA
- involutes spontaneously over months

Keratoacanthoma

135

Tx: keratoacanthoma

- Always biopsy these to be sure
- If small, excise; if large, biopsy and observe

136

Increased sweating, especially noticeable in the palms.
- Tx?

Hyperhidrosis

Tx: thoracic sympathectomy if refractory to variety of antiperspirants

137

Infection of apocrine sweat glands, usually in axilla and groin regions
- Staph / strep most common organisms

Hidradenitis

138

Tx: hidradenitis

Antibiotics, improved hygiene first; may need surgery to remove skin and associated sweat glands

139

Most common benign cysts

Epidermal inclusion cyst
- Have completely mature epidermis with creamy keratin material

140

Benign cyst: in scalp, no epidermis

Trichilemmal cyst

141

Benign cyst: over tendons, usually over wrist; filled with collagen material

Ganglion cyst

142

Benign cyst: midline intra-abdominal and sacral lesions usual; need resection due to malignancy risk

Dermoid cyst

143

Benign cyst: congenital coccygeal sinus with ingrown hair; gets infected and needs to be excised

Pilnoidal cyst