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Surgery Mock Oral Board Prep > Skin > Flashcards

Skin Flashcards

1
Q

A patient comes to your office with a worrisome skin lesion for melanoma. What do you do?

A

Do a punch biospy. The most important thing that will direct your surgical care is the depth of a lesion. Doing a punch biospy is the best way to get this information.

  • If worried enough about melanoma, don’t forget to do a thorough H&P (lymph node exam)
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2
Q

A patient comes to your office after having a shave/tangential biopsy of a lesion that returned as melanoma. Is punch biopsy needed?

A

No. Do not re-biopsy. When they come to see you after a shave/tangential biopsy there will just be a great big ugly scab over the area. There is no way to know where to do a repeat biopsy and there is no need to. It adds nothing. You just have to go with the depth on the intial biopsy.

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3
Q

What are worrisome features on melanoma pathology results?

A
  • Ulcerations
  • Mitotic rate >2/mm2
  • Lymphovascular invasion
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4
Q

In melanoma, which lymph node basins would you examine for melanoma on upper extremity? Lower extremity? Trunk?

A

Melanoma can be tricky for lymph node basins, but the following are generally safe.

  • Upper extremity - axillary lymph node basin
  • Lower extremity - inguinal lymph node basin
  • Trunk - inguinal, axillary, and cervical lymph node basins
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5
Q

In melanoma, what is the T staging?

A

T Staging (a = without ulcerations; b = with ulcerations)

  • T1 - <1 mm
  • T2 - >1.0-2.0 mm
  • T3 - >2.0-4.0 mm
  • T4 - >4.0 mm
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6
Q

In melanoma, what is the N staging?

A

N Staging (a = clinically occult; b = clinically detected; c = In-transit, Satellite, and/or Microsatellite mets)

  • N1 - 1 node
  • N2 - 2-3 nodes
  • N3 - >3 nodes
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7
Q

What are the recommended margins for wide local excision of melanoma?

A
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8
Q

In melanoma, who should get a SLNB?

A

Safe answer:

  • <0.8 mm WITH worrisome features (ulcerations, >2 mitoses/mm2, lymphovascular invasion.
  • >/= 0.8 mm

Some exceptions to above: medically unfit, information won’t change treatment decision.

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9
Q

In melanoma, how do you find sentinel lymph nodes?

A
  1. Lymphoscintigraphy is done either the day of surgery or on the afternoon the day prior (higher dose). The images let you know which basin(s) to focus on. Gamma probe can be use in OR to help identify nodes.
  2. Isosulfan blue or methylene blue is injected intradermally at the site of the lesion.

SLNB is continued until all nodes that have gamma counts >10% of the highest SLN count and/or are blue in color are obtained.

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10
Q

In melanoma, should SLNB be sent for frozen pathology?

A

No. Send lymph nodes for permanent.

  • Further staging imaging is required to plan for further treatment recommendations regardless of findings.
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11
Q

In melanoma, what do you do with a positive SLN?

A
  1. Full body PET scan for Staging.
    • If PET shows additional node(s) of concern, MUST GO BACK and get those nodes
  2. Refer to Med Onc to discuss PD-1 directed therapy.
  3. Consider BRAF testing. Med Onc may be able to consider BRAF directed therapy.
  4. DISCUSS options of regional nodes:
    1. Observation (regional US); if PET doesn’t show +LNs
      • q4months x2 years, followed by
      • q6months x3 years
    2. Completion lymph node dissection
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12
Q

In melanoma, what are the common systemic treatments?

A
  1. anti-PD-1
    • Nivolumab
  2. BRAF/MEK inhibitor
    • Dabrafenib
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13
Q

In melanoma surveillance/follow-up, what do you do if a LN becomes clinically noticeable and/or PET avid?

A
  1. +/- biopsy. Will likely excise the node either way.
  2. Perform a therapeutic lymph node dissection.
    • If CLND already performed, excise the nodal recurrence. Then:
  3. Consider systemic therapy and/or locoregional RT.
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14
Q

During the work-up of melanoma, a patient has palpable nodes. What is the next step?

A
  • Perform US guided biopsy
    • Core needle preferred
    • FNA okay
    • Excisional if nothing else possible

If biopsy is negative, perform SLNB at time of WLE and be sure to excise biopsied node.

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15
Q

During the work-up of melanoma, a LN biopsy comes back positive. What are next steps and treatment plan?

A
  1. Imaging (PET scan)
  2. BRAF testing
  3. WLE + TLND (Therapeutic lymph node dissection)
    • If no metastatic disease
  4. Adjuvant tx (Systemic and/or locoregional RT)
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16
Q

A patient presents with concerns of metastatic melanoma. What are next steps?

A

Complete staging workup:

  1. Biopsy to confirm mets whenever possible
  2. Obtain LDH
  3. PET scan
  4. BRAF testing
17
Q

In melanoma, what are treatment options for confirmed metastasis?

A

Hold multidisciplinary discussion.

This can be broken down to resectable and unresectable.

Resectable

  • Resect disease followed by systemic treatment OR
  • Systemic treatment with potential resection later

Unresectable (disseminated) - brain mets

  • Can discuss systemic treatment vs palliative options
18
Q

In melanoma, what do you do if in-transit mets are discovered in surveillance/follow-up?

A
  1. Get a PET to evaluated for distant mets
  2. BRAF testing if not already done
  3. If no distant mets, resect. Continue to resect in-transit mets until the patient gets distant mets or dies.
  4. Consider systemic therapy
19
Q

In melanoma, if Cloquet’s node is positive, must you do a deep inguinal dissection?

A

A deep dissection is NOT MANDATORY, but you can consider it.

20
Q

In melanoma, when might you consider doing a deep inguinal (iliac/obturator) lymph node dissection?

A

Consider doing a deep (iliac/obturator) lymph node dissection when:

  1. Clinically positive inguinofemoral nodes, OR
  2. 3+ positive ingiunofemoral nodes, OR
  3. Imaging shows resectable lymphadenopathy
21
Q

In melanoma, who gets radiation?

A

Almost no one with melanoma get radiation.

The following are times when to consider radiation or at least have the patient meet with rad onc:

  • After surgical tx in patients with clinical node + disease
  • Unresectable node + disease
  • Unresectable in-transit recurrence
  • Nodal recurrence
  • Unresectable disseminated metastasis
22
Q

In melanoma, what is appropriate follow-up?

A
  • H&P q6-12months x5 years, then annually
  • PRN imaging for specific signs/symptoms
  • Nodal US surveillance if SLNB+ and observing
    • q4months x2 years, THEN
    • q6months x3 years
  • Stage 0-IIA -> NO IMAGING
  • Stage IIB- IV -> Whole Body PET scan
    • q6-12months x5 years
23
Q

A patient has a palpable inguinal LN that after US and core needle biopsy returns as melanoma. What is next steps?

A

Hopefully a skin exam was performed prior to US and biopsy, but either way I would perform a thorough skin exam as well as an anal exam.

The patient would also need BRAF testing and PET scan.

24
Q

When performing a superficial inguinal lymph node dissection, what can be done to provide coverage over the femoral vessels?

A
  1. Sartorius muscle flap
  2. Gracilis muscle flap

Surgery Mock Oral Board Prep (15 decks)

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