SKIN & SOFT TISSUE

Question 1

Which sarcomas spread to lymph nodes more often

Answer 1

rhabdomyosarcoma
epithloid sarcoma
clear cell sarcoma
synovial sarcoma
vascular sarcoma

Question 2

Pt with 10 cm mass in the root of small bowel mesentery - desmoid tumor. Treatment?

Answer 2

Watch and reimage in 3 months. Often remain stable in size for many years or even spontaneously regress

Question 3

Hurley stage I (no sinus tracts or scarring) tx

Answer 3

clindamycin gel

Question 4

cephalad limit for ilioinguinal lymphadenectomy

Answer 4

bifurcation of the CIA to internal and external iliacs

Question 5

Caudad extent of ilioinguinal lymphadenectomy

Answer 5

inguinal ligament

Question 6

inferior extemnt of inguinal lymphadenectomy

Answer 6

apex of the femoral triangle (defiened by adductor longus mediall and sartorius muscle laterally). Superior boundary is inguinal ligament.

Question 7

Risk factors that warrant consideration for SLN bx in SCC

Answer 7

tumor >2 cm for trunk and extremities and >1 cm for face, scalp hands and feet
[poorly differentiated tumors
angiolymphatic invasion and perineural invasion
tumor depth >6 mm or invasion beyond subcutaneous fat
immunosuppressed

Question 8

30% of all mets to skin are of what primary origin?

Answer 8

breast

70% of skin mets in women are from primary breast tumor

Question 9

tx of clinically localized Merkel cell ca

Answer 9

resection with 1-2 cm margins and SLN bx

Question 10

paronychial infection MCC

Answer 10

staph aureus

Question 11

metastatic melanoma - tx

Answer 11

Pembrolizumab is a monoclonal antibody against PD-1 and has significantly increased long-term survival, up to 40% or more, for patients with metastatic melanoma. When combined with ipilimumab, this dual immunotherapy increases survival up to 50% or more.

Question 12

Retroperitoneal sarcoma and RT

Answer 12

Neoadjuvant radiation for resectable retroperitoneal sarcoma (RPS) has been studied in a prospective, randomized clinical trial (STRASS trial). The rationale for a neoadjuvant approach is that often the RPS has mobilized the viscera within the abdomen to a large degree, and the appropriate radiation dose can thereby be delivered without the attendant toxicity to organs that may be spared during the course of resection. Conversely, the delivery of a therapeutic radiation dose in the adjuvant setting is often precluded because of toxicity incurred by surrounding viscera, namely bowel. Biologically speaking, radiation is biologically more effective in the neoadjuvant setting due to optimal oxygen tension of the tissue relative to the postoperative setting.

Question 13

What feature of dermatofibrosarcoma protuberans increases the metastatic potential?

Answer 13

If it has fibrosarcomatous change - usually mets to lungs

Question 14

What is the main cell type in epidermis? Where does it originate from?

Answer 14

Keratinocytes originate from basal layer - provide mechanical barrier

Question 15

Melanocytes are of what origin? Where are they found?

Answer 15

Neuroectdermal origin (neural crest cells) in basal layer of epidermis
Havge dendritic processes that transfer melanin to neighboring keratinocytes via melanosomes. The density is the same among races but melanin production is different

Question 16

Sensory nerves - pressure

Answer 16

pacinian corpuscles

Question 17

Sensory nerves - warmth

Answer 17

Ruffinis endings

Question 18

Sensory nerves - cold

Answer 18

Krause’s end bulbs

Question 19

Sensory nerves - tactile sense

Answer 19

Meissner’s corpuscles

Question 20

Which sweat glands responsible for aqqueous sweat?

Answer 20

Eccrine - thermal regulation, usually hypotonic

Question 21

Which sweat glands responsible for milky sweat?

Answer 21

Apocrine

Highest concentration in palms and soles; most result of SNS via acetylcholine

Question 22

TRAM flaps rely on what vessel

Answer 22

superior epigastric

Question 23

Most impt determinant of TRAM flap viability

Answer 23

periumbilical muscle perforators

Question 24

hypertrophic scar - which type of collagen?

Answer 24

organized type III collagen

Question 25

keloid scar - which type of collagen?

Answer 25

disorganized I/III collagen

Question 26

Hypertrophic or keloid scars stay within boundaries?

Answer 26

hypertrophic

Question 27

Single beset factor for protecting skin from UYV radiation

Answer 27

Melanin

Question 28

Responsible for chronic sun damage

Answer 28

UV B

Question 29

Familial BK mole syndrome gives what risk for melanoma?

Answer 29

Almost 100%

Question 30

MC location for distant melanoma mets

Answer 30

Lung

Question 31

MC met to small bowel

Answer 31

melanoma

Question 32

<2 cm lesion concerning for melanoma - biopsy type?

Answer 32

Excisional (Tru-Cut core needle biopsy)

Question 33

When are 0.5 cm margins appropriate in melanoma?

Answer 33

Melanoma in situ or thin lentigo maligna (Hutchinson's freckle) -- just in the epidermis

Question 34

Least aggressive melanoma subtype

Answer 34

lentigo maligna melanoma

Question 35

Most aggressive melanoma subtype

Answer 35

Nodular. Most likely to have mets at time of dx. Deepest growth at time of dx. Vertical growth 1st.

Question 36

Staging for melanoma >1 mm

Answer 36

CT C/A/P, LFTs and LDH

Question 37

When do you excise LN in melanoma?

Answer 37

If clinically positive or if SLNBx positive

Question 38

What do you need to include for all scalp/face melanomas anterior to the ear and above the lip >1 mm deep

Answer 38

superficial parotidectomy

Question 39

Axillary node melanoma with no other primary - tx?

Answer 39

Complete ALND (level I-III)

Question 40

First line chemo for metastatic melanoma

Answer 40

Dacarbazine

Question 41

Where does BCC originate?

Answer 41

Epidermis (basal epithelial cells and hair folicles)

Question 42

Path shows peripheral palisading of nuclei and stromal retraction - dx?

Answer 42

BCC

Question 43

Most aggressive BCC

Answer 43

Morpheaform type. Has collagewnase production

Question 44

Margins for BCC

Answer 44

0.3-0.5 cm

Question 45

Margins for SCC

Answer 45

0.5-1.0 cm except in Marjolin's ulcers (2 cm) and penile/vulvar areas)

Question 46

MC soft tissue sarcoma

Answer 46

malignant fibrous histiocytoma

Question 47

What comes first when concern for sarcoma?

Answer 47

MRI before biopsy

Question 48

What can you give to decrease size of dermatofibrosarcoma protuberans

Answer 48

Imatinib

Question 49

Spindle cells containing CD34

Answer 49

DFS protuberans

Question 50

Margins for DFS protuberans

Answer 50

2 cm

Question 51

Excisional biopsy for sarcomas < what size?

Answer 51

<4 cm

Question 52

MC site of sarcoma met

Answer 52

Lung

Question 53

Staging of sarcomas is based on?

Answer 53

grade (tumor grade is also most important prognostic factor)

Question 54

What margins do you want for sarcoma?

Answer 54

2-3 cm and at least 1 uninvolved fascial plane. Place clips to mark site of likely recurrence

Question 55

Post op XRT for sarcoma when?

Answer 55

High grade tumors Close margins Tumors > 5 cm

Question 56

Chemotherapy for sarcoma

Answer 56

Doxorubicin (adriamycin) based

Question 57

What size sarcoma may benefit from pre op chemo/XRT?

Answer 57

>10 cm

Question 58

Isolated sarcoma mets

Answer 58

Resect if no other evidence of systemic disesase

Question 59

Most impt prognostic factor in retroperitoneal sarcoma

Answer 59

Ability to completely remove tumor

Question 60

MC retroperitoneal tumor

Answer 60

Lymphoma

Question 61

Risk factor for angiosarcoma

Answer 61

PVC, arsenic

Question 62

MC sites for Kaposi's sarcoma

Answer 62

Oral and pharyngeal mucosa

Question 63

MC malignancy in AIDS

Answer 63

Kaposi's sarcoma

Question 64

Primary goal in tx of Kaposi's

Answer 64

palliation | AIDS Tx shrinks AIDS related KS

Question 65

Disseminated Kaposi's sarcoma tx

Answer 65

Interferon alpha

Question 66

Local disease tx for Kaposi's sarcoma

Answer 66

XRT or intra lesional vinblastine

Question 67

#1 soft tissue sarcoma in kids

Answer 67

Rhabdomyosarcoma

Question 68

Most common rhabdomyossarcoma in kids

Answer 68

embryonal

Question 69

Worst prognosis rhabdomyosarcoma in kids

Answer 69

Alveolar

Question 70

Rhadomyosarcoma contains what protein

Answer 70

Desmin

Question 71

Tx for childhood rhabdomyosarcoma

Answer 71

Surgery; doxorubicin based chemo

Question 72

Osteosarcoma originates from what type of cells

Answer 72

Metaphyseal cells

Question 73

Neurofibromatosis - what types of tumors

Answer 73

CNS, peripheral sheath tumors, pheo

Question 74

Li-Fraumeni syndrome - what type of soft tissue tumor?

Answer 74

rhabdomyosarcoma

Question 75

Tuberous sclerosis is assoc with what soft tissue tumor

Answer 75

angiomyolipoma

Question 76

Tx for actinic keratosis

Answer 76

Diclofenac sodium; liquid nitrogen

Question 77

Arsenical keratosis is assoc with>

Answer 77

SCC

Question 78

Merkel cell CA - what proteins?

Answer 78

neuron-specific enolase, cytokeratin, neurofilament

Question 79

What is ineffective in merkel cell cA?

Answer 79

chemo. can consider if curative sx or XRT not feasible

Question 80

MC site of glomus cell tumor

Answer 80

terminal aspect of the digit

Question 81

Tx of desmoid tumor if vital structures involved or too much bowel taken

Answer 81

chemotherapy with sulindac, tamoxifen

Question 82

Tx of Bowen's disease

Answer 82

imiquimod, cautery ablation, topical 5-FU. AVOID WLE if possible. Regular bx to r/o CA

Question 83

Worsening nodular cellulitis often mistaken for a fungal infection - name and what bug?

Answer 83

Botryomycosis is due to local inoculation of bacteria into the wound of an immunocompromised patient. It presents as a worsening, nodular cellulitis and is often mistaken for a fungal infection (hence the "mycosis"), but it is actually most often due to S aureus.

Question 84

Sandfly byte

Answer 84

Leishmaniasis

Question 85

Touching contaminated plant matter - "rose gardener's disease"

Answer 85

Sporotrichosis - infection due to fungus, Sporothrix schenckii. Cutaneous form usually appears as red or pink bumps but can progress to slow healing ulcer.

Question 86

LRINEC score

Answer 86

``` WBC > 15 Na < 135 CRP > 150 Cr > 1.6 Glucose > 180 Hgb < 13.5 ```

Question 87

T1 sarcoma

Answer 87

<5 cm

Question 88

T4 sarcoma

Answer 88

>15 cm

Question 89

Stage I and II melanoma - additional workup for staging?

Answer 89

None

Question 90

MC short term complication 2/2 inguinal lymph node dissection

Answer 90

Wound infection

Question 91

MCC lymphangitis

Answer 91

S pyogenes

Question 92

Merkel cell CA a/w what virus

Answer 92

Polyomavirus

Question 93

Bridging node between deep and superficial LN basins (inguinal)

Answer 93

Cloquet

Question 94

Where can you find saphenous vein in a superficial inguinal lymphadenectomy

Answer 94

Junction of sartorius and adductor

Question 95

What nerve runs under fascia of sartorius (superficial ILND)

Answer 95

lateral femoral cutaneous

Question 96

Where does the obturator nerve run between?

Answer 96

External and internal iliac

Question 97

MC monomicrobial cause of nec fasc

Answer 97

group a beta hemolytic strep

Question 98

MCC nec fasc

Answer 98

polymicrobial

Question 99

partial thickness nuclear pleomorphism

Answer 99

AK

Question 100

DFSP commonly shows immune reactivity to CD?

Answer 100

CD34

Question 101

Hurley Stage I

Answer 101

single or multiple nodules or abscesses, absence of sinus tracts and scarring

Question 102

Hurley Stage II

Answer 102

recurrent abscesses, sinu stracts, scarring

Question 103

Hurley STage III

Answer 103

interconnections between recurring abscesses and coalesced sinus tracts diffuse disease

Question 104

Clinical signs of subungual melanoma | ABC

Answer 104

ABCDEF Age (40-60) Band of brown/black color >3 mm with irregular borders Change in size of band Digits involved Extension of pigmentation to nail fold (Hutchison) Family hx of melanoma

Question 105

What is keratoacanthoma

Answer 105

Rare clinical variant of SCC which presents with painful onycholysis as well as digital erythema and swelling

Question 106

Drugs that commonly cause TEN or SJS

Answer 106

sulfonamides aminopenicillins anticonvulsants NSAIDs allopurinal

Question 107

How to treat dopamine extravasation

Answer 107

Infiltrate ASAP with 10-20 mL of NS containing 10 mg of phentolamine

Question 108

Markers for melanoma

Answer 108

HMB 45 Melan-A S-100 MITF SOX-100

Question 109

Merkel cell stains + for what and - for what

Answer 109

+ for CK20 - for TTF-1 (which differentiates it from small cell lung CA)

Question 110

dense proliferation of spindle shaped tumor cells from the dermis to the subcutaneous adipose tissue wit hsparing of the epidermis

Answer 110

dermatofibrosarcoma protuberans

Question 111

tumor cells stain positive for CD34 and vimentin

Answer 111

dermatofibrosarcoma protuberans

Question 112

finger like projections fo spindle cells

Answer 112

dermatofibrosarcoma protuberans

Question 113

ABCD classification is poor sensitivity for what type of melanoma

Answer 113

nodular