Surg Flashcards
(99 cards)
1
Q
Mustarde rotation flap
A
Cheek rotation flap
2
Q
Acute side effects of ray
A
Radiodermatitis: erythema dry desquamarion and moist desquamatoon
Mucositis
3
Q
Chronic side effects from ray
A
Atrophy Loss of appendages: alopecia and anhidrosis Hyper or hypo pigmentation Telangiectasia Ulceration
Secondary malignancy 1/1000-2000 risk, average 24 years later: BCC SCC AFX MFH fibrosarcoma angiosarcoma
4
Q
List all possible treatment of cutaneous tumors
A
Mohs Excision Cryotherapy Radiation therapy C&C Intralesional interferon, 5-fu, methotrexate PDT Ablative laser Topical 5FU and ingenol and imiquimod Vidmodegib
5
Q
Normal bread loafing of histo examines what % of tumour margins
A
Less than 1%
6
Q
5 year cure rate mohs vs excision
A
Mohs 99%
Conventional 93%
7
Q
5 year cure rate for recurrent cancers Mohs vs excision
A
Mohs 95%
Excision 80%
8
Q
Cancers on ear make up what % of cutaneous cancers
A
6% but high recurrences likely due to embryonic fusion planes
9
Q
Post auricular tumors spread where
A
The ear
10
Q
Pre auricular tumors spread where
A
Towards the tragus and medial and superior aspects of the helix. Once at tragus can spread down the external part of tragus between tragar cartilage and parotid gland to deeper like facial nerve
11
Q
Which site most common recurrence for BCC
A
Nose
12
Q
Indications for Mohs
A
Recurrent Positive margin High risk for recurrence or mets Sites that require tissue conservation Embryonic fusion planes: peri orbital (medial canthi), nasal, lips, ears, retroauricular sulcus, melolabial folds Poorly defined clinical margins PNI >2 cM Immunosuppressed Previous ray treatment Demonstrated biological aggressiveness
13
Q
Sites where tissue conservation is important
A
Eyelids Ears Nose Lips Digits Hails Genitalia
14
Q
Best site for cure rate for Mohs on penis
A
Glans or prepuce, <1 cm
15
Q
Supplements that make you bleed
A
Vitamin E
Gingko biloba
Garlic
16
Q
Ways to identify where the tumour is on the skin
A
Magnification Dermoscopt Woods light Curette lightly Ask patient
17
Q
What angle do you have blade in Mohs
A
30-45 degrees
18
Q
What kind of specimen is best in Mohs
A
Saucer shaped with 30 degree beveled edges so it can be flattened
19
Q
What size specimen can fit on a microscope slide
A
0.5-1.5 cm
20
Q
How do you number the edges of tissue specimens in Mohs
A
Clockwise, starting at one o clock
21
Q
How is a Mohs specimen cut
A
Horizontal sections from the deep surface first
22
Q
What do you freeze Mohs specimens with
A
Tetrafluorethylchloride
Liquid nitrogen
23
Q
What intervals of sections are sliced in Mohs
A
4-8 um
24
Q
What stains do you use in Mohs
A
After sliced, stain with H&E, sometimes toludine blue
After gone through slide drainer than rinse and use a clear mounting medium: Cytosdal-60 or similar
Other stains to help with diagnosis
MART1
Cytokerstin
CD34 for DFSP
25
What % of tissue shrinkage from frozen section processing
10-20
26
If tumour involved eyelid margin how should you protect the eye
Lubricated plastic eye shield after topical Anaesthetia of tetracain Ophthal drops
27
Which instruments are good for perinocular excisions
Castro Viejo needle driver
| Westcott scissors
28
Patients with high risk of IE who need prophylactic abx
Prosthetic cardiac valve
Previous IE
Unrepaired CHD or repaired with prosthetic within 6 m of procedure
Repaired CHD with residual defects
Cardiac transplant recipients with valvulopathy
29
Patients at high risk of joint infection
```
Joint replacement within last 2 years
Previous prosthetic joint infection
Immunocompromised
T1 DM
HIV
Malignancy
Malnourishment
Haemophilia
```
30
Sites of high risk of surgical infection
```
Wedge on lip or ear
Genitalia
Below knee
Skin flap on nose
Skin grafts
Extensive inflammatory disease
```
31
Aldabra response rates for BCC
Superficial 87%
| More invasive 65%
32
BCC most important predictor of sub clinical spread a part from agresiva histo
>2.5 cm
33
BCC margins excision versus Mohs
<2 cm 4 mm margin clears 95% in excision
| Mohs <1 cm 99.9%, 1-2 cm 99.3%, 2-3 98 and >3 84.3
34
Recurrent BCC excision versus Mohs
Excision 12.1% recurrent at 5 years
| Mohs 2.4%
35
Facial BCC excision versus Mohs
Mohs 2.5
| Excision 4.1
36
Basosquamous recurrent Mohs versus excision
Mohs 4.1
| Excision 12-45
37
What % of BCC become metastatic
<0.5%
38
Biologically aggressive SCCs
Cystic
Clear cell carcinoma
Adenoid SCC
Spindle cell SCC
39
Risk of PNI in SCC
<2.5 cm 11 %
| >2.5 cm 64%
40
Margins for SCC excision
4-6 mm depending on risk
41
Recurrent SCC Mohs clearance rates
94%
42
Verrucous carcinoma rates Mohs versus excision
Excision 80
| Mohs 98
43
Merkel CC recurrence, nodes and Mets rates
Recurrence 30%
Regional LN 50%
Mets 40%
44
Merkel cell carcinoma clinical margins
1-2 cm
45
Treatment of choice for DFSP
Mohs - no recurrence
| Imatinib - tyrosine kinase inhibitor for Mets
46
AFX margins
1 cm
47
MAC recurrent rates
Excision 50%
| Mohs 10%
48
Eccrine porocarcinona - appropriate for Mohs?
Well it has skip areas
| Also it’s radio resistant
49
Is sebaceous carcinoma appropriate for Mohs
CAn have skip lesions and recognizing pagetoid spread may be tricky
50
DFSP margins
<2 cm 1.5 cm
| Larger 2.5 cm
51
When is adjuvant radiation usually performed
Witihin 4-8 weeks post operatively
52
What is the usual total dose of radiation over how many fractions
50-55 gy over 20 daily fractions
53
What is the preferred treatment of choice for rad onc treating keratinocyte cancers
Electron beam radiotherapy
54
What is the radiation threshold dose that predisposes eyes to cataracts
5-10 gray
55
Acute reactions from radiation
```
Erythema
Dry and then moist desquamation
Dyspigmentation
Ulceration, haemorrhage
Pruritos
Temporary alopecia
Temporary loss of fingernails or toenails
Temporary hypohidrosis
Mucositis
```
Suspect infection if not healing
56
Late reactions from radiation
```
Telangiectasias
Fibrosis
Necrosis of soft tissue, cartilage, bone
Dyspigmentation
Permanent alopecia
Hypohidrosis, sweat gland atrophy
Xerostomia
Delayed wound healing
NMSC ~20 yrs later
```
57
Success % with radiation usually
~90%
58
Ideal tumour size for TEBR
< 5 cm diameter, <0.5 cm depth
59
Ideal tumour size for Brachytherapy (both surface and interstitial) radionuclide
<2 cm diameter and <0.5 cm depth
60
Ideal tumour size for superficial ray
<5 cm diameter and <0.5 cm depth
61
Contraindications for radiation
Absolute: genoderm Gorlins, XP
```
Relative:
AICTD - lupus, scleroderma (Bolognia says this is absolute)
Poorly vasculairsed
Chronic ulceration
Trauma
Thermal burns
Prior radiation
Deeply invading into the cartilage
Extremities: foot, anterior lower leg, dorsum of hand
<50-60
```
62
When to do adjuvant radiation for BCC
Substantial perineural involvement: >0.1 mm in caliber or >3 nerves, or positive margins
63
When to do adjuvant radiation for SCC if clear margins
| What margins
if substantial peri neural involvement, larger than 0.1 mm or invasion of nerve below the dermis
Also for nodal mets to the head and neck, unless the patient has 1 small node with no extracapsular extension
Most treated with 1-1.5 cm margin
64
What is the first and second line treatment for DFSP now
WLE first
Imatinib second
Radiation is third now and you do a wide field 3-5 cm
65
Can you use radiation treatment for MCC
Yes - its recommended as adjuvant regardless of positive or negative margins
Recommend doing within 4 weeks after surgery
The excision site, in transit tissue and draining nodal basins are irradiated to account for subclinical disease UNLESS the primary tumour is <1 cm, negative post operative margins are obtained, no lymphovascular invasion, and SLNB is negative
66
What sort of radiation field for MCC
5 cm
67
Common cx post radiation for Kaposi
Lymphoedema
68
When to do radiation for melanoma
Definitive: large facial lentigo maligna not amenable to surgery - 1-1.5 cm margin
Adjuvant:
Post operatively desmoplastic
LN mets
Stereotactic: CNS mets
Palliative for cutaneous mets, in transit disease etc
69
When to do radiation for UPS
Always - post operaatively whether negative or positive margins
70
What is the concern of radiation with systemic therapies for melanoma
BRAF and MEK inhibitors may lead to increased toxicity when used with RT - so hold at least 3 days before and after fractionated RT
71
Risk of BCCs and SCCs from radiation (according to bolognia)
2% and 1.5% respectively
72
How to deal with a haematoma post op
<48 hours large bore needle 16-18 gauge aspiration
>48 hours irrigation
If liquefied (7-10 days) then can needle aspirate
73
When does a haematoma liquefy
7-10 days post op
74
Most common timeframe for surgical site infections
4–10 days
75
Risk of transformation of individual AK to invasive SCC is what at 5 years
2.88%
76
Action spectrum of 8 mop
330-335
77
Maximum EMLA dosage
0-3 m: 10 cm2 for 1 hour
3-12 m: 20 for 4 hrs
1-6 yes: 100 for 4 hrs
7-12: 200 for 4 hrs
78
Nasal tip side to side closure can do for defects less than what
8 mm
79
Max size for dorsal nasal rotation
2-2.5 cm
80
with myocutaneous flap incise down to where
lateral to subcut fat
| medial to periosteum
81
where should you put the peng flap
supra tip best site
82
width of paramedian flap
1.2-1.5 cm
83
blood supply for nasolabial interpolation
random
84
size for composite graft
<1 cm
85
principles of the transposed island pedicle
draw and ellipse lateral to the defect
undermine distal 3/4 in fat, then swing deeper into muscle to create fat/mm island pedicle
undermine widely
swing around 45-90 degrees
good for deep defects
86
shark island pedicle sutures
1st: back of shark to nasofacial sulcus - this should make head and snout drape down into defect
second: snout down to inf border of defect
87
with second intention healing how much contraction occurs/decrease in size
30%
88
second intention how long will have open wound
4-6 weeks
89
three best closures for nasal dorsum defect
peri alar unilateral single sided advancement flap
SCIP
back cut rotation (dorsal nasal rotation essentially)
90
Nasolabial advancement flap - design and where to put sutures
Design: inferomedial aspect of defect around alar crease and down nasolabial fold
Sutures:
1. Pex middle of flap at NF sulcus, pull superomedially
2. 1/2 cm behind advancing corner of flap to periosteum under superior edge of defect
91
Nasolabial advancement flap negatives
Can lower eyelid
Blunting of nasofacial sulcus
Elevation of alar rim
Webbing of medial canthus
92
Rules for back cut rotation flap
Surface area of flap needs to be twice the size of the defect
Angle of inverse V should be 30-45 degrees
Undermine above procerus and corrugator supercilli
Close glabella defect first, then close the primary defect
93
If do side to side on lateral forehead, what is the size of the defect
<1 cm to ensure no lateral eyebrow elevation
94
Rotation flap general principle regarding area of flap within the arc compared to defect
2-3 times the size of defect
95
how long does it take for eyebrow hairs to re grow
4 months
96
when in the eyebrow, what considerations for surgery
undermine beneath the hair bulb
medial eyebrow hairs grow vertically
lateral eyebrows grow horizontally
make sure to incise parallel to the hair shafts
97
Best closure for the eyebrow
O to U or O to H or SCIP
Do O to U if medial or lateral
O to H if in centre of eyebrow
98
DCP initial
2%
4X4 cm area
Photoprotect
99
What is the trigeminocardiac reflex
Operating in trigeminal nerve - ophthalmic and maxillary branch, trigeminal nerve connects with trigeminal nucleus - links with motor nuclehys of vagus nerve
Results in bradycardia, hypotension, asystole, apnoea, death
