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Questions and Answers
Which of the following describes a tumor classified as Breslow Stage III?
Which of the following describes a tumor classified as Breslow Stage III?
- 0.76 - 1.5 mm
- > 4 mm
- ≤ 0.75 mm
- 1.5 mm - 4 mm (correct)
According to Clarke's Classification, Stage V involves only the epidermis.
According to Clarke's Classification, Stage V involves only the epidermis.
False (B)
What is the recommended surgical procedure for localized disease?
What is the recommended surgical procedure for localized disease?
Wide local excision (WLE)
A tumor measuring greater than ____ mm is classified as Breslow Stage IV.
A tumor measuring greater than ____ mm is classified as Breslow Stage IV.
Match the following treatments with their mechanisms:
Match the following treatments with their mechanisms:
What is the first step in managing a primary pneumothorax if the size is greater than 2 cm and the patient is breathless?
What is the first step in managing a primary pneumothorax if the size is greater than 2 cm and the patient is breathless?
A chest X-ray is used for the diagnostic workup of pneumothorax.
A chest X-ray is used for the diagnostic workup of pneumothorax.
Name one clinical feature of pneumothorax.
Name one clinical feature of pneumothorax.
For a secondary pneumothorax with size 1-2 cm, if the patient is not breathless, you should ______.
For a secondary pneumothorax with size 1-2 cm, if the patient is not breathless, you should ______.
Match the following conditions to their management:
Match the following conditions to their management:
What is the most common type of malignant melanoma?
What is the most common type of malignant melanoma?
Moh's micrographic surgery is primarily used for melanoma treatments.
Moh's micrographic surgery is primarily used for melanoma treatments.
List one risk factor for malignant melanoma.
List one risk factor for malignant melanoma.
Moh's micrographic surgery involves layer-by-layer removal of the lesion and __________ examination.
Moh's micrographic surgery involves layer-by-layer removal of the lesion and __________ examination.
Match the following risk factors to the related conditions:
Match the following risk factors to the related conditions:
What type of skin cancer is associated with precursor lesions such as cutaneous horn and keratoacanthoma?
What type of skin cancer is associated with precursor lesions such as cutaneous horn and keratoacanthoma?
Marjolin's ulcer is commonly associated with lymph node involvement due to scarring of lymphatics.
Marjolin's ulcer is commonly associated with lymph node involvement due to scarring of lymphatics.
Which type of soft tissue sarcoma is most common in children?
Which type of soft tissue sarcoma is most common in children?
The _____ is a condition where long-standing lymphedema can lead to angiosarcoma or lymphangiosarcoma.
The _____ is a condition where long-standing lymphedema can lead to angiosarcoma or lymphangiosarcoma.
Match the following associated syndromes with their relevant condition:
Match the following associated syndromes with their relevant condition:
What is the most common route of spread for sarcomas?
What is the most common route of spread for sarcomas?
Desmoid tumors are known for their ability to metastasize.
Desmoid tumors are known for their ability to metastasize.
What is the role of mitotic figures in determining the prognosis of soft tissue sarcomas?
What is the role of mitotic figures in determining the prognosis of soft tissue sarcomas?
Soft tissue sarcomas may commonly spread to the ________ and retroperitoneum to the ________.
Soft tissue sarcomas may commonly spread to the ________ and retroperitoneum to the ________.
Match the following soft tissue sarcomas with their characteristics:
Match the following soft tissue sarcomas with their characteristics:
What is the primary reason for performing bronchoscopic removal when a foreign body is suspected?
What is the primary reason for performing bronchoscopic removal when a foreign body is suspected?
Primary spontaneous pneumothorax typically occurs more in older patients than in younger patients.
Primary spontaneous pneumothorax typically occurs more in older patients than in younger patients.
What imaging technique is primarily used to diagnose foreign body aspiration?
What imaging technique is primarily used to diagnose foreign body aspiration?
The right mainstem bronchus is _____ and _____ compared to the left mainstem bronchus.
The right mainstem bronchus is _____ and _____ compared to the left mainstem bronchus.
Match the types of spontaneous pneumothorax with their characteristics:
Match the types of spontaneous pneumothorax with their characteristics:
Which of the following complications is most common following submandibular gland surgery?
Which of the following complications is most common following submandibular gland surgery?
Extracapsular dissection has an effect on oncological safety regarding tumor recurrence.
Extracapsular dissection has an effect on oncological safety regarding tumor recurrence.
What investigation is typically performed for diagnosing submandibular swelling?
What investigation is typically performed for diagnosing submandibular swelling?
The most common tumor found in the sublingual and minor salivary glands is __________.
The most common tumor found in the sublingual and minor salivary glands is __________.
Match the following conditions with their management options:
Match the following conditions with their management options:
What is a characteristic of a total parotidectomy?
What is a characteristic of a total parotidectomy?
Which type of melanoma presents with a poor prognosis and is characterized by rapid vertical growth?
Which type of melanoma presents with a poor prognosis and is characterized by rapid vertical growth?
Frey's Syndrome causes gustatory sweating due to nerve misdirection.
Frey's Syndrome causes gustatory sweating due to nerve misdirection.
Acral melanoma is the most common type found in dark-skinned individuals.
Acral melanoma is the most common type found in dark-skinned individuals.
What is the most common nerve used for grafting in a total radical parotidectomy?
What is the most common nerve used for grafting in a total radical parotidectomy?
The _____ nerve is located 1 cm inferior and deep, as referred to by surgeons during parotid gland surgery.
The _____ nerve is located 1 cm inferior and deep, as referred to by surgeons during parotid gland surgery.
Name one of the ABCDE changes that suggest malignant transformation in skin lesions.
Name one of the ABCDE changes that suggest malignant transformation in skin lesions.
Match the following complications with their descriptions:
Match the following complications with their descriptions:
The melanoma variant that lacks pigment is called __________ melanoma.
The melanoma variant that lacks pigment is called __________ melanoma.
Match the following types of melanoma with their descriptions:
Match the following types of melanoma with their descriptions:
What is the most common site for Basal Cell Carcinoma (BCC)?
What is the most common site for Basal Cell Carcinoma (BCC)?
Basal Cell Carcinoma commonly undergoes distant metastasis.
Basal Cell Carcinoma commonly undergoes distant metastasis.
What is the characteristic histological pattern seen in a biopsy of Basal Cell Carcinoma?
What is the characteristic histological pattern seen in a biopsy of Basal Cell Carcinoma?
The most aggressive type of localized Basal Cell Carcinoma is known as __________.
The most aggressive type of localized Basal Cell Carcinoma is known as __________.
Match the following types of Basal Cell Carcinoma to their characteristics:
Match the following types of Basal Cell Carcinoma to their characteristics:
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Study Notes
Squamous Cell Carcinoma
- Precursor lesions: Cutaneous horn, Keratoacanthoma
- Marjolin's Ulcer: Seen in long-standing varicose ulcers and burn scars; rarely involves lymph nodes due to lymphatic scarring
- Marjolin's Ulcer Management: Wide local excision
Soft Tissue Sarcomas
- Most common soft tissue sarcomas: Liposarcoma (retroperitoneum), Rhabdomyosarcoma (genitourinary and head & neck regions in children)
- Etiology: Radiation, chemical exposure, immunosuppression, viral infection (Kaposi sarcoma)
- Associated syndromes: Stewart-Treves syndrome (angio/lymphangiosarcoma), retinoblastoma, Li-Fraumeni syndrome, NF-1, Gardner's syndrome (desmoid tumor), Gorlin syndrome (sarcomas + BCC)
Clarke's Classification
- Stage I: Epidermis
- Stage II: Papillary dermis
- Stage III: Dermal papillae
- Stage IV: Reticular dermis
- Stage V: Subcutaneous tissue
Breslow Classification
- Stage I: ≤ 0.75 mm
- Stage II: 0.76 - 1.5 mm
- Stage III: 1.5 mm - 4 mm
- Stage IV: > 4 mm
Melanoma Management
- Localized disease: Wide local excision (WLE)
- NCCN criteria for margins: ≥ 2 cm for tumors ≤ 2 mm
- Gross lymph node involvement: Sentinel lymph node biopsy for clearance
- Metastasis: Dabrafenib (BRAF inhibitor), Trametinib (MAPK pathway inhibitor), Ipilimumab (checkpoint inhibitor)
Pneumothorax Management
- Clinical features: Sharp pleuritic pain, partial/complete lung collapse, hyper-resonant percussion, absent breath sounds
- Diagnostic workup: Chest X-ray
- Primary spontaneous pneumothorax (size > 2 cm or breathless): Aspirate if yes, consider discharge review in 2-4 weeks if no
- Secondary spontaneous pneumothorax (size > 2 cm, or breathless): Aspirate if yes, chest drain (8-14 Fr) if size 1-2 cm and breathless, admit and observe if not
- Secondary spontaneous pneumothorax (bilateral, or hemodynamically unstable): Chest drain
- Secondary spontaneous pneumothorax (age > 50, significant smoking history, or underlying lung disease): Chest drain or appropriate management based on clinical judgment
Indications for Surgical Intervention in Pneumothorax
- Secondary ipsilateral pneumothorax
- First contralateral pneumothorax
- Bilateral spontaneous pneumothorax
- Pneumothorax failing to settle with chest drainage
- Spontaneous hemothorax
- At-risk professions (pilots, divers)
- Pregnancy
Moh’s Micrographic Surgery
- High-risk features: > 1 cm size, sites where infiltration can lead to cranial extension, recurrent lesions, after immunosuppression
- Layer-by-layer removal of lesion with microscopic examination
- Most common for Basal Cell Carcinoma (BCC), also used for other skin cancers
- Indications: Recurrent cases, close to vital structures, close to vital nerves
- Advantages: Less tissue removed, better cosmesis
- Disadvantages: Time-consuming
Malignant Melanoma
- Tumor of melanocytes
- Risk factors: UV radiation, white population, Familial atypical mole melanoma syndrome
- Phases of growth: Horizontal, followed by vertical invasion
- Types: Superficial spreading (most common, prolonged horizontal phase, commonly found in pre-existing moles), acral melanoma (most common in dark-skinned individuals, rapid vertical growth phase, palm & sole), nodular melanoma (rapid vertical growth phase, poor prognosis, amelanotic variant), desmoplastic melanoma (head/neck, perineural invasion, often painful, locoregional recurrence)
- ABCDE changes: Asymmetry, Border irregularity, Color change, Diameter > 6mm, Evolution
Desmoid Tumor
- Site: Anterior abdominal wall, often over scars
- Association: Gardner's syndrome
- Features: Locally invasive but does not metastasize
- Management: Wide local excision, Tamoxifen
Thorax and Mediastinum
- Right lung: Upper, middle, lower lobes
- Left lung: Upper, lower lobes
- Right main stem bronchus: Shorter and straighter
- Aspiration risk: Abscess formation
- Common aspiration sites: Posterior upper lobe, Superior lower lobe
- Foreign body clinical features: Wheezing, stridor, complete block (collapse)
- Foreign body diagnosis: X-ray
- Foreign body treatment: Bronchoscopic removal
- Thoracoscore: 9 criteria for mortality prediction post lung resection
- DLCO: Diffusion capacity of the lung for carbon monoxide
Spontaneous Pneumothorax
- Definition: Air in the pneumothorax
- Primary spontaneous: Young, tall, males > females, often family history, leak from blebs, normal lung function, better pneumothorax tolerance
- Secondary spontaneous: Older patients, secondary to lung disease (TB, tumors, emphysema), less pneumothorax tolerance
Faciomaxillary Surgery
- Extracapsular dissection: Done for benign tumors, no effect on oncological safety, less facial nerve injury and Frey's syndrome
Submandibular and Sublingual Glands
- Submandibular swelling: Bimanual palpation used for lymph node differentiation, palpable swelling (benign: pleomorphic adenoma, malignant: adenoid cystic carcinoma)
- Investigation: Fine needle aspiration cytology (FNAC)
- Submandibular gland excision management
- Complications of submandibular gland surgery: Hemorrhage, nerve injury (lingual nerve, marginal mandibular nerve - most common, hypoglossal nerve), injury to other structures (anterior facial vein, facial artery)
- Sublingual & minor salivary gland: Most common tumor - adenoid cystic carcinoma, management - excision + radiotherapy
- Surgery: v1.0, Marrow: 8.0, Year: 2024
Basal Cell Carcinoma
- AKA: Rodent ulcer
- Characteristic features: Locally invasive, no lymph node or distant mets, most common site - face (above mouth-to-ear lobule line)
- Risk factors: White population, UV rays, Gorlin syndrome (chromosome 9)
- Types: Localized (nodular - most common, nodulocystic, pigmented), generalized (infiltrative - most aggressive, superficial, multifocal)
- Clinical features: Ulcer with rolled out pearly white edges
- Investigations: Biopsy (pallisading pattern)
- Management: Wide local excision + rhomboid/Limberg flap (bilobed flap for tip of nose, bipedicled flap for eyelid)
- Surgery: v1.0, Marrow: 8.0, Year: 2024
Surgery for Parotid Gland
- Incision: Lazy s/modified Blair's incision (prevents marginal mandibular nerve injury)
- Total parotidectomy: Conservative (superficial + deep lobe removal, facial nerve preserved), radical (superficial + deep lobe removal + facial nerve sacrificed, repaired by cable graft - greater auricular nerve - most common, sural nerve graft - best)
- Superficial Parotidectomy
- Complications: Hemorrhage, nerve injury (marginal mandibular nerve - drooping mouth, facial nerve prevented by pointers: Tragal - most specific, styloid process, posterior belly of digastric, retrograde, nerve stimulators), fistula (low output - closes spontaneously, high output - Newman & Seabrook surgery), recurrence, Frey's syndrome (gustatory sweating, nerve misdirected, Starch iodine test, management: Botox, antiperspirants), prevention: Muscle flap (sternocleidomastoid/digastric), tympanic neurectomy (definitive)
Types of Melanoma
- Lentigo maligna (Hutchinson's melanotic freckle, in-situ, elderly patients, best prognosis)
- Acral melanoma (most common in dark-skinned individuals, palm & sole, rapid vertical growth, poor prognosis)
- Nodular melanoma (rapid vertical growth, poor prognosis, amelanotic variant)
- Desmoplastic melanoma (head/neck, perineural invasion, often painful, locoregional recurrence)
Features Suggesting Malignant Transformation
- ABCDE changes: Asymmetry, Border irregularity, Color change, Diameter > 6mm, Evolution
Investigations for Melanoma
- Biopsy
- Immunohistochemistry (IHC) markers: S-100, Melan-A, HMB 45 (positive brown color indicates melanocytes in epidermis & dermis)
Active Space
- Features: Mass, painless swelling, rapid increase in size, nerve infiltration (painful)
- Spread: Hematogenous (common), Lymph node (uncommon)
- Sarcomas which spread to lymph nodes Mnemonic: MARCES (Malignant fibrous histiocytoma, Angiosarcoma, Rhabdomyosarcoma, Clear cell, Epithelial, Synovial sarcoma)
- LN clearance required.
- Large, heterogenous lesion.
- Limb: m/c to lungs
- Retroperitoneum: m/c to liver
- Investigations: Core needle biopsy
- Prognostic factors: Grade based on mitotic figures (most important)
- Management: Surgery (WLE/compartmental excision), Chemotherapy (methotrexate + Adriamycin), Radiotherapy (↓ loco-regional recurrence)
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