Surgery Marrow Pg 527-536 (Miscellaneous)
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Surgery Marrow Pg 527-536 (Miscellaneous)

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Questions and Answers

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.

    False

    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.

    <p>4</p> Signup and view all the answers

    Match the following treatments with their mechanisms:

    <p>Dabrafenib = BRAF Inhibitor Trametinib = Against MAPK pathway Ipilimumab = Checkpoint inhibitor</p> Signup and view all the answers

    What is the first step in managing a primary pneumothorax if the size is greater than 2 cm and the patient is breathless?

    <p>Aspirate</p> Signup and view all the answers

    A chest X-ray is used for the diagnostic workup of pneumothorax.

    <p>True</p> Signup and view all the answers

    Name one clinical feature of pneumothorax.

    <p>Sharp pleuritic pain</p> Signup and view all the answers

    For a secondary pneumothorax with size 1-2 cm, if the patient is not breathless, you should ______.

    <p>Admit. High flow oxygen. Observe for 24 hours.</p> Signup and view all the answers

    Match the following conditions to their management:

    <p>Bilateral spontaneous pneumothorax = Chest drain Pregnancy = Appropriate management based on clinical judgment Pneumothorax fails to settle = Surgical intervention First contralateral pneumothorax = Chest drain</p> Signup and view all the answers

    What is the most common type of malignant melanoma?

    <p>Superficial spreading</p> Signup and view all the answers

    Moh's micrographic surgery is primarily used for melanoma treatments.

    <p>False</p> Signup and view all the answers

    List one risk factor for malignant melanoma.

    <p>UV radiation</p> Signup and view all the answers

    Moh's micrographic surgery involves layer-by-layer removal of the lesion and __________ examination.

    <p>microscopic</p> Signup and view all the answers

    Match the following risk factors to the related conditions:

    <p>UV radiation = Malignant Melanoma Close to vital structures = Moh's Micrographic Surgery Recurrent lesions = Moh's Micrographic Surgery White population = Malignant Melanoma</p> Signup and view all the answers

    What type of skin cancer is associated with precursor lesions such as cutaneous horn and keratoacanthoma?

    <p>Squamous Cell Carcinoma</p> Signup and view all the answers

    Marjolin's ulcer is commonly associated with lymph node involvement due to scarring of lymphatics.

    <p>False</p> Signup and view all the answers

    Which type of soft tissue sarcoma is most common in children?

    <p>Rhabdomyosarcoma</p> Signup and view all the answers

    The _____ is a condition where long-standing lymphedema can lead to angiosarcoma or lymphangiosarcoma.

    <p>Stewart-Treves syndrome</p> Signup and view all the answers

    Match the following associated syndromes with their relevant condition:

    <p>Li-Fraumeni syndrome = Sarcoma predisposition Gardner's syndrome = Desmoid tumor Gorlin syndrome = Sarcomas + BCC NF-1 = Neurofibromatosis</p> Signup and view all the answers

    What is the most common route of spread for sarcomas?

    <p>Hematogenous spread</p> Signup and view all the answers

    Desmoid tumors are known for their ability to metastasize.

    <p>False</p> Signup and view all the answers

    What is the role of mitotic figures in determining the prognosis of soft tissue sarcomas?

    <p>They are the most important factor for grading.</p> Signup and view all the answers

    Soft tissue sarcomas may commonly spread to the ________ and retroperitoneum to the ________.

    <p>lungs, liver</p> Signup and view all the answers

    Match the following soft tissue sarcomas with their characteristics:

    <p>Malignant fibrous histiocytoma = Commonly spreads to lymph nodes Angiosarcoma = Vascularised tumor Rhabdomyosarcoma = Most common in children Desmoid tumor = Locally invasive, does not metastasize</p> Signup and view all the answers

    What is the primary reason for performing bronchoscopic removal when a foreign body is suspected?

    <p>To clear the airway</p> Signup and view all the answers

    Primary spontaneous pneumothorax typically occurs more in older patients than in younger patients.

    <p>False</p> Signup and view all the answers

    What imaging technique is primarily used to diagnose foreign body aspiration?

    <p>X-ray</p> Signup and view all the answers

    The right mainstem bronchus is _____ and _____ compared to the left mainstem bronchus.

    <p>shorter, straighter</p> Signup and view all the answers

    Match the types of spontaneous pneumothorax with their characteristics:

    <p>Primary Spontaneous = Normal lung function, often in young males Secondary Spontaneous = Associated with underlying lung disease, seen in older patients</p> Signup and view all the answers

    Which of the following complications is most common following submandibular gland surgery?

    <p>Injury to the marginal mandibular nerve</p> Signup and view all the answers

    Extracapsular dissection has an effect on oncological safety regarding tumor recurrence.

    <p>False</p> Signup and view all the answers

    What investigation is typically performed for diagnosing submandibular swelling?

    <p>FNAC</p> Signup and view all the answers

    The most common tumor found in the sublingual and minor salivary glands is __________.

    <p>adenoid cystic carcinoma</p> Signup and view all the answers

    Match the following conditions with their management options:

    <p>Pleomorphic adenoma = Submandibular gland excision Adenoid cystic carcinoma = Excision + Radiotherapy Lingual nerve injury = Nerve repair Hemorrhage = Surgical intervention</p> Signup and view all the answers

    What is a characteristic of a total parotidectomy?

    <p>Facial nerve is preserved.</p> Signup and view all the answers

    Which type of melanoma presents with a poor prognosis and is characterized by rapid vertical growth?

    <p>Nodular melanoma</p> Signup and view all the answers

    Frey's Syndrome causes gustatory sweating due to nerve misdirection.

    <p>True</p> Signup and view all the answers

    Acral melanoma is the most common type found in dark-skinned individuals.

    <p>True</p> Signup and view all the answers

    What is the most common nerve used for grafting in a total radical parotidectomy?

    <p>Greater auricular nerve</p> Signup and view all the answers

    The _____ nerve is located 1 cm inferior and deep, as referred to by surgeons during parotid gland surgery.

    <p>tragal</p> Signup and view all the answers

    Name one of the ABCDE changes that suggest malignant transformation in skin lesions.

    <p>Asymmetry</p> Signup and view all the answers

    Match the following complications with their descriptions:

    <p>Hemorrhage = Excessive bleeding after surgery Fistula = Abnormal connection between gland and duct Recurrence = Return of the condition after treatment Frey's Syndrome = Sweating triggered by eating</p> Signup and view all the answers

    The melanoma variant that lacks pigment is called __________ melanoma.

    <p>amelanotic</p> Signup and view all the answers

    Match the following types of melanoma with their descriptions:

    <p>Lentigo maligna = Best prognosis and affects the elderly Desmoplastic melanoma = Typically develops on the head or neck and may be painful Nodular melanoma = Characterized by a rapid vertical growth phase and often detected late Acral melanoma = Most common in dark-skinned individuals with poor prognosis</p> Signup and view all the answers

    What is the most common site for Basal Cell Carcinoma (BCC)?

    <p>Face</p> Signup and view all the answers

    Basal Cell Carcinoma commonly undergoes distant metastasis.

    <p>False</p> Signup and view all the answers

    What is the characteristic histological pattern seen in a biopsy of Basal Cell Carcinoma?

    <p>Pallisading pattern</p> Signup and view all the answers

    The most aggressive type of localized Basal Cell Carcinoma is known as __________.

    <p>infiltrative</p> Signup and view all the answers

    Match the following types of Basal Cell Carcinoma to their characteristics:

    <p>Nodular = Most common type of BCC Pigmented = Contains areas of pigmentation Superficial = Flat, scaly lesions Infiltrative = Most aggressive and invasive type</p> Signup and view all the answers

    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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    Test your knowledge on squamous cell carcinoma, including precursor lesions and management strategies. Additionally, explore the details of soft tissue sarcomas, their etiology, associated syndromes, and classifications. This quiz covers important concepts in dermatology and oncology.

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