What is the basis behind the ABCD rule for malignant melanoma?
5-10% of melanomas are not pigmented and a significant number of basal and squamous cell carcinomas are pigmented. Asymmetry, Border irregularity, Color variation and Diameter > 0.6cm are all associated with melanoma. Ulceration and nodularity are also concerning.
Management of larger (> 2-3cm) melanomas contiguous with important structures on the face
Incisional biopsy of full-thickness skin at the border of the lesion. Otherwise you should always excise the lesion.
Excisional biopsy comes back as basal cell carcinoma. What do you do next?
If margins are free, you're done because these tumors rarely metastasize. If margins are positive, re-excise to 2-4mm margins. You can also tx with topical 5-FU or radiation.
Excisional biopsy comes back as squamous cell carcinoma. What do you do next?
Squamous cell is locally agressive and metastasizes to local LNs. If CIS (Bowen's disease) > 4mm in thickness, excise w/1cm margins. If > 10mm in thickness, excise w/1cm margins + resect clinically palpable LNs. Tx w/topical 5-FU or radiation is also appropriate.
Excisional biopsy comes back as melanoma in situ. What do you do next?
Re-excise the lesion to a 0.5-1cm margin should result in a cure. Note that dysplastic nevi do not need a margin, only resection and careful observation.
What are the different types of malignant melanoma?
Superficial spreading, nodular, lentigo maligna and acral lentiginous...note that, aside from nodular, these all have a similar prognosis when corrected for thickness.
How is malignant melanoma staged?
Clark level has fallen out of style and Breslow thickness is typically used in the TNM classification. Tumors 4mm deep are T4 w/ 5 year survival of 25%. Note that even if the lesion is stage I, ulceration drops survival by 1/3. N1 = 1 +LN 1 +LN, fixed LN, LN > 5cm or mets w/+ LN. M1 = skin or subQ tissue beyond regional LN basin. M2 = visceral mets.
If you could pick anywhere to have melanoma where would it be?
Face or trunk have a worse prognosis than those on the extremities. Women also do better than men. So pick depending if you want to live or die.
Management of a patient with malignant melanoma of 0.7mm?
Excision with 1cm margin down to the deep fascia. Check CXR, CBC, LFTs and regional LNs for mets.
A patient presents with malignant melanoma 1.6mm deep. How do you manage this patient?
Excision w/2cm margins + therapeutic regional lymphadenectomy for palpable nodes and consider sentinel node biopsy.
A patient presents with malignant melanoma 4.5mm deep. How do you manage this patient?
Excise w/2-3cm margins, excise palpable LNs, CT abdomen and MRI of the brain looking for mets. Enter tx protocol with interferon. This patient will most likely die.
Why are mets really really bad with malignant melanoma?
75% chance of recurrence.
Stage IV melanoma tx
Identify and tx distant mets, systemic therapy w/interferon, dacarbazine (DNA alkylator), radiation and/or polyvalent vaccination.
A 75 year old woman has a brownish discoloration on her cheek that is slowly enlarging. How do you treat this?
If biopsy shows lentigo maligna melanoma, it spreads superficial and can be treated with narrow margin excision. Note that any excision on the face should likely involve a plastic surgeon.
What is this?
Hutchinson freckle, note the lesion is large, brown and macular on the cheek, this can be a precursor for lentigo maligna melanoma and should be watched.
An African-American man presents with malignant melanoma the sole of his foot. How do you treat this?
Acral-lentigionous lesions are more common in dark-skinned individuals and have a poorer prognosis. Tx is excision. Note there is also a subungual melanoma that merits emputation at the DIP.
Tx of anal malignant melanoma
These have a 5 year mortality rate near 100%. Tx thin lesions w/local excision. Thicker lesions require abdominoperineal resection. Lymphadenectomy for clinically palpable nodes.
A patient with PMHx significant for stage I malignant melanoma presents to the ED with nausea, vomiting, abdominal distention and the radiograph shown below. How will you likely treat this patient?
Malignant melanoma is unique because it loves to metastasize to the peritoneal cavity. You need to resect the involved bowel and explain to the patient they will likely die from the disease.
Risk factors to look out for when a patient presents with a soft tissue mass
Sarcoma risk factors include therapeutic radiation (fibrosarcomas), axillary lymphadenectomy 10-20 years earlier (lymphangiosarcomas), hx of trauma w/persistent mass, firmness, painlessness and regional lymphadenopathy.
Dx and tx for sarcomas
Excisional biopsy for masses < 3cm. Incisional biopsy for masses > 3cm due to difficulty with primary closure after surgery and can contaminate additional compartments with tumor. CXR, CT, bone scan and MRI to assess for liver, lung, bone and brain mets (present 22% of time). Extensive initial resection and/or amputation have highest potential for local control, so do total compartmental resection or radical amputation if higher grade + neoadjuvant chemorads + adjuvant chemorads.
Poor prognostic indicators for sarcomas
High mitotic figures, high degree of necrosis, symptomatic lesion and size > 15cm.
Where do sarcomas love to metstasize? How do you treat the mets?
Lung. Note that most sarcoma recurrences occur withing the first 2 years after primary resection, so keep resecting mets during this period to improve survival. Tx lung mets with thoracic wedge resection can result in significant long-term disease free intervals.
Tx for sarcoma that metastasized to liver?
Wedge resection w/1cm margins or formal lobectomy
What is the order of the femoral triangle neurovascular structures from lateral to medial?
Nerve, Artery, Vein, Empty space, Lymphatics
Which type of hernias most often strangulate and thus should pretty much always be fixed when patients are asymptomatic?
Femoral followed by indirect inguinal hernias.
What is the difference between and indirect and a direct inguinal hernia?
What are the boundaries of Hesselbach's triangle?
Lateral border of rectus abdominis, inferior epigastric vessels and inguinal ligament. A hernia through this region indicates a direct inguinal hernia.
What are the normal structures that traverse the inguinal ring?
Spermatic cord, testicular vessels and genital branch of the genitofemoral nerve.
What are the layers of the abdomen?
Skin, Camper's fascia, Scarpa's fascia, EO, IO, Transversus abdominus, Trasversalis fascia and peritoneum
What is the basis behind most of the open inguinal hernia repairs?
Suturing of the transversalis fascia to the floor of the inguinal canal or Cooper's ligament