Surgery Evals1 Rationale2013

Evals # 1 Topics: 1. Skin and Soft Tissue tumors- Dr. Cagingin 2. Plastic Surgery- Dr. Salvano Rationale by: Lee Lujero

1.

Patients with unilateral cleft lip and associated nasal deformities have each of the following findings, EXCEPT: A. Attenuation and inferior positioning of the lower lateral cartilage on the side of the cleft B. Insertion of the orbicularis oris muscle into the cleft margin and alar wing C. Outward rotation and projection of the premaxilla D. Elongation of the philtrum E. Unilateral shortening of the columella

The philtrum is formed where the nasomedial and maxillary processes meet during embryonicdevelopment. When these processes fail to fuse fully in humans, a cleft lip (sometimes called a "hare lip") can result. So I guess there is absence of philtrum in cleft lip? :p From Schwartz: The unilateral cleft lip is classically associated with a cleft lip nasal deformity. The cleft lip nasal deformity includes lateral, inferior, and posterior displacement of the alar cartilage. This results from the deficient and clefted underlying skeleton as well as the unopposed pull of the clefted orbicularis oris muscle abnormally inserted on the alar base. The maxillary minor segment (the smaller alveolar/maxillary segment on the clefted side) is collapsed medially. The picture on the right also shows that the columella is shorter on the cleft side and because of the unilateral cleft lip the philtrum also becomes shorter on the cleft side.

2.

During development, primary cleft lip occurs as a result of the failure of fusion of which of the following structures? A. Nasomedial and nasolateral processes of the embryo B. Maxillary prominence and mandibular prominence C. Maxillary prominence and lateral palatine process D. Lateral palatine processes and median palatine processes.

Cleft Lip •

3.

Etiology 1. Embryogenesis • Classic theory – results from failure of the nasomedial and nasolateral process of the embryo to fuse • Mesodermal penetration theory – embryo is an epithelial bilayer in the region of the face until mesoderm migrates between the bilayers, forming the facial process; failure results in clefting *must know itong embryogenesis etiology 1. Increased parental age 2. Drug use and infections during pregnancy 3. Smoking during pregnancy

In a patient who has just undergone skin grafting of a recipient wound bed, how is the graft supposed to survive within the first 24 hours? A. Coaptation of the cut vessels in the graft to the vessels in the recipient bed B. Peripheral ingrowth of the capillary buds into the skin graft C. Plasmatic imbibition D. Development of a fine network of capillaries from the vascularised bed of exposed bone or tendon E. Maintenance of a barrier of blood between the graft and the recipient bed

3 Phases of Skin Graft Take (due to absence of blood vessels) 1. Plasmatic imbibitions (24-48h)- absorption of nutrients into the graft occurs by capillary action from the recipient bed 2. Inosculation (after 48h)- recipient and donor (graft) and capillaries are aligned (establish circulation) 3. Revascularization (after 72h) *for more details:

Chicha Notes 2013  

 

SURGERY  EVALS  1     1  of  13  

Skin graft take occurs in three phases: imbibition, inosculation, and revascularization. Plasmatic imbibition refers to the first 24 to 48 hours after skin grafting, during which time a thin film of fibrin and plasma separates the graft from the underlying wound bed. o It remains controversial whether this film provides nutrients and oxygen to the graft or merely a moist environment to maintain the ischemic cells temporarily until a vascular supply is re- established. o After 48 hours a fine vascular network begins to form within the fibrin layer. These new capillary buds interface with the deep surface of the dermis and allow for transfer of some nutrients and oxygen. o This phase, called inosculation, transitions into revascularization, the process by which new blood vessels either directly invade the graft or anastomose to open dermal vascular channels and restore the pink hue of skin. o Revascularization of the graft is accomplished through those capillaries as well as by ingrowth of new vessels through neovascularization in the third and final phase, which is generally complete within 4-7 days. Reinnervation of skin grafts begins approximately 2-4 weeks after grafting and occurs by ingrowth of nerve fibers from the recipient bed and surrounding tissue. Sensory return is greater in full-thickness grafts because they contain a higher content of neurilemmal sheaths. Similarly, hair follicles may be transferred with a fullthickness graft, which allows the graft to demonstrate the hair growth of the donor site. Split-thickness grafts are ultimately hairless. o

4.

These phases are generally complete by 4 to 5 days after graft placement. During these initial few days the graft is most susceptible to deleterious factors such as infection, mechanical shear forces, and hematoma or seroma.

A 42 y/o man has a 3-cm scar on the forehead parallel to the resting lines of skin tension. Which of the following is the most appropriate surgical technique for scar revision? A. W-plasty B. Elliptical incision following Langer’s lines C. Z-plasty D. V-Y plasty

Human skin exists in a state of tension created by internal and external factors. Externally, skin and underlying subcutaneous tissue are acted on by gravity and clothing. Internally, skin is subjected to forces generated by underlying muscles, joint extension and flexion, and tethering of fibrous tissues from zones of adherence. As a result, when skin is incised linearly it gapes to variable degrees. When a circular skin excision is performed, the skin defect assumes an elliptical configuration paralleling the lines of greatest tension. Relaxed skin tension lines may be exploited to create incisions and reconstructions that minimize anatomic distortion and improve cosmesis. W-plasty is the technique of scar excision and reconstruction in zigzag fashion to camouflage the resulting scar. A Z-plasty is a type of transposition flap in which two flaps are rotated, each into the donor site of the other, to achieve central limb lengthening. Z plasty is a type of random flap that are typically used to reconstruct relatively small, full-thickness defects that are not amenable to skin grafting. Y-V or V-Y advancement flap are commonly used to lengthen scars around the nose and mouth. 5.

nd

th

th

Which of the following is the 2 stage of graft take which occurs during the 36 -60 hours post skin grafting A. Plasmatic imbibitions B. Inosculation C. Angiogenesis D. All of the above E. None of the above

Refer to number 3 6.

A 55 y/o F with necrotic decubitus ulcer came in for treatment. She has exposed bone on further inspection. The best option for management will be: A. Debridement only B. Debridement and skin graft C. Debridement and groin flap D. Debridement and gluteus maximus flap

Since there is already involvement of the bone, this is a stage IV ulcer. Pressure ulcers are treated conservatively. However this case is already a deep pressure ulcer that bore to the bone and the mainstay for deep pressure ulcer reconstruction is coverage with well-vascularized local flaps. So now we are left with two answers, groin flap or gluteus maximus flap. Since it was specified that the patient has a decubitus ulcer ( ulcer on the butt or dorsal part of the body from prolonged supination), the answer is gluteus maximux flap. Stage 1 - Skin intact but reddened for greater than 1 hour after relief of pressure Stage 2 - Blister or other break in dermis with or without infection Stage 3 - Subcutaneous destruction into muscle with or without infection Stage 4 - Involvement of bone or joint with or without infection *from previous batch: NECROTIC DECUBITUS ULCER / PRESSURE ULCER -­‐ -­‐ -­‐

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described by their stage, based on depth of tissue injury. Stage I and II ulcers are treated conservatively with dressing changes and basic pressure ulcer prevention strategies. Patients with stage III or IV ulcers should be evaluated for flap reconstruction. Conservative management includes antibiotics, serial dressing, physiotherapy, nutritional support, pressure relief and management of primary illness; but is not always successful. If a superficial ulcer does not reduce by 30% after two weeks, management should be reviewed. Surgical management includes serial dressing/debridements, locoregional skin/myocutaneous flaps and osteotomy (total/partial) if osteomyelitis is present. Direct closure of a pressure ulcer is rarely performed because it usually creates tension in the healing tissues already stressed by nonphysiologic external pressure, predisposing the closure to breakdown. Skin grafting is useful for shallow ulcers with well-vascularized beds that are not subjected to high mechanical shear. The mainstay of deep pressure ulcer reconstruction is coverage with well-vascularized local flaps. Regardless of the wound site, however, the flap design should be very large, more than needed for closure, so that if the ulcer recurs the flap can be readvanced. Myocutaneous/muscle flaps have good vascularity, withstand infections, obliterate dead space and are the best choice in paraplegics. Gluteus maximus is a quadrilateral muscle (Type III flap) with dual blood supply from the superior and inferior gluteal arteries.

Chicha Notes 2013  

 

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7.

A 39 y/o woman underwent mole excision on the R cheek. When is the best time to remove the suture? A. 1-2 days B. 3-5 days C. 6-8 days D. 9-10 days

DIGEST. Skin sutures/staples are removed within 5 days to prevent “cross-hatching” (marks on skin left by the suture). 8.

A 5 day old neonate has bilateral prominent ears with loped superior poles. Which of the following is the most appropriate management? A. Injection of a corticosteroid B. Observation C. Molding the ears using tape and splinting D. Otoplasty at 2 years old E. Otoplasty at 6 years old

Historically, prominent or protruding ears have been treated surgically. In the past decade, nonsurgical techniques have emerged to treat neonates immediately after delivery. Since neonatal auricular cartilage is extremely pliable, early splinting is used to correct deformational ear anomalies. The posterior helical rim is taped to the posterior retroauricular region with surgical tape. Tubular elastic net bandage or some type of ear wrap is used for reinforcement. To achieve the desired result, such techniques must begin in the first few weeks of life and take several weeks or months of constant and vigilant therapy. A protruding ear tends to become more apparent as the child ages, particularly in the neonatal period. Matsuo believes most prominent ear deformities are acquired and recommends careful positioning of babies in their cribs to keep the auricles from folding anteriorly. One preventive method is to lay babies in a prone position.” Otoplasty is indicated in candidates for the procedure once the ears reached its full size – usually 5 to six years of age.Thus, the most commonly quoted age for otoplasty in children is between 6 to 8 years old. Observation is not helpful since (as stated above) as the child ages his ears become more prominent. While injection of a corticosteroid has no medical use in the management of prominent ears. 9.

A split thickness skin graft is composed of the epidermis and A. All of the dermis B. The dermis and the subcutaneous tissue C. Part of the dermis D. None of the above

Types of Skin Grafts • Split thickness skin grafts (STSGs)- consist of the epidermis and varying degrees of dermis. They can be described as thin, intermediate or thick. • Full thickness (FTSGs)- consist of the entire epidermis and dermis • Other grafts 1. Nerve 2. Fat 3. Tendon 4. Cartilage 5. Bone 6. Muscle 7. Composite – graft that has more than one component

  10. Isolated cleft palate: A. Is more common in males B. Is usually not associated with other congenital anomalies C. Results when fusion of the two palatal processes is complete D. None of the above Cleft Palate • Etiology 1. Multifactorial 2. Animal models have shown vitamin A, corticosteroids and phenytoin to produce cleft palate when given during pregnancy 3. Results when fusion of the two palatal processes is incomplete • Incidence 1. Isolated cleft palate is more common in females and more commonly associated with other congenital anomalies 2. 1/2000 live births (Caucasians) • Pathology 1. Abnormal insertion of tensor veli palatini and levator palatine 2. Hard and soft palate are not attached in the midline (vomer) 11. A 16 y/o female came into the ER 2 hours post vehicular crash with a 7cm laceration on the R cheek. The best option for management is to: A. Suture the wound B. Debride and suture the wound C. Debride and leave open to granulate In general, facial lacerations should be carefully cleaned and gently débrided of obviously devitalized tissue. In most circumstances, primary closure is performed with deep stitches as required and fine, carefully placed sutures in the skin. These skin sutures should be removed early, usually within 3 days, to minimize crosshatching of the scar

Chicha Notes 2013  

 

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12. Tummy tuck is the common term for: A. Liposuction B. Gastropexy C. Abdominoplasty D. All of the above 13. Common aesthetc plastic surgery procedures include: A. Breast augmentation B. Blepharoplasty C. Rhinoplasty D. Abdominoplasty E. All of the above For numbers 12 and 13: Common Cosmetic Surgeries • Blepharoplasty- eyebag removal • Rhinoplasty- nose lift • Rhytidectomy- face lift • Abdominoplasty- tummy tuck • Liposuction- fat modelling/removal • Alarplasty- nose trim/reduction • Otoplasty- ear surgery/ correction

• • • •

Gastropexy- no common name, attaches stomach to abdominal wall/ diaphragm; corrects GERD Breast augmentation- Boob job/ breast enlargement Filler injections- Botox Mastoplexy- breast lift

14. Scaphocephaly is associated with which of the following suture synostoses? A. Bilateral coronal B. Labdoid C. Metopic D. Sagittal E. Unilateral coronal CRANIOSYNOSTOSIS -­‐ is the abnormal early fusion of a cranial suture line with resultant restriction of skull growth in the affected area and compensatory bulging at the other sutures. Skull growth occurs at the cranial sutures for the first 2 years of life, at the end of which the skull has achieved >90% of its eventual adult size Scaphocephaly Tritonocephaly Brachycephaly Anterior Plagiocephaly Posterior Plagiocephaly Kleeblattschadel

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Sagittal Metopic/ Frontal bilateral coronal unilateral coronal unilateral lambdoid pansyntosis

15. Which of the following is the most common cause of graft failure? A. Shearing B. Poor recipient bed vascularity C. Insufficient graft thickness D. Infection E. Fluid collection between the graft and the recipient bed The most common causes of skin graft failure are hematoma (or seroma), infection, and movement (shear). Hematoma is most often the consequence of inadequate intraoperative hemostasis and can be identified before irreversible damage has occurred. By examining the skin graft before the fourth postoperative day, a hematoma or seroma can be evacuated, and the mechanical obstruction to revascularization of the graft is thus removed. Some surgeons make stab incisions in the graft preemptively to create small outlets for fluid to drain from beneath the graft, a technique known as pie crusting. 16. A 40 year old male sustains a contact burn to the anterior aspect of the scalp. Following debridement, she has a 4x6cm defect of the anterior scalp with exposed brain tissue. Which of the following is the most appropriate next step in management. A. Tissue expansion B. Hair transplantation C. Coverage with a rotation flap D. Full thickness skin grafting E. Primary closure In the answer key it says B, but in the batch 2012 recon it says that the answer should be C. Coverage with a rotation flap. I guess this is a correction. LO please verify.

Review:  The  scalp  is  formed  of  five  layers:   Skin,  subCutaneous  tissue,  galea  Aponeurotica,  Loose  areolar  tissue,  and   Pericranium  (SCALP).   Emedicine:  Coverage  of  exposed  bone   Before  skin  grafts  are  placed,  exposed  bone  requires  coverage  with  some  type  of  vascularized  soft  tissue.   Rotation  of  temporoparietal  or  galeal  flaps  provides  an  excellent  option  for  coverage.  These  flaps  are  usually  based   off   of   1   or   both   of   the   superficial   temporal   arteries.   Potentially,   they   can   be   based   off   of   any   of   the   5   pairs   of   scalp   arteries.   In   general,   these   flaps   provide   good   conformity   to   the   underlying   bone,   appropriate   thickness,   excellent   blood   supply   (with   good   subsequent   skin   graft   take),   and   a   wide   arc   of   rotation   with   minimal   donor   site   scar   or   deformity.  Furthermore  rotational  flaps  ,may  be  unilateral  or  bilateral,  are  extremely  useful  for  closing  defects  of   the  hair-­‐bearing  scalp.  

Chicha Notes 2013  

 

SURGERY  EVALS  1     4  of  13  

17. In patients with acute thermal burn, which of the following measurements most effectively monitors adequate resuscitation? A. Mean arterial blood pressure B. CVP C. Urine Output D. Pulmonary capillary wedge pressure E. Heart rate Again, from what i researched and from batch 2012 recon, Answer should be Urine output. Edit and correct otherwise. Following fluid resuscitation after trauma, blood pressure may be low, normal, or high. Blood pressure correlates poorly with either blood volume or flow. Urine output is often diminished early after trauma or operation because of hypovolaemia, a decrease in renal blood flow, and a hormonal milieu that leads to sodium and water reabsorption. However, resuscitation with large volumes of crystalloid solutions as well as commonly used osmotically active agents such as radiological contrast media and mannitol, increase urine output. The single best monitor of fluid replacement is urine output. Hourly urine output is a very useful guide to the adequacy of cardiac output, splanchnic perfusion and renal function. Acceptable hydration is indicated by a urine output of more than 30 ml/hr is an adult (0.5 ml/kg/hr) and at least 1 ml/kg/hr in a child. Diuretics are generally not indicated during the acute resuscitation period. Pulse rate and pulse pressure are more sensitive indicators of hemodynamic status than blood pressure. Hypotension is a late finding in burn shock. Normal sensorium and adequate peripheral capillary refill are additional clinical indicators of adequate organ perfusion. Invasive hemodynamic monitoring with central venous catheters, arterial lines, and Swan Ganz catheters is usually not needed in the absence of a severe inhalation injury, and discretion is advised. Pulmonary artery lines especially carry an inordinate risk of sepsis, thrombophlebitis and endocarditis in thermal injury patients. Heart rate, mental status, and capillary refill may be affected by the underlying disease process and are less reliable markers. Because of compensatory vasoconstriction, mean arterial pressure (MAP) is only a rough guideline; organ hypoperfusion may be present despite apparently normal values. 18. Pierre Robbin Syndrome is associated with A. Cleft palate, micrognathia, glossoptosis B. Cleft lip, macrognathia, cleft palate C. Cleft lip, micrognathia, gossoptosis D. Cleft palate, glossoptosis, cleft lip Digest. 19. Examples of skin flaps are A. Limberg flap B. Z-plasty C. Bilobed flap D. All of the above E. None of the above Review: Graft vs Flap Graft- does not maintain original blood supply Flap- maintains original blood supply Types of Flaps  Rotation flap – local  Axial Pattern Flap  Advancement – local  Deltopectoral Flap - regional  Z-plasty – changes the direction of the scar, interposition flap  Limberg flap – also changes scar direction; a.k.a rhombic flap, transposition flap  Bilobed flap- configurational/ transpositional flap       20. A full thickness skin graft is composed of the epidermis and A. All of the dermis B. Part of the dermis C. The dermis and the subcutaneous tissue D. None of the above Refer to number 9 21. Other types of grafts include A. Nerve B. Fat C. Composite D. All of the above E. None of the above Refer to number 9 th

22. On the 5 day post grafting, new blood vessels grow into the graft and the graft becomes vascularised. This is called: A. Plasmatic imbibitions B. Inosculation C. Angiogenesis D. All of the above E. None of the above Refer to number 3

Chicha Notes 2013  

 

SURGERY  EVALS  1     5  of  13  

23. Are elevated from a donor site and transferred to the recipient site with an intact vascular supply. A. Skin grafts B. Flaps C. Nerve grafts D. Composite grafts Refer to number 19 24. Flaps classified by location can be: A. Local B. Distant C. Regional D. All of the above E. None of the above Digest. 25. The groin flap is nourished by the A. Deep circumflex iliac artery B. Superficial circumflex iliac artery C. Both D. Neither Digest. Write:

A-if all the statements are correct B-if only 3 statements are correct C-if only 2 statements are correct D-if only 1 statement is correct

26. Abscess A. Usually caused by strep organisms B. Incision and drainage is mandatory C. Giving antibiotics is optional D. Debridement is also done if necessary All are correct. EPIDERMAL INFECTIOUS: Abscess is a localized accumulation of pus with an associated superficial cellulitis a. Folliculitis *most simple *Hair + Pus >infection and inflammation of the hair follicle b. Furuncle (boil or pigsa) *localized organized abscess + begins as a folliculitis but progresses to form a nodule that eventually becomes fluctuant. >skin infection of a gland or hair follicle characterized by pain, redness and swelling c. Carbuncle + Deep-seated infections that results in multiple draining cutaneous sinuses. >essentially a bigger furuncle >Common Locations: BACK of the NECK and BUTTOCKS d. Hidratenitis Suppurativa *when plucking or shaving +once termed as “apocrine acne” +is actually a follicular defect that leads to a blockage of the apocrine glands or sweat glands, which secondarily becomes infected. +Common Locations: Axilla, Inguinal area and perianal regions +treatment: application of warm compress, antibiotics, and open drainage e. Paronychias / Onychocryptosis *affects the fingernails (paronychias) and toenails (ingrown toenails/onychocryptosis) *common among those who gets manicure and pedicure - Cellulitis *involving the whole extremities +a superficial spreading infection of the skin and subcutaneous tissue. +heralded by erythema, warmth, tenderness, and edema. Treatment: 1. Incision and Drainage (I and D) st i. 1 line of treatment ii. *it is important to drain the pus 2. Antibiotics nd i. >2 line of treatment ii. >broad spectrum antibiotics to deal with both Staph and Strep infection ~from Merck Manual: Dicloxacillin or Cephalexin for mild cases; Oxacillin or Nafcillin for serious infection and Vancomycin for penicillin allergic patients and confirmed MRSA infection. 3. Daily Dressing- includes debridement 4. Warm Compress ~this will cause vasodilatation->w/c will increase the blood circulation-> increasing absorption and delivery of antibiotics to the affected area

Chicha Notes 2013  

 

SURGERY  EVALS  1     6  of  13  

27. Hidradinitis suppurativa A. Involves the sweat gland B. Armpits and groins are usually affected C. Incision and drainage is mandatory D. Giving antibiotics is boptional All are correct. Refer to number 26 28. Sunblock SPF 40 A. Sun protection is only good for 40 minutes B. Re-application is required every 40 minutes C. Application should be done 40 minutes before sun exposure D. 1 minute of unprotected skin exposure after 40 minutes A, B, and D are correct. Sun protection factor (SPF) • represents the amount of time in minutes required to get the equivalent of 1 minute of unprotected exposure • not an indication of how much time you can spend in the sun • For SPF 40, o 40 minutes with sunscreen under the sun = 1 minute of unprotected skin exposure o sun protection is only good for 40 minutes, so sunscreen should be applied every 40 mins. (Actually, wala akong mahanap na text/article na ganito ang sinasabi. Sabi sa mayoclinic.com: Don't rely on the SPF factor to decide how long you're safe in the sun) o (C) is not the answer, because duh… According to (A), you’re protected for 40 minutes. So if you spend those 40 minutes NOT being exposed to the sun, anong use nun? =) 29. Achrocordons A. Skin tags B. Excision is usually done if unsightly C. May arise from any site in the body D. Antibiotics are useful for these cases All are correct. EPIDERMAL BENIGN a. Acrochordons > skin tags or “kuntil” + fleshy, pedunculated masses located on the axillae, trunk, and eyelids. + composed of hyperplastic epidermis over a fibrous connective tissue stalk. + usually small and always benign *has its own blood supply ~kaya don’t pull, it might bleed :P b. Papillomas >warts, verucca or kulugo +epidermal growth associated with HPV +hystologically characterized by keratosis, acanthosis, and papillomatosis. Koilocytes are also present. +usually found pm the fingers and toes, and has rough, gray-brown surface. ~plantar warts – found on soles and palms, may look like callus ~flat warts – flat but slightly raised, appear on face, legs and hands. ~venereal warts c. Epidermal Inclusion Cyst (EIC or Sebaceous Cyst) *bread and butter *sebaceous cyst is a misnomer, not actually sebaceous in nature. *meron bukol, mata (punctum) and round +most common type of cutaneous cyst and can occur anywhere in the body as a single firm nodule. >epidermal components grow inward and form a cyst composed of dead skin *encapsulated, desquamated epithelium and when it ruptures is very foul smelling. Treatment: 1. Excision Biopsy >after excision of specimen, it needs to be biopsied to confirm diagnosis ~for EIC 2. Cauterization >specific for burning of warts, use pinpoint setting so as to not burn surrounding normal tissue. ~uses topical anesthesia *I guess B is correct for cosmesis. C might be correct since it can be located in several locations such as the axilla, trunk and eyelids. D might also be correct since antibiotic prophylaxis can be done with excision biopsy.

Chicha Notes 2013  

 

SURGERY  EVALS  1     7  of  13  

30. Papillomas A. Viral in origin B. Can become malignant C. Cauterization is the preferred treatment D. Excision can also be done According to Answer key, only two are correct, probably A and C. But from Schwartz all are correct. Please verify. PAPILLOMAS • warts, verucca • epidermal growth resulting from HPV infection • treatment: application of chemicals, curettage with electrodessication • from tranx: cauterization for burning of warts Di ko po alam kung bakit mali ang (B) at (C). Sabi ni Schwartz: • treatment of extensive areas of skin requires surgical excision under general anesthesia • Larger lesions (condyloma cuminata) have a significant risk of malignant transformation 31. EIC (Epidermal Inclusion Cyst) A. Also known as sebaceous cyst B. Contain dead cells from the epidermis C. Ideally excised D. Can be treated conservatively with antibiotics if infected All are correct. Refer to number 29. D is correct since antibiotics are always warranted for infection. 32. Squamous cell CA A. Mostly seen in the face and head areas B. Prolonged sun exposure is the causative factor C. Locally invasive D. Wide local excision is the preferred treatment According to the answer key only 3 are correct, A, B, and D. This may be due to the fact that local invasion is a more distinct feature in Basal Cell Carcinoma. But from what i gathered, squamous cell carcinoma can also be locally invasive, specifically the Primary Cutaneous Squamous cell carcinoma. Also there is the Invasive Squamous cell carcinoma that refers to cancer cells that have grown into deeper layers of the skin, the dermis. So I guess, all statements could be correct. Please correct. SQUAMOUS CELL CARCINOMA a. Squamous Cell Most abundant cells in the skin Located primarily in the epidermis b. Major Risk Factors Exposure to sunlight/sunburns Especially - face, neck, bald scalp, hands, shoulders, arms, back, rim of ear, and the lower lip Fair skin Blonde or red hair Blue, green or gray eyes Frequent or long exposure to sun c. Treatment Can usually be removed by: i. Surgical excision ii. Destroying tumor with electrical current (electrodessication) iii. Freezing tumor (cryosurgery) iv. Radiation is used in some cases •

•

Chicha Notes 2013  

Wide local excision  Most commonly used technique  Excise the whole lesion including a few of the normal cells in the surrounding area (1-2cm) that depends on the tissue biopsy result *Other Options:  Topical 5-flourouracil • For suspicious lesions • An anti-cancer drug; specific for skin  Mohs’ microsurgery • Not available in the Philippines but one of the best treatments • Method to serially excise tumor taking a small increments of tissue until the entire tumor is removed (excision by mm) • Each piece of tissue removed is frozen and immediately examined microscopically to determine whether tumorous tissue has been resected • Advantage of this method over standard histological examination: the entire margin of resection is evaluated • Major benefit ability to remove a tumor with least sacrifice of uninvolved tissue • Effective for treating carcinomas around the eyelids and nose, where tissue loss is most conspicuous  Radiotherapy • The treatment of neoplastic diseases by using x-rays or gamma rays, usually from a cobalt source is to determine the proliferation of malignant cells by decreasing the rate of mitosis or impairing DNA synthesis  Chemotherapy • The treatment of infections and other diseases with chemical agents usually refers to the use of chemicals to destroy cancer cells on a selective basis.

 

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33. Basal cell CA A. Slowly growing tumor B. Predilection on the facial area C. Capable of metastasis D. Wide local excision is the preferred treatment According to the answer key 3 are correct. A, B, and D are correct. However, C might also be correct. Although rare, basal cell carcinoma can also metastasize, such as the so-called metastatic basal cell carcinoma. Please Check. Basal Cell Carcinoma a. Basal Cells i. Form the deepest layer (basal layer) of the epidermis ii. Function as the precursors of all the skin cells above them b. Appearance i. Open sores, reddish patches, shiny bump, pink growth, scar like area ► NOTE: Many non-cancerous skin blemishes will have some of these traits. It is important to have any suspicious areas evaluated by a doctor. o Major Risk Factors  Exposure to sunlight/sunburns • Especially - face, neck, bald scalp, hands, shoulders, arms, back, rim of ear, and lower lip  Fair skin • Blonde or red hair • Blue, green or gray eyes • Frequent or long exposure to sun  Other Risk Factors: • Chronic sun exposure • Fair skin • Precursor lesions ( actinic keratosis , Bowen’s disease , Marjolin’s ulcer ) • Tobacco • Chemicals ► *Treatment is the same as Squamous Cell Carcinoma ► Accdg to Medscape: Basal cell carcinoma (BCC) is the most common skin cancer in humans, yet it accounts for less than 0.1% of patient deaths due to cancer. Basal cell skin cancer tumors typically appear on sun-exposed skin, are slow growing, and rarely metastasize (0.028-0.55%). 34. Clarke’s staging A. Shows the anatomic extent in relation to the layers of the skin B. Fairly accurate as basis for staging C. Excision biopsy is required D. Staging tool specific for basal cell or squamous cell CA of the skin A, B, and C are correct. D is wrong since Clark’s staging is a staging tool for all skin malignancies.

For  34  and  35:   Clark’s staging and Breslow’s staging are used for malignant melanoma. Because they are staging tools, excision biopsy should be done to assess the depth of invasion. CLARK LEVEL - anatomic depth of invasion, using histologic levels; Since layers of the skin is used, the depth of invasion is not accurately measured Level I Superficial to basement membrane (in situ) Level II Papillary dermis Level III Papillary/reticular junction Level IV Retricular dermis Level V Subcutaneous tissue BRESLOW THICKNESS • makes use of the vertical thickness of the primary tumor, measured from the granular layer of the epidermis or base of the ulcer to the greatest depth of the tumor • I: 0.75mm or less • II: 0.76 to 1.5mm • III: 1.51 to 4.0mm • IV: 4.0mm or more 35. Breslow’s staging A. Shows the depth or thickness of the lesion B. Most accurate as basis for treatment C. Excision biopsy is required D. Staging tool for all skin malignancies All are correct.

Chicha Notes 2013  

 

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36. Lipomas A. May arise from any part of the body B. May involve all the layers of the skin C. Mostly originates from the subcutaneous layer D. May render dysfunction of an extremity Only A, C, and D are correct. B is incorrect since lipoma since it only involves soft tissue such as the subcutaneous layer. LIPOMAS • most common subcutaneous neoplasm • found mostly on the trunk but may appear anywhere • may grow to a large size and substantially deforming • Diagnosis and treatment: excision 37. Decubitus ulcers A. Results from pressure necrosis of tissues B. Usually seen in bed ridden patients C. May go beyond the muscles D. Frequent debridement and dressing is required All are correct. Refer to number 6. 38. ABCDE’s of melanomas A. Asymmetry B. Irregular borders C. Uniform color of the lesion D. Occasional bleeding Only A, B, and D are correct. • A – asymmetry – one half doesn’t look like the other • B – border – irregular, ragged or blurred edges • C – color – a mixture of colors or marks that change color • D – diameter – a growth more than 6 millimeters across • E – evolution – changes in shape, size or color, itchiness, ulcerations 39. Etiologic factors for skin malignancies A. Prolonged or chronic sun exposure B. Family history C. Chemical exposure D. Inadequate sunscreen protection Only A, C, and D are correct. From Schwartz, etiologic factors • increased exposure to UV radiation • chemical carcinogens: tar, arsenic, nitrogen mustard • radiation • chronically irritated or nonhealing areas 40. Skin biopsy is done by A. Excision B. Shaving C. Punch biopsy D. Fine needle aspiration According to the answer key only 3 are correct, A, B, and C. But from what i gathered, skin biopsy can also be done via fine needle aspiration. From emedicinehealth.com: How the procedure is performed • In an excision biopsy, the entire area of suspect skin is cut out. Excision biopsy is normally done with a scalpel. Stitches are used to close theincision. • In a punch biopsy, a sharp cookie cutter -like instrument is used to remove a small cylinder of skin. Sometimes stitches are necessary to close this type of biopsy wound. • The outermost part of a lesion can also be shaved off with a scalpel. This is called a shave biopsy. • If you have a lesion on your skin that is fluid-filled and not solid, this can be evaluated with aspiration. Your doctor can put a small needle attached to asyringe into this lesion and suction out the fluid. • *Wikipedia also says so, so idk. Haha

Chicha Notes 2013  

 

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41. Treatment modalities for metastatic melanomas A. Wide surgical excision B. Lymph node dissection C. Radiotherapy D. Systemic chemotheraphy According to the answer key only 2 are correct. My guess is that only B and C are correct. According to Schwartz, treatment of melanoma includes: o surgical excision with at least 1-cm margin, depending on depth of lesion o regional nodal dissection for all microscopically or clinically positive lymph nodes o radiation therapy is the treatment of choice for symptomatic multiple brain abscess o interferon alfa-2b – adjuvant treatment for stage IIB/III o systemic chemotherapy: under investigation -So D is surely incorrect. Metastatic melanoma is a stage IV melanoma. Wide excision is only the standard treatment for Stage II melanoma and sometimes stage III, but not Stage IV thus, i eliminated A. Also, According to the National Cancer Institute, Melanoma metastatic to distant, lymph node-bearing areas may be palliated by regional lymphadenectomy. Although melanoma is a relatively radiation-resistant tumor, palliative radiation therapy may alleviate symptoms. Retrospective studies have shown that patients with multiple brain metastases, bone metastases, and spinal cord compression may achieve symptom relief and some shrinkage of the tumor with radiation therapy. 42. Paronychias A. Results from the improper cutting of nails B. Also known as ingrown toe nail C. Infection of the nail bed D. Unguectomy-removal of the involved nail is required for treatment My guess is that only A, B, and C are correct. D is incorrect since Unguectomy is rarely done thus, is not required. PARONYCHIA • infection of the nail bed or periungal soft tissue • presents as a collection of purulent material at the side of the nail bed • organisms enter through break in the epidermis (aggressive manicuring/pedicuring, nail biting) • treatment: warm compresseser or soaks; anti-staphylococcal antibiotic; drainage of abscess; partial removal of nail plate if abscess extends below the nail • The nail disease paronychia (/ˌpærəәˈnɪkiəә/, Greek: παρονυχία), commonly misidentified as a synonym for whitlowor felon, is an often-tender bacterial or fungal hand infection or foot infection where the nail and skin meet at the side or the base of a finger or toenail “ingrown toe nail”. • Treatment: Warm soaks can be used 3 or 4 times a day for acute paronychia to promote drainage and relieve some of the pain. Most cases of acute paronychia should be treated with antibiotics such . as cephalexin or dicloxacillin Topical antibiotics or anti-bacterial ointments do not effectively treat paronychia. If there is pus or an abscess involved, the infection may need to be incised and drained. Rarely, a portion of the nail may need to be removed. 43. Treatment modality/ies for early stages of squamous cell CA and basal cell CA A. Wide surgical excision B. Electrodessication C. Cryosurgery D. Immunotherapy Only A, B, and C are correct. Treatment of BCC and SCC from Schwartz: BCC: curettage, electrodessication, laser surgery, surgical excision SCC: curettage, electrodessication, surgical excision From emedicine.medscape.com: Cryotherapy may be used for superficial BCC. Immunotherapy (interferon alfa-2b) is for malignant melanoma.

Chicha Notes 2013  

 

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44. Nodular type of melanoma A. Accounts for almost 70% of cases B. Can be seen in the palms or plantar areas C. Involves mainly the face D. Fairly good prognosis The answer key says that 3 are correct. But from what i read, only B is correct. Nodular melanomas comprise only 10 to 15% of all melanomas but account for 60 to 70% of deep melanomas. It can appear anywhere on the body and occurs more often in males than females. It can develop at any age; however, it is most often seen in people aged 60 and older. NM differs from other types of melanoma in three ways: • Tends to grow more rapidly in thickness (penetrate the skin) than in diameter • May not have a readily visible phase of development • Instead of arising from a pre-existing mole, it may appear in a spot where a lesion did not previously exist • Since NM tends to grow deeper more quickly than it does wide and can occur in a spot that did not have a previous lesion, the prognosis is often worse because it takes longer for a person to be aware of the changes. Superficial spreading Melanoma (anywhere / Irregular / raised / epidermal)- 70% of diagnosed cases Nodular Melanoma (any where / irregular / raised / dermal)- 15% of diagnosed cases Lentigo Maligna (Hutchinson Melanotic Freckle) (Face / elderly / basal layer of epidermis)- 10% of diagnosed cases Acral-Lentiginous Melanoma (Palm & soles & nail bed)- 5% of diagnosed cases Amelanotic Melanoma (very poor prognosis) Superficial Spreading Melanoma Superficial spreading melanoma (SSM) is the most common type of melanoma in the United States, accounting for about 70% of all diagnosed melanoma cases. This type of melanoma can strike at any age and occurs slightly more often in females than males. SSM is the leading cause of death from cancer in young adults. When SSM occurs in females, it most commonly appears on the legs. In males, it is more likely to develop between the neck and pelvis. However, this does not mean that females do not get SSM on their trunks or that males do not see SSM on their legs. This melanoma can occur anywhere on the skin’s surface. Lentigo Maligna Melanoma Lentigo maligna melanoma (LMM) typically occurs on sun-damaged skin in the middle-aged and elderly, especially on the face. This melanoma may be mistaken in its early, and most treatable, stages for a benign "age spot" or "sun spot.” LMM accounts for about 10% of the melanomas diagnosed in the United States. Since LMM is so easily mistaken, it can go undetected for years. This can be quite dangerous. Acral Lentiginous Melanoma In the United States, acral lentiginous melanoma (ALM) accounts for about 5% of all diagnosed melanomas. It also is the most common form of melanoma in Asians and people with dark skin, accounting for 50% of melanomas that occur in people with these skin types. ALM is sometimes referred to as a “hidden melanoma” because these lesions occur on parts of the body not easily examined or not thought necessary to examine. ALM develops on the palms, soles, mucous membranes (such as those that line the mouth, nose, and female genitals), and underneath or near fingernails and toenails.  

 

Non-pigmented Subtypes While uncommon, melanoma occasionally does not have brown or black pigmentation. An uncommon subtype called amelanotic melanoma usually appears as a pink or red nodule (lump). Another uncommon subtype,desmoplastic neutrotrophic melanoma (DNM), usually looks like a non-pigmented scar. When a scar or keloid appears on the skin and the skin has not been injured, DNM is suspected. The lesion also can appear as a cyst that may or may not be pigmented. DNM tends to appear on sundamaged skin in elderly patients, occurring mostly on the head and neck.

45. Acral type of melanoma A. Wide surgical excision is the preferred treatment for early stages B. Adjuvant therapy may be helpful C. May required amputation of the extremity D. Immunotherapy for advanced cases Answer key says only 3 are correct. Based on readings and batch 2012 recon, all are correct. Surgical management with either wide excision or amputation is appropriate for the primary lesion [acral melanoma]. It is apparent that some form of adjuvant therapy (immunotherapy) is indicated, in addition to wide local excision and regional lymph node dissection.

Melanoma in general: Regardless of tumor depth or extension, surgical excision is the treatment of choice. Interferon-alpha is the only FDA-approved adjuvant treatment for stages IIB/III melanoma. 46. Hairy mole A. Benign in nature B. Have malignant potential C. Excision can be done D. Mostly observation only Only A, B, and C are correct. Hairy nevi can be very small, or very large, and are generally divided into categories based on their size: small, medium and large. They can appear on virtually any place on the body and about 50 percent of hairy nevi will develop coarse surface hairs. Although most hairy nevi are benign, or not dangerous, they can occasionally turn into malignant melanoma. The most common treatment for hairy nevi is surgical removal/excision.

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47. Hemangiomas A. Vascular in origin B. Mostly congenital C. May become malignant D. Surgical excision is curative Only A, B, and D are correct. Hemangioma + Benign vascular neoplasm that arise soon after birth. a. Cavernous • Bright red or purple and spongy in consistency • Histology: large, blood filled spaces lined by normal appearing endothelial cells b. Capillary • Strawberry hemangiomas • Soft compressible papular lesions with sharp borders located mostly on shoulders, face and scalp • Histology: endothelial cells seen primarily in fetal veins TREATMENT: 1. Excision 2. Debridement – removal of necrotic tissue *Hemangiomas have no malignant potential 48. Metastatic work up/s for malignancies would mean requesting for the following: A. Ultrasound of the liver B. Chest x-ray C. Skull x-ray D. Bone scan Im not sure if A or C is incorrect. But using this diagram as basis, A is incorrect.

49. Precursor lesions A. Actinic keratoses B. Bowen’s disease C. Marjolin’s ulcers D. Huchinson’s freckles Answer key says only 2 are correct but based from what i found and batch 2012 recon A, B, and D are all precursor lesions. If the question however was precursor lesions for Squamous cell carcinoma, only A and B would be correct. Precursor lesions for SCCactinic keratosis, Bowen’s disease, Leukoplakia, Keratocanthoma. Hutchinson’s freckles is the precursor lesion for Lentigo Maligna Melanoma. -­‐ ACTINIC KERATOSES: Premalignant lesion, consisting thick, scaly, or crusty patches of skin; may progress to SCC -­‐ BOWEN’S DISEASE: in situ SCC lesion -­‐ MARJOLIN’S ULCERS: aggressive ulcerating SCC presenting in an area of previously traumatized, chronically inflamed, or scarred skin -­‐ HUTCHINSON’S FRECKLES: a tan patch on the skin that grows slowly and becomes mottled, dark, thick, and nodular. The lesion is usually seen on one side of the face of an elderly person. Local excision is recommended because it often becomes malignant

50. Condition/s where there is localized collection of pus A. Folliculitis B. Furuncle C. Carbuncle D. Cellulitis Only A, B, and C are correct. Refer to number 26

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Chicha Notes 2013  

 

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