CHAPTER 18- PLASTICS, SKIN, AND SOFT TISSUES.txt

Card Set Information

Author:
scottmreis
ID:
126438
Filename:
CHAPTER 18- PLASTICS, SKIN, AND SOFT TISSUES.txt
Updated:
2012-01-07 18:10:46
Tags:
ABSITE
Folders:

Description:
ABSITE
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user scottmreis on FreezingBlue Flashcards. What would you like to do?


  1. Epidermis:
    Keratinocytes- main cell type in epidermis; originates from basal layer; provide mechanical barrier

    • Melanocytes- neuroectodermal origin (neural crest cells); in basal layer of epidermis
    • - have dendritic processes that transfer melanin to neighboring keratinocytes via melanosomes
    • - density of melanocytes is the same among races; difference is in production
  2. Dermis:
    primarily structural proteins for the epidermis
  3. Langerhans cells
    • 1) act as antigen-presenting cells (MHC class II)
    • 2) originate from bone marrow
    • 3) have a role in contact hypersensitivity reactions (type IV)
  4. Sensory nerves:
    • 1) pacinian corpuscles- pressure
    • 2) ruffini's endings- warmth
    • 3) krause's end-bulbs- cold
    • 4) meissner's corpuscles- tactile sense
  5. Eccrine sweat glands:
    aqueous sweat (thermal regulation, usually hypotonic)
  6. Apocrine sweat glands
    • 1) milky sweat
    • 2) highest concentration of glands in palms, and soles
    • 3) most sweat is the result of sympathetic nervous system via acetylcholine
  7. What type of drugs have increased skin absorption?
    lipid soluble drugs
  8. Type I collagen:
    • 1) predominant type
    • 2) 70% of weight of dermis
    • 3) gives tensile strength
  9. Tension
    resistance to stretching (collagen)
  10. Elasticity
    ability to regain shape (branching proteins that can stretch to 2x)
  11. Cushing's striae
    caused by loss of tensile strength and elasticity
  12. Split-thickness skin grafts (STSGs)
    • 1) include all of the epidermis and part of the dermis
    • 2) donor site skin regenerated from hair follicles and skin edges on split-thickness grafts
    • 3) STSGs- are more likely to survive --> graft not as thick so easier for imbibition and subsequent revascularization to occur
  13. Full-thickness skin grafts-
    have less wound contraction--> good for areas such as the palms and back of hands
  14. imbibition (osmotic)
    blood supply to skin graft for days 0-3
  15. Neovascularization
    • 1) starts around day #3
    • 2) poor vascularized beds are unlikely to support skin grafting -->
    • - tendon
    • - bone without periosteum
    • - XRT areas
  16. What is the most common cause of pedicled or anastomosed free flap necrosis?
    venous thrombosis
  17. How does tissue expansion work?
    • Tissue expansion occurs by:
    • 1) local recruitement
    • 2) thinning of the dermis + epidermis
    • 3) mitosis
  18. TRAM flaps
    • 1) rely on superior epigastric vessels
    • 2) periumbilical perforators are the most important determinant of TRAM flap viability
    • 3) complications:
    • 1- flap necrosis
    • 2- ventral hernia
    • 3- bleeding
    • 4- infection
    • 5- abdominal wall weakness
  19. Pressure sores:
    • Stage I:
    • Erythema and pain, no skin loss

    • Stage II:
    • Partial skin loss with yellow debris
    • Tx: local treatment, keep pressure off

    • Stage III:
    • Full-thickness skin loss, subcutaneous tissue exposure
    • Tx: sharp debridement; will likely need myocutaneous flap

    • Stage IV:
    • Usually involves bony cortex
    • Tx: myocutaneous flaps
  20. UV radiation
    • 1) damages DNA and repair mechanisms
    • 2) both promotor and initiator
    • 3) melanin single best factor for protecting skin from UV radiation
    • 4) UV-B: responsible for chronic sun damage
  21. Melanoma
    1) represents only 3-5% of skin Ca but accounts for 65% of deaths
  22. What are risk factors for melanoma:
    • 1) dysplastic, atypical or large, or large congenital nevi- 10% lifetime risk for melanoma
    • 2) familial BK mole syndrome- almost 100% risk of melanoma
    • 3) xeroderma pigmentosum
    • 4) fair complexion, easy sunburn, intermittent sunburns, previous skin Ca, previous XRT
  23. What percent of melanomas are familial?
    10%
  24. Most common melanoma site on skin:
    • 1) back in men
    • 2) legs in women
  25. Who is prognosis worst for:
    • 1) men
    • 2) ulcerated lesions
    • 3) ocular and mucosal lesions
  26. Signs of transformation of melanoma:
    • 1) color change
    • 2) angulations
    • 3) indentation/notching
    • 4) englargement
    • 5) darkening
    • 6) bleeding
    • 7) ulceration
  27. Where do melanoma cells originate from:
    originates from neural crest cells (melanocytes) in basal layer epidermis
  28. What is the most ominous sign of melanoma
    blue color
  29. Whats the most common location for distant melanoma metastases?
    lung
  30. What is the most common metastasis to small bowel
    melanoma
  31. Dx of melanoma:
    1) <2 cm lesion- excisional biopsy (tru-cut core needle biopsy) unless cosmetically sensitive area- need resection w/margins if pathology comes back as melanoma

    2) >2cm lesions or cosmetically sensitive area- incisional biopsy (or punch biopsy), will need to resect w/margins if pathology shows melanoma
  32. Types of Melanoma:
    • Lentigo maligna:
    • 1) least aggressive
    • 2) minimal invasion
    • 3) radial growth 1st usually
    • 4) elevated nodules

    • Superficial spreading melanoma:
    • 1) most common
    • 2) intermediate malignancy
    • 3) originates from nevus/sun-exposed areas

    • Nodular:
    • 1) most aggressive
    • 2) mostly likely to have metastasized at time of diagnosis
    • 3) deepest growth at time of diagnosis
    • 4) vertical growth first
    • 5) bluish/black with smooth borders
    • 6) occurs anywhere in the body

    • Acral lentiginous:
    • 1) very aggresive
    • 2) palms/soles of african americans

  33. What kind of margins should you have for melanoma in situ or thin lentigo maligna
    0.5cm margins are OK
  34. Staging melanomas
    • 1) need CXR and LFTs
    • 2) examine all possible draining lymph nodes
  35. Treatment for all stages of melanoma:
    resection of primary tumor with appropriate margins
  36. What treatments can be used for systemic melanoma:
    • 1) alpha-interferon
    • 2) IL-2
    • 3) tumor vaccines
  37. Nodes (in relation to melanoma)
    • 1) always need to resect clinically positive nodes with melanoma
    • 2) perform sentinel lymph node biopsy if nodes clinically negative and tumor >1mm deep
    • 3) involved nodes usually nontender, round, hard, 1-2 cm
    • 4) all stage III tumors need full lymph node dissection
    • 5) need to include superficial parotidectomy for anterior head and neck melanomas
  38. What should you do if there is axillary node melanoma with no other primary?
    complete axillary node dissection
  39. Comment on resection of melanoma metastases (i.e. lung of liver)
    1) Resection of metastases has provided some patients with long disease-free interval and is the best chance for cure.

    2) Isolated metastases (i.e. lung or liver) that can be resected with a low risk procedure should probably undergo resection
  40. American Joint Commission on Cancer Melanoma Staging System, TNM definitions
    • Primary Tumor
    • Tx: cannot be assessed (shaved biopsy, regressed lesion)
    • T0: unknown primary
    • Tis: in situ melanoma
    • T1: 1.0 mm Breslow thickness
    • a) without ulceration
    • b) with ulceration or clark level IV or V
    • T2: 1.01-2.0 mm
    • a) without ulceration
    • b) with ulceration
    • T3: 2.01-4.0 mm
    • a) without ulceration
    • b) with ulceration
    • T4: >4mm
    • a) without ulceration
    • b) with ulceration

    • Regional Lymph Node Involvement
    • Nx: cannot be assessed (previously removed)
    • N0: no regional node metastasis
    • N1: Metastasis to one regional node
    • a) micrometastasis (diagnosed by SLNB or elective node dissection)
    • b) macrometastasis (clinically palpable or found on imaging studies, confirmed histologically, or gross extracapsular extension)
    • N2: metastasis in two or three regional nodes
    • a) micrometastasis
    • b) macrometastasis
    • c) in-transit or satellite metastasis without nodal metastasis
    • N3: metastasis 4 regional nodes, matted nodes, or in-transit or satellite metastasis with positive metastatic nodes

    • Distant Metastasis
    • Mx: cannot be assessed
    • M0- no distant metastasis
    • M1a: distant skin, subcutaneous, or lymph node metastasis with normal LDH
    • M1b: lung metastasis with normal LDH
    • M1c: all other distant metastasis or any distant site with elevated LDH
  41. Clark's Levels for Melanoma
    • I- epidermis basement membrane intact
    • II- papillary dermis through basement membrane
    • III- juncitonal dermis between papillary and reticular dermis
    • IV- reticular dermis
    • V- fat
  42. Melanoma margins
    • <1mm depth: 1cm margin
    • 1-4mm depth: need 2cm margin
    • >4mm depth: need 2-3cm margin
  43. look at survival chart on page 112
  44. What is the most common malignancy in the united states?
    • 1) basal cell carcinoma
    • 2) it is 4x more common than squamous cell carcinoma
  45. Where are most basal cell carcinomas found?
    80% are on the head and neck
  46. Where do basal cell carcinomas originate from?
    originates from epidermis- basal epithelial cells and hair follicles
  47. Describe what basal cell cancer looks like:
    pearly appearance, rolled borders
  48. What is the pathologic description of basal cell carcinoma?
    peripheral palisading of nuclei and stromal retraction
  49. Describe the growth of basal cell carcinoma?
    • 1) slow indolent growth
    • 2) ulcerative, rare metastases, deep invasion, occasionally dark
  50. What do you do for clinically positive nodes?
    regional adenectomy
  51. Morpheaform type
    • 1) most aggressive
    • 2) has collagenase production
  52. Treatment of basal cell carcinoma:
    • 1) 0.3-0.5cm margins
    • 2) XRT and chemotherapy- may be of limited benefit for inoperable disease or metastases; neuro, lymphatic, or vessel invasion
  53. Describe appearance of squamous cell carcinoma:
    • 1) overlying erythema, papulonodual with crust and ulceration
    • 2) may have surrounding induration and satellite nodules
    • 3) usually red/brown; can have a pearly appearance
  54. Metasasis in squamous cell carcinoma:
    1) metastasizes more frequently than basal cell ca but less commonly than melanoma
  55. Risk factors:
    • 1) actinic keratosis
    • 2) xeroderma pigmentosum
    • 3) bowen's disease
    • 4) atrophic epidermis
    • 5) arsenics
    • 6) hydrocarbons (coal tar)
    • 7) cholorophenols
    • 8) nitrates
    • 9) HPV
    • 10) immunosuppression
    • 11) sun exposure
    • 12) fair skin
    • 13) XRT exposure
    • 14) previous skin Ca
    • 15) can develop in old burn scars
  56. Risk factors for metastasis of squamous cell ca:
    • 1) poorly differentiated
    • 2) greater depth
    • 3) recurrent lesions
    • 4) immunosuppression
  57. Treatment of squamous cell carcinoma:
    • 1) 0.5-1cm margins for low risk
    • 2) can treat high risk with MOHS surgery (margin mapping using conservative slices; not used for melanoma) when trying to minimize area of resection (i.e. lesions on face)
    • 3) regional adenectomy for clinically positive nodes
    • 4) XRT and chemotherapy- may be of limited benefit for inoperable disease or metastases; neuro, lymphatic or vessel invasion.
  58. What are the most common soft tissue sarcomas:
    • #1- malignant fibrous histiosarcoma
    • #2- liposarcoma
  59. Describe the characteristics of sarcomas and where they are usually found:
    • 1) most sarcomas are large, grow rapidly, and are painless
    • 2)50% arise from extremities, 50% in children (arise from embryonic mesoderm)
  60. Symptoms:
    • 1) asymptomatic mass (most common presentation)
    • 2) GI bleeding
    • 3) bowel obstruction
    • 4) neurologic deficit
  61. What imaging studies may you get for sarcoma and why:
    • CXR: to r/o lung mets
    • MRI before biopsy to r/o vascular, neuro, or bone invasion
  62. Biopsy of sarcoma:
    • 1) excisional biopsy if mass <4cm
    • 2) longitudinal incisional biopsy for masses >4cm (may need to eventually resect biopsy skin site if biopsy shows sarcoma
  63. How do sarcomas metastasize?
    • 1) hematogenous spread, not to lymphatics--> metastasis to nodes is rare
    • 2) Lung is the most common site of metastasis
  64. What is staging of sarcomas based on?
    staging based on grade, not size or nodes
  65. Treatment of sarcoma:
    • 1) want at least 3cm margins and at least 1 uninvolved fascial plane--> try to perform limb sparing operation
    • 2) place clips to mark site of likely recurrence --> will XRT these later
    • 3) postop XRT- for high-grade tumors, close margins, or tumors >5cm
    • 4) chemotherapy is doxorubicin based
    • 5) tumors >10cm may benefit from preop XRT and chemotherapy- may allow limb sparing resection
    • 6) Isolated sarcoma metastases without other evidence of systemic disease (i.e. lung or liver) can be resected and are the best chance for survival; otherwise can palliate with XRT
    • 7) midline incision favored for pelvic and retroperitoneal sarcomas
    • 8) with resection, try to preserve motor nerve and retain or reconstruct vessels
  66. Whats the prognosis for sarcomas:
    • 1) prognosis is poor overall
    • 2) delay in diagnosis
    • 3) difficulty with total resection
    • 4) difficulty getting XRT to pelvic tumors
    • 5) 40% 5 year survival rate with complete resection
  67. Head and neck sarcoma
    • 1) can occur in the pediatric population (usually rhabdomyosarcoma)
    • 2) hard to get margin because of proximity to vital structures
    • 3) posop XRT for positive or close margins as negative margins may be impossible to obtain
  68. Visceral and retroperitoneal sarcomas
    • 1) most common are leiomyosarcomas and liposarcomas
    • 2) ability to completely remove the tumor is the most important prognostic factor in visceral and retroperitoneal sarcomas
  69. Risk factors:
    asbestos:
    PVC and arsenic:
    Other risk factors:
    Chronic lymphadema:
    • asbestos: mesothelioma
    • PVC and arsenic: angiosarcoma
    • Other risk factors: XRT, chlorophenols, pesticides
    • Chronic lymphedema: lymphangiosarcoma
  70. Kaposi's sarcoma
    • 1) vascular sarcoma
    • 2) can involve skin, mucous membranes, or GI tract
    • 3) associated with immunocompromised state
    • 4) rarely a cause of death in AIDS; 15-20 year survival; slow growing
    • 5) Treatment: XRT or intralesional vinblastine for local disease; systemic chemotherapy for disseminated disease
    • 6) surgery for intestinal hemorrhage
  71. Childhood rhabdomyosarcoma
    • 1) #1 soft tissue sarcoma in kids
    • 2) head/neck, genitourinary, extremeties + trunk (poorest prognosis)
    • 3) embryonal subtype- most common
    • 4) alveolar subtype- worst prognosis
    • 5) Tx: surgery, doxorubicin-based chemotherapy
  72. Bone sarcomas
    • 1) most are metastatic at the time of diagnosis
    • 2) Osteosarcoma:
    • 1- increased incidence around the knee
    • 2- originates from metaphyseal cells
    • 3- usually in children
    • 3) usually need to take the joint, followed by reconstruction; may require amputation
  73. Neurofibromatosis:
    • 1) CNS tumors
    • 2) peripheral sheath tumors
    • 3) pheochromocytoma
  74. Li-Fraumeni syndrome
    1) childhood rhabdomyosarcoma, many others
  75. hereditary retinoblastoma
    also include other sarcoma
  76. tuberous sclerosis
    angiomyolipoma
  77. Gardner's syndrome
    • 1) familial adenomatous polyposis
    • 2) intraabdominal desmoids
  78. Xanthoma
    • 1) yellow
    • 2) contains histiocytes
    • 3) Tx: excision
  79. Warts
    • 1) verruca vulgaris
    • 2) viral origin
    • 3) contagious
    • 4) autoinoculable
    • 5) can be painful
    • 6) liquid nitrogen initially
  80. Lipomas
    • 1) common but rarely malignant
    • 2) back, neck, between shoulders
  81. Neuromas
    • 1) can be associated with neurofibromatosis and von Recklinghausen's disease
    • 2) cafe-au-lait spots, axillary freckling, optic nerve gliomas, CNS tumors
  82. Keratosis
    • Actinic keratosis-
    • 1) premalignant
    • 2) in sun-damaged areas
    • 3) need excisional biopsy if suspicious

    • Seborrheic keratosis
    • 1) not premalignant
    • 2) trunk on elderly
    • 3) can be dark

    Arsenical keratosis- associated with squamous cell carcinoma
  83. Merkel cell carcinoma
    • 1) are neuroendocrine
    • 2) aggressive regional and systemic spread
    • 3) patients have red to purple papulonodule/indurated plaque
    • 4) have:
    • 1- neuron-specific enolase (NSE)
    • 2- cytokeratin
    • 3- neurofilament protein
  84. Glomus cell tumor
    • 1) painful tumor composed of blood vessels and nerves
    • 2) benign; most common in the terminal aspect of the digit
    • 3) tx: tumor excision
  85. Hutchinson's freckle
    • 1) in elderly
    • 2) often on face
    • 3) premalignant, not aggressive
  86. What is an important point in repair of lip lacerations
    important to line up vermillion border
  87. Desmoid tumors
    • 1) usually benign
    • 2) occur in fascial planes
    • 3) Anterior abdominal wall (most common location) desmoids can occur during or following pregnancy; can also occur after trauma or surgery
    • 4) Intra-abdominal desmoids associated with gardner's syndrome and retroperitoneal fibrosis
    • 5) high risk of local recurrences, not distant spread
    • 6) Tx: surgery or chemotherapy/XRT if vital structure involved
  88. Bowen's disease
    • 1) squamous cell carcinoma in situ
    • 2) 10% turn into invasive squamous cell carcinoma
    • 3) Tx: excision with negative margins usual (exception includes peri-anal region)
  89. Keratoacanthoma
    • 1) rapid growth, rolled edges, crater filled with keratin
    • 2) is not malignant but can be confused with squamous cell carcinoma
    • 3) involutes spontaneously over months
    • 4) always biopsy these to be sure
    • 5) if small, excise; if large, biopsy and observe
  90. Hyperhydrosis
    • 1) increased sweating
    • 2) especially noticeable in the palms
    • 3) sympathectomy if refractory
  91. Hidradenitis
    • 1) infection of the apocrine sweat glands
    • 2) usually in the axilla and groin regions
    • 3) staph/strep is most common organism
    • 4) antibiotics, improved hygiene 1st; may need surgery
  92. Epidermal inclusion cyst
    • 1) most common benign cyst
    • 2) have completely mature epidermis with creamy keratin material
  93. Trichilemmal cyst
    • 1) in scalp
    • 2) no epidermis
  94. Ganglion cyst
    • 1) over tendons
    • 2) usually over wrist
    • 3) filled with collagenous material
  95. dermoid cyst
    • 1) midline abdominal and sacral lesions
    • 2) occiput and nose
    • 3) found along body fusion planes
  96. pilonidal cyst
    • 1) congenital coccygeal sinus with ingrown hair
    • 2) gets infected and needs to be excised
  97. Keloids
    • 1) autosomal dominant; dark skin
    • 2) collagen goes beyond original scar
    • 3) XRT, steroids, silicone, pressure garments
  98. Hypertrophic scar tissue
    • 1) dark skin
    • 2) flexor surfaces of upper torso
    • 3) collagen stays within confines of scar
    • 4) often occurs in burns or wounds that take a long time to heal
    • 5) steroids, silicone, pressure garments

What would you like to do?

Home > Flashcards > Print Preview