Skin and Soft Tissue
Melanoma
Melanoma
- Dx:
- ABC's of melanoma:
- Asymmetry
- Border
- Color variance
- Diameter > 6mm
- Evolution or change in lesion
- Types:
- Superficial spreading
- Nodular
- Lentigo maligna
- Acral lentiginous
- Desmoplastic
- Biopsy all suspiciou lesions.
- < 1.5cm gets excision
- >1.5cm gets punch to include normal skin. Do 2 areas and include thickest area.
- ABC's of melanoma:
- Tx:
- Margins:
- Tis= 0.5mm
- <1mm thick= 1cm
- 1-2mm= 2cm
- >2mm= 2cm
- Sentinel lymph node biopsy is used for:
- > 1mm thick
- Ulceration
- Clark level IV
- Regression
- Incomplete stage (shave biopsy)
- Discuss as an option for all invasive melanoma because <1mm thick has <5% chance of nodal involvement.
- Adjuvent Tx:
- >4mm gets interferon alpha
- Positive sentinel node gets:
- Regional lymph node dissection
- 1yr of interferon alpha
- Margins:
- Subungual and digital melanomas can have Hutchinson's sign (pigment changes of cuticle.
- worse prognosis.
- Biopsy by removing nail.
- Treat with amputation one joint proximal to tumor.
- Head and face melanoma needs to have superficial parotidectomy when the parotid lights up as the sentinal lymph node or when doing regional lymph node dissection
Hernia
Hernia
- Inguinal hernias in woman are recommended to be repaired; men can have watchful waiting with 64% requiring surgery in 10yrs.
- Types of surgical mesh
- Shouldice technique= pure tissue repair
- Incise transverses fascia and mobilize flap
- Two layer closure of transverses fascia – tightens the internal ring
- Join conjoint tendon to inguinal ligament in two running layers; 2nd layer includes rectus sheath and external oblique apaneurosis – closes floor
- Bassini repair= similar to shouldice, but tightening internal ring and closing floor are each only one layer
- Cooper ligament repair (McVay repair)= definitively repairs inguinal and femoral hernias
- Cirrhotic umbilical hernia
- Tx: medically optimize ascites, tips if needed, semielective repair.
Retroperitoneal Liposarcoma
Retroperitoneal Liposarcoma
- Sx: large, invade adjacent organs
- Dx: CT
- Tx:
- resection with grossly negative margins
- chemo reserved for metastasis
Spleen
Spleen
Ideopathic Thrombocytopenia Purpura (ITP)
Ideopathic Thrombocytopenia Purpura (ITP)
- thrombocytopenia alone, without underlying cause
- Tx: start for bleeding or very low platelets
- 1st line= steroid, IVIG
- 2nd line= rituximab, thrombopoietin agonists (romiplostim, eltrombopag), splenectomy (often use trombopoietin agonist to improve platelet and then pts can decide on surgery)
Spontaneous atraumatic splenic rupture
Spontaneous atraumatic splenic rupture
- From cancer, inflammatory state, drug related
- Tx: splenectomy, IR, non-op
Splenic Cyst
Splenic Cyst
- Sx: pain, h/o infarct, abscess, parasite
- Dx: CT, parasite assays
- Tx:
- aspiration confirms dx
- splenectomy (can consider aspiration and sclerosis, especially for parasites)