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SCORE School Soft Tissue Neoplasms, Part 1 of 2
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SCORE School Soft Tissue Neoplasms, Part 1 of 2
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ALFRED CHAHINE: OK, it's 2 o'clock Eastern Standard Time. Let's get started. Good afternoon, everyone and welcome to SCORE school. My name is Alfred Chahine. I'm the assistant editor of SCORE. And I'll be your moderator today. Some housekeeping items before we start today's session-- you will see a QR code for attendance tracking displayed a few times throughout the presentation. You only need to submit it once.
ALFRED CHAHINE: And you'll receive an email confirming your attendance. For today's SCORE school, the topic is Soft Tissue Neoplasms, 1 out of 4. The modules we're discussing today are non-melanoma skin cancers, melanoma nevi, melanoma wide excision, sentinel lymph node biopsies for melanoma, ilioinguinal and femoral lymphadenectomies. It is now my pleasure to introduce our faculty presenter for the day, Dr. Farah Karipineni.
ALFRED CHAHINE: Dr. Karipineni is an assistant clinical professor at UCSF Fresno. After completing an undergraduate degree at UC Berkeley, she earned her medical degree from the University of California, Irvine, School of Medicine. She also completed an MPH at USC. Her residency in general surgery was completed at Albert Einstein Medical Center in Philadelphia.
ALFRED CHAHINE: And she completed a fellowship in endocrine surgery at Johns Hopkins School of Medicine. She is passionate about culturally sensitive care. She has been involved in global health initiatives, including the Malek Medical Clinic which serves displaced Sudanese families and the Educate Refugees Program, which provides refugees with scholarships for higher education in health care fields.
ALFRED CHAHINE: Dr. Karipineni has been published in journals, including The American Surgeon, the International Journal of Surgery, and the Journal of Surgical Education. Her hobbies include tennis, traveling, and colonial and post-colonial literature. Thank you, Dr. Karipineni, for lending your expertise to us and take it away, please.
FARAH KARIPINENI: Absolutely. Thank you so much for that introduction. Thank you to you as well, Dr. Joshi, and the entire SCORE team for allowing me to participate.
ALFRED CHAHINE: Sure.
FARAH KARIPINENI: I'm very excited to introduce this topic of soft tissue neoplasms. Next slide. First, we'll go into the anatomy and physical exam of the skin.
ALFRED CHAHINE: Sorry. Yes, there you go.
FARAH KARIPINENI: And then we'll go into some non-melanoma skin cancers. We'll continue talking about melanomas and their precursors and then how we treat melanomas. Next slide. Just as a refresher for the anatomy of the skin, it's comprised of the dermal and epidermal layers. So when we talk about where these cancers arise from, it'll be important to come back to this refresher here. We see the epidermis is the top layer.
FARAH KARIPINENI: The dermis is the bottom layer. You can also see from this picture where different cells live, so the melanocytes being a little bit deeper down in the epidermis. Also in the skin is, of course, sweat glands, hair follicles, sebaceous glands, and also our apocrine and eccrine glands. Next slide. So very important when we do a focused exam of the skin. As surgeons, there are certain things that we should think about when we see patients for skin lesions that may not be apparent when we do our regular physical exam for a hernia or any other pathology.
FARAH KARIPINENI: So we want to start with our history, of course. The history of the lesion. We want to know if there has been any prior trauma to that area. Have they had any procedures done there? We want to know about the evolution of the lesion as well. So how was this a year ago? How was it two years ago?
FARAH KARIPINENI: Has it been there since birth? Any associated symptoms which generally provide us in pain are important to ask about as well. Because that can lead us to think about what type of lesion it might be. Also, we want to know about relevant exposures. Has the patient had any radiation exposure? Arsenic is a known exposure. Is the patient a smoker?
FARAH KARIPINENI: The past medical history is, of course, very important, any previous cancers the patient has had, if the patient is immunosuppressed for any reason, and also if there's a relevant family history of certain types of skin cancers. Next slide. So once we've gotten a good history, we want to move on to the physical exam. So, of course, we want to look at the lesion itself.
FARAH KARIPINENI: But you always want to look at the surrounding skin, too. What does the rest of the skin look like? Is this in a background of normal skin? Are there multiple lesions? And then when it comes to the lesion itself, the presence or absence of ulceration is very important to note, whether the lesion is fixed or mobile. It might be a flat lesion, so it might not make sense to consider whether it's fixed or mobile.
FARAH KARIPINENI: But if it's a raised lesion or an exophytic lesion, then you want to know if some of it is going down under the skin. How much of that is mobile or fixed? And then, of course, you can't forget during your physical exam to check the lymph node basins. So this depends on where the lesion is, whether you're concerned about neck, actually, or growing adenopathy.
FARAH KARIPINENI: But generally, it's a good idea to check all the lymph node basins, especially when there is a concern that this lesion could be cancer. Next slide. So now, we'll move on to some of the non-melanoma skin cancers. So this is important to go over. Because these can be surgical diseases, but we don't see them as often as, say, dermatologists or primary care physicians.
FARAH KARIPINENI: But it's very important to be able to see these lesions, know what they are, be aware of them. And so we'll go over the most common sub-types. Next slide. First, in the non-melanoma category is basal cell carcinoma. So this is the most common sub-type. It forms in the innermost layer of the epidermis. And then there's squamous cell carcinoma, second most common, by far less common than basal cell carcinoma.
FARAH KARIPINENI: These also arise in the layer of the epidermis, but from the squamous cell. So these are keratin-producing cells. One of the precursors to squamous cell carcinoma that we know of is actinic keratosis. That's something that is commonly asked. It's common questions that arise, is, what is a precursor for squamous cell carcinoma? And this is a picture of actinic keratosis that you can see on this slide here, which shows there's heaped up edges of-- or heaped up keratin here, but not quite the suspicious features that we'll go over that are present in the squamous cell carcinoma lesion.
FARAH KARIPINENI: Next slide. So these two are a lot less common, but still worth knowing about. Dermatofibrosarcoma protuberans is a cutaneous soft tissue sarcoma. So these are lumps and bumps that patients may present with that are unusual diagnoses, but worth knowing about when you see these patients in the office who present with something that-- somebody might call it a lipoma or just a mass.
FARAH KARIPINENI: And you go and excise it. But you need to be cognizant that it could end up being something like a dermatofibrosarcoma. Now, these arise from the fibroblasts within the dermis, so that deeper layer than we're talking about with squamous and basal cell cancer. And lastly, there's Merkel cell carcinoma. So these arise from neuroendocrine cells in the epidermis.
FARAH KARIPINENI: And we'll talk a little bit more about each one of these in detail. Next slide. As far as these non-melanoma skin cancers, the lifetime risk is high. So Americans have about a 20% lifetime risk of these skin cancers, so very relevant to our knowledge base when we take care of patients. Basal cell carcinoma-- 80% of them are going to be a basal cell tumor when you see these patients.
FARAH KARIPINENI: And you have to ask about certain risk factors. So we discussed some of those earlier. UV exposure-- of course, that is very important. So patients who use tanning beds, who are out in the sun over a long period of time, those who are of older age, who have fair skin, of course. Smokers, immunosuppression, certain exposure, as we talked about. Arsenic, also.
FARAH KARIPINENI: Hydrocarbons have been shown to increase risk. Next is squamous cell carcinoma, similar risk factors to basal cell carcinoma. But also, you have to remember HPV infection can lead to squamous cell cancers. Similarly, Merkel cell carcinoma has a history of immunosuppression as a risk factor, so leukemia and lymphoma specifically. And then Merkel cell polyomavirus.
FARAH KARIPINENI: It's important to keep that in the back of your head. That can also be a risk factor. So not everybody who tests positive for Merkel cell polyomavirus is going to end up with Merkel cell carcinoma, but it can be a risk factor. Next slide. So these are just going to be some pictures of the classic presentation, so you've seen what each of these lesions can look like.
FARAH KARIPINENI: And so you remember the buzzwords of what you're looking for and also the way that it looks. So squamous cell carcinoma is generally a scaly and erythematous lesion, usually going to be in sun damaged areas, so areas that are exposed. An ulceration is pretty common with these as well as raised edges. So if you look closely at this lesion, you can see that around the borders of the main part of the lesion, there is some raised edges there.
FARAH KARIPINENI: It looks like a little crater in the middle. Next slide. With basal cell carcinoma, these are also generally raised, but not quite so much as squamous cell carcinoma. They're well circumscribed. And they have more of a waxy appearance. And you can see from the picture there with rolled pearlescent edges.
FARAH KARIPINENI: So those are buzzwords again for-- if this is being described to you, then you generally will think of, OK, pearlescent, waxy-- basal cell carcinoma. And it also has a more variable presentation or appearance so that you can have a more nodular presentation. Some of them can appear cystic or superficial, so just keep that in mind. Next slide.
FARAH KARIPINENI: So now, under more rare tumors. To just say you've seen what this looks like, this is dermatofibrosarcoma protuberans, two different pictures. You can see this is a seemingly much, much more aggressive type of lesion. It's larger and more raised. And that's what it looks like. So if someone comes to you with something like this, you're going to immediately have to start thinking about this possibly being a cancer margin.
FARAH KARIPINENI: This is not something that you just excised to negative margins. It requires more thought than that. Next slide. And here's a Merkel cell carcinoma. So this is a firm bump within the skin. It has a little bit more of a well-circumscribed appearance-- reddish, purplish hue. And it is known to grow more rapidly and also can metastasize.
FARAH KARIPINENI: Next slide. So let's go on to how we diagnoses these lesions. There's lots of different ways. And It depends a lot on what your suspicion is and how large the lesion is. As surgeons, we have in our toolbox more things than other physicians who see these lesions do. And so we should use each of those appropriately, depending on what we think we're dealing with.
FARAH KARIPINENI: So, of course, punch biopsy is one of the most common ways of doing this. So punch biopsy is done with a small punch biopsy kit, which takes a full thickness piece of the mass that you're worried about. The importance of that is you see the depth of the lesion. And you can get a better diagnosis that way, versus commonly, we compare that to a shaved lesion where they shave a little piece off the top of something, which is harder to diagnose and also harder to get an idea of how deep the lesion goes into the skin.
FARAH KARIPINENI: Excisional biopsy is another commonly used technique. So this is for lesions that are not quite large enough that you are worried about having to close it later. You think you can get the whole thing out with negative margin. And you may even cure the patient in addition to diagnosing what this lesion is. So that's a good candidate for an excisional biopsy. It's really important when you do these to maintain the orientation of the specimen, which it sounds obvious.
FARAH KARIPINENI: But when you actually are doing the procedure, it's important to remember that you need to know exactly how you took this piece out so that if you need to go back for additional margins, you know exactly where you need to get what specific additional margin. So you don't want any confusion between yourself and the pathologist as well. So that's maintaining orientation of the specimen, perhaps even putting clips in or something to mark the cavity for when you return.
FARAH KARIPINENI: So again, that's for a possible re-excision if you need additional margins. And it's always advisable to think that you may need to come back. And I tell my patients, even for a simple lipoma. Because you may be surprised. These are rare lesions. But if you do enough of them, you may come across these things at some point.
FARAH KARIPINENI: And it's important to be able to have in the back of your mind that if I do an excisional biopsy, I may need to come back for reorientation. It doesn't mean that every simple lipoma should need to have orientation. But if you have suspicion, then make sure you do that. Because you could possibly be coming back. And you want to make sure that you get good margins based on [INAUDIBLE].
ALFRED CHAHINE: May I ask a question?
FARAH KARIPINENI: Yes.
ALFRED CHAHINE: So with that in mind, what's the best approach for incisions, let's say, on the extremities for, say, a 1-centimeter skin lesion on the extremity? How should folks approach that?
FARAH KARIPINENI: So from a specimen orientation standpoint, it's best to orient it longitudinally. So longitudinal is best if you have some suspicion that you're dealing with a skin cancer.
ALFRED CHAHINE: Thank you.
FARAH KARIPINENI: So if you're not worried about that, then going along the skin lines and doing what might be more cosmetic is OK. But if you have any concern that it's for cancer, I would do a longitudinal.
ALFRED CHAHINE: Thank you.
FARAH KARIPINENI: Absolutely. So going down our list here, so what if it's not possible to get an excisional biopsy? What if it's a large tumor and you really have a suspicion that you're going to have to do more for this patient than just do an excisional biopsy with negative margins or with a 1 or 2-centimeter margin? Well, that's a good case for doing core needle biopsy or an incisional biopsy.
FARAH KARIPINENI: Obviously, for a core needle biopsy, the benefit for the patient is that they don't need to go to surgery. This can be done minimally, invasively with a core needle biopsy kit. Incisional biopsy-- obviously, it does require surgery. And then you have to manage the closure of your incision with thought to how you're going to proceed later on.
FARAH KARIPINENI: This is best for, again, larger or deeper tumors. And when you do this, you're obviously going to either come back again to do incisional biopsy with negative margins, with whatever margins are needed for definitive treatment. Or sometimes after this, you're going on to chemoradiation first, and see if there's a response, and then go to surgery. So these are much more complex.
FARAH KARIPINENI: Sometimes patient needs PET/CTs as well. Because you're worried about this being larger and possible metastasis, depending on what type of skin tumor it is. Maybe it's a melanoma. Maybe it's a Merkel cell cancer or a dermatofibrosarcoma. And then you have to think about a lot more issues with the wound. Next slide.
FARAH KARIPINENI: So other things in terms of diagnosis-- we don't-- seen those a lot as general surgeons. But it's important to be cognizant that if you have a patient who has a head and neck tumor, and it's in a very visible area, and you're trying to avoid a large tissue defect, then consider that. And even though we may not be-- some of us may know what Mohs is and be able to do it, and have the setup in our office.
FARAH KARIPINENI: Some of us don't. But it's important to be able to know when to refer a patient from those who is low-risk basal cell cancer or squamous cell carcinoma and in an area where a cosmetic outcome is going to be particularly important. Usually, those are inferior to an excisional biopsy. So it's important to be able to counsel patients on what the pluses and minuses are.
FARAH KARIPINENI: But it's an important tool in our toolbox. And for the specific low-risk cancers, it can be very helpful to a patient's quality of life if safe. So I mentioned shave biopsy earlier, usually not ideal, inadequate, never going to be the right answer and then additional considerations as well, as far as PET/CT. These are typically not going to be for your basal cell carcinoma or squamous cell carcinoma, but for dermatofibrosarcoma or Merkel cell.
FARAH KARIPINENI: Those are faster growing. And it has a higher risk of mets, so it's important to think about that. A patient comes and says, I have a lump. OK. Well, if it looks like one of those things in the picture, it may be tempting to just take it out and orient the specimen. But you always have to think with those specific sub-types. There could be something more going on here.
FARAH KARIPINENI: And that would only come to light if you do additional imaging. Next slide. OK. So surgical management of these patients has to do with margins. So depending on what the pathology is based on, the biopsy or the suspicion, the margins are everything with regard to the details of the surgery.
FARAH KARIPINENI: So with basal cell cancer, squamous cell cancer, the margins are obviously going to be smaller. Because these are less aggressive tumors, so 4 to 10 millimeters. Dermatofibrosarcoma is going to have a larger margin, so 2 to 4 centimeters. So if you get your 4-centimeter margin, that's going to be a very large defect. So again, thinking about what type of biopsy we're going to do.
FARAH KARIPINENI: How we're going to close those defects is really important. For cutaneous adnexal tumors, a little bit smaller, so 1 to 2 centimeters. But only if those are malignant. If they're not malignant, then the negative margin is enough. And for Merkel cell carcinoma, it's the same as above for cutaneous tumors. It's 1 to 2 centimeters. And then always think about a sentinel node biopsy, because these are fast growing and metastasized as well.
FARAH KARIPINENI: So think about that for sentinel node for Merkel cell. Next slide. And then, of course, post-operatively, we have to manage these patients. So this can be done either by the dermatologist or by the surgeon, depending on how involved the tumor was. So sometimes for a smaller squamous cell carcinoma that was just a little bigger than what the dermatologist or the dermatologic person who did the procedure to do the diagnosis, just a little bigger than what they are comfortable dealing with.
FARAH KARIPINENI: Sometimes they send you to the general surgeon. And then you can send the patient back to do regular skin examinations, because these patients need a head-to-toe exam to make sure. Because every year or two years, they can get new lesions. Or you can decide that you want to be the one managing that. But it's important to make sure patients know that they need regular skin examinations. These generally can be done on a yearly basis, but it depends on what the tumor type is.
FARAH KARIPINENI: And then patients should also know how to self-exam. So in between those yearly visits, something may come up. So patients need to be educated on, what do these lesions look like, based on what pathology they just had removed, what they're at risk for, what looks abnormal? Also need to be told about sun protection. So these patients really need to avoid UV rays, avoid other exposures that can cause them to be at risk such as smoking.
FARAH KARIPINENI: And then, again, they may need follow-up PET/CTs, depending on whether they were systemic disease and what the typical tumor type was. Next slide. OK, so we've talked about non-melanoma skin cancers at this point. So now, we're going to move on to melanoma. And the rest of what we talk about will be relevant for melanoma.
FARAH KARIPINENI: Next slide. Melanomas arise from the melanin-producing, neural crest-derived cells in the epidermis. So the melanin-producing cells, the melanocytes. Next slide. They come in several different sub-types. So we're not going to go into what each specific sub-type is in detail in this lecture, but it's important that you know that these exist and to familiarize yourself with them.
FARAH KARIPINENI: So superficial spreading is the most common one. It's more flat, like the name suggests. And it typically arises from a nevus. We'll talk about nevi shortly as well. There's a nodular sub-type-- acral lentiginous, which is the palms, and soles, and nail beds one, lentigo maligna, and mucosal, which has the poorest prognosis. And then, of course, desmoplastic.
FARAH KARIPINENI: Desmoplastic is very low incidence and also the more benign sub-type. Next slide. So nevi are basically what we consider to be moles. They can be congenital. They can appear over your lifetime and be something you're not born with. But these are pigmented lesions like the picture shows here.
FARAH KARIPINENI: They can be associated with an increased risk of melanoma at larger size. So what is a large size? Well, a 20-centimeter congenital nevis, specifically, can carry anywhere from a 5 to a 20% risk of melanoma. So the larger the nevis, the more we care about it, the more we pay attention to it. So it's important to keep that in the back of your mind, depending on the size of the nevis.
FARAH KARIPINENI: Your patient may ask you about a certain lesion. And you need to be able to determine what the risk is, whether it can be watched, whether it should be removed, and really know how to counsel patients, depending on what the size is, what the risk is of developing a melanoma, especially because these are congenital lesions that were mostly congenital, what we're talking about. So over a lifetime, this could be a significant risk, especially if it's a growing nevis.
FARAH KARIPINENI: Next slide. So like I said before, nevi can predispose to melanoma. This happens to a pathway, whereby at some point, it becomes a dysplastic nevis. So in contrast to the picture I showed you in the last slide, you see here. This is a different beast. This is larger. It's a bit more raised in an irregular fashion.
FARAH KARIPINENI: It also has irregular borders. And the color is very uneven. As opposed to a nice, smooth, brown lesion, this is now ranging from pink to dark brown with an uneven color. This is more concerning. And again, you wouldn't know whether this was always like this or whether it transformed from the previous picture, unless you ask that.
FARAH KARIPINENI: So it's important to elicit a history of the pathophysiology of the news or whatever the patient is clinically experiencing in order to be able to tell that this is a lesion that's on the go. It's on the move to possibly becoming melanoma. Next slide. So when we do our physical exam-- and we went through some of the important parts of the physical exam for the skin.
FARAH KARIPINENI: Important to talk about the A, B, C, D of the physical exam for melanoma. So on the left-hand side here, you see what are benign features of a skin lesion, so symmetry, even borders, a single color, smaller than 6 millimeters. And at the bottom, you see what look like a nevus, just an ordinary mole. Now, on the right side, you see the A, B, C, D is the asymmetry.
FARAH KARIPINENI: The borders are no longer even. There's different colors ranging from pink to dark brown, like we talked about. The diameter is larger than 6 millimeters. And the evolution-- so that's partly you asking about the history. So any change in the above characteristics is concerning, that you want these to remain the same. And if they don't, you are concerned.
FARAH KARIPINENI: Next slide. So also, a physical exam. We discussed the lymph node exam is very important for melanoma. So melanoma-- you have to look for lymph node basins. And what you're looking for is any node that appears fixed, or matted, or enlarged and the lymph node basins near the initial tumor. But you should really examine others as well. And in that same vein, you should look for other skin lesions, too.
FARAH KARIPINENI: So this isn't a common vocabulary that we have to be aware of when we talk about melanoma, is something called in-transit metastasis and satellite metastasis. So in-transit metastasis is located still within the regional lymphatic. So it's still within the same region, but more than two centimeters away from the primary tumor. And a satellite metastasis is conversely located within 2 centimeters of the primary tumor.
FARAH KARIPINENI: So the satellite mets is closer to the primary tumor. In-transit mets is further away, but still within the same draining lymphatic region. So these are things that you should be looking for very intentionally when a patient comes to you with a biopsy proven melanoma, or with a mole, or a lesion, concerning for melanoma. We need to look intentionally for those. And when we see them, we should measure the distance between what we think is the initial tumor and that in order to know, whether it's satellite mets or in-transit mets Next slide.
FARAH KARIPINENI: So again, once we have this lesion we're concerned about being a melanoma, we need to do a biopsy. And again, it's important to discuss a different option-- punch biopsy, or excisional biopsy, or specimen orientation, or incisional biopsy. Next slide. So as far as the lymph node evaluation, we discussed whether we have clinically positive nodes.
FARAH KARIPINENI: That can be determined at the time of seeing the patient in the office. So clinically suspicious nodes are, as we said, those hard nodes, matted, fixed, or enlarged nodes. So those should undergo percutaneous biopsy. So we can't assume anything about these nodes. For instance, if you have melanoma of the head and neck and you have a clinically suspicious node, you can't assume that that's related to the melanoma.
FARAH KARIPINENI: You should do a percutaneous biopsy. There's a lot of things in the head and neck that can cause a cancer. Let's say the patient is a smoker. Just because the patient has a melanoma does not mean that that node could not be, for instance, a squamous cell carcinoma or a papillary thyroid carcinoma with the mets. So a percutaneous biopsy is very important to secure the diagnosis.
FARAH KARIPINENI: If you have clinically negative nodes, on the other hand, then we can talk about doing sentinel lymph node biopsy. There's very specific indications. So at the time of excision of the melanoma, consider sentinel lymph node biopsy for a thickness greater than 1 millimeter in general. However, high-risk patients with a thickness under 1 millimeter-- for instance, we talk about a smaller 0.8 millimeter thickness, but with ulceration.
FARAH KARIPINENI: That should be considered as well for a sentinel node biopsy. It's not unreasonable at all. Because the ulceration confers a greater risk of melanoma. You'll see it's even part of the staging system. So that will be a discussion with the patient. So a patient with a smaller lesion-- it should definitely be given as an option to do a sentinel node biopsy if there is ulceration and something that is less than 1 millimeter, but approaching 1 millimeter.
FARAH KARIPINENI: These are important discussions to have with the patient. Next slide. So moving on to the melanoma wide excision, we'll talk about some of the details related to a definitive surgical management of the melanoma itself. Next slide. Again, we need to talk about margins. So margins are extremely important with skin cancers.
FARAH KARIPINENI: And they're very specific for melanoma. So before, we talked about different margins for different tumors. But this is the same tumor as melanoma. Depending on the depth of it, we have a different excision margin. So in general, wide local excision with margins is what we do for melanoma with or without the sentinel node biopsy.
FARAH KARIPINENI: And the size of the melanoma dictates the excision margin, as you can see in this table here on the right. So a melanoma [INAUDIBLE] is 5 millimeters. Less than 1 millimeter-- you get a 1-centimeter margin. And then here with a 1 to 4 millimeter lesions, 1 to 2-centimeter margins needed. Greater than 4 millimeters-- you need a 2-centimeter margin. So you can think 4 millimeters is not very large. You can see that somebody with a melanoma on their face who has a 4-millimeter lesion is going to be left with a 4-centimeter defect or larger.
FARAH KARIPINENI: So these are large defects, especially when you're talking about areas of the body where it's visible to the head and neck. And that's where the idea of those comes in. Not for a [INAUDIBLE] tumor, but for some of the smaller ones, which would still leave a defect that would be very visible. So margins are very important. Familiarize yourself with this table on the right in order to know what the definitive treatment would be for these.
FARAH KARIPINENI: Next slide.
ALFRED CHAHINE: Dr. Karipineni?
FARAH KARIPINENI: Yes?
ALFRED CHAHINE: Just a clarification. These sizes that you mentioned-- less than 1, 1 to 2, 2 to 4-- their size of the actual lesion or depth after biopsy?
FARAH KARIPINENI: Depth of the biopsy.
ALFRED CHAHINE: Depth of the biopsy?
FARAH KARIPINENI: Yes. Thank you. Next slide. So when we have to talk about in-transit and satellite mets-- so let's say we don't have just one tumor. Let's say we have an in-transit tumor or a satellite tumor. Well, we still resect those when possible. And the one possible comes in with the picture of how much of a defect is going to be left behind.
FARAH KARIPINENI: Is there anything in terms of additional information from the PET/CT or an MRI of the brain that's going to make resection impossible? So those have to be considered when you have in-transit or satellite mets. Because now, you're talking about a more involved tumor. Isolated limb perfusion is something we talk about with these tumors as well in order to be able to infuse chemotherapy, very specifically to the limb that has the multiple sites of tumor as well as systemic therapy, which can be in the form of chemotherapy, molecular agents, or immunotherapy.
FARAH KARIPINENI: Some of the newer drugs have molecular targets, for instance. Those are for CK or for BRAF. So it's important to know about those as well. And then, of course, definitive management for a subungual melanoma would be digit amputation. There's no way to achieve those margins that you're going to need while preserving the function of the digit.
FARAH KARIPINENI: And so digit amputation is generally what we recommend for those. Next slide. So again, we need to consider what the final defects will be. Not at the time of surgery, but prior to the time of surgery and not just with our plastic surgery colleagues who we call in order to do the case with, but with the patient.
FARAH KARIPINENI: So again, when we have a defect like this, it can leave considerable cosmetic or functional issue. And that needs to be dealt with. And the patient needs to be aware of what to expect. So there are lots of ways to close the final defect. Significant undermining is obviously the most common kind. Because it doesn't require anything additional to be done to the patient, which basically means undermining the underlying tissue in order to bring the skin edges together.
FARAH KARIPINENI: And that can be very, very useful, very effective for some of these smaller lesions. However, you do have to also be aware that skin grafts may be necessary for these patients as well as flaps. So they might need a rotational advancement or a free flap, which is where you may involve plastic surgery colleagues and until the patient is well, that they might need that additional procedure in order to close a larger defect.
FARAH KARIPINENI: Next slide. OK. So we've taken our melanoma out. We have discussed our indications for doing a sentinel lymph node biopsy. So let's get into what that sentinel lymph node biopsy actually entails. Next slide.
FARAH KARIPINENI: So the idea behind sentinel node biopsy for melanoma is quite simple. It aids in the detection of occult metastasis. So we discussed that during the patient's presentation, we're going to determine if there's clinically positive or negative nodes. So the sentinel node biopsy is for patients who have occult metastases, possibly. At the very least, we know they don't have clinically positive nodes.
FARAH KARIPINENI: They're clinically negative nodes. The objective is to localize. What are the first draining lymph nodes of this tumor? It can use radiotracer, or blue dye, or sometimes both. And it has been shown to be the strongest prognosticator for stage I to II disease. Next slide. So again, just to refresh your memories, the indications are going to be based on tumor thickness.
FARAH KARIPINENI: And that's because the thinner it is, the lower the risk. So less than 8 millimeters-- there is a 5% or less risk of you having the sentinel node be positive. So for those patients who don't have ulceration or don't have any other high-risk factors, you're unlikely to provide any benefit to the patient. However, for intermediate tumors greater than 1 millimeters, the risk jumps up to 17%.
FARAH KARIPINENI: So that's the idea behind doing a sentinel node biopsy for those patients and the ones who are 0.8 to 1 with ulceration, the high mitotic index, lymphovascular invasion. So those are the patient population that we should offer sentinel lymph node biopsy to. Next slide. So those are some of the key steps.
FARAH KARIPINENI: Many of you may have seen it before, at least for breast cancer. But some have not. Melanomas are not particularly common in certain centers. For instance, I didn't see a lot of it as a resident. And so this is just to familiarize yourself with the details. So, for instance, when you're on your boards talking about this, you may never have seen it.
FARAH KARIPINENI: Well, at least you have seen what it would look like in this lecture. So pre-operatively, injection of technetium-99 is done intradermally around the tumor site. They may have the patient change positions in order to distribute that throughout the area. And then lymphoscintigraphy is done. And you will receive an image that may look something like what is on this slide here.
FARAH KARIPINENI: In the left upper corner, you can see that's the lesion in question. And the dot in the right axilla is the draining lymph node. So you get a picture of something like that, which is what you would expect, that that would be the draining lymph node basin. But that's just the first step. Next slide. At the time of the surgery, we can also inject blue dye, which in the form of isosulfan blue or methylene blue.
FARAH KARIPINENI: So this is just a picture showing the injection site on the left. And then on the right, what you would see which is following the afferent lymphatic channels, which should have a bluish appearance-- following goes to the sentinel lymph nodes. So that increases the sensitivity. And then next slide. Here's what you do with the technetium that you injected.
FARAH KARIPINENI: You can use a gamma probe. So on the right upper corner, you see this blue thing. That's actually a gamma probe. And there's a display in the center of it, which shows a number. So it's used to detect the highest counts to localize the sentinel node. So that's an additional way that we can actually, numerically see which one of these is the draining node.
FARAH KARIPINENI: So obviously, the node with the highest count is the node that took up the most technetium. And that's the one that should be removed. And then additional nodes that have counts within at least 10% of the highest gamma count should also be removed. So once you're done taking out that biggest node or that highest count node, you also want to check around with the probe, as you see in this lower right-hand corner picture, to make sure that none of the other counts are high enough to need to be removed as well.
FARAH KARIPINENI: And so you're using this dual technique here in some cases. Some people just use the gamma probe. Some people just use the blue dye. Some people use both, but if you use both of those and you have a little bit higher sensitivity of locating that central node. Next slide. So once we have all that information, we've done our wide local excision.
FARAH KARIPINENI: We'd say it's a 1-millimeter depth tumor. And we've checked for our lymph nodes. This is a very basic cartoon here of just what the different stages are. So stage 0, going to stage I, II, III, and IV. So as long as you don't have any lymph node involvement, you're stage II or less. Once you have any spread to any lymph nodes, then you're stage III or greater.
FARAH KARIPINENI: And that staging, which we'll get into a little bit more detail a little bit later, will determine what the management will be going forward. Next slide. So in terms of post-operative follow-up, again, we want to do skin and nodal exams. So if it's stage IA to IIA disease-- and just to let you know about what that means-- up to 1 to 2 millimeters with ulceration or twice as large as that-- 2 to 4 millimeters with no ulceration.
FARAH KARIPINENI: And again, we're not talking about any nodal or distant mets here for IA or IIA disease. Those patients have 6 to 12 months skin and nodal exams. And that's repeated every 6 to 12 months for five years and thereafter annually. Next slide. For the more advanced patients, stage IIB to stage IV-- those are patients who have 2 to 4 millimeters with ulceration, or greater than 4 millimeters with no ulceration, or any nodal disease, or any distant mets.
FARAH KARIPINENI: Those patients need to be surveyed much more closely, so every three to six months. Skin and nodal exam for two years. And then it can be spaced out a little bit more, up to the discretion of the physician, up to 3 to 12 months-- skin and nose and for the following three years. And then after that first five-year period post-op, it can be annually.
FARAH KARIPINENI: And then consider imaging for these patients to look for recurrence or metastasis every 3 to 12 months, depending on the burden of nodal or metastatic disease. Next slide. So finally, we'll talk about lymphadenectomy. Now, this is a topic that's important to touch on, I think, because it's not as commonly performed. We'll go into one of the studies, which is a bit controversial, but which has shown one of the reasons why I think we don't do this as often anymore.
FARAH KARIPINENI: However, when we discuss melanomas and lymph node disease, what we do once the sentinel lymph node is positive, it's important to keep this in mind. Because it's something that you may not see, but need to be able to at least discuss and know. For instance, the anatomy, the indications, and all that. So we'll go into that in a little detail now. So for inguinal lymphadenectomy, what are the indications? So positive sentinel node biopsy, for instance.
FARAH KARIPINENI: So let's say you're in the operating room. What are we going to do with that positive sentinel node information? So first of all, in itself, that information is a great prognostic indicator. And in mFlt-1 trial, which is a little beyond what we're going to discuss in this lecture, but you can look it up, it was definitely shown to not only be important for prognostication.
FARAH KARIPINENI: But patients who had sentinel node biopsy had decreased rate of recurrence. It was associated with an improved 10-year melanoma-specific survival as well as 10-year distant disease survival. So that was established in that. So that's why we do the sentinel node biopsy. It's important. So when we have biopsy proven lymph nodes on that sentinel node, do we need to do an inguinal lymphadenectomy?
FARAH KARIPINENI: So in the past, we used to say, yes, we do. We do a superficial and deep lymphadenectomy for those patients. That's why we do it, right? So we'll put a pin in that, because that is one of the classic indications. And then it's important when we consider whether or not we're going to do an inguinal lymphadenectomy. Is there any distant disease?
FARAH KARIPINENI: So that requires PET/CT, MRI, brain at this point when we're talking about positive lymph nodes. Because we're going to go on to do an inguinal lymphadenectomy, we need to discuss whether that's worth doing or not. And that will be dependent on whether there's distant disease. So keep in mind when you have a patient who has positive adenopathy, PET/CT, MRI, brain-- those things are very important to ensure that we're not putting the patient through a procedure that's going to have morbidity with no associated benefit.
FARAH KARIPINENI: Next slide. So as I said, the indications for completion lymphadenectomy with positive sentinel node are controversial. This is in large part, because of the mFlt-2 trial. So this was a randomized controlled trial that was done which showed that completion node dissections do obviously improve local disease control. Because you're taking out that whole nodal packet.
FARAH KARIPINENI: And we'll go into the steps of that in just a minute. And they do aid in prognostication, as we can understand why that would be the case. But they did not lead to an increase in survival. An increase in morbidity was found, which led to lymphedema in a significantly larger amount of patients here, so 24% versus 6%. So in large part, because of this trial, it has somewhat fallen out of favor, become at least more controversial to do the completion lymphadenectomy after a sentinel node biopsy.
FARAH KARIPINENI: And more so, that information gained with a sentinel node biopsy can be used to guide what systemic therapy will be done, how the patient will be followed later on by the staging information that's gotten. Next slide. But as I said, it's still important to know about what a lymphadenectomy entails. First of all, for melanoma, it may be controversial. But it's still something you should know that may need to be done, depending on the patient and each individual patient's presentation.
FARAH KARIPINENI: Secondly, the inguinal lymph nodes and the removal of them is important for other tumor types as well. So it's important to know this. And this isn't something that we see a lot of. So at least you know what the steps are, what the anatomy is. So the inguinal nodes are divided into superficial and deep. And that's based on whether they lie superficial or deep to the fascia lata along the femoral vein.
FARAH KARIPINENI: The superficial nodes are more along the inguinal ligament and the saphenous vein, so inguinal ligament orienting horizontally in the saphenous vein or orienting vertically. And then the deep nodes are medial to the femoral vessels. In order to get to these, you can use either a longitudinal incision or a curvilinear incision. But you need to make sure when making that incision that you know, based on seeing this, you need to be above and below the inguinal ligament.
FARAH KARIPINENI: So you need access to both. Next slide. So basic principle is dissecting the nodal tissue off the external oblique, starting about 8 to 10 centimeters above the inguinal ligament. And then coming inferior to the inguinal ligament, in order to get to that deep compartment, you need to incise the fascia of the sartorius and the adductor. And that's how you get to those deep nodes.
FARAH KARIPINENI: And once you get into that space, you're going to see the femoral vessels-- skeletonize the femoral vessels and remove the lymph node bearing tissue in the femoral triangle, including Cloquet's node. And I put this here, because it's commonly asked-- Cloquet's node. So I'll show you some pictures of what that is, so you can visualize what we're talking about.
FARAH KARIPINENI: Next slide. So in this picture, you can see the sartorius. And you can see the adductor. So in between that area, you see a triangle formed by the inguinal ligament and those two muscles-- the sartorius and the adductor. So within that area are the femoral vessels. I talked about skeletonizing and the lymph node package that lies in that area.
FARAH KARIPINENI: So we are cleaning out all of that tissue in that area. Next slide. And this is just to show you the lymph node of Cloquet, so you can visualize that. So where you see that lymph node packet, that lymph node of Cloquet is the node that we discussed as one of the first draining lymph nodes in that area. So that's its claim to fame.
FARAH KARIPINENI: And with that, I'm done with the topics that we were going to discuss today. And I can take any questions and thank you very much.
ALFRED CHAHINE: Thank you so much, Dr. Karipineni. This was a very nice review. This would be the first out of four [INAUDIBLE] dedicated to soft tissue neoplasms. And that was a very nice introduction to the topic. We have a question on the Chat from Dr. Joshi. But can you talk about lymph leaks at the node dissections? Very good question.
FARAH KARIPINENI: Absolutely. So lymphatic leaks can happen for a number of reasons. The most common reason is failure of a device that's used to feel the lymphatics. If you're using a harmonic scalpel or anything similar to that instead of tying off lymphatics, or a clip falls off, or a tie is not tight enough, or the patient has had radiation in the past, the tissue is compromised in some fashion, then a leak can form in that area.
FARAH KARIPINENI: And it can be quite difficult to treat. It depends on the area, so whether it's in the neck, the axilla, or the groin. It also depends on when it presents. So, for instance, if it presents later in the course after surgery, for instance, about 5 to 10 days after surgery, it can be very difficult to go back in and find where the leak is. Draining the lymph tissue and waiting for it to seal off, you might be able to get away with that.
FARAH KARIPINENI: But sometimes you're forced to go back into surgery. If forced to go back into surgery, I think the best course of action is obviously to find which one of these drained lymphatics is the leaking one. In order to do that, it's helpful to use dye. So at the time of surgery, if you have to go back into surgery, I would have methylene blue given to the patient.
FARAH KARIPINENI: And then I would wait and try and see where the draining lymphatic is, that is leaking. And look for blue to come out of that area. And if I'm lucky enough to be able to find it, then, of course, you can easily manage it by tying it off if you have a lymphatic that you can localize that way.
ALFRED CHAHINE: Great. There's another question-- your opinion. Hold on. It's moving quickly. Your opinion on resection of soft tissue tumors. Do you close down the dead space? Or do we even need to to do that?
FARAH KARIPINENI: Yeah, so that's really important. So especially, again, we talked about undermining as well. When you undermine the tissue, you increase the risk. You already have an empty space. And now, you're going to increase the risk of having a seroma. And so it's important to close down the dead space for a number of reasons. But technically, that is one of the problems with managing these patients is that they can get seromas.
FARAH KARIPINENI: And they can be difficult to manage. And so closing down the dead space, closing in multiple layers is really important. Some of these patients are going to go on to have radiation or chemotherapy. Their tissue is going to be weaker. So you're going to have a higher risk of having issues like that. So closing multiple layers is really important.
FARAH KARIPINENI: Sometimes cauterizing the edges before you close is important as well. Because that can make the tissue less susceptible to forming seroma. And then pressure dressings are important as well. So if you have a large defect, having the patient use a compression bandage can be very helpful. That requires compliance. So you may [INAUDIBLE].
FARAH KARIPINENI: But they have to continue that for the next couple weeks or several weeks sometimes. Sometimes using negative pressure therapy is useful as well in order to prevent a seroma from forming and keep that dead space closed. So consider those, depending on the size of the tumor.
ALFRED CHAHINE: Thanks a lot. I don't see any other questions. And so I really want to thank you for taking the time, Dr. Karipineni.
FARAH KARIPINENI: Of course.
ALFRED CHAHINE: And for the audience, don't forget to scan the QR code if your residency requires proof of attendance. And with that, we will call it a day. And we'll see you next week. Thank you so much.
FARAH KARIPINENI: Thank you.
Segment:0 .
ALFRED CHAHINE: OK, it's 2 o'clock Eastern Standard Time. Let's get started. Good afternoon, everyone and welcome to SCORE school. My name is Alfred Chahine. I'm the assistant editor of SCORE. And I'll be your moderator today. Some housekeeping items before we start today's session-- you will see a QR code for attendance tracking displayed a few times throughout the presentation. You only need to submit it once.
ALFRED CHAHINE: And you'll receive an email confirming your attendance. For today's SCORE school, the topic is Soft Tissue Neoplasms, 1 out of 4. The modules we're discussing today are non-melanoma skin cancers, melanoma nevi, melanoma wide excision, sentinel lymph node biopsies for melanoma, ilioinguinal and femoral lymphadenectomies. It is now my pleasure to introduce our faculty presenter for the day, Dr. Farah Karipineni.
ALFRED CHAHINE: Dr. Karipineni is an assistant clinical professor at UCSF Fresno. After completing an undergraduate degree at UC Berkeley, she earned her medical degree from the University of California, Irvine, School of Medicine. She also completed an MPH at USC. Her residency in general surgery was completed at Albert Einstein Medical Center in Philadelphia.
ALFRED CHAHINE: And she completed a fellowship in endocrine surgery at Johns Hopkins School of Medicine. She is passionate about culturally sensitive care. She has been involved in global health initiatives, including the Malek Medical Clinic which serves displaced Sudanese families and the Educate Refugees Program, which provides refugees with scholarships for higher education in health care fields.
ALFRED CHAHINE: Dr. Karipineni has been published in journals, including The American Surgeon, the International Journal of Surgery, and the Journal of Surgical Education. Her hobbies include tennis, traveling, and colonial and post-colonial literature. Thank you, Dr. Karipineni, for lending your expertise to us and take it away, please.
FARAH KARIPINENI: Absolutely. Thank you so much for that introduction. Thank you to you as well, Dr. Joshi, and the entire SCORE team for allowing me to participate.
ALFRED CHAHINE: Sure.
FARAH KARIPINENI: I'm very excited to introduce this topic of soft tissue neoplasms. Next slide. First, we'll go into the anatomy and physical exam of the skin.
ALFRED CHAHINE: Sorry. Yes, there you go.
FARAH KARIPINENI: And then we'll go into some non-melanoma skin cancers. We'll continue talking about melanomas and their precursors and then how we treat melanomas. Next slide. Just as a refresher for the anatomy of the skin, it's comprised of the dermal and epidermal layers. So when we talk about where these cancers arise from, it'll be important to come back to this refresher here. We see the epidermis is the top layer.
FARAH KARIPINENI: The dermis is the bottom layer. You can also see from this picture where different cells live, so the melanocytes being a little bit deeper down in the epidermis. Also in the skin is, of course, sweat glands, hair follicles, sebaceous glands, and also our apocrine and eccrine glands. Next slide. So very important when we do a focused exam of the skin. As surgeons, there are certain things that we should think about when we see patients for skin lesions that may not be apparent when we do our regular physical exam for a hernia or any other pathology.
FARAH KARIPINENI: So we want to start with our history, of course. The history of the lesion. We want to know if there has been any prior trauma to that area. Have they had any procedures done there? We want to know about the evolution of the lesion as well. So how was this a year ago? How was it two years ago?
FARAH KARIPINENI: Has it been there since birth? Any associated symptoms which generally provide us in pain are important to ask about as well. Because that can lead us to think about what type of lesion it might be. Also, we want to know about relevant exposures. Has the patient had any radiation exposure? Arsenic is a known exposure. Is the patient a smoker?
FARAH KARIPINENI: The past medical history is, of course, very important, any previous cancers the patient has had, if the patient is immunosuppressed for any reason, and also if there's a relevant family history of certain types of skin cancers. Next slide. So once we've gotten a good history, we want to move on to the physical exam. So, of course, we want to look at the lesion itself.
FARAH KARIPINENI: But you always want to look at the surrounding skin, too. What does the rest of the skin look like? Is this in a background of normal skin? Are there multiple lesions? And then when it comes to the lesion itself, the presence or absence of ulceration is very important to note, whether the lesion is fixed or mobile. It might be a flat lesion, so it might not make sense to consider whether it's fixed or mobile.
FARAH KARIPINENI: But if it's a raised lesion or an exophytic lesion, then you want to know if some of it is going down under the skin. How much of that is mobile or fixed? And then, of course, you can't forget during your physical exam to check the lymph node basins. So this depends on where the lesion is, whether you're concerned about neck, actually, or growing adenopathy.
FARAH KARIPINENI: But generally, it's a good idea to check all the lymph node basins, especially when there is a concern that this lesion could be cancer. Next slide. So now, we'll move on to some of the non-melanoma skin cancers. So this is important to go over. Because these can be surgical diseases, but we don't see them as often as, say, dermatologists or primary care physicians.
FARAH KARIPINENI: But it's very important to be able to see these lesions, know what they are, be aware of them. And so we'll go over the most common sub-types. Next slide. First, in the non-melanoma category is basal cell carcinoma. So this is the most common sub-type. It forms in the innermost layer of the epidermis. And then there's squamous cell carcinoma, second most common, by far less common than basal cell carcinoma.
FARAH KARIPINENI: These also arise in the layer of the epidermis, but from the squamous cell. So these are keratin-producing cells. One of the precursors to squamous cell carcinoma that we know of is actinic keratosis. That's something that is commonly asked. It's common questions that arise, is, what is a precursor for squamous cell carcinoma? And this is a picture of actinic keratosis that you can see on this slide here, which shows there's heaped up edges of-- or heaped up keratin here, but not quite the suspicious features that we'll go over that are present in the squamous cell carcinoma lesion.
FARAH KARIPINENI: Next slide. So these two are a lot less common, but still worth knowing about. Dermatofibrosarcoma protuberans is a cutaneous soft tissue sarcoma. So these are lumps and bumps that patients may present with that are unusual diagnoses, but worth knowing about when you see these patients in the office who present with something that-- somebody might call it a lipoma or just a mass.
FARAH KARIPINENI: And you go and excise it. But you need to be cognizant that it could end up being something like a dermatofibrosarcoma. Now, these arise from the fibroblasts within the dermis, so that deeper layer than we're talking about with squamous and basal cell cancer. And lastly, there's Merkel cell carcinoma. So these arise from neuroendocrine cells in the epidermis.
FARAH KARIPINENI: And we'll talk a little bit more about each one of these in detail. Next slide. As far as these non-melanoma skin cancers, the lifetime risk is high. So Americans have about a 20% lifetime risk of these skin cancers, so very relevant to our knowledge base when we take care of patients. Basal cell carcinoma-- 80% of them are going to be a basal cell tumor when you see these patients.
FARAH KARIPINENI: And you have to ask about certain risk factors. So we discussed some of those earlier. UV exposure-- of course, that is very important. So patients who use tanning beds, who are out in the sun over a long period of time, those who are of older age, who have fair skin, of course. Smokers, immunosuppression, certain exposure, as we talked about. Arsenic, also.
FARAH KARIPINENI: Hydrocarbons have been shown to increase risk. Next is squamous cell carcinoma, similar risk factors to basal cell carcinoma. But also, you have to remember HPV infection can lead to squamous cell cancers. Similarly, Merkel cell carcinoma has a history of immunosuppression as a risk factor, so leukemia and lymphoma specifically. And then Merkel cell polyomavirus.
FARAH KARIPINENI: It's important to keep that in the back of your head. That can also be a risk factor. So not everybody who tests positive for Merkel cell polyomavirus is going to end up with Merkel cell carcinoma, but it can be a risk factor. Next slide. So these are just going to be some pictures of the classic presentation, so you've seen what each of these lesions can look like.
FARAH KARIPINENI: And so you remember the buzzwords of what you're looking for and also the way that it looks. So squamous cell carcinoma is generally a scaly and erythematous lesion, usually going to be in sun damaged areas, so areas that are exposed. An ulceration is pretty common with these as well as raised edges. So if you look closely at this lesion, you can see that around the borders of the main part of the lesion, there is some raised edges there.
FARAH KARIPINENI: It looks like a little crater in the middle. Next slide. With basal cell carcinoma, these are also generally raised, but not quite so much as squamous cell carcinoma. They're well circumscribed. And they have more of a waxy appearance. And you can see from the picture there with rolled pearlescent edges.
FARAH KARIPINENI: So those are buzzwords again for-- if this is being described to you, then you generally will think of, OK, pearlescent, waxy-- basal cell carcinoma. And it also has a more variable presentation or appearance so that you can have a more nodular presentation. Some of them can appear cystic or superficial, so just keep that in mind. Next slide.
FARAH KARIPINENI: So now, under more rare tumors. To just say you've seen what this looks like, this is dermatofibrosarcoma protuberans, two different pictures. You can see this is a seemingly much, much more aggressive type of lesion. It's larger and more raised. And that's what it looks like. So if someone comes to you with something like this, you're going to immediately have to start thinking about this possibly being a cancer margin.
FARAH KARIPINENI: This is not something that you just excised to negative margins. It requires more thought than that. Next slide. And here's a Merkel cell carcinoma. So this is a firm bump within the skin. It has a little bit more of a well-circumscribed appearance-- reddish, purplish hue. And it is known to grow more rapidly and also can metastasize.
FARAH KARIPINENI: Next slide. So let's go on to how we diagnoses these lesions. There's lots of different ways. And It depends a lot on what your suspicion is and how large the lesion is. As surgeons, we have in our toolbox more things than other physicians who see these lesions do. And so we should use each of those appropriately, depending on what we think we're dealing with.
FARAH KARIPINENI: So, of course, punch biopsy is one of the most common ways of doing this. So punch biopsy is done with a small punch biopsy kit, which takes a full thickness piece of the mass that you're worried about. The importance of that is you see the depth of the lesion. And you can get a better diagnosis that way, versus commonly, we compare that to a shaved lesion where they shave a little piece off the top of something, which is harder to diagnose and also harder to get an idea of how deep the lesion goes into the skin.
FARAH KARIPINENI: Excisional biopsy is another commonly used technique. So this is for lesions that are not quite large enough that you are worried about having to close it later. You think you can get the whole thing out with negative margin. And you may even cure the patient in addition to diagnosing what this lesion is. So that's a good candidate for an excisional biopsy. It's really important when you do these to maintain the orientation of the specimen, which it sounds obvious.
FARAH KARIPINENI: But when you actually are doing the procedure, it's important to remember that you need to know exactly how you took this piece out so that if you need to go back for additional margins, you know exactly where you need to get what specific additional margin. So you don't want any confusion between yourself and the pathologist as well. So that's maintaining orientation of the specimen, perhaps even putting clips in or something to mark the cavity for when you return.
FARAH KARIPINENI: So again, that's for a possible re-excision if you need additional margins. And it's always advisable to think that you may need to come back. And I tell my patients, even for a simple lipoma. Because you may be surprised. These are rare lesions. But if you do enough of them, you may come across these things at some point.
FARAH KARIPINENI: And it's important to be able to have in the back of your mind that if I do an excisional biopsy, I may need to come back for reorientation. It doesn't mean that every simple lipoma should need to have orientation. But if you have suspicion, then make sure you do that. Because you could possibly be coming back. And you want to make sure that you get good margins based on [INAUDIBLE].
ALFRED CHAHINE: May I ask a question?
FARAH KARIPINENI: Yes.
ALFRED CHAHINE: So with that in mind, what's the best approach for incisions, let's say, on the extremities for, say, a 1-centimeter skin lesion on the extremity? How should folks approach that?
FARAH KARIPINENI: So from a specimen orientation standpoint, it's best to orient it longitudinally. So longitudinal is best if you have some suspicion that you're dealing with a skin cancer.
ALFRED CHAHINE: Thank you.
FARAH KARIPINENI: So if you're not worried about that, then going along the skin lines and doing what might be more cosmetic is OK. But if you have any concern that it's for cancer, I would do a longitudinal.
ALFRED CHAHINE: Thank you.
FARAH KARIPINENI: Absolutely. So going down our list here, so what if it's not possible to get an excisional biopsy? What if it's a large tumor and you really have a suspicion that you're going to have to do more for this patient than just do an excisional biopsy with negative margins or with a 1 or 2-centimeter margin? Well, that's a good case for doing core needle biopsy or an incisional biopsy.
FARAH KARIPINENI: Obviously, for a core needle biopsy, the benefit for the patient is that they don't need to go to surgery. This can be done minimally, invasively with a core needle biopsy kit. Incisional biopsy-- obviously, it does require surgery. And then you have to manage the closure of your incision with thought to how you're going to proceed later on.
FARAH KARIPINENI: This is best for, again, larger or deeper tumors. And when you do this, you're obviously going to either come back again to do incisional biopsy with negative margins, with whatever margins are needed for definitive treatment. Or sometimes after this, you're going on to chemoradiation first, and see if there's a response, and then go to surgery. So these are much more complex.
FARAH KARIPINENI: Sometimes patient needs PET/CTs as well. Because you're worried about this being larger and possible metastasis, depending on what type of skin tumor it is. Maybe it's a melanoma. Maybe it's a Merkel cell cancer or a dermatofibrosarcoma. And then you have to think about a lot more issues with the wound. Next slide.
FARAH KARIPINENI: So other things in terms of diagnosis-- we don't-- seen those a lot as general surgeons. But it's important to be cognizant that if you have a patient who has a head and neck tumor, and it's in a very visible area, and you're trying to avoid a large tissue defect, then consider that. And even though we may not be-- some of us may know what Mohs is and be able to do it, and have the setup in our office.
FARAH KARIPINENI: Some of us don't. But it's important to be able to know when to refer a patient from those who is low-risk basal cell cancer or squamous cell carcinoma and in an area where a cosmetic outcome is going to be particularly important. Usually, those are inferior to an excisional biopsy. So it's important to be able to counsel patients on what the pluses and minuses are.
FARAH KARIPINENI: But it's an important tool in our toolbox. And for the specific low-risk cancers, it can be very helpful to a patient's quality of life if safe. So I mentioned shave biopsy earlier, usually not ideal, inadequate, never going to be the right answer and then additional considerations as well, as far as PET/CT. These are typically not going to be for your basal cell carcinoma or squamous cell carcinoma, but for dermatofibrosarcoma or Merkel cell.
FARAH KARIPINENI: Those are faster growing. And it has a higher risk of mets, so it's important to think about that. A patient comes and says, I have a lump. OK. Well, if it looks like one of those things in the picture, it may be tempting to just take it out and orient the specimen. But you always have to think with those specific sub-types. There could be something more going on here.
FARAH KARIPINENI: And that would only come to light if you do additional imaging. Next slide. OK. So surgical management of these patients has to do with margins. So depending on what the pathology is based on, the biopsy or the suspicion, the margins are everything with regard to the details of the surgery.
FARAH KARIPINENI: So with basal cell cancer, squamous cell cancer, the margins are obviously going to be smaller. Because these are less aggressive tumors, so 4 to 10 millimeters. Dermatofibrosarcoma is going to have a larger margin, so 2 to 4 centimeters. So if you get your 4-centimeter margin, that's going to be a very large defect. So again, thinking about what type of biopsy we're going to do.
FARAH KARIPINENI: How we're going to close those defects is really important. For cutaneous adnexal tumors, a little bit smaller, so 1 to 2 centimeters. But only if those are malignant. If they're not malignant, then the negative margin is enough. And for Merkel cell carcinoma, it's the same as above for cutaneous tumors. It's 1 to 2 centimeters. And then always think about a sentinel node biopsy, because these are fast growing and metastasized as well.
FARAH KARIPINENI: So think about that for sentinel node for Merkel cell. Next slide. And then, of course, post-operatively, we have to manage these patients. So this can be done either by the dermatologist or by the surgeon, depending on how involved the tumor was. So sometimes for a smaller squamous cell carcinoma that was just a little bigger than what the dermatologist or the dermatologic person who did the procedure to do the diagnosis, just a little bigger than what they are comfortable dealing with.
FARAH KARIPINENI: Sometimes they send you to the general surgeon. And then you can send the patient back to do regular skin examinations, because these patients need a head-to-toe exam to make sure. Because every year or two years, they can get new lesions. Or you can decide that you want to be the one managing that. But it's important to make sure patients know that they need regular skin examinations. These generally can be done on a yearly basis, but it depends on what the tumor type is.
FARAH KARIPINENI: And then patients should also know how to self-exam. So in between those yearly visits, something may come up. So patients need to be educated on, what do these lesions look like, based on what pathology they just had removed, what they're at risk for, what looks abnormal? Also need to be told about sun protection. So these patients really need to avoid UV rays, avoid other exposures that can cause them to be at risk such as smoking.
FARAH KARIPINENI: And then, again, they may need follow-up PET/CTs, depending on whether they were systemic disease and what the typical tumor type was. Next slide. OK, so we've talked about non-melanoma skin cancers at this point. So now, we're going to move on to melanoma. And the rest of what we talk about will be relevant for melanoma.
FARAH KARIPINENI: Next slide. Melanomas arise from the melanin-producing, neural crest-derived cells in the epidermis. So the melanin-producing cells, the melanocytes. Next slide. They come in several different sub-types. So we're not going to go into what each specific sub-type is in detail in this lecture, but it's important that you know that these exist and to familiarize yourself with them.
FARAH KARIPINENI: So superficial spreading is the most common one. It's more flat, like the name suggests. And it typically arises from a nevus. We'll talk about nevi shortly as well. There's a nodular sub-type-- acral lentiginous, which is the palms, and soles, and nail beds one, lentigo maligna, and mucosal, which has the poorest prognosis. And then, of course, desmoplastic.
FARAH KARIPINENI: Desmoplastic is very low incidence and also the more benign sub-type. Next slide. So nevi are basically what we consider to be moles. They can be congenital. They can appear over your lifetime and be something you're not born with. But these are pigmented lesions like the picture shows here.
FARAH KARIPINENI: They can be associated with an increased risk of melanoma at larger size. So what is a large size? Well, a 20-centimeter congenital nevis, specifically, can carry anywhere from a 5 to a 20% risk of melanoma. So the larger the nevis, the more we care about it, the more we pay attention to it. So it's important to keep that in the back of your mind, depending on the size of the nevis.
FARAH KARIPINENI: Your patient may ask you about a certain lesion. And you need to be able to determine what the risk is, whether it can be watched, whether it should be removed, and really know how to counsel patients, depending on what the size is, what the risk is of developing a melanoma, especially because these are congenital lesions that were mostly congenital, what we're talking about. So over a lifetime, this could be a significant risk, especially if it's a growing nevis.
FARAH KARIPINENI: Next slide. So like I said before, nevi can predispose to melanoma. This happens to a pathway, whereby at some point, it becomes a dysplastic nevis. So in contrast to the picture I showed you in the last slide, you see here. This is a different beast. This is larger. It's a bit more raised in an irregular fashion.
FARAH KARIPINENI: It also has irregular borders. And the color is very uneven. As opposed to a nice, smooth, brown lesion, this is now ranging from pink to dark brown with an uneven color. This is more concerning. And again, you wouldn't know whether this was always like this or whether it transformed from the previous picture, unless you ask that.
FARAH KARIPINENI: So it's important to elicit a history of the pathophysiology of the news or whatever the patient is clinically experiencing in order to be able to tell that this is a lesion that's on the go. It's on the move to possibly becoming melanoma. Next slide. So when we do our physical exam-- and we went through some of the important parts of the physical exam for the skin.
FARAH KARIPINENI: Important to talk about the A, B, C, D of the physical exam for melanoma. So on the left-hand side here, you see what are benign features of a skin lesion, so symmetry, even borders, a single color, smaller than 6 millimeters. And at the bottom, you see what look like a nevus, just an ordinary mole. Now, on the right side, you see the A, B, C, D is the asymmetry.
FARAH KARIPINENI: The borders are no longer even. There's different colors ranging from pink to dark brown, like we talked about. The diameter is larger than 6 millimeters. And the evolution-- so that's partly you asking about the history. So any change in the above characteristics is concerning, that you want these to remain the same. And if they don't, you are concerned.
FARAH KARIPINENI: Next slide. So also, a physical exam. We discussed the lymph node exam is very important for melanoma. So melanoma-- you have to look for lymph node basins. And what you're looking for is any node that appears fixed, or matted, or enlarged and the lymph node basins near the initial tumor. But you should really examine others as well. And in that same vein, you should look for other skin lesions, too.
FARAH KARIPINENI: So this isn't a common vocabulary that we have to be aware of when we talk about melanoma, is something called in-transit metastasis and satellite metastasis. So in-transit metastasis is located still within the regional lymphatic. So it's still within the same region, but more than two centimeters away from the primary tumor. And a satellite metastasis is conversely located within 2 centimeters of the primary tumor.
FARAH KARIPINENI: So the satellite mets is closer to the primary tumor. In-transit mets is further away, but still within the same draining lymphatic region. So these are things that you should be looking for very intentionally when a patient comes to you with a biopsy proven melanoma, or with a mole, or a lesion, concerning for melanoma. We need to look intentionally for those. And when we see them, we should measure the distance between what we think is the initial tumor and that in order to know, whether it's satellite mets or in-transit mets Next slide.
FARAH KARIPINENI: So again, once we have this lesion we're concerned about being a melanoma, we need to do a biopsy. And again, it's important to discuss a different option-- punch biopsy, or excisional biopsy, or specimen orientation, or incisional biopsy. Next slide. So as far as the lymph node evaluation, we discussed whether we have clinically positive nodes.
FARAH KARIPINENI: That can be determined at the time of seeing the patient in the office. So clinically suspicious nodes are, as we said, those hard nodes, matted, fixed, or enlarged nodes. So those should undergo percutaneous biopsy. So we can't assume anything about these nodes. For instance, if you have melanoma of the head and neck and you have a clinically suspicious node, you can't assume that that's related to the melanoma.
FARAH KARIPINENI: You should do a percutaneous biopsy. There's a lot of things in the head and neck that can cause a cancer. Let's say the patient is a smoker. Just because the patient has a melanoma does not mean that that node could not be, for instance, a squamous cell carcinoma or a papillary thyroid carcinoma with the mets. So a percutaneous biopsy is very important to secure the diagnosis.
FARAH KARIPINENI: If you have clinically negative nodes, on the other hand, then we can talk about doing sentinel lymph node biopsy. There's very specific indications. So at the time of excision of the melanoma, consider sentinel lymph node biopsy for a thickness greater than 1 millimeter in general. However, high-risk patients with a thickness under 1 millimeter-- for instance, we talk about a smaller 0.8 millimeter thickness, but with ulceration.
FARAH KARIPINENI: That should be considered as well for a sentinel node biopsy. It's not unreasonable at all. Because the ulceration confers a greater risk of melanoma. You'll see it's even part of the staging system. So that will be a discussion with the patient. So a patient with a smaller lesion-- it should definitely be given as an option to do a sentinel node biopsy if there is ulceration and something that is less than 1 millimeter, but approaching 1 millimeter.
FARAH KARIPINENI: These are important discussions to have with the patient. Next slide. So moving on to the melanoma wide excision, we'll talk about some of the details related to a definitive surgical management of the melanoma itself. Next slide. Again, we need to talk about margins. So margins are extremely important with skin cancers.
FARAH KARIPINENI: And they're very specific for melanoma. So before, we talked about different margins for different tumors. But this is the same tumor as melanoma. Depending on the depth of it, we have a different excision margin. So in general, wide local excision with margins is what we do for melanoma with or without the sentinel node biopsy.
FARAH KARIPINENI: And the size of the melanoma dictates the excision margin, as you can see in this table here on the right. So a melanoma [INAUDIBLE] is 5 millimeters. Less than 1 millimeter-- you get a 1-centimeter margin. And then here with a 1 to 4 millimeter lesions, 1 to 2-centimeter margins needed. Greater than 4 millimeters-- you need a 2-centimeter margin. So you can think 4 millimeters is not very large. You can see that somebody with a melanoma on their face who has a 4-millimeter lesion is going to be left with a 4-centimeter defect or larger.
FARAH KARIPINENI: So these are large defects, especially when you're talking about areas of the body where it's visible to the head and neck. And that's where the idea of those comes in. Not for a [INAUDIBLE] tumor, but for some of the smaller ones, which would still leave a defect that would be very visible. So margins are very important. Familiarize yourself with this table on the right in order to know what the definitive treatment would be for these.
FARAH KARIPINENI: Next slide.
ALFRED CHAHINE: Dr. Karipineni?
FARAH KARIPINENI: Yes?
ALFRED CHAHINE: Just a clarification. These sizes that you mentioned-- less than 1, 1 to 2, 2 to 4-- their size of the actual lesion or depth after biopsy?
FARAH KARIPINENI: Depth of the biopsy.
ALFRED CHAHINE: Depth of the biopsy?
FARAH KARIPINENI: Yes. Thank you. Next slide. So when we have to talk about in-transit and satellite mets-- so let's say we don't have just one tumor. Let's say we have an in-transit tumor or a satellite tumor. Well, we still resect those when possible. And the one possible comes in with the picture of how much of a defect is going to be left behind.
FARAH KARIPINENI: Is there anything in terms of additional information from the PET/CT or an MRI of the brain that's going to make resection impossible? So those have to be considered when you have in-transit or satellite mets. Because now, you're talking about a more involved tumor. Isolated limb perfusion is something we talk about with these tumors as well in order to be able to infuse chemotherapy, very specifically to the limb that has the multiple sites of tumor as well as systemic therapy, which can be in the form of chemotherapy, molecular agents, or immunotherapy.
FARAH KARIPINENI: Some of the newer drugs have molecular targets, for instance. Those are for CK or for BRAF. So it's important to know about those as well. And then, of course, definitive management for a subungual melanoma would be digit amputation. There's no way to achieve those margins that you're going to need while preserving the function of the digit.
FARAH KARIPINENI: And so digit amputation is generally what we recommend for those. Next slide. So again, we need to consider what the final defects will be. Not at the time of surgery, but prior to the time of surgery and not just with our plastic surgery colleagues who we call in order to do the case with, but with the patient.
FARAH KARIPINENI: So again, when we have a defect like this, it can leave considerable cosmetic or functional issue. And that needs to be dealt with. And the patient needs to be aware of what to expect. So there are lots of ways to close the final defect. Significant undermining is obviously the most common kind. Because it doesn't require anything additional to be done to the patient, which basically means undermining the underlying tissue in order to bring the skin edges together.
FARAH KARIPINENI: And that can be very, very useful, very effective for some of these smaller lesions. However, you do have to also be aware that skin grafts may be necessary for these patients as well as flaps. So they might need a rotational advancement or a free flap, which is where you may involve plastic surgery colleagues and until the patient is well, that they might need that additional procedure in order to close a larger defect.
FARAH KARIPINENI: Next slide. OK. So we've taken our melanoma out. We have discussed our indications for doing a sentinel lymph node biopsy. So let's get into what that sentinel lymph node biopsy actually entails. Next slide.
FARAH KARIPINENI: So the idea behind sentinel node biopsy for melanoma is quite simple. It aids in the detection of occult metastasis. So we discussed that during the patient's presentation, we're going to determine if there's clinically positive or negative nodes. So the sentinel node biopsy is for patients who have occult metastases, possibly. At the very least, we know they don't have clinically positive nodes.
FARAH KARIPINENI: They're clinically negative nodes. The objective is to localize. What are the first draining lymph nodes of this tumor? It can use radiotracer, or blue dye, or sometimes both. And it has been shown to be the strongest prognosticator for stage I to II disease. Next slide. So again, just to refresh your memories, the indications are going to be based on tumor thickness.
FARAH KARIPINENI: And that's because the thinner it is, the lower the risk. So less than 8 millimeters-- there is a 5% or less risk of you having the sentinel node be positive. So for those patients who don't have ulceration or don't have any other high-risk factors, you're unlikely to provide any benefit to the patient. However, for intermediate tumors greater than 1 millimeters, the risk jumps up to 17%.
FARAH KARIPINENI: So that's the idea behind doing a sentinel node biopsy for those patients and the ones who are 0.8 to 1 with ulceration, the high mitotic index, lymphovascular invasion. So those are the patient population that we should offer sentinel lymph node biopsy to. Next slide. So those are some of the key steps.
FARAH KARIPINENI: Many of you may have seen it before, at least for breast cancer. But some have not. Melanomas are not particularly common in certain centers. For instance, I didn't see a lot of it as a resident. And so this is just to familiarize yourself with the details. So, for instance, when you're on your boards talking about this, you may never have seen it.
FARAH KARIPINENI: Well, at least you have seen what it would look like in this lecture. So pre-operatively, injection of technetium-99 is done intradermally around the tumor site. They may have the patient change positions in order to distribute that throughout the area. And then lymphoscintigraphy is done. And you will receive an image that may look something like what is on this slide here.
FARAH KARIPINENI: In the left upper corner, you can see that's the lesion in question. And the dot in the right axilla is the draining lymph node. So you get a picture of something like that, which is what you would expect, that that would be the draining lymph node basin. But that's just the first step. Next slide. At the time of the surgery, we can also inject blue dye, which in the form of isosulfan blue or methylene blue.
FARAH KARIPINENI: So this is just a picture showing the injection site on the left. And then on the right, what you would see which is following the afferent lymphatic channels, which should have a bluish appearance-- following goes to the sentinel lymph nodes. So that increases the sensitivity. And then next slide. Here's what you do with the technetium that you injected.
FARAH KARIPINENI: You can use a gamma probe. So on the right upper corner, you see this blue thing. That's actually a gamma probe. And there's a display in the center of it, which shows a number. So it's used to detect the highest counts to localize the sentinel node. So that's an additional way that we can actually, numerically see which one of these is the draining node.
FARAH KARIPINENI: So obviously, the node with the highest count is the node that took up the most technetium. And that's the one that should be removed. And then additional nodes that have counts within at least 10% of the highest gamma count should also be removed. So once you're done taking out that biggest node or that highest count node, you also want to check around with the probe, as you see in this lower right-hand corner picture, to make sure that none of the other counts are high enough to need to be removed as well.
FARAH KARIPINENI: And so you're using this dual technique here in some cases. Some people just use the gamma probe. Some people just use the blue dye. Some people use both, but if you use both of those and you have a little bit higher sensitivity of locating that central node. Next slide. So once we have all that information, we've done our wide local excision.
FARAH KARIPINENI: We'd say it's a 1-millimeter depth tumor. And we've checked for our lymph nodes. This is a very basic cartoon here of just what the different stages are. So stage 0, going to stage I, II, III, and IV. So as long as you don't have any lymph node involvement, you're stage II or less. Once you have any spread to any lymph nodes, then you're stage III or greater.
FARAH KARIPINENI: And that staging, which we'll get into a little bit more detail a little bit later, will determine what the management will be going forward. Next slide. So in terms of post-operative follow-up, again, we want to do skin and nodal exams. So if it's stage IA to IIA disease-- and just to let you know about what that means-- up to 1 to 2 millimeters with ulceration or twice as large as that-- 2 to 4 millimeters with no ulceration.
FARAH KARIPINENI: And again, we're not talking about any nodal or distant mets here for IA or IIA disease. Those patients have 6 to 12 months skin and nodal exams. And that's repeated every 6 to 12 months for five years and thereafter annually. Next slide. For the more advanced patients, stage IIB to stage IV-- those are patients who have 2 to 4 millimeters with ulceration, or greater than 4 millimeters with no ulceration, or any nodal disease, or any distant mets.
FARAH KARIPINENI: Those patients need to be surveyed much more closely, so every three to six months. Skin and nodal exam for two years. And then it can be spaced out a little bit more, up to the discretion of the physician, up to 3 to 12 months-- skin and nose and for the following three years. And then after that first five-year period post-op, it can be annually.
FARAH KARIPINENI: And then consider imaging for these patients to look for recurrence or metastasis every 3 to 12 months, depending on the burden of nodal or metastatic disease. Next slide. So finally, we'll talk about lymphadenectomy. Now, this is a topic that's important to touch on, I think, because it's not as commonly performed. We'll go into one of the studies, which is a bit controversial, but which has shown one of the reasons why I think we don't do this as often anymore.
FARAH KARIPINENI: However, when we discuss melanomas and lymph node disease, what we do once the sentinel lymph node is positive, it's important to keep this in mind. Because it's something that you may not see, but need to be able to at least discuss and know. For instance, the anatomy, the indications, and all that. So we'll go into that in a little detail now. So for inguinal lymphadenectomy, what are the indications? So positive sentinel node biopsy, for instance.
FARAH KARIPINENI: So let's say you're in the operating room. What are we going to do with that positive sentinel node information? So first of all, in itself, that information is a great prognostic indicator. And in mFlt-1 trial, which is a little beyond what we're going to discuss in this lecture, but you can look it up, it was definitely shown to not only be important for prognostication.
FARAH KARIPINENI: But patients who had sentinel node biopsy had decreased rate of recurrence. It was associated with an improved 10-year melanoma-specific survival as well as 10-year distant disease survival. So that was established in that. So that's why we do the sentinel node biopsy. It's important. So when we have biopsy proven lymph nodes on that sentinel node, do we need to do an inguinal lymphadenectomy?
FARAH KARIPINENI: So in the past, we used to say, yes, we do. We do a superficial and deep lymphadenectomy for those patients. That's why we do it, right? So we'll put a pin in that, because that is one of the classic indications. And then it's important when we consider whether or not we're going to do an inguinal lymphadenectomy. Is there any distant disease?
FARAH KARIPINENI: So that requires PET/CT, MRI, brain at this point when we're talking about positive lymph nodes. Because we're going to go on to do an inguinal lymphadenectomy, we need to discuss whether that's worth doing or not. And that will be dependent on whether there's distant disease. So keep in mind when you have a patient who has positive adenopathy, PET/CT, MRI, brain-- those things are very important to ensure that we're not putting the patient through a procedure that's going to have morbidity with no associated benefit.
FARAH KARIPINENI: Next slide. So as I said, the indications for completion lymphadenectomy with positive sentinel node are controversial. This is in large part, because of the mFlt-2 trial. So this was a randomized controlled trial that was done which showed that completion node dissections do obviously improve local disease control. Because you're taking out that whole nodal packet.
FARAH KARIPINENI: And we'll go into the steps of that in just a minute. And they do aid in prognostication, as we can understand why that would be the case. But they did not lead to an increase in survival. An increase in morbidity was found, which led to lymphedema in a significantly larger amount of patients here, so 24% versus 6%. So in large part, because of this trial, it has somewhat fallen out of favor, become at least more controversial to do the completion lymphadenectomy after a sentinel node biopsy.
FARAH KARIPINENI: And more so, that information gained with a sentinel node biopsy can be used to guide what systemic therapy will be done, how the patient will be followed later on by the staging information that's gotten. Next slide. But as I said, it's still important to know about what a lymphadenectomy entails. First of all, for melanoma, it may be controversial. But it's still something you should know that may need to be done, depending on the patient and each individual patient's presentation.
FARAH KARIPINENI: Secondly, the inguinal lymph nodes and the removal of them is important for other tumor types as well. So it's important to know this. And this isn't something that we see a lot of. So at least you know what the steps are, what the anatomy is. So the inguinal nodes are divided into superficial and deep. And that's based on whether they lie superficial or deep to the fascia lata along the femoral vein.
FARAH KARIPINENI: The superficial nodes are more along the inguinal ligament and the saphenous vein, so inguinal ligament orienting horizontally in the saphenous vein or orienting vertically. And then the deep nodes are medial to the femoral vessels. In order to get to these, you can use either a longitudinal incision or a curvilinear incision. But you need to make sure when making that incision that you know, based on seeing this, you need to be above and below the inguinal ligament.
FARAH KARIPINENI: So you need access to both. Next slide. So basic principle is dissecting the nodal tissue off the external oblique, starting about 8 to 10 centimeters above the inguinal ligament. And then coming inferior to the inguinal ligament, in order to get to that deep compartment, you need to incise the fascia of the sartorius and the adductor. And that's how you get to those deep nodes.
FARAH KARIPINENI: And once you get into that space, you're going to see the femoral vessels-- skeletonize the femoral vessels and remove the lymph node bearing tissue in the femoral triangle, including Cloquet's node. And I put this here, because it's commonly asked-- Cloquet's node. So I'll show you some pictures of what that is, so you can visualize what we're talking about.
FARAH KARIPINENI: Next slide. So in this picture, you can see the sartorius. And you can see the adductor. So in between that area, you see a triangle formed by the inguinal ligament and those two muscles-- the sartorius and the adductor. So within that area are the femoral vessels. I talked about skeletonizing and the lymph node package that lies in that area.
FARAH KARIPINENI: So we are cleaning out all of that tissue in that area. Next slide. And this is just to show you the lymph node of Cloquet, so you can visualize that. So where you see that lymph node packet, that lymph node of Cloquet is the node that we discussed as one of the first draining lymph nodes in that area. So that's its claim to fame.
FARAH KARIPINENI: And with that, I'm done with the topics that we were going to discuss today. And I can take any questions and thank you very much.
ALFRED CHAHINE: Thank you so much, Dr. Karipineni. This was a very nice review. This would be the first out of four [INAUDIBLE] dedicated to soft tissue neoplasms. And that was a very nice introduction to the topic. We have a question on the Chat from Dr. Joshi. But can you talk about lymph leaks at the node dissections? Very good question.
FARAH KARIPINENI: Absolutely. So lymphatic leaks can happen for a number of reasons. The most common reason is failure of a device that's used to feel the lymphatics. If you're using a harmonic scalpel or anything similar to that instead of tying off lymphatics, or a clip falls off, or a tie is not tight enough, or the patient has had radiation in the past, the tissue is compromised in some fashion, then a leak can form in that area.
FARAH KARIPINENI: And it can be quite difficult to treat. It depends on the area, so whether it's in the neck, the axilla, or the groin. It also depends on when it presents. So, for instance, if it presents later in the course after surgery, for instance, about 5 to 10 days after surgery, it can be very difficult to go back in and find where the leak is. Draining the lymph tissue and waiting for it to seal off, you might be able to get away with that.
FARAH KARIPINENI: But sometimes you're forced to go back into surgery. If forced to go back into surgery, I think the best course of action is obviously to find which one of these drained lymphatics is the leaking one. In order to do that, it's helpful to use dye. So at the time of surgery, if you have to go back into surgery, I would have methylene blue given to the patient.
FARAH KARIPINENI: And then I would wait and try and see where the draining lymphatic is, that is leaking. And look for blue to come out of that area. And if I'm lucky enough to be able to find it, then, of course, you can easily manage it by tying it off if you have a lymphatic that you can localize that way.
ALFRED CHAHINE: Great. There's another question-- your opinion. Hold on. It's moving quickly. Your opinion on resection of soft tissue tumors. Do you close down the dead space? Or do we even need to to do that?
FARAH KARIPINENI: Yeah, so that's really important. So especially, again, we talked about undermining as well. When you undermine the tissue, you increase the risk. You already have an empty space. And now, you're going to increase the risk of having a seroma. And so it's important to close down the dead space for a number of reasons. But technically, that is one of the problems with managing these patients is that they can get seromas.
FARAH KARIPINENI: And they can be difficult to manage. And so closing down the dead space, closing in multiple layers is really important. Some of these patients are going to go on to have radiation or chemotherapy. Their tissue is going to be weaker. So you're going to have a higher risk of having issues like that. So closing multiple layers is really important.
FARAH KARIPINENI: Sometimes cauterizing the edges before you close is important as well. Because that can make the tissue less susceptible to forming seroma. And then pressure dressings are important as well. So if you have a large defect, having the patient use a compression bandage can be very helpful. That requires compliance. So you may [INAUDIBLE].
FARAH KARIPINENI: But they have to continue that for the next couple weeks or several weeks sometimes. Sometimes using negative pressure therapy is useful as well in order to prevent a seroma from forming and keep that dead space closed. So consider those, depending on the size of the tumor.
ALFRED CHAHINE: Thanks a lot. I don't see any other questions. And so I really want to thank you for taking the time, Dr. Karipineni.
FARAH KARIPINENI: Of course.
ALFRED CHAHINE: And for the audience, don't forget to scan the QR code if your residency requires proof of attendance. And with that, we will call it a day. And we'll see you next week. Thank you so much.
FARAH KARIPINENI: Thank you.
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