Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 257 - файл
.pdf
Approximately 13 000 new cases diagnosed annually in the
United States.
Approximately 1% of all malignancies in adults and 15% of
those in children.
Approximately 50% are located on the extremities.
Risk Factors
The majority of sarcomas have no clearly defined
environmental or genetic etiology.
Radiation exposure
Associated with osteosarcomas and malignant fibrous
histiocytomas.
Typically, there is a 10- to 20-year latency period after
exposure.
Thorium dioxide (Thorotrast): contrast agent used in
1940-1950s for radiologic procedures; linked with a
high incidence of hepatic angiosarcoma.
Chemical exposure: arsenic, vinyl chloride, and dioxin
(found in Agent Orange).
Genetic factors
Type 1 neurofibromatosis: benign neurofibromas can
undergo malignant change to malignant peripheral
nerve sheath tumors
Mutation in Rb1 tumor suppressor gene:
retinoblastoma (sarcoma of the eye)
Mutation in p53 tumor suppressor gene: Li-Fraumeni
syndrome (variety of sarcomas)
Lymphedema or chronic irritation
Surgical procedures, radiation therapy, parasitic
infection, idiopathic
10- to 20-year latency for the development of
lymphangiosarcoma
Kaposi sarcoma: strongly associated with HIV infection
and HHV8
DIAGNOSIS
https://t.me/medicina_free
Paucity of local symptoms often leads to advanced disease at
diagnosis.
Tumors grow along tissue planes; compress nearby normal
tissue leading to pseudocapsule.
Most commonly spread hematogenously depending on
histology.
Extremity Sarcoma: generally painless. Delay in diagnosis is
common and patients are often erroneously treated for a
hematoma or “pulled muscle.”
Suspicious findings include mass >5 cm, enlarging or
symptomatic mass, mass present for >4 weeks, or
recurrence after removal.
MRI is the preferred imaging modality.
Pulmonary metastases are the most common location for
metastatic disease.
Around 65% 5-year survival rate for all forms of soft tissue
sarcoma.
Sarcoma of the Abdomen or Retroperitoneum
Can present with vague abdominal complaints (early
satiety, pain, obstruction).
Metastatic disease: most commonly to lungs.
Palpable mass in 80% of patients at the time of
presentation.
Imaging: CT is the preferred diagnostic tool to evaluate
primary site and rule out metastasis to lungs, liver, or
peritoneum. MRI may be helpful for disease in pelvis.
Biopsy: low threshold for percutaneous core needle biopsy
if diagnosis in doubt.
CLASSIFICATION AND STAGING
Subtypes are named for the cell of origin (Table 7-5).
Undifferentiated pleomorphic sarcoma, liposarcoma, and
leiomyosarcoma are the most common sarcomas in adults and
rhabdomyosarcoma is the most common in children.
https://t.me/medicina_free
Table 7-5 Tissue Classification of Soft Tissue Sarcomas
Histologic type has little prognostic significance; histologic grade
(including frequency of mitotic aures, cellular atypia, and
presence or absence of tumor necrosis) is the best for prognosis
and therapy.
Staging Criteria
Histologic grade is the most important prognostic
factor: indicator of malignancy and distant metastases and
death, but poor predictor of local recurrence.
Tumor size: risk of local recurrence and distance
metastases increase with tumor size.
Nodal and distant metastases are associated with poor
prognosis. Classified as stage III in retroperitoneum and
stage IV on trunk and extremities.
Imaging: various techniques used to define etiology and
determine extent for surgical planning including X-ray, CT, MRI,
and PET-CT.
SARCOMA MANAGEMENT
Extremities (especially the thighs) are the most common sites
for sarcoma.
Surgery
Complete resection while avoiding tumor plane
violation is the mainstay of treatment.
WLE is the standard of care, with 3- to 5-cm margins
of normal tissue proximally and distally. En bloc
https://t.me/medicina_free
resection of uninvolved fascial plane with tumor is
performed for control of the other margins.
WLE is performed after excisional biopsy even if the
margins are clear.
Major neurovascular structures are generally preserved
for low-grade lesions but are sacrificed and
reconstructed as needed for high-grade tumors.
There is no survival benefit of amputation compared to
limb-sparing procedure.
Radiation therapy is not indicated for small (<5 cm) lowgrade tumors due to excellent prognosis with WLE alone. It
can be used as primary therapy for patients who cannot
tolerate or refuse surgery; also useful as combination
therapy for sarcomas up to 10 cm.
Chemotherapy is of undetermined benefit in soft tissue
sarcoma.
Retroperitoneal and intra-abdominal sarcomas have a
uniformly poor prognosis. Excision with tumor-free margins is
curative but difficult to achieve. Radiation is rarely used because
surrounding organs cannot tolerate therapeutic doses.
PEARLS
1. Skin and soft tissue neoplasms are derived from a myriad of
skin components and are the most common cancers of the
body. Treatment depends on patient characteristics and
outcome.
2. Changing, symptomatic skin lesions are suspicious for
malignancy, warranting biopsy.
3. Perform full-thickness biopsies of pigmented lesions (ie,
excisional) rather than shave biopsy or curettage so the depth of
the lesion can be determined if it is a melanoma.
4. Excision is appropriate when definitive pathology and/or
margins are required.
5. Design excisions as ellipses with sharp corners to facilitate
closure and avoid if dog ears.
https://t.me/medicina_free
1.
2.
3.
4.
5.
QUESTIONS YOU WILL BE ASKED
1. Should you undermine the wound arising from excision of a
suspected malignant skin lesion to facilitate wound closure?
No. It will permit the spread of malignancy.
2. A 35-year-old breast augmentation patient also mentions a 5mm, nonhealing wound on the face that has been present for 2
months. What do you recommend?
Immediate biopsy.
3. What is the risk of malignant transformation of an actinic
keratosis, and what type of skin cancer can it progress to?
Rates of AK progression to SCC are ~0.6 percent at 1 year and
2.6% at 4 years. Of SCCs, 75% considered invasive and the
remainder were in situ.
5. What is the most common location of dermoid cysts?
Periocular region.
6. What malignancy can Spitz nevi appear histologically similar to?
Melanoma.
Recommended Readings
Apalla Z, Nashan D, Weller RB, et al. Skin cancer: epidemiology, disease
burden, pathophysiology, diagnosis, and therapeutic approaches. Dermatol
Ther. 2017;7:5‐19.
Keung EZ, Gershenwald JE. The eighth edition American Joint Committee on
Cancer (AJCC) melanoma staging system: implications for melanoma
treatment and care. Expert Rev Anticancer Ther. 2018;18:775‐784.
Lee EH, Nehal KS, Disa JJ. Benign and premalignant skin lesions. Plast
Reconstr Surg. 2010;125:188e‐198e.
Netscher DT, Leong M, Orengo I, et al. Cutaneous malignancies: melanoma
and nonmelanoma types. Plast Reconstr Surg. 2011;127:37E.
Rogers-Vizena CR, Lalonde DH, Menick FJ, et al. Surgical treatment and
reconstruction of nonmelanoma facial skin cancers. Plast Reconstr Surg.
2015;135:895e‐908e.
https://t.me/medicina_free
*
Denotes common in-service examination topics.
https://t.me/medicina_free
8
Lymphedema and Vascular
Anomalies
Geoffrey E. Hespe
LYMPHEDEMA
THE LYMPHATIC SYSTEM
Structure
Made up of superficial (capillary) and deep (collecting)
lymphatic vessel networks connecting to lymphoid organs,
which direct lymph fluid in a unidirectional flow back to the
venous system
Superficial lymphatics are open-ended, single-layer
thick, valveless vessels, which absorb interstitial fluid
and macromolecules.
Deep lymphatics contain valves and are surrounded by
smooth muscle cells, which allow for propulsion of
lymph fluid unidirectionally.
The thoracic duct is the main collecting lymphatic
vessel for the majority of the body except the right
upper extremity, right head and neck, and right
hemithorax.
The terminal end of the thoracic duct can have
varying anatomy and can anastomose to the
internal jugular vein, left subclavian artery, or the
junction of the two.
https://t.me/medicina_free
The right lymphatic duct drains the right upper
extremity, right head and neck, and right hemithorax,
and terminates typically at the junction of the right
internal jugular and right subclavian veins.
Found in all tissues except cornea, retina and bone marrow
Ongoing research has recently identified lymphatics in
bone, brain and spinal cord, tissues traditionally
thought to be void of lymphatics
Function
Collects and transports interstitial fluid back to the vascular
system
Participates in the immune response by trafficking antigens
and immune cells to lymphoid organs
Transports fats, lipids, and chylomicrons from the GI tract to
the circulatory system
LYMPHEDEMA
Definition: end-organ dysfunction of the lymphatic system that
leads to stasis of protein-rich lymph fluid in the interstitium
leading to edema, adipose deposition, and fibrosis.
Most common cause of lymphedema in developing countries is
from filariasis, a parasitic infection of Wuchereria bancrofti; in
developed countries, it is secondary to cancer therapy.
Affects ~250 million people worldwide.
Primary vs secondary
Primary lymphedema: developmental abnormality in
lymphatic vessels with variable penetrance and
severity of disease
Congenital lymphedema (10%-25%):
Usually present at birth
More commonly seen in females
Affects lower extremities > upper extremities;
typically bilateral lower extremity lymphedema
Milroy disease (hereditary lymphedema type
I): ~2% of all congenital lymphedemas; sex-
https://t.me/medicina_free
linked genetic mutation in vascular endothelial
factor receptor-3 (VEGFR-3)
Results in malformation and agenesis of
lymphatic vessels resulting in
lymphedema, steatorrhea, and defective
cell-mediated immune system
Hereditary lymphedema type II (lymphedema
praecox, Meige disease; 80%): typically unilateral
lower extremity lymphedema due to fewer and
small lymphatic vessels
Most common form of primary lymphedema
*Develops between birth and age 35;
typically around puberty
More common in females 4:1
Lymphedema tarda (<10%): lymphedema that
develops after the age of 35 usually in lower
extremities secondary to hypoplastic lymphatic
vessels without valves
Secondary lymphedema: result of damage and/or
mechanical obstruction of lymphatic vessels
*Filariasis: most common cause of secondary
lymphedema worldwide (120 million people
worldwide)
Caused by parasitic roundworm W bancrofti,
which obstructs lymphatic vessels
Typically affects the lower extremity or
genitalia
Endemic to India, Indonesia, Bangladesh, and
Nigeria
Treatment: ivermectin
Cancer treatment
Postmastectomy lymphedema
Affects ~4%-40% of women
Increased risk in patients who receive
axillary lymph node dissection (ALND),
receive radiation therapy, and/or are
obese
https://t.me/medicina_free
Decreasing incidence due to increase in
prevalence of sentinel lymph node
dissection (approximately 5% risk)
Presents as persistent swelling, pain, and
at increased risk of infection
Location
Lower extremities (90%)
Upper extremities (10%)
Occurs in ~14%-49% of women after mastectomy with
ALND
8-10× increased risk of lymphedema in women after
axillary node dissection and radiation
Genitalia (<1%)
Pathophysiology
Remains poorly understood.
Studies have demonstrated that it is likely due to fibrosis of
lymphatic vessels secondary to chronic inflammation.
CD4+ T cells and macrophages have been shown to
play a role in lymphedema.
Leads to chronic lymphedema, which is characterized by
soft tissue fibrosis and adipose tissue deposition secondary
to chronic inflammation and sclerosis of lymphatic vessels.
Risk Factors
Obesity (>30 BMI; 3.6× increased risk)
Radiation (2-4.5× increased risk)
Infection
Genetics
DIAGNOSIS
History and physical examination
Family history of lymphedema
Comorbidities (eg, heart failure, venous stasis, renal
dysfunction)
Recent surgery or trauma
Foreign travel: concern for W bancrofti infection (filariasis)
https://t.me/medicina_free
Соседние файлы в папке @xirurgi_2025