Which of the following is not correct with respect to the axilla?
The axillary artery and vein pass in front of the tendon of pectoralis minor as it passes superiorly to insert into the coracoid process. This statement is incorrect; the axillary artery and vein actually pass behind the tendon of pectoralis minor. The bony wall of the axilla is the inter-tubercular sulcus of the humerus and is concealed by biceps and coracobrachialis.
Regarding melanoma:
Nodular histological types have no radial growth phase. The commonest subtype is superficial spreading melanoma (approximately 70%). Acral lentiginous melanomas are the most common subtype found on the palm of the hand, and acral melanomas account for less than 10% of lesions except in those with black skin where they may account for between 35- 60% of lesions. Other subtypes include desmoplastic, amelanotic, and mucosal melanoma.
References:
1. Janis JE. Essentials of plastic surgery. St Louis, USA: Quality Medical Publishing Inc., 2007: 124-5.
From the following statements regarding the prognosis for patients with primary cutaneous malignant melanoma, which is incorrect?
Five-year survival for a patient with a melanoma of Breslow thickness of 4mm without evidence of metastases is approximately 15%. This statement is incorrect. In a big published series the 5-year survival for a patient with a thick melanoma of 4mm Breslow thickness and no evidence of metastases is still greater than 50%. Female sex on its own is a good prognostic factor, probably because women tend to present with thinner lesions on the extremities - itself a good variable. The presence of ulceration significantly worsens prognosis. Older patients do less well but this is probably because they tend to present with thicker lesions. Breslow thickness is a better prognostic variable than Clark’s level or tumour/skin thickness ratios.
1. Balch CM, Buzaid AC, Soong SJ, Atkins MB, Cascinelli N, Coit DG, Fleming ID, Gershenwald JE, Houghton A Jr, Kirkwood JM, McMasters KM, Mihm MF, Morton DL, Reintgen DS, Ross MI, Sober A, Thompson JA, Thompson JF. Final version of the American Joint Committee on Cancer Staging system for cutaneous melanoma. J Clin Oncol 2001; 19(16): 3635-48.
The following are specific risk factors for melanoma except:
Blue eyes. Risk factors for melanoma include: UV light exposure, increased age, Fitzpatrick Type 1 and 2 skin, red hair, male sex (1:49 vs 1:72 lifetime risk men vs women), family history, atypical naevus syndromes, congenital naevi (small increased risk), greater than 50 typical moles, and lentigo maligna. A single dysplastic naevus has a 6-10% lifetime risk of malignant transformation.
1. Janis JE. Essentials of plastic surgery. St Louis, USA: Quality Medical Publishing Inc., 2007: 122-3.
The following is false concerning photodynamic therapy (PDT):
It is a good choice for treatment of low-risk SCCs, but only those of the well-differentiated subtype. C is false. There is good evidence for efficacy of photodynamic therapy for the treatment of basal cell carcinoma (BCC), Bowen’s disease and actinic (solar) keratosis and this evidence is adequate to support its use for these conditions provided that the normal arrangements are in place for consent, audit and clinical governance. Evidence is lacking in relation to SCC, and the chance of local recurrence and metastatic risk is too high. There is a good summary of indications and evidence for PDT in the UK NICE guidelines 1. A study in 2007 reported that CO2 laser and PDT appeared to play a synergistic role in the treatment of nodular BCCs. The cosmetic results were excellent and the mean recurrence-free follow-up was 18.1 months 2. Photodynamic therapy should not generally be used on areas such as the medial canthus or used for the treatment of morpheic BCCs. The lack of histological confirmation of clearance and high risk of local recurrence in these situations preclude its widespread use with current evidence.
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