Now, we've done that. We've done an
excision biopsy. Leave that for one
minute, I'll come back to that. You've done
an excision biopsy, and that comes up as a
let's say, 2.1 mm Breslow thick melanoma.
Then you'd go for excision margin of two to
three centimetres. So in your exam, if they
ask you, patient has come with a Breslow
thickness of seven millimetres, it's pretty
much impossible for you to remember this.
You won't remember because even when we work
in plastics, we just won't remember every
measurement, but have in your head, up to
two millimetre; two to three centimetres,
two centimetre is fine. Anything more than
two millimetre, go for three. Leave that for
a minute because it's quite important to get the
margins for melanoma. Two millimetre Breslow
depth; two centimetre margin. More than two
millimetre Breslow depth, three centimetre
margin. Sentinel node biopsy.
Who knows about sentinel node?
What's the definition of sentinel node biopsy?
It’s the first node to be drained by the --
Tumour? Okay. Is it diagnostic or therapeutic?
Diagnostic. Diagnostic. And it really hasn't
got any prognostic
value as well. It's more of a diagnostic tool.
What are the contraindications for sentinel
node, from which areas you don't do a sentinel
Groin? No, groin you do. Head and neck.
head and neck drainage is so variable, you
don't know which way it's going to drain into.
So sentinel node is mainly done for the limbs,
very commonly, breast, and maybe for the trunk.
Anything in from back is also very very,
you don't know if it's going to drain
the neck, axilla or the groin. It is most
significant for the limbs.
Okay, management of melanoma. Now, I’m
not sure whether I should cover this because
it might be bit too detailed for you regarding
melanoma. I don't think they’re asking you
this much of detail. They'll ask you Breslow
depth but I don't think they’ll go into
management or further investigations. So I'll
just skip this slide. And go to the last bit,
this one. Management options are surgery plus
radiotherapy. Chemotherapy only for advanced
disease. Biopsy proven melanoma we've discussed.
Up to 2 mm: 2 cm; more than 2 mm: 3 cm.
So BCC is three to five millimetre,
SCC is six to ten millimetre. Melanoma, one
to two centimetre. Okay we are on the last
bit now. We are almost done.
Vascular. Now, this I’m going to skip through
quickly. Venous ulcer. I won't spend too much
time show you all the images.
If I give you the history, you'll be able
to understand. Venous ulcer, classically
in the medial gaiter area of the leg, usually
have sloping margins. They may have surrounding
cellulitis or some dermatitis. What is the
single most appropriate treatment for
Compression bandage? Compression. Four layered
after ruling out arterial disease. That's
correct. Four layered compression bandage.
What are the changes you can see in a
venous ulcer? Lipodermatosclerosis, haemosiderin
deposition, atrophic blanch. And shiny, no,
shiny skin is for arterial. Varicose eczema,
yes. So these are things you need to look
for. So I’ll just go through the bits.
Rest, elevation, control infection, moisturise.
That are all basic things. Single most one
is compression bandage for venous. That's
it. Four layered compression bandage that's
what they're looking for. And what do you do before that?
So haemosiderin deposition, lipodermatosclerosis,
atrophic blanch; what
is atrophic blanch? Atrophic blanch is this
white scars you'll get with recurrent ulceration
and healing. They're painful.
And this is the inverted champagne bottle leg.
Where do you get that? Because the bandage
slips to the calf and they end up with this
sort of leg. So in your exam if they give
you any of these terminologies, it's venous.
So there's a sixty four year old lady presenting
with ulceration over the medial maleolus or
thereabouts, with surrounding lipodermatosclerosis.
Don't waste time, venous. Nothing else.
What's this? Arterial. Why is it arterial?
It’s punched out. Okay, a bit of punched
out, what else can
you see? Shiny skin. Okay, what else would
you expect? Loss of hair. What happens in
the nails? Loss of toe nail or atrophic nails.
Skin changes, dusky
skin, loss of hair, cool to touch, brittle
nail or opaque nail, loss of nail. So if
they give you any of these features in the
exam, go for arterial. History you'll focus
on or what other history they will give you?
Risk factors. Other arterial diseases.
So, smoker, systemic arterial disease, patient
presented with IC - intermittent claudication,
rest pain, other sites of ulceration. You
can't miss this because if they give any of
this, arterial. Bang. Investigation.
Let's say you have
seen a patient with arterial disease or peripheral
arterial disease, what's the next investigation,
first thing you do? So, you do the ABPI
first. Formal ultrasound, what is it called?
Duplex. What's the next investigation? CT
or angiogram. CT angiogram or just angiogram.
This is an old form of angiogram,
but we do a CT angiogram now.
ABPI measurements. Do you know these values?
What are the risk factors for any arterial disease?
Hypercholesteremia, smoking, obesity,
hypertension, diabetes. What are non-modifiable
risk factors? Age, gender, positive family
history. Increase in age, male sex, male gender,
male sex and positive family history. Those
are non-modifiable. And these are modifiable
risk factors. If they ask you a question related to
surgery in arterial disease, what are the
features you need to look for? When do you
operate on somebody with arterial disease?
If they're presenting with intermittent claudication,
disabling intermittent claudication, critical
ischemia, rest pain, gangrene. These are all
absolute indications. So non-healing, recurrent
ulceration with infection, disabling claudication,
rest pain, gangrene. All these are indications
for offering surgery.
Dry or wet? Dry. Management?
Auto amputation, conservative. That's fine.
Prevent infection, allow to auto-amputate.
Diagnosis? Gangrene, wet gangrene. Tell me
why you say its wet gangrene? Tell me three
features you can see. Oedema, blisters, and cellulitis.
So this is moist gangrene, or wet gangrene.
Management? Amputation, no not so quickly.
First elevate at least -- I'm not sure, why
do you want that? You mean anticoagulation? Sure.
So, 24 to 48 hours of IV first and then you
have to consider surgery if it is progressing
or getting worse. So consider control
of proximal spread of infection, sepsis control,
consider improving circulation. What's
the risk of amputation in this patient
without controlling infection? What is the
risk of amputating or doing surgery without
controlling the infection? Because the wound
will get infected. Spread of the wound, the
wound will get infected. So you need to make
sure that the infection is under control before
you operate. Okay this a diabetic foot ulcer.
Fine. What's the
single most thing in management? There are
two things. Control diabetes, good
glycaemic control, and secondly, pressure relief.
What did you say? Osteomyelitis, fine. Yes.
So diabetic ulcer investigations. FBC/UC&Es,
glucose, HbA1C, x-ray. Okay. Doppler,
duplex, depending on what it is. Management,
glycemic control, supervening, prevent
infection and pressure relief. Other
aetiologies will be just to confuse