Surgical Pathology

00:01 There is a critical skill station.

00:02 As I said, we're rushing through a few of these things, just to make sure that you get an idea of what to revise afterwards. The last bit of the presentation is on -- Okay we'll quickly go through this, clearly. This is just to, in short giving you a scenario in detail, I’m just going to look at this and ask you what it is? What's the diagnosis? Lipoma. Yeah, that's what you’re looking for.

00:51 Yeah, yes it's probably most likely to be a lipoma. What could be the differentials? What else can it be? Sebaceous cyst.

00:59 Sebaceous cyst. So anything else? It could be a fibroma or an osteoma. It's quite unlikely.

01:05 Lipoma, sebaceous cyst is fine. Then, management. If at all you are asked in the exam, patient comes with a lipoma. Management. Management depends on what the patient wants. And is the patient symptomatic or asymptomatic? If the patient is asymptomatic, wait and watch.

01:22 No treatment. The patient is symptomatic, offer surgery under local anaesthetic, and excise it. Make an incision on the lesion, take the lipoma out. So that's all you need to know for the exam.

01:43 Okay another diagnosis. Similar scenario. 44 year old man, with a lump over his left shoulder. Lipoma, sebaceous cyst.

01:51 Lipoma, sebaceous cyst. Fibroma? No.

01:54 Myofibroma, no. Something more important they're asking for the exam. A big lump, big soft tissue lump in a person. Sarcoma. So what sort of sarcoma? This could be a liposarcoma. Any lump more than five centimetres, it should be considered as a sarcoma. How do you manage if at all you are given a clinical scenario, not an image but with a scenario saying this patient has got a 8cm lump, what is your most appropriate investigation? An MRI? First one? Before MRI? X-ray? X-ray won’t show. What will an x-ray show? Ultrasound.

02:43 Ultrasound. Always go for a non-invasive and the next is invasive. For the purpose of your exam, anything abdomen, go for ultrasound first and then go for CT. Soft tissue, joints, hip, knee, go for ultrasound. Hip, knee, shoulder and toes or something for ultrasound? So for soft tissues, if they offer you two choices, ultrasound or MRI, which would you go first? Most appropriate statement will be ultrasound. Ultrasound. Then, the best would be a MRI.

03:26 MRI, yes. What would be the best diagnostic tool? Ultrasound. That pretty much applies to your entire exam.

03:37 What they're asking you is if you have a choice, if you have all the investigations in this room, the patient is here, what do you do? MRI. But what is realistic, what do you really do it in your clinical practice? Ultrasound. So they're saying, best is MRI. What do you do is ultrasound. Don’t go for CT. Any soft tissue, always go for MR. Okay, as ultrasound, MRI and the management depends on the above.

04:09 So sarcoma. Why do you have to do MRI? Why MRI? Why not ultrasound? It’s to see how much is infiltrated. Yeah, if it has gone under the trapezius muscle, because you just can't excise it. So that's why you need to do an MR scan.

04:28 Multiple painful lipomas. What's the diagnosis? Neurofibromatosis? No, no.

04:35 There's a name for this condition. Dercum’s disease. Multiple painful lipomas.

04:53 So you get patients, in a scenario, they'll give you patient presenting with a painful lipoma. Either they'll ask you the direct diagnosis or management. Management is similar to a lipoma, you excise only those which are painful, very similar to a neurofibroma. Neurofibroma, you can't cut out everything. You just excise those which are symptomatic.

05:20 In this scenario, I will skip the questions. What do you think diagnosis is? Could be a lipoma? Could be a lipoma. No, okay. Let's say this patient has come to you, or in the exam situation, you're given a scenario, lump over the lateral canthus of the eye. And it's present since birth. They've given 2 clues, present since birth, on lateral canthus of the eye. Now let's say you saw in the medial glabellar region. What's in the mid-line structure? What’s the lump? Classical scene.

06:02 Dermoid? Dermoid cyst, yes. So these are the questions you need to ask, most likely the diagnosis is dermoid.

06:10 A dermoid cyst normally arises at the sites of embryological fusion. So either the midline or wherever there are sites of embryological fusion like the lateral canthus. Lateral canthus, the pretty much whole of the midline, yes, near the mastoid process. Yeah yeah. I think that's all, mainly.

06:37 Management again depends on, you'll have to do an ultrasound, plus a CT/MR.

06:45 Why do you have to do an MR or a CT for this? To determine if it’s actually cyst? No, even before that. Intracranial extension. Because it is a congenital thing, it can be coming from inside the brain. So you need a rule out intracranial extension by doing a CT or an MR. Probably CT in this because you're going into the skull.

07:13 Types of dermoid? Congenital and acquired. Where do you get acquired dermoid or who gets it? Classically? Hair-dressers, between the cleft of fingers, the hair going in and it's called the inclusion dermoid. When the epidermis is pushed into the skin, into the skin, and then you develop a dermoid cyst. So that's called an inclusion dermoid or an epidermoid cyst. Is that called pilonidal? Similar to that, yeah. Pilonidal is also very, very similar to a dermoid. But it's not classified as a dermoid though. Pilonidal you really don’t have a clear definition, but you're right, it is very similar to pilonidal. If it is congenital, they arise in the sites of embryological fusion. If it is acquired, it can happen anywhere.

08:06 Principles of management. If they're asking, in the exam the most appropriate investigation here, you can say ultrasound, because if the ultrasound, says that it's a dermoid and its outside the cranium, then you do not need any further investigation. Only if the ultrasound is ambiguous or says well it may be going in, then you go for the MR scan. You know even in your exam, always think of ultrasound as your first investigation because that's what we do. How many times will you get an MRI done within two days? It's very, very rare, isn't it? Ultrasound. You have the patients waiting there, send them for an ultrasound.

08:50 You have diagnosis within half an hour. And then you have something to discuss. How long does an outpatient ultrasound take? Well, actual time yes, it only takes.

09:11 But waiting hour we say, it takes a little longer than that.

09:17 Okay. If you're given a scenario like this, what do you think it is? Here. Ganglion.

09:28 What you don’t want to miss? What's the structure there? Radial artery. So if you have a radial artery, either radial artery aneurysm or a pseudoaneurysm. So whenever they give anything related to a blood vessel, intravenous drug abuser, or even a normal person, anything related to a vessel, always think of aneurysm. Pseudoaneurysm. So they could have damaged their artery and lead to a pseudoaneurysm.

09:58 Why do you think it's not a ganglion? It's quite far away from the joint.

10:08 Plus it’s on the extensor surfaces. You can get it at the flexor surface as well, but it has to be quite close to the joint, as you see here, this one. That's a ganglion.

10:19 There's a classical history they'll give you in the exam. And they usually say it's transilluminant, it's more of a spherical swelling, cystic and it is not attached to the skin. If they say attached to the skin, what is your first diagnosis? Sebaceous cyst. If they say something lump is attached to the skin, they may give a punctum, but otherwise they'll say it's just attached to the skin, always think of sebaceous cyst. Okay.

10:54 If it is not attached to the skin, you can think of a lipoma, or a ganglion. Ganglion is always next to the joint. Dorsal wrist ganglion. So that is a ganglion, it's a cystic swelling arising in relation to the tendons of joint. They're not cysts because they are not lined by any epithelium. So that's the ganglion coming out of the joint.

11:23 Management of a ganglion. What are the things you can think of? How do you manage a ganglion? Conservative. Before, hit it with a book. It was hitting with a Bible.

11:33 Yeah, that's probably because Bible was the only book available. Anything else, apart from hitting with the Bible? That won’t be option in your option in the exam! It would be too politically incorrect. Anything else you can think of? Excision is one. You can aspirate. You can aspirate and inject steroid. Wait and watch, like that. You can aspirate the ganglion and inject the steroids into it. Surgical excision is the preferred option. What's the biggest problem with any of these? Recurrence. Huge chance, about forty percent, is it? Fifty percent. With aspirations, it's about fifty percent; with surgery, it's about forty percent recurrence. So you got a fair idea about sebaceous cyst, ganglion, lipoma and dermoid cyst. These are things which come up.

12:32 What is this diagnosis? Incisional hernia, very good. Incisional hernia. How do you confirm the diagnosis? Cough? What did you say? Clinical examination and one simple test you can ask him to do? Lift the head up and flex the hip as well. So that's your incisional hernia. That's fine. I'll quickly go through this.

13:02 Hang on a minute. Hang on a minute. I'm sorry, I shouldn't have said to you that. This is an incisional hernia. Hernia, always cough impulse. If it's a divarication of the rectii, that's why we said, lifting the head up and flexing the hip. That's the next patient.

13:23 That's the next patient. So that is divarication of the rectii and this is what protrudes when we flex the neck and flex the hip. Any hernia is cough impulse.

13:41 Lifting head and flexing the hip simultaneously.