Can the use of hyaluronidase reduce capsule formation?

BACKGROUND

The purpose of this study was to find whether the use of hyaluronidase reduces capsule formation.

METHODS

Ten New Zealand White rabbits were used. Eight pockets were created using an aseptic technique, four on the right side and four on the left side, along the vertebral column of every animal. One piece of silicone from a silicone block was inserted inside every pocket. The dimensions of each piece were 3.5 × 2 × 1.5 cm. In every pocket on the right side of each animal we placed 0.5 ml of hyaluronidase solution. The animals were sacrificed 5 months postoperatively. Capsule formation in the each side of the animals was compared.

RESULTS

Two rabbits presented infection in two pockets and were excluded from the study. There was a statistically significant difference between groups concerning the capsule thickness variable using parametric (P = 0.003) and nonparametric (P = 0.001) analysis [capsule thickness on the right side: 256.46 ± 114.88 (mean ± SD) and on the left side: 369.10 ± 147.81 (mean ± SD); capsule thickness on the right side: 235.69 (104.72) [median (IQR)] and on the left side: 332.12 (188.68) median (IQR)].

CONCLUSION

The use of hyaluronidase may reduce capsule formation around implants.

Giant dermoid cyst of the lower limb: presentation of a rare case

BACKGROUND

Dermoid cysts are unusual neoplasms that often present in childhood and are usually located in the head and neck region.

OBJECTIVE AND METHOD

We describe a rare case of a giant dermoid cyst of congenital inclusion type located at the lower extremity of a young male. Preoperative imaging studies were performed for evaluation of the mass.

RESULT

The cyst was surgically removed, and histopathologic examination confirmed the diagnosis.

CONCLUSION

Dermoid cysts rarely appear in the lower extremity and must be included in the differential diagnosis of cystic lesions of the lower limb.

Evaluation of six CTLA-4 polymorphisms in high-risk melanoma patients receiving adjuvant interferon therapy in the He13A/98 multicenter trial

Purpose

Interferon is approved for adjuvant treatment of patients with stage IIb/III melanoma. The toxicity and uncertainty regarding survival benefits of interferon have qualified its acceptance, despite significant durable relapse prevention in a fraction of patients. Predictive biomarkers that would enable selection of patients for therapy would have a large impact upon clinical practice. Specific CTLA-4 polymorphisms have previously shown an association with response to CTLA-4 blockade in patients with metastatic melanoma and the development of autoimmunity.

Experimental design

286 melanoma patients and 288 healthy controls were genotyped for six CTLA-4 polymorphisms previously suggested to be important (AG 49, CT 318, CT 60, JO 27, JO30 and JO 31). Specific allele frequencies were compared between the healthy and patient populations, as well as presence or absence of these in relation to recurrence. Alleles related to autoimmune disease were also investigated.

Results

No significant differences were found between the distributions of CTLA-4 polymorphisms in the melanoma population compared with healthy controls. Relapse free survival (RFS) and overall survival (OS) did not differ significantly between patients with the alleles represented by these polymorphisms. No correlation between autoimmunity and specific alleles was shown. The six polymorphisms evaluated where strongly associated (Fisher's exact p-values < 0.001 for all associations) and significant linkage disequilibrium among these was indicated.

Conclusion

No polymorphisms of CTLA-4 defined by the SNPs studied were correlated with improved RFS, OS, or autoimmunity in this high-risk group of melanoma patients.

Correlation of molecular human leukocyte antigen typing and outcome in high-risk melanoma patients receiving adjuvant interferon

BACKGROUND:

Interferon is approved for adjuvant treatment of patients with stage IIB/III melanoma. The identification of predictive markers that would permit selection of patients would be beneficial. Specific human leukocyte antigen (HLA) class I and II antigens have previously shown an association with response to therapy or overall survival of patients with metastatic melanoma.

METHODS:

A total of 284 high-risk melanoma patients participating in a randomized trial and 246 healthy controls were molecularly typed for HLA class I and II. Specific allele frequencies were compared between the healthy and patient populations, as well as presence or absence of these in relation to recurrence. Alleles related to autoimmune disease were also investigated.

RESULTS:

No significant differences were found between the distribution of HLA genotype in the melanoma population compared with healthy controls. Correlations between nonrecurrence and the presence of HLA-Cw*06 allele were noted present in 19.3% of melanoma patients. The median relapse-free survival of the Cw*06-positive cohort was 100.2 months versus 37.3 months in the Cw*06-negative cohort (P = .013). The median overall survival for the Cw*06-positive cohort has not yet been reached, versus 78.9 months in the Cw*06-negative cohort (P = .025). HLA-Cw*06 was present in 29.79% of patients in the autoimmunity group and 15.38% of patients in the nonautoimmunity group (P = .049).

CONCLUSIONS:

No allele was associated with absence of recurrence in patients receiving adjuvant interferon with the exception of HLA-Cw*06, an allele correlated with psoriasis. HLA-Cw*06-positive patients have better relapse-free and overall survival. Cancer 2010. © 2010 American Cancer Society.

The Use of a New Wound Alginogel for the Treatment of Partial-thickness Hand Burns

 The following retrospective analysis reports on patients with partial-thickness wounds admitted to the burn unit of the General Hospital of Athens who were treated with a new alginogel and were later compared to the burn center's standard treatment.

METHODS

Patient information from January-December 2008 was analyzed for the number of days until healing and wound bacterial loads. Wound healing was characterized as a quick onset of epithelialization and low occurrence of inflammation.

RESULTS

A limited number of wounds (15%) were found to be positive for wound swabs and accordingly few signs of inflammation were reported. The organisms that were retrieved from the alginogel treated wounds were Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus hominis, and Acinetobacter baumanii.

CONCLUSION

These data are discussed and compared with the experience of the burn unit and its standard treatment. .

Hyperthermic isolated limb perfusion for recurrent melanomas and soft tissue sarcomas: feasibility and reproducibility in a multi-institutional Hellenic collaborative study

Hyperthermic isolated limb perfusion with TNF-alpha and melphalan (TM-HILP) is a complicated surgical procedure. Herein, we present the experience of the Hellenic collaborating centers with TM-HILP for inoperable in-transit melanoma and soft tissue sarcoma (STS) of the extremities to examine safety and feasibility of collaborating as a multi-institutional group for future research studies. From 2001 to 2009, twenty patients (median age 63.5 years) underwent TM-HILP for locally advanced in-transit melanoma (n=14) or unresectable STS (n=6). All patients underwent a 90-min isolated limb perfusion with melphalan (10 mg/l limb volume) and TNF-alpha (1-2 mg) under mild hyperthermia (39-40 degrees C). No major intra-operative complications occurred and all patients completed the procedure successfully. One patient developed postoperative ischemic necrosis of the limb necessitating amputation. All melanoma patients showed a response to TM-HILP with 7 (62%) of them experiencing complete response. All STS patients attained complete response after excision of residual tumor. The median disease specific and limb-relapse-free survival was 15 and 12 months, respectively. TM-HILP can be safely applied even in low volume tertiary hospitals provided that technology to minimize intraoperative systemic leakage is available. Future prospective studies can be performed reproducibly by this multi-institutional collaborative group.

Hyperthermic isolated limb perfusion for recurrent melanomas and soft tissue sarcomas: feasibility and reproducibility in a multi-institutional Hellenic collaborative study

Hyperthermic isolated limb perfusion with TNF-alpha and melphalan (TM-HILP) is a complicated surgical procedure. Herein, we present the experience of the Hellenic collaborating centers with TM-HILP for inoperable in-transit melanoma and soft tissue sarcoma (STS) of the extremities to examine safety and feasibility of collaborating as a multi-institutional group for future research studies. From 2001 to 2009, twenty patients (median age 63.5 years) underwent TM-HILP for locally advanced in-transit melanoma (n=14) or unresectable STS (n=6). All patients underwent a 90-min isolated limb perfusion with melphalan (10 mg/l limb volume) and TNF-alpha (1-2 mg) under mild hyperthermia (39-40 degrees C). No major intra-operative complications occurred and all patients completed the procedure successfully. One patient developed postoperative ischemic necrosis of the limb necessitating amputation. All melanoma patients showed a response to TM-HILP with 7 (62%) of them experiencing complete response. All STS patients attained complete response after excision of residual tumor. The median disease specific and limb-relapse-free survival was 15 and 12 months, respectively. TM-HILP can be safely applied even in low volume tertiary hospitals provided that technology to minimize intraoperative systemic leakage is available. Future prospective studies can be performed reproducibly by this multi-institutional collaborative group.

The efficacy of Helix aspersa Müller extract in the healing of partial thickness burns: a novel treatment for open burn management protocols

Snail extracts have been increasingly used in numerous dermatologic conditions and recent literature attributes healing, soothing and anti-aging properties to them. This study evaluates the efficacy of Helix aspersa extract in an open wound management protocol for deep partial thickness (PT) facial burns and compares it to moist exposure burn ointment(MEBO). A total of 27 adult patients with deep partial thickness facial burns (group A) were treated by application of a snail extract cream twice daily for a maximum period of 14 days or until full epithelialization. Times until debridement and epithelialization of the burn surface were compared with those of 16 patients (group B, control) treated by MEBO. Pain scores were recorded using a visual analogue scale (VAS) on the fourth post-burn day before and 30 min after application. Mean times for eschar detachment were 9 +/- 2 days (group A) and 11 +/- 2 days (group B) (p = 0.003) and for burn surface epithelialization were 11 +/- 2 days and 15 +/- 3 days respectively (p < 0.001). VAS pain scores after application in group A were significantly lower compared to group B (p < 0.001). Helix aspersa extract is a natural, safe and effective alternative treatment in open wound management of partial thickness burns in adults.

Evaluation of IL-10 polymorphisms in high-risk melanoma patients receiving adjuvant interferon

9049

Background: Attempts to identify patients who benefit from adjuvant treatment of interferon alfa-2b (IFN) have been disappointing. Interleukin-10 polymorphisms have been implicated with the prognosis of patients with advanced melanoma and associated with response to biochemotherapy. Several polymorphisms have been found within the IL-10 gene. We evaluated three IL-10 Single Nucleotide Polymorphisms (SNPs) in high-risk melanoma patients enrolled in a study of two regimens of high-dose IFN and compared the distribution of SNPs found in healthy controls. Methods: We genotyped DNA from peripheral blood of 280 stage IIb, IIc and III melanoma patients and 288 healthy controls for 592 C/A, 819 C/T and 1082 G/A with PCR and pyrosequencing technology (Biotage, Uppsala, Sweden). Results: At a median follow up of 56.3 months (95% CI 47.4–63.7), 147 patients have recurred and 94 have died. The median DFS was 53 months and the median OS 86 months. There were no statistically significant differences in the incidence of IL-10 polymorphisms between the melanoma patients and healthy controls. The incidence of these polymorphisms is presented in table . RFS and OS did not differ significantly between the alleles of these polymorphisms (p=0.88 and p=0.55 for 592 C/A, p=0.84 and p=0.68 for 819 C/T and p=0.26 and p=0.30 for 1082 G/A respectively). Conclusions: No SNP studied was correlated with improved RFS and OS in this high-risk group of melanoma patients.

[Table: see text]

[Table: see text]

Dermal skin template for the management of multiple cutaneous leiomyomas

BACKGROUND

Multiple leiomyomas are rare benign tumors of the skin, originating from the arrector pili muscle, and usually appear as painful nodules. Several pharmacologic agents have been used with some success to reduce pain and discomfort since surgery may be an impractical approach owing to the extent of the disease.

OBJECTIVE

This article reports on a patient with multiple cutaneous leiomyomas of the upper limb who was managed by a method not previously reported for leiomyomas.

METHOD

The management involved total surgical resection of the defect and immediate reconstruction with the Integra artificial dermal template (Integra LifeSciences Corp., Plainsboro, NJ).

RESULTS

With this treatment, the patient was totally relieved from the pain, and optimal functional and esthetic results were achieved.

CONCLUSION

Complete surgical resection of multiple cutaneous leiomyomas prevented the disease's recurrence. The immediate reconstruction of the resultant full-thickness defect with artificial dermis ensured uneventful wound healing, resulting in optimal functional and esthetic outcome and total relief from leiomyoma-associated discomfort.

Randomized Phase III Study of 1 Month Versus 1 Year of Adjuvant High-Dose Interferon Alfa-2b in Patients With Resected High-Risk Melanoma

Purpose

A high-dose interferon alfa (IFN-α) regimen as reported in E1684 was unique for the incorporation of an induction phase of maximally tolerated dosages of intravenous (IV) therapy for the initial 4 weeks. This is the only trial that has shown prolongation of overall survival and relapse-free survival (RFS) in comparison with observation. Analysis of the hazard curves for RFS and overall survival (OS) in E1684 revealed separation of the high-dose and observation arms, suggesting that the induction phase may represent a critical component of this regimen, although this has not been tested prospectively.

Patients and Methods

We conducted a prospective randomized study of IV induction therapy versus a full year of high-dose IFN, with primary end points of RFS and OS for patients with stage IIB, IIC, and III melanoma, within 56 days of curative surgery. Patients were randomly assigned to receive IFN-α-2b 15 × 106 U/m2 IV × 5/7 days weekly × 4 weeks (arm A) versus the same regimen followed by IFN-α-2b 10 × 106 U (flat dose) administered subcutaneously three times a week for 48 weeks (arm B).

Results

Between 1998 and 2004, 364 patients were enrolled (353 eligible: arm A, n = 177; arm B, n = 176). At a median follow-up of 63 months (95% CI, 58.1 to 67.7), the median RFS was 24.1 months versus 27.9 months (P = .9) and the median OS was 64.4 months versus 65.3 months (P = .49). Patients in arm B had more grade 1 to 2 hepatotoxicity, nausea/vomiting, alopecia, and neurologic toxicity.

Conclusion

There were no significant differences in OS and RFS between the regimens of 1 month and 1 year of treatment.

Preservation of venous outflow improves transverse rectus abdominis musculocutaneous flap survival following vascular delay

BACKGROUND

The rat abdominal island model has proved to be a reliable and reproducible model for the study of surgical delay procedures. It has been customary to simultaneously divide both the artery and the accompanying vein to obtain maximum survival of the rat TRAM flap undergoing delay procedure. This study evaluates the effect of selective arterial interruption compared to standard vascular delay on flap survival in the rat TRAM flap model.

METHODS

Thirty-six Wistar rats were randomly assigned to three groups (n=12), depending on the vascular ligation selected for the initial experimental delay stage. In group A (control group) no vessels were ligated. In group B the right deep inferior epigastric vessels were preserved and the right superior and left inferior and superior deep vessels were ligated. In group C the right inferior epigastric vessels and the left inferior epigastric vein were preserved while superior epigastric vessels and the left inferior epigastric artery were ligated. For the second stage one week later, TRAM flaps were elevated based on the right deep inferior epigastric vessels, re-inset in their original position and digitally photographed. Skin island viability was determined 96 hours later using digital photography and image-analysis software SigmaScan (SPSS, Inc., Chicago, IL).

RESULTS

The percentage of flap survival in control group A was 50+/-6%, in group B 60+/-4% and in group C 85+/-4%. The occlusion of the three vascular pairs in group B improved the survival percentage in comparison to the control group A, but this did not achieve statistical significance. In contrast, the percentage of flap survival in control group C was statistically significant compared to groups A and B (p<0.05, ANOVA). Zone IV exhibited no necrosis in any group C animals.

CONCLUSIONS

This indicates that delay with preservation of the venous outflow of zone IV results in increased blood supply.

Quality and safety of fresh-frozen plasma inactivated and leucoreduced with the Theraflex methylene blue system including the Blueflex filter: 5 years' experience

BACKGROUND AND OBJECTIVES

The objective of this paper is to present 5 years' experience of pathogen inactivation of fresh-frozen plasma with the methylene blue system in a blood centre in Athens.

MATERIALS AND METHODS

Eight thousand and five hundred units treated by methylene blue and 54 435 untreated were issued for transfusion in four hospitals during the period 2000-2005. Eighty-eight units were evaluated for changes in coagulation factor activity and cytokine concentrations following treatment.

RESULTS

Coagulation factor losses were in the accepted range. Adverse reactions were 1 : 8500 with treated and 1 : 2177 with untreated units. The five serious reactions were all in untreated units. No seroconversions for infectious diseases were reported.

CONCLUSIONS

Methylene-blue-treated fresh-frozen plasma is safer than the untreated product even in patients who require large quantities of plasma transfusion.

A randomized phase III trial of 1 month versus 1 year adjuvant high-dose interferon alfa-2b in patients with resected high risk melanoma

8505

Background: High dose IFNa regimen as reported in E1684 was unique for the incorporation of an induction phase of maximally-tolerated dosages of IV therapy for the initial 4 weeks. This is the only trial that has shown prolongation of overall survival and disease-free survival in comparison to observation. Analysis of the hazard curves for DFS and OS in E1684 reveal early and durable separation of the high-dose and observation arms suggesting that the induction phase may represent a critical component of the high-dose regimen, although this has not been tested prospectively. Methods: We conducted a prospective randomized study of IV induction therapy vs a full year of high-dose IFN with primary endpoints of DFS and OS for stage IIB, IIC and III melanoma patients within 56 days of curative surgery. Patients were randomized to receive IFN alfa-2b 15×106 U/m2 IV × 5/7 days weekly × 4 weeks (arm A) versus the same regimen followed by 10×106 U(flat dose) SC 3 times a week for 48 weeks (arm B). The proposed treatment would be considered at least as good as the conventional treatment, if the relapse rate at 3 years from study entry is at most 15% higher in the former arm (power 85%, one-sided test a=0.05, required sample size: 340). Results: Between 1998 and 2004, 364 patients were enrolled (355 eligible: 178 arm A and 177 arm B). Patients′ and tumor characteristics were well balanced between the two arms. At a median follow up of 51 months (95% CI 46–55), the median DFS is 32 months vs 31 months (p=0.836) and the median OS is 61 months vs 63 months (p=0.444). Eleven patients discontinued treatment in arm A and 54 in arm B. The discontinuation rate is significantly higher in group B (p<0.001), possibly due to the longer duration. Reasons for discontinuation were disease progression (69%) and toxicity (19%). Patients in arm B had more grade 3–4 hematologic, constitutional and neurologic toxicity. Conclusions: There are no significant differences in OS and DFS between the regimen of 1 month and 1 year treatment tested.

[Table: see text]

Burned Breast Reconstruction by Expanded Artificial Dermal Substitute

Full-thickness anterior chest wall burns result in contractures that may restrict the development of breast in young female patients. The management of postburn contractured anterior chest wall scars and unilateral breast hypoplasia with the expansion of bilayered artificial skin is herein presented for the first time in literature to the best of our knowledge. A 21-year-old female with chest wall contractures after thermal injury she had suffered at the age of 27 months was managed in three stages. The first stage included release and excision of contractures and scars, submuscular insertion of anatomical tissue expander, and coverage of the anterior chest wall with Integra artificial skin (Skin, Johnson & Johnson Medical, Division of Ethicon, Inc., Sommerville, NJ). One month later, the outer silicone layer of Integra was substituted by a split-thickness skin autograft and the expander was partly inflated with saline. During the third stage and after overexpansion of the expander had been completed, the expander was removed and a permanent silicone implant was subsequently inserted. No immediate or late complications were observed. At 17 months, the breast contour remains stable, no recontracture has occurred, and the patient evaluates the result as very satisfactory. Expansion of artificial skin Integra appears to be a reliable and safe alternative for reconstruction of the burned breast, lacking the morbidity associated with deep donor sites of full-thickness skin autografts or flaps.

Postoperative analgesic effect of locally infiltrated levobupivacaine in fleur-de-Lys abdominoplasty

BACKGROUND

This prospective double-blind study compared the analgesic properties of locally infiltrated levobupivacaine with those of ropivacaine in fleur-de-lys abdominoplasty.

METHODS

A total of 46 patients subjected to fleur-de-lis abdominoplasty under general anesthesia were included. The patients were randomly assigned to receive local infiltration of the peri-incisional and dissected area with the following solutions: group A (placebo group, n = 15) received 100 ml of saline 0.9%, group B (n = 15) received 50 ml of ropivacaine 0.75% in 50 ml of saline 0.9%, and group C (n = 16) received 60 ml of levobupivacaine 0.25% in 40 ml of saline 0.9%. The anesthetic technique was standardized for all the groups. The patients were asked to assess their pain at rest on a visual analog scale (VAS) at 2 h, 4 h, and 24 h postoperatively. Data were analyzed by mixed analysis of variance (ANOVA), simple ANOVA, and repeated measures ANOVA, followed by Tukey's test.

RESULTS

Groups B and C did not differ significantly in their VAS scores at 2 h postoperatively, but group C experienced significantly less pain (p < 0.001) than either the control group or the B group at 4 h and 24 h postoperatively. Group B also registered significantly lower VAS scores (p < 0.001) than the placebo group at 4 h postoperatively.

CONCLUSIONS

It is concluded that for mini abdominoplasty, adequate analgesia is achieved for at least 4 h postoperatively by local tissue infiltration with either ropivacaine or levobupivacaine. However, in terms of intensity and duration of analgesia, levobupivacaine was found to be more effective than ropivacaine in reducing postoperative pain associated with mini abdominoplasty.

p53 codon 72 Pro homozygosity increases the risk of cutaneous melanoma in individuals with dark skin complexion and among noncarriers of melanocortin 1 receptor red hair variants

BACKGROUND

p53 has a common polymorphism at amino acid 72, encoding either arginine or proline. p53Arg and p53Pro exhibit differences in various biological activities, such as cell-cycle arrest and induction of apoptosis. Numerous epidemiological studies have examined the role of this polymorphism in several human malignancies, including cutaneous cancers, with contradictory results.

OBJECTIVES

To investigate the germline frequency of p53 codon 72 polymorphism in malignant melanoma in a Mediterranean population, and to examine possible associations with various clinicopathological factors.

METHODS

In this hospital-based case-control study we used allele-specific polymerase chain reaction for p53 codon 72 genotyping in blood specimens from 107 Greek patients with sporadic cutaneous melanoma and 145 healthy controls.

RESULTS

After adjustment for age, sex and phototype the Pro/Pro genotype was associated with increased risk for cutaneous melanoma compared with the Arg/Arg genotype (adjusted odds ratio, OR 3.17, 95% confidence interval, CI 1.03-9.78). This correlation was more pronounced in subjects with phototypes III or IV (adjusted OR 9.56, 95% CI 1.56-58.46), dark skin (adjusted OR 10.96, 95% CI 1.64-73.28), dark eyes (adjusted OR 8.86, 95% CI 1.69-46.52) and dark hair (adjusted OR 3.17, 95% CI 1.01-9.95), and among noncarriers of melanocortin 1 receptor gene (MC1R) red hair polymorphisms (adjusted OR 2.99, 95% CI 1.02-8.78).

CONCLUSIONS

p53 codon 72 Pro/Pro genotype could be a risk factor for the development of melanoma in the Greek population, especially in subgroups with darker skin pigmentation, as well as among noncarriers of the MC1R red hair polymorphic variants.