A proposal for the timing of management of patients with melanoma presenting during pregnancy

The treatment of melanoma during and immediately after pregnancy poses a significant challenge to surgeons, oncologists, and patients alike. With the overall increase in incidence of melanoma in the United States and worldwide, it is likely that more surgeons will be faced with management decisions regarding pregnant patients with melanoma. We report on five patients who presented to the Yale Melanoma Unit with melanoma during their pregnancy. We propose the management option of resection of the primary tumor under local anesthesia, and postponing of the sentinel lymph node biopsy until after the birth of the child. The completion lymphadenectomy can be performed if these nodes are found to be harboring metastases. We further discuss treatment options and propose an algorithm for management of patients diagnosed with melanoma while pregnant.

A novel device for minimally invasive harvest of the sural nerve

The sural nerve is ideal for autologous nerve reconstruction. Traditional open harvest techniques result in a large prominent scar, delayed ambulation and poor patient satisfaction. Accordingly, we have designed a neurotome device to exclusively harvest the sural nerve as a safe and effective alternative to traditional techniques. Five patients underwent sural nerve harvest using our neurotome device. Scanning electron microscopy confirmed the preservation of histological nerve architecture when compared to nerves harvested by traditional open technique. Patients who underwent traditional open harvest of the sural nerve were asked to fill out a questionnaire to assess patient satisfaction. Ninety-three percent preferred a shorter scar, 20% complained of difficult ambulation, while 50% found troubling sensory deficits. Patients undergoing sural nerve harvest by our novel technique were satisfied with the cosmetic results and had less difficulty in ambulation. To optimize operative technique, cadaveric dissection of 15 limbs was done to further define the anatomic relationship of the sural nerve to the short saphenous vein. Minimally invasive harvest of sural nerve through our novel technique yields good cosmetic and functional results.

Detecting copy number status and uncovering subclonal markers in heterogeneous tumor biopsies

Background

Genomic aberrations can be used to determine cancer diagnosis and prognosis. Clinically relevant novel aberrations can be discovered using high-throughput assays such as Single Nucleotide Polymorphism (SNP) arrays and next-generation sequencing, which typically provide aggregate signals of many cells at once. However, heterogeneity of tumor subclones dramatically complicates the task of detecting aberrations.

Results

The aggregate signal of a population of subclones can be described as a linear system of equations. We employed a measure of allelic imbalance and total amount of DNA to characterize each locus by the copy number status (gain, loss or neither) of the strongest subclonal component. We designed simulated data to compare our measure to existing approaches and we analyzed SNP-arrays from 30 melanoma samples and transcriptome sequencing (RNA-Seq) from one melanoma sample.

We showed that any system describing aggregate subclonal signals is underdetermined, leading to non-unique solutions for the exact copy number profile of subclones. For this reason, our illustrative measure was more robust than existing Hidden Markov Model (HMM) based tools in inferring the aberration status, as indicated by tests on simulated data. This higher robustness contributed in identifying numerous aberrations in several loci of melanoma samples. We validated the heterogeneity and aberration status within single biopsies by fluorescent in situ hybridization of four affected and transcriptionally up-regulated genes E2F8, ETV4, EZH2 and FAM84B in 11 melanoma cell lines. Heterogeneity was further demonstrated in the analysis of allelic imbalance changes along single exons from melanoma RNA-Seq.

Conclusions

These studies demonstrate how subclonal heterogeneity, prevalent in tumor samples, is reflected in aggregate signals measured by high-throughput techniques. Our proposed approach yields high robustness in detecting copy number alterations using high-throughput technologies and has the potential to identify specific subclonal markers from next-generation sequencing data.

Correction of postpneumonectomy syndrome using a custom implant

The authors describe a patient who underwent a right pneumonectomy for removal of a bronchial carcinoid tumour. Over time she developed recurrent infections, dyspnoea and wheeze despite no evidence of tumour recurrence. A marked mediastinal shift caused severe narrowing of the left main-stem bronchus as it was draped over the vertebral column consistent with a diagnosis of postpneumonectomy syndrome. Mediastinal reorientation was accomplished with the placement of two breast implants. Failure of the superior implant resulted in a recurrence of symptoms 4 months postoperatively. A durable custom expander with wall thickness three times that of a standard expander was placed after rupture of one of the two initially placed saline implants. At 2-years follow-up the patient has complete resolution of symptoms, without any further postoperative complications.

Tunnelled tensor fascia lata flap for complex abdominal wall reconstruction

This study describes the treatment of two patients with recurrent, infected abdominal wall defects using bilateral delayed and tunnelled pedicled tensor fascia lata (TFL) myofascial flaps. TFL flaps were elevated and delayed for 4 weeks in both cases. In the second case, Parietex Composite mesh was positioned underneath the TFL flap and allowed to incorporate. After a delay of 4 weeks, the flaps were harvested and tunnelled subcutaneously to repair the abdominal wall defect. Both patients have stable repairs but had donor site seromas requiring drainage. Cadaver dissection was also performed to identify structures related to TFL flap harvest. We identified a variant of lateral femoral cutaneous nerve that traversed the TFL flap, necessitating meticulous dissection during surgery. In summary, we describe a new technique of incorporating mesh into the TFL prior to flap harvest for reconstruction of complex abdominal wall.

A common variant in the patatin-like phospholipase 3 gene (PNPLA3) is associated with fatty liver disease in obese children and adolescents

The genetic factors associated with susceptibility to nonalcoholic fatty liver disease (NAFLD) in pediatric obesity remain largely unknown. Recently, a nonsynonymous single-nucleotide polymorphism (rs738409), in the patatin-like phospholipase 3 gene (PNPLA3) has been associated with hepatic steatosis in adults. In a multiethnic group of 85 obese youths, we genotyped the PNLPA3 single-nucleotide polymorphism, measured hepatic fat content by magnetic resonance imaging and insulin sensitivity by the insulin clamp. Because PNPLA3 might affect adipogenesis/lipogenesis, we explored the putative association with the distribution of adipose cell size and the expression of some adipogenic/lipogenic genes in a subset of subjects who underwent a subcutaneous fat biopsy. Steatosis was present in 41% of Caucasians, 23% of African Americans, and 66% of Hispanics. The frequency of PNPLA3(rs738409) G allele was 0.324 in Caucasians, 0.183 in African Americans, and 0.483 in Hispanics. The prevalence of the G allele was higher in subjects showing hepatic steatosis. Surprisingly, subjects carrying the G allele showed comparable hepatic glucose production rates, peripheral glucose disposal rate, and glycerol turnover as the CC homozygotes. Carriers of the G allele showed smaller adipocytes than those with CC genotype (P = 0.005). Although the expression of PNPLA3, PNPLA2, PPARγ2(peroxisome proliferator-activated receptor gamma 2), SREBP1c(sterol regulatory element binding protein 1c), and ACACA(acetyl coenzyme A carboxylase) was not different between genotypes, carriers of the G allele showed lower leptin (LEP)(P = 0.03) and sirtuin 1 (SIRT1) expression (P = 0.04).

CONCLUSION

A common variant of the PNPLA3 gene confers susceptibility to hepatic steatosis in obese youths without increasing the level of hepatic and peripheral insulin resistance. The rs738409 PNPLA3 G allele is associated with morphological changes in adipocyte cell size.

Downregulation of ADIPOQ and PPARγ2 gene expression in subcutaneous adipose tissue of obese adolescents with hepatic steatosis

Hepatic steatosis is associated with hypoadiponectinemia. The mechanism(s) resulting in lower serum adiponectin levels in obese adolescents with fatty liver is unknown. In two groups of equally obese adolescents, but discordant for hepatic fat content, we measured adiponectin, leptin, peroxisome proliferator-activated receptor γ 2 (PPARγ2) and tumor necrosis factor-α (TNFα) gene expression in the abdominal subcutaneous adipose tissue (SAT). Twenty six adolescents with similar degrees of obesity underwent a subcutaneous periumbilical adipose tissue biopsy, in addition to metabolic (oral glucose tolerance test, and hyperinsulinemic--euglycemic clamp), and imaging studies (magnetic resonance imaging (MRI), DEXA). Using quantitative real-time-PCR; adiponectin, PPARγ2, TNFα, and leptin mRNA were measured. Based on a hepatic fat content (hepatic fat fraction, HFF) >5.5%, measured by fast MRI, the subjects were divided into low and high HFF group. In addition to the hypoadiponectinemia in the high HFF group, we found that the expression of adiponectin as well as PPARγ2 in the SAT was significantly decreased in this group. No differences were noted for TNFα and leptin plasma or mRNA levels between the groups. An inverse relationship was observed between adiponectin or PPARγ2 expression and hepatic fat content, whereas, adiponectin expression was positively related to PPARγ2 expression. Independent of overall obesity, a reduced expression of adiponectin and PPARγ2 in the abdominal SAT is associated with high liver fat content, as well as with insulin resistance in obese adolescents.

Cellularity and adipogenic profile of the abdominal subcutaneous adipose tissue from obese adolescents: association with insulin resistance and hepatic steatosis

OBJECTIVE

We explored whether the distribution of adipose cell size, the estimated total number of adipose cells, and the expression of adipogenic genes in subcutaneous adipose tissue are linked to the phenotype of high visceral and low subcutaneous fat depots in obese adolescents.

RESEARCH DESIGN AND METHODS

A total of 38 adolescents with similar degrees of obesity agreed to have a subcutaneous periumbilical adipose tissue biopsy, in addition to metabolic (oral glucose tolerance test and hyperinsulinemic euglycemic clamp) and imaging studies (MRI, DEXA, (1)H-NMR). Subcutaneous periumbilical adipose cell-size distribution and the estimated total number of subcutaneous adipose cells were obtained from tissue biopsy samples fixed in osmium tetroxide and analyzed by Beckman Coulter Multisizer. The adipogenic capacity was measured by Affymetrix GeneChip and quantitative RT-PCR.

RESULTS

Subjects were divided into two groups: high versus low ratio of visceral to visceral + subcutaneous fat (VAT/[VAT+SAT]). The cell-size distribution curves were significantly different between the high and low VAT/(VAT+SAT) groups, even after adjusting for age, sex, and ethnicity (MANOVA P = 0.035). Surprisingly, the fraction of large adipocytes was significantly lower (P < 0.01) in the group with high VAT/(VAT+SAT), along with the estimated total number of large adipose cells (P < 0.05), while the mean diameter was increased (P < 0.01). From the microarray analyses emerged a lower expression of lipogenesis/adipogenesis markers (sterol regulatory element binding protein-1, acetyl-CoA carboxylase, fatty acid synthase) in the group with high VAT/(VAT+SAT), which was confirmed by RT-PCR.

CONCLUSIONS

A reduced lipo-/adipogenic capacity, fraction, and estimated number of large subcutaneous adipocytes may contribute to the abnormal distribution of abdominal fat and hepatic steatosis, as well as to insulin resistance in obese adolescents.

Buried dermal flap for the treatment of chronic postoperative seroma

Postoperative seroma is a common postoperative complication, particularly following surgery on massive weight loss patients. Within this patient population, seromas are often chronic, requiring multiple invasive procedures to adequately control. Here, the authors describe a unique dermal flap approach for the long-term treatment of postoperative seroma.

Incidence of the V600K mutation among melanoma patients with BRAF mutations, and potential therapeutic response to the specific BRAF inhibitor PLX4032

Activating mutations in BRAF kinase are common in melanomas. Clinical trials with PLX4032, the mutant-BRAF inhibitor, show promising preliminary results in patients selected for the presence of V600E mutation. However, activating V600K mutation is the other most common mutation, yet patients with this variant are currently excluded from the PLX4032 trials. Here we present evidence that a patient bearing the BRAF V600K mutation responded remarkably to PLX4032, suggesting that clinical trials should include all patients with activating BRAF V600E/K mutations.

Recent advances in postoperative pain management

Good pain control after surgery is important to prevent negative outcomes such as tachycardia, hypertension, myocardial ischemia, decrease in alveolar ventilation, and poor wound healing. Exacerbations of acute pain can lead to neural sensitization and release of mediators both peripherally and centrally. Clinical wind up occurs from the processes of N-Methyl D-Aspartate (NMDA) activation, wind up central sensitization, long-term potentiation of pain (LTP), and transcription-dependent sensitization. Advances in the knowledge of molecular mechanisms have led to the development of multimodal analgesia and new pharmaceutical products to treat postoperative pain. The new pharmacological products to treat postoperative pain include extended-release epidural morphine and analgesic adjuvants such as capsaicin, ketamine, gabapentin, pregabalin dexmetomidine, and tapentadol. Newer postoperative patient-controlled analgesia (PCA) in modes such as intranasal, regional, transdermal, and pulmonary presents another interesting avenue of development.

Genome-wide screen of promoter methylation identifies novel markers in melanoma

DNA methylation is an important component of epigenetic modifications, which influences the transcriptional machinery aberrant in many human diseases. In this study we present the first genome-wide integrative analysis of promoter methylation and gene expression for the identification of methylation markers in melanoma. Genome-wide promoter methylation and gene expression of eight early-passage human melanoma cell strains were compared with newborn and adult melanocytes. We used linear mixed effect models (LME) in combination with a series of filters based on the localization of promoter methylation relative to the transcription start site, overall promoter CpG content, and differential gene expression to discover DNA methylation markers. This approach identified 76 markers, of which 68 were hyper- and eight hypomethylated (LME, P < 0.05). Promoter methylation and differential gene expression of five markers (COL1A2, NPM2, HSPB6, DDIT4L, MT1G) were validated by sequencing of bisulfite-modified DNA and real-time reverse transcriptase PCR, respectively. Importantly, the incidence of promoter methylation of the validated markers increased moderately in early and significantly in advanced-stage melanomas, using early-passage cell strains and snap-frozen tissues (n = 18 and n = 24, respectively) compared with normal melanocytes and nevi (n = 11 and n = 9, respectively). Our approach allows robust identification of methylation markers that can be applied to other studies involving genome-wide promoter methylation. In conclusion, this study represents the first unbiased systematic effort to determine methylation markers in melanoma and revealed several novel genes regulated by promoter methylation that were not described in cancer cells before.

Integrative analysis of epigenetic modulation in melanoma cell response to decitabine: clinical implications

Decitabine, an epigenetic modifier that reactivates genes otherwise suppressed by DNA promoter methylation, is effective for some, but not all cancer patients, especially those with solid tumors. It is commonly recognized that to overcome resistance and improve outcome, treatment should be guided by tumor biology, which includes genotype, epigenotype, and gene expression profile. We therefore took an integrative approach to better understand melanoma cell response to clinically relevant dose of decitabine and identify complementary targets for combined therapy. We employed eight different melanoma cell strains, determined their growth, apoptotic and DNA damage responses to increasing doses of decitabine, and chose a low, clinically relevant drug dose to perform whole-genome differential gene expression, bioinformatic analysis, and protein validation studies. The data ruled out the DNA damage response, demonstrated the involvement of p21(Cip1) in a p53-independent manner, identified the TGFbeta pathway genes CLU and TGFBI as markers of sensitivity to decitabine and revealed an effect on histone modification as part of decitabine-induced gene expression. Mutation analysis and knockdown by siRNA implicated activated beta-catenin/MITF, but not BRAF, NRAS or PTEN mutations as a source for resistance. The importance of protein stability predicted from the results was validated by the synergistic effect of Bortezomib, a proteasome inhibitor, in enhancing the growth arrest of decitabine in otherwise resistant melanoma cells. Our integrative analysis show that improved therapy can be achieved by comprehensive analysis of cancer cells, identified biomarkers for patient's selection and monitoring response, as well as targets for improved combination therapy.

An unusual log-splitter injury leading to radial artery thrombosis, ulnar artery laceration, and scapholunate dissociation

A log splitter is a gasoline- or diesel-powered machine that uses a hydraulic-powered cutting wedge to do the work of an axe. Log-splitter injuries that do not result in amputation of digits or limbs are uncommon and not well described in the literature. We present a unique case of a patient who sustained a log-splitter injury that resulted in thrombosis of the radial artery and avulsion laceration of the ulnar artery leading to acute hand ischemia, in addition to scapholunate ligament disruption leading to a DISI deformity. In this case, thrombolytic therapy was contraindicated and surgical revascularization was the best possible treatment option. Our case illustrates the pitfalls of using this modality in a crush injury, since the use of thrombolytics in this instance would have resulted in severe hemorrhage. An important clinical caveat is the potentially misleading arteriographic diagnosis of thrombosis and/or spasm.

Squamous cell carcinoma in a linear epidermal nevus

An 81-year-old African American female presented with a 3-year history of a slow, persistently enlarging mass on the medial aspect of her left thigh. Her past history was remarkable for a congenital linear epidermal naevus that was present on the inner aspect of her left thigh. A biopsy of the mass was performed and histology results confirmed the diagnosis of a well differentiated squamous cell carcinoma. Such an occurrence is extremely rare and less than 10 cases have been reported in the literature.

Article Commentary: Pain after Mastectomy and Breast Reconstruction

Breast cancer is a potentially deadly disease affecting one in eight women. With the trend toward minimally invasive therapies for breast cancer, such as breast conserving therapies, sentinel node biopsies, and early treatments of radiation and chemotherapy, life expectancy after breast cancer has increased. However, pain after breast cancer surgery is a major problem and women undergoing mastectomy and breast reconstruction experience postoperative pain syndromes in approximately one-half of all cases. Patients post mastectomy and breast reconstruction can suffer from acute nociceptive pain and chronic neuropathic pain syndromes. Several preventative measures to control acute post operative pain and chronic pain states such as post mastectomy pain and phantom pain have been tried. This review focuses on the recent research done to control acute and chronic pain in patients receiving minimally invasive therapies for breast cancer, such as breast conserving therapies of mastectomies and breast reconstruction, sentinel node biopsies, and early treatments of radiation and chemotherapy.

Pain after mastectomy and breast reconstruction

Breast cancer is a potentially deadly disease affecting one in eight women. With the trend toward minimally invasive therapies for breast cancer, such as breast conserving therapies, sentinel node biopsies, and early treatments of radiation and chemotherapy, life expectancy after breast cancer has increased. However, pain after breast cancer surgery is a major problem and women undergoing mastectomy and breast reconstruction experience postoperative pain syndromes in approximately one-half of all cases. Patients post mastectomy and breast reconstruction can suffer from acute nociceptive pain and chronic neuropathic pain syndromes. Several preventative measures to control acute post operative pain and chronic pain states such as post mastectomy pain and phantom pain have been tried. This review focuses on the recent research done to control acute and chronic pain in patients receiving minimally invasive therapies for breast cancer, such as breast conserving therapies of mastectomies and breast reconstruction, sentinel node biopsies, and early treatments of radiation and chemotherapy.

Frontal sinus fractures: a review of trends, diagnosis, treatment, and outcomes at a level 1 trauma center in Connecticut

The purpose of this retrospective study is to document the incidence and etiology of frontal sinus fracture at a level 1 traumacenterin Connecticut, assess the variability of management within our institution, and assess the effect on outcome over a seven-year period (January 1995-March 2002). Sixty-three cases were identified. Mean age was 31 years (92% male). The most common mechanism of injury was motor vehicle accident, followed by falls. The rates of associated facial fracture and intracranial injury were 83%, and 54% respectively. Diagnostic imaging missed two fractures. This study documents significant intrainstitutional variation in surgical management across contemporaneous primary treatment teams. There was no significant difference in outcome noted based on the treating specialty of the primary team for a given fracture type. The material used for sinus obliteration had no affect on outcome. Notable complications ofcerebrospinal fluid leak and mucocele are discussed as they contribute to current management guidelines.

Prosthetic vascular graft infection: a multi-center review of surgical management

A multi-center retrospective review of major prosthetic graft infection outcomes was undertaken to determine graft preservation and limb salvage rates. The management of infected prosthetic vascular grafts continues to be controversial. The purpose of this study was to review the surgical management of major extracavitary prosthetic vascular graft infections and to correlate the outcomes on the basis of bacteriology and grade. The change in patient population seen by vascular surgeons and the recent emergence of more virulent bacterial strains should influence surgical management. Bacteriology and severity of infection based on grade must play a greater role in the selection criteria for graft salvage. Despite advancement in the understanding of these interactions and the emergence of new management algorithms, we are continuing to operate without a uniform standard in managing this difficult and rapidly evolving clinical problem.

Giant nevi: a review

Congenital nevi are benign neoplasms that are present at birth and composed of nevomelanocytes. Approximately 1-3% of all newborns have congenital pigmented nevi, and the number of nevi increases with age, peaking by late adolescence to 20-40 nevi in an individual. Giant congenital nevi are often defined as nevi that are greater than 20 cm in diameter in an adult, or nevi that occupy 2% or more of the body surface area. Histologically, nevi are transformed melanocytes, which are normally highly dendritic cells interspersed among basal keratinocytes. The genetic basis of these lesions is not known. Findings of a culture of melanocytes from such a lesion from a showed chromosome rearrangements involving 1p,12q, and 19p. The giant nevi might be associated to several diseases: neurocutaneous melanosis, diffuse lipomatosis, structural brain malformations, hypertrophy of skull bones, limb atrophy, skeletal asymmetry involving both soft tissue hyper-and hypoplasia, von Recklinghausen's disease and vitiligo. The risk of malignant change in giant nevi is probably the most contentious issue in its management. The consensus is that lesions are pre-malignant, but the purported incidence of malignancy varies wildly from 0-42%. Surgical excision remains the mainstay of treatment for large congenital melanocytic nevi, and most giant nevi are managed by staged excision and resurfacing with skin grafts or tissue expanders and flaps.

Diagnosis and treatment of interval sentinel lymph nodes in patients with cutaneous melanoma

BACKGROUND

Interval sentinel lymph nodes in patients with melanoma are occasionally found outside conventional nodal basins. In this study, the authors examined the frequency, location, and incidence of nodal metastasis of such interval nodes in a large cohort of patients with primary cutaneous melanoma.

METHODS

Between September of 1997 and February of 2003, 374 consecutive patients at the Yale Cancer Center Melanoma Unit underwent sentinel lymph node biopsy for primary cutaneous melanoma with a Breslow thickness of at least 1.0 mm and/or Clark IV or greater histologic dermal invasion. All patients underwent preoperative lymphoscintigraphy to map the lymphatic drainage for the primary lesion and intraoperative confirmation, and biopsy was performed on all sentinel lymph nodes identified.

RESULTS

Unequivocal interval sentinel lymph nodes were identified in eight of 374 patients (2.1 percent). Three of these eight patients had metastatic spread to the interval sentinel nodes. In four of the eight patients, the interval sentinel lymph node was not located in the anticipated lymphatic pathway between the primary tumor and the sentinel lymph node basin.

CONCLUSIONS

Interval sentinel nodes seem as likely to contain micrometastatic disease as those in the expected sentinel lymph node basin. Half of the subjects displayed interval sentinel lymph nodes that were not in the anticipated lymphatic pathway between the primary tumor and the sentinel lymph node basin. These findings suggest that adequate preoperative lymphoscintigraphy and intraoperative recognition of interval nodes are of paramount importance in the treatment of melanoma.