The Inverted V-Shaped Fasciocutaneous Advancement Flap Effectively Solves the Complication of Tracheostomal Stenosis

ABSTRACT

Tracheostomal stenosis after laryngectomy is a distressing complication. We present a retrospective study on sequential 9 patients who underwent stomaplasty with inverted V-shaped fasciocutaneous advancement flap. This procedure effectively solves tracheostomal stenosis, providing large stoma for breathing with no need for further stenting and low revision rates.

First Reported Case of Skin Necrosis Due to Prolonged Mechanical Compression After Transradial Catheterization

We present a patient under triple-antithrombotic therapy who underwent prolonged mechanical compression after radial intervention; the subsequent necrosis at the access site required surgical repair.

Microbiology of acute bacterial skin and skin-structure infections in Greece: A proposed clinical prediction score for the causative pathogen

Although clinical definitions of acute bacterial skin and skin-structure infection (ABSSSI) are now well established, guidance of the prediction of likely pathogens based on evidence is missing. This was a large survey of the microbiology of ABSSSIs in Greece. During the period November 2014 to December 2016, all admissions for ABSSSI in 16 departments of internal medicine or surgery in Greece were screened to determine the likely bacterial aetiology. Samples were cultured on conventional media. Expression of the SA442, mecA/mecC and SCCmec-orfX junction genes was assessed. Following univariate and forward logistic regression analysis, clinical characteristics were used to develop scores to predict the likely pathogen with a target of 90% specificity. In total, 1027 patients were screened and 633 had positive microbiology. Monomicrobial infection by Gram-positive cocci occurred in 52.1% and by Gram-negative bacteria in 20.5%, and mixed infection by Gram-positive cocci and Gram-negative bacteria in 27.3%. The most common isolated pathogens were Staphylococcus aureus and coagulase-negative staphylococci. Resistance to methicillin was 57.3% (53.5-61.1%). Three predictive scores were developed: one for infection by methicillin-resistant S. aureus, incorporating recent hospitalisation, atrial fibrillation, residency in long-term care facility (LTCF) and stroke; one for mixed Gram-positive and Gram-negative infections, incorporating localisation of ABSSSI in lumbar area, fluoroquinolone intake in last 6 days, residency in LTCF and stroke; and another for Gram-negative infection, incorporating skin ulcer presentation, peptic ulcer and solid tumour malignancy. In conclusion, methicillin-resistant staphylococci are the main pathogens of ABSSSIs. The scores developed may help to predict the likely pathogen.

Giant Cell Tumor of Tendon Sheath Developed over Chimeric-Free Latissimus Dorsi and Serratus Anterior Muscle Flaps

This article describes a rare case of giant cell tumor of the tendon sheath (GCTTS) that was developed over the substance of chimeric-free latissimus dorsi and -serratus -anterior muscle flaps performed for lower limb reconstruction. To our knowledge, development of GCTTS over a free flap is first described in the literature. A 71-year-old -woman was presented with a large protuberant ulcerated tumor mass that was developed over the substance of chimeric free muscle flaps at the foot and ankle. We performed an extensive tumor resection, and the pathology report confirmed the presence of a primary giant cell tumor. The patient was advised to have a below-knee amputation. However, the patient refused the amputation, and 4 months later, she was presented with a metastatic mass proximally at the upper thigh. We believe that the GCTTS was associated with the chronic inflammation of the soft tissue and bones along with the recurrent episodes of infection, mainly due to proteus mirabilis and proteus syndrome (PS). PS may lead to the development of malformations and overgrowth of different tissues in unusual locations. In cases resistant to antibiotics, the radical surgical debridement should be considered as the most effective treatment.

Sentinel lymph node metastasis in primary cutaneous basosquamous carcinoma. A cross-sectional study

BACKGROUND AND OBJECTIVES

Basosquamous carcinoma (BSC) is a rare, biologically aggressive tumor. This cross-sectional study aims to define risk factors for subclinical nodal metastasis in primary BSC, and identify the patients who would benefit from routine sentinel node biopsy (SLNB) as part of the initial management.

METHODS

A total of 142 patients, with histologically proven BSC without palpable lymph nodes, underwent SLNB after the initial excision. Clinicopathological features and demographics were analyzed between the patients with detected micrometastasis (SLNM) and those with negative SLN.

RESULTS

In 7.7% patients, subcapsular and <0.1 mm SLNM were found. The frequency of SLNM was 0.9%, 11.8%, and 80.0% in patients with maximum lesion diameter ≤ 2 cm, 2.1-3.0 cm and >3.0 cm, respectively (P < 0.001) and was strongly associated with perineural (P < 0.001; OR = 26.46, 95% CI = 5.62-124.52) and lymphatic invasion (P < 0.001; OR = 17.35, 95% CI = 4.44-67.91). Within 18-84 months, no recurrence or metastasis were observed in SLNM positive patients. False negative SLNB rate of 15.4% was recorded.

CONCLUSION

Cutaneous BSC is associated with early nodal metastatic potential. Tumor size >2 cm, lymphatic and perineural invasion are significant determinants for SLN micrometastasis. In the absence of palpable lymphadenopathy, wide resection and SLNB with long-term follow-up are highly recommended in these patients.

Changes of Arterio-venous Differences in pH and pCO2 by Hemodialysis

Normally the differences in arterial-venous pH (A-VpH) and veno-arterial pCO2 (V-ApCO2) are small and constant. This study deals with A-VpH and V-ApCO2 and their effect on arterial-venous saturation hemoglobin percentage (A-VSHb%) in uremic patients under hemodialysis (HD). In 17 uremic patients under HD with acetate, blood samples were collected anaerobically in heparinized syringes from artery (fistula) and vein (forearm without fistula) pre- and post-HD. In these samples pH, pCO2 and SHb% were determined and A-VpH, V-ApCO2 and A-VSHb% were estimated. Comparison between the values pre- and post-HD of A-VpH, V-ApCO2 and A-VSHb% shows that these three values were decreased significantly post-HD (p<0.001). The correlation of all values (pre- and post-HD) of A-VpH and V-ApCO2 with that of A-VSHb% was significant and positive (r=0.514 p<0.01, r=0.505 p<0.01, respectively).

Serum S100B levels correlate with stage, N status, mitotic rate and disease outcome in melanoma patients independent to LDH

PURPOSE

S100B protein is currently used as an immunohistochemistry marker to confirm melanoma diagnosis in biopsy specimens. Moreover, accumulating evidence supports its potential use as a tumor biomarker in blood. This study aimed to explore the potential uses of serum S100B protein as a biomarker in melanoma patients.

METHODS

From 2012 to 2015, 107 sequential patients were diagnosed and treated for melanoma. All patients were tested for serum S100B and lactate dehydrogenase (LDH) at diagnosis and during their regular follow-up. Potential correlations between S100B serum levels and baseline characteristics and its impact on survival were assessed.

RESULTS

S100B serum levels were within normal limits in patients with stages I and II, elevated in stage III, and very high in stage IV. In bivariate analysis, serum S100B levels >0.11μg/l and stage IV were the only independent prognostic factors associated with poor survival. Furthermore, S100B >0.5μg/l was associated with stage IV and poor survival. However, there was no significant association with LDH. S100B serum levels were positively correlated with mitotic rate (p=0.003), but only in stage IV patients (p=0.015). In stage III, a statistically significant difference in S100B serum levels were observed between N3, N2 and N1 stages, with higher levels for N2 (p=0.012) and N3 (p=0.009) compared to N1, and no difference between stages N2 and N3 (p=1.000). Also, no correlation was found between the number of primary melanoma lesions and S100B.

CONCLUSIONS

S100B serum levels reflect tumor load, correlate with response to treatment, might identify patients who are at increased risk of disease relapse, may predict prognosis independent to LDH, and could be used as early biomarkers of tumor recurrence.

Tips and Outcomes of a New DIEP Flap Inset in Delayed Breast Reconstruction: The Dual-Plane Technique

Purpose The dual-plane deep inferior epigastric perforator (DIEP) flap inset technique is herein presented with tips for optimizing the aesthetic outcome in delayed autologous breast reconstruction after radiation therapy. Patients and Methods A total of 42 women who underwent microsurgical reconstruction with a free DIEP flap participated in this prospective study. The flap was inset in a dual plane lying behind the pectoralis major at the upper pole and in front of the muscle at the lower pole of the reconstructed breast. Results The dual-plane flap inset resulted in natural transition from native and reconstructed tissues, excellent scar quality, optimal outline of the breast, and overall breast appearance. Moreover, dual-plane reconstruction was associated with constantly high patient satisfaction without wearing brassiere due to fullness of the upper pole and minimal ptosis with time. Conclusion The dual-plane DIEP flap inset results in optimal scar quality, breast shape, and fullness of the upper pole, resulting in high patient satisfaction.

Burn injuries and soft tissue traumas complicated by mucormycosis infection: a report of six cases and review of the literature

Mucor fungus infection is a rare opportunistic infection, rapidly progressive and often fatal in immunocompromised patients, or in patients with chronic debilitating diseases. We report six cases of trauma patients with mucormycosis. Three had severe thermal burns, one of them with a medical history of diabetes mellitus. The other three patients suffered from severe soft tissue injuries caused by traffic accidents. In all cases there had been spontaneous exposure and contact of the wounds with soil. During hospitalization, fungi cultures and/or biopsies of all wounds were performed and all resulted positive. The patients were treated with Amphotericin B (AmB) and surgical debridement. Two of them died and the other four were fully healed and discharged. Mucormycosis should be considered in any case of aggressive skin tissue necrosis with a history of soiled wounds. We suggest that mucormycosis is treated by intravenous and local administration of AmB, extensive and repeated debridement and cautious coverage of the wound. The plastic surgeon must wait for negative swab cultures and biopsies before covering the defects with skin grafts or flaps. Reconstruction may be challenging, depending on the extent, depth, location and special indications of the affected site and the donor site availability.

Recurrent giant mandibular ameloblastoma in young adults

BACKGROUND

The purpose of the study was to define the most appropriate management of the giant mandibular ameloblastoma (GMA) in young adults.

METHODS

A retrospective study was performed on patients with GMA <30 years old. The data collected included initial treatment, tumor margins, reconstruction, and follow-up. Patients evaluated speech, chewing, swallowing, and facial appearance after definitive treatment.

RESULTS

Thirteen patients were identified with recurrent solid/multicystic disease requiring further treatment. Definitive treatment involved segmental mandibulectomy and reconstruction with free fibular flap in all patients. Seven patients had immediate reconstruction (group A) and 6 had secondary (group B). Mandibular resection was planned at least 2 cm beyond the radiological limit, free margins were achieved in all patients, and all flaps were transplanted successfully. In group A, functional score was 13.7 ± 0.45 and facial appearance score was 4.5 ± 0.49, whereas in group B were 11.16 ± 0.37 and 3.3 ± 0.5, respectively (both p < .05).

CONCLUSION

Aggressive resection of the GMA and immediate reconstruction is strongly advised. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1947-E1954, 2016.

The use of the ALT Flap and Lateral Femoral Cutaneous Nerve for the Reconstruction of Carpal Soft Tissue and Ulnar Nerve Defects: a Case Report

The anterolateral thigh (ALT) flap has become one of the workhorse flaps, with indications including diverse reconstructive problems. The lateral thigh area is also a useful donor site for nerve grafts. The lateral femoral cutaneous (LFC) nerve can be dissected along with the ALT flap for a substantial length, depending on the requirements of the recipient site. The LFC nerve can be used as a vascularized or non-vascularized nerve graft. The technique offers advantages and it can find clinical applications, satisfying the functional and aesthetic reconstructive requirements of a complex defect. We report the case of a patient who presented with traumatic soft tissue defect of the volar aspect of the wrist and ulnar nerve defect as a complication of a fracture of distal radius. An ALT flap was used to reconstruct the soft tissue defect. The ulnar nerve was resected due to necrosis and the gap was repaired with non-vascularized grafts of the anterior branch of the LFC nerve. The soft tissues were resurfaced successfully without complications. Functional recovery was good for the superficial branch of the ulnar nerve, whereas it was variable for the deep branch of the ulnar nerve. The anterolateral thigh area offers significant advantages as donor site in the reconstruction of complex soft tissue defects being a large source of vascularized skin, fat, fascia, muscle and nerve. This availability allows for single donor site dissection, minimizing the operating time and the associated morbidity.

Flap reconstruction of the knee: A review of current concepts and a proposed algorithm

A literature search focusing on flap knee reconstruction revealed much controversy regarding the optimal management of around the knee defects. Muscle flaps are the preferred option, mainly in infected wounds. Perforator flaps have recently been introduced in knee coverage with significant advantages due to low donor morbidity and long pedicles with wide arc of rotation. In the case of free flap the choice of recipient vessels is the key point to the reconstruction. Taking the published experience into account, a reconstructive algorithm is proposed according to the size and location of the wound, the presence of infection and/or 3-dimensional defect.

Demographic, behavioural and physician-related determinants of early melanoma detection in a low-incidence population

BACKGROUND

Knowledge of the factors that influence early detection of melanoma is important in developing strategies to reduce associated mortality.

OBJECTIVES

To identify sociodemographic, behavioural and medical care-related factors associated with melanoma thickness in a low-incidence population but with a high case fatality.

PATIENTS AND METHODS

In a multicentre, retrospective, survey-based study of 202 patients with a recent diagnosis of invasive melanoma (< 1 year), we collected data on demographic and behavioural factors, attitudes towards prevention, access to medical care, frequency of skin self-examination (SSE) and physician skin examination (PSE) in relation to melanoma thickness.

RESULTS

Thinner tumours (≤ 1 mm, 80 melanomas) were associated with female sex (P ≤ 0.049), nonnodular (superficial spreading melanoma, lentigo maligna melanoma, acral lentiginous melanoma) histological subtypes (P < 0.001), absence of ulceration (P ≤ 0.001), and location other than lower extremity or trunk location (P ≤ 0.004). Patients married at the time of diagnosis or who performed SSE during the year prior to diagnosis were more likely to have thinner tumours than those who did not [odds ratio (OR) 3.45, 95% confidence interval (CI) 1.48-8.04 and OR 2.43, 95% CI 1.10-5.34, respectively]. Full-body skin examination by a physician was not significantly associated with thinner melanoma (OR 1.99, 95% CI 0.66-6.07).

CONCLUSIONS

SSE was shown to be an important factor in the detection of thin melanoma, in contrast to partial or full-body PSE, which did not show any statistically significant effect on tumour thickness.

Integrating imaging techniques in lower limb microsurgical reconstruction: focusing on ultrasonography versus computed tomography angiography

Recent developments in the field of biomedical imaging have facilitated the use of various imaging techniques as adjunctive tools in microsurgical lower limb reconstructions. Frequently-used imaging modalities in reconstructive microsurgery are colour-Doppler ultrasound and computed tomography angiography. Here, we present basic principles of the above applied techniques and analyze the surgical rationale of integrating imaging techniques in lower limb reconstruction.

Changes in donor site selection in lower limb free flap reconstructions by integrating duplex ultrasonography in the preoperative design

BACKGROUND

The flap selection criteria in lower extremity reconstruction are based on the wound characteristics and donor site morbidity. We hypothesized that the decision-making could be influenced by integrating Duplex Ultrasound (DU) in the preoperative design.

METHODS

We retrospectively reviewed data on patients who underwent lower-extremity microvascular soft-tissue reconstruction at our institution by the same surgeon. In Group A, DU was integrated in the preoperative design of the microsurgical reconstruction, whilst in Group B the choice of free flap donor site and level of anastomosis were based on clinical criteria only.

RESULTS

A total of 48 microvascular reconstructions were recorded. DU was used preoperatively in 20-patients, whilst in 28-patients flap selection was based on clinical criteria. There was a significant decrease in perforator flap (45% over 64%) and a significant increase in muscle flap preference (55% over 32%) in the DU-group. There was no significant difference (10% over 11%) in the donor site selection with considerable morbidity. There was no flap failure in the DU-group, whilst 3 flaps failed in the second-group (p< 0.05, χ(2)-test). Wound healing was significantly faster in the DU-group (21±3 days) compared to 37±3 days in the other group (p< 0.05, t-test).

CONCLUSION

Preoperative ultrasound studies moved flap preference towards chimeric and muscle flaps with low morbidity to match the three-dimensional defect and to promote healing.

KEYWORDS

lower limb reconstruction; free flap; donor site; duplex ultrasound.

The efficacy of recombinant human activated protein C (rhAPC) vs antithrombin III (at III) vs heparin, in the healing process of partial-thickness burns: a comparative study

This is an experimental study regarding the positive effect of recombinant human activated protein C (rhAPC) in the healing process of partial-thickness burns, in comparison to antithrombin III and heparin. On a porcine model we induced superficial partial-thickness and deep partial-thickness burns and performed intravenous administration of the elements of study during the first 48 h. The progress of the condition of the injured tissues was evaluated by histopathological examination at specific time intervals. The results showed an improved healing response of the specimens treated with rhAPC compared to those treated with antithrombin III, heparin, and placebo.

Is expansion of artificial dermis a reliable reconstructive option?

Reconstruction of full-thickness defects with the use of artificial dermis has been well established in the recent literature. The capacity of artificial dermis to expand over a period of years, months, or even days is described. Three such cases are reported. Two female patients, aged 21 and 30 years, with post-burn contractures of the chest with right breast hypoplasia and abdominal wall post-burn contractures respectively, and a 14-year-old male with a giant congenital naevus on the forearm, are presented. After excision of the contractures and the congenital naevus, the patients underwent staged reconstruction with the use of artificial dermal template and split-thickness skin autografts at monthly intervals. The 21-yr-old female also had a tissue expander placed submuscularly which six months later was replaced by a permanent silicone implant. Gradual expansion of artificial dermis within three weeks resulted in reconstruction of a breast of natural shape, size, and volume. In the second patient the artificial dermis was expanded over a period of months, until full-term pregnancy, while the third patient took years to achieve expansion naturally as he grew up. In conclusion, artificial dermis can be expanded over various periods of time (days to years), providing a reliable and safe alternative reconstructive method, particularly in areas where expansion is an absolute necessity for a good functional and aesthetic result.

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.

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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.