Back to the future: breast surgery with tumescent local anesthesia (TLA)?

PURPOSE

Breast surgery is usually performed under general anesthesia. Tumescent local anesthesia (TLA) offers the possibility to anesthetize large areas with highly diluted local anesthetic.

METHODS

In this paper, the implementation, and experiences with TLA in the field of breast surgery are discussed.

CONCLUSION

For carefully selected indications, breast surgery in TLA represents an alternative to ITN.

[Infiltration of the skull by dedifferentiated cutaneous leiomyosarcoma]

Wir berichten über einen 81-jährigen Patienten mit bereits mehrfach voroperiertem Tumor der Kopfhaut. In der histologischen erneuten Aufarbeitung ließ sich ein dedifferenziertes Leiomyosarkom nachweisen, das bereits die Schädeldecke infiltriert hatte. In einem interdisziplinären Ansatz mit den Kollegen der Klinik für Neurochirurgie konnte eine Komplettexzision erreicht werden. Kutane Leiomyosarkome sind seltene Tumoren der Haut, die typischerweise als langsam wachsende, erythematöse Knoten imponieren. Aufgrund des Metastasierungspotenzials ist eine komplette, schnittrandkontrollierte Resektion erforderlich.

Three-dimensional histology vs. serial section histology in the treatment of primary basal cell carcinoma: a randomized, prospective, blinded study of 569 tumours

BACKGROUND

For basal cell carcinoma (BCC), only few controlled data have been published so far, which directly compare micrographically controlled surgery with conventional serial section histology. In addition to Mohs surgery, which uses cryostat sections, also three-dimensional histology (3D-histology), based on paraffin sections, is available to ensure complete control of the margins and basic sections.

OBJECTIVES

To investigate the rate of local recurrence (LR) as well as the number of required re-excisions for basal cell carcinomas with serial section histology vs. 3D-histology.

METHODS

We compared serial sections histology with 3D-histology in a prospective, randomized, controlled blinded trial and analysed 569 BCC of all subtypes up to 30 mm diameter, 287 BCC in the 3D group and 282 BCC in the serial section group. Excisions were performed with adapted primary resection margin according to location and size of the tumour. Surgeons were blinded at the time of surgery as they did not know which histological method will be used. Both methods used paraffin sections.

RESULTS

Both groups did not differ regarding patients age, tumour location, tumour diameter, tumour subtypes or primary resection margins. In the serial section group, re-excisions were required in 21%; 24 tumours (8.4%) recurred after a median of 2.2 years. In the 3D-histology group, re-excisions were required in 39%; 10 tumours recurred (3.5%) after a median of 2.8 years. The recurrence rates differed significantly between both groups. Mean follow-up was 4.5 years.

CONCLUSIONS

3D-histology is a useful technique to detect tumour outgrowths at the excision margins, but required a high rate of re-excisions. 3D-histology was associated with a significantly lower LR rate than serial section histology.

[Two neutrophilic dermatoses and one multiple myeloma : A case report]

Pyoderma gangraenosum and subcorneal pustulosis are neutrophilic diseases. Different neutrophilic dermatoses can very rarely occur together in one patient, even with a latent period. Furthermore, there seems to be a direct association between IgA gammopathy and neutrophilic dermatosis. Therefore, a gammopathy must always be clarified in the presence of a neutrophilic dermatosis.

[Sequential digital dermatoscopic imaging. How much time is required per patient?]

BACKGROUND

Melanoma screening is possible using the naked eye, a loupe, a dermatoscope or a sequential digital dermatoscopic imaging (SDDI) device. The latter provides photodocumentation and makes it possible to assess changes over time. One potential disadvantage of this method has been felt to be in the time expenditure per patient.

OBJECTIVES

Objective was to prospectively assess the time required for routine melanoma screening, using a SDDI device.

MATERIALS AND METHODS

All patients screened for melanoma using a SDDI system (Mole Max2) in a private dermatology practice during 1 year were included prospectively. The time needed per patient was measured. Suspicious lesions were excised and histologically evaluated. The number needed to treat (NNT) was calculated. Excisions performed exclusively due to cosmetic reasons were not included.

RESULTS

381 patients with 10,356 melanocytic lesions were documented using SDDI and clinically assessed (mean: 27.18 melanocytic lesions per patient; min:1, max:110). Mean time consumption per lesion was 15.4 s. (min:3, max:57) and per patient about 7 min. 98 suspicious lesions were excised, among them13 melanomas; yielding a NNT of 7.54.

CONCLUSIONS

SDDI can be easily integrated into the daily routine; a variety of systems are available. The time required is reasonable, about 7 min per patient and about 15 s per lesion. The quality of the evaluation is operator-dependent; it can be evaluated by determining the NNT. A major advantage of this diagnostic procedure is the photodocumentation which makes it possible to assess potential progression of a melanocytic lesion.

A case of dog-related human seminal plasma allergy

Allergy to human seminal plasma (HSP) is rare. It presents with a variety of symptoms, ranging from localized changes to generalized reactions or even anaphylactic shock. Symptoms typically start within minutes to one hour after exposure. Diagnosis is based on history, evidence of specific IgE antibodies and skin prick testing (SPT). A 25-year-old Caucasian woman presented with eyelid swelling, generalized urticaria and dyspnea immediately after unprotected coitus with her partner. No symptoms occurred when barrier contraception was used. SPTand IgE testing (ImmunoCAP) demonstrated sensitization to HSP and dog dander. The patient's self-designed desensitization protocol, consisting of H1 blocker premedication followed by unprotected sexual intercourse, ameliorated her systemic reactions gradually and reduced the frequency of emergency hospital visits. She had a known allergy to male but not female dogs, and was highly sensitized to dog allergen Can f 5, a protein homologous to human prostate-specific antigen (PSA), suggesting a possible link to her HSP allergy.