Can prophylactic incisional negative pressure wound therapy Reduce Wound Complications After Inguinal Lymph Node Dissection for Melanoma? Results from a Randomized Controlled Trial.

Background: Inguinal lymph node dissection (ILND) is associated with a high complication rate. Retrospective studies suggest that incisional negative pressure wound therapy (iNPWT) might reduce complications, especially seroma, following ILND. Methods: This was a prospective multicenter, randomized (1:1), open-labeled, parallel-group trial. Patients with macrometastic melanoma to the inguinal lymph nodes and eligible for ILND were randomized to receive either iNPWT for 14 postoperative days or conventional wound dressing. The primary outcome was seroma incidence. Secondary outcomes included surgical-site infection, wound rupture, wound necrosis, hematoma, rehospitalization and readmission rates between groups. All outcomes were registered 3 months after ILND and analyzed according to the intention-to-treat principle. Results: The trial was terminated early due to a low recruitment rate as a consequence of a change in the national treatment protocol, and the estimated sample size was not reached. Twenty patients were included and randomized in the study. The trial showed less seroma formation between the iNPWT 6/11 (55%) and control 7/9 (78%) groups; however, this was not statistically significant (p = 0.29). Similarly, there were no differences in the rates of surgical-site infection (p = 0.63), wound rupture (p = 0.19), wound necrosis (p = 0.82), hematoma (p = 0.19), reoperation (p = 0.82) or readmission (p = 0.34) between groups. Conclusion: There was a tendency toward fewer complications in the iNPWT group, however this trial was underpowered and could not confirm the hypothesis that iNPWT reduces complications after ILND. Future randomized controlled trials are required to fully evaluate the treatment potential of iNPWT. Trial registration: The trial was prospectively registered at https://clinicaltrials.gov/ct2/show/NCT03433937.

[Malignant adnexal carcinomas of the skin].

Malignant adnexal carcinomas of the skin are rare but associated with high propensity for local recurrence, and for some of the distinct subgroups they are known to metastasize regionally or distant. Biopsy is necessary for correct diagnosis, as the lesions cannot be separated from other tumour types entirely on their clinical appearance. The histologic diagnosis is troublesome, and the lesions are often mistaken for their benign counterpart, basal cell carcinoma or squamous cell carcinoma. The lesions are treated with surgery. Radiotherapy and chemotherapy may play a role in treatment, although the evidence is limited.

Poor adherence to clinical guidelines for women undergoing breast reduction.

INTRODUCTION: Indication for breast reduction in a publically funded or an insurance-funded setting depends on the severity of the subjective symptoms and on the clinical evaluation. The purpose of this study was to evaluate whether Danish surgeons follow a clinical practice recommending a minimum tissue resection weight of 400-500 g per breast. METHODS: Included in the study were a total of 366 female patients with breast hypertrophy who underwent bilateral breast reduction surgery at three large university hospitals in Denmark in the period from August 2008 to November 2013. The patients' height, weight and standard breast measurement were registered as was the weight of breast tissue resection. The preoperative breast volume was measured using transparent plastic cups designed for this purpose. RESULTS: Among the 366 female participants, the median age was 40 years, the median BMI was 24 kg/m2, and the median breast volume was 1,050 cc on each side. Only 201 (55%) cases met the resection criterion of a minimum of 400 g tissue per breast, and 130 (36%) had 500 g or more resected. We found a highly significant correlation between the amount of resected breast tissue and the preoperative breast volume (p < 0.001, n = 366). CONCLUSIONS: Many surgeons did not follow the clinical practice of resecting 400-500 g of breast tissue in women who underwent breast reduction surgery at three large hospitals in Denmark in the 2008-2013 period. Our findings are surprising and beg the question if the guidelines should be revised to reflect the current practice or vice versa. FUNDING: none. TRIAL REGISTRATION: not relevant.

Tumour response after hyperthermic isolated limb perfusion for locally advanced melanoma.

INTRODUCTION: The aim was to describe tumour response, complications, recurrence and survival after hyperthermic isolated limb perfusion (ILP) with melphalan or melphalan in combination with tumour necrosis factor-alpha in patients with melanoma metastases confined to an extremity. MATERIAL AND METHODS: A total of 84 perfusions were performed (53 women, 31 men, median age 63 years) from 1993 to 2010. 95% of the perfusions were administered to the lower limbs and 5% to the upper limbs. The inclusion criteria were recurrent and/or clinically apparent cutaneous/subcutaneous extremity in-transit melanoma metastases. RESULTS: The response rate after ILP was 85%; 42% had complete response (CR), 43% partial response (PR), 12% no change (NC) and 3% progression. Two- and five-year survival rates were 57% and 31%, respectively, and they were higher for patients with than without lymph node metastases. Time from ILP to recurrence was a median of seven months (range 1-37 months) for patients with CR or PR. Survival was longer for patients with CR or PR than for patients showing NC or progression. Several patients had mild or moderate local toxicity reactions, two patients developed severe local toxicity. CONCLUSION: ILP induces tumour regression in the vast majority of patients. One patient, i.e. 1% of the group, died from surgical complications. Otherwise, ILP treatment had an acceptable morbidity in this group of very sick patients. We are convinced that the treatment should be offered to improve local disease control in patients with multiple and/or recurrent melanoma confined to an extremity if surgical excision is not possible. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Measurement of breast volume is a useful supplement to select candidates for surgical breast reduction.

INTRODUCTION: The indication for breast reduction in a public welfare or an insurance paid setting depends on the severity of the subjective symptoms and the clinical evaluation. The purpose of this study was to evaluate the use of breast volume as an objective criterion to establish the indication for breast reduction surgery, thus establishing a standard decision basis that can be shared by surgeons and departments to secure patients fair and equal treatment opportunities. MATERIAL AND METHODS: A total of 427 patients who were referred to three Danish public hospitals with breast hypertrophy in the period from January 2007 to March 2011 were included prospectively in the study. The patients' subjective complaints, height, weight and standard breast measurements were registered as well as the decision for or against surgery. Breast volume was measured using transparent plastic cups. RESULTS: Cut-off values for breast volume were calculated based on whether or not the patients were offered reduction surgery. Most patients (93%) with a breast volume below 800 cc were not offered surgery, while most with a volume exceeding 900 cc were offered surgery (94%). In the grey zone between 800 and 900 cc, the indication seemed to be less clear-cut, and additional parameters need to be included. CONCLUSION: Breast volume can be used as an objective criterion in addition to the presently used criteria. Breast volume can easily be measured and has become appreciated by plastic surgeons dealing with patients with breast hypertrophy as a tool which facilitates their decision-making and patients' acceptance of the decisions made. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Trends in the incidence of malignant melanoma in Denmark 1978-2007. Incidence on the island of Bornholm compared with the whole country incidence in Denmark.

INTRODUCTION: In Denmark, malignant melanoma is among the most rapidly increasing cancer types. Malignant melanoma accounts for the majority of skin cancer-related deaths. Sunshine is the main cause of the increase seen in melanoma incidence. Within Denmark, Bornholm is the area that receives most sunshine. It is therefore relevant to compare incidence data between Denmark and Bornholm. MATERIAL AND METHODS: Incidence data from the period 1978-2007 were extracted from The National Cancer Database. Incidence rates were analysed to determine any difference between Bornholm and Denmark in total. A prognosis was made based on extrapolation of incidence data from 1978-2007. RESULTS: Incidence rates increased exponentially in Denmark as well as on Bornholm. A significant annual increase in incidence rates over the 1978-2007 period was found. The difference in incidence was estimated to be 3.4%. The annual increase was significantly higher on Bornholm than in the rest of Denmark, a 20% increase was assessed. The increase in incidence rates in malignant melanoma is supported by the literature. The difference between Bornholm and Denmark is possibly due to differences in behaviour that translate into differences in UV exposure. CONCLUSION: If the current development continues, the incidence rate will increase more than 100% from 2007 to 2030. The effect of campaigns addressing behavioural sun exposure has yet to be recorded. UV exposure is expected to comprise the main reason for the difference in incidence rate between Bornholm and Denmark in total. More evidence is needed on the relation between malignant melanoma and UV radiation and socio-demographic conditions.