Axillary metastases from recurrent oral carcinoma.

The rationale for surgical treatment of head and neck cancer is based on a predictable pattern of metastasis. There is aberrant or unpredictable spread rarely and typically only in recurrent disease. There are few published reports to our knowledge of axillary metastases from squamous cell cancer (SCC) of the head and neck. We present a patient who developed axillary node disease on the other side after recurrence of a squamous cell carcinoma of the floor of the mouth. She died 11 months after excision of the recurrence.

Prosthetic metal implants and airport metal detectors.

INTRODUCTION: Metal detectors have been present in airports and points of departure for some time. With the introduction of heightened security measures in response to fears of an increased threat of terrorism, they may become more prevalent in other public locations. The aim of this study was to ascertain which prosthetic devices activated metal detector devices used for security purposes. METHODS: A range of prosthetic devices used commonly in orthopaedic and plastic surgery procedures were passed through an arch metal detector at Birmingham Airport in the UK. Additionally, each item was passed under a wand detector. Items tested included expandable breast prostheses, plates used in wrist and hand surgery, screws, K-wires, Autosuture™ ligation clips and staples. RESULTS: No prostheses were detected by the arch detector. The expandable implants and wrist plates were the only devices detected by passing the wand directly over them. No device was detected by the wand when it was under cover of the axillary soft tissue. Screws, K-wires, Autosuture™ clips and staples were not detected under any of the study conditions. CONCLUSIONS: Although unlikely to trigger a detector, it is possible that an expandable breast prosthesis or larger plate may do so. It is therefore best to warn patients of this so they can anticipate detection and further examination.

Redefining gigantomastia.

Gigantomastia is a rare but disabling condition characterised by excessive breast growth. Most definitions of gigantomastia refer to a particular weight of excess breast tissue. We speculate that in gigantomastia the weight of the breasts contributes significantly to the BMI, which has implications for healthcare rationing. This study aims to establish the contribution breast tissue makes to BMI in gigantomastia. In so doing, we propose a new definition of gigantomastia. Retrospective data was collected from the case notes of 68 females who underwent breast reduction or therapeutic mastectomy for gigantomastia. For the purposes of patient inclusion, gigantomastia is arbitrarily defined as excessive breast growth of over 1.5kg per breast. The difference between pre- and post-operative BMI is statistically significant (P<0.001). Mean pre-operative BMI is 38.7 with a mean specimen weight of 4506g. Mean contribution of specimen to body weight is 4.29%. There is no correlation between pre-operative body weight and the percentage contribution the breast resection specimen makes to body weight. Based on our data, we define gigantomastia as excess breast tissue that contributes 3% or more to the patient's total body weight, approximately one standard deviation below the mean. We suggest that the estimated excess breast tissue weight is taken into account when calculating pre-operative BMI in the gigantomastia population. The challenge of estimating excess breast weight pre-operatively may be met by 3D photography coupled with computer-assisted volumetry.

A review of diagnostic imaging in melanoma.

The incidence of melanoma continues to rise, and is responsible for 50% of deaths related to skin cancer. Imaging plays a vital role in the diagnosis, assessment, treatment and follow-up of patients. Costs have risen dramatically over the last few years, largely due to increased use of newer technologies. This article examines the evidence for the use of radiological imaging in melanoma, in particular, ultrasound, computerised tomography (CT), magnetic resonance imaging (MRI), sentinel lymph node biopsy (SLNB), positron emission tomography (PET) and combined CT/PET. Recommendations are made on the basis of comparison of costs of imaging methods.

Is crow's feet sign a reliable indicator of corneal injury in facial burns?

Facial burns occur commonly, although they rarely result in serious ophthalmological injuries. Despite this, failure to identify and manage minor eye injuries can have serious consequences. When the blink reflex is forcibly suppressed, the cornea is left exposed, resulting in serious injury. One indicator of possible corneal injury is the absence of 'Crow's feet sign'. Crow's feet sign describes the sparing of the skin creases or crow's feet around the eye with forced eyelid closure. The implication is that the patient was conscious at the time of injury and therefore able to protect the eye from ocular injury. We present a consecutive series of 145 people with facial burns attending the burns unit at Selly Oak Hospital, Birmingham over a 2-year period. Demographics, cause, presence of inhalational injury and outcome were examined for all patients. Eleven patients were diagnosed with ocular injury, and none of these patients had crow's feet sign. To date, we have found 100% correlation between the presence of crow's feet sign and the absence of ocular injury. We would recommend that clinicians are alert to the absence of this sign as a marker of possible eye injury.

Experience with the modified hockey stick incision for block dissection of neck.

BACKGROUND: The modified hockey stick incision was originally described by Lahey in 1940. This allows elevation of a superiorly based cervical skin flap, with additional exposure of the parotid as necessary. METHODS: The longitudinal portion of the incision runs from the mastoid process downward, behind the anterior border of the trapezius muscle, and curves gently at the junction of the lateral one-third and medial two-thirds of the clavicle. The transverse component extends medially, approximately 2 cm below the clavicle. When parotidectomy is required, incision is extended in front of the ear and a forward cut is made for additional exposure. RESULTS: We present our experience with a series of 16 patients, undergoing a total of 17 neck dissections for various pathologies. The majority (11 patients) received postoperative radiotherapy. There were two episodes of minor skin necrosis which were not related to radiotherapy, but to patient co-morbidity, and settled with conservative management. All patients had a satisfactory cosmetic result. CONCLUSION: We find the modified hockey stick incision to be cosmetically superior and provide excellent exposure of the neck, with protection of the carotid vessels.

Morphea of the breast. Two case reports and discussion of the literature.

UNLABELLED: Morphea, or localised scleroderma, is characterised by excess collagen deposition by lesional fibroblasts. This results in thickening and induration of the skin and subcutaneous tissues, often causing considerable morbidity. Radiation-induced morphea was mentioned as early as the 1900s, but since then awareness of this condition has declined. The incidence of radiation-induced morphea is said to be two in 1000. Extension of the morphea beyond the radiation ports occurs in approximately one quarter of cases. No proven effective treatments exist, and to our knowledge, surgical excision has not been attempted. CASE PRESENTATIONS: We present two cases of morphea of the breast. The first patient developed progressive morphea in the absence of any causative factors. This was treated by Wise pattern breast reduction, incorporating the morphea within the excised skin. The second patient developed morphea following a course of radiotherapy for breast carcinoma. She has declined any surgical intervention, but suffers from considerable morbidity. Morphea is a recognised sequelae of radiotherapy which should be distinguished from sclerotic recurrence of the original tumour. Surgical excision is possible in certain patients.

Merkel cell carcinoma: a report of 34 cases and literature review.

BACKGROUND: Merkel cell carcinoma (MCC) is a rare and aggressive skin cancer, with unclear histogenesis. To date there is no consensus on the optimal treatment of this neoplasm, with controversy surrounding the use of radiotherapy and chemotherapy. There are also limited data on biological behaviour and prognosis, with reported survival ranging from 31% at three years to 74% at five years. METHOD: The medical records of 34 patients with a diagnosis of primary MCC, treated at two NHS trusts in Birmingham and Coventry, were reviewed. An extensive review of the English literature was also performed. RESULTS: MCC occurred predominantly in Caucasians (97%) with a mean age of 75 years. Identified risk factors were a previous history of SCC (37%), BCC (18%) and AK (20%). Ten percent of patients showed evidence of immunocompromise. Most tumours were located on the extremity, where they reached a mean size of 2.1cm. Fifty percent had regional metastasis during the course of their disease. A sub group analysis of the excision margins showed that a 2-cm excision margin, extending to the deep fascia, resulted in a 50% incomplete excision rate and a 33% local recurrence rate. In contrast a 3-cm margin including deep fascia resulted in no incomplete excisions and a 10.5% local recurrence rate Prognosis was poor with a 40% 3-year survival. Combining the data from two trusts has produced a relatively large series and highlighted differences in patient characteristics and management between the units. We advocate a 3-cm excision margin, including fascia wherever possible, combined with post-operative radiotherapy to offer the best chance of local control. Survival is fairly dismal and in keeping with the aggressive nature of this tumour. The respective roles of radiotherapy and chemotherapy remain controversial.

Views of UK melanoma patients on routine follow-up care.

Although the need for melanoma follow-up is universally accepted, there is still much debate on the duration and frequency of appointments. The UK guidelines were revised in June 2002 to streamline melanoma follow-up. Following the change in protocol, some of our patients expressed concern at the shorter duration of follow-up. We therefore polled all our active melanoma patients to obtain their views on the outpatient clinics. In particular we asked whether they would be happy to have routine follow-up in a primary care setting. In conjunction with the department of psychology, a short questionnaire was devised assessing patient satisfaction and concerns about follow-up. This was sent to all active melanoma patients in our trust. Out of 304 eligible patients currently attending outpatients, 231 (76%) completed replies were received. Ninety-eight percent of respondents found the clinics to be useful. Twenty two and a half percent felt it was difficult to attend the clinic and this was mainly due to logistical problems, i.e. hospital car parking. The majority were reassured by the clinic visits and felt it was a chance to ask questions and check for new disease. Of the 12% of respondents who had a recurrence, 52% indicated that they had detected it themselves. Sixty percent of patients would be happy to consider routine follow-up with their GP, provided they were suitably experienced and trained. A survey of 50 local GP's found that 70% would be unhappy to monitor their patients. Patients want and benefit from follow-up. However, they are an increasing burden on outpatient clinics, given the increasing incidence of melanoma. GP follow-up may be appropriate for a small subgroup of patients. This combined with shared care and practice based clinical nurse specialists may be the way forward in melanoma follow-up.