Patients with lymphatic metastasis of cutaneous malignant melanoma benefit from sentinel lymphonodectomy and early excision of their nodal disease.

Early versus delayed excision of lymph node metastases is still being assessed in malignant melanoma. In the present retrospective, multicentre study, the outcome of 314 patients with positive sentinel lymphonodectomy (SLNE) was compared with the outcome of 623 patients with delayed lymph node dissection (DLND) of clinically enlarged lymph node metastases. In order to avoid the lead-time bias, survival was generally calculated from the excision of the primary tumour. Survival curves were constructed using the Kaplan-Meier product-limit estimate. Cox's proportional hazards model was used to perform a multivariate analysis of factors related to overall survival. Compared with SLNE and early performed complete lymph node dissection, DLND yielded a significantly higher number of lymph node metastases. Median and mean tumour thickness were nearly identical in the two therapy groups. The estimated 3-year overall survival rate was 80.1+/-2.8% (+/-standard error of the mean (SEM)) in patients with positive SLNs, and 67.6+/-1.9% in patients with DLND (5-year survival rates 62.5+/-5.5 and 50.2+/-5.4%, respectively). The difference between the two survival curves was statistically significant (P=0.002). Using multifactorial analysis, SLNE (P=0.000052), American Joint Committee on Cancer (AJCC) Breslow thickness category (P<0.000001), age (P=0.01) and gender (P=0.028) were independent predictors of overall survival. The location of the primary tumour (P=0.59) was non-significant. Considering only those centres with sufficient data for epidermal ulceration, this risk factor was also significant. In cutaneous malignant melanoma, early excision of lymphatic metastases, directed by the sentinel node procedure, provides a highly significant overall survival benefit.

Pyoderma gangrenosum associated with the secondary antiphospholipid syndrome.

A 64-year-old woman with an 11-year history of systemic lupus erythematosus and amputation of her left lower leg as a consequence of arterial embolism, presented with two large, non-healing ulcers on her right shank. Pyoderma gangrenosum associated with secondary antiphospholipid syndrome was diagnosed based upon the typical clinical features and increased antibodies to cardiolipin. Although an aggressive therapy with corticosteroids and cyclosporine was started, her condition continued to worsen. She finally died as a result of sepsis. We discuss the difficulties in diagnosis and therapy of SLE combined with the antiphospholipid syndrome and pyoderma gangrenosum.

[First experiences with a new radiopharmaceutical for sentinel lymph node detection in malignant melanoma: (99m)Tc colloidal rhenium sulphide]. / Erste Erfahrungen mit einem neuen Radiopharmakon für die Wächterlymphknoten - Detektion beim malignen Melanom: (99m)Tc markiertes kolloidales Rheniumsulfid.

UNLABELLED: AIM of this study was to localize the sentinel lymph node by lymphoscintigraphy using technetium-99m colloidal rhenium sulphide (Nanocis), a new commercially available radiopharmaceutical. Due to the manufacturers' instructions it is licensed for lymphoscintigraphy. PATIENTS AND METHODS: 35 consecutive patients with histologically proved malignant melanoma, but without clinical evidence of metastases, were preoperatively examined by injecting 20-40 MBq Nanocis with (mean particle size: 100 nm; range: 50-200 nm) intradermally around the lesion. Additionally blue dye was injected intraoperatively. A hand-held gamma probe guided sentinel node biopsy. RESULTS: During surgery, the preoperatively scintigraphically detected sentinel lymph nodes were identified in 34/35 (97%) patients. The number of sentinel nodes per patient ranged from one to four (mean: n = 1.8). Histologically, metastatic involvement of the sentinel lymph node was found in 12/35 (34%) patients; the sentinel lymph node positive-rate (14/63 SLN) was 22%. Thus, it is comparable to the findings of SLN-mapping using other technetium-99m-labeled nanocolloides. CONCLUSION: (99m)Tc-bound colloidal rhenium sulphide is also suitable for sentinel node mapping.

[Diagnosis of sentinel lymph node in malignant melanoma: preoperative lymphoscintigraphy and intraoperative gamma probe guidance]. / Diagnostik des "Sentinel Lymph Node" bei malignem Melanom: präoperative Lymphszintigraphie und intraoperative Sondenmessung.

AIM: The sentinel lymph node (SLN) has shown to reflect the histologic features of the remainder of the lymphatic basin in patients with melanoma and is of considerable prognostic relevance. Aim of the study was to localize the SLN pre and intraoperatively by means of lymphoscintigraphy and gamma probe guidance. METHODS: 38 patients with histologically proven malignant melanoma (tumor thickness > 0.75 mm) were preoperatively examined by injecting 40 MBq 99mTc-Nanocoll intradermally around the lesion. The first lymph node identified was marked on the skin. Immediately after scintigraphy patients were referred to the operation room and intraoperatively mapped using a handheld gamma probe. Activity of the SLN and of the adjacent nodes was measured ex vivo. After excision of the SLN, the lymphatic basin was re-checked for radioactivity and activity of the SLN and of the adjacent nodes was re-measured after removal. RESULTS: The hottest reading was found in all patients in vivo and ex vivo in the preoperatively marked lymph node. Morphologically (macroscopically, ultrasound, CT) all nodes were unsuspicious. Histologically, in 8 patients metastatic involvement of the lymph node was found which led to a wide exploration of the lymphatic basin with consecutive lymph node excision in 7 patients. CONCLUSION: The findings suggest that combined preoperative lymphoscintigraphy and intraoperative mapping with a gamma probe is a powerful approach for exact localization of the SLN. Diagnostic detection of the SLN may have considerable impact for patient management, since extended lymph node dissection may be confined to patients presenting with positive SLN.

[Metastases in malignant melanoma despite histologically negative sentinel lymph node: should the concept be changed?]. / Metastasierung beim malignen Melanom trotz histologisch negativem Sentinel Lymph Node: Muss das Konzept in Frage gestellt werden?

AIM: The Sentinel Lymph Node (SLN) is of considerable prognostic relevance, because extended lymph node dissection may not be performed in patients presenting with histologically negative SLN. The aim of the present study was to prove the prognostic value of the SLN-concept in these patients. METHODS: So far the clinical follow-up of 162 patients with histologically proven malignant melanoma and metastatically uninvolved (negative) SLN was investigated. Histological examination included standard methods (HE-Test) and special histochemical techniques (S-100, HMB-45). All patients underwent clinical examination, ultrasonic diagnosis of the regional lymph nodes, and x-ray of the chest every 3 months. RESULTS: Despite of negative SLN-findings in 8/162 patients metastases of the malignant melanoma were found after a time period of 5-27 months. Three patients presented with recurrence in the previously mapped (negative) SLN-basin. In another case the scintigraphically visualized SLN could not be identified intraoperatively by means of the hand-held gamma probe. One patient showed intransit-metastases or skin-metastases, respectively; another patient recurred in the scar area. One patient showed hematogenic dissemination (liver) which is not detectable by lymphoscintigraphy; in another patient metastases were found outside the primary lymphatic basin (cervical). CONCLUSION: In our patient group 4.9% presented with metastases despite negative SLN while published data report up to 11% (observation period 35 months), among them only 3 patients (1.9%) being real concept failures. Our results underline that there is no evidence to change this concept in patients with clinically early stage.

[Therapy of congenital melanocytic nevi. Excision, dermabrasion, laser]. / Therapie kongenitaler melanozytärer Nävi. Exzision, Dermabrasion, Laser.

Congenital melanocytic nevi are rare lesions which depending on their size and location may cause major cosmetic and psychological problems. Large congenital melanocytic nevi may undergo malignant change and can also be associated with neurocutaneous melanosis. The different treatment approaches reach different levels of the skin. Complete excision is the treatment of choice, but is not always possible with giant nevi. Superficial treatment can reduce the pigmentation, but repigmentation is not uncommon. Incomplete removal of melanocytic nevi does not reduce the melanoma risk. Surgical intervention must be carefully planned; the advantages and disadvantages of the different modalities must be discussed with the parents. The risk of malignant transformation must be weighed up against the expected aesthetic and functional outcomes.

[Current recommendations in the treatment of basal cell carcinoma and squamous cell carcinoma of the skin]. / Aktuelle Therapieempfehlungen für das Basalzellkarzinom und Plattenepithelkarzinom der Haut.

The incidence of the most common tumors of the skin, basal cell carcinoma and squamous cell carcinoma, has risen rapidly in recent years. Dermatologists see in their daily practice many different clinical and histological variants of these tumors. They must be able to develop therapeutic strategies adapted to the tumor and the patient. Surgical excision remains the standard treatment. Micrographic histological evaluation should be employed in difficult locations, for large tumors and when there is increased risk of recurrence or metastasis. For initial or superficial lesions, other approaches such as radiation therapy, as well as curettage, cryosurgery, laser therapy and photodynamic therapy can be employed. An additional option is topical treatment with imiquimod or 5-flourouracil.

Deep subcutaneous application of poly-L-lactic acid as a filler for facial lipoatrophy in HIV-infected patients.

INTRODUCTION: Facial lipoatrophy is a crucial problem of HIV-infected patients undergoing highly active antiretroviral therapy (HAART). Poly-L-lactic acid (PLA), provided as New-Fill/Sculptra, is known as one possible treatment option. In 2004 PLA was approved by the FDA as Sculptra for the treatment of lipoatrophy of the face in HIV-infected patients. While the first trials demonstrated relevant efficacy, this was to some extent linked to unwanted effects. As the depth of injection was considered relevant in this context, the application modalities of the preparation were changed. The preparation was to be injected more deeply into subcutaneous tissue, after increased dilution. MATERIAL AND METHODS: To test this approach we performed a pilot study following the new recommendations in 14 patients. RESULTS: While the efficacy turned out to be about the same, tolerability was markedly improved. The increase in facial dermal thickness was particularly obvious in those patients who had suffered from lipoatrophy for a comparatively small period of time. CONCLUSION: With the new recommendations to dilute PLA powder and to inject it into the deeper subcutaneous tissue nodule formation is a minor problem. However, good treatment results can only be achieved if lipoatrophy is not too intense; treatment intervals should be about 2-3 weeks.

[Congenital giant nevi. Clinical picture and therapy]. / Angeborene Riesennavei ("Giant nevi"). Klinik und Therapie.

Congenital giant nevi are rare. There is high risk of malignant melanoma in large congenital nevi. Therefore the early operative removal is advised, not only for the prevention of malignant tumors, but also for psychologic and social reasons. The surgical and reconstructive methods include serial excisions, free skin-grafts and local pedicled flaps. The special advantages of free full-thickness grafts in the treatment of giant nevi in the facial region are outline.

Use of skin flaps in dermatologic surgery of the face.

Different flap techniques for plastic repair of defects are described, namely, local flaps (advancement, transposition and rotation flaps) and regional flaps. Such use of skin of similar structure and pigmentation gives excellent cosmetic results. The indications for using local or regional flaps depends on size and location of the defect. Total extirpation of cutaneous malignancy particularly by microscopically monitored serial excision is a prerequisite to reconstruction.

[Dermatome excision of multiple basaliomas of the trunk skin]. / Dermatomexzision multipler Rumpfhautbasaliome

Superficial basal cell carcinomas of the trunk may be removed by dermatome excision. The procedure following the usual excision of a split-skin graft with a thickness of 0,6 mm. Histological control of the tumor excision is possible when the split-skin graft, including the tumor, is rolled before sectioning. In this way the adequate tumor removal, both in depth and at the peripheral margin, can be judged.

[Disseminated circumscribed acleroderma associated with diffuse scleroderma of an acrosclerotic type]. / Disseminierte zirkumskripte Sklerodermie und diffuse Sklerodermie vom Typ der Akrosklerodermie.

A case of disseminated, circumscribed scleroderma with diffuse scleroderma of the acrosclerotic type is reported. The relationship between circumscribed and diffuse scleroderma is discussed. Obstructive changes of peripheral vessels are an early feature of scleroderma.

[Skin necroses following the use of a 2-per-cent Pyoctanin solution]. / Hautnekrosen nach Anwendung 2%iger Pyoktaninlösung

The case of a child is reported in whom a circumscribed necrotic skin reaction developed in the gluteal fold after application of 2% crystal violet (Pyoktanin) in aqueous solution. Similar cases are described after topical treatment with 1% solutions of dyes. For direct application to intertriginous areas, triphenylmethane dyes should be used in lower concentrations.

[Spinocellular carcinoma of the hand]. / Das spinozelluläre Karzinom der Hand.

The proper treatment of squamous cell carcinoma of the hand is surgical only. Radical cure and preservation of function need not exclude one another if the following points are considered: praeoperative biopsy and intraoperative pathological examination, consideration of the degree of malignancy and the possibilities of surgical reconstruction.

[Diagnosis by intra-operative cryostatic section in suspected malignant melanoma (author's transl)]. / Intraoperative Kryostatschnittdiagnostik bei Verdacht auf malignes Melanom.

In 233 (40.6%) of 535 patients referred for hospital treatment with a strong suspicion of melanoma, a diagnosis of malignant melanoma could be established on the grounds of the macroscopic clinical picture alone. In 302 patients (56.5%) a clinical diagnosis was not possible so that an intra-operative cryostatic section investigation was necessary to determine future operative measures. This gave a clear diagnosis of malignant melanoma in 101 (34.4%) patients and a benign pigmented skin tumor was established in 171 (56.6%) patients. In 14 cases (4.64%) no diagnosis could be made from the cryostatic investigation. In 16 (5.3%) patients diagnosis from cryostatic section had to be corrected after analysis of paraffin sections. Altogether an accuracy of over 85% was achieved.

[Possibilities for tattoo removal. Report of experiences]. / Behandlungsmöglichkeiten von Tätowierungen. Erfahrungsbericht.

Different motivations are seen in patients with tattoos, which can be seen in a tattooed picture. Two kinds of tattoos can be distinguished: Professional and self-made tattoos. In general, patients with self-made tattoos call for their removal, because the private situation has changed. These tattoos are more difficult in treatment than professional ones, because the colour is located in the whole dermis. The method of treatment depends on size, form and shape of the tattoo. For treatment simple excision of small tattoos, dermabrasion in one or two sessions are recommended. Own experiences and results in 121 patients with tattoos are reported and discussed.

[Coincidence of multiple cylindroma and trichoepitheliomas (Brooke-Spiegler-Syndrome)]. / Koinzidenz multipler Zylindrome mit Trichoepitheliomen (Brooke-Spiegler-Syndrom).

The coincidence of cyclindromas and trichoepitheliomas has been subject of a rather broad discussion for its principal pathogenetic aspects. Clinical cases, however, have only rarely been observed. Therefore, a case-report is given. Although the heredity of the Brooke-Spiegler syndrome seems well established by now, there is no anamnestic data in our case.

[Micrographic surgery. A current methodological assessment]. / Mikrographische Chirurgie. Eine methodische Bestandsaufnahme.

Micrographic surgery is one of the most effective methods in the treatment of basal cell carcinoma. In the last 20 years this method has been further developed and modified. Three kinds of micrographic surgery are now available: the Mohs method, the margin strip method ("Tübingen torte") and the "Munich" method. All three variants have the same goal; radical tumour removal with optimal sparing of surrounding tumour-free tissue. They differ, however, in the technique of tumour excision, the preparation of the histological specimens and the interpretation of the slides. In this paper the authors take stock of the methods available and describe the differences, advantages and disadvantages.