Obliteration of empyema tract with deepithelialized unipedicle transverse rectus abdominis myocutaneous flap.

Four patients with chronic empyema after pneumonectomy have undergone successful obliteration of the empyema tract with a deepithelialized transverse rectus abdominis myocutaneous flap. The deepithelialized skin island has provided sufficient bulk for tract obliteration. Rotation of the skin island into the long axis of the rectus muscle has added considerable length to this flap, allowing it to reach the apex of the thoracic cavity. A recurrent loculation developed 4 months after the obliteration procedure in one patient. This was successfully treated with open pleural drainage and a second Clagett procedure. Over a mean follow-up period of 35 months, all four patients are free of further infectious sequelae. Chest roentgenograms have confirmed eradication of the tracts in all four patients.

Interferon gamma enhances lymphokine-activated killer cell adhesion but not lysis of head and neck squamous cell carcinoma.

OBJECTIVES: To determine if treatment with recombinant human interferon gamma (rHuIFN-gamma) increases the adhesion to, and lysis of, head and neck squamous cell carcinoma (SCC) cells by lymphokine-activated killer (LAK) and peripheral blood mononuclear (PBM) effector cells in vitro and to evaluate the role of cell surface adhesion molecules in these processes. DESIGN: Two human SCC cell lines, JHU-020-SCC and JHU-022-SCC, were used. Lymphokine-activated killer cells were generated by interleukin-2 stimulation of PBM cells obtained from the hemapheresis blood donor packs of healthy individuals. Adhesion assays were performed to assess the level of binding of both effector populations to SCC cells, which were treated with either fresh media or rHuIFN-gamma (100 U/mL). Binding was measured by flow cytometric detection of effector cells labeled with fluorescein-conjugated anti-CD45 monoclonal antibody. Monoclonal antibodies to the cell adhesion molecules HLA-DR, lymphocyte function-associated antigen 1, and intercellular adhesion molecule 1 were used in blocking experiments to determine their contribution to the process of effector-SCC cell adhesion. Cytotoxicity experiments were performed using a colorimetric assay to determine the cytotoxic response generated by LAK and PBM cells against SCC cells, with and without prior rHuIFN-gamma treatment of the tumor cells. MAIN OUTCOME MEASURES: Effector cell binding level and percent cytotoxicity of SCC cells. RESULTS: Recombinant human interferon gamma treatment of JHU-020-SCC cells resulted in increased adhesion to both LAK cells and PBM cells (P < .001). The presence of anti-lymphocyte function-associated antigen 1 antibody resulted in elimination of the enhanced adhesion seen with rHuIFN-gamma pretreatment of SCC cells (P =.03), but antibody to intercellular adhesion molecule 1 and HLA-DR did not reduce the level of effector binding. The greatest cytotoxic response against both JHU-020-SCC and JHU-022-SCC was seen with LAK cells (P < or = .001). Pretreatment of tumor targets by rHuIFN-gamma (100 U/mL) resulted in no enhancement of cytotoxic response by either LAK or PBM cells; at the effector-target ratio of 30:1, there was a significant decrease in LAK cell-mediated cytotoxic response against rHuIFN-gamma-treated SCC cells (P < or = .02). CONCLUSIONS: Recombinant human interferon gamma treatment of head and neck SCC cells does increase binding of both LAK cells and PBM cells to tumor cells, in part via the lymphocyte function-associated antigen 1 ligand mechanism. The cytotoxic effect mediated by LAK cells against head and neck SCC cells is reduced after rHuIFN-gamma treatment, suggesting that the activity of this cytokine may be more important in regulating antigen-specific cytotoxic response mediated by cytotoxic T-lymphocytes.

Functional outcome after soft-tissue reconstruction for limb salvage after sarcoma surgery.

Limb salvage has been achieved for patients with sarcoma by means of compartmental resection, soft-tissue reconstruction, and adjuvant therapy without increased rates of local recurrence, metastasis, or mortality. Despite the prevalence of limb salvage procedures in the treatment of these tumors, relatively little information has been published regarding late functional results in these reconstructed extremities. This study reports on the functional outcome for soft-tissue reconstruction for limb salvage in patients with sarcoma. Over the past 6 years, 28 patients were treated for sarcomas of the extremity in which soft-tissue reconstruction was needed for complete limb salvage. The mean age of these patients was 48 years (range, 14 to 83 years); there were 14 male and 14 female patients. Of the 28 sarcomas, 23 cases involved the lower extremity and 5 cases were in the upper extremity. Reconstruction was performed primarily in 12 patients; 16 reconstructions were performed secondarily because of wound complications after initial extirpation. Adjuvant radiation therapy was administered either preoperatively or postoperatively in all cases. Of the 33 reconstructive procedures performed in these 28 patients, 16 involved free flaps and 17 involved local flaps. All patients achieved initial limb salvage after the reconstructive procedure(s). Mean follow-up was 38 months. Twenty patients were available for the evaluation portion of the study. Two patients had delayed amputations: one for recurrent disease and another for osteoradionecrosis. Two patients died before beginning the examination process: one patient from the sarcoma and another patient from colon cancer. Twenty of the remaining 24 patients agreed to participate and were examined using the Enneking outcome measurement scale. Patients were examined for range of motion, deformity, stability, pain level, strength, functional activity, and emotional acceptance and assigned a numerical score for each category. Based on this, an overall rating of excellent, good, fair, or poor was assigned. Nine patients (45 percent) achieved an overall rating of excellent, five patients (25 percent) achieved a rating of good, and six patients (30 percent) achieved a fair score. None had received a rating of poor. There were no differences in the results obtained comparing upper versus lower extremity, immediate versus delayed reconstruction, or reconstructions performed with a free flap versus a pedicled flap. This study supports the continued use of soft-tissue reconstruction for limb salvage in sarcoma surgery with good to excellent late functional results obtained in the majority of patients.

Free tissue transfer in pediatric patients.

The majority of reports on free tissue transfer involve adults; few have specifically addressed children. During the past 5 years, 20 free tissue transfers were performed in 19 pediatric patients. Patients ranged in age from 3 to 17 years, with a mean age of 10 years. Eight patients were 6 years and younger; 11 patients were 13 to 17 years old. Soft-tissue defects requiring reconstruction resulted from acute trauma in 12 patients, tumor ablation in 5 patients, infection in 1 patient, and hemifacial atrophy in 1 patient. Soft-tissue defects occurred in the lower extremity in 16 patients, the head and neck in 2 patients, and the upper extremity in 1 patient. The donor tissues included the latissimus dorsi muscle in 7 patients, the radial forearm flap in 7 patients, the rectus abdominis muscle in 4 patients, and the scapular fasciocutaneous flap in 2 patients. All patients received aspirin preoperatively. Mean operative time was 6.5 hours, with a range of 4 to 8 hours. Postoperative heparin infusion was used for 5 days in 7 of the 8 patients age 6 years and younger. All free tissue transfers were successful. One flap to a traumatic foot wound (patient age, 4 years) had a venous thrombosis on the second postoperative day, and was successfully treated with urokinase and heparin infusions and repeat venous anastomosis. There were no other significant morbidities and no mortalities. Hospitalization following free tissue transfer averaged 13 days, with a range of 6 to 37 days. Follow-up has averaged 31 months, with a range of 8 to 59 months. Late complications included a progressive equinus deformity 3 years after a heel reconstruction following a lawn mower injury and a contour deformity following a scapula flap to a gunshot wound of the foot. Sixteen of the 17 lower extremity reconstructions have shown normal growth. No growth disturbances or significant functional losses have occurred at the donor sites. Most patients have maintained normal extremity function including participation in athletics. Special considerations in this group of patients have included subtherapeutic heparin infusion during the postoperative period in young children, minimizing the aesthetic defect at the donor site and providing composite reconstructions whenever possible.