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.

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.

[Infiltration of the skull by dedifferentiated cutaneous leiomyosarcoma]. / Infiltration der Schädelkalotte durch ein dedifferenziertes kutanes Leiomyosarkom.

We present a brief report of an 81-year-old man with a pretreated leiomyosarcoma of the skull. Histologically the diagnosis of a dedifferentiated cutaneous leiomyosarcoma with an infiltration of the skull was confirmed. In an interdisciplinary approach together with the University Clinic for Neurosurgery, complete removal of the tumour was performed. Cutaneous leiomyosarcoma are rare tumors of the skin and typically present as slowly growing erythematosus nodes. Because of the risk of metastatic spread, complete micrographically confirmed resection is necessary.

[Sentinel node biopsy and lymph node dissection in the era of new systemic therapies for malignant melanoma]. / Sentinel-node-Biopsie und Lymphknotendissektion im Zeitalter neuer Systemtherapien des malignen Melanoms.

BACKGROUND: Recently, adjuvant therapies with checkpoint inhibitors and BRAF/MEK inhibitors have become available for patients with malignant melanoma and microscopic nodal disease. Meanwhile the number of complete nodal dissections for a melanoma-positive sentinel node (SN) have decreased significantly. OBJECTIVE: The authors discuss the significance of sentinel node biopsy (SNB) and early lymph node dissection in the era of adjuvant systemic therapy for stage III melanoma. MATERIALS AND METHODS: Current publications and recommendations were evaluated. RESULTS: Complete nodal dissection for a positive SN significantly reduces the risk of regional nodal relapse. However, neither SNB nor complete nodal dissection following a positive SN are associated with a benefit in survival. With the availability of novel adjuvant systemic treatment strategies for stage III melanoma, SNB has become an even more important part of modern staging diagnostics. Thus, detection of early dissemination of melanoma cells into the SN as well as the quantification of the tumor load are decisive for further therapy planning. CONCLUSION: Accurate assessment of the regional lymph node status by SNB is becoming even more important in the era of novel effective adjuvant therapies for microscopic nodal disease. Whether complete lymph node dissection is performed in patients with a positive SN needs to be assessed individually. In the case of "active nodal surveillance" instead of surgery, long-term close follow-up in specialized centers, including ultrasonographic controls, is required.

[Two neutrophilic dermatoses and one multiple myeloma : A case report]. / Zwei neutrophile Dermatosen und ein multiples Myelom : Ein Fallbericht.

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.

Surgical treatment of hidradenitis suppurativa: an analysis of postoperative outcome, cosmetic results and quality of life in 255 patients.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease with increasing incidence. Severe disease stages are seen as a therapeutic challenge and pose the threat of significant restrictions on patients' life quality. OBJECTIVES: We evaluated postoperative outcome after wide local excision for HS as well as postoperative course, cosmetic results, disease recurrence and quality of life. METHODS: All patients receiving radical surgical treatment for HS (Hurley III) between 2006 and 2015 were identified and received a letter-based survey. They were asked about postoperative course, cosmetic results, recurrence and life quality. RESULTS: Two hundred and fifty-five patients (103 men, 152 women) answered the questionnaire. Ninety-five percentage of patients reported disease-specific restrictions on everyday life. Seventy-five percentage of patients did not experience any postoperative adverse events; however, postoperative pain with need for analgesics was reported in 38%. The majority of patients (80%) were very satisfied or satisfied after surgery, and 85% of patients would recommend surgery to other affected persons. LIMITATIONS: The retrospective design of the study was a limitation. CONCLUSIONS: The well-known negative psychological and social effects are a relevant part of HS and emphasize the importance of immediate therapy. As long-lasting local disease-control can be achieved, surgery should be considered as first-line therapy.

Tumescent local anaesthesia for early dermatosurgery in infants.

BACKGROUND: Early paediatric dermatosurgery reveals excellent cosmetic results due to high skin elasticity and pronounced capacity to recover from trauma. Furthermore, the size of skin lesions increases during life proportionally to skin growth and therefore early removal is of major importance. Selected local anaesthetics like prilocaine can cause methaemoglobinemia. However, in contrast to general anaesthesia, many other local anaesthetics do not bare any major risks for infants. OBJECTIVE: In this retrospective study, we analysed infants aged less than 7 months receiving tumescent local anaesthesia (TLA) followed by dermatosurgery at our department between 2005 and 2015. The analysis is mainly based on our records. Additional information for a subset of patients was gained by a postoperative survey. METHODS: Ninety-two infants (39 male, 53 female) with a median age of 4.2 months (range: 1.5 months; 6.7 months) were included in this study. Additional postoperative information was available for 33 of the 92 studied patients (35%). RESULTS: Infants were mainly operated for removal of a melanocytic naevus (n = 54), followed by haemangioma (n = 23), naevus sebaceous (n = 6) and other lesions (n = 9). The lesions were located on the scalp or neck (n = 31), on the extremities (n = 31), on the trunk (n = 21), in the face (n = 6) or on the buttocks (n = 3). The median size of excision was 509 mm2 (range: 16 mm2 ; 3600 mm2 ). Primary defect closure was performed by intracutaneous (n = 68) or extracutaneous (n = 24) suture techniques. No side-effects of local anaesthesia were observed in any patient. Postoperative complications include pain (1/33; 3%), wound-healing disorder (1/33; 3%) and visible severe scarring (2/33; 6%). CONCLUSIONS: The combination of TLA and dermatosurgery in infants is a suitable outpatient treatment option for small lesions without any major risks or side-effects and the benefit of prolonged postoperative analgesia.

[Acrokeratosis paraneoplastica Bazex 6 years prior to diagnosis of gastric cancer]. / Acrokeratosis paraneoplastica Bazex 6 Jahre vor Diagnose eines Magenkarzinoms.

BACKGROUND: Bazex's syndrome is a rare paraneoplasia that is usually associated with cancer. DIAGNOSIS: Characteristic for the disease are diffuse, psoriasis-like, acral erythema, distal hyperkeratosis and onychodystrophy. Differential diagnoses comprise psoriasis, eczema and tinea. CASE REPORT: We present the case of a 73-year-old man with acral hyperkeratosis, onychodystrophy, and diffuse palmar erythema. Gastric carcinoma was diagnosed by gastroscopy. After a gastrectomy was performed, regression of the skin lesions that the patient had been suffering from for more than 6 years was observed, confirming the diagnosis of Bazex's syndrome.

[Sequential digital dermatoscopic imaging. How much time is required per patient?]. / Sequenziell digitale Dermatoskopie. Wie groß ist der Zeitaufwand pro 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.

Biological effects of the respirable dusts from ore mines.

The biological effects of ore dusts were examined on peritoneal macrophages in vitro and on rat lung in vivo. The methylene blue adsorption of the dust samples, cytotoxicity, and phospholipid and hydroxyproline content of the lung were determined. It was realized that the examined ore samples had cytotoxic effects and from the in vitro results one can get information about the type of damage to be expected in the lung tissue. It is supposed that the examined ore dusts are less dangerous and slower acting than quartz, but they cause progressive fibrosis. The in vivo biochemical experiments do not give information about the type of damage to be expected in lung tissue; and the data on ore, bentonite, and coal do not differ from each other. To determine the typical biochemical changes caused by quartz, we obtain the most valuable information by determination of lung weight and phospholipid, phosphatidylcholine, and hydroxyproline content.