Clinical results after doxorubicin extravasation treated with excision guided by fluorescence microscopy.

Doxorubicin (DR) and epirubicin (ER) produce progressive tissue necrosis when extravasation occurs. Early detection and excision of all affected tissue is important. The clinical experience with fluorescence microscopic guided detection and excision in 24 patients is evaluated. 9 patients with fluorescence negative specimens were kept under observation without excision. None developed necrosis. Wide excision was performed on 15 patients with fluorescence positive specimens. Sequelae, defined as impaired function of the affected limb at the last control examination in the out-patient clinic, were observed in 8 patients. 4 of 5 patients with extravasation in the hand and 2 of 3 with extravasation in the cubital fossa were among these. Delay, defined as time from injury to surgery, was a median of 7 h, range from 3 h to 69 days. Patients developing sequelae had a median delay of roughly 4-fold that of patients without these complications. Patients with extravasation in the cubital fossa were hospitalised for the longest period: 30 days, range 24-45 days, vs. 12 days, range 7-80 days, for those with extravasation at other sites (P < 0.03). Our conclusions are: (1) fluorescence microscopic analysis is a reliable method for the detection and delineation of extravasation of DR or ER. (2) Do not use the cubital fossa or hand for the infusion of these cytostatics. (3) Act promptly if extravasation is suspected--delay leads to sequelae.

Prognosis of thin cutaneous head and neck melanoma (<1mm).

Thin malignant melanomas, i.e. tumours less than 1 mm, are generally considered to have a good prognosis. The records of 148 patients with thin invasive melanomas located to the head and neck region were reviewed. All patients were followed for the excision of the primary tumour until death, or the closing date of this study (31 December 1989). Follow-up was median 9.6 years, (range: 3 months to 26.5 years). Increasing tumour thickness led to an increasing number of recurrences. However, there was no statistically significant difference in the length of recurrence-free survival or total survival between patients with tumours less than 0.76 mm and patients with tumours measuring between 0.76 mm and 0.99 mm (P>0.08). Tumours located in the scalp, neck and ears did relapse more often than tumours located to the face (P<0.03). No difference in prognosis was found in tumours that were excised with a free margin of <2.0 cm or of > or = 2.0 cm (P>0.29). Sixteen of the patients (11%) developed recurrences, 12 of these 16 patients (75%) died of disseminated melanoma. We conclude that thin head and neck melanomas do not necessarily carry an excellent prognosis. Prognosis is not dependent upon tumour thickness when less than 1.00 mm.

Aplasia of the anterior cruciate ligament with a compensating posterior cruciate ligament.

Aplasia of the anterior cruciate ligament is a rare condition and is usually associated with other abnormalities of the lower extremities. We report aplasia of the anterior cruciate ligament with a compensating posterior cruciate ligament in a 15-year-old boy.

Hip fractures in previously amputated patients.

In four previously amputated patients with hip fractures, the ratios between the mean thickness of the femoral cortex and the total width of the femoral shaft in two patients with a low degree of prior mobilization (0.03 and 0.07) are compared to those of two formerly fully ambulatory patients (0.17 and 0.31). These are then compared to the ratios in a group of twenty age-matched and previously normal, non-amputated patients with hip fractures (median 0.23, range: 0.16-0.29). The obvious difference between the ratios of those patients who suffered perioperative problems, and those who did not, appears to be related to the degree of prior mobilization.

[Hyperthermic regional perfusion in malignant melanoma of an extremity]. / Hyperterm regional perfusion ved malignt melanom på en ekstremitet.

Circulatory isolation of an upper or lower limb and perfusion of this with heated cytostatics is an established method of treating local recurrence and in-transit metastases from malignant melanoma. Not only recurrence-free survival but also total survival are increased compared with the results after surgical excision alone. Even when this method is employed in connection with excision of a primary tumour, there appear to be favourable effects as regards recurrence-free and total survival of patients in high risk groups (tumour thickness > 1.5 mm and/or Clark level IV-V). The actual treatment is well tolerated by the patients and complications in the form of oedema of the limb and wound infection are reversible. The frequency of amputation is low and, similarly, the mortality which is 0.6%. As the frequency of malignant melanoma is increasing and, as a great proportion of the melanomata are localized to the extremities, these patients should be offered hyperthermic regional perfusion on removal of the primary tumour and also if recurrence occurs.

[Significant prognostic factors for recurrence-free survival after surgical treatment of head-neck melanoma]. / Prognostiske faktorer af betydning for den recidivfrie overlevelse efter kirurgisk behandling af hoved-hals-melanom.

The clinico-pathological and therapeutic data of 512 patients with clinical stage I invasive head and neck melanoma of the skin were re-evaluated. There were 287 females and 225 males. The median age at primary surgery was 65 years, range 18 to 96 years. The median observation period was 5 years, range 1 month to 25 years. Sex, age, ulcerated tumor and tumor thickness were found by Cox multivariate regression analysis to act as independent prognostic factors for recurrence-free survival. In addition, size of the excision margin was found of no significance for survival without relapse when adjusting for the independent risk factors.

Local melanoma recurrences in the scar after limited surgery for primary tumor.

The clinical and histologic records of 46 consecutive patients were reviewed who during the period 1980-1993 had recurrence from melanoma in the scar after limited surgery for a skin tumor. They constituted about 50% of all patients admitted with local recurrence from melanoma during this period. At reexamination of the primary tumors, 16 were found to be malignant melanomas and 9 were nevi (four atypical and five benign). Twenty-one were missing, 11 of which had never been set for histologic examination. The median thickness of nine measurable melanomas was 0.66 mm. The recurrences in scar consisted of 34 primary melanomas: 18 superficial spreading, 4 nodular, 3 lentigo malignant, and 9 unclassified. Twelve tumors were dermal melanoma metastases. The median thickness of the 25 measurable melanomas was 0.78 mm. The 5-year overall survival was 69%. At the closing date of the study 15 patients had died, 13 of them because of disseminated melanoma. A comparison of the survival curves from this study with those from other series of melanomas with comparable tumor thickness indicates a considerably worse prognosis than is expected with such thin tumors. We believe that the considerable number of local recurrences in the form of a new primary in a scar following limited surgery supports the theory of limited field change around a primary melanoma. Furthermore, limited procedures for primary melanoma, if followed by a recurrence in the scar, worsen the prognosis.

Outcome in 282 lower extremity amputations. Knee salvage and survival.

Lower-extremity amputation for arterial insufficiency was performed in 282 cases ineligible for vascular surgery. In 203 cases (Group I), amputation was elective without previous vascular surgery. In 14 cases (Group II), amputation followed recent vascular reconstruction, and in 12 cases (Group III) amputation was performed after failed thromboembolectomy. In 53 cases (Group IV), amputation was done acutely, i.e., as a life-saving procedure because of septicemia. The results as regards both knee salvage and survival were much better in Groups I and II than in Groups III and IV. We conclude that knee salvage is poor and mortality high after acute amputations and after failed thrombembolectomy. These factors should be taken into account when comparing series from different centers.

Treatment of excoriations with a transparent hydrocolloid dressing: a prospective study.

A transparent hydrocolloid dressing (THCD) was compared with a traditional paraffin gauze dressing (PGD) in the treatment of excoriations with special focus on patient acceptability. A series of 12 emergency ward patients with 16 traumatic excoriations were included in the study. There were 9 women and 3 men. Average age was 26 years (range 12-66 years). Seven wounds were dressed with THCD and nine with PGD. Patients treated with THCD felt less pain than those treated with PGD. A significantly higher number of patients treated with PGD than THCD complained of wound or bandage sticking to their clothes (P = 0.0007). No infection was seen. We conclude that THCD is suitable for dressing acute excoriations. And the level of comfort is better than in traditional treatment with PGD.

Long-term results after surgical reduction cheiloplasty in patients with Melkersson-Rosenthal syndrome and cheilitis granulomatosa.

Cheilitis granulomatosa in patients with Melkersson-Rosenthal syndrome has proven difficult to treat, and various forms of symptomatic treatment of orofacial swellings have been used with varying success. To evaluate long-term results after surgical reduction cheiloplasty in patients suffering from persistent lip swellings, a follow-up study was performed on 13 patients after 16 years (median). The operations were performed after unsuccessful conservative treatment and regardless of disease activity. Pre- and postoperative medical histories were updated and a clinical examination evaluated the following criteria for a good result: symmetry of the lip, a normalized anterior projection, dimensional harmony between upper and lower lip, no disfiguring cicatrices, and no sensory disturbances. In spite of postoperative disease activity in 6 patients, all 13 patients were satisfied with the long-term result. Clinically, the results in 12 patients were considered good. We therefore recommend lip resection as described when a stationary swelling becomes associated with permanent aesthetic deformity or functional disturbances and conservative measures are unsuccessful.

Dysplasia in gastric mucosa: prognostic significance.

Forty-seven patients having dysplasia in biopsies from the gastric mucosa were subjected to re-investigation. Twenty-three patients were alive at follow-up and 14 underwent gastroscopy with removal of random biopsies. The median duration of observation was 39 months, range 10-63 months. Regression of the dysplasia was found in all patients; in nine there was normal mucosa without dysplastic alterations in the control biopsies, mild dysplasia was still present in five of the patients. Our results suggest that the incidental finding of mild or moderate dysplasia does not, per se, indicate the necessity of further control, whereas severe dysplasia indicates repeat gastroscopies with biopsies, as such epithelial changes can occur together with gastric carcinoma.

Skin melanoma of the head and neck. Prognostic factors and recurrence-free survival in 512 patients.

The clinicopathologic and therapeutic data of 512 patients, with clinical Stage I invasive head and neck melanoma of the skin were retrospectively evaluated. There were 287 females and 225 males. Median age at primary surgery was 65 years (range, 18 to 96 years). Median observation period was 5 years (range, 1 month to 25 years). Site of first recurrence was local in 7% (38 of 512), regional in 13% (67 of 512) and distant in 6% (31 of 512). Sex, age, ulcerated tumor, and tumor thickness were found to act as independent risk factors to recurrence-free survival by Cox multivariate regression analysis. In addition, size of excision margin was found to be of no significance to survival without relapse when adjusting for the independent risk factors.

Changes in C-reactive protein and erythrocyte sedimentation rate after hip fractures.

Serial measurements of C-reactive protein (CRP) levels and erythrocyte sedimentation rates (ESR) were performed during the week after operation in 140 patients with hip fractures. There was no selection, and patients with minor or major complications before or after operation were included. In uncomplicated cases, the ESR was variably raised during the first week, whereas the CRP showed a distinct pattern with a rapid increase on the second day; it then decreased by the 7th day. In cases with early postoperative bronchopneumonia and deep wound infection, the CRP was high, but minor infections did not influence the usual levels. Complications had no effect on the ESR during the 1st week.

Wide local excision of recurrent breast cancer in the thoracic wall.

BACKGROUND: Local recurrence is one of the major problems in treatment of breast cancer. Approximately 20% of patients who have radical or modified radical mastectomy have a local recurrence. METHODS: The records of 98 women with locally recurrent breast cancer treated with wide local excision, in the years 1983-1987, were reviewed. The median age at excision was 62 years (range, 32-84 years). All patients were observed until death or December 31, 1989. The median follow-up period was 36 months (range, 2-79 months). RESULTS: At follow-up, 44 of 98 patients (45%) had had a new local relapse and 47 of 98 (48%) were dead. The median duration of local control for all patients was 21 months (range, 1-79 months). The diameter of the local recurrence seemed to influence the duration of local disease control but not total survival. Patients admitted directly for surgery had a longer period of local control compared with patients admitted after unsuccessful oncologic treatment of the local recurrence. The 5-year local control rates were 50% and 24%, respectively (P > 0.92). No statistically significant difference in local control could be shown whether or not the patient received additional oncologic therapy in continuity with the wide local excision. The 5-year local control rate in patients treated only by surgery was 33% compared with 42% in patients also receiving additional oncologic treatment (P > 0.63). CONCLUSIONS: Wide local excision of recurrent breast cancer seems to provide as good or even better local control than other treatment modalities. Surgery should not be postponed in cases of ineffective medical treatment or radiation therapy.

Functional and social long-term results after free tissue transfer to the lower extremity.

We report the long-term social and functional results in 53 patients receiving free tissue transfer after trauma to the lower extremity. The results are compared with those of a matched group of patients receiving primary amputation. The microsurgically treated patients had significantly more complaints over pain during walk (p = 0.02) and edema (p < 0.00005). Regarding social results, no significant differences between the two groups were found. Time until surgery, infection, or bone defect before free flap surgery did not alter the overall results significantly. It is concluded that the long-term functional and social results after free tissue transfer are almost the same as those achieved after simple amputation. Because the median time until free flap surgery in this series was 158 days, early limb-saving procedures could possibly improve the long-term results.

Use of fluorine-18 fluorodeoxyglucose positron emission tomography in the detection of silent metastases from malignant melanoma.

Correct staging is crucial for the management and prognosis of patients with malignant melanoma. The aim of this prospective study was to compare staging by whole-body positron emission tomography using fluorine-18 fluorodeoxyglucose (18F-FDG) with staging by conventional methods. Thirty-eight patients with malignant melanoma of clinical stage II (local recurrence, in-transit and regional lymph node metastases) or III (metastases to other sites than in stage II) were included in the study. The results of the PET scans were compared with those obtained by clinical examination, computed tomography, ultrasound, radiography, and liver function tests and histology or clinical follow-up. With 18F-FDG PET we found for all foci a sensitivity of 97% and a specificity of 56%, compared with 62% and 22%, respectively, when using routine methods. For intra-abdominal foci, the sensitivity and specificity were 100% for both 18F-FDG PET and routine methods. Corresponding figures for pulmonary/intrathoracic foci were 100% and 33%, respectively. Of the patients included in this study, 34% would not have been staged correctly by conventional methods alone. We conclude from this study that 18F-FDG PET is a sensitive method superior to conventional methods for detecting widespread metastases from malignant melanoma. Mutilating surgery of no benefit can thereby be avoided. 18F-FDG PET is useful as a supplement to clinical examination in melanoma staging.