A strategy for the successful management of dermatofibrosarcoma protuberans.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a rare, locally invasive soft tissue sarcoma with extensive subclinical involvement. The National Comprehensive Cancer Network guidelines recommend immediate reconstruction in most cases. Our study reviewed the methods of treatment of DFSP at our institution, examined the types of closure used after surgical excision, and analyzed the prevalence of positive margins on permanent pathology after immediate closure after conventional non-Mohs excision of DFSP. METHODS: The charts of 25 patients treated with surgical excision and 16 with Mohs surgery from 1990 to 2009 for lesions consistent with DFSP were reviewed for clinical variables including disease state, tumor site, closure type, permanent pathology margin status, disease recurrence/persistence, and excisional margin size. RESULTS: The trunk, followed by the head and neck, were the most common sites for DFSP. No patients had distant metastasis at diagnosis or experienced recurrence in either the surgical excision or the Mohs surgery group. Twelve (48%) patients were found to have positive margins after initial surgical resection. All lesions treated with Mohs surgery had clear histological margins at completion. Average margin size for surgical excision patients was 2.33 cm (range, 0.75-4.5 cm), and 1.36 cm (range, 0.74-2.55 cm) for Mohs excision. The average duration of follow-up was 107.9 months. CONCLUSIONS: The extent of DFSP is difficult to determine intraoperatively with traditional surgical excision, which leads to a higher rate of positive margins. Considering this difficulty and the complications of reconstruction with positive margins, we believe that reconstruction after tumor resection should be dependent on definitive pathologic clearance of the tumor.

Hueston revisited: use of acellular dermal matrix following fasciectomy for the treatment of Dupuytren's disease.

Various surgical treatment modalities have been advocated for the treatment of Dupuytren's disease. However, recurrence following surgical treatment of Dupuytren's disease remains a common problem. Previous studies have demonstrated lower recurrence rates with use of a full-thickness skin graft. We therefore postulated that use of acellular dermal matrix may be associated with a similar outcome, based on the common inhibitory effect on underlying myofibroblasts. We performed a retrospective cohort study of 43 patients undergoing open fasciectomy for Dupuytren's disease from years 2005 to 2012 at our academic institution. Standard fasciectomies of the affected palmar and digital fascia were performed via Brunner incisions on all patients. Patients in the experimental group had a sheet of acellular dermal matrix (Alloderm; LifeCell, Bridgewater, NJ) sutured into the surgical bed with interrupted absorbable sutures before closure, whereas patients in the control group were not closed with acellular dermal matrix. Patients were then evaluated at follow-up for disease recurrence, defined as presence of Dupuytren's tissue in an area previously operated on with a contracture greater than that recorded following the surgical fasciectomy, or presence of contracture requiring surgery. Among our cohort of 43 patients, 23 (53.5%) were treated with acellular dermal matrix while 20 (46.5%) were not. The median age of our cohort was 66.5 years (range 54-91 years). The median follow-up was 1.8 years. During this follow-up period, recurrence of contracture was observed in 1 of 23 patients in the group receiving acellular dermal matrix, compared to 5 of 20 in the control group (P = 0.045). No differences in the incidence of minor wound complications were observed. Our novel technique of placement of acellular dermal matrix into the wound bed following fasciectomy for Dupuytren's disease may be an important surgical strategy to reduce recurrence rates in patients with Dupuytren's disease.

A proposal for the timing of management of patients with melanoma presenting during pregnancy.

The treatment of melanoma during and immediately after pregnancy poses a significant challenge to surgeons, oncologists, and patients alike. With the overall increase in incidence of melanoma in the United States and worldwide, it is likely that more surgeons will be faced with management decisions regarding pregnant patients with melanoma. We report on five patients who presented to the Yale Melanoma Unit with melanoma during their pregnancy. We propose the management option of resection of the primary tumor under local anesthesia, and postponing of the sentinel lymph node biopsy until after the birth of the child. The completion lymphadenectomy can be performed if these nodes are found to be harboring metastases. We further discuss treatment options and propose an algorithm for management of patients diagnosed with melanoma while pregnant.

Pilot testing of a decision support tool for patients with abdominal aortic aneurysms.

OBJECTIVE: Patients with abdominal aortic aneurysms (AAAs) who are surgical candidates have as many as three options: open surgery, endovascular surgery, or no surgery. As with all treatment decisions, informed patient preferences are critical. Decision support tools have the potential to better inform patients about the risks and benefits associated with each treatment option and to empower patients to participate meaningfully in the decision-making process. The objective of this study was to develop and pilot test a decision support tool for patients with AAAs. METHODS: We developed a personalized, interactive, computer-based decision support tool reflecting the most current outcomes data and input from surgeons and patients. We piloted the tool with AAA repair candidates who used the tool prior to meeting with their surgeon. Patients were recruited from a university-based vascular surgery clinic and affiliated VA hospital clinic. To determine feasibility and acceptability, the following outcomes were measured: (1) percent of patients who agreed to participate, (2) length of time required to use the tool, (3) the amount of assistance required to use the tool, and (4) patients' opinions on the acceptability of the tool. To assess effectiveness of the tool, we measured change in knowledge and decisional conflict pre- and post-tool using the paired t-test. RESULTS: One hundred percent of patients who were approached (n = 12) agreed to participate in the study. The tool was administered in a median time of 35 minutes (range, 25-45 minutes), and all patients were able to navigate the program with minor technical assistance. Mean knowledge scores increased from 56% to 90% (P = .005), and decisional conflict scores decreased from 29% to 8% (P = .04). Overall, patients reported that the program content was balanced across treatment options, presented information clearly and concisely, helped them to organize their thoughts about the decision, and prepared them to talk to their surgeon about what mattered most to them. CONCLUSIONS: Preliminary evidence suggests that use of an evidence-based AAA decision support tool is feasible and acceptable to patients, increases knowledge, and decreases decisional conflict. Widespread use of such a tool might improve the content and quality of informed consent for this difficult treatment decision.

Limitations of online information on abdominal aortic aneurysm.

Background. Patients with AAA face a complex decision, and knowledge of the risks and benefits of each treatment option is essential to informed decision-making. Here we assess the current information on the internet accessible to patients regarding the management of AAA. Study Design. We performed a search on Google using the keywords "abdominal aortic aneurysm" and reviewed the top 50 web sites. We focused on information related to treatment options and alternatives to treatment and the risks of each option. Results. Twenty-seven websites were included in the study. Nearly 30% of websites discussed the risk of mortality and myocardial infarction after open surgery, compared to only 7.4% for both risks after EVAR. Other complications were listed by fewer websites. Fifty-five percent of websites reported that patients had a faster recovery following EVAR, but only 18.5% mentioned the risk of reintervention after EVAR or the need for long-term surveillance with CT scans. Conclusions. While most websites included descriptive information on AAA and mentioned the potential treatment options available to patients, the discussion of the risks of open surgery and EVAR was inadequate. These results suggest that websites frequently accessed by patients lack important information regarding surgical risk.

The role of gap junctions in megakaryocyte-mediated osteoblast proliferation and differentiation.

Gap junctions (GJs) are membrane-spanning channels that facilitate intercellular communication by allowing small signaling molecules (e.g. calcium ions, inositol phosphates, and cyclic nucleotides) to pass from cell to cell. Over the past two decades, many studies have described a role for GJ intercellular communication (GJIC) in the proliferation and differentiation of many cells, including bone cells. Recently, we reported that megakaryocytes (MKs) enhance osteoblast (OB) proliferation by a juxtacrine signaling mechanism. Here we determine whether this response is facilitated by GJIC. First we demonstrate that MKs express connexin 43 (Cx43), the predominant GJ protein expressed by bone cells, including OBs. Next, we provide data showing that MKs can communicate with OBs via GJIC, and that the addition of two distinct GJ uncouplers, 18alpha-glycyrrhetinic acid (alphaGA) or oleamide, inhibits this communication. We then demonstrate that inhibiting MK-mediated GJIC further enhances the ability of MKs to stimulate OB proliferation. Finally, we show that while culturing MKs with OBs reduces gene expression of several differentiation markers/matrix proteins (type I collagen, osteocalcin, and alkaline phosphatase), reduces alkaline phosphatase enzymatic activity, and decreases mineralization in OBs, blocking GJIC does not result in MK-induced reductions in OB gene expression, enzymatic levels, or mineralized nodule formation. Overall, these data provide evidence that GJIC between MKs and OBs is functional, and that inhibiting GJIC in MK-OB cultures enhances OB proliferation without apparently altering differentiation when compared to similarly treated OB cultures. Thus, these observations regarding MK-OB GJIC inhibition may provide insight regarding potential novel targets for anabolic bone formation.