Atypical late presentation of muscular metastasis of melanoma in the contralateral limb.

A man in his 50s presented to plastic surgery again with a lesion on his left upper arm. He had previously been treated for a malignant melanoma (MM) on his right arm over 5 years earlier. Sentinel lymph node biopsy (SLNB) had been negative, and he had completed the recommended 5 years follow-up period. Imaging was suspicious for an intramuscular soft tissue malignancy within the triceps muscle. After discussion with the regional sarcoma service, a core biopsy was performed. Histopathology suggested a diagnosis of metastatic MM, which was confirmed after surgical excision. This case highlights a rare example of an isolated muscular metastasis of MM, which presented at a distant site, over 5 years from the original treatment. This case highlights the unpredictable nature of MM, reminding clinicians of the need for a low threshold for investigation of soft tissue masses in patients with a history of cutaneous malignancy.

Use of Artificial Intelligence to Reduce Radiation Exposure at Fluoroscopy-Guided Endoscopic Procedures.

OBJECTIVES: Exposure to ionizing radiation remains a hazard for patients and healthcare providers. We evaluated the utility of an artificial intelligence (AI)-enabled fluoroscopy system to minimize radiation exposure during image-guided endoscopic procedures. METHODS: We conducted a prospective study of 100 consecutive patients who underwent fluoroscopy-guided endoscopic procedures. Patients underwent interventions using either conventional or AI-equipped fluoroscopy system that uses ultrafast collimation to limit radiation exposure to the region of interest. The main outcome measure was to compare radiation exposure with patients, which was measured by dose area product. Secondary outcome was radiation scatter to endoscopy personnel measured using dosimeter. RESULTS: Of 100 patients who underwent procedures using traditional (n = 50) or AI-enabled (n = 50) fluoroscopy systems, there was no significant difference in demographics, body mass index, procedural type, and procedural or fluoroscopy time between the conventional and the AI-enabled fluoroscopy systems. Radiation exposure to patients was lower (median dose area product 2,178 vs 5,708 mGym, P = 0.001) and scatter effect to endoscopy personnel was less (total deep dose equivalent 0.28 vs 0.69 mSv; difference of 59.4%) for AI-enabled fluoroscopy as compared to conventional system. On multivariate linear regression analysis, after adjusting for patient characteristics, procedural/fluoroscopy duration, and type of fluoroscopy system, only AI-equipped fluoroscopy system (coefficient 3,331.9 [95% confidence interval: 1,926.8-4,737.1, P < 0.001) and fluoroscopy duration (coefficient 813.2 [95% confidence interval: 640.5-985.9], P < 0.001) were associated with radiation exposure. DISCUSSION: The AI-enabled fluoroscopy system significantly reduces radiation exposure to patients and scatter effect to endoscopy personnel (see Graphical abstract, Supplementary Digital Content, http://links.lww.com/AJG/B461).

An image-based skeletal dosimetry model for the ICRP reference adult male--internal electron sources.

In this study, a comprehensive electron dosimetry model of the adult male skeletal tissues is presented. The model is constructed using the University of Florida adult male hybrid phantom of Lee et al (2010 Phys. Med. Biol. 55 339-63) and the EGSnrc-based Paired Image Radiation Transport code of Shah et al (2005 J. Nucl. Med. 46 344-53). Target tissues include the active bone marrow, associated with radiogenic leukemia, and total shallow marrow, associated with radiogenic bone cancer. Monoenergetic electron emissions are considered over the energy range 1 keV to 10 MeV for the following sources: bone marrow (active and inactive), trabecular bone (surfaces and volumes), and cortical bone (surfaces and volumes). Specific absorbed fractions are computed according to the MIRD schema, and are given as skeletal-averaged values in the paper with site-specific values reported in both tabular and graphical format in an electronic annex available from http://stacks.iop.org/0031-9155/56/2309/mmedia. The distribution of cortical bone and spongiosa at the macroscopic dimensions of the phantom, as well as the distribution of trabecular bone and marrow tissues at the microscopic dimensions of the phantom, is imposed through detailed analyses of whole-body ex vivo CT images (1 mm resolution) and spongiosa-specific ex vivo microCT images (30 µm resolution), respectively, taken from a 40 year male cadaver. The method utilized in this work includes: (1) explicit accounting for changes in marrow self-dose with variations in marrow cellularity, (2) explicit accounting for electron escape from spongiosa, (3) explicit consideration of spongiosa cross-fire from cortical bone, and (4) explicit consideration of the ICRP's change in the surrogate tissue region defining the location of the osteoprogenitor cells (from a 10 µm endosteal layer covering the trabecular and cortical surfaces to a 50 µm shallow marrow layer covering trabecular and medullary cavity surfaces). Skeletal-averaged values of absorbed fraction in the present model are noted to be very compatible with those weighted by the skeletal tissue distributions found in the ICRP Publication 110 adult male and female voxel phantoms, but are in many cases incompatible with values used in current and widely implemented internal dosimetry software.

Patient satisfaction with two different methods of umbilicoplasty.

BACKGROUND: Creating a youthful appearing umbilicus as part of an abdominoplasty enhances the overall result. Various different methods have been reported as producing equally good results. METHODS: Twenty-five patients undergoing abdominoplasty were divided into two groups: 12 patients had round umbilicoplasty and 13 had an inverted U flap inset. Three independent surgeons assessed the aesthetic outcome of the two different techniques in specially designed clinics by using four-point ordinal scales, which were also used by the patients for subjective self-assessment. RESULTS: Surgical assessment demonstrated equally good results with both methods, whereas the inverted U flap was the favorite method for reconstruction among patients (p < 0.029). Fifty-eight percent of patients in the round method group were conscious that they had umbilicoplasty, as opposed to only 15 percent in the inverted U flap group. Twenty-five percent of patients in the round group preferred their old umbilicus compared with this new one. None of the patients in the inverted U flap group preferred their old umbilicus. CONCLUSIONS: The authors discuss the surgical technique of the inverted U flap. This is currently the method of choice in recreating the umbilicus at the time of abdominoplasty.

The use of free groin flaps in children.

The free groin flap is a well-established method of skin coverage. Although its use in children has been reported, there have been no published series specifically in such cases. The authors report 33 consecutive cases of free groin flaps in children in their unit over a period of 9 years (1992 to 2001). Tissue transfer was performed to provide soft-tissue coverage during reconstruction of congenital defects and tumor resection and following trauma. Twenty-six cases (79 percent) involved the upper limb, six cases (18 percent) involved the lower limb, and one case involved the head. The complication rate compares favorably with similar series published for adults, with only two complete failures (6 percent), three (9 percent) minor donor-site complications (superficial wound infection, hypertrophic scarring, and dog-ears), and nine flaps requiring debulking. The reexploration rate was 24 percent, with seven of the eight flaps undergoing reexploration surviving. The groin flap is a reliable flap that can be used safely in children, with minimal morbidity.