Surgical prevention and treatment of lymphedema after lymph node dissection in patients with cutaneous melanoma.

Despite the development of minimal access dissection techniques, use of superficial groin dissection alone, and other recommendations to reduce morbidity in melanoma treatment, the incidence of lymphedema is still significant. The purpose of the current study was to assess the efficacy of microsurgical methods to limit the morbidity of inguinal lymphadenectomy. We conducted a retrospective review of patients who underwent groin dissection for melanoma treatment from February 2006 to April 2009. A total of 59 melanoma patients with positive groin lymph nodes comprised 18 patients (T-group) with melanoma in the trunk and 41 patients (E-group) who had melanoma in an extremity and currently have lymphedema. The T-group patients underwent primary prevention of lymphedema with microsurgical lymphatic-venous anastomoses (LVA) performed simultaneously with groin dissection. The E-group patients underwent LVA to treat the secondary lymphedema after an accurate oncological and lymphological assessment. Limb volume measurements and lymphoscintigraphy were performed pre- and postoperatively to assess short and long term outcome. No lymphedema occurred after microsurgical primary preventive approach in the T- group. Significant (average 80% reduction of pre-op excess volume) reduction of lymphedema resulted after microsurgical treatment for secondary leg lymphedema. Post-operative lymphoscintigraphy in 35 patients demonstrated patency of microsurgical anastomoses in all cases with an average follow-up of 42 months. Study results demonstrate that microsurgical LVA primary prevention prevented lymphedema after inguinal lymphadenectomy in the T-group patients. In addition, lymphatic-venous multiple anastomoses proved to be a successful treatment for clinical lymphedema with particular success if treated at the early stages.

A comparative study of proliferation and hepatic differentiation of human adipose-derived stem cells.

Human adipose-derived stem cells possess a lot of stem cell characteristics, so they may be considered a source of stem cell population. On the basis of that, we have investigated the hepatic potential of adipose-derived stem cells, obtained from liposuction, following two differentiation protocols. In the first procedure, medium was supplemented with epidermal growth factor (EGF), basic fibroblast growth factor, hepatocyte growth factor (HGF) and nicotinamide; the second involved the addition of factors such as dexametasone, EGF, insulin-transferrin-sodium selenite, HGF, dimethyl sulfoxide and oncostatin. In parallel, we carried out our study in the Hep G2 cell line, as human hepatic differentiated in vitro model. Immunocytochemical analysis and RT-PCR were performed using hepatic markers to evaluate cell differentiation. DNA content, MTT test and carboxyl fluorescein succinimidyl ester staining were carried out to evaluate cell proliferation. We reported the evidence of basal hepatic marker in undifferentiated adipose-derived stem cells, which confirmed their multipotency. A strong expression of albumin and alpha-fetoprotein was observed in hepatic-induced adipose-derived stem cells following both differentiation procedures. Morphological aspects of the two types of hepatic adipose-derived stem cells were alike. Proliferation index suggested that the first differentiation procedure promoted better growth than the second. These preliminary findings suggest adipose-derived stem cells may be induced into hepatic lineage, and the most significant difference between the two standard differentiation procedures concerns proliferation rate. This aspect is to be considered when adipose-derived stem cells are employed in research and clinical studies.

Oncoplastic breast surgery: comprehensive review.

Breast cancer is the most common female cancer in Western populations, affecting 12.5% of women, with 1.38 million patients per year. Breast-conserving surgery followed by postoperative radiotherapy replaced the radical and modified-radical procedures of Halsted and Patey as the standard of care for early-stage breast cancer once the overall and disease-free survival rates of breast-conserving surgery were demonstrated to be equivalent to those of mastectomy. However, excision of >20% of breast tissue, low or centrally located cancer, and large-sized breasts with various grades of breast ptosis, result a in unacceptable cosmetic outcomes. Oncoplastic breast surgery evolved from the breast-conserving surgery by broadening its general indication to achieve wider excision margins without compromising on the cosmetic outcomes. Thus, oncoplastic breast surgery can be defined as a tumor-specific immediate breast reconstruction method that applies aesthetically derived breast reduction techniques to the field of breast cancer surgery and allows for higher volume excision with no aesthetic compromise. However, contralateral breast symmetrization should be regarded as an intrinsic component of the oncoplastic surgery. The main procedures involved are volume-displacement or volume-replacement techniques, which depend on breast size and cancer size/location. Volume-displacement or reshaping procedures apply the plastic surgery principles to transpose a dermo-glandular flap of breast tissue into the defect site, while volume-replacement techniques use autologous tissues to replace the volume loss that follows tumor resection. Furthermore, these procedures are more complex and time-consuming than those involved in breast-conserving surgery. Based on current literature, the authors analyze the different techniques and indications of the oncoplastic breast surgery, determining its complication rate, in order to help both surgeons and their patients in the decision-making stage of breast reconstruction.

Intercellular adhesion molecule-1 (ICAM-1) and granulocyte-macrophage colony stimulating factor (GM-CSF) co-expression in cutaneous malignant melanoma lesions.

The expression of intercellular adhesion molecule-1 (ICAM-1) and granulocyte-macrophage colony stimulating factor (GM-CSF) was investigated in 25 melanoma patients by evaluating 34 fresh biopsy specimens. ICAM-1 in situ hybridization and immunochemistry for ICAM-1 and GM-CSF were performed. Most of the metastatic melanoma samples (12 out of 18) and a few of the primary melanoma lesions (three out of 16) showed ICAM-1 expression. The expression of ICAM-1 was significantly (P < 0.01) higher in metastatic lesions than in primary tumours. GM-CSF mRNA and protein were detected in 10 of the 18 metastatic samples and in two of the 15 primary lesions. A significantly high degree (P < 0.0002) of concordance between ICAM-1 and GM-CSF expression was observed: the samples that were negative or positive for ICAM-1 expression were correspondingly negative or positive for GM-CSF. Correlation with clinical and histological parameters was examined. The expression of both molecules in metastatic samples was found to be significantly (P < 0.001) associated with a shorter recurrence-free period. These findings, if confirmed by a wider number of patients, could suggest the prognostic value of the simultaneous, and probably co-ordinated, expression of ICAM-1 and GM-CSF. They also highlight the importance of preventive molecular and biochemical characterization of neoplastic cell cytokine receptors, specifically focusing on the particular cytokine to be used as anticancer therapy and/or as adjunct to chemotherapy.

Cytokine expression in human primary and metastatic melanoma cells: analysis in fresh bioptic specimens.

In recent years, several studies have documented that melanoma cell lines produce various cytokine/growth factors and their receptors. Since cell lines can acquire altered properties, such as changes in growth requirements, we studied constitutive cytokine gene expression in melanoma cells from 20 fresh surgical specimens: seven primary melanomas and 13 metastases (12 lymph-node metastases and one subcutaneous metastasis). After tumour cell isolation by discontinuous gradient, we tested for mRNA expression by means of reverse-transcriptase polymerase chain reaction. Most melanoma cells tested expressed growth factors: basic fibroblast growth factor (bFGF), interleukin (IL)1 alpha, IL-1 beta, IL-6 and IL-8 and, in five cases out of 20, expressed granulocyte-macrophage colony-stimulating factor (GM-CSF) (two out of five were also positive for GM-CSF receptor). Our results do not point to a direct correlation between cytokine expression and clinical stage at the time when the bioptic specimen was obtained. However, they allow us to suggest a possible metastatic tumour cell phenotype, in which autogenous GM-CSF expression could modulate immune response against the tumour cell itself or could potentiate metastatic colonization properties.

In vitro antimicrobial effects of fresh split skin, homologous-cultured epithelium and porcine split skin grafts for wound coverage.

Various biological dressings, for example, human fresh and cadaver skin grafts, homologous cultured human epithelium and deep frozen porcine split skin (Lyocutis), have been used to treat skin loss. Each of these biological dressings has its advantages and disadvantages. The antimicrobial properties of each dressing type are important since bactericidal activity influences the lifespan of the transplanted tissue. In the present study the in vitro antimicrobial effects of human fresh skin, homologous cultured epithelium and Lyocutis were compared to in vivo bactericidal activity of these dressings and possible clinical applications are recommended.

Multicentre experience in the treatment of burns with autologous and allogenic cultured epithelium, fresh or preserved in a frozen state.

This report describes the clinical results obtained from a multicentre experience of the use of autologous and allogenic cultured human epidermal cells in the treatment of partial and full skin thickness burns. A laboratory has been organized to supply cultured epithelium to Burns Units in different cities. From May 1986 to December 1988, 58 patients with an age range of 1 to 59 years, and with burns covering between 7 and 95 per cent of the body surface area, have been treated. Graftable cultured epithelium can be frozen and remain viable if stored in a skin bank. Such grafts were used successfully to treat patients with partial and full skin thickness wounds.

Undermining of the scalp: quantitative effects.

The aim of the present study was to evaluate to what extent undermining affects the closing-tension of scalp defects to quantify the surgery-related benefits provided by this procedure. Data were collected by stepwise loading in 10 patients, 20 scalp flaps (obtained by a reversed Y scalp incision), and three different degrees of subgaleal undermining (1, 5, and 15 cm). The obtained data confirmed the value of undermining to diminish the tension on wound margins when closing a scalp defect. There was a progressive decrease in tension required to advance the wound edge when the amount of undermining was sequentially increased. Most of this reduction occurred with the 5-cm undermining, although statistically the 15-cm undermining also resulted in a significant decrease in the tension required to close the defect. Mean 83.3- and 92.2-percent reductions of the closing tension were obtained with 5 cm and 15 cm of undermining, respectively, compared with that achieved by the 1-cm undermining with the same width of defect.

Psychological evaluation of patients undergoing breast reconstruction using two different methods: autologous tissues versus prostheses.

Breast reconstruction has become an available option for most patients undergoing mastectomy. In fact, many authors agree that breast reconstruction does not interfere with possible therapies and improves the women's quality of life. The aim of this study was to evaluate the psychological adjustment of patients who had immediate or delayed reconstruction using two different methods: implants and autologous tissues. Specifically, it was explored whether the different methods of breast reconstruction have caused significant changes in psychological functioning. The study population (102 patients) was derived from patients who underwent breast reconstruction in the period January 1988 to December 1991 at the Department of Plastic and Reconstructive Surgery of the National Institute for Cancer Research in Genoa, Italy. Fifty-two patients underwent breast reconstruction using implants and 50 using the transverse rectus abdominis myocutaneous (TRAM) flap. Demographic information was gathered from each patient. The psychological instruments consisted of three standardized self-administered questionnaires: Psychological Distress Inventory, State Trait Anxiety Inventory, Form Y, and the Eysenck Personality Inventory. To better assess the changes in body image after breast reconstruction, three more specific questions about sexual desire, physical image, and social relationships were added. The 102 patients assessed in this study indicated a low incidence of psychological distress. Impairment was reported regarding body image by patients who underwent delayed reconstruction; these patients also showed higher distress scores. The type of breast reconstruction also seems to influence body image, showing in the patients with TRAM flap reconstruction more relevant psychological discomfort.(ABSTRACT TRUNCATED AT 250 WORDS)

[Considerations in immediate and delayed breast reconstruction]. / Considerazioni sulle alternative chirurgiche nella ricostruzione mammaria immediata e differita.

The authors evaluate the different procedures for breast reconstruction in order to determinate the best indication of each technique. From January 1983 to June 1992, 196 reconstructions for breast cancer using implants, including 100 immediate and 96 delayed, were performed. Different types of breast implants were used in this period: in 1983-84 46 double lumen prostheses were performed, in 1985-86 34 Radovan temporary tissue expanders, from January 1986 to June 1991 115 Becker and Gibney permanent tissue expanders and 8 microstructured prostheses. Due to unavailability of silicon-gel implants, from January to June 1992 12 breast reconstructions with saline temporary tissue expanders were performed. In the patients with radical mastectomy 39 latissimus dorsi muscular flaps were carried out for implant coverage. In the same decade 204 breast reconstructions using Rectus abdominis myocutaneous (TRAM) flaps, including 201 delayed and 3 immediate were performed. It can be concluded that the implants are first choice for small or medium size breast, with light ptosis, in immediate reconstruction and when the patients refuse harder surgical procedures. On the contrary the autologous tissue, such as TRAM flap, can be used in patients with redundant abdomen, with controlateral large and ptotic breast and in delayed reconstruction.

[Reconstructive method for the repair of substantial loss of the head and neck area, following the excision of malignant melanoma]. / Metodiche ricostruttive per la riparazione di perdite di sostanza del distretto cervico-cefalico, conseguenti ad asportazione di melanomi maligni.

The general increase in the incidence of malignant melanoma has caused a more massive presence at the level of special sites such as the face, posing problems of the reconstruction from a cosmetic point of view. The widespread move away from large margins of exercise (3-5 cm) towards margins of approximately 1 cm surrounding the lesion, together with the improved prognosis for this pathology on the face compared to other sites, calls for greater attention to be paid to the reconstructive techniques used. Since surgery is the only solution "quoad vitam" for the patient, it is now preferable to attempt to offer the patient both a complete exeresis of the neoplasia and a satisfactory cosmetic result. In this study the authors report four cases involving the excision of malignant melanoma in the cervico-cephalic district and their consequent reconstruction using special surgical techniques.

[Evaluation of the tolerability of Hydrogel breast implants: a pilot study]. / Studio pilota per la valutazione della tollerabilità delle protesi tipo hydrogel.

BACKGROUND: During the 90s the widely publicised controversy regarding the use of silicone gel breast implants stimulated research into alternative alloplastic filling materials. In this context, a new type of breast implant, containing Carboxymethylcellulose at 3.7% in the form of Hydrogel, was introduced into the European market. METHODS: A preliminary pilot study was carried out to evaluate the tolerability and reliability of breast implants pre-filled with Hydrogel. A group of 12 consecutive patients was recruited for this purpose and underwent plastic surgery for breast augmentation or reconstruction (20 implants) at the Department of Plastic and Reconstructive Surgery at the University of Genoa between December 1996 and October 1997. All patients were then followed up for a minimum of 3.5 years. The mean age of patients was 50 years and ranged from 28 to 67 years old. After surgery the patients were examined at 4 weeks (evaluation of any immediate complications), 3 months, 6 months and 1 year (evaluation of any delayed complications). RESULTS: No immediate complications were reported in any patient. After 3.5 years of follow-up, the degree of capsular contraction according to Baker in these patients varies between 1 and 2. In general, the implants were very soft to touch even some time after surgery, above all in patients undergoing breast augmentation. Four implants (20%) were removed from 3 patients for reasons unconnected to the implants themselves (because of neoplasm in one case and due to inadequate volume in the other two patients). No case of rupture has been reported. CONCLUSIONS: This pilot study appears to confirm the validity of implants prefilled with Hydrogel in reconstructive or cosmetic breast surgery. A larger population and longer periods of minimum follow-up are obviously required to confirm these results over the long term.

[Permanent expanders in esthetic, corrective and reconstructive surgery of the breast]. / Gli espansori a permanenza nella chirurgia estetica, malformativa e ricostruttiva della mammella.

Since 1986 we used the permanent expandable implant (PEI) as the first choice of prosthesis in breast surgery. The possibilities offered by multiple over-expansions and deflations have been explored: 224 PEI were utilized in 162 patients for aesthetic (38 with bilateral hypoplasia), corrective (20 with asymmetry, tubular breasts or Poland's Syndrome) and reconstructive breast surgery (104 patients for immediate and delayed reconstruction following radical, modified radical, partial and subcutaneous mastectomy). All implants were positioned submuscularly; a latissimus dorsi flap was transposed when pectoralis major was absent or damaged. Either the Becker or the Gibney implant was used. All PEI were immediately or progressively overinflated by 25-80% and then deflated to the planned volume. Twenty-two patients developing capsular contracture were treated by overinflations and deflations with subjective and objective improvement. Many of augmentation mammaplasty patients refused implant deflation to the planned preoperative volume. The over-expansion/deflation process proved to be effective in obtaining ptosis, in maintaining permanent volume symmetry and in keeping the base of tubular breast unfolded.

[Minimally-invasive endoscopic transthoracic sympathectomy of the upper limbs. A new method]. / Denervazione simpatica mini-invasiva degli arti superiori. Nuova metodica.

OBJECTIVE: Indications for endoscopic transthoracic upper dorsal sympathectomy are axillary and palmar hyperhidrosis, upper extremities ischemia (due to, e.g., Raynaud s disease), and upper extremities causalgia. METHODS: At present, this methodology relies on (at least) double trocar insertion (per side) and/or carbon dioxide insufflation. Thus, although this approach, compared with the traditional open sympathectomy techniques, it guarantees the smallest number of postoperative complications, it still determines a certain amount of postoperative discomfort as well as a risk of complications related to carbon dioxide insufflation, as intraoperative profound bradycardia and hypotension due to mediastinal shift, and postoperative subcutaneous emphysema. From December 1995, we are using a minimally-invasive endoscopic transthoracic sympathectomy technique, performed by a single-entry specifically modified thoracoscope and without the need for carbon dioxide insufflation, with the aim to reduce the drawbacks associated with the above-mentioned currently adopted endoscopic techniques. After general anesthesia with double-lumen endotracheal tube, with the patient placed in a half-sitting position with both arms abduced to 90 degrees, a 1 cm incision is performed, along the midclavear line (in male patients) or the anterior axillary line (in female patients), in the second or third intercostal space. RESULTS: The effects of sympathectomy are immediate, and the patients wake up with warm and dry hands and axillae. CONCLUSIONS: In personal opinion, this single-entry technique, compared with other reported approaches, should minimize any damage to the intercostal neurovascular bundle, while avoiding the complications connected with carbon dioxide insufflation.

[Computer planning for postmastectomy breast reconstruction by tissue expansion]. / Pianificazione computerizzata per la ricostruzione mammaria postmastectomia mediante espansione tissutale.

Aim of this paper is to present a computer program able to provide objective and quantitative data useful to guarantee the selection of the proper implant in order to obtain symmetry with the contralateral breast, in case of unilateral breast reconstruction by tissue expansion, especially for surgeons without experience or for occasional operators. Our C++ program provides the final implant volume using the measurements of the semi-circumference and projection of the contralateral breast performed on the supine patient. The aim is the symmetry of the two breasts. According to personal experience in breast reconstruction by tissue expanders, this program allows non invasive and simple measurements of the breast volume, useful to obtain the mammary symmetry. In case of breast reconstruction by tissue expansion, the preoperative evaluation is usually based on the surgeon experience and on the empirical observation without knowing the correct volume to reach. Since this program is useful to know the precise necessary volume for breast reconstruction, it allows the surgeon to obtain a better plastic result.

[The cost as an additional variable in the choice among different techniques of postmastectomy breast reconstruction]. / Il costo come ulteriore variabile di scelta tra le diverse metodiche di ricostruzione mammaria postmastectomia.

Breast reconstruction is an important step for patients after mastectomy. In our Department for immediate reconstruction, smooth or textured temporary tissue expanders filled with saline solution or permanent expandable implants (PEI) with silicon gel saline solution or soyabean oil are usually used. Only in a few selected cases reconstruction using autologous tissues are performed. Delayed reconstruction is performed using autologous tissues: Transversus Rectus Abdominis Myocutaneus Flap (TRAMF) or Latissimus Dorsi flap (LD). The choice between reconstruction with prostheses or muscular flaps depends on previous demolition, local skin condition, contralateral breast size and ptosis, body structure, medical problems, patients' wishes and expectation. Following the legislation defining the privatisation of Italian Health Care Structure and in particular the Decree of December 14, 1994, the need to accurately assess the costs incurred for surgical operations is very important. The aim of this study is to evaluate the clinical limits of each surgical technique and their cost in order to optimize the cost-benefit relationship.

[Computer-based preoperative planning for breast reconstruction in the woman with unilateral breast hypoplasia]. / Pianificazione computerizzata per la ricostruzione mammaria in donne affette da ipoplasia mammaria unilaterale.

BACKGROUND: Aim of this paper is to describe a computer program which can provide objective and quantitative data useful for the selection of the proper implant in order to obtain the symmetry with the contralateral breast in case of unilateral breast reconstruction by tissue expansion, especially for the surgeon without experience or for the occasional operator. METHODS: Our C++ program provides the final implant volume using the measurements of the semi-circumference and projection of the contralateral breast performed on the supine patient. The aim is the symmetry of the two breasts. RESULTS: According to our experience in breast reconstruction by tissue expanders, this program allows non invasive and simple measurements of the breast volume, useful to obtain the mammary symmetry. CONCLUSIONS: In case of breast reconstruction by tissue expansion, the preoperative evaluation is usually based on the surgeon's experience and on empirical observations without knowing the correct volume to reach. For this reason our program is useful to know the necessary volume for breast reconstruction, and therefore it allows the surgeon to obtain a better plastic result.

[Psychological assessment of patients who have ++undergone breast reconstruction using 2 different technics: autologous tissue versus prosthesis]. / Valutazione psicologica di pazienti sottoposte a ricostruzione mammaria mediante uso di due differenti tecniche: tessuti autologhi verso protesi.

Breast reconstruction has become an available option for most patients undergoing mastectomy: in fact many authors agree that breast reconstruction does not interfere with possible therapies and improves the quality of life of women. The aim of the study was to evaluate the psychological adjustment of patients who had immediate or delayed reconstruction using 2 different methods: implants and autologous tissues. The study population (115 patients) was derived from patients who underwent breast reconstruction in the period January 1988-December 1991, in follow-up at the Department of Plastic and Reconstructive Surgery; no patient was undergoing psychological therapy. 58 patients underwent breast reconstruction using implants and 57 using Transverse Rectus Abdominis Myocutaneous Flap (TRAMF). Informations were gathered, including the patient's age, the number of offspring, the marital status, the scholastic education, the job and the relapse between mastectomy and reconstruction. The psychological instruments consisted in three standardized self-administered questionnaires: Psychological Distress Inventory (PDI), State Trait Anxiety Inventory form Y (STAI), Eysenk Personality Inventory (EPQ-R). These tests were chosen to gauge the psychological distress, such anxiety, anger, depression and psychosocial maladjustment. To better perform the changes of body image after breast reconstruction, women were requested to answer three more specific questions about the sexual desire, physical image and social relationships. The 102 patients assessed in this study indicate low incidence of psychological distress and adaptive coping strategies. Impairment was reported, regarding body image, by patients undergoing delayed reconstruction; in these patients higher scores in distress tests were observed.

[Perioperative teicoplanin prophylaxis in patients undergoing breast reconstruction with the abdominal wall. A case-control study]. / Profilassi perioperatoria con teicoplanina in pazienti sottoposte a ricostruzione mammaria con retto addominale. Studio caso-controllo.

The authors report the results of a randomized clinical trial of antibiotic prophylaxis of postoperative infection following breast reconstruction by transposition of rectus abdominis myocutaneous flap (TRAMF). The aim was to evaluate the efficacy and tolerability of a short-term parenteral prophylaxis with Teicoplanin and the end-point of the study was the evaluation of wound contamination assessed by means of microbiologic culture of drainage fluid. From October 1990 to March 1992 38 patients were recruited: 20 patients in the antibiotic prophylaxis arm and 18 patients in the control group. Analysis of drainage fluids showed a higher contamination rate (15/18 = 83%) in the control group as compared to the prophylaxis arm (2/20 = 10%) (p < 0.0001). Moreover, 11 patients in the control arm suffered from fever > 37.5 degrees C for at least 3 days as compared to 1 patient in the antibiotic prophylaxis group; the postoperative stay was 13.3 +/- 4.3 and 9.0 +/- 1.6 in the control and antibiotic arm respectively. No antibiotic related side effects were evidenced through the study. These results seem to confirm the value of parenteral short-term antibiotic prophylaxis of postoperative infection in such kind of "clean" operative procedure.