Analysis of alterations adjacent to invasive squamous cell carcinoma of the penis and their relationship with associated carcinoma.

BACKGROUND: In contrast to vulvar squamous cell carcinoma (SCC), the etiologic factors and precancerous lesions associated with penile carcinoma remain uncertain. OBJECTIVES: To describe the morphologic features of lesions adjacent to invasive penile SCC and their relationship with the associated carcinoma and to compare these associations with vulvar carcinoma. METHODS: This was a retrospective histologic analysis of 68 cases of penile SCC. Adjacent lesions were considered to be premalignant lesions. They were classified as penile intraepithelial neoplasia (PIN), squamous hyperplasia (SH), and lichen sclerosus (LS). PIN cases were divided into two subtypes depending on the extension of atypia throughout the epithelium and, by analogy, with the classification of the vulvar intraepithelial neoplasia (VIN). Thus they were designated as undifferentiated (or bowenoid) PIN, defined by full-thickness atypia throughout the epithelium, and differentiated PIN, characterized by atypia confined to the lower third of the epithelium. SCC subtypes were classified as usual, verrucous, warty (condylomatous), basaloid, and mixed. RESULTS: Undifferentiated PIN was observed in 22 cases; LS was observed in 26 cases. Differentiated PIN and SH (except for two cases) were associated with underlying LS. Undifferentiated PIN was always associated with warty (condylomatous) (4 cases), basaloid (16 cases) or mixed SCC (2 cases), and LS with usual (19 cases) or verrucous SCC (7 cases). LIMITATIONS: This was a retrospective analysis CONCLUSION: This study suggests that, similarly to vulvar carcinoma, penile SCC occurs in association with two types of penile lesions: undifferentiated (or bowenoid) PIN and LS-linked differentiated PIN and/or SH. It appears that the subtype of these carcinomas is related to these adjacent lesions.

Lessons from a case of oromandibular mucormycosis treated with surgery and a combination of amphotericin B lipid formulation plus caspofungin.

A rare case of oromandibular Rhizopus oryzae infection is described in a 55-year-old woman with acute myeloid leukaemia and decompensated diabetes mellitus. The infection developed during induction chemotherapy when the patient was neutropenic. She was treated with a combination of amphotericin B lipid formulation and caspofungin plus surgery. Debridement surgery included excision of the lower lip, chin, floor of the mouth, a portion of the tongue, as well as mandibular resection at the level of the horizontal branches. Eight weeks of combined antifungal therapy were followed by secondary prophylaxis with amphotericin B lipid formulation during consolidation chemotherapy after achieving complete response of both leukaemia and mucormycosis. Reconstructive surgery was carried out including insertion of a new biomaterial porous mandibular prosthesis, which showed excellent functionality after long-term follow-up, followed by several plastic surgery procedures once good tolerability and no adverse effects of the prosthesis were observed. This case shows that a well-coordinated multidisciplinary approach is critical to increase the chances of clinical success in this life-threatening infection.

Location of communicating veins for medial plantar venous flap.

BACKGROUND: The medial plantar venous flap is suitable for reconstruction of the palmar surface of the finger. However, it is sometimes difficult to detect and harvest the distal subcutaneous vein of the flap. In such a situation, the communicating vein can be used as a distal vein for the flap. However, the location of these veins is not obvious. METHODS: By using 20 feet from 10 cadavers and ultrasound imaging for 40 feet from 20 healthy individuals, we investigated the location of communicating veins. RESULTS: In cadavers, 11 communicating veins (45.8%, n = 24) were located in the area above the abductor hallucis muscle and 12 veins (50%) in the area below it. Ultrasound imaging revealed 15 bifurcations of the communicating veins (31.3%, n = 48) in the upper area and 27 bifurcations in the lower area of the medial plantar region (56.3%). CONCLUSION: It was observed that the communicating veins were concentrated in the areas above and below the abductor hallucis muscle.

Prognostic significance of a combined clinicopathologic score for response to primary systemic therapy in locally advanced breast cancer.

The response to chemotherapy is one of the best indicators of prognosis in locally advanced breast cancer (LABC). The pathologic response (pR) of 108 LABC patients was analysed and compared with their clinical response (cR). Our aim was to define a new combined clinicopathologic response score (cpR) and to explore its correlation with survival data. The 108 stage IIB to IIIB breast carcinomas were first treated with high-dose anthracycline-based chemotherapy. Standard criteria were used to assess cR. Pathologic analysis of surgical specimens allowed the definition of 5 types of pR. Three groups of combined clinicopathologic response were defined. Twenty-two patients (20%) had complete or almost complete pR. Most patients (88, 81%) had partial cR. This large group of partial cR was very heterogeneous, ranging from pR1 to pR5 and from cpR1 to cpR3. In univariate analysis, pR and cpR both strongly correlated with EFS. cR, pR and cpR all correlated with OS. Subgroups of incomplete pathologic responses were not prognostically different. In multivariate analysis, only cpR correlated strongly with both EFS and OS (p<0.002), identifying good (20%), intermediate (61%) and poor (19%) prognosis patients. In conclusion, in 108 stage IIB to IIIB breast cancer patients initially treated by high-dose chemotherapy, combined grading of clinical and pathologic responses in a single score allowed accurate prediction of outcome.

Depression, anxiety and quality of life: outcome 9 months after facial cosmetic surgery.

OBJECTIVE: The request for cosmetic surgery is of a psychological nature. Very few studies have quantitatively assessed whether or not this psychological need was actually satisfied, and more precisely, which psychic components were satisfied. MATERIAL AND METHODS: This is a multicentric, prospective cohort study. One hundred and three patients scheduled for facial cosmetic surgery from three different hospitals were examined before and after surgery using four assessment scales validated using European populations. The Montgomery and Asberg depression rating scale (MADRS) measured the existence and intensity of depression, the self-assessment test of thoughts in social interaction (SISST) measured the positive or inhibitory thoughts in the context of social relationships, and the European quality of life 5 dimensions (EQ-5D) (generic test) measured the quality of life. In addition, a semi-directive interview was specially created by our team. For statistical analysis, ANOVA and Student's t test were applied. RESULTS: Twenty-four patients were lost to follow-up. Although the initial MADRS index was high (p<0.05), it did not change after surgery (p>0.1). SISST+ (positive thoughts): the social anxiety of the individual examined was significantly greater than that of the control group (p<0.005) and improved after surgery (p<0.01). The SISST- (inhibitory thoughts) did not change (p>0.1). The EQ-5D visual analogue scale (VAS) did not reveal any difference (p>0.1) while the descriptive EQ-5D demonstrated over-representation of anxiety/depression (p<0.01), and an improvement of this (p<0.05) postoperatively. The mean subjective satisfaction index was 8.1 (scale of 1-10) without sharing any influence of the complications suffered (65% of the patients made self-assessments). CONCLUSION: The best indications for facial cosmetic surgery seem to be a lack of self-confidence associated with a desire for social interaction, and a request focused on a specific physical feature. The results presented add documentary confirmation to the impression shared by the majority of cosmetic surgeons. However, it was also confirmed that cosmetic surgery is not limited to its technical components, but remains a medical act which must consider the overall effect on the whole patient.

Tendon transfers as applied to tetraplegia.

The techniques of the tendon transfers that are used primarily for the functional rehabilitation of upper limbs in tetraplegia are described in this article. The restoration of active elbow extension can be obtained either by biceps-to-triceps or by deltoid-to-triceps transfers. Grasp and key grip can be restored either by active or by passive tendon transfers. The usual motors of active transfer are the BR and ECRL. The usual tenodesis involve the FDS (via lassos), EDC, EPL, FPL, and APL.

A review of 105 subscapular-based flaps harvested using a new dorsal decubitus position: how far can we go?

OBJECTIVE: Interest in flaps based on the subscapular vascular system has decreased because of the need for intraoperative patient repositioning and the inability to employ a simultaneous 2-team approach. The aims of this study are to review our experience using dorsal decubitus patient positioning for subscapular-based flap harvest and to demonstrate the effectiveness and safety of this approach. METHODS: A retrospective review of all subscapular-based flap cases performed by the senior author at 2 hospital centers from 1995 to 2010 was conducted. Variables studied included indications for reconstruction, flap characteristics, and postoperative complications. A longitudinal roll placed between the scapulae as well as an optional perpendicularly placed shoulder roll are used to achieve dorsal decubitus patient positioning. RESULTS: One hundred five flaps were performed during the study period, and dorsal decubitus positioning was used in all cases. Eighty-four flaps were free and 21 were pedicled. Indications for reconstruction included cancer resection (n = 58), trauma (n = 32), infection (n = 9), and others (n = 6). A simultaneous 2-team approach was carried out in 70 cases. Major complications included 9 cases of arterial or venous thrombosis/insufficiency, 2 of which resulted in total flap failure. Intraoperative conversion to lateral decubitus positioning was never required. CONCLUSIONS: Dorsal decubitus harvesting for subscapular-based flaps is a practical and effective technique that enables a simultaneous 2-team approach in complex reconstructive cases. Previous limitations of these highly versatile flaps, such as the need for intraoperative patient repositioning, can thus be avoided. This approach is employed for all subscapular-based flap reconstructions performed by the senior author.

A new dorsal decubitus position for raising subscapular-based flaps.

Flaps based on the subscapular vascular system are reliable and versatile tools that provide excellent coverage for a wide range of tissue deficits. Raising these flaps in the described dorsal decubitus position permits two surgical teams to work simultaneously while obviating the need for intra-operative position changes. In cases where a subscapular-based flap is deemed the most suitable option for reconstruction, the dorsal decubitus technique eliminates many of the limitations associated with the traditional lateral decubitus approach without compromising the range of tissue obtainable.

Dorsal decubitus positioning: a novel method to harvest the latissimus dorsi flap for massive upper extremity defect reconstruction.

The latissimus dorsi, whether taken as a muscle or with a skin paddle, is one of the most useful flaps in the reconstructive surgeon's arsenal. With its predictable type V vascular pedicle, this broad muscle can be elevated on its dominant thoracodorsal pedicle or used in a reverse manner on its secondary thoracic and lumbar perforators. Traditionally harvested in a lateral decubitus position, over the last 10 years we have chosen to elevate this muscle in a dorsal decubitus position, enabling 2 surgical teams to operate simultaneously. With only one cushion placed along the vertebral column between the scapulas, each element of the subscapular system, including scapular bone, can be used to reconstruct complex upper limb defects. A vertical incision in front of the anterior axillary line is performed to identify the anterior border of the muscle, followed by a dissection in the submuscular plane to reveal the thoracodorsal pedicle and its branches. When a more complex chimeric flap is required, scapular bone, serratus muscle, and scapular or parascapular fasciocutaneous flaps are all available. To achieve the longest length possible, the pedicle can be isolated from the axillary vessels. The most common complications are related to donor site, with seroma and delayed wound healing being the most prevalent. Complaints of shoulder pain and functional disability were rare and mostly encountered in the first 2 weeks postoperatively.

Imatinib mesylate as a preoperative therapy in dermatofibrosarcoma: results of a multicenter phase II study on 25 patients.

AIMS: The treatment of dermatofibrosarcoma protuberans (DFSP) involves wide local excision with frequent need for reconstructive surgery. A t(17;22) translocation resulting in COL1A1-PDGFB fusion is present in >95% of cases. Certain patient observations and a report on nine patients suggest that imatinib mesylate, targeting platelet-derived growth factor receptor beta, has clinical potential in DFSP. The primary aim of this phase II multicenter study was to define the percentage of clinical responders (Response Evaluation Criteria in Solid Tumors) to a 2-month preoperative daily administration of 600 mg of imatinib mesylate before wide local excision. The secondary aims were to determine tolerance, objective response from imaging results (ultrasound and magnetic resonance imaging), and pathologic responses observed in sequential tissue specimens. PATIENTS AND METHODS: A two-stage flexible design was used with interim analysis after the recruitment of six patients. Twenty-five adults suffering from primary or recurrent DFSP were included from July 2004 to May 2006. RESULTS: The COL1A1-PDGFB fusion gene was detected in 21 out of 25 patients following fluorescence in situ hybridization analysis (two cases were noninformative). A clinical response was achieved in nine (36%) patients (95% confidence interval, 18.9-57.5). The median relative tumoral decrease was 20.0% (range, -12.5 to 100). Apart from expected grade 1 or 2 side effects, we observed one grade 3 neutropenia, one grade 3 maculopapular rash, and one grade 4 transient transaminitis. CONCLUSION: Our results support the use of imatinib in a neoadjuvant setting in nonresectable DFSP, or when surgery is difficult or mutilating. These results will be useful for setting hypotheses in the evaluation of new drugs to treat primary or secondary resistance to imatinib.

Highly sensitive multivariable assay detection of melanocytic differentiation antigens and angiogenesis biomarkers in sentinel lymph nodes with melanoma micrometastases.

OBJECTIVES: To evaluate the prognostic value of melanocytic differentiation antigens and angiogenesis biomarkers in sentinel lymph nodes (SLNs) with melanoma micrometastases. DESIGN: Prognostic study of an inception cohort. SETTING: Academic research. Patients Between July 1, 1999, and July 31, 2002, all patients who had primary cutaneous or mucosal melanomas that have a Breslow depth of 1.5 mm or greater, ulceration, or Clark level IV or V, or had SLN biopsies. MAIN OUTCOME MEASURES: By the use of quantitative reverse transcription-polymerase chain reaction, the expression of the following was analyzed in SLNs: 2 melanocytic differentiation antigens (tyrosinase [P17646] and melanoma antigen recognized by T cells [MART-1; Q16655]) and genes involved in angiogenesis (VEGF [NM_001025366] and VEGFR2 [AF035121]), lymphangiogenesis (VEGFC [NM_005429], VEGFR3 [X68203], LYVE1 [NM_016164], and PROX1 [002763]), and invasion (uPA [NM_002658], PAI1 [NM_00602], and EMMPRIN [L10240]). Outcome measures were the association of these melanocytic differentiation antigens and angiogenesis biomarkers with clinicopathologic characteristics of patients, and an evaluation of the prognostic value for relapse-free survival and overall survival. RESULTS: Ninety-one patients were included, with a median follow-up period of 41 months. Micrometastases were present in 15% (14 of 91) of patients. Tyrosinase (P < .001), MART-1 (P < .001), vascular endothelial growth factor 121 (VEGF(121)) (P = .007), and PAI1 (P = .02) expression was significantly associated with micrometastasis. In univariate analysis, histologic findings and tyrosinase and MART-1 expression were significantly associated with relapse-free survival. Tyrosinase and MART-1 expression was associated with overall survival. A multiple Cox proportional hazards regression model identified negative histologic findings and tyrosinase expression that exceeded 27 copies/copy of TATA box-binding protein (third quartile) as significantly associated with an increased risk of relapse or death. CONCLUSIONS: Quantitative assessment of melanocytic differentiation antigens in SLNs, which has prognostic value, is more specific than qualitative assessment. Prognosis may be more effectively predicted by the combination of quantitative assessment of melanocytic differentiation antigens in SLNs with histologic assessment. A significant association was found between the presence of micrometastases and the expression of angiogenesis biomarkers.

A simplification for harvesting medial plantar venous flap with communicating veins: usefulness of preoperative ultrasound imaging.

BACKGROUND: The medial plantar venous flap is ideally suited for reconstruction of injuries to the palmar surface of the finger. However, when the distal veins of such flaps are narrow, harvesting is no longer simple and anastomosis to the digital artery presents a challenge. METHODS: Using ultrasound imaging, we investigated the presence or absence of communicating veins in the medial plantar region in 40 feet of 20 healthy individuals. In addition, we performed preoperative ultrasound imaging in 8 patients. RESULTS: The investigation in healthy individuals revealed a mean number of 1.2 communicating veins in the medial plantar region. Communicating veins were confirmed preoperatively in 6 of our 8 patients. CONCLUSION: Preoperative ultrasound imaging to investigate the course and diameter of subcutaneous veins and communicating veins in the medial plantar region allows the flap design to be determined appropriately and for the surgery to proceed more simply.

Slow dynamic lymphoscintigraphy is not a reliable predictor of sentinel-node negativity in cutaneous melanoma.

We reviewed data from 160 consecutive patients (89 M/71 F; 53.5 [range, 9-88] years) who had under-gone lymphoscintigraphy and sentinel lymph node biopsy (SNB) in our hospital for histologically proven cutaneous malignant melanoma (CMM) (located on the upper limb: 33; lower limb: 57; trunk: 44; and head and neck: 26 patients), with a Breslow index > 1 mm and without clinical or radiologic evidence of metastatic spread. Colloidal (99m)Tc-rhenium sulfide (36-76 MBq) was injected intradermally in the four quadrants around the tumorectomy scar, followed by dynamic acquisition and static imaging. SN(s) were identified in 157 patients (overall identification rate, 98%). Fast (< 20 minutes), intermediate (20-30 minutes), or slow (> 30 minutes) lymphatic drainage was observed, respectively, in 122 (78%), 24 (15%), or 11 (7%) cases. Overall malignancy rate was 15%, respectively found in 19 (16%), 2 (8%), and 2 (18 %) patients with fast, intermediate, or slow drainage. No statistical difference between SN-positivity rates of patients with fast (19/122 = 16%) versus intermediate or slow drainage (4/35 = 11.4%) was observed (p = 0.69). Therefore, lymphoscintigraphic SN appearance time in CMM patients is unable both to predict SN metastasis and spare them from undergoing SN excision.

Reconstruction of large thoracoabdominal defects using two-stage free tissue transfers and prosthetic materials.

Very large full thickness defects of the thorax or abdomen after tumoral resections commonly need to be reconstructed with free tissue transfers. We retrospectively analysed the protocol of performing the free tissue transfer before the wide excision in 15 patients (mean age of 48) with large tumours of the thorax and abdomen. During the first stage, the flap was folded on itself in a strategic position close to the future resection site and microsurgical anastomoses performed. The second stage surgery consisted of the full thickness excision and definitive reconstruction of the defect by unfolding the flap over prosthetic material. The inclusion criteria were: large thoracoabdominal resections exposing lung or bowel and requiring the use of prosthetic material as part of the reconstruction after resection for locally aggressive tumours such as dermatofibrosarcoma protuberans. In 8/10 patients, vein grafts were used in the arterial anastomosis. The mean time interval between the first and the second stage was 17 days (7-50 days). Flap survival was one hundred percent on first attempt. In one patient who had presented with a large abdominal haemangioma, pulmonary embolism occurred during the second stage. In another patient, an infection under the flap occurred 3 years after reconstruction. Results of this series of patients support our belief that a two-stage microsurgical strategy can be useful in selected patients where large free flaps (with grafted pedicle) in combination with prosthetic materials have to be performed for reconstruction of full thickness defects of the trunk or the abdomen.

A scanning electron microscopical study of the two sides of polypropylene mesh (Marlex) and PTFE (Gore Tex) mesh 2 years after complete abdominal wall reconstruction. A study of 15 cases.

The use of biomaterials for the repair of abdominal wall defect is becoming common and safe. It has been 20 years since the senior author developed a method to reconstruct the very large transfixing abdominal wall defect with a combination of two biomaterials (Gore Tex) PTFE as a neo peritoneum and polypropylene superficial to this in order to give rigidity to the abdominal wall) and a superficial flap. An observation at the electron microscopy level of the two sides of the implants' surfaces was performed. At the time of a late abdominal wall surgical revision on 15 patients, the prosthesis fragments have been analyzed at the electron microscopy level. The aim of our study was to analyze the late evolution of the different sides of these prostheses. Our results showed, for the first time in vivo, that there is an impressive stability of the deep side of PTFE ultra structure after implantation, a significant difference of the two sides of PTFE at the ultrastructural level and the creation of an intermediate tissue between the two meshes. In contrast, the polypropylene invariably gave rise to adhesions and colonisation by the surrounding tissues. Findings confirmed that the structure and porosity of a biomaterial play a key role in the appearance of adhesions and their consistency.

Detection of hemodynamic turbulence in experimental stenosis: an in vivo study in the rat carotid artery.

In a previous study, we have demonstrated that turbulences in arteries less than 1.5 mm in diameter perfused ex vivo by an oscillated flow can be determined using nonlinear mathematical models. The hypothesis tested here was that nonlinear analyses enable the in vivo detection of turbulences in blood flow in vessels with dimensions affected by microsurgery. Twenty Wistar male rats were studied. After an intraperitoneal anesthesia (50 mg/kg sodium pentobarbital), each right carotid artery was dissected and a transit time flowmeter was used to measure blood flow. Arteries were studied in control conditions and graded stenoses, which were performed by a collar system and progressively increased from 0 to 95%. For each flow signal, time delay, false-nearest neighbors, correlation dimension and the largest Lyapunov exponent were computed to characterize the level of turbulence. The level of turbulence was highly correlated with the degree of stenosis induced (p < 0.001). The correlation dimensions of all the flow signals varied between 3 and 5, thus implying that more than three independent noninteger control variables were necessary to account for the complexity of rat carotid artery dynamics. Turbulence flow significantly increased in arteries with 40-95% stenosis. Nonlinear analysis may be useful to determine the turbulence level of an in vivo flow in arteries less than 1.5 mm in diameter and might be clinical useful for turbulence detection after microsurgery.

Depression, anxiety and quality of life among scheduled cosmetic surgery patients: multicentre prospective study.

Objective: To measure cosmetic surgery patients' state of psychological vulnerability. Method: A multicentre prospective study was carried out in three hospital departments. One hundred and three patients scheduled for cosmetic surgery were examined using a structured interview and using three assessment scales: the MADRS (Montgomery and Asberg Depression Rating Scale), the SISST (Social Interaction Self Statement Test) and the EQ-5D (EuroQol) which measures quality of life. Results: The MADRS index was higher than that of the control group (p<0.01) with 20% depressive patients. SISST: the social anxiety was greater than that of the control group (p<0.001). The EQ-5D visual analogue scale average was 77.39% indicating that there was no significant difference when compared with the control group, but the descriptive EQ-5D revealed an over-representation of the anxiety/depression category (p<0.01); 50% had already taken psychotropic treatment of which 27% were an antidepressant. Conclusion: The cosmetic surgery population presents a significant state of psychological vulnerability. Copyright 2001 European Association for Cranio-Maxillofacial Surgery.