The management of regional lymph nodes in cancer.

Early clinical observation in cancer patients suggested that tumours spread in a methodical, stepwise fashion from the primary site to the regional lymphatics, and only then to distant locations. Based on these observations, the regional lymphatics were believed to be mechanical barriers preventing the widespread dissemination of tumour. Despite evidence now available disputing its validity, this barrier theory has guided the surgical management of the regional lymphatics for more than a century, influencing the use of such surgical modalities as therapeutic lymph node dissection, elective lymph node dissection and most recently sentinel lymph node biopsy. No published randomized controlled trial exists that demonstrates improved overall survival for patients with cancer of any type undergoing surgery of the regional lymphatics. We believe the presence of tumour in the regional lymphatics indicates the presence of systemic disease, and therapeutic interventions should be directed accordingly.

Mohs micrographic surgery for the treatment of spindle cell tumors of the skin.

BACKGROUND: Because of the uncommon nature of dermal spindle cell tumors, the effectiveness of various treatment modalities is difficult to assess. OBJECTIVE: Our purpose was to measure the effectiveness of treating dermatofibrosarcoma protuberans, atypical fibroxanthoma, malignant fibrous histiocytoma, and leiomyosarcoma by means of Mohs micrographic surgery (MMS). In addition, we attempted to determine whether MMS is useful in treating dermal spindle cell tumors when no definitive histopathologic diagnosis can be rendered. METHODS: In a retrospective chart review, demographic data, tumor data, treatment characteristics, recurrence, and follow-up data were tabulated. RESULTS: The recurrence rate for dermatofibrosarcoma protuberans treated by MMS was 3.0%, for atypical fibroxanthoma was 6.9%, for malignant fibrous histiocytoma was 43%, and for leiomyosarcoma was 14%. The recurrence rate for spindle cell tumors not otherwise specified was 0%. CONCLUSION: These data establish the effectiveness of MMS in the treatment of dermal spindle cell tumors, including those for which no definitive histopathologic diagnosis can be rendered.

Undermining in cutaneous surgery.

BACKGROUND: Benefits, risks, and technical aspects of undermining in cutaneous surgery are presented and reviewed in order to facilitate the execution of this fundamental task of cutaneous surgery. METHODS: The authors' extensive experience with thousands of cutaneous reconstructions and literature consultation form the basis of this review. RESULTS: Literature review and practical experience indicate that undermining reduces wound closing tension. Pertinent anatomic considerations, benefits, risks, as well as sharp and blunt undermining techniques and regional undermining recommendations are discussed. CONCLUSIONS: It is concluded that judicious undermining, properly performed by surgeons knowledgeable of cutaneous anatomy facilitates the execution and enhances cosmesis in cutaneous reconstruction. It is the authors' opinion that sharp undermining technique is the optimal method for most cutaneous reconstructions.

Primary closure for midline defects of the nose: a simple approach for reconstruction.

We present a modification of the standard linear closure for small to medium-sized defects of the lower nose that avoids many of the limitations of flap or graft reconstruction. The surgical technique detailed yields predictable functional and cosmetic reconstruction with very few complications. The dermatologic surgeon should consider this option when reconstructing defects of the lower nose.

A single postoperative application of nitroglycerin ointment does not increase survival of cutaneous flaps and grafts.

BACKGROUND: Nitroglycerin is a vasodilator that has been reported to improve cutaneous flap and graft survival. It has not been tested in controlled studies. OBJECTIVE: We designed our study to test the effectiveness of a single postoperative application of nitroglycerin on flap and graft survival. METHODS: Eighty-eight surgical repairs received topical nitroglycerin and 85 received control ointment (polysporin). Treatment sites were evaluated on postoperative day 7 and assigned a percentage of surface area survival. RESULTS: There was no significant difference in the complication rate of flaps and grafts treated with nitroglycerin (12.5%) compared with those treated with control ointment (8.4%) (P = .244). Subset analysis of flaps as a group and grafts as a group were not meaningful because the complication rates were so low. CONCLUSION: There is no survival increase of flaps and grafts treated with a single application of nitroglycerin ointment.

Review of sentinel lymph node biopsy and systemic interferon for melanoma: promising but investigational modalities.

BACKGROUND: There is conflicting data regarding the efficacy of systemic interferon as adjuvant therapy for high-risk cutaneous melanoma. Sentinel lymph node biopsy has recently gained acceptance in the surgical management of high-risk melanoma, despite a lack of data supporting its efficacy. OBJECTIVE: To review the evidence concerning interferon and lymph node biopsy in the management of melanoma. METHODS: A systematic review of all randomized, controlled trials involving adjuvant interferon and sentinel lymph node biopsy in management of melanoma is presented. RESULTS: Current data regarding the efficacy of adjuvant interferon in the management of melanoma is conflicting. The conflicting results of studies involving both low-dose and high-dose systemic interferon for the adjuvant treatment of melanoma remain unresolved. There is no randomized, controlled data to support the use of sentinel lymph node biopsy in the management of melanoma, despite its widespread acceptance. CONCLUSION: Sentinel lymph node biopsy and systemic interferon remain promising modalities in the management of melanoma, although there is no affinitive evidence to support their efficacy.

Acute excisional wounds treated with a tissue-engineered skin (Apligraf).

BACKGROUND: Tissue-engineered products are usually composed of living cells and their supporting matrices that have been grown in vitro, using a combination of engineering and life sciences principles. Apligraf is a bilayered product composed of neonatal-derived dermal fibroblasts and keratinocytes, and Type I bovine collagen. OBJECTIVE: To evaluate in a prospective, multicentered open study, the effects of tissue therapy with a tissue-engineered skin (Apligraf) with partial or full-thickness excisional wounds. METHODS: One hundred and seven patients participated in this study. The tissue-engineered skin was applied once, immediately after excisional surgery, usually for skin cancer, and patients were followed for up to one year. RESULTS: The safety results were impressive, with no clinical or laboratory evidence of rejection. Clinically, graft persistence was good to excellent in 77 of 105 (73.3%) of patients at one week, falling to 56.6% and 53.6% at two weeks and one month respectively. CONCLUSION: To date, this is the largest experience with a tissue-engineered skin product in acute wounds, and this study suggests that tissue therapy may be safe and useful.

Mohs micrographic surgery: a cost analysis.

BACKGROUND: The incidence of skin cancer is increasing significantly, and many people have declared the increase an epidemic. It was estimated that 900,000 to 1.2 million cases of nonmelanoma skin cancer occurred in the United States in 1994. With increasing pressure to deliver cost-effective medical care, physicians must understand the cost and value of the various methods to treat skin cancer. OBJECTIVE: Our purpose was to define the true cost of treating a series of skin cancers with the Mohs micrographic technique and compare our costs with calculated estimates of the costs to treat the same cancers with traditional methods of surgical excision. METHODS: A group of 400 consecutive tumors was selected. The cost of treatment in the reference group included diagnosis, Mohs micrographic surgery, reconstruction (if applicable), follow-up, and the cost to treat disease recurrence. These costs were then compared with traditional methods of surgical excision: excision with permanent section margin control, excision with frozen section margin control, and excision with frozen section margin control in an ambulatory surgical facility. For cost comparisons, it was assumed that all tumors in the comparison groups would be excised with standard surgical margins and the resultant surgical defects would be reconstructed with the simplest method possible. The costs of diagnosis, excision, pathology, reconstruction, and the cost to treat disease recurrence were then calculated and compared with the costs of treating the lesions with Mohs micrographic surgery. RESULTS: Our calculation of costs documents that Mohs micrographic surgery is similar in cost to office-based traditional surgical excision and less expensive than ambulatory surgical facility-based surgical excision. The average cost of Mohs micrographic surgery was $1243 versus $1167 for excision with permanent section margin control, $1400 for excision in the office with frozen section margin control, and $1973 for excision with frozen section margin control in an ambulatory surgical facility. Analysis based on anatomic location yielded similar results. CONCLUSION: Mohs micrographic surgery is a method of surgical excision with high intrinsic value that is cost-effective in comparison to traditional surgical excision.

Mohs micrographic surgery using HMB-45 for a recurrent acral melanoma.

BACKGROUND: Acral melanomas are uncommon. Due to the thick overlying stratum corneum, accurate estimation of margins is difficult for minimally pigmented or amelanotic melanomas on the palm or sole. OBJECTIVE: To describe the use of Mohs micrographic surgery using frozen sections and HMB-45 immunostaining in the treatment of a multiply recurrent acral melanoma that had failed both standard surgery and Mohs surgery. METHODS: The melanoma was excised by Mohs technique, and the margins were checked by frozen section and HMB-45 immunostaining. RESULTS: The melanoma was completely excised in 11 stages, resulting in a defect that covered much of the plantar surfaces of the ball of the left foot, great, second, third, fourth, and fifth toes. No recurrence has been noted in 22 months of follow-up. CONCLUSIONS: HMB-45 immunostaining is a very valuable adjunct to examination of surgical margins for melanoma, particularly when combined with such histologic features as clustering of cells, melanocyte position within the epidermis, and cytologic atypia.

Intra-incisional prophylactic antibiotics for dermatologic surgery.

OBJECTIVE: To determine the efficacy of intra-incisional antibiotics in decreasing the risk of wound infections in cutaneous surgery. DESIGN: Prospective, blinded, randomized, placebo-controlled trial conducted during an 8-month period. SETTING: A private practice Mohs micrographic surgery referral center. PATIENTS: Seven hundred ninety consecutive patients referred for Mohs surgery or other dermatologic surgery were randomized to receive anesthesia either with study compound or placebo. The 2 groups were equivalent with respect to age and sex distribution and the lesions treated were similar in character. No patients were withdrawn for adverse effects. INTERVENTIONS: Patients received local anesthesia before surgery with either buffered lidocaine hydrochloride or a solution consisting of nafcillin sodium in buffered lidocaine. MAIN OUTCOME MEASURES: All surgical wounds were evaluated in a blinded fashion at the time of suture removal (5-7 days) and scored according to a standardized assessment chart based on erythema, edema, and the presence of purulent discharge. RESULTS: Seven hundred ninety consecutive patients with 908 surgical wounds were enrolled in this study. A total of 12 wound infections were recorded. Eleven (2.5%) of these occurred in the control group, while only 1 (0.2%) occurred in the nafcillin group. This difference was highly significant (P = .003). Observers were blinded to patient groupings particularly for surgical wound scoring. CONCLUSIONS: This study offers strong supporting data for the use of a single intra-incisional dose of an antibiotic administered immediately before dermatologic surgery. The use of nafcillin and buffered lidocaine solution is inexpensive, safe, convenient, and effective.

Surgical margins for excision of primary cutaneous melanoma.

BACKGROUND: A major controversy in the treatment of melanoma is the width of the surgical margin necessary for complete excision. Although surgical margins have decreased in recent years, the current recommendations are mainly based on arbitrary choices, only two of which have been tested in clinical trials. OBJECTIVE: Our purpose was to use prospective data, measuring the extent of subclinical melanoma extensions, to develop guidelines for predetermined surgical margins for the excision of cutaneous melanoma. METHODS: A prospectively collected series of 535 patients with 553 primary cutaneous melanomas was studied. All melanomas were excised by means of the fresh tissue technique of Mohs micrographic surgery with frozen section examination of the margin. The surgical margin needed for excision of melanoma was determined by measuring the invisible extensions of tumor around the melanoma. The minimum surgical margin was 6 mm and the total margin was calculated by adding an additional 3 mm for any melanoma requiring a subsequent stage to remove the tumor completely. RESULTS: Eighty-three percent of melanomas were successfully excised with a 6 mm margin; 9 mm removed 95% of the melanomas; and a 1.2 cm margin was necessary to remove 97% of all melanomas. Margins to remove melanomas on the head, neck, hands, and feet were wider than those on the trunk and extremities. Margins to remove melanomas that were more than 2 to 3 cm in diameter were wider than for smaller melanomas. CONCLUSION: Predetermined surgical margins for excision of melanoma or melanoma in situ by standard surgical techniques should include 1 cm of normal-appearing skin for melanomas on the trunk and proximal extremities that are smaller than 2 cm in diameter, or a 1.5 cm margin for tumors larger than 2 cm in diameter. For melanomas on the head, neck, hands, and feet, a minimum surgical margin of 1.5 cm is recommended or a margin of 2.5 cm for melanomas larger than 3 cm in diameter. Mohs micrographic surgery is a useful alternative to standard surgery when more narrow margins are desired, particularly for melanomas on the head, neck, hands, and feet, or melanomas larger than 2.5 cm in diameter, or for melanomas without distinct clinical margins.

Mohs micrographic surgery for the treatment of primary cutaneous melanoma.

BACKGROUND: Mohs micrographic surgery is thought to be a useful therapy for cutaneous melanoma. Controversy persists, however, because there are few published reports that document its safety and efficacy. OBJECTIVE: Our purpose was to determine the safety and efficacy of Mohs micrographic surgery for the treatment of cutaneous melanoma. METHODS: A consecutive sample of 535 patients referred for treatment of 553 primary cutaneous melanomas was entered into the study. Of this sample, 99.5% of patients completed their first 5 years of follow-up. All melanomas were excised by means of fresh-tissue Mohs micrographic surgery with frozen-section examination of the margin. The 5-year Kaplan-Meier melanoma mortality, metastasis, and local recurrence rates were compared with historical control cases. RESULTS: Mohs micrographic surgery provided 5-year survival and metastatic rates equivalent to or better than historical controls that were treated by standard wide-margin surgery. Satellite metastases were not more common with the narrow margins used with Mohs micrographic surgery. Local recurrences from inadequate excision of the primary tumor were infrequent (0.5%). The majority of melanomas were successfully excised with a narrow margin (83% were excised with a 6 mm margin). CONCLUSION: Mohs micrographic surgery is an effective therapy for primary cutaneous melanoma. It may be particularly useful to conserve tissue for melanomas on the head, neck, hands, or feet or for melanomas with indistinct clinical margins.

Favorable prognostic factors in recurrent and metastatic melanoma.

Survival among patients with recurrent and metastatic melanoma varies widely. Several clinical and pathologic variables correlate with improved survival. Awareness of these favorable prognostic characteristics should assist in patient counseling and help identify those who may benefit from more aggressive therapeutic intervention.