Robot-Assisted Pelvic Dissection for Enlarged Lymph Nodes in Melanoma Improves Recovery with Equivalent Oncological Outcomes to Open Pelvic Dissection.

BACKGROUND: Robot-assisted pelvic lymph node dissection (rPLND) has been reported in heterogenous groups of patients with melanoma, including macroscopic or at-high-risk-for microscopic metastasis. With changing indications for surgery in melanoma, and availability of effective systemic therapies, pelvic dissection is now performed for clinically detected bulky lymph node metastasis followed by adjuvant drug therapy. rPLND has not been compared with open pelvic lymph node dissection (oPLND) for modern practice. METHODS: All patients undergoing pelvic node dissection for macroscopic melanoma at a single institution were reviewed as a cohort, observational study. RESULTS: Twenty-two pelvic lymph node dissections were identified (8 oPLND; 14 rPLND). The number of pelvic lymph nodes removed was similar (median oPLND 6.5 (interquartile range [IQR] 6.0-12.5] versus rPLND 6.0 [3.75-9.0]), with frequent matted nodes (11/22, 50.0%). Operative time (median oPLND 130 min [IQR 95.5-182] versus rPLND 126 min [IQR 97.8-160]) and complications (Clavien-Dindo scale) were similar. Length of hospital stay (median 5.34 days (IQR 3.77-6.94) versus 1.98 days (IQR 1.39-3.50) and time to postoperative adjuvant therapy (median 11.6 weeks [IQR 10.6-18.5] versus 7.71 weeks [IQR 6.29-10.4]) were shorter in the rPLND group. No differences in pelvic lymph node recurrence (p = 0.984), distant metastatic recurrence (p = 0.678), or melanoma-specific survival (p = 0.655) were seen (median follow-up 21.1 months [rPLND] and 25.7 months [oPLND]). CONCLUSIONS: rPLND is an effective way to remove bulky pelvic lymph nodes in melanoma, with a shorter recovery and reduced interval to initiating adjuvant therapy compared with oPLND. This group of patients may especially benefit from neoadjuvant systemic approaches to management.

Phosphaturic Mesenchymal Tumor of the Ankle: A Case Report and Review of the Literature.

We report the case of a phosphaturic mesenchymal tumor of the ankle; an extremely rare lesion that causes osteomalacia via paraneoplastic renal phosphate wasting. A 41-year-old man was referred to plastic surgery with a swelling over the anterior ankle, which had been increasing in size for 1 year. Focused ultrasound assessment was inconclusive, but excision biopsy demonstrated features in keeping with a phosphaturic mesenchymal tumor. Evidence of tumor-induced osteomalacia was subsequently identified on review of historical biochemistry. The patient was followed-up for 1 year with normalization of serum phosphate. In this case report, we present a discussion of the differential diagnosis for foot and ankle soft tissue lesions, and a review of the literature regarding the diagnosis and management of these tumors. Accurate identification of any soft tissue lesion on clinical examination alone is extremely challenging and excision biopsy should be considered in cases of diagnostic uncertainty.

Lymph node dissections in cutaneous malignancy: Where are we now? A review of 10 years' experience at a tertiary centre.

The surgical management of cutaneous malignancies has evolved over recent years with the introduction of novel medical therapies and an increasing emphasis upon early adjuvant systemic therapy. As such, completion lymph node dissection (cLND) is now no longer recommended following a positive sentinel lymph node biopsy (SLNB) in melanoma. We evaluated our ten-year practice at a regional tertiary centre, assessing the change in lymph node dissection (LND) caseload volume, anatomical distribution, and indication for the procedure. A retrospective search was carried out of all LNDs performed by the Plastic Surgery department at Cambridge University Hospitals NHS Trust, UK from 1 January 2010 to 31 December 2019. Case notes were retrospectively analysed for each procedure, with the site and pathology recorded. A total of 491 LNDs were performed over the 10-year period. Surgical volume peaked in 2015 with 67 cases, followed by a decline to 41 cases in 2019. The number of neck dissections increased over the decade, as well as the proportion of cases due to macroscopic nodal disease. We sub-analysed the number of LNDs in three contiguous 18-month intervals, corresponding to changes in practice due to evidence from the DeCOG and MSLT-II Trials. We found a 41.67% reduction in LNDs caseload between July 2018-Dec 2019, compared to a similar period prior to trial evidence (July 2015-Dec 2016) (p=0.0.14). In summary, the surgical volume of LNDs has decreased significantly since 2018, reflecting emerging evidence and changes to national guidelines. This will require ongoing monitoring for workforce planning and surgical training.

Free Flap Selection and Outcomes of Soft Tissue Reconstruction Following Resection of Intra-oral Malignancy.

Introduction: Surgery to resect intra-oral malignancy is a well-established mode of primary treatment. The tissue requirement in this area is for a thin, pliable flap with minimal bulk and this has historically been provided by free tissue transfer with a radial forearm free flap (RFFF). More recently, a role for the anterolateral thigh free flap (ALTFF) has been described, although in populations with a westernized diet, body habitus may preclude use of an ALTFF due to flap thickness, relative to a radial forearm free flap. Methods: An analysis of data was performed retrospectively for 90 consecutive patients with intra-oral malignancy, requiring immediate soft tissue reconstruction by the senior author, at Addenbrooke's Hospital between July 2008 and April 2016. Cases requiring bony reconstruction were excluded. Data on patient age, sex, indication for surgery, tumor location and defect type, complications, success rates, and length of stay were recorded. Results: The majority of patients received an ALTFF (n = 56) with 38% receiving a RFFF (n = 34). Surgical resection took place in the floor of the mouth most frequently. These were closed with ALTFF and RFFF in 41 and 28 occasions, respectively. A success rate of 97% was observed in the RFFF group; 1 flap developed partial necrosis and required complete revision. In the ALTFF group, there was a 100% flap success rate. ALTFF usage resulted in a reduction in the number of intraoperative (p = 0.021) in addition a reduction in the number of days in ITU (p = 0.01) and post-operative clinic visits (p = 0.025). Conclusion: We present a series that used predominately the ALTFF to reconstruct intra-oral defects following resection of squamous cell carcinoma in a Western population. The results demonstrate that this treatment can produce at least as comparable results as to the use of a RFFF repair in this population, whilst avoiding the donor site morbidity and aesthetic compromise of a RFFF.

Vismodegib for Locally Advanced Periocular and Orbital Basal Cell Carcinoma: A Review of 15 Consecutive Cases.

Basal cell carcinoma (BCC) is the most common periocular skin cancer and can lead to significant morbidity. We assess the effectiveness of vismodegib, a first-in-class Hedgehog signaling pathway inhibitor, in the management of periocular and orbital BCCs based on clinical response, tolerability, and orbital content preservation. All patients with periocular or orbital BCCs who met criteria for vismodegib treatment were recruited prospectively between May 2012 and 2014 from 2 hospitals. Patients received oral vismodegib (150 mg daily) until disease progression, unacceptable toxicity, or withdrawal. All patients were followed up monthly. Patient demographics, tumor size, treatment duration including dosing regimen, adverse events, response rate, duration of response, progression-free survival, and disease-free survival were analyzed. All 15 patients had biopsy-proven BCCs with no metastatic disease at presentation. The mean age was 74 years and 10 patients (67%) had orbital involvement. The mean lesion longest dimension was 51 mm and 7 cases (47%) represented recurrence following previous surgery and/or radiotherapy. The mean treatment duration was 13 months and mean follow-up duration 36 months. Ten patients (67%) had a complete response, 3 (20%) had a partial response, and 2 had progressive disease following an initial partial response (13%). The partial response of 55% in 1 patient allowed subsequent surgical resection with clear margins. Vismodegib is effective for treating periocular and orbital BCCs with orbital salvage of patients who otherwise would have required exenteration. There is a neoadjuvant role for vismodegib but further studies are required.

An algorithmic approach to perineal reconstruction after cancer resection--experience from two international centers.

AIM: This paper aims to simplify the approach to reconstruction of the perineum after resection of malignancies of the anal canal, lower rectum, vulva, and vagina. MATERIALS AND METHODS: The data were collected from 2 centers, namely, Addenbrooke's Hospital, University of Cambridge, United Kingdom and Christchurch Hospital, University of Otago, New Zealand. All patients who underwent perineal reconstruction from 1997 to 2009 at Christchurch Hospital (13 years) and 2001 to 2009 at Addenbrooke's Hospital (9 years) were included. The diagnosis (indication), primary surgery, reconstructive surgery, complications, tumor outcomes (recurrence and survival), and follow-up were entered into a database (Microsoft Excel; Redmond, Wash). The incidence of previous radiotherapy, requirement for adjuvant radiotherapy, and length of inpatient stay were also recorded. RESULTS: Forty-six patients were identified for this study--13 in New Zealand and 33 in Cambridge. Indications for perineal reconstruction included resection of anal and rectal malignancies (24), vulval and vaginal malignancy (19), perineal sarcoma (1), and perineal squamous cell carcinoma arising in an enterocutaneous fistula (Table 1). The reconstructive strategies adopted included rectus abdominis myocutaneous flaps (26), gluteal fold flaps (9), gracilis V-Y or advancement flaps (7) and others (4), gluteal rotation flaps (1), local flap (2), and free latissimus dorsi flaps (1). CONCLUSIONS: Although various surgeons performed the reconstructive surgeries at 2 different centers, the essential approach remained the same. Smaller defects were best treated by local flaps, whereas the rectus abdominis flap remained the standard option for larger defects that additionally required closure of dead space. On the basis of our 2 center experience, we propose a simple algorithm to facilitate the planning of reconstructive surgery for the perineum.

Management of chyle leak post neck dissection: a case report and literature review.

Chyle leakage post head-and-neck resection is a rare but potentially life-threatening complication. Management may be problematic and prolonged. Recently, thoracoscopic ligation of the thoracic duct has emerged as a promising technique to definitively treat this difficult problem. We present a recent case of a hemimandibulectomy, radical modified neck dissection and osseocutaneous fibular-free-flap complicated by a chyle leakage. The chyle leak was successfully treated with thoracoscopic ligation of the thoracic duct. In the light of our clinical experience and following a thorough literature review, we have proposed that complicated or high-output chyle leaks (>1000 ml day(-1)) should be treated with early thoracoscopic thoracic duct ligation.

Anatomical variation in deep inferior epigastric pedicles and implications for harvest of lower abdominal flaps.

The transverse rectus abdominis musculocutaneous (TRAM) flap based on the deep inferior epigastric artery is useful in head and neck reconstruction as it provides substantial skin and soft tissue cover, and allows volume to be replaced in large defects. A major advantage is the anatomical reliability of the deep inferior epigastric pedicle. We report a case in which neither rectus abdominis muscles had a blood supply from the deep inferior epigastric artery, which necessitated a change in the planned reconstruction. We review variations in the anatomical course of the artery and, although rare, stress the importance of reconstructive surgeons being aware of such variations.