Incomplete excision of basal cell carcinoma: a prospective multicentre audit.

The audit of incomplete excision of basal cell carcinoma can be used as a parameter for clinical governance in plastic surgery units. However, there are no national standards, and all the previous reports from the UK have been retrospective and from regional units only. This 1 year prospective audit was undertaken simultaneously in the plastic surgery units of three different categories of hospital: a regional plastic surgery unit (University Hospital of South Manchester), a supraregional cancer hospital (Christie Hospital) and a district general hospital (Royal Bolton Hospital). A total of 757 lesions were excised from 600 patients, with 34 lesions (4.5%) being incompletely excised. The incidences of incomplete excision were similar in the regional unit (3.2%) and the district general hospital (3.1%), but higher in the supraregional cancer hospital (7.5%). The commonest site for incomplete excision was the eyebrow, followed by the postauricular area, the nose and the temple. There were no statistically significant differences in the distributions of the age and sex of the patients, the site and size of the lesions or the methods of repair between the three hospitals. However, there were significant differences in the distribution of syndromal, multiple and recurrent lesions, the grade of surgeon, and the clinical and histological subtypes. When the various confounding factors were adjusted by logistic regression, the variables most likely to have affected the incidence of incomplete excision were found to be grade of surgeon, minimal excision margin and histological subtype.

An isolated abdominal wall metastasis of ovarian carcinoma ten years after primary surgery.

This report describes the case of a woman with early stage ovarian carcinoma who developed an isolated metastasis in the anterior abdominal wall following an apparent disease-free interval of ten years. The management of the case is discussed and important factors are highlighted. Comparison is also made to the phenomenon of port-site recurrence following laparoscopy in cases of ovarian carcinoma.

Malignant melanoma showing ganglioneuroblastic differentiation: report of a unique case.

We report a case of metastatic malignant melanoma in an inguinal lymph node, expressing ganglioneuroblastic differentiation. This was characterized by the presence of discrete nests and islands of large ganglion cells with abundant cytoplasm and eccentric nuclei with prominent nucleoli admixed with smaller primitive neuroblasts. The cells were separated by pale pink fibrillar material representing neuritic cell processes. These foci of ganglioneuroblastoma were seen over a background of an otherwise typical metastatic epithelioid, focally melanotic, malignant melanoma. Immunohistochemistry showed positivity for neurofilament, synaptophysin, chromogranin, vasoactive intestinal peptide, and glial fibrillary acidic protein in the areas with ganglioneuroblastic differentiation, but not in the melanocytic component. Conversely, HMB45 positivity was expressed by the melanocytic cells only. S-100 protein and Melan-A, a putative melanocytic marker, showed positivity in both melanocytic and ganglioneuroblastic components. Ultrastructurally, neuritic cell processes and dense core neurosecretory granules were identified in the ganglionic and neuroblastic cells. A subsequent nodal metastasis in the same region showed focal neuroblastic differentiation without the ganglionic element. No evidence of neuronal or ganglionic differentiation was seen in the primary skin melanoma.

Psychosocial outcome and patient satisfaction following breast reduction surgery.

There is an increasing awareness that psychosocial outcome and health status are important outcomes following breast reduction surgery. In this study, patients awaiting breast reduction surgery completed detailed and comprehensive psychosocial assessments before and after surgery. Of 33 patients who completed the preoperative assessment, 20 patients were operated on and 19 were reassessed 4 months post-surgery. Patients expressed high levels of satisfaction with specific and overall results of surgery. Scores for anxiety, depression, body image and body satisfaction improved significantly using specific questionnaires. Patients also reported significant improvements on five out of eight subscales on the Short Form 36 health status questionnaire. This study provides further evidence for overall improvement in health status and psychological functioning in patients undergoing breast reduction surgery and supports the provision of this service by the NHS.

Epidermal differentiation and dermal changes in healing following treatment of surgical wounds with sheets of cultured allogeneic keratinocytes.

AIMS: To establish the structural changes that occur in deep surgical wounds engrafted with allogeneic sheets, their time course and inter-relation. METHODS: Deep surgical wounds following shave excision of tattoos (down to deep dermis/subcutaneous fat) were treated with sheets of sex mismatched allogeneic keratinocytes in 19 patients and then biopsied weekly until wound healing was complete. More superficial surgical wounds--that is, 20 standard skin graft donor sites, were biopsied at seven to 10 days (all healed) following application of keratinocyte allografts. All biopsy specimens were examined with a large panel of monoclonal antibodies to keratins, envelope proteins, basement membrane components, and to extracellular matrix components. RESULTS: The hyperproliferative keratin pair K6/16 was expressed in all wounds, for up to six weeks in keratinocyte grafted deep wounds, and up to six months in split thickness skin grafted wounds. CONCLUSIONS: Keratins 6 and 16 have not been detected in normal skin, although the relevant mRNA has. This raises the possibility of regulation at a post-transcriptional level allowing a rapid response to injury with cytoskeletal changes that may aid cell migration. This keratin pair offers the most sensitive marker for altered epidermis following wounding.

Early lymphopenia in burned children with and without the toxic shock syndrome.

The white cell count (WCC) response to thermal injury in children in week 1 postburn has been investigated in a prospective study of 33 patients. Two of these patients developed the toxic shock syndrome (TSS) and, together with seven previously diagnosed cases of the TSS, were studied as a separate group. The WCC response in the non-TSS (control) patients was compared with the response observed in the TSS group. In all patients there was an initial leucocytosis followed by a fall in WCC to a nadir between days 2 and 4. The nadir was significantly lower in the TSS group than that observed in the control group. A rise in the WCC was observed over the following 3-4 days in both groups. In the control group the changes in the WCC were mainly attributable to changes in the granulocyte count with little change in the lymphocyte count. There were similar changes in the granulocyte count in the TSS group but, in contrast to the control group, the lymphocyte count fell, to below the normal range, on day 3. The lowest lymphocyte count observed in the TSS group was significantly lower than that seen in the control group. The observation of a profound fall in the total WCC, granulocytes, and in particular the lymphocytes, between days 2 and 4 are additional factors that may help with the diagnosis of TSS.

The toxic shock syndrome in burned children.

Seven cases of presumed Toxic Shock Syndrome (TSS), occurred in burned children admitted to the Regional Burn Unit at St Andrew's Hospital, Billericay. Four patients died, and three caused concern. 30 per cent of Staphylococcus aureus isolates available for retrospective study were found to be toxin producing. On reviewing children in this age group admitted between September 1982 and April 1984 we feel that a form of TSS has occurred commonly, in some cases where the burned area was less than 5 per cent. Certain recommendations are made.