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Kofler L, Breuninger H, Schreiber RH, Eichner M, Häfner HM, Schnabl SM. Three-dimensional histology vs. serial section histology in the treatment of primary basal cell carcinoma: a randomized, prospective, blinded study of 569 tumours. J Eur Acad Dermatol Venereol 2021; 35:1323-1330. [PMID: 33539573 DOI: 10.1111/jdv.17155] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/14/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND For basal cell carcinoma (BCC), only few controlled data have been published so far, which directly compare micrographically controlled surgery with conventional serial section histology. In addition to Mohs surgery, which uses cryostat sections, also three-dimensional histology (3D-histology), based on paraffin sections, is available to ensure complete control of the margins and basic sections. OBJECTIVES To investigate the rate of local recurrence (LR) as well as the number of required re-excisions for basal cell carcinomas with serial section histology vs. 3D-histology. METHODS We compared serial sections histology with 3D-histology in a prospective, randomized, controlled blinded trial and analysed 569 BCC of all subtypes up to 30 mm diameter, 287 BCC in the 3D group and 282 BCC in the serial section group. Excisions were performed with adapted primary resection margin according to location and size of the tumour. Surgeons were blinded at the time of surgery as they did not know which histological method will be used. Both methods used paraffin sections. RESULTS Both groups did not differ regarding patients age, tumour location, tumour diameter, tumour subtypes or primary resection margins. In the serial section group, re-excisions were required in 21%; 24 tumours (8.4%) recurred after a median of 2.2 years. In the 3D-histology group, re-excisions were required in 39%; 10 tumours recurred (3.5%) after a median of 2.8 years. The recurrence rates differed significantly between both groups. Mean follow-up was 4.5 years. CONCLUSIONS 3D-histology is a useful technique to detect tumour outgrowths at the excision margins, but required a high rate of re-excisions. 3D-histology was associated with a significantly lower LR rate than serial section histology.
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Affiliation(s)
- L Kofler
- Department of Dermatology, Eberhard-Karls University, Tübingen, Germany
| | - H Breuninger
- Department of Dermatology, Eberhard-Karls University, Tübingen, Germany
| | - R H Schreiber
- Department of Dermatology, Eberhard-Karls University, Tübingen, Germany
| | - M Eichner
- Institute of Clinical Epidemiology and Applied Biometry, Eberhard-Karls University, Tübingen, Germany
| | - H-M Häfner
- Department of Dermatology, Eberhard-Karls University, Tübingen, Germany
| | - S M Schnabl
- Department of Dermatology, Eberhard-Karls University, Tübingen, Germany
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Volc S, Maier JCP, Breuninger H, Hund V, Häfner HM, Kofler L. Manufacture and use of tumescence solution meeting hospital-required hygiene conditions - practical implications. J Eur Acad Dermatol Venereol 2019; 33:e434-e435. [PMID: 31220369 DOI: 10.1111/jdv.15754] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 05/15/2019] [Accepted: 06/06/2019] [Indexed: 12/28/2022]
Affiliation(s)
- S Volc
- Department of Dermatology, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - J C P Maier
- Department of Dermatology, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - H Breuninger
- Department of Dermatology, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - V Hund
- University Pharmacy, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - H-M Häfner
- Department of Dermatology, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - L Kofler
- Department of Dermatology, Eberhard-Karls University Tübingen, Tübingen, Germany
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Kofler L, Schweinzer K, Heister M, Kohler M, Breuninger H, Häfner HM. Surgical treatment of hidradenitis suppurativa: an analysis of postoperative outcome, cosmetic results and quality of life in 255 patients. J Eur Acad Dermatol Venereol 2018; 32:1570-1574. [DOI: 10.1111/jdv.14892] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 01/29/2018] [Indexed: 12/30/2022]
Affiliation(s)
- L. Kofler
- Department of Dermatology; University Medical Center; Eberhard Karls University; Tübingen Germany
| | - K. Schweinzer
- Department of Dermatology; University Medical Center; Eberhard Karls University; Tübingen Germany
| | - M. Heister
- Department of Dermatology; University Medical Center; Eberhard Karls University; Tübingen Germany
| | - M. Kohler
- Department of Dermatology; University Medical Center; Eberhard Karls University; Tübingen Germany
| | - H. Breuninger
- Department of Dermatology; University Medical Center; Eberhard Karls University; Tübingen Germany
| | - H.-M. Häfner
- Department of Dermatology; University Medical Center; Eberhard Karls University; Tübingen Germany
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Rühle M, Breuninger H, Schippert W, Möhrle M, Strölin A, Häfner HM, Jünger M. Venous surgery for the treatment of chronic venous insufficiency with respect to global venous haemodynamics and clinical symptoms. Phlebologie 2018. [DOI: 10.1055/s-0037-1622249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
SummaryOur goal was to document changes in venous drainage function ΔV and venous refill times to and th achieved with venous surgery and compare them with preoperative measurements acquired using a variety of venous function tests. Preoperative measurements were performed with two pressure cuffs to predict postoperative outcome; they were compared with actual postoperative measurements made without a pressure cuff. In addition we also analyzed whether the postoperative improvement in venous haemodynamics was correlated with an improvement in clinical findings and symptoms. Patients, methods: 64 patients (14 men and 50 women) were enrolled into the study. Inclusion criteria were Doppler sonographic evidence of insufficiency of the saphenous veins and impaired venous haemodynamics, which form the medical indication for venous surgery. Before and after surgery a variety of diagnostic tests of venous function were carried out simultaneously with the patient in a seated position and performing dorsal extensions: mercury strain gauge plethysmography (MSGP) at the forefoot and calf, phlebodynamometry (PDM), light reflection rheography (LRR), digital photoplethysmography (DPPG) with Elcat measuring head and with Laumann Elcat measuring head, universal light reflection plethysmography (ULP). Results: All the examined methods are suitable for monitoring progress and evaluating therapeutic success after the selective surgical removal of insufficient vein segments. All examination methods showed that refill times t0 and th were significantly improved 6 weeks after venous surgery. The postoperative results of ΔV, t0 and th were most reliably predicted by MSGP (forefoot). ΔV, to and th values determined with MSGP at the calf differed significantly from those acquired with PDM, so MSGP (calf) should not be used for preoperative screening. Conclusions: A close correlation between improvement of clinical symptoms and improvement in venous haemodynamics was found. Selection of the suitable preoperative measurement method makes it possible to accurately predict postoperative outcome.
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Heister M, Häfner H, Breuninger H, Schulz C, Meier K, Kofler L, Spott C, Röcken M, Schnabl S, Eberle F. Tumescent local anaesthesia for early dermatosurgery in infants. J Eur Acad Dermatol Venereol 2017; 31:2077-2082. [DOI: 10.1111/jdv.14461] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 06/20/2017] [Indexed: 01/02/2023]
Affiliation(s)
- M. Heister
- Department of Dermatology; Eberhard Karls University; Tübingen Germany
| | - H.M. Häfner
- Department of Dermatology; Eberhard Karls University; Tübingen Germany
| | - H. Breuninger
- Department of Dermatology; Eberhard Karls University; Tübingen Germany
| | - C. Schulz
- Department of Dermatology; Eberhard Karls University; Tübingen Germany
| | - K. Meier
- Department of Dermatology; Eberhard Karls University; Tübingen Germany
| | - L. Kofler
- Department of Dermatology; Eberhard Karls University; Tübingen Germany
| | - C. Spott
- Operational Controlling and Reporting; Eberhard Karls University; Tübingen Germany
| | - M. Röcken
- Department of Dermatology; Eberhard Karls University; Tübingen Germany
| | - S.M. Schnabl
- Department of Dermatology; Eberhard Karls University; Tübingen Germany
| | - F.C. Eberle
- Department of Dermatology; Eberhard Karls University; Tübingen Germany
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Koenen W, Kunte C, Hartmann D, Breuninger H, Moehrle M, Bechara F, Schulze H, Lösler A, Löser C, Wetzig T, Pappai D, Rapprich S, Weiß C, Faulhaber J. Prospective multicentre cohort study on 9154 surgical procedures to assess the risk of postoperative bleeding - a DESSI study. J Eur Acad Dermatol Venereol 2017; 31:724-731. [DOI: 10.1111/jdv.14080] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 11/22/2016] [Indexed: 12/21/2022]
Affiliation(s)
- W. Koenen
- Department of Dermatology and Allergy; University Hospital Mannheim; Mannheim Germany
| | - C. Kunte
- Department of Dermatology and Allergy; University Hospital Munich (LMU); Munich Germany
| | - D. Hartmann
- Department of Dermatology and Allergy; University Hospital Munich (LMU); Munich Germany
| | - H. Breuninger
- Department of Dermatology; University Hospital Tübingen; Tübingen Germany
| | - M. Moehrle
- Department of Dermatology; University Hospital Tübingen; Tübingen Germany
| | - F.G. Bechara
- Department of Dermatology, Venereology and Allergology; Ruhr-University Bochum; Bochum Germany
| | - H.J. Schulze
- Department of Dermatology; Center for Skin Tumors; Münster-Hornheide; Münster Germany
| | - A. Lösler
- Department of Dermatology; Center for Skin Tumors; Münster-Hornheide; Münster Germany
| | - C.R. Löser
- Dermatology Hospital and Skin Tumor Center; Ludwigshafen Hospital; Ludwigshafen Germany
| | - T. Wetzig
- Department of Dermatology, Venereology and Allergology; University of Leipzig Medical Centre; Leipzig Germany
| | - D. Pappai
- Department of Dermatology; University Hospital Münster; Münster Germany
| | - S. Rapprich
- Department of Dermatology; Hospital of Darmstadt; Darmstadt Germany
| | - C. Weiß
- Department of Biostatistics; University Hospital Mannheim; Mannheim Germany
| | - J. Faulhaber
- Department of Dermatology and Allergy; University Hospital Mannheim; Mannheim Germany
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Abstract
Squamous cell carcinomas of the skin and their precursors, actinic keratosis as well as basal cell carcinomas are classified as non-melanocytic skin cancer and belong to the group of epithelial skin tumors. This tumor entity is one of the most common forms of malignant cancer in western countries with an incidence of approximately 100-170 per 100,000 inhabitants per year in Europe. In German-speaking countries no exact numbers are available on the early forms of squamous cell carcinoma, actinic keratosis (carcinoma in situ); however, results from Great Britain show that at ages over 70 years old the prevalence of actinic keratosis is 34 % in men and 18 % in women. Because invasive epithelial cancer is very common and most commonly occurs in the head region, a safe but skin-sparing approach to surgical treatment is desirable. The safest procedure with respect to local recurrence is surgical excision with subsequent complete 3-dimensional histological preparation (micrographic surgery). With this method it is possible to excise tissue affected by tumor tissue in small steps. This facilitates defect coverage and leads to very good results as well as good esthetic results. The local recurrence rates are extremely low compared to alternative treatment methods, such as photodynamic therapy, topical application of imiquimod or cryosurgery and for the treatment of basal cell carcinoma, for example is 0.7 %. Dermatological operations are therefore interventions with a very high guarantee of tumor-free survival and functional and esthetic results.
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Affiliation(s)
- H-M Häfner
- Universitäts-Hautklinik, Eberhard Karls Universität, Liebermeisterstr. 25, 72076 Tübingen, Deutschland.
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8
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Abstract
BACKGROUND Large nonhealing ulcers and wounds frequently pose a great therapeutic challenge to clinicians and often require skin grafting. Various skin grafting methods are available to cover large skin defects that fail to epithelize. These methods include the use of small pinch grafts, full-thickness punch grafts, large-sized full-thickness grafts and split-thickness grafts. Large-sized full-thickness and split-thickness skin grafting requires expertise to produce cosmetically acceptable results and prevent cobblestoning, unlike small pinch and full-thickness punch grafts. OBJECTIVES To describe a modified technique of split-thickness skin grafting that can be considerably faster than alternative methods. METHODS We describe a method for split-thickness skin grafting using tumescent anaesthesia at the donor site and an electrodermatome and a polyurethane membrane without sutures at the site of the skin defect. RESULTS Since 1997, we have practised a modified, improved, quick and easy split-thickness skin grafting method to cover large skin defects at the extremities. Complete healing is usually achieved 4-6 weeks after the split-thickness skin transplantation, and long-term results are aesthetically successful. CONCLUSIONS We provide a sophisticated modified split-thickness skin graft procedure that has been practised for many years and provides cosmetically acceptable results while saving time.
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Affiliation(s)
- M Kneilling
- Department of Dermatology, Eberhard Karls University, Liebermeisterstr. 25, 72076 Tübingen, Germany.
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9
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Abstract
Meningiomas of the skin are extremely rare. In this case of a congenital meningioma of the scalp, magnetic resonance imaging showed no communication to the meninges. The histological examination discovered a small group of meningioma cells in the periosteum, supporting the assumption that primary cutaneous meningiomas may develop from rudimentary meningoceles.
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Affiliation(s)
- K D Brantsch
- Department of Dermatology, Eberhard Karls University, Tuebingen, Germany.
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10
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Schüle D, Breuninger H, Schippert W, Dietz K, Moehrle M. Confocal laser scanning microscopy in micrographic surgery (three-dimensional histology) of basal cell carcinomas. Br J Dermatol 2009; 161:698-700. [PMID: 19575731 DOI: 10.1111/j.1365-2133.2009.09354.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Güler-Nizam E, Leiter U, Metzler G, Breuninger H, Garbe C, Eigentler TK. Clinical course and prognostic factors of Merkel cell carcinoma of the skin. Br J Dermatol 2009; 161:90-4. [PMID: 19438439 DOI: 10.1111/j.1365-2133.2009.09155.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Merkel cell carcinoma (MCC) is a rare neuroendocrine malignancy of the skin first described by Toker as 'trabecular carcinoma of the skin' in 1972. To date, the origin of the tumour cells still remains unclear. OBJECTIVES The present study analyses prognostic factors of MCC. PATIENTS AND METHODS The medical records of 57 patients with MCC treated between 1988 and 2006 at the Department of Dermatology in Tübingen were reviewed. RESULTS We identified 26 (45.6%) male and 31 (54.4%) female patients with MCC; the age at diagnosis ranged from 26 to 97 years (median 71 years). Primary tumours were located mainly on the head and neck areas (27 cases, 47.4%) and upper extremities (14 cases, 24.6%); 11 tumours were found on the lower extremities (19.3%) and four lesions on the chest (7%); one patient had an unknown primary location. Forty-five (78.9%) patients were diagnosed at stage I of the disease, 11 (19.3%) at stage II, and one patient (1.8%) at stage III at initial presentation. Stage of the disease and age at initial presentation were statistically significant with regard to overall (P < 0.0001; P = 0.0327) and tumour-specific survival (P < 0.0001; P = 0.0156). Use of the Cox regression model revealed initial stage of the disease as the only significant factor in the multivariate analysis. Radiotherapy applied promptly after excision of the primary tumour extended the time to progression significantly (P = 0.0376) but did not prolong overall or tumour-specific survival. Other parameters such as sex, site of tumour, sentinel node biopsy, excision margins, skin and noncutaneous malignancies were found to be not significant. CONCLUSIONS Currently, early recognition of the disease seems to be the only method of ensuring overall survival. However, evidence-based treatment modalities are still urgently needed.
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Affiliation(s)
- E Güler-Nizam
- Department of Dermatology, University-Hospital Tübingen, Eberhard-Karls-University, Liebermeisterstrasse 25, Tübingen D-72076, Germany
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Ernemann U, Rebmann H, Breuninger H, Besch D, Koitschev A, Hoffmann J. Diagnostik und Therapie bei Hämangiomen und vaskulären Malformationen der Kopf-Hals-Region. ROFO-FORTSCHR RONTG 2009. [DOI: 10.1055/s-0029-1221087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lichte V, Breuninger H, Metzler G, Haefner H, Moehrle M. Acral lentiginous melanoma: conventional histology vs. three-dimensional histology. Br J Dermatol 2009; 160:591-9. [DOI: 10.1111/j.1365-2133.2008.08954.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Hoffmann J, Schmid J, Breuninger H, Rebmann H, Besch D, Ernemann U, Reinert S. O.592 Differential diagnosis and treatment of vascular anomalies. J Craniomaxillofac Surg 2008. [DOI: 10.1016/s1010-5182(08)71716-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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16
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Häfner HM, Moehrle M, Eder S, Trilling B, Röcken M, Breuninger H. 3D-Histological evaluation of surgery in dermatofibrosarcoma protuberans and malignant fibrous histiocytoma: Differences in growth patterns and outcome. Eur J Surg Oncol 2008; 34:680-6. [PMID: 17716851 DOI: 10.1016/j.ejso.2007.07.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Accepted: 07/02/2007] [Indexed: 11/28/2022] Open
Abstract
AIMS To evaluate the microscopic growth pattern of dermatofibrosarcoma protuberans (DFSP) and malignant fibrous histiocytoma (MFH) and the long-term outcome using 3D-histologic surgery with paraffin sections to cover complete margins and to detect subclinical spreads very sensitively. METHODS One hundred and one patients have been included comprising 70 DFSP, 31 MFH. Data from 87 patients treated since 1992 were collected prospectively. RESULTS Mean clinical tumor-size was 45 mm, mean histological tumor size 65 mm. A mean excision margin of 19 mm achieved negative margins. The histological infiltration shows an asymmetrical pattern with horizontal or vertical extension either cord-, sector- or multiple-like up to 70 mm in length, detectable by 3D-histology. Age and localization differed significantly between DFSP and MFH lesions. MFH tumors had a significantly deeper infiltration than DFSP. The mean follow up was 60 months. In 70 patients with DFSP one local recurrence after 62 months occurred, but no metastasis. 31 patients with MFH developed 8 local recurrences, and 4 metastases (lymph nodes and/ or lungs); 3 of them died of the disease, all 3 had a postoperative status of R1 (p=0.001). CONCLUSIONS There are significant differences in growth pattern and clinical outcome between DFSP and MFH. DFSP can be cured by surgery following 3D-histology with paraffin sections. MFH is significantly more malignant. After local R0-resection proofed by 3D-histology higher cure rates can be achieved.
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Affiliation(s)
- H-M Häfner
- Department of Dermatology, University of Tuebingen, School of Medicine (UKT), Liebermeisterstrasse 25, D-72076 Tuebingen, Germany.
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Breuninger H. Psychogen ausgelöste Seufzerattacken bei einem 9jährigen Mädchen (mit Bemerkungen zur Pathophysiologie des Seufzens). Laryngorhinootologie 2008. [DOI: 10.1055/s-2007-1008656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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19
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Moehrle M, Breuninger H, Taïeb A, de Mascarel A, Vergier B. Histologie 3D : une technique de chirurgie micrographique adaptée aux dermatologues et pathologistes hospitaliers et libéraux. Ann Pathol 2007; 27:163-71. [PMID: 17909482 DOI: 10.1016/s0242-6498(07)91309-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We present 2 techniques of micrographic surgery (3D-histology) useful to control lateral and deep limits of cutaneous tumors. We have adapted the protocol created in Germany, at the University of Tuebingen, for French pathologists and dermatologists.
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Affiliation(s)
- M Moehrle
- Service de Dermatologie, Universitäts-Hautklinik, Eberhard-Karls-Universität, Liebermeisterstr. 25, D-72076 Tübingen, Allemagne.
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22
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Abstract
Complete three-dimensional histology of excised skin tumour margins has a long tradition and, unfortunately, a multitude of names as well. Mohs, who introduced it, called it 'microscopically controlled surgery'. Others have described it as 'micrographic surgery', 'Mohs' micrographic surgery', or simply 'Mohs' surgery'. Semantic confusion became truly rampant when variant forms, each useful in its own way for detecting subclinical outgrowths of malignant skin tumours, were later introduced under such names as histographic surgery, systematic histologic control of the tumour bed, histological control of excised tissue margins, the square procedure, the perimeter technique, etc. All of these methods are basically identical in concept. All involve complete, three-dimensional histological visualization and evaluation of excision margins. Their common goal is to detect unseen tumour outgrowths. For greater clarity, the authors of this paper recommend general adoption of '3D histology' as a collective designation for all the above methods. As an added advantage, 3D histology can also be used in other medical disciplines to confirm true R0 resection of, for example, breast cancer or intestinal cancer.
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Affiliation(s)
- M Moehrle
- Department of Dermatology, University Hospital, Eberhard-Karls-University, Tübingen, Germany.
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23
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Moehrle M, Breuninger H, Taïeb A, De Mascarel A, Vergier B. Histologie 3D : une technique de chirurgie micrographique adaptée aux dermatologues et pathologistes hospitaliers et libéraux. Ann Dermatol Venereol 2007; 134:87-93. [PMID: 17384558 DOI: 10.1016/s0151-9638(07)89004-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- M Moehrle
- Service de Dermatologie, Universitäts-Hautklinik, Eberhard-Karls-Universität, Liebermeisterstr. 25, D-72076 Tübingen, Allemagne.
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24
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Abstract
BACKGROUND The ear's specific anatomical and lymphatic characteristics impose special requirements on the treatment of melanoma of the ear. OBJECTIVES The aim of this prospective study was to define prognostic factors for melanoma of the ear and to evaluate surgical strategies for excision margins, histological evaluation and sentinel lymph node biopsy (SLNB) in order to achieve better cosmetic and functional results. PATIENTS AND METHODS One-hundred and sixty-one patients with stage I/II melanoma of the external ear were treated in the Department of Dermatology, University of Tuebingen, from March 1976 to March 2004 (median follow-up 62 months). Malignant melanoma of the external ear represented 3% of the stage I/II cutaneous melanomas and 20% of the stage I/II head and neck melanomas recorded in the Melanoma Registry of the Department of Dermatology at the University of Tuebingen. Twenty of 42 lentigo maligna melanomas (LMM) underwent conventional histological evaluation, 22 underwent complete three-dimensional histology of excision margins (3D histology) in a paraffin-technique, i.e. micrographic surgery. SLNB was performed in 28 patients with melanomas thicker than 1.0 mm. Clinical, histological and surgical risk factors were evaluated by univariate and multivariate analysis. RESULTS The median thickness of the tumours in the present study was 1.08 mm (mean 1.51 mm; range 0.18-8.50 mm), and the median excision margins were 11.0 mm (mean 12.61 mm; range 2.0-31.0 mm). The 3-year disease-specific survival rate was 98%, and the 3-year recurrence-free survival rate was 83%. Tumour thickness and invasion level were the only risk factors significant for disease-specific survival. Tumour thickness, location of the tumour and extent of excision margins were independently significant risk factors for recurrence-free survival. LMMs removed surgically with accompanying 3D histology were thicker than those examined by conventional histology (median 0.93 mm vs. 0.83 mm). The use of surgery with 3D histology, i.e. micrographic surgery, made it possible to reduce the excision margins (median 5 mm vs. 10 mm) without an increased risk of recurrence. Two of 29 SLNBs were positive (6.9%). There were six preregional recurrences after negative SLNB and one after positive SLNB. None of the patients who underwent SLNB died of melanoma-related causes during the observation period. CONCLUSIONS This is the largest series of ear melanomas reported so far. The overall survival depended only on the tumour thickness and Clark level of invasion. Local recurrence was more frequent with smaller excision margins, but this did not influence the overall survival. Smaller excision margins under 3D-histological control did not carry an increased risk of local recurrence. Our results do not permit conclusions regarding the prognostic impact of SLNB for patients with melanoma of the ear.
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Affiliation(s)
- V Jahn
- Department of Dermatology, University of Tuebingen Clinics, Eberhard-Karls-Universität, Liebermeisterstr. 25, D-72076 Tuebingen, Germany
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25
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Abstract
BACKGROUND Conventional surgery for lentigo maligna melanoma (LMM) is based on normal histological evaluation. However, such evaluation leaves diagnostic gaps. In contrast, complete three-dimensional (3D) histology of excision margins permits accurate detection of continuously spreading tumour strands like those of LMM. These can be specifically excised in tumour-positive areas with smaller excision margins, and better cosmesis and function. To date there have been no controlled studies of micrographic surgery of LMM. OBJECTIVES Clinical parameters and surgical strategies influencing the prognosis of patients with LMM were evaluated in a prospective study of melanoma patients in the Department of Dermatology of the University of Tübingen (1980-99). METHODS The 292 LMMs comprised 7.4% of 3960 primary stage I and II melanomas treated during this period. One hundred and thirty-six patients in this group (46.6%) underwent surgery on the basis of 3D histology. RESULTS The geometric mean excision margins were significantly smaller in the 3D histology group (P < 0.0001). Patients with micrographic surgery had fewer recurrences. Multivariate analysis of clinical, histological and surgical variables was carried out, and tumour thickness and 3D histology proved to be independent, significant factors for the prognosis of recurrence-free survival (relative risk, RR 2.08, P < 0.0001 and RR 2.11, P = 0.0037, respectively). There were no melanoma-related deaths in the 3D histology group. All 16 melanoma-related deaths were observed among the 156 patients of the conventional histology group (10.3%). CONCLUSIONS Excision of LMM using 3D histology resulted in a twofold lower probability of recurrence and twofold smaller excision margins. 3D histology is a valuable diagnostic tool and can be used in the management of LMM because of the latter's pattern of continuous tumour spread.
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Affiliation(s)
- M Moehrle
- Department of Dermatology, Universitätsklinikum Tübingen, Germany.
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Breuninger H. [Reader's letter concerning K. Kreutzer, B.Bonnekoh, I. Franke, H. Gollnick. Photodynamic therapy with methylaminooxopentanoate (Metvix) and a broad band light source (Photdyn 501): practical experiences in problem patients with actinic keratoses and basal cell carcinomas. JDDG 2004,12:992-999]. J Dtsch Dermatol Ges 2005; 3:397. [PMID: 16372809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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Abstract
Sentinel node biopsy (SNB) is increasingly being used as a minimally invasive staging procedure in patients with malignant melanoma. For decades elective lymph node dissection (ELND) was performed in many centers on patients at risk for lymph node metastasis but without clinically detectable lymph node involvement. Today, selective lymph node dissection (SLND) is offered only to patients with histologically proven metastasis in a SN (10-29%). A positive SN is one of the most important prognostic parameters. Ten years after the introduction of the technique, the role of SNB in the treatment of cutaneous melanoma still remains controversial. Issues include the usefulness of highly sensitive evaluation of SN using molecular biology or cytology techniques, as well as the therapeutic impact of the SNB per se and the associated combined surgical or medical adjuvant therapies.
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Affiliation(s)
- M Möhrle
- Universitäts-Hautklinik, Klinikum der Eberhard-Karls-Universität Tübingen.
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Abstract
Microcystic adnexal carcinoma (MAC) belongs to the spectrum of locally aggressive adnexal carcinomas and most commonly occurs in the head and neck region. Recently it has been proposed that MAC is an apocrine tumor. It is characterized by slow, but locally aggressive growth with infiltration of subcutaneous fat tissue, muscles, perichondrium, periosteum, or perineurium. As a result, surgical treatment often leads to ablation defects, which are many times the size of the clinical lesion. In 1982, Goldstein and colleagues first reported MAC to be a distinct histologic entity characterized by a combination of keratinous cysts in the upper dermis, islands and strands of small basaloid, benign-appearing keratinocytes or squamous cells in the deeper dermis within a dense desmoplastic stroma, and areas of ductular differentiation. The authors report the case of a 78-year-old woman in whom a diagnosis of MAC was made when a tumor on the right cheek recurred for the second time. Previous histopathologic diagnoses were squamous cell carcinoma and desmoplastic trichoepithelioma. Local recurrences of the tumor occurred, despite histographic surgery because in hematoxylin and eosin stains, small islands of the deceptively benign-appearing small basaloid cells of MAC were not recognized as tumor cells. The reported case demonstrates the difficulties in diagnosing MAC and indicates that MAC should always be considered in the differential diagnosis of slowly growing tumors in the head and neck region. If MAC is diagnosed too late, it can be inoperable because of its infiltrative growth.
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Affiliation(s)
- S Fischer
- Department of Dermatology, University Hospital Tübingen, D-72076 Tübingen, Germany
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Moehrle M, Kraemer A, Schippert W, Garbe C, Rassner G, Breuninger H. Clinical risk factors and prognostic significance of local recurrence in cutaneous melanoma. Br J Dermatol 2004; 151:397-406. [PMID: 15327547 DOI: 10.1111/j.1365-2133.2004.06050.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND True local recurrence (LR) means clinically detectable regrowth of parts of the tumour which were not completely excised. In the literature the term 'LR' has been used in a vague and inconsistent manner that may include satellite and in-transit metastasis. OBJECTIVE The aim of this study was to establish clinical, histological and surgical risk factors for the manifestation of LR and to evaluate the prognostic significance of LR. STUDY DESIGN Data from 3960 Stage I and II melanoma patients who visited the melanoma clinic of the Department of Dermatology at the University of Tuebingen from 1980 to 1999 were documented in a prospective manner. A retrospective comparative analysis of patients with and without LR was performed. RESULTS Of all patients 1.4% had a LR as a first recurrence and 1.7% had a LR in the course of the follow-up period. LR were most frequent after previous clinical or histological misdiagnosis and inadequate therapy. In the univariate analysis significant risk factors for LR-free survival were age, tumour surface area, locality, tumour thickness, level of invasion, histological type, associated naevus, surgery (one step vs. multiple steps) and compliance with recommended excision margins. In the multivarate analysis the factors locality (P < 0.0001), tumour thickness (P = 0.0086) and compliance with recommendations on excision margins (P = 0.014) were significant independent risk factors for the manifestation of LR. The overall survival of patients with LR as first progression did not significantly differ from the overall survival of the other patients with melanoma (P = 0.60). CONCLUSION True LR is a rare event for which tumour locality, tumour thickness and surgery are independent risk factors. The occurrence of LR might not impair the prognosis of melanoma patients. However, in the published literature numerous definitions of 'LR', including lymphogenic metastasis, complicate comparison.
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Affiliation(s)
- M Moehrle
- Department of Dermatology, Universitaetsklinikum Tuebingen, Eberhard-Karls-Universitaet, Liebermeisterstr. 25, D-72076 Tuebingen, Germany.
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Moehrle M, Schippert W, Rassner G, Garbe C, Breuninger H. Micrometastasis of a sentinel lymph node in cutaneous melanoma is a significant prognostic factor for disease-free survival, distant-metastasis-free survival, and overall survival. Dermatol Surg 2004; 30:1319-28. [PMID: 15458529 DOI: 10.1111/j.1524-4725.2004.30376.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Sentinel lymph node biopsy (SLNB) has been proposed as a minimally invasive procedure for the histopathologic staging of the regional lymph node basin. The aim of this work was to investigate the prognostic value of detection of micrometastasis by SLNB. METHODS In the period from January 1996 to March 2000, a sentinel lymph node (SLN) was identified in 283 patients at the Department Dermatology, University of Tuebingen. In the case of 38 patients (13.4%) histopathologic examination led to the detection of micrometastasis in at least one SLN. The median follow-up period was 29 months. RESULTS Thirty-one of 245 patients (12.7%) suffered a tumor recurrence following a negative SLNB, and 19 of 38 patients (50%) following positive SLNB. In the case of disease-free survival the remaining significant independent prognostic factors of the multivariate analysis were tumor thickness (p=0.011), ulceration (p=0.026), and the detection of micrometastasis in SLNB (p=0.021). With respect to distant-metastasis-free survival the significant independent prognostic factors of the multivariate analysis were tumor thickness (p=0.0022) and the SLNB results (p=0.0068). For overall survival the tumor thickness (p=0.013) and the SLNB results (p=0.034) were significant independent prognostic parameters in the multivariate analysis. CONCLUSION The study examined patients with melanomas of all tumor thicknesses and SLNB for which the prognostic significance of SLNB was tested. Recurrences were more frequent in patients with a micrometastatic SLN. Patients with a negative SNLB are still at risk for tumor recurrence. The histopathologic result of SLNB is, after tumor thickness, the most significant prognostic factor for disease-free survival, distant-metastasis-free survival, and overall survival.
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Affiliation(s)
- M Moehrle
- Department of Dermatology, Universitaetsklinikum Tuebingen, Eberhard-Karls-Universitaet, Tuebingen, Germany.
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Jahn V, Breuninger H, Garbe C, Möhrle M. Melanome der Nase – Prognosefaktoren und operative Strategien. Akt Dermatol 2004. [DOI: 10.1055/s-2004-835571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Jahn V, Breuninger H, Garbe C, Möhrle M. Melanome des Ohres – Prognosefaktoren und operative Strategien. Akt Dermatol 2004. [DOI: 10.1055/s-2004-835572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Möhrle M, Schippert W, Rassner G, Garbe C, Breuninger H. Is Sentinel Lymph Node Biopsy of Therapeutic Relevance for Melanoma? Dermatology 2004; 209:5-13. [PMID: 15237261 DOI: 10.1159/000078580] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2003] [Accepted: 01/25/2004] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION It is still unclear whether sentinel lymph node biopsy (SLNB) has an effect on the survival or recurrence-free survival of patients. It would be necessary to compare patients with SLNB (or with selective lymph node dissection in the case of positive SLNB) and patients without SLNB who received only a close clinical and sonographic follow-up. To date, no results from prospective, randomized studies of SLNB are available. MATERIAL AND METHODS Patients with SLNB (n = 283) and patients in clinical stage I and II with close follow-up examinations only (n = 3,514) were studied retrospectively in this investigation with regard to prognostic factors established in the literature: sex, age, tumor thickness, histological tumor type, ulceration and localization. RESULTS Multivariate analysis did not show an independent significant advantage with regard to survival when SLNB had been performed (p = 0.37). Compared with patients in clinical stage I and II with close follow-up only (n = 2,617),patients in stage I and II with negative SLNB (n = 238) had no significantly lower melanoma-related mortality (p =0.36) but significantly fewer recurrences in the regional lymph node area (p = 0.0015). With regard to survival without distant metastases and disease-specific survival, patients with positive SLNB (n = 33) did not significantly benefit by comparison with patients who developed lymph node metastasis identified clinically or sonographically later during follow-up examinations (n = 246; p =0.89 and p = 0.38, respectively). CONCLUSION In the relatively short follow-up period after SLNB, patients for whom SLNB had been performed did not have - on the whole - a prognostic advantage over patients who were subject only to close follow-up monitoring. Patients for whom subclinical lymph node metastases had been removed as the result of a positive SLNB did not have a better prognosis than patients without SLNB who had developed lymph node metastases within the follow-up period [corrected]
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Affiliation(s)
- M Möhrle
- Department of Dermatology, Universitätsklinikum Tübingen, Eberhard-Karls-Universität, Tübingen, Germany.
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Kretschmer L, Hilgers R, Möhrle M, Balda BR, Breuninger H, Konz B, Kunte C, Marsch WC, Neumann C, Starz H. Patients with lymphatic metastasis of cutaneous malignant melanoma benefit from sentinel lymphonodectomy and early excision of their nodal disease. Eur J Cancer 2004; 40:212-8. [PMID: 14728935 DOI: 10.1016/j.ejca.2003.07.003] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Early versus delayed excision of lymph node metastases is still being assessed in malignant melanoma. In the present retrospective, multicentre study, the outcome of 314 patients with positive sentinel lymphonodectomy (SLNE) was compared with the outcome of 623 patients with delayed lymph node dissection (DLND) of clinically enlarged lymph node metastases. In order to avoid the lead-time bias, survival was generally calculated from the excision of the primary tumour. Survival curves were constructed using the Kaplan-Meier product-limit estimate. Cox's proportional hazards model was used to perform a multivariate analysis of factors related to overall survival. Compared with SLNE and early performed complete lymph node dissection, DLND yielded a significantly higher number of lymph node metastases. Median and mean tumour thickness were nearly identical in the two therapy groups. The estimated 3-year overall survival rate was 80.1+/-2.8% (+/-standard error of the mean (SEM)) in patients with positive SLNs, and 67.6+/-1.9% in patients with DLND (5-year survival rates 62.5+/-5.5 and 50.2+/-5.4%, respectively). The difference between the two survival curves was statistically significant (P=0.002). Using multifactorial analysis, SLNE (P=0.000052), American Joint Committee on Cancer (AJCC) Breslow thickness category (P<0.000001), age (P=0.01) and gender (P=0.028) were independent predictors of overall survival. The location of the primary tumour (P=0.59) was non-significant. Considering only those centres with sufficient data for epidermal ulceration, this risk factor was also significant. In cutaneous malignant melanoma, early excision of lymphatic metastases, directed by the sentinel node procedure, provides a highly significant overall survival benefit.
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Affiliation(s)
- L Kretschmer
- Department of Dermatology, Georg August University of Göttingen, v. Siebold-Str. 3, D-37075 Göttingen, Germany.
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35
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Blaheta HJ, Roeger S, Sotlar K, Schittek B, Breuninger H, Bueltmann B, Garbe C. Additional reverse transcription-polymerase chain reaction of peripheral slices is not superior to analysis of the central slice in sentinel lymph nodes from melanoma patients. Br J Dermatol 2004; 150:477-83. [PMID: 15030330 DOI: 10.1046/j.1365-2133.2004.05792.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The status of the sentinel lymph node (SLN) is an important prognostic factor in patients with cutaneous melanoma. Reverse transcription-polymerase chain reaction (RT-PCR) has been used as a sensitive means of detecting tumour cells in SLNs. OBJECTIVES To determine whether RT-PCR analysis of the SLN using both the central and the peripheral slices is more sensitive than molecular analysis of the central slice only. METHODS Eighty-three SLNs from 59 patients with primary cutaneous melanoma were identified by SLN mapping. All SLNs were bisected along their longitudinal axis to produce two equal halves. One half was used for histology and immunohistochemistry, and the other was analysed by RT-PCR for tyrosinase and MelanA. Parallel to the longitudinal axis, one central slice (approximately 2 mm in thickness) was cut manually. This central slice was used for our standard RT-PCR protocol. In the current study, up to eight additional peripheral slices (each approximately 2 mm in thickness) were cut parallel to the existing cut surface. These peripheral slices were analysed by additional RT-PCR. RESULTS Standard RT-PCR of the central slice yielded positive results in 34 of 59 patients (57%). Additional RT-PCR of peripheral slices demonstrated positive findings in six additional patients (10%) who were initially negative by standard RT-PCR of the central slice. In detail, seven of those 34 patients positive by standard RT-PCR of the central slice had positive histological findings. In each of these seven patients, RT-PCR was positive both in the central slice as well as in the peripheral slices. The remaining 27 patients with positive RT-PCR results of the central slice showed negative histological findings. Only nine (33%) of these 27 patients had a positive RT-PCR also in the peripheral slices. Finally, all 25 patients with negative RT-PCR results in the central slice showed negative histological findings. Six of these patients (24%) revealed positive RT-PCR results on the analysis of peripheral slices. However, three of these patients expressed only MelanA but not tyrosinase. Thirty lymph nodes from 24 nonmelanoma patients served as negative controls for RT-PCR. In three of these 24 patients (13%) expression of MelanA but not tyrosinase was detected by RT-PCR. CONCLUSIONS Molecular analysis of peripheral slices yielded six additional patients (10%) positive by RT-PCR who were initially negative by standard RT-PCR of the central slice. However, three of these six patients were found to express only MelanA but not tyrosinase. As MelanA expression was also found in 13% of control lymph nodes, positive MelanA expression alone in SLNs of melanoma patients requires cautious interpretation in order to avoid false-positive findings. Thus, additional molecular processing of peripheral slices did not significantly increase the number of patients with RT-PCR-positive SLNs.
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Affiliation(s)
- H-J Blaheta
- Department of Dermatology, Skin Cancer Program, and Department of Pathology, Eberhard-Karls-University, Liebermeister Str. 25, 72076 Tuebingen, Germany.
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Abstract
A pilonidal sinus is a invagination of the skin over the sacrum containing a tuft of hair which enlarges by repeated friction causing the hairs to penetrate the skin. It may become symptomatic if an infection occurs. There are similarities with acne inversa, which is present in about 23% of cases. Acne inversa is an inflammation of the sebaceous glands and terminal hair follicles, chiefly in the intertriginous areas. The first manifestation can occur at any time from puberty to advanced age. 90% of patients are smokers. Initially giant comedones and indolent subcutaneous nodules are found; they progress to form draining sinus tracts. Conservative treatment, incision and/or surgical removal of the abscesses and fistulas is futile. The method of choice is the early complete surgical excision of the involved skin extending into normal tissue both laterally and at the base. In most cases healing of the defects by secondary intention is uneventful.
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Abstract
The treatment of paediatric patients with extended vascular anomalies in the head and neck requires a multidisciplinary approach involving paediatricians, maxillofacial surgeons, dermatologists and radiologists. Therapeutic strategies are based on an internationally accepted classification of vascular anomalies, which distinguishes haemangiomas and vascular malformations. Whereas haemangiomas are endothelial proliferations, vascular malformations are considered to be developmental anomalies which are classified into high-flow or low-flow lesions and, according to their vascular channels, into capillary, lymphatic or venous malformations. In this review we present guidelines for the diagnostic assessment of paediatric patients with vascular anomalies in the head and neck region. The indications for treatment are discussed and therapeutic options are outlined.
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Affiliation(s)
- U Ernemann
- Abteilung für Neuroradiologie, Radiologische Universitätsklinik Tübingen.
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Kretschmer L, Hilgers R, Möhrle M, Balda BR, Breuninger H, Konz B, Kunte C, Marsch WC, Neumann C, Starz H. Patienten mit malignem Melanom profitieren von der Früherkennung regionaler Lymphknotenmetastasen mittels Sentinel-Technik. Akt Dermatol 2003. [DOI: 10.1055/s-2003-822215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Eigentler TK, Caroli UM, Möhrle M, Breuninger H, Radny P, Blank G, Garbe C. Eine randomisierte, offene Therapiestudie zur Überprüfung der Wirksamkeit und Sicherheit von Imiquimod 5%-Creme bei topischer Anwendung 3-mal wöchentlich über 8 oder 12 Wochen in der Behandlung des soliden Basalzellkarzinoms – Eine Analyse von 28 Patienten. Akt Dermatol 2003. [DOI: 10.1055/s-2003-822264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
BACKGROUND In treated facial melanomas, the safety margins generally applied in other body sites cannot be achieved for functional and esthetical reasons. To date there are no controlled studies on safety margins for facial melanomas. Clinical parameters and surgical strategies influencing the prognosis of patients with a facial melanoma were evaluated in a retrospective study of melanoma patients in the Department of Dermatology of the University of Tuebingen (1980-1999). PATIENTS AND METHODS The 368 melanomas of the face comprised 9.3% of 3960 primary stage I and II melanomas and 63% of the melanomas in the head and neck area. RESULTS Multistep procedures, excisional biopsy for histological diagnosis followed by a subsequent resection of a clinical safety margin or re-excision when the tumor extended to the margin, were associated with a higher probability for recurrence-free survival (p = 0.0007), but had no statistical influence on overall survival. In a multivariate analysis, level of invasion (p = 0.0049), ulceration (p = 0.011), 3D-histology (p = 0.027) and defined safety margins (tumor thickness < or = 1.00 mm: 10 mm; > 1.00 mm 20 mm; lentigo maligna melanoma 5 mm with 3D-histology) (p = 0,033) were independent significant risk factors for recurrence-free survival. Level of invasion (p = 0.032), ulceration (p = 0.029), 3D-histology (p = 0.0047) were identified as independent significant risk factors for overall survival. Multivariate analysis did not show that the histological type of melanoma was of prognostic significance. CONCLUSION Reduced safety margins can be employed in melanomas of the face. 3D-histology allows further reduction of safety margins, detects subclinical tumor strands and is correlated with an improved prognosis in patients with facial melanomas.
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Affiliation(s)
- M Möhrle
- Universitäts-Hautklinik, Universitätsklinikum Tübingen, Eberhard-Karls-Universität, Tübingen.
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Ernemann U, Hoffmann J, Breuninger H, Reinert S, Skalej M. [Interdisciplinary concept for classification and treatment of vascular anomalies in the head and neck]. Mund Kiefer Gesichtschir 2002; 6:402-9. [PMID: 12447652 DOI: 10.1007/s10006-002-0418-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE In patients with extended vascular anomalies in the head and neck, therapeutic decisions may pose a challenge to maxillofacial surgeons, dermatologists, and interventional radiologists. We analyzed the value of an interdisciplinary classification and treatment concept. PATIENTS AND METHODS The classification distinguishes hemangiomas and vascular malformations. Whereas hemangiomas are endothelial proliferations, vascular malformations are considered to be developmental anomalies, which are further classified into high-flow or low-flow lesions and according to the vascular channels into capillary, venous, or lymphatic malformations. Since 2000 we have provided interdisciplinary consultation for patients with vascular anomalies. In patients with hemangiomas and venous malformations, the clinical diagnosis is confirmed by color-coded duplex sonography and magnetic resonance imaging; angiography is performed as part of the treatment planning for patients with arteriovenous malformations. Patients with hemangiomas are treated surgically by cryosurgery or laser surgery or conservatively according to lesion size and behavior. In patients with venous malformations, percutaneous sclerotherapy is combined with surgical reduction; patients with arteriovenous malformations undergo transarterial embolization prior to surgical excision of the nidus. RESULTS A total of 73 patients attended the interdisciplinary consultation. This group included 53 patients with facial hemangiomas, 7 with venous malformations, 2 with capillary malformations, 5 with lymphatic malformations, and 6 with high-flow arteriovenous malformations. CONCLUSIONS The interdisciplinary protocol increases diagnostic accuracy and helps to establish individual treatment plans for patients with extended vascular anomalies.
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Affiliation(s)
- U Ernemann
- Abteilung für Neuroradiologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany.
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Breuninger H. [Comment on R. Gillitzer, "Modern wound management"]. Hautarzt 2002; 53:644; author reply 644-5. [PMID: 12432902 DOI: 10.1007/s00105-002-0396-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Möhrle M, Breuninger H. [Comment on the contribution by A. Hauschild et al.: "Safety margins in excision of primary malignant melanoma"]. Hautarzt 2002; 53:291-2. [PMID: 12053699 DOI: 10.1007/s00105-002-0349-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Affiliation(s)
- V Wienert
- RWTH Aachen, Abteilung Dermatologische Phlebologie, Hautklinik, Pauwelsstrasse 30, 52074 Aachen
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Abstract
Pediatric surgical procedures under local anesthesia have been limited by the pain of injections and, because of low body weight, rapidly reached maximum doses. In subcutaneous infusion anesthesia (SIA) highly diluted local anesthetics are administered by flow- and volume-controlled infusion pumps. This article presents a retrospective review of the use of SIA in children undergoing excision of dermatologic problem lesions. A total of 354 surgical procedures, predominantly excisions of nevi in 271 children (3 months-16 years) were performed in 1999: 67 children were operated on under general anesthesia and 204 children with local anesthesia. For local anesthesia we used SIA with diluted prilocaine and ropivacaine (equivalent mixtures of 0.3%, 0.15%, 0.08%). The 67 children operated on under general anesthesia were younger (mean age 3.05 +/- 2.93 years, median age 2.00 years) than the 204 children who had surgery with SIA (mean age 9.00 +/- 4.2 years, median age 9.00 years). The sizes of excisions under general anesthesia were larger (maximum 1060 cm2, mean 76 +/- 225 cm2, median 7 cm2) than those under SIA (maximum 628 cm2, mean 22 +/- 100 cm2, median 3 cm2). No side effects of local anesthesia were observed in these pediatric procedures. The additional use of ropivacaine resulted in prolonged postoperative analgesia. SIA in children is a well-accepted, safe anesthesia that in some cases offers an alternative to general anesthesia.
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Affiliation(s)
- M Moehrle
- Department of Dermatology, University of Tuebingen, Tuebingen, Germany.
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Forschner A, Schippert W, Rassner G, Breuninger H. [Stripping operations of the parva and magna saphenous veins. Long-term study in relation to pre- and postoperative dysfunction]. Hautarzt 2001; 52:797-802. [PMID: 11572071 DOI: 10.1007/s001050170069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Little data is available on the log-term effects of stripping the greater and lesser saphenous veins in combination with pre- and post-operative function tests. The goal of this study was to record the long-term course after surgery based on the function data. PATIENTS/METHODS Drain-off capability was measured preoperatively and postoperatively by light reflection rheography in 203 patients (58 men, 145 women) between 17 and 79 years. Questionnaires were used about 9 years after surgery to determine the nature of the post-operative complaints. RESULTS Nine years after surgery 58% of the patients still had no discomfort, and 78% had fewer problems with venous ulcers. About 60% reported improvement of swelling and skin changes. The results tended to be better in men. Freedom of complaints was longer-lasting where venous drainage had been good before surgery. CONCLUSIONS Stripping operations can produce long-lasting improvement of venous ulceration and the above-mentioned complaints in a high percentage of patients.
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Affiliation(s)
- A Forschner
- Universitäts-Hautklinik, Liebermeisterstrasse 25, 72076 Tübingen
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Blaheta HJ, Paul T, Sotlar K, Maczey E, Schittek B, Paul A, Moehrle M, Breuninger H, Bueltmann B, Rassner G, Garbe C. Detection of melanoma cells in sentinel lymph nodes, bone marrow and peripheral blood by a reverse transcription-polymerase chain reaction assay in patients with primary cutaneous melanoma: association with Breslow's tumour thickness. Br J Dermatol 2001; 145:195-202. [PMID: 11531779 DOI: 10.1046/j.1365-2133.2001.04334.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Tyrosinase reverse transcription-polymerase chain reaction (RT-PCR) has been shown to be highly sensitive in detecting tumour cells in melanoma patients. OBJECTIVE To assess whether the detection of minimal residual disease by RT-PCR is improved by concomitant analysis of sentinel lymph nodes (SLNs), bone marrow (BM) and peripheral blood (PB) in patients with primary melanoma. METHODS Thirty-five SLNs, 41 BM samples and 26 PB specimens from 26 patients with primary cutaneous melanoma (tumour thickness > or = 0.75 mm) were examined by nested RT-PCR for tyrosinase and Melan-A. SLNs and BM samples were also analysed by histopathology. RT-PCR findings were related to tumour thickness of the primary melanoma. RESULTS Overall, melanoma cells were detected by RT-PCR in 13 of 26 patients (50%). Seven patients had positive RT-PCR results in their SLNs (27%), including all patients (n = 4) with histologically positive SLNs, two patients had positive findings in their BM exclusively detected by RT-PCR (8%) and six patients in PB (23%). The presence of tumour cells detected by RT-PCR in SLNs was not related to the presence of melanoma cells in BM and/or PB. The incidence of RT-PCR-positive SLNs was significantly associated with greater tumour thickness (P = 0.004). Both patients with positive RT-PCR findings in their BM had a large tumour thickness (> or = 2 mm). No association between positive RT-PCR findings in PB and greater tumour thickness was observed. CONCLUSIONS RT-PCR-positive SLNs were strongly associated with greater tumour thickness, underlining the prognostic significance of SLN positivity. Similar to certain epithelial malignancies, molecular investigation of the BM might provide complementary prognostic information in the early stages of melanoma. In contrast, no association between positive RT-PCR results in PB and increasing tumour thickness was found, implying that RT-PCR findings in PB are of doubtful clinical relevance in primary melanoma.
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Affiliation(s)
- H J Blaheta
- Department of Dermatology, Skin Cancer Programme, Eberhard-Karls-University, Liebermeister Str. 25, 72076 Tübingen, Germany.
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Breuninger H. [Comment on the contribution by S. Stander, K. Assmann, D. Nashan, B. Wigbels, T. Luger, D. Metze: "Uninterrupted incision margin controlled surgery with paraffin section of melanomas of the face"]. Hautarzt 2001; 52:543-4. [PMID: 11428087 DOI: 10.1007/s001050100220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
BACKGROUND Although the technique of vein removal with a cryoprobe is both simple and well known, it has not yet been widely accepted. A modified probe now eliminates difficulties in its use. OBJECTIVE The original probe has a tip that can be cooled with NO2 or CO2 to -85 degrees C to permit stripping by freezing the vein to the probe from inside the vein. This tip has now been provided with an anatomic curvature and a flexible guide tip, making it easier to introduce the probe into the incision and guide it distally with percutaneous support. WE report on the use of this modified instrument to strip 325 long saphenous veins. RESULTS The modified probe has permitted us to increase the percentage of complete stripping procedures without further distal incisions from 67% to 91%. The procedure was successful in 62% of veins that had already undergone previous sclerosing procedures. Incomplete removal or duplicated long saphenous veins were easily remedied by subsequent stripping starting proximally from a small, distal incision. CONCLUSION Stripping of the long saphenous vein with this modified and easily guided cryoprobe is rapid, uncomplicated, highly effective, and leaves fewer scars.
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Affiliation(s)
- H Breuninger
- University of Tübingen, Liebermeisterstr. 25, 72026 Tübingen, Germany.
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Blaheta HJ, Sotlar K, Breuninger H, Bueltmann B, Rassner G, Garbe C, Horny HP. Does intensive histopathological workup by serial sectioning increase the detection of lymph node micrometastasis in patients with primary cutaneous melanoma? Melanoma Res 2001; 11:57-63. [PMID: 11254116 DOI: 10.1097/00008390-200102000-00007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Various histopathological techniques have been developed in order to improve the detection of micrometastasis in the regional lymph nodes of patients with malignant melanoma. Our standard histopathological examination of lymph nodes included haematoxylin and eosin (H & E) staining and immunohistochemistry (IH) using antibodies to HMB-45 and S-100 proteins of three paraffin sections at one level. In addition, lymph nodes were examined by molecular biological methods using tyrosinase reverse transcription-polymerase chain reaction (RT-PCR). In this study, we investigated the use of step sections and IH in lymph nodes regarded as negative by standard histopathology but positive by tyrosinase RT-PCR, suggesting the presence of tumour cells. In a series of 76 consecutive patients with stage I and II cutaneous melanoma, a total of 156 regional lymph nodes were examined by H & E staining, IH and tyrosinase RT-PCR. All lymph nodes were bisected along their long axis for separate evaluation. In 21 patients, at least one lymph node in the regional nodal basin reported as tumour-negative by standard histopathology was demonstrated to express tyrosinase (total number of nodes = 33). These 33 lymph nodes were re-examined by H & E and IH at 10 additional levels of the paraffin block. Only one lymph node from one patient had occult melanoma cells in deeper levels detected exclusively by IH. Six out of 20 patients with positive findings exclusively on tyrosinase RT-PCR developed tumour recurrences during a median follow-up of 34 months. We therefore conclude that additional step sectioning with IH does not significantly increase the detection of tumour-positive lymph nodes. Patients with melanoma cells detected exclusively by RT-PCR, however, were shown to be at increased risk for tumour recurrence.
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Affiliation(s)
- H J Blaheta
- Department of Dermatology, Skin Cancer Program, Eberhard-Karls-University, Tuebingen, Germany.
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