Topically Administered Macromolecular Heparin Proteoglycans Inhibit Thrombus Growth in Microvascular Anastomoses

Previously, during blood perfusion over collagen-coated surfaces; soluble or immobilized heparin proteoglycans (HEP-PG) have been shown to block thrombus growth. Our aim was to study the antithrombotic effect of locally applied unfractionated heparin (UFH, 1 mg/ml), or rat mast cell-derived HEP-PG (MW 750 kD, 10 µg/ml) compared with saline in early (10 min) and late (3 days) thrombus formation upon anastomosis of rat common femoral arteries. In both semiquantitative scanning electron microscopy (SEM) and quantitative platelet Indium 111 -labeling HEP-PG inhibited thrombus growth in comparison with saline. At 10 min, the extent of thrombosis (scale 1-4) in SEM followed the order: saline (3.2+/-0.8) > UFH (2.8+/-1.0) > HEP-PG (1.8+/-0.8), and also Indium111-positive platelets (106) accumulated on the anastomosed vessel in the same order 14.2 +/-7.2, 10.3 +/-5.0, and 7.7 +/-3.1 (saline vs. HEP-PG, p = 0.03 and 0.05, respectively). At 3 days all HEP-PGtreated vessels remained patent with only small mural thrombi, whereas 2/7 saline and 1/7 UFH-treated anastomoses occluded and showed more thrombosis overall. We conclude that locally administered HEPPG inhibit arterial thrombus growth in anastomosed small-sized arteries and could prevent thrombotic complications in (micro)vascular surgery and arteriovenous shunts.

Immediate Breast Reconstruction

Immediate breast reconstruction (IBR) in conjunction with mastectomy for cancer or high risk of breast cancer is safe from an oncological point of view. The cosmetic outcome can be excellent, especially when performing mastectomy by sparing the skin of the breast and reconstructing the breast mound with autogenous tissue.

The majority of women at their working age are willing to have their breast reconstructed. Patients with newly diagnosed cancer undergoing major surgery need extra support compared with those undergoing late reconstructions. Immediate reconstructions with one operation, one hospital stay and one sick leave are economically favourable by diminishing the demand of delayed reconstructions. Preference in patient selection for IBR should be in patients with good prognoses like those with diffuse noninvasive cancer and those with a considerable risk to develop breast cancer. Women with axillary-node negative invasive cancer and women with late local recurrences in breast earlier conservatively treated are also suitable for IBR. If needed, oncological treatments can be given after IBR, although radiotherapy after pure implant reconstructions is not recommended.

In order to give all eligible patients an equal opportunity to have IBR, treatment of breast patients should be centralised to hospitals with a team comprising breast cancer surgeons, pathologists, radiologists, and plastic surgeons.

Microscopic margins and results of surgery for dermatofibrosarcoma protuberans

BACKGROUND

Dermatofibrosarcoma protuberans is a rare low-grade sarcoma of the skin with a tendency to recur locally after inadequate excision. Treatment has traditionally been wide excision with a 2- to 3-cm gross margin. Because of the variable results presented in mainly retrospective reports, it has been queried whether local control can be as good with conventional surgery as with micrographic surgery.

METHODS

Forty patients with dermatofibrosarcoma protuberans treated by surgical excision were operated on at our center from 1987 to 2001. Data were recorded prospectively. Twenty-seven patients presented with a primary tumor and 13 with a locally recurrent tumor primarily operated on elsewhere. Gross and histologic margins were studied in detail.

RESULTS

At a mean follow-up of 40 months, there were no recurrences. Thirty-four patients required single, five patients two, and one patient three operations before the margins were adequate (mean, 1.2 stages per patient). Twenty-three patients (58 percent) needed reconstructions. Tumor-free margins were obtained in 39 patients. The average thickness of surgical gross margins was 3.1 cm; histologically defined margins averaged 1.6 cm.

CONCLUSIONS

Good local control can be achieved with wide surgery. Histologic tumor-free margins differ greatly from gross margins and are difficult to assess clinically and macroscopically. Careful postoperative histologic examination with margins measured in millimeters should be carried out to define the adequacy of excision in all directions. On average, a 1.6-cm histologic margin was adequate for complete local control. Most patients can be operated on in one stage. Reconstructions are often needed.

Changes in articulatory proficiency following microvascular reconstruction in oral or oropharyngeal cancer

Articulatory proficiency of /r/ and /s/ sounds, voice quality and resonance, speech intelligibility, and intraoral sensation were examined prospectively before operation, and at four time points during a 1-year follow-up after microvascular transfer. Forty-one patients with a large oral or oropharyngeal carcinoma undergoing tumor resection and free-flap reconstruction usually combined with radiotherapy participated in the study. Articulation, voice, and resonance were investigated both live and from recorded speech samples by two trained linguistic examiners. The patients completed a self-rating of their speech intelligibility and were assessed for anterior intraoral surface sensation by means of 2-point moving discrimination. Misarticulations of /r/ and /s/ increased significantly after the therapy. Voice quality and resonance remained essentially normal. Speech intelligibility deteriorated significantly. Intraoral sensation decreased postoperatively but was not related to speech outcome. Sensate flaps did not prove to be superior in relation to speech tasks. A multidisciplinary approach is advocated in assessment of speech outcome after cancer surgery. Speech therapy is strongly recommended, even in the absence of a gross articulatory handicap.

Ki-67, Bcl-2 and p53 expression in primary and metastatic melanoma

The aim of this study was to clarify the roles of the tumour proliferation marker Ki-67, the anti-apoptotic protein Bcl-2 and the cell cycle regulator p53 in primary cutaneous and metastatic melanoma. One hundred and seventeen primary melanomas and 18 metastatic tissue samples were analysed for immunohistochemical expression of Ki-67, Bcl-2 and p53. The staining results were correlated with disease progression and clinical outcome. The patient population comprised patients diagnosed with melanoma between 1988 and 1991. The clinical follow-up period for disease recurrence was 4.6 years (median; range, 0.2-7.5 years) and the follow-up period for overall survival was 10.0 years (median; range, 8.6-15.6 years). Ki-67 expression was not a prognostic factor in primary melanoma. High Bcl-2 expression was associated with such adverse prognostic factors as male gender, old age of the patient and tumour ulceration. High Bcl-2 expression was also associated with an adverse prognosis in intermediate-thickness (1.01-4.0 mm) melanomas (n=52) for disease-free (P=0.09) and overall (P=0.08) survival. In multivariate analysis, tumour thickness was the strongest prognostic factor for disease-free survival (P<0.01). High p53 expression indicated a poorer prognosis (P=0.05). In metastatic melanoma, the expression levels of Bcl-2 and p53 were lower than those in their primary counterparts (P=0.08 for each). Ki-67 expression showed no remarkable changes. It can be concluded that high p53 expression in tumour cells is associated with a poorer prognosis in primary melanoma, and high Bcl-2 expression in tumour cells is an adverse prognostic marker in intermediate-thickness primary melanoma.

Quality of life after free-flap reconstruction in patients with oral and pharyngeal cancer

BACKGROUND

Our aim was to investigate quality of life and outcome after microvascular free-flap reconstruction after oncologic surgery.

METHODS

Forty-four patients with a large carcinoma in the oral cavity, oral pharynx, or hypopharynx underwent free-flap surgery with or without radiotherapy. Patients completed the University of Washington Quality-of-Life Questionnaire preoperatively and four times during the 12 postoperative months. Survival rates and complications were analyzed.

RESULTS

Postoperative composite quality-of-life scores were significantly lower than before treatment with no significant overall improvement during the follow-up. The scores for disfigurement, chewing, speech, and shoulder function remained significantly below the preoperative level throughout the follow-up. Sociodemographic factors predicted quality of life. Heavy drinking and unemployment caused a 2.4-fold and a 4.4-fold increase in risk of death, respectively. The rates for overall survival, tumor recurrence, flap success, and surgical complications were consistent with previous literature.

CONCLUSION

Sociodemographic variables affect quality of life and patient survival in patients with oral cancer treated with microvascular free-flap reconstruction.

Swallowing after free-flap reconstruction in patients with oral and pharyngeal cancer

Swallowing and intraoral sensation outcome were investigated prospectively after microvascular free-flap reconstruction. Forty-one patients with a large oral or oropharyngeal carcinoma underwent free-flap surgery usually combined with radiotherapy. The patients completed modified barium swallow, self-rating of swallowing, and 2-point moving discrimination preoperatively and at four time points during the 12-month follow-up period, and a plain chest X-ray one year after operation. Swallowing was impaired with respect to an objective and subjective measure after therapy. Rates for nonsilent and silent aspiration increased during the follow-up. Intraoral sensation deteriorated. Swallowing outcome was not related to sensation. One year after surgery, 86% of the patients ate regular masticated or soft food. Microvascular transfers offer a reasonable option for oral reconstruction. This study does not support the need for sensate flaps. Swallowing problems should be routinely sought and patients rehabilitated during a sufficiently long follow-up with videofluorography regardless of the patient's perception of swallowing.

Speech Aerodynamics and Nasalance in Oral Cancer Patients Treated with Microvascular Transfers

The purpose of the current study was to assess speech aerodynamics and nasal acoustic energy during a follow-up period of 12 months in patients having undergone microvascular free flap reconstruction after tumor ablation from the oral cavity or oropharynx, usually followed by radiotherapy. Velopharyngeal function was assessed in terms of velopharyngeal orifice size by a pressure-flow measurement technique as well as by determining the instrumental correlate of perceived nasality (i.e., nasalance) during speech production. Velopharyngeal closure and nasalance were estimated to be adequate before operation both in oral cavity and oropharyngeal cancer patients. After the operation, at the group level, the oral cavity patients showed adequate velopharyngeal closure and nasalance. In contrast, the postoperative velopharynx orifice size was significantly bigger in the oropharyngeal cancer patients as compared with the oral cavity patients 6 months after operation. However, based on average aerodynamic as well as the nasalance data, the impairment of velopharyngeal function was not regarded clinically significant at the group level in either group of patients. The present treatment protocol served to maintain the prerequisites for normal or close to normal speech physiology.

Cyclooxygenase-2 expression in human soft-tissue sarcomas is related to epithelial differentation

BACKGROUND

Cyclooxygenase-2 (Cox-2) is expressed by several types of epithelial malignancies, i.e., carcinomas, and inhibition of Cox-2 may have a therapeutic role in chemoprevention and treatment of cancer. The role of Cox-2 in non-epithelial malignancies, however, is unclear.

MATERIALS AND METHODS

We investigated, by immuno- histochemistry, the expression of Cox-2 in 103 human soft-tissue sarcomas.

RESULTS

All 10 biphasic synovial sarcomas were positive for Cox-2, but positivity was observable only in the epithelial component of these tumours. Excluding sarcomas with epithelial differentation, uniform staining of the tumour was observed in only 2 samples. In addition, positivity for Cox-2 appeared in tumour cells in only 18 samples around necrotic areas.

CONCLUSION

In human soft-tissue sarcomas, Cox-2 expression seems to be associated with epithelial differentation and, in some types of sarcomas, to be expressed in otherwise negative tumours at sites of necrosis.

Ezrin in primary cutaneous melanoma

Ezrin is a member of the ezrin-radixin-moesin family of proteins that link the actin-containing cytoskeleton to the plasma membrane. Ezrin is also connected to signaling molecules involved in the regulation of cell survival, proliferation and migration. Here, we examined the expression of ezrin in 95 primary cutaneous melanomas and correlated ezrin expression with conventional prognostic factors and biomarkers. From 12 patients metastatic tissue samples were also examined. In addition to ezrin staining, Mib-1 proliferation antigen, p53 and Bcl-2 were evaluated. Ezrin immunoreactivity was seen in most tumors; only 19 (20%) melanomas were negative. A total of 48 (51%) tumors had weak immunoreactivity and 28 (29%) strong immunoreactivity. The intensity of ezrin immunoreactivity was associated with tumor thickness (Breslow, P=0.0008) and with tumor invasion level (Clark, P=0.004), thicker tumors having stronger immunoreactivity. Also, there was a correlation between higher Mib-1 index in tumors and strong ezrin expression. All metastatic samples (n=12) showed positive ezrin immunoreactivity. In univariate analysis of survival, patients (n=76) with positive ezrin immunoreactivity had worse clinical disease behavior than those (n=19) without ezrin immunoreactivity, but the difference was not significant (P=0.19). In multivariate analysis of survival, the ezrin immunoreactivity was not a significant marker. The results indicate that ezrin is expressed in most primary melanomas of the skin and in all metastatic tumors. Ezrin expression correlates with tumor thickness and level of invasion suggesting an association between ezrin expression and tumor progression.

Births and perinatal health of infants among women who have had silicone breast implantation in Finland, 1967-2000

BACKGROUND

Potential problems with breast implants have been widely discussed, but few data exist on the childbearing and offspring of women with implants. The purpose of this study was to investigate the occurrence and conditions of pregnancies of women who have had cosmetic breast implantation (exposed women), and the health of their newborns.

METHODS

Women who had breast implants for cosmetic reasons in the period 1967-1999 (n = 2236) were identified from hospital surgical records. The births of the exposed women were identified through record linkage to the Population Register. The perinatal health of the infants was studied by the data in the Medical Birth Register in 1987-1999. For each birth to an exposed woman, 20 control mothers who gave birth in the same year were chosen randomly from the Medical Birth Register. Differences in mothers' background characteristics were adjusted by logistic regression.

RESULTS

The women had received their first cosmetic breast implants at young ages (mean 31 years). By year 2000, 26% of the exposed women had one or more children. Half of these women had not had a liveborn child before getting implants. Of the 1661 exposed women who had not (yet) had children, 32% were less than 35 years of age at the end of follow-up. The women had children at a mean of 4.7 years after the implants. Some of the perinatal health indicators suggested poorer health and others better health for infants of exposed women, but only transfers to other hospitals and lower birthweight among infants of exposed multipara were statistically significant.

CONCLUSIONS

The study shows that pregnancy and infant health are relevant considerations with regard to breast implants; further studies on implants are needed.

Safety of Immediate Breast Reconstruction

The benefits of immediate breast reconstructions (IBR) compared with late reconstructions are one operation instead of two and excellent aesthetic result with the skin-sparing mastectomy technique. Indications for mastectomy vary from risk reduction of healthy women to preinvasive, invasive and locally recurrent breast cancer. IBR has been successfully performed in all of these patient groups and local control has been comparable with the series treated with breast conservation or mastectomy without reconstruction. We review this literature and discuss patient selection, the use of skin-sparing mastectomy, possibilities of nipple conservation and limitations with the use of implants. Cooperation of multidisciplinary breast cancer teams is needed to tailor the treatment of breast cancer for each individual patient. To define guidelines for the use of IBR, multicentre studies with follow-up data of large enough series stratified by patient, tumour and treatment characteristics are needed.

Massive intra-abdominal bleeding due to injury in the mesenteric artery during late breast reconstruction with a free TRAM flap: a case report

We report on a rare case of major intra-abdominal bleeding that occurred in a patient undergoing late breast reconstruction with a transversus rectus abdominis musculocutaneous (TRAM) flap. During the flap-raising procedure, a small rupture was found at the base of the superior mesenteric artery, probably caused by electric current. The ruptured vessel required immediate laparotomy and suturing, and the final outcome of the patient was good. The massive bleeding, almost 8-fold as compared with three normal cases, caused clear activation of coagulation seen with elevated TAT values at the end of the operation, and remarkably enhanced fibrin turnover with elevated D-dimer, up to 25-fold from baseline, on the first postoperative day. As a result of major bleeding, the fibrinolytic system was also activated: a biphasic elevation of tPA was seen, first immediately after the bleeding event at 2 h, and later on the first postoperative day, followed by fibrinolytic shutdown associated with increased PAI-1 values.

The Effect of Intravenous Dopamine and Dobutamine on Blood Circulation During a Microvascular TRAM Flap Operation

A study was conducted to assess the effect of intraoperatively administered inotropic agents on blood flow in the recipient and donor vessels, during breast reconstruction with a muscle sparing free TRAM flap. Twenty-one consecutive patients were randomized into 3 groups receiving either dopamine, dobutamine, or placebo. When the flap and all vessels had been fully dissected but not yet divided, the study drug was administered intravenously for 15 minutes. Hemodynamic parameters and transit-time flow of the thoracodorsal and inferior epigastric arteries were monitored. Both dobutamine and dopamine infusions resulted in significant raises in cardiac output and mean arterial pressure. However, while dobutamine resulted in a higher cardiac output (P = 0.001) and a decrease in systemic vascular resistance (P = 0.028), the increase in mean arterial pressure was greater with dopamine (P = 0.002). Only the dobutamine group showed increased blood flow, in both the thoracodorsal (P = 0.043) and the inferior epigastric (P = 0.043) arteries. If vasoactive agents are needed during microvascular anesthesia, dobutamine seems to be more advantageous than dopamine.

Tenascin-C in primary malignant melanoma of the skin

AIMS

To investigate the expression and the prognostic role of glycoprotein Tenascin-C (Tn-C) in primary melanoma of the skin.

METHODS AND RESULTS

The immunohistochemical expression of Tn-C was studied in 98 primary melanomas and related to inflammation, invasion, and patient outcome. Patients were followed up for disease recurrence for 0.04-7.4 years (median 3.9) and for survival for 0.5 to 12.1 years (median 9.3). The expression of Tn-C was evaluated for each tumour invasion border; the stromal and intracytoplasmic Tn-C of the melanoma islets were also recorded. Tn-C is widely expressed in primary melanoma samples, the staining pattern varying from focal to diffuse in different parts of the tumour. No correlation existed between intensity of Tn-C staining and inflammation. No stromal Tn-C was detected at the upper dermal lateral border in 12 patients, nor at the deep, dermal or subcutaneous border in 14 patients. These patients showed better disease-free survival (DFS) than did those cases with focal or diffuse staining (P = 0.06, P = 0.05). Also, absence of intracytoplasmic Tn-C was a beneficial prognostic factor for DFS (P = 0.04). In multivariate analysis, tumour ulceration and intracytoplasmic Tn-C expression of melanoma cells were independent adverse prognostic factors for DFS.

CONCLUSIONS

In primary melanoma of the skin, absence of Tn-C in the stroma of invasion fronts and within tumour cells seems to be related to a more benign disease behaviour with a lower risk of developing metastases.

Vascular endothelial growth factor‐C gene therapy restores lymphatic flow across incision wounds

Edema and insufficient blood perfusion are common problems in reconstructive surgery. The blood vasculature is reconstructed in microvascular flaps, whereas lymphatic vessel function is lost after surgical incision. Here, we demonstrate that vascular endothelial growth factor C (VEGF-C) gene transfer can be used to reconstruct a lymphatic vessel network severed by incision of skin flaps. We used adenoviral VEGF-C gene transfer at the edges of epigastric skin flaps in mice. Our results show that VEGF-C gene expression results in the formation of anastomoses between the lymphatic vessels of the skin flap and the surrounding lymphatic vasculature. Some spontaneous lymphangiogenesis also took place in the control mice, but the lymphatic vessels generated remained nonfunctional even 2 months postoperatively. In contrast, the VEGF-C treated mice demonstrated persistent lymphatic vessel function during the 2 month follow-up despite the transient nature of the adenoviral VEGF-C gene expression. The restoration of lymphatic function by VEGF-C in skin flaps provides new tools to promote vascular perfusion and to reduce tissue edema in skin and muscle flaps. These results have important implications for the prevention and treatment of surgically induced secondary lymphedema.

Matrilysin-1 (MMP-7) and MMP-19 are expressed by Paget's cells in extramammary Paget's disease

BACKGROUND

Extramammary Paget's disease (EMPD) is a rare malignant neoplasm of apocrine gland bearing skin characterized by intraepidermal proliferation of adenocarcinoma cells. Tumor growth depends on the ability of tumor cells to migrate by proteolysis and on angiogenesis. The matrix metalloproteinase (MMP) enzymes have been implicated in both of these processes in other types of skin cancer.

METHODS

The expression of MMP-1, MMP-2, MMP-3, MMP-7, MMP-9, MMP-13, and MMP-19 was analyzed by immuno- histochemistry and/or in situ hybridization in 27 EMPD and five mammary PD (MMPD) specimens. The distribution of laminin-5 (LN-5) and tenascin-C, two extracellular matrix proteins associated with tumor invasion, was studied by immunohistochemistry.

RESULTS

MMP-7 (matrilysin-1) and MMP-19 were the most frequently expressed MMPs in Paget's cells. Overexpression of MMP-2, MMP-9, or MMP-13, which is seen in many cancers, was not evident in EMPD. LN-5 and tenascin-C positivity did not correlate with the level of invasion. MMP-7, MMP-13, and MMP-19 were detected abundantly in MMPD, while MMP-9 was absent.

CONCLUSIONS

MMP expression did not generally associate with the level of invasion of EMPD. In three samples positive for MMP-7 and four samples positive for MMP-19, an underlying carcinoma was detected, suggesting the importance of these two MMPs as predictors of secondary EMPD or the putative origin of Paget's cells from the dermal adenocarcinoma cells of apocrine duct origin.

Satellite cell proliferation, reinnervation, and revascularization in human free microvascular muscle flaps

BACKGROUND

Satellite cell proliferation, reinnervation, and revascularization were studied in human nonreinnervated free microvascular muscle flaps to characterize mechanisms of muscle regeneration after flap surgery.

MATERIALS AND METHODS

Patient biopsies (n = 19) were taken at operation and five timepoints up to 9 months after operation, and corresponding clinical data were obtained. Immunohistochemistry for Ki-67 was used to detect proliferating satellite cells, CD-31 to identify endothelial cells, and S-100 and PGP 9.5 proteins to detect reinnervation.

RESULTS

Two weeks after operation, the expression of PGP 9.5 and S-100 had virtually disappeared in all larger nerve fibers and half of smaller nerve fibers. By 6 months, however, a strong expression of PGP 9.5 and S-100 had reappeared in larger nerve fibers in three of four flaps, suggesting that reinnervation had taken place. The number of mitotic satellite cells already peaked at 2 weeks, indicating onset of muscle regeneration. The number of intramuscular capillaries first increased but later decreased to lower than original level. Flaps with more muscle volume showed more reinnervation and satellite cell mitotic activity. In cases of a delay occurring in reconstructive surgery, a low level of reinnervation was seen.

CONCLUSION

Three patients of four showed spontaneous muscle reinnervation in microvascular free flaps with satellite cell activation followed by restored morphology. Late reconstruction and obesity lead to poor reinnervation, placing emphasis on timing of surgery and patient selection.

Soft-tissue sarcomas of the upper extremity: surgical treatment and outcome

The objective of this retrospective follow-up study was to evaluate the outcome of patients with soft-tissue sarcoma treated by the authors' protocol, which consists of a selective combination of conservative surgery and radiotherapy. Patients who relapsed were especially evaluated to improve treatment results. The authors examined 80 patients with local soft-tissue sarcoma in the upper extremity referred to their multidisciplinary group. Fifteen patients were referred for first or subsequent local recurrence, and 65 patients were treated for primary tumor. The goal of treatment was local control and preservation of a functional limb. Wide excision was attempted. If the margin was less than 2.5 cm, postoperative radiotherapy was administered. Eighty-five percent of the patients were treated by limb salvage. Thirty patients needed reconstructive procedures such as pedicled (20 patients) or free flaps (10 patients). No free flaps were lost. The 5-year disease-specific overall survival rate was 75 percent, the local recurrence-free survival rate was 79 percent, and the metastasis-free survival rate was 68 percent. In univariate analysis, prognostic factors for local recurrence were extracompartmental site; for development of metastases, large size and extracompartmental site; and for decreased disease-specific overall survival, large size and extracompartmental site. Intramuscular, cutaneous, and subcutaneous tumors had a 5-year local control rate of 100 percent, and extracompartmental tumors had a local control rate of 69 percent. Extracompartmental tumors clearly have the worst prognosis and should be the main target for improving treatment strategies. After exclusion of patients with inadequate treatment according to the authors' protocol, the local control rate at 5 years was 90 percent. Strict adherence to treatment protocol should be practiced.

Microvascular reconstructions of full-thickness oncological chest wall defects

OBJECTIVE

To evaluate the suitability of microvascular flaps for the reconstruction of extensive full-thickness defects of the chest wall.

SUMMARY BACKGROUND DATA

Chest wall defects are conventionally reconstructed with pedicular musculocutaneous flaps or the omentum. Sometimes, however, these flaps have already been used, are not reliable due to previous operations or radiotherapy, or are of inadequate size. In such cases, microvascular flaps offer the only option for reconstruction.

METHODS

From 1988 to 2001, 26 patients with full-thickness resections of the chest wall underwent reconstruction with microvascular flaps. There were 8 soft tissue sarcomas, 8 recurrent breast cancers, 5 chondrosarcomas, 2 desmoid tumors, 1 large cell pulmonary cancer metastasis, 1 renal cancer metastasis, and 1 bronchopleural fistula. The surgery comprised 5 extended forequarter amputations, 5 lateral resections, 8 thoracoabdominal resections, and 8 sternal resections. The mean diameter of a resection was 28 cm. The soft tissue defect was reconstructed with 16 tensor fasciae latae, 5 tensor fascia latae combined with rectus femoris, and 3 transversus rectus abdominis myocutaneous flaps. In 2 patients with a forequarter amputation, the remnant forearm was used as the osteomusculocutaneous free flap.

RESULTS

There were no flap losses or perioperative mortality. Four patients needed tracheostomy owing to prolonged respiratory difficulties. The mean survival time for patients with sarcomas was 39 months and for those with recurrent breast cancer 18 months.

CONCLUSIONS

Extensive chest wall resections are possible with acceptable results. In patients with breast cancer, the surgery may offer valuable palliation and in those with sarcomas it can be curative.

HER2 oncogene amplification in extramammary Paget's disease

AIMS

To study HER2 oncogene amplification and over-expression in skin samples of 23 patients with extramammary Paget's disease (EMP). EMP is a rare intra-epidermal adenocarcinoma, which has been reported to over-express the HER2 oncoprotein.

METHODS AND RESULTS

HER2 gene amplification, detected by chromogenic in-situ hybridization, was found in 43% (10/23) of the lesions. HER2 protein over-expression (3+ immunostaining intensity) was found in 12 tumours (52%), including all 10 tumours with gene amplification. Two tumours showed low-level (2+) HER2 immunostaining. Mammary Paget's lesions, which were used as controls, showed HER2 amplification and over-expression in all 10 cases studied.

CONCLUSIONS

These results indicate that HER-2 protein over-expression in EMP is common and due exclusively to gene amplification. They open up the possibility of HER2-targetted immunotherapy for patients with HER2+ disease.

Incidence of breast and other cancers among Finnish women with cosmetic breast implants, 1970-1999

Epidemiologic evidence does not point to a carcinogenic effect of silicone implants on the breast, and evidence for or against a carcinogenic effect at sites other than the breast is limited. To examine subsequent cancer risk among women with cosmetic breast implants, we conducted a cohort study of 2171 women in Finland identified from operation diaries of major hospitals and private clinics, 1970-1999. The nationwide population and health outcome registries in Finland were used to trace these women for cancer incidence through 1999. Standard statistical techniques were used to compute expected values based on general population rates. The measure of risk was taken as the ratio of observed to expected cancers, that is, the standardized incidence ratio (SIR) and its 95% confidence interval (CI). Among the 2171 women with cosmetic breast implants, 30 developed cancer against 33.7 expected (SIR = 0.9,95% CI = 0.6-1.3). There was no evidence for an increase in breast cancer risk (SIR 0.5, 95% CI, 0.2-1.0), even among those followed for more than 10 years (2 observed, 4.6 expected). Stage at breast cancer diagnosis did not differ from that expected nor did incidence of any other cancer. Although hindered by small numbers, the consistency of our results with those of other Nordic studies leads us to conclude that cosmetic breast implants are not a cause of cancer and that they do not appear to delay the detection of breast cancers.

Hereditary breast cancer and handling of patients at risk

The identification of BRCA1 and BRCA2, the two known genes causing a dominantly inherited susceptibility for breast and ovarian cancer has allowed genetic testing and identification of high risk individuals in a proportion of breast cancer families. In the future, when both the surveillance methods and prophylactic measures will be further developed this will have even more important clinical value in the management of breast cancer families. To date, as prophylactic mastectomy and/or oophorectomy have been shown to offer a significant risk reduction, these should be considered at least for known mutation carriers. Before considering this, patients should be referred for genetic counseling including risk assessment and genetic testing. Identification of a mutation in the family facilitates carrier detection by allowing predictive testing of healthy individuals. In mutation positive families, a negative test result for an individual has great value as it releases from coping with high risk of cancer and from intensive surveillance. When prophylactic surgery is considered, young age is an important determinant. A skin-sparing mastectomy with implant or autologous tissue transfer is the reconstruction method of choice. Other options like surveillance or chemoprevention can be accepted, but their uncertainty should be pointed out.

Colour Doppler ultrasound evaluation of haemodynamic changes in free tram flaps and their donor sites

Colour Doppler ultrasound (US) was used to measure the blood flow in the donor and recipient arteries as well as in the deep superior epigastric artery of 10 patients having free transverse rectus abdominis myocutaneous (TRAM) flaps. The peak, minimum and mean velocities, the diameter of the vessel, and the resistance index of both the deep superior and inferior epigastric arteries and thoracodorsal arteries were recorded preoperatively and at 4-6 and 15-30 days postoperatively. Colour Doppler US showed increased minimum velocity and decreased resistance index in the pedicle (p < 0.05) throughout the follow-up when compared with the baseline. In the ipsilateral superior epigastric artery the mean and minimum velocities increased (p < 0.05) while the resistance index decreased (p < 0.05) during the first month postoperatively. No changes were recorded in the opposite epigastric arteries or in the control vessel (opposite thoracodorsal artery). In all patients the diameter of the deep inferior epigastric artery was larger than that of the superior epigastric and remained so after the transfer. From the fourth to the thirtieth postoperative day blood flow increased in the free TRAM flap, presumably because of decreased vascular resistance. Blood flow also increased in the superior epigastic artery on the donor side after free TRAM transfer as expected (indicating the delay phenomenon), but harvesting the flap did not affect the circulation in the opposite rectus abdominis muscle. The inferior epigastric arterial system was dominant in all patients.

Prognosis of primary melanoma

MATERIALS AND METHODS

To investigate the prognosis of primary melanoma, we studied a Finnish population of 298 primary melanoma patients, the majority with stage I or II tumours. The median clinical follow-up (4.8 years) was acquired from the patients' records, and the overall survival thereafter was collected from patient registries. The median follow-up for overall survival was 9.5 years.

RESULTS

The overall survival rate was 66.8%. 24.5% developed metastasis, 17.8% died of melanoma, and 15.4% died of some other cause. Surgical margins had no effect on survival. In univariate analysis the most significant prognostic factors for disease-free and overall survival were stage of tumour (p < 0.0001), thickness of tumour (p < 0.0001), depth of tumour invasion (p < 0.0001) and tumour ulceration (p = 0.0005, p < 0.0002). Ulceration was an unfavorable prognostic marker. Younger patients had better survival outcomes than older ones (p = 0.04). Accordingly, in the multivariate Cox model the independent prognostic factors for both disease-free and overall survival were stage of tumour and thickness of tumour. Tumour location on trunk was an independent adverse prognosticator for overall survival.

CONCLUSION

We conclude that the prognosis of primary melanoma has improved in Finland in the last decades being in line with a global tendency.

Patient satisfaction with delayed breast reconstruction: a prospective study

Several studies have shown that mastectomy causes psychosocial disturbances and problems with body image. Patients experience inconvenience with an external prosthesis. Reconstruction can correct these disturbances and make prosthesis redundant. This prospective study was designed to evaluate satisfaction among women who underwent delayed breast reconstruction. The study population consisted of 75 women operated at Töölö Hospital from August to December 1999. Sixty-seven operations were free microvascular transverse rectus abdominis musculocutaneous reconstructions and eight were latissimus dorsi flap reconstructions. The response rate was 80% at both 3 and 6 months postoperatively. The main reason why the women sought reconstruction was the inconvenience of the prosthesis. Preoperative expectations were fulfilled in 90% of patients. An overwhelming majority expressed satisfaction with the outcome. The most often reported benefit was having a new breast of one's own. The main drawbacks were the difficult operation and the unexpectedly long recovery time. Reconstruction alleviated markedly neck, shoulder, and back pain. There was no change in patient self-esteem but there was a substantial positive change in how they felt about their looks. The authors suggest that breast reconstruction should be offered as an option to all women undergoing mastectomy.

Radical excision and reconstruction of chronic tibial osteomyelitis with microvascular muscle flaps

We report a series of 21 patients with chronic osteomyelitis of the tibia treated with microvascular muscle flap reconstruction. All patients underwent a radical bone and soft-tissue excision until healthy, well-bleeding tissue was exposed. Six patients required cancellous bone grafting. Latissimus dorsi was used in 14 patients, gracilis in 4, and rectus abdominis in 4. One gracilis flap was lost due to vessel thrombosis and was replaced with a rectus abdominis free flap. Average follow-up was 2.5 years. There was no evidence of clinical infection in 20 patients at follow-up; the bone had healed, the soft-tissue cover was stable, and the laboratory parameters were normal. Bone infection recurred in 1 patient, resulting in a below-knee amputation. The radical excision of infected bone and affected soft tissue and reconstruction with a well-vascularized large free-muscle flap is an excellent solution in most difficult chronically infected cases.

Topically administered macromolecular heparin proteoglycans inhibit thrombus growth in microvascular anastomoses

Previously, during blood perfusion over collagen-coated surfaces; soluble or immobilized heparin proteoglycans (HEP-PG) have been shown to block thrombus growth. Our aim was to study the antithrombotic effect of locally applied unfractionated heparin (UFH, 1 mg/ml), or rat mast cell-derived HEP-PG (MW 750 kD, 10 microg/ml) compared with saline in early (10 min) and late (3 days) thrombus formation upon anastomosis of rat common femoral arteries. In both semiquantitative scanning electron microscopy (SEM) and quantitative platelet Indium 111-labeling HEP-PG inhibited thrombus growth in comparison with saline. At 10 min, the extent of thrombosis (scale 1-4) in SEM followed the order: saline (3.2+/-0.8) > UFH (2.8+/-1.0) > HEP-PG (1.8+/-0.8), and also Indium 111-positive platelets (10(6)) accumulated on the anastomosed vessel in the same order 14.2 +/-7.2, 10.3 +/-5.0, and 7.7 +/-3.1 (saline vs. HEP-PG, p = 0.03 and 0.05, respectively). At 3 days all HEP-PG-treated vessels remained patent with only small mural thrombi, whereas 2/7 saline- and 1/7 UFH-treated anastomoses occluded and showed more thrombosis overall. We conclude that locally administered HEP-PG inhibit arterial thrombus growth in anastomosed small-sized arteries and could prevent thrombotic complications in (micro)vascular surgery and arteriovenous shunts.

Patients' satisfaction with breast reconstruction and reduction mammaplasty

Patients' satisfaction is widely recognised as an important measure of the quality of care. This study measured patients' satisfaction with the outcome of breast reconstruction surgery and reduction mammaplasty and with the treatment received in hospital. A questionnaire about patients' reasons for having the operation and postoperative satisfaction was therefore sent to 137 patients after breast reconstruction and 142 who had had reduction mammaplasty. The response rate in the former group was 84% and in the latter 65%. In both groups of patients the main reasons for having the operation were difficulties with physical activities and in finding clothes to fit. Other factors were poor self-esteem and problems with body image. A total of 69% of the patients who had had reconstructions referred to problems with wearing an external prosthesis. In the reduction mammaplasty group one of the most important reasons for having the operation was pain, in particular neck, shoulder, and back pain. In the reconstruction group 94%, and in the reduction group 88%, thought the outcome of the operation was good or very good. They had no regrets about their decision to seek surgical treatment, even when the aesthetic outcome fell short of their expectations. The patients were generally satisfied with the treatment they had received. In the reconstruction group 97%, and in the reduction group 96%, of patients felt satisfied with their overall decision to have the operation. Our results confirm that these surgical procedures help to improve patients' quality of life. Among the patients who had had reconstructions, the resolved problems with body image were considered to be the main benefit of the operation. In the reduction group the main benefits were reduced neck, shoulder, and back pain. In both groups 91% of patients would have recommended the operation to a friend under similar circumstances. In the light of this evidence doctors should more readily recommend reconstruction to patients after mastectomy and reduction to women with heavy breasts.

Activation of coagulation and fibrinolysis during reconstructive microsurgery in patients with cancer

Cancer patients are subjected to increased systemic risk of thrombotic events and may therefore be at higher risk of even local thrombosis compromising the outcome of reconstructive microsurgery. Coagulation and fibrinolysis activities were studied serially during and after reconstructive microsurgery in seven patients with oropharyngeal cancer or sarcoma in the extremities. A preoperative hypercoagulable state was found in four patients (elevated fibrinogen, TAT, F1+2, or D-dimer); two of these patients also had a local thrombotic event. In all patients, the plasma markers generally varied perioperatively: fibrinogen decreased, whereas TAT and subsequently D-dimer increased at the end of the operation. However, tPA and PAI-1 remained unaltered, except in the patients with thrombosis in whom PAI-1 activity increased progressively during the operation. F1+2 was also clearly elevated in these two patients at the time of thrombosis. Preoperative assessment of hypercoagulability for this group of patients could be helpful in targeting meticulous antithrombotic protection.

Activation of coagulation and fibrinolysis in microsurgical reconstructions in the lower extremities

Coagulation and fibrinolysis activities in relation to trauma, surgery and thrombosed microanastomoses were studied during free-flap surgery in eight patients with lower-extremity defects due to recent trauma or chronic ulcers. One patient had an intraoperative thrombosis, and three more patients required reoperations on the same day due to postoperative thromboses; one of these also required a second reoperation due to flap failure. The baseline level of fibrinogen was slightly elevated in all patients except one, and was significantly higher in the patients who underwent reoperation. At the end of the primary surgery, distinct thrombin generation (TAT and F1+2) was seen in three patients with excessive bleeding, and all three later underwent reoperations. One of these patients generated excessive thrombin on the eighth postoperative day, upon removal of a necrotic flap. Thrombin generation (F1+2) was also seen at baseline in the patient with the intraoperative thrombosis, and persisted on the first postoperative day. D-dimer at baseline was higher in patients with recent trauma, and in two of these, both of whom underwent reoperations on the same day, D-dimer remained high perioperatively. Resistance to fibrinolysis with increased PAI-1 levels was seen in these two patients at the time of reoperation. In all, TAT and F1+2 were associated with the threat of flap failure. A preoperative hypercoagulable state and excessive bleeding during the operation were predictors of reoperation. The markers for coagulation and fibrinolysis could be used preoperatively to target antithrombotic control, and postoperatively to detect the threat of flap failure. Meticulous haemostasis during surgery might help to diminish the need for reoperations.

Blood flow in a pedal bypass combined with a free muscle flap

OBJECTIVE

to assess the haemodynamic effect of a free muscle flap on the midterm success of a pedal bypass.

DESIGN

prospective consecutive study.

MATERIALS

a pedal bypass (autogenous vein graft) combined with a free muscle flap was performed in 13 patients with critical leg ischaemia. The feeding artery of the flap was anastomosed end-to-side to the bypass.

METHODS

blood flow was measured in the bypass before and after transplanting the flap. Doppler was used postoperatively to assess the patency.

RESULTS

the bypass and flap pedicle were patent in 11 cases six months postoperatively. Two grafts were thrombosed and the legs amputated. In the successful group the median (range) blood flow in the bypass was 50 (10-100) ml/min. It increased (p<0.05) after transplantation to 64 (20-113) ml/min, being 44 (14-97) ml/min distributed to the foot. Blood flow through the flap was 20 (6-37) ml/min. The two failing grafts had a flow of 30 and 51 ml/min before and 48 and 52 ml/min after transplantation, respectively. Blood flow through the flap was 47 ml/min and 36 ml/min, respectively. In the failure group the free flap received most of the blood supply through the bypass.

CONCLUSIONS

a free muscle flap connected to an infrapopliteal bypass increases the distal outflow bed and thus decreases the outflow resistance and increases graft flow.

Patients with pressure ulcers in Finnish hospitals

The purpose of this descriptive study was to produce knowledge of the degree of pressure ulcers, pressure ulcer patients' physical and psychological well-being and the association of these factors with pressure ulcers' severity. These patients were treated in Finland's capital area hospitals. The pressure ulcer patients' sampling was gathered during 1 day with two questionnaires, which was completed by nurses. The response rate was 94%, and data analysis was based on percentage distributions. Statistical association was tested with the chi2 test. The measurement identified 164 patients with a total of 257 pressure ulcers. Prevalence was 6.4%. Most of the ulcers (40%) were grade II ulcers. Fifty-six per cent of patients suffered poor general health, 63% of the patients were immobile, but psychological well-being was better with 29% of pressure ulcer patients being adequately motivated to follow treatment for their pressure ulcers. It is essential to identify high-risk patients in order to provide optimal care.

Intraoperative evaluation of blood flow in the internal mammary or thoracodorsal artery as a recipient vessel for a free TRAM flap

Although the free microvascular transverse rectus abdominis musculocutaneous (TRAM) flap is in routine use for breast reconstruction, little is known of its hemodynamics. The purpose of this study was to determine whether any differences exist when the free TRAM flap is anastomosed to the thoracodorsal or internal mammary vessels. The study comprised 25 patients receiving a free TRAM flap for breast reconstruction. The thoracodorsal vessels were used as recipients in 21 patients and the internal mammary vessels were used in 4 patients. Blood flow rate was measured directly in the donor and recipient arteries, and after anastomosis by a transit-time ultrasonic flowmeter (CardioMed). Two- and 3-mm probes were used. The blood flow rate in the donor artery (deep inferior epigastric) before flap dissection was 11 +/- 6 ml per minute (mean +/- standard deviation). The rate was significantly (p < 0.05) lower (5 +/- 3 ml per minute) in the recipient thoracodorsal artery than in the donor, but after transplantation it increased to 14 +/- 5 ml per minute (p < 0.05), attaining the same value as the donor artery. The blood flow rate in the intact internal mammary artery was significantly higher (25 +/- 10 ml per minute) than in the donor and thoracodorsal arteries, but after anastomosis it dropped to the same value (12 +/- 3 ml per minute; p < 0.05) as the donor artery. The intake of blood in TRAM flaps supplied by the intemal mammary artery seems to be no greater than that in free flaps anastomosed to thoracodorsal vessels, although the flow in the internal mammary artery was much higher. The authors concluded that the blood supply in a free TRAM flap is independent of the flow in the recipient artery and that thoracodorsal vessels, although often in a scarred bed and radiated, are as suitable for anastomosing a free TRAM flap as are internal mammary vessels.

Sebaceous carcinoma of the eyelid associated with retinoblastoma

OBJECTIVE

To analyze the association between retinoblastoma (Rb) and sebaceous carcinoma (SC) of the eyelid to improve surveillance of survivors of RB:

DESIGN

Case report and systematic literature review.

METHODS

Ten patients who had SC develop after Rb were identified by systematic literature review, and a child who died with lymph node, lung, and liver metastases 7 years after irradiation for Rb is described. The data were analyzed by univariate statistics, including cumulative frequency distribution plots and Kaplan-Meier analysis.

RESULTS

Of 11 children with SC of the eyelid who all had hereditary RB, 9 (82%; 95% confidence interval, 48-98) received a median of 46 Gy (range, 21-89) of radiotherapy at a median age of 16 months (range, 0.5-15 years) and had SC develop within the field of radiation. Their median age at diagnosis of SC was 14 years (range, 8-30 years), median diagnostic delay 12 months (range, 6 months-3 years), and median interval from irradiation 11 years (range, 5-26 years); 7 of them (78%; 95% confidence interval, 40-97) were diagnosed between 5 and 15 years after radiotherapy. SC also developed at the age of 32 and 54 years in two nonirradiated Rb patients. Five patients had regional lymph node metastases after a median time of 12 months (range, 1 month-24 years). The 5-year cumulative probability of survival was 87%.

CONCLUSIONS

SC of the eyelid may occur in patients with hereditary Rb regardless of primary treatment, especially within the field 5 to 15 years after radiotherapy.

Evaluation of blood flow in free microvascular flaps

Free flap surgery is routine today, yet little is known of its pathophysiology. In this study, the authors evaluated the hemodynamics in different types of free microvascular flaps, by measuring intraoperative transit-time flow. Eighty-six free transplants--21 free TRAM flaps for breast reconstruction, 18 radial forearm flaps for head and neck reconstructions, and 47 muscle flaps for head and neck, trunk and lower extremity reconstructions--were studied. Donor artery flow was highest in the radial artery (mean: 57.5 +/- 50 (SD) ml/min) but dropped (p < 0.001) to one tenth (6.1 +/- 2 ml/min) after anastomosis. The flow was lowest (4.9 +/- 3 ml/min) in the recipient artery of the TRAM flap but, after anastomosis, increased significantly (13.7 +/- 5 ml/min) to the level of the flow in the donor artery. The donor-artery flow in muscle flaps had a mean of 15.9 +/- 11 ml/min, and it significantly increased after anastomosing (23.9 +/- 12 ml/min). Weight-related intake of blood was highest in the radial forearm flap (18.5 +/- 6 ml/ min/100g) and lowest in the TRAM flap (2.5 +/- 1 ml/min/100g). The study showed that blood flow through a free microvascular flap does not depend on recipient artery flow. Even low-flow arteries can be used as recipients, because the flow increases according to free-flap requirements. The blood flow through a free microvascular flap depends on the specific tissue components of the flap.

Free flap reconstructions in the management of oral and pharyngeal cancer

Fifty patients who had undergone microvascular free flap reconstruction of the oral cavity or pharynx for malignancy between 1989 and 1995 were retrospectively analysed to find factors predicting postoperative complications and outcomes. The mean follow-up time was 2.6 years. More than half (26/50) of the patients had a stage IV malignancy and 10 patients had a recurrent tumour. The overall flap success rate, with 2 flap losses, was 96%. Postoperative medical complications occurred in 29/50 (58%) cases. The recipient site of 10/50 (20%) flaps required re-exploration. Mortality was 2%, with 1 death occurring within 30 days. The mean survival rate after the microvascular operation was 1.6 years, and the 3- and 5-year survival rates were 42% and 23%, respectively. Patients with an oropharyngeal tumour seemed to have the best prognosis and those with a hypopharyngeal tumour the poorest. Men had a threefold greater risk of dying within < 1 year postoperatively compared with women. Tumour stage was the strongest attribute influencing survival. The risk of death after the microvascular procedure increased 2.8-fold when the stage advanced from II to III or from II to IV. None of the tested variables alone could predict complications.