[Electrochemotherapy for treatment of cutaneous metastases]

Cutaneous metastases occur in up to 9% of all patients with cancer and may cause discomfort and stigmatization. Electrochemotherapy is a local treatment using electric pulses to permeabilize cell membranes, enabling chemotherapy, such as bleomycin, to enter the cells and increase the cytotoxic effect by at least 300-fold. Electrochemotherapy is an efficient, once only treatment for cutaneous metastases with an objective response of 62-99%. Electrochemotherapy can reduce discomfort such as ulceration, oozing, bleeding and pain. Adverse events depend on the size of treatment area, but are very limited.

Tumour response after hyperthermic isolated limb perfusion for locally advanced melanoma

INTRODUCTION

The aim was to describe tumour response, complications, recurrence and survival after hyperthermic isolated limb perfusion (ILP) with melphalan or melphalan in combination with tumour necrosis factor-alpha in patients with melanoma metastases confined to an extremity.

MATERIAL AND METHODS

A total of 84 perfusions were performed (53 women, 31 men, median age 63 years) from 1993 to 2010. 95% of the perfusions were administered to the lower limbs and 5% to the upper limbs. The inclusion criteria were recurrent and/or clinically apparent cutaneous/subcutaneous extremity in-transit melanoma metastases.

RESULTS

The response rate after ILP was 85%; 42% had complete response (CR), 43% partial response (PR), 12% no change (NC) and 3% progression. Two- and five-year survival rates were 57% and 31%, respectively, and they were higher for patients with than without lymph node metastases. Time from ILP to recurrence was a median of seven months (range 1-37 months) for patients with CR or PR. Survival was longer for patients with CR or PR than for patients showing NC or progression. Several patients had mild or moderate local toxicity reactions, two patients developed severe local toxicity.

CONCLUSION

ILP induces tumour regression in the vast majority of patients. One patient, i.e. 1% of the group, died from surgical complications. Otherwise, ILP treatment had an acceptable morbidity in this group of very sick patients. We are convinced that the treatment should be offered to improve local disease control in patients with multiple and/or recurrent melanoma confined to an extremity if surgical excision is not possible.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Rising incidence of Merkel cell carcinoma

Merkel cell carcinoma (MCC) is a rare, aggressive, skin cancer of obscure histogenesis, the incidence of which is rising. There is no consensus on the optimal treatment. Our aim was to evaluate the staging, investigation, treatment, and follow-up of MCC in eastern Denmark, and to investigate the incidence. We suggest guidelines for treatment. First we reviewed the medical records of 51 patients diagnosed with MCC from 1995 until 2006 in eastern Denmark. The nation-wide incidence of MCC was extracted from the Danish Cancer Registry for the calculations for the period 1986-2003. We reviwed published papers about MCC based on a MEDLINE search. Fourteen of the 51 patients developed recurrence, and 37 (73%) died during the study period. Mean follow-up was 13 months (range 1-122). A total of 153 patients were identified in the Danish Cancer Registry, and showed that incidence rates had increased 5.4 fold over the 18 year period from 1986 until 2003. Rates were highest in people over the age of 65. Recommended treatment with curative intent includes excision of the primary tumour with wide margins, excision of the sentinel node, computed tomogram (CT) or positron emission tomography (PET) of the thorax and abdomen, and adjuvant radiotherapy to the surgical bed. In the case of advanced disease, systemic palliative chemotherapy remains a possibility. There is a need for prospective multicentre evaluation of staging investigations and treatment of MCC.

Polyacrylamide gel treatment of antiretroviral therapy-induced facial lipoatrophy in HIV patients

BACKGROUND

Today, highly active antiretroviral therapy is lifesaving for most HIV-infected patients, but the treatment can result in facial lipoatrophy, which changes the face so radically that patients may develop severe psychological and social problems. Since 2001 polyacrylamide gel (PAAG) has been used successfully in HIV patients abroad. This article describes the results of a Danish study.

METHODS

Forty HIV patients recruited from two major referral hospitals in the capitol area of Copenhagen, Denmark, each received a series of PAAG gel injections (small deposits in several sessions) with a 14-day interval. Patient satisfaction, injector's evaluation, evaluation by an external specialist in plastic surgery, and long-term aesthetic effect and complications were registered with follow-up until 2 years.

RESULTS

All patients were very satisfied or satisfied with the result. The injector found the result very satisfying in 33 cases and a slight irregularity in 7. The external specialist found improvement in all cases with a one-grade reduction of the lipoatrophy in 11 cases, a two-grade reduction in 20, and a three-grade reduction in 3 cases. No filler-associated complications were recorded.

CONCLUSION

This study has shown that PAAG can normalize contours in patients suffering from facial lipoatrophy within 3-6 sessions, with a mean amount of gel per session of 1.8 ml and a mean total amount of 8.8 ml. The results are in accordance with those of other large studies, confirming a high degree of biocompatibility and safety.

[Keystone flap for reconstruction of skin defects]

INTRODUCTION

The keystone design perforator island flap was first described in 2003. It is a local flap based on axial perforators from the underlying structures. It is designed as a curvilinear shaped trapezoidal design flap which is essentially two V-Y flaps end to end. Most reports are of the lower limbs, but it has been used successfully almost all over the body.

MATERIAL AND METHODS

We report our experience in 21 patients, who underwent excision of skin malignancies and reconstruction of the defect with a keystone flap (24 flaps in total).

RESULTS

Only few complications were seen. Two patients had signs of infection at the border of the flap and were treated with local and/or oral antibiotics. In two cases a small necrosis developed at the border of the flap. In both cases, it healed conservatively.

CONCLUSION

The keystone flap has proven to be very reliable with only few reported flap losses. Furthermore, it is technically easy to perform and thus may be performed by trainee surgeons as well as senior surgeons. The cosmetic result is excellent and far superior to the alternative skin grafting with its color differences and contour defect. In addition, many patients may be treated as day-only surgery or discharged from the hospital after only one day.

[Long-term complications after injection of permanent tissue-fillers to the lips]

We present two cases with signs of infection and granulomas seen years after injection of permanent fillers to the lips. These side effects are difficult to treat. They resemble an immunological foreign body response and late-onset infection as well as granuloma and scaring depending on the substance injected. Steroid injections are indicated in case of granuloma, and antibiotics should be used when infection occurs, but surgical excision can be required. It is important to emphasize this condition in order to give patients proper advice prior to treatment and to recognize symptoms.

[Primary mucinous carcinoma of the skin--a literature review]

Primary mucinous carcinoma of the skin (PKMK) is a rare malignant tumour of the sweat glands. It is often misdiagnosed as it has an uncharacteristic gross appearance - and may microscopically resemble a cutaneous metastasis from a mucinous carcinoma of the breast, gastrointestinal tract, lungs, ovaries or prostate. The recurrence rate is high, but mortality is low. A MEDLINE literature search was performed for reports on PKMK. A total of 228 cases were identified. These are presented with regard to tumour characteristics and clinical features as well as histopathological and immunohistochemical findings.

[Primary mucinous carcinoma of the skin]

Primary mucinous carcinoma of the skin is a rare malignant tumour originating from the sweat glands. It is often misdiagnosed clinically since it has an uncharacteristic and variable presentation, and microscopically because it resembles a cutaneous metastasis from the more frequent mucinous adenocarcinomas of the colon, mammae, lungs and ovaries. The tumour often recurs, but mortality is low. We present a case with regional lymph node metastases five years after excision of the primary tumour.

Survival After a Psychoeducational Intervention for Patients With Cutaneous Malignant Melanoma: A Replication Study

Purpose

The results of a randomized, intervention study done in 1993 of psychoeducation for patients with early-stage malignant melanoma showed a beneficial effect on recurrence and survival 6 years after the intervention. In the present study, we replicated the study with 258 Danish patients with malignant melanoma. We also compared recurrence and survival among the participants in the randomized study with 137 patients who refused to participate.

Patients and Methods

We randomly assigned 262 patients with primary malignant melanoma to a control or an intervention group. Patients in the intervention group were offered six weekly 2-hour sessions of psychoeducation. Participants and nonparticipants were followed up for vital status and recurrence 4 to 6 years after surgical treatment. Prognostic factors (thickness of the tumor and lymph node status), sex, and age were adjusted for in a Cox regression model (proportional hazards regression) to derive an adjusted survival rate ratio and an adjusted relapse-free survival rate ratio, with 95% CIs.

Results

The hazard ratio was 1.30 (95% CI, 0.5 to 3.5) for survival and 0.73 (95% CI, 0.3 to 1.9) for recurrence. Being a nonparticipant increased the risk for death by more than two-fold (hazard ratio, 2.26; 95% CI, 1.0 to 5.2) over that of participants.

Conclusion

Psychoeducation did not increase survival or the recurrence-free interval among patients with malignant melanoma; however, nonparticipants had a statistically significantly greater risk for death than participants.

Treatment of anthracycline extravasation with Savene (dexrazoxane): results from two prospective clinical multicentre studies

BACKGROUND

The purpose of this study was to assess the efficacy and tolerability of i.v. dexrazoxane [Savene (EU), Totect (US)] as acute antidote in biopsy-verified anthracycline extravasation.

PATIENTS AND METHODS

Two prospective, open-label, single-arm, multicentre studies in patients with anthracycline extravasation were carried out. Patients with fluorescence-positive tissue biopsies were treated with a 3-day schedule of i.v. dexrazoxane (1000, 1000, and 500 mg/m(2)) starting no later than 6 h after the incident. Patients were assessed for efficacy (the possible need for surgical resection) and toxicity during the treatment period and regularly for the next 3 months.

RESULTS

In 53 of 54 (98.2%) patients assessable for efficacy, the treatment prevented surgery-requiring necrosis. One patient (1.8%) required surgical debridement. Thirty-eight patients (71%) were able to continue their scheduled chemotherapy without postponement. Twenty-two patients (41%) experienced hospitalisation due to the extravasation. Mild pain (10 patients; 19%) and mild sensory disturbances (nine patients; 17%) were the most frequent sequelae. Haematologic toxicity was common as expected from the fact that the extravasation occurred during a chemotherapy course. Other toxic effects were transient elevation of alanine aminotransferases, nausea, and local pain at the dexrazoxane injection site.

CONCLUSION

Dexrazoxane proved to be an effective and well-tolerated acute treatment with only one out of 54 assessable patients requiring surgical resection (1.8%).

Psychoeducational Intervention for Patients With Cutaneous Malignant Melanoma: A Replication Study

Purpose

In 1993, a randomized intervention study among patients with malignant melanoma showed a significant decrease in psychological distress and increased coping capacity 6 months after the intervention and enhanced survival 6 years later. We applied a similar intervention with a few modifications in a randomized controlled trial among Danish patients with malignant melanoma and evaluated results on immediate and long-term effects on psychological distress and coping capacity.

Patients and Methods

A total of 262 patients with primary cutaneous malignant melanoma were randomly assigned to the control or intervention group. Patients in the intervention group were offered six weekly sessions of 2 hours of psychoeducation, consisting of health education, enhancement of problem-solving skills, stress management, and psychological support. The participants were assessed at baseline before random assignment and 6 and 12 months after surgery. The analyses of the main effects of the intervention were based on analyses of covariance.

Results

The patients in the intervention group showed significantly less fatigue, greater vigor, and lower total mood disturbance compared with the controls, and they used significantly more active-behavioral and active-cognitive coping than the patients in the control group. The improvements were only significant at first follow-up.

Conclusion

The findings of this study support the results of an earlier intervention study among patients with malignant melanoma and indicate that a psychoeducational group intervention for such patients can decrease psychological distress and enhance effective coping. However, this effect is short term and the clinical relevance is not obvious.

Use of fluorine-18 fluorodeoxyglucose positron emission tomography in the detection of silent metastases from malignant melanoma

Correct staging is crucial for the management and prognosis of patients with malignant melanoma. The aim of this prospective study was to compare staging by whole-body positron emission tomography using fluorine-18 fluorodeoxyglucose (18F-FDG) with staging by conventional methods. Thirty-eight patients with malignant melanoma of clinical stage II (local recurrence, in-transit and regional lymph node metastases) or III (metastases to other sites than in stage II) were included in the study. The results of the PET scans were compared with those obtained by clinical examination, computed tomography, ultrasound, radiography, and liver function tests and histology or clinical follow-up. With 18F-FDG PET we found for all foci a sensitivity of 97% and a specificity of 56%, compared with 62% and 22%, respectively, when using routine methods. For intra-abdominal foci, the sensitivity and specificity were 100% for both 18F-FDG PET and routine methods. Corresponding figures for pulmonary/intrathoracic foci were 100% and 33%, respectively. Of the patients included in this study, 34% would not have been staged correctly by conventional methods alone. We conclude from this study that 18F-FDG PET is a sensitive method superior to conventional methods for detecting widespread metastases from malignant melanoma. Mutilating surgery of no benefit can thereby be avoided. 18F-FDG PET is useful as a supplement to clinical examination in melanoma staging.

UV induced erythema evaluated 24 h post-exposure by skin reflectance and laser Doppler flowmetry is identical in healthy persons and patients with cutaneous malignant melanoma and basal cell cancer

Twenty-one patients with invasive cutaneous malignant melanoma and 19 patients with basal cell skin cancer and 29 healthy volunteers were phototested on non-UV exposed buttock skin to examine their 24 h reaction to a series of increasing doses of simulated sunlight with 25% dose increments. Skin pigmentation at the phototest sites was determined by skin reflectance before testing to assure an equal level of constitutive skin pigmentation in the 3 groups. Erythema reactions were scored visually 24 hours post-exposure and objective measurements of erythema were performed by skin reflectance and laser Doppler flowmetry. In adjacent non-irradiated skin the redness was also quantified to determine the increase in redness in irradiated skin compared to non-irradiated skin. Constitutional skin pigmentation correlated well to UV sensitivity (r = 0.75) and skin redness measured by skin reflectance technique correlated to laser Doppler flowmetry (r = 0.86). No significant differences in UV doses to barely perceptible erythema or to the higher erythema grades were found between the two skin tumour groups and the control group, and no significant differences were found in skin reflectance measured redness or in laser Doppler flowmetry of any erythema reactions between the 3 groups. The 24 h erythema reaction to sunlight can therefore not be used to distinguish patients with invasive cutaneous malignant melanoma or basal cell carcinoma from normal persons.

Epidermal thickness, skin pigmentation and constitutive photosensitivity

The important factors for UV sensitivity in humans are considered to be the skin pigmentation and the epidermal thickness. In this study on 73 Caucasians (age 20-85 years), we investigated in UV unexposed buttock skin the relationship between the UV sensitivity and constitutive skin pigmentation and thickness of the stratum corneum and the cellular part of the epidermis, in 34 normal people and in 39 skin cancer patients (20) patients with cutaneous malignant melanoma and 19 patients with basal cell carcinoma of the skin). Skin pigmentation was measured by skin reflectance spectroscopy, and UV sensitivity by phototest with a solar simulator. Thicknesses of the stratum corneum and the cellular part of the epidermis were determined by light microscopic evaluation of skin biopsies from the phototest areas. We found that epidermal thickness was independent of skin type and was not correlated to constitutive skin pigmentation. Thickness of the stratum corneum was statistically not different in normal persons and in skin cancer patients (P = 0.41) and was independent of gender (P = 0.61) and age (P = 0.56), while thickness of the cellular epidermis decreased with age (P < 0.01). Stratum corneum thickness was found to be of minor importance for the constitutive UV sensitivity (accounting for on average 11% of the total photoprotection), which was mainly determined by the constitutive skin pigmentation (goodness-of-fit for correlation r = 0.83). A theoretical model for the relationship of UV dose to induction of clinical erythema grade and skin pigmentation and thickness of the stratum corneum was developed. Objective measurements of skin pigmentation in UV unexposed skin by skin reflectance spectroscopy in Caucasians, normal people and people with cutaneous malignant melanoma and basal cell carcinoma of the skin predicts the constitutive UV sensitivity with a high degree of precision.

The yeast site-specific recombinase Flp mediates alcoholysis and hydrolysis of the strand cleavage product: mimicking the strand-joining reaction with non-DNA nucleophiles

The yeast site-specific recombinase Flp is covalently linked to DNA via a 3'-phosphotyrosyl bond during the strand-breakage step of recombination. We show that this phosphotyrosyl diester bond formed between Flp and DNA can serve as the target for alcoholysis or hydrolysis in an Flp-assisted reaction. Flp does not mediate alcoholysis of the labile phosphodiester bond within the DNA chain under our assay conditions. The body of available evidence supports the notion that the alcoholysis/hydrolysis reaction is mechanistically analogous to the strand-joining step of the recombination pathway. The only difference is that the DNA 5'-hydroxyl group that acts as the nucleophile during recombination is substituted by a non-DNA nucleophile. We find that the alcoholysis reaction occurs only within the normal cleavage complex produced by the "shared active site" assembled at the interface of two Flp monomers. Unlike the strand-joining reaction, alcoholysis does not occur on an activated DNA substrate linked at its 3'-phosphate end to a short tyrosyl peptide (not to the full-length Flp), and bound non-covalently by a Flp monomer. However, even in this substrate that mimics the strand-cleaved state, the joining reaction is competitively inhibited by a polyhydric alcohol such as glycerol.

Intravascular studies with iohexol (Omnipaque). Results from the first 49 clinical trials

In order to assess the vascular clinical trial program of iohexol (Omnipaque) in Europe, the results from the first 49 vascular trials are collectively reported. The included iohexol material comprises 1742 patients. In 40 comparative trials, other contrast media like metrizamide (Amipaque), ioxaglate (Hexabrix) and various monomeric ionic media were administered in 1292 patients included in this analysis. No severe or unexpected adverse reactions related to iohexol were encountered. No clinically significant differences in radiographic image quality between the media were documented. The overall tolerability of iohexol was superior to that of monomeric ionic media and seemed to be as good as that of metrizamide.

Phase II studies in urography, cardioangiography and cerebral angiography with iohexol. An evaluation of the clinical trial program and the clinical findings

The first experience in patients (phase II studies) with iohexol (Omnipaque) - a new non-ionic contrast medium - in intravenous urography (34 patients), cardioangiography (45 patients) and cerebral angiography (38 patents) is collectively reported. A non-comparative, multicentre design was used in all 3 applications. The objective was to assess the efficacy (the opacity to X-rays) and the tolerability of iohexol using routine contrast medium doses in a well defined adult population. No unexpected or severe reactions occurred in the 117 included or 9 excluded patients. Good efficacy was confirmed, and the contrast medium was well tolerated. The results warrant advancing iohexol into comparative phase III trials. The iohexol phase II studies and initial research in patients with contrast media in general are discussed.

Amipaque (metrizamide) in vascular use and use in body cavities: a survey of the initial clinical trials

A review of the initial 76 clinical trials with Amipaque in vascular radiology and in examinations of the body cavities, mostly performed in the Scandinavian countries, is given. The clinical material presented comprises a total of 2,661 Amipaque examinations, 1,784 examinations performed intravascularly and 515 in body cavities. In addition, 362 vascular examinations with Amipaque in children are presented. Generally, no difference in visualization compared to ionic media was found. However, improved visualization was reported in some few angiographic studies and higher contrast density was indicated in the urograms. Compared to ionic media, Amipaque caused considerably less subjective reactions and less hemodynamic effects. A remarkable reduction in post-phlebographic thrombosis following leg phlebography was found with Amipaque. No death related to Amipaque occurred, and few contrast medium reactions have been recorded. Thus, the good tolerability of the non-ionic Amipaque shown in animal studies has also been confirmed clinically outside the subarachnoid space.