Locally recurrent malignant melanoma characteristics and outcomes: a single-institution study

Despite improvements in the identification and treatment of melanoma, local recurrence continues to challenge the success of current melanoma therapy. A retrospective analysis of 1,996 patients presenting from 1990 to 1997 at the Pigmented Lesion Group of the University of Pennsylvania was performed to assess clinical characteristics and outcomes of locally recurrent melanoma. The cases were analyzed by chart and pathological slide review. A control group was identified for statistical comparison. The incidence of locally recurrent melanoma during the study period was 2.2%. Lentigo maligna melanoma (LMM) accounted for 37% of the local recurrences. Increased tumor thickness and microsatellites were associated with "early" local recurrence and decreased survival from time of recurrence. Nineteen percent of the local recurrences occurred more than 5 years after the initial definitive treatment. The preponderance of locally recurrent LMM suggests the need for refinements in the techniques of margin identification and surgical excision of LMM. Tumors with increased thickness and microsatellites should receive particularly close attention. Lastly, with nearly 20% of the local recurrences occurring more than 5 years after the initial date of treatment, the authors suggest extending the follow-up time for all melanoma lesions beyond 5 years.

Ultraviolet-Assisted Punch Biopsy Mapping for Lentigo Maligna Melanoma

Lentigo maligna melanoma (LMM) accounts for a substantial incidence of all locally recurrent melanoma. In addition, the head and neck area accounts for 60% to 90% of all LMMs, which has important functional and cosmetic implications. The difficulty in the identification of the true borders of LMM may account for the high incidence of local recurrence. The purpose of this study was to evaluate the efficacy of ultraviolet-assisted punch biopsy mapping to identify clear margins using identified, 2-mm circumferentially arranged punch biopsies at the junction of the pigmented and nonpigmented borders. A retrospective chart review of 20 patients with biopsy-confirmed LMM of the head and neck was performed. Using ultraviolet identification, 2-mm circumferentially arranged biopsy specimens were obtained and sent for formal pathological review, including immunohistochemical staining. The average time for completion of pathological review was 5 to 7 days. If the punch biopsies were positive for lentigo maligna or LMM, punch biopsies were obtained more peripherally. Once clear, margins were obtained and definitive resection was performed. Twenty patients with biopsy-proved LMM were evaluated. Follow-up ranged from 6 months to 3 years (mean follow-up, 1 year). Fourteen patients were cleared after their first series of biopsies, 3 patients required a second series of biopsies, 2 patients required a third session, and 1 patient required a fourth biopsy session. To date, there has been no evidence of recurrence. No patients required reexcision for positive surgical margins. One complication has been local cellulitis of a punch biopsy site requiring a short course of antibiotics. Ultraviolet-assisted punch biopsy mapping of LMM is a safe, well-tolerated, and accurate technique for identifying the true histological margin of LMM. The procedure reduces the need for repeat surgical excisions to obtain clear margins and may decrease the risk for recurrence by mapping accurately the true histological margin.

Incidence of sentinel node metastasis in patients with thin primary melanoma (< or = 1 mm) with vertical growth phase

BACKGROUND

Patients with thin primary melanomas (< or = 1 mm) generally have an excellent prognosis. However, the presence of a vertical growth phase (VGP) adversely impacts the survival rate. We report on the rate of occurrence of nodal metastasis in patients with thin primary melanomas with a VGP who are offered sentinel lymph node (SLN) biopsy.

METHODS

Among 235 patients with clinically localized cutaneous melanomas who underwent successful SLN biopsy, 71 had lesions 1 mm or smaller with a VGP. The SLN was localized by using blue dye and a radiotracer. If negative for tumor by using hematoxylin and eosin staining, the SLN was further examined by immunohistochemistry.

RESULTS

The rate of occurrence of SLN metastasis was 15.2% in patients with melanomas deeper than 1 mm and 5.6% in patients with thin melanomas. Three patients with thin melanomas and a positive SLN had low-risk lesions, based on a highly accurate six-variable multivariate logistic regression model for predicting 8-year survival in stage I/II melanomas. The fourth patient had a low- to intermediate-risk lesion based on this model. At the time of the lymphadenectomy, one patient had two additional nodes with metastasis.

CONCLUSIONS

VGP in a melanoma 1 mm or smaller seems to be a risk factor for nodal metastasis. The risk of nodal disease may not be accurately predicted by the use of a multivariate logistic regression model that incorporates thickness, mitotic rate, regression, tumor-infiltrating lymphocytes, sex, and anatomical site. Patients with thin lesions having VGP should be evaluated for SLN biopsy and trials of adjuvant therapy when stage III disease is found.

99mTc-human serum albumin: an effective radiotracer for identifying sentinel lymph nodes in melanoma

Sentinel lymph node (SLN) biopsy has emerged as a novel approach for identifying patients with melanoma and regional nodal micrometastasis who may benefit from full nodal basin resection. To identify the pattern of tumor lymphatic drainage and the SLN, lymphoscintigraphy has been performed using primarily 99mTc-sulfur colloid (SC). In this study, we compare the efficacy of SLN biopsy using 99mTc-human serum albumin (HSA) with SLN biopsy after SC-based lymphoscintigraphy.

METHODS

One hundred and six patients with localized cutaneous melanoma were studied. Lymphoscintigraphy was performed after intradermal injection of HSA in 85 patients and SC in 21 patients. Four patients underwent lymphoscintigraphy twice, once with SC and once with HSA. Dynamic images were acquired for up to 1 h, followed by high-count images of the SLN in various projections so that the most likely site was marked on the skin for biopsy. Intraoperatively, blue dye was injected around the primary site. Twenty-four patients underwent SLN dissection directed by preoperative lymphoscintigraphy and vital blue dye mapping; in the remaining 80 patients, a gamma probe was added intraoperatively to the localization procedure. Two patients underwent mapping with gamma probe alone.

RESULTS

Draining lymphatic basins and nodes were identified by lymphoscintigraphy in all patients. The SLN was identified in 95% of patients when both blue dye and intraoperative gamma probe were used. When 99mTc-HSA was used for imaging, 98% of the SLNs ultimately identified were radiolabeled, and 82% were both hot and blue. Of the SLN recovered with SC, all the nodes were radiolabeled; however, there was only 58% hot and blue concordance. Greater numbers of SLNs were removed in the SC group (median 2.0 versus 1.0, P = 0.02); however, the incidence of micrometastasis was statistically similar in both HSA and SC cohorts. In the 4 patients examined with both tracers, SLN mapping was similar.

CONCLUSION

Although SC has been the radiotracer of choice for SLN mapping in melanoma, HSA appears to be a suitable alternative, with identical success rates. In fact, the higher concordance between hot and blue nodes using HSA suggests superiority of this tracer for this purpose.

Salvage of free flaps after secondary venous ischemia by local delivery of heparin

Recent studies have demonstrated that heparin may protect against reperfusion injury through a direct effect on the microvascular endothelium that is independent of its effect on systemic coagulation. The purpose of this study was to determine whether local delivery of low-dose heparin has a role in the salvage of musculocutaneous flaps after secondary venous ischemia and revascularization. Cutaneous maximus musculocutaneous flaps were transplanted to the contralateral groin in adult Sprague-Dawley rats. All flaps were subjected to 2 hours of primary arteriovenous ischemia followed by 20 hours of reperfusion. The flaps were then subjected to a 6-hour secondary venous ischemic insult followed by anastomotic revision and reperfusion. Animals in group I received no adjunctive treatment. Those in group II were treated with low-dose heparin (5-6 U per kilogram per hour) infused systemically via the inferior epigastric vein. Those in group III received the same dose of heparin infused locally into the flap via the inferior epigastric artery. The dose of heparin used in groups II and III was insufficient to prolong the activated partial thromboplastin time above normal values. At 7 days, mean flap necrosis was 60.8% in group I and 62.1 in group II. Local heparin delivery (group III) resulted in complete survival of all flaps. Histological examination after 48 hours of reperfusion demonstrated improved microvascular patency and reduced neutrophilic infiltration in the flaps of group III animals. Thus, local infusion of low-dose heparin resulted in significantly improved flap salvage through a mechanism independent of its effect on systemic coagulation.

A retrospective study of changes in physical symptoms and body image after reduction mammaplasty

Reduction mammaplasty is performed typically to alleviate the painful physical symptoms of macromastia. Women who suffer from macromastia also frequently present to the plastic surgeon with heightened body image dissatisfaction and maladaptive behavioral changes in response to their breast size. Numerous investigations have demonstrated improvement in physical symptoms after breast reduction surgery. Studies have also suggested that psychological improvement occurs postoperatively; however, they have not used well-validated, standardized psychological measures. The present study is a retrospective analysis of the physical and psychological status of women who underwent reduction mammaplasty. One hundred ten patients who underwent a reduction mammaplasty between 1982 and 1996 were mailed a packet of questionnaires designed to assess current physical symptoms and body image. Sixty-one of the 110 patients (55 percent) responded. The vast majority reported substantial improvement or elimination of neck, back, shoulder, and breast pain, grooving from bra straps, poor posture, skin irritation, and social embarrassment. In addition, they reported significantly less dissatisfaction with their breasts as compared with a sample of breast reduction patients assessed preoperatively. Symptom relief and improved body image occurred independently of preoperative body weight, as we found few significant differences between obese and non-obese women concerning the resolution of physical symptoms or improvement in body image. Results provide further evidence of the efficacy of reduction mammaplasty not only for relief of physical symptoms but also for alleviation of body image dissatisfaction.

Bigger is not always better: body image dissatisfaction in breast reduction and breast augmentation patients

This study investigated body image dissatisfaction in breast reduction and breast augmentation patients. Thirty breast reduction and 30 breast augmentation patients completed two body image measures preoperatively. Breast reduction patients reported greater dissatisfaction with their overall body image as compared with breast augmentation patients, part of which can be understood as a function of their increased body weight. When asked specifically about their breasts, reduction patients displayed increased body image dysphoria and maladaptive behavioral change, including embarrassment about their breasts in public areas and social settings and avoidance of physical activity. Results are discussed in the context of ideal body weight cutoffs by third-party payers for reimbursement for breast reduction. Recommendations for reimbursement criteria that de-emphasize the role of body weight are made.

Avoiding pitfalls and managing complications of aesthetic contouring of the craniofacial skeleton

Contouring of the facial skeleton has become applicable to a wide spectrum of patients. Although complications do occur, they now can be managed in a safe and predictable fashion. Moreover, it has been our experience that through increased use and attention to the tenets described in this article, the incidence of postoperative complications is significantly reduced.

Melanoma of unknown primary site: presentation, treatment, and prognosis--a single institution study. University of Pennsylvania Pigmented Lesion Study Group

BACKGROUND

A retrospective analysis of 40 patients diagnosed with melanoma of unknown primary site (MUP) was undertaken to analyze the etiology and clinical behavior of this presentation.

METHODS

The patient records were located by a computer search of the Pigmented Lesion Clinic data base at the University of Pennsylvania. With the Cox proportional hazards model, the survival of the MUP patients with lymph node presentation was compared with that of patients with lymph node disease and a known concurrent primary melanoma.

RESULTS

Sixty-five percent of the patients presented with lymph node metastasis only, 28% presented with visceral lesions, and 8% presented with subcutaneous nodules. The prevalence of dysplastic nevi was 22.5%. The overall 4-year survival rate for the 40 MUP patients was 55% +/- 9%. The 4-year survival (57% +/- 12%) of patients with lymph node presentation was compared with that of patients presenting with lymph node disease and a known concurrent primary melanoma (19 +/- 6%). Survival was significantly different between the groups (P = 0.008). This survival difference remained significant (P = 0.02) even after adjustments for number of positive lymph nodes, year of diagnosis, and age at diagnosis.

CONCLUSIONS

This analysis revealed that MUP patients with lymph node metastasis survived significantly longer than patients diagnosed with lymph node metastasis concurrent with a known cutaneous primary melanoma. The prevalence of dysplastic nevi in the MUP patient series was intermediate between that reported among primary melanoma patients and that reported among population controls, suggesting the likelihood of a primary cutaneous origin for the metastatic melanoma.

Reduction of burn injury by inhibiting CD18-mediated leukocyte adherence in rabbits

The progressive nature of dermal ischemia and subsequent tissue destruction within the "zone of stasis" is a central focus in burn research. To examine the role of neutrophils and neutrophil adherence within the zone of stasis, we utilized the monoclonal antibody (MAb) 60.3, directed to the human leukocyte adherence glycoprotein CD18 to block neutrophil adherence to endothelium and intravascular aggregation in a rabbit model of partial-thickness burn. Burns were created by applying an 80 degrees C brass template to the dorsal rabbit skin for 5 or 10 seconds. Animals treated with MAb 60.3 thirty minutes following a 5-second burn had less edema, thinner eschar, and earlier elevation of the eschar than control animals. Histologic analysis revealed an eightfold increase in live hair follicles (p < 0.05) and 43 percent greater reepithelialization at 8 days (p < 0.05) and a 15 percent reduction in burn surface area at 24 hours (p < 0.0001) in the antibody-treated group. There was no significant difference between treatment and control groups exposed to 10-second burns. We conclude that neutrophils and increased neutrophil adherence play important roles in the progressive tissue destruction within the zone of stasis in burns. Furthermore, moderate burn injury may be significantly attenuated by blocking neutrophil adherence functions with a CD18 MAb.

The capsule quality of saline-filled smooth silicone, textured silicone, and polyurethane implants in rabbits: a long-term study

Recently, there have been many new designs in both the surface texture and chemical composition of breast implants that claim reduced constrictive capsular formation. The purpose of this study was to utilize a quantitative method to determine the firmness of capsules formed around saline-filled smooth silicone, textured silicone, and polyurethane implants in an experimental rabbit model 1 year after implantation. Our objective was to analyze the histologic, biologic, and biochemical content of the respective capsules to account for any differences in physical behavior. Forty-five smooth silicone, textured silicone, and polyurethane implants were placed in one of three positions beneath the panniculus carnosus muscle of New Zealand White rabbits. After 1 year, all capsules were palpated and classified according to firmness. Intracapsular static and dynamic pressure measurements were obtained by placing a pressure monitor (Stryker) in an injector port attached to the individual implants. Capsular firmness was significantly greater in the textured silicone implants than in the smooth silicone or polyurethane implants after 1 year. The dynamic qualities of the periprosthetic soft tissues were measured while saline was injected into the implants. The capsules around the textured silicone implants generated significantly higher pressures than the smooth silicone or polyurethane counterparts. The capsules around the polyurethane implants were the softest and most compliant in all categories. Histologically, there is a significant inflammatory response surrounding the textured silicone implants that does not exist in the capsules around the smooth silicone implants. The capsules around the polyurethane implants have the least fibrous tissue deposition. There is a decrease in the proportion of type III collagen in the capsules around the textured silicone implants versus smooth silicone or polyurethane implants. The in vitro contraction patterns of the fibroblast-populated collagen lattices do not reveal the contraction differences observed in vivo in rabbits. However, there are many components that determine contractility. This area deserves further investigation.

Synthetic mesh. Its use in abdominal wall reconstruction after the TRAM

This technique has evolved over 13 years and has been associated with very few mesh-related complications. A recently reported study of 65 consecutive patients with a mean follow-up of 47.4 months reported a hernia rate of 1.5% (1 of 65) and an incidence of mesh-related infection of 1.5% (1 of 65). It appears that the use of polypropylene (Marlex mesh) offers the reconstructive surgeon several advantages, including elevation of the entire rectus flap, thereby preserving the entire blood supply to the rectus muscle. Second, the interrupted suture technique surrounding the mesh allows for greater distribution of force and diminishes the risk of fascial dehiscence. Therefore, one can obtain a tighter, narrower abdomen to achieve an improved aesthetic abdominal result. The TRAM flap breast reconstruction should not only yield a fine reconstructed breast but also deliver an aesthetic abdominal contour improvement that represents a significant benefit to the patient undergoing this procedure.

Improved survival rates of random flaps in rabbits with a monoclonal antibody that blocks leukocyte adherence

To examine the role of neutrophil adhesiveness in the tissue injury involving the ischemic "at risk" area of random flaps, we used the monoclonal antibody 60.3, which binds selectively to the primary neutrophil adherence-mediating glycoprotein CD18 in a random cutaneous flap model. Control animals that had flaps elevated and replaced (n = 12) had a mean distal necrosis of 31.9 +/- 9.3 percent of the total flap surface area. Treatment with monoclonal antibody 60.3 (n = 12) reduced distal necrosis to 10.6 +/- 7.5 percent (p < 0.005). Inhibiting inosculation by interposing a thin silicone sheet decreased distal flap survival; however, the protective effect of monoclonal antibody 60.3 on improving flap survival was unchanged. Control isolated flaps (n = 13) had a mean distal necrosis of 49.0 +/- 15.5 percent compared with 22.2 +/- 5.6 percent for the antibody-treated (n = 8) isolated flaps (p < 0.05). We conclude that increased neutrophil adhesiveness plays an important role in the tissue injury involving the ischemic "at risk" area of random flaps and the transient, specific inhibition of leukocyte adherence by monoclonal antibody 60.3 improves the distal survival of random flaps in this model. Moreover, we conclude that "graft inosculation" contributes to "flap" survival in this model; however, conclusions regarding the effect of treatment are not altered by blocking inosculation.

The roles of revascularization and resorption on endurance of craniofacial onlay bone grafts in the rabbit

A total of 32 New Zealand white rabbits underwent subperiosteal implantation of fresh autogenous unicortical calvarial and iliac crest grafts on their snouts with microscrew rigid fixation. After 3 and 10 days, vascularity was assessed by latex casting, and osteoclastic activity was determined by histochemical staining for tartrate-resistant acid phosphatase. After 70 days, volumetric analysis and tartrate-resistant acid phosphatase staining were performed on six animals. The calvarial grafts demonstrated greater volume maintenance than the iliac bone (72 percent versus 32 percent, p < 0.025). There were significantly greater osteoclastic activity and revascularization in the cancellous portion of calvarial and iliac crest bone grafts by the 10th day of onlay grafting. Minimal activities were present at the cortical bone. Because calvarial grafts contain more cortical bone, its superior volume maintenance can be understood by the architectural influence on revascularization and resorption.

Smooth versus textured expander implants: a double-blind study of capsule quality and discomfort in simultaneous bilateral breast reconstruction patients

Textured silicone expanders are alleged to be less painful in the filling process, to have less capsular contracture, and to stay in position better than smooth silicone expanders. To test these three hypotheses, 6 patients undergoing bilateral simultaneous expander implant placement for breast reconstruction after mastectomy were studied. In a double-blind fashion, after smooth and textured implant placement (one in each side) and initial wound healing, each patient was sequentially expanded with equal volumes of saline. In each patient, at each expansion, pressure data, discomfort scores, and implant placement measurements were made. At implant removal, smooth and textured capsule tissues were studied for collagen type content and ability to contract the patient's own fibroblast-populated collagen lattice. In 4 of 6 patients the smooth expander was associated with lower injection pressures and less discomfort. In all patients the expanders maintained their position, except in 1 patient whose smooth implant shifted laterally. The capsular collagen typing and fibroblast-populated collagen lattice studies demonstrated no difference between smooth and textured capsules. In this double-blind clinical study in simultaneous bilateral breast reconstruction patients we could not confirm the suggestion that textured silicone expanders produce less capsular contracture and cause less pain with injection.

The fate of suctioned and surgically removed fat after reimplantation for soft-tissue augmentation: a volumetric and histologic study in the rabbit

The use of autologous fat transplantation has seen renewed popularity with the recent advent of liposuction as a body recontouring technique. However, clinicians are still faced with uncertainty concerning the ultimate volume maintenance of the transplanted fat graft at its recipient site. This study was initiated to examine and evaluate the changes in volume of suctioned versus surgically excised fat grafts over a 9-month period in the New Zealand White rabbit. Fat grafts of equal volume were harvested from the groin using standard suction and surgical techniques and transferred into isolated pockets in the ear. Results demonstrate that both suctioned and surgically removed fat grafts undergo significant volume reduction. However, surgically excised fat maintains its volume (42.2 percent; n = 16) better than suction-assisted fat grafts (31.6 percent; n = 16; p < 0.05). Histologic examination showed that fibrous connective tissue was more prevalent in the suctioned fat grafts than in the surgically removed fat grafts.