A simple technique for improving the cosmesis of excision of a melanoma and skin grafting

A simple technique is described to reduce the size of the skin defect resulting from excision of a malignant melanoma. An added advantage of this technique is the smoother contour at the native skin to skin graft junction. These effects are achieved by apposing the skin edge to the muscle using a simple pursestring suture technique which simultaneously draws the wound edges centrally. The resultant smaller area to be grafted, smaller donor site, better graft survival and superior cosmesis represent an improvement over conventional skin grafting techniques.     

Effects of early tangential excision and grafting on survival after burn injury

This report quantifies the increase of burn survival, which we believe is associated with the use of early tangential excision and grafting as opposed to conventional therapy in adult patients with burns. To quantify the increase, we compared the lethal area 50 of various age groups with that of previous historical studies that used other techniques. These data suggest that early excision and grafting are associated with a marked improvement in survival in patients 41 to 60 years of age with 20 to 65 per cent total body surface area burns.     

Laparoscopic excision of ovarian neoplasms subsequently found to be malignant.

One hundred fifty-six members and candidate members of the Society of Gynecologic Oncologists responded to a survey concerning the "laparoscopic management of ovarian neoplasms subsequently found to be malignant." Twenty-nine responders (19%) reported a total of 42 cases of ovarian malignancy. The laparoscopic procedure was aborted or the cyst was aspirated in 38% of the cases, and partial or complete excisions were attempted in 33 and 29%, respectively. The characteristics of the masses were as follows: less than 8 cm 67%, cystic 62%, unilocular 48%, and unilateral 81%. All four "benign" characteristics were present in 31% of the cases found to be malignant, and three of four characteristics were present in 24%. Laparotomy was performed at the time of laparoscopy in 17% of cases, after laparoscopy in 71% with an average interval of 4.8 weeks, and not at all in 12%. Fifty-seven percent of the cases were invasive epithelial malignancies, whereas 29% were tumors of low malignant potential. At least 50% of the patients had stages II-IV. We conclude that attempted laparoscopic excisions of adnexal masses that are subsequently found to be malignant are not uncommon, and that the presence of so-called "benign" characteristics does not preclude malignancy. Attempts at partial or complete excision are common, as are delays in subsequent definitive surgery. The stage of disease is often advanced, and all histologic types of malignancy are encountered. We advocate careful evaluation of this practice, with development of strict guidelines to ensure optimal patient care.     

Adenofibroma of the uterus: Multiple recurrences following wide local excision

The uterine adenofibroma is a form of mixed mesodermal tumor in which both epithelial and stromal components are benign. A case is presented in which a patient with this lesion was treated with excision of the tumor rather than hysterectomy. Two years later, she developed a recurrence of the lesion, which was again treated with wide local excision. A hysterectomy was done 9 months later, and a polypoid lesion was noted in the fundus of the uterus which on histologic examination was thought to be potentially either an adenofibroma precursor or a maturation of the previous cellular adenofibroma. Since uterine adenofibroma usually occurs in older patients, the standard treatment has been hysterectomy. Because of this patient's age, she was initially treated with a more conservative approach. However, despite the fact that the uterine adenofibroma is a benign lesion, it has an obvious potential to recur when treated conservatively.     

Primary vaginal melanoma: Thirteen-year disease-free survival after wide local excision and review of recent literature

Objectives: We present a case report of a woman who has survived 13 years after conservative treatment with wide excision for vaginal melanoma and review and evaluate the literature on this disease since the last metaanalysis in 1989. Study Design: A database literature search along with cross referencing from related articles uncovered 66 patients who were reported to have vaginal melanoma since 1989 with adequate information for our analysis. We add to this one original case reported by us. Where information was available, we analyzed outcomes on these cases on the basis of patient age, tumor thickness, tumor size, and treatment. Results: The patient we describe is only the eighteenth reported patient to survive vaginal melanoma 5 years and only the third to survive for 10 years. Of the 67 patients in our overall review, mean age at the time of diagnosis was 62 years. Patients with tumor size <3 cm had a mean survival of 41 months compared with 12 months for those with tumor size ≥3 cm (p < 0.0024). Tumor thickness did not significantly affect patient survival at any of the depths analyzed, although there was a tendency toward significance at depths >8 mm (p < 0.0778). There also was no significant difference in patient outcome among five treatment groups: (1) wide excision, (2) radical surgery, (3) radiation therapy, (4) wide excision plus radiation therapy, and (5) other. Conclusion: Tumor size appears to affect survival in patients with vaginal melanoma. Tumor thickness, at least at the levels at which vaginal melanomas are currently being diagnosed, does not seem to affect survival. Because no single treatment is clearly preferable, we suggest conservative resection where possible. We find it difficult to support radical surgery as primary treatment for vaginal melanoma unless necessary to achieve clear tumor margins. Radiation therapy appears to offer results comparable to those of surgery. (Am J Obstet Gynecol 1998;178:1177-84.)     

卵巢子宫内膜异位囊肿术后复发处理

卵巢子宫内膜异位囊肿（简称卵巢内异囊肿）是子宫内膜异位症的最常见类型,腹腔镜下卵巢内异囊肿剥除被公认为是标准的手术治疗方式。对于术后卵巢内异囊肿复发的患者,再次手术并非首选。反复手术有可能对卵巢组织造成进一步的损伤,甚至使其功能丧失。因此,对于复发的卵巢内异囊肿患者治疗应慎重,综合考虑患者年龄、疾病严重程度及生育要求,可供选择的方法包括药物治疗、超声引导下囊肿穿刺或联合囊肿内药物灌注以及保守性手术/子宫+附件切除手术。要在遵循初治原则的基础之上,体现个体化与规范治疗。     

Pneumocephalus after thoracoscopic excision of posterior mediastinal tumor.

Pneumocephalus is a very rare complication of video-assisted thoracoscopic surgery (VATS). A 66-year-old man developed pneumocephalus secondary to thoracoscopic excision of a neurogenic tumor in the posterior mediastinum. Pneumocephalus was diagnosed by brain computed tomography. Neurosurgical intervention was performed after conservative therapy had failed. The patient's condition had resolved without any neurologic sequelae 2 years later. When a patient has a relatively large amount of chest tube drainage and neurologic symptoms after VATS, the possibility of pneumocephalus due to cerebrospinal fluid leakage must be considered.     

Large disposable trephines for circular excision biopsy of the skin

Large disposable circular trephines have been developed specially for circular excision biopsy of the skin. This technique is a simple and practical alternative to the traditional method of excision. It has the advantages of aligning the incision in the direction of the maximum skin tensions and reducing the length of the final wound closure.     

Radical wide excision and selective inguinal node dissection for squamous cell carcinoma of the vulva

Limited resection of some vulvar cancers may provide cure rates equivalent to those obtained with radical vulvectomy and bilateral inguinal node dissection. Rapid recovery, fewer complications, and better functional result have been described as advantages to less extensive procedures. Since 1978, 32 patients with invasive squamous cell cancer of the vulva (depth greater than 1 mm) and clinically negative inguinal lymph nodes underwent radical wide excisions as primary therapy. Mean age at diagnosis was 61 years. Seventeen patients had T1 and 15 had T2 tumors. Resection of the primary lesion was tailored to lesion location and size, and dissection was carried to the deep perineal fascia. Twenty-two patients had unilateral superficial inguinal lymph node dissections, five with midline lesions had bilateral superficial dissections, and five had node samplings which included deep inguinal nodes. Depth of invasion ranged from 1.5 to 13.0 mm. Mean largest lesion dimension was 23 mm. Five-year lifetable survival for the entire group was 84%. Univariate analysis of potential prognostic variables showed no significant recurrence or survival differences for patient age (P = 0.56), symptom duration (P = 0.57), FIGO stage (P = 0.67), tumor grade (P = 0.20), tumor location (P = 0.26), depth of invasion (P = 0.56), or resection margin status (P = 0.63). Thirty-one percent of patients had perioperative complications, and 16% developed delayed complications. Mean hospital stay was 10 days. Three patients (10%) developed new or recurrent vulvar disease and underwent additional therapy. None have died of disease, although one is alive with persistent tumor. Radical wide excision and selective inguinal lymphadenectomy constitute a reasonable alternative to radical vulvectomy with bilateral inguinal node dissections for squamous tumors clinically limited to the vulva. Outcome may not be strongly influenced by lesion size or depth of invasion.     

Long-term effects of the menopause and sex hormones on skin thickness

Summary. Skin collagen content and skin thickness in a group of postmenopausal women who had been treated with sex hormone implants were compared with those in an untreated group of similar women. Both skin collagen content and thickness were found to be significantly greater in the treated than in the untreated group. In the untreated women skin collagen content declined in relation to menopausal age but not to chronological age. No correlation was found with menopausal age, chronological age or duration of therapy in the treated group. These data suggest that skin collagen is influenced by the sex hormone status arid declines after the menopause. contributing to the increase in urinary hydroxyproline excretion that has been reported to occur a t this time.     

Long-term effects of the menopause and sex hormones on skin thickness

Skin collagen content and skin thickness in a group of postmenopausal women who had been treated with sex hormone implants were compared with those in an untreated group of similar women. Both skin collagen content and thickness were found to be significantly greater in the treated than in the untreated group. In the untreated women skin collagen content declined in relation to menopausal age but not to chronological age. No correlation was found with menopausal age, chronological age or duration of therapy in the treated group. These data suggest that skin collagen is influenced by the sex hormone status and declines after the menopause, contributing to the increase in urinary hydroxyproline excretion that has been reported to occur at this time.     

Histological incomplete excision of CIN after large loop excision of the transformation zone (LLETZ) merits careful follow up, not retreatment.

OBJECTIVE: To quantify and analyse the influence of a histological report of incomplete excision of CIN after LLETZ on frequency of detection of residual CIN. DESIGN: Review of a computerised database of sequential women treated by LLETZ. Initial follow-up was three months post-treatment. SETTING: The Colposcopy Clinic, Regional Department of Gynaecological Oncology, Queen Elizabeth Hospital, Gateshead, Tyne and Wear, UK. SUBJECTS: 721 women with CIN diagnosed histologically on LLETZ specimens. RESULTS: In spite of a first time treatment success rate of 95% at 3 months, only 56% of the women were reported to have complete histological excision of CIN. A report suggesting incomplete excision was more likely with more severe CIN, extensive lesions and involvement of the endocervical canal. Furthermore, 21% with residual CIN had apparent complete excision of CIN at LLETZ. CONCLUSIONS: A histological report of incomplete excision of CIN at LLETZ does not equate with residual disease. The high treatment success rate of LLETZ means that a report of incomplete excision should stimulate close colposcopic and cytologic follow-up to identify the small number of women with residual CIN after therapy.