Flap reconstruction and interstitial brachytherapy in nonextremity soft tissue sarcoma

Radiotherapy is an integral component of management of high-grade soft tissue sarcomas. Interstitial brachytherapy is used to deliver a boost or radical dose with several advantages over external beam radiotherapy. There has always been a concern to use brachytherapy with flap reconstruction of skin defects after wide excision. We preset our initial experience with interstitial brachytherapy in two patients of recurrent high-grade non-extremity sarcomas treated with surgical excision and soft tissue reconstruction of surgical defect.     

Excision of exposed cartilage for management of Mohs surgery defects of the ear

Cartilage of the ear is often exposed during Mohs surgical procedures. Fenestration of the cartilage with a skin punch has been recommended to stimulate granulation tissue where the perichondrium has been destroyed. This article describes an alternative method--the excision of a window through the exposed cartilage, fully exposing the perichondrium on the other side of the cartilage. This promotes the rapid healing by second intention or provides a vascular bed for immediate skin grafting. Also, aggressive excision of nonviable cartilage helps prevent chondritis or perichondritis.     

Prevention of extravasation necroses as a complication following intravenous cytostatic drug therapy. Results of an open pilot study

Extravasation of some cytostatics applied i.v. can often cause local edema with skin redness, thrombophlebitis and not infrequently skin necrosis with chronic ulcera. Local treatment is usually ineffective, and so far surgical excision of ulcera is the only curative approach. Tetrachlorodecaoxygen anion complex (TCDO) has shown high activity in healing chronic leg ulcera, by increasing pO2 in hypoxic wound tissue and stimulating phagocytosis as one of anti-inflammatory processes To study the local activity of TCDO in tissue necrosis and chronic ulcera caused by cytostatic extravasation, 23 patients with local skin complications underwent local treatment with TCDO, made as isotonic water solution. Seventeen patients experienced only local edema with redness, while 6 patients showed deep chronic ulcera. All the skin changes were complications after i.v. doxorubicin, cisplatinum, dactinomycin or vinblastine application. The treatments with TCDO followed 1-3 months after ulcera appeared, while skin inflammations were treated 1-8 days after they occurred. TCDO was applied locally twice a day by impregnated cotton tissue for 4-6 weeks. Evaluable were only measurable lesions. From 17 patients with only skin inflammation 3 patients obtained complete resolution, 8 partial resolution and 6 had stable lesions. Thus, overall response was recorded in 65% of patients (11/17). In 6 patients with deep chronic ulcera a longer treatment (6 weeks) was needed, and in 5 of them the complete epithelization and resolution occurred. One patient had a partial wound healing. No side effects of treatment were observed. The effect of locally applied TCDO in chronic ulcera seems to be preferable to surgical treatment. A controlled study will show the exact therapeutic value of this new anti-inflammatory compound.     

Surgical repair of atresia of nasal passages

Surgical correction of nasal atresia following healing of smallpox lesions in a 15-year-old girl is presented. The surgical technique used was complete excision of the scars and resurfacing of the resulting wound with grafts of full-thickness retroauricular skin. Particular attention was paid to prevention of postoperative contracture.     

Clinical factors and treatment parameters affecting prognosis in adult high-grade soft tissue sarcomas: a retrospective review of 267 cases

Data on 267 adults with high-grade soft tissue sarcomas were reviewed. Male sex, large tumor size, Stage IIIC, IV A and sarcomatous skin invasion, as well as marginal excision, amputation, postoperative fever and wound infection, were found to be associated with shorter survival time. Head and neck location, multifocal growth of sarcoma. Stage IIIC, malignant skin infiltration, locally recurrent tumor as well as marginal excision and limb-sparing resection, were found to influence local control unfavorably in single factor analyses. Each of the significant variables were entered into a multivariate proportional hazards model in a stepwise manner. Stage, postoperative fever, the surgical margin and type of surgery, and sarcomatous skin changes significantly affected survival time. Local recurrence was significantly affected by the surgical margin and type of surgery, the status of tumor (primary or recurrent), stage and malignant skin infiltration.     

Image-guided tumor resection using real-time near-infrared fluorescence in a syngeneic rat model of primary breast cancer

Tumor involvement of resection margins is found in a large proportion of patients who undergo breast-conserving surgery. Near-infrared (NIR) fluorescence imaging is an experimental technique to visualize cancer cells during surgery. To determine the accuracy of real-time NIR fluorescence imaging in obtaining tumor-free resection margins, a protease-activatable NIR fluorescence probe and an intraoperative camera system were used in the EMR86 orthotopic syngeneic breast cancer rat model. Influence of concentration, timing and number of tumor cells were tested in the MCR86 rat breast cancer cell line. These variables were significantly associated with NIR fluorescence probe activation. Dosing and tumor size were also significantly associated with fluorescence intensity in the EMR86 rat model, whereas time of imaging was not. Real-time NIR fluorescence guidance of tumor resection resulted in a complete resection of 17 out of 17 tumors with minimal excision of normal healthy tissue (mean minimum and a mean maximum tumor-free margin of 0.2 ± 0.2 mm and 1.3 ± 0.6 mm, respectively). Moreover, the technique enabled identification of remnant tumor tissue in the surgical cavity. Histological analysis revealed that the NIR fluorescence signal was highest at the invasive tumor border and in the stromal compartment of the tumor. In conclusion, NIR fluorescence detection of breast tumor margins was successful in a rat model. This study suggests that clinical introduction of intraoperative NIR fluorescence imaging has the potential to increase the number of complete tumor resections in breast cancer patients undergoing breast-conserving surgery.     

隆突性皮肤纤维肉瘤85例临床分析

目的：探讨隆突性皮肤纤维肉瘤的临床特点和治疗方法。方法：回顾性分析85例隆突性皮肤纤维肉瘤临床诊治过程。结果：85例隆突性皮肤纤维肉瘤行扩大切除术45例，扩大切除加植皮或转移皮瓣修补术34例，术前放疗2例，术后合并放疗10例，全组病例复发率为64．7％，5例死于肿瘤转移，结论：隆突性皮肤纤维肉瘤是皮肤低度恶性肿瘤，复发率高，首次治疗时彻底切除极为关键，外科手术是其主要的治疗方法，治疗作为辅助治疗有一定疗效。     

Mohs micrographically controlled surgery and the treatment of malignant melanoma

Mohs micrographic surgery is a technique that offers surgeons and pathologists a means to examine the entire surgical margins of excised cutaneous malignancies in a more complete manner than conventional methods. Initially developed to treat nonmelanoma skin cancers, its use has been expanded to include histologic margin evaluation for treatment of malignant melanoma. Clinical studies demonstrate equivalent or better 5-year survival rates with Mohs surgery compared to conventional wide local excision. For surgical treatment of melanoma, it offers unique advantages for lesions requiring tissue conservation and accurate margin determination, particularly in anatomic sites where cosmetic and functional concerns are of importance (head and neck, hands, and feet), and for large or ill-defined lesions such as lentigo maligna or lentigo maligna melanoma.     

Recurrent episodic foot-drop following surgery to the thigh

Subject. We present the case history of a 47-year-old lady who, 10 months following excision of a soft tissue sarcoma from the left thigh, was struck with recurrent episodes of foot drop.Discussion. The curious phenomenon of recurrent foot drop was found to be secondary to pressure symptoms from a tense seroma of the thigh. She underwent surgical excision of the sac and had immediate and complete relief of symptoms.     

Differentiation of melanoma from non-cancerous tissue in an animal model using elastic light single-scattering spectroscopy

Cutaneous melanoma is the most serious form of skin cancer and is curable only if it is detected early. The most effective treatment for the melanoma is surgical excision of the lesion. Traditionally, wide margins of excision have been used for effective treatment, but are not always desirable due to increased risk of infection and esthetic reasons. Besides, safe surgical margins of the lesion are not always correlated well with the size of the lesions. We have previously developed a system using elastic light single-scattering spectroscopy to differentiate cancerous tissue from non-cancerous tissue and tested it in vitro. The goal of this study was, therefore, to determine the effectiveness of this system ex vivo by using a mouse model of melanoma. First, a melanoma cell line; B16F10 were injected subcutaneously at right mid flank region of C57BL6 mice (n=5) and allowed to develop for two weeks. Tumors were dissected and spectra were taken on tumor tissue and on normal looking skin tissue that was 10 mm distant from the incision. Since these tumors become markedly necrotic in the middle, spectra of necrotic area was also taken. Slopes of the spectra were positive taken on non-cancerous skin tissues that were later verified by histological examination. On the other hand, it gave negative slopes on melanomas. Increased sizes of the nuclei correlated with the negative slope while smaller nuclei found in non-cancerous tissue gave positive slope. Spectrum taken from necrotic area differed from both cancerous and non-cancerous tissue such that it gave a U-shaped spectrum. These results demonstrate that elastic light single-scattering spectroscopy system can differentiate cancerous tissue from non-cancerous and has potential to be used intraoperatively to determine the surgical margins.     

Supraestructure maxillectomy and orbital exenteration for treatment of basal cell carcinoma of inferior eyelid: case report and review

Basal cell carcinoma (BCC) is the most frequent type of skin cancer in humans, with cumulative exposure to ultraviolet radiation (UVR) as important risk factor for development of the illness as such as severe solar burns during childhood or adolescence. BCC is mainly located on sun exposed sites, being head and neck the areas of more incidence; although nose, eyelids and periorbitary tissue are unfavorable due to cosmetic results that BCC involves. Tumors can be classified as: nodular, superficial, micronodular, morphea variety, infiltrating, pigmented, metatypic and fibroepithelioma of Pinkus. Several treatment options as surgical and non-surgical are available. The goal of treatment is complete excision of the tumor with preservation of surrounding structures in a way aesthetically acceptable. Mohs' micrographic surgery is the standard treatment for all non-melanoma skin cancer. Orbital exenteration is also used for treatment of malignancies of ocular tissues, mainly squamous cell carcinoma, sebaceous cell carcinoma and BCC. The tissue beneath the surgical site can be left for second-intention granulation or covered with a cutaneous implant of partial thickness. The case of a 77 year-old patient is presented with BCC of inferior eyelid of 14 years duration, formerly managed with radiotherapy and, due to recurrent illness and invasion to the maxillary antrum; he needed supraestructure maxillectomy with left orbital exenteration.     

Supraestructure maxillectomy and orbital exenteration for treatment of basal cell carcinoma of inferior eyelid: case report and review

Basal cell carcinoma (BCC) is the most frequent type of skin cancer in humans, with cumulative exposure to ultraviolet radiation as an important risk factor for development of illness such as severe solar burns during childhood or adolescence. BCC is mainly located on sun-exposed sites, head and neck being the areas of more incidences; although nose, eyelids and periorbitary tissue are unfavorable due to cosmetic results that BCC involves. Tumors can be classified as nodular, superficial, micronodular, morphea variety, infiltrating, pigmented, metatypic and fibroepithelioma of Pinkus. Several treatment options such as surgical and nonsurgical are available. The goal of treatment is complete excision of the tumor with preservation of surrounding structures in a way aesthetically acceptable. Mohs' micrographic surgery is the standard treatment for all nonmelanoma skin cancers. Orbital exenteration is also used for treatment of malignancies of ocular tissues, mainly squamous cell carcinoma, sebaceous cell carcinoma and BCC. The tissue beneath the surgical site can be left for second-intention granulation or covered with a cutaneous implant of partial thickness. The case of a 77-year-old patient is presented with BCC of inferior eyelid of 14 years' duration, formerly managed with radiotherapy; however, due to recurrent illness and invasion to the maxillary antrum, he needed supraestructure maxillectomy with left orbital exenteration.     

Mohs micrographic surgery for skin cancer

Mohs micrographic surgery is a reliable outpatient surgical method of removing skin cancer. The method includes tissue excision in thin layers, colour-coding of excised specimens, accurate orientation of excised tissue through construction of tissue maps, and microscopic examination of horizontal frozen sections. Selected basal and squamous cell carcinomas are treated most commonly by this method, however, a variety of less common tumors are also amenable to treatment. Mohs micrographic surgery offers the highest cure rates for selected malignancies while maintaining maximal preservation of normal tissue and important anatomic structures.     

Plastic surgical treatment of facial skin cancer

The principles and application of surgical treatment for skin cancer are outlined. Procedures ranging from simple excision to complex plastic repair are described. The primary aims of providing diagnosis, cure, and maximal retention of function and esthetics are illustrated. Attainment of secondary aims including minimal morbidity and pain, simplicity, and economy of time and expense is discussed. Cancers of the head and neck have been selected for illustrating the fundamentals of surgical treatment for cancer of the skin. These locations are the most common sites of skin cancer and demonstrate the need for combining adequate tumor resection with minimal tissue sacrifice. Selection of specific surgical procedures as optimal therapy is considered as compared to other modalities such as X-ray therapy, electrocoagulation, and topical chemotherapy. The need for early diagnosis and prompt treatment in order to avoid the development of more serious clinical problems requiring correspondingly more complex procedures is indicated.     

Neoadjuvant radiation therapy for the management of myoepithelial carcinoma of the upper extremity

Myoepithelial tumors of the soft tissue are a rare tumor displaying myoepithelial elements and lacking obvious ductal differentiation. The rarity of these precludes any evidence‐based consensus regarding optimal management. Nevertheless, the current approach to these lesions begins with amputation or complete excision. The efficacy of neoadjuvant or adjuvant radiation therapy or chemotherapy has not been established. Here, we present the first report to the authors’ knowledge of neoadjuvant radiation therapy for the treatment of this rare soft tissue neoplasm and review the management and outcomes of published cases of myoepithelial carcinoma. A patient with a soft tissue myoepithelial carcinoma that declined both amputation and chemotherapy was treated with neoadjuvant radiation therapy and wide surgical excision followed by a brachytherapy boost to the resected tumor bed. Neoadjuvant radiation therapy resulted in an excellent response with extensive treatment‐related changes consisting predominantly of fibrosis, hyalinization and hemorrhage and only 10% residual viable myoepithelial carcinoma present in the surgical specimen.     

Quadrantectomy versus lumpectomy for small size breast cancer

Between 1985 and 1987 quadrantectomy plus external radiotherapy and lumpectomy plus external and interstitial radiotherapy were compared in a randomized trial of patients with small carcinomas of the breast. Quadrantectomy involves excision of 2–3 cm of normal tissue around the tumour plus the removal of a sufficiently large portion of overlying skin and underlying fascia whilst lumpectomy removes only the tumour mass with a narrow margin of normal tissue. Patients in both groups also received total axillary dissection. 705 cases were evaluable, 360 quadrantectomies and 345 lumpectomies. No differences in distant metastases and survival were observed in the two groups. However, lumpectomy patients had a much higher frequency of local recurrences (7.0 vs. 2.2%). Since a local recurrence needs a second operation and creates severe psychological distress to the patient, conservative surgical procedures should include generous excision of normal tissue around the primary carcinoma plus intensive postoperative radiotherapy.     

Mohs micrographic surgery: established uses and emerging trends

Mohs micrographic surgery is a surgical technique that seeks to ensure the clearance of cutaneous tumors while maximizing normal tissue conservation. This is accomplished through the sequential removal of thin layers of tissue in which the entire peripheral and deep margins are examined for residual tumor. This approach appears to be superior to conventional surgical excision in the treatment of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), the two most common cancers of the skin. Its efficacy in treating BCC and SCC has led clinicians to explore the role of Mohs micrographic surgery in the management of less common cutaneous neoplasms, such as melanoma, Merkel cell carcinoma, dermatofibrosarcoma protuberans, extramammary Paget's disease, and microcystic adnexal carcinoma.     

Leiomyosarcoma of the skin: A case report

A middle-aged man presented with an ulcerated nodule of the right posterior thigh that was histologically evaluated as leiomyosarcoma of the skin. A wide excision of the tumor was followed by split-thickness skin grafting. Leiomyosarcomas of the skin and subcutaneous tissue are rare tumors, usually occurring in the proximal lower extremities. The treatment of choice is a wide local excision with a 3- to 5-cm margin including the subcutaneous tissue and fascia. The defect is covered by a split-thickness skin graft.     

Basal cell carcinoma in a patient with acquired immunodeficiency syndrome: treatment with Mohs micrographic surgery fixed-tissue technique

A case illustrating Mohs micrographic surgery fixed-tissue technique in the treatment of a large basal cell carcinoma of the left nasal alar groove in a patient with acquired immunodeficiency syndrome is described. Fixation of the tissue before excision and appropriate infectious disease precautions minimize exposure to the human immunodeficiency virus by the surgical and laboratory personnel, while Mohs micrographic mapping assures complete removal of a potentially life-threatening cancer in an immunocompromised patient.     

Omental transposition for recurrent breast carcinoma following limited surgical excision and radiation therapy

Failure to control local disease following limited surgical excision and radiotherapy for primary treatment of breast carcinoma often precludes the use of conventional mastectomy techniques. This series reports the use of mastectomy and omental transposition on a gastroepiploic pedicle and delayed skin grafting in 17 such patients. The transposition of omentum permits removal of neoplastic and secondarily infected tissue including sternum, ribs and chest wall muscles if necessary. Fourteen patients underwent hormonal manipulation and 8 patients chemotherapy before surgical referral, which was often as a last resort for ulcerated and secondarily infected masses. Three patients required concomitant chest wall excision. There was no mortality and no long-term morbidity. Local disease was completely eradicated in 9 patients, although 2 now have distant disease; 4 patients had marked symptomatic improvement despite failure to control local disease and 4 patients had poor results. Dermal lymphatic involvement and failure to resect all macroscopic disease accounted for all of the local failures. Omental transposition can provide a safe, effective and occasionally curative surgical means of dealing with these difficult local recurrences in irradiated breasts.