Mohs显微描记手术在鼻部皮肤基底细胞癌治疗中的应用

目的 评价Mohs显微描记手术治疗鼻部皮肤基底细胞癌的效果。方法 2014年,对40例鼻部皮肤基底细胞癌患者进行Mohs显微描记手术,观察手术效果,并与传统扩大切除手术进行比较。结果 40例基底细胞癌均通过Mohs显微描记法切除,肿瘤扩大切除范围平均1.8 mm。39例均Ⅰ期愈合,术后外形、效果满意。术后随访6~24个月,无1例复发。结论 对于鼻部基底细胞癌,Mohs显微描记手术比传统扩大切除更彻底,可提供更多的创面修复方案。     

手背巨大隆突性皮肤纤维肉瘤1例报告

隆突性皮肤纤维肉瘤（dermato fibrosarcoma protuberans,DFSP）临床上少见,术后容易复发。2009年3月我院收治手背巨大DFSP1例,经外院多次手术切除均复发,治疗难度大。本次治疗采用肿物扩大根治切除术＋皮瓣转移术＋植皮术,疗效满意,随访1年未复发,现报告如下。     

皮肤恶性肿瘤切除后的修复

目的　探讨皮肤恶性肿瘤手术切除后的修复效果。　方法　 1 984年～ 2 0 0 1年对 38例皮肤体表恶性肿瘤进行切取 ,其中皮肤鳞状上皮癌 1 2例 ,隆突性皮肤纤维肉瘤 1 4例 ,皮肤原位癌 2例 ,皮肤疣状癌 1例 ,皮肤湿疹样癌 4例 ,慢性溃疡恶变 5例 ;手术后残留创面最大为 1 4 cm× 2 0 cm。采用 7种不同类型的皮瓣、肌皮瓣、游离植皮和手术后直接缝合等方法进行修复 ,其中腓肠肌皮瓣 4例 ,背阔肌皮瓣 6例 ,阔筋膜张肌皮瓣 2例 ,腹直肌皮瓣 1例 ,足底内侧皮瓣 5例 ,邻近皮瓣 3例 ,游离大块植皮 1 2例 ,肿瘤切除后直接缝合 5例。　结果　 38例手术全部成功 ,切口 期愈合。2 1例获得随访 ,随访时间 3～ 1 2年 ,1 9例术后恢复良好 ,2例术后局部复发 ,再次手术后治愈。 2 1例均成活。　结论　手术彻底切除肿瘤 ,修复方法应根据病情而制定 ,是根治皮肤恶性肿瘤的决定性因素     

足跟恶性黑色素瘤的切除与修复

目的探讨足跟恶性黑色素瘤的切除范围及修复方法。方法 2007年7月-2009年6月,收治足跟恶性黑色素瘤15例。男9例,女6例;年龄32～71岁,平均47.2岁。其中原发初治13例,外院局部切除术后2例。病灶范围1.3cm×0.5cm～5.0cm×3.5cm,病灶厚度0.6～7.2mm。根据美国癌症联合会(AJCC)分期:ⅠA期1例,ⅠB期2例,ⅡA期3例,ⅡB期5例,ⅡC期1例,Ⅲ期3例。局部广泛切除后分别采用大小为7cm×5cm～12cm×8cm的足内侧皮瓣(5例)、足外侧皮瓣(2例)及腓肠神经营养血管逆行皮瓣(8例)进行修复;3例行淋巴结清扫术。供区植皮修复。结果术后1例足外侧皮瓣局部皮缘坏死,2例足内侧皮瓣供区出现部分植皮坏死,均经换药后愈合;其余皮瓣及植皮均成活,切口Ⅰ期愈合。术后15例均获随访,随访时间12～36个月,平均21个月。足外侧皮瓣感觉及功能恢复佳,足内侧皮瓣次之,腓肠神经营养血管逆行皮瓣较差。随访期间无局部复发;5例出现腹股沟淋巴结转移,其中1例死于肺转移。结论足跟恶性黑色素瘤行广泛切除后可获得较好局部控制率;应用局部皮瓣可修复创面,但腓肠神经营养血管逆行皮瓣的感觉恢复较差。     

局部旋转皮瓣在老年人面部恶性肿瘤切除修复中的应用

目的：探讨老年患者面部恶性肿瘤切除后创面修复的较好办法。方法：应用面部局部旋转皮瓣对我科收治的53例老年人面部恶性肿瘤扩大切除后遗留创面进行修复。结果：53例患者局部旋转皮瓣全部成活,切口均I期愈合,面部器官无移位,术后随访,肿瘤无复发,皮瓣颜色和质地与周围皮肤一致,切口瘢痕不明显。结论：面部局部旋转皮瓣设计简单,手术操作方便,成活率高,围手术期短,可作为老年患者面部恶性肿瘤切除术后创面修复的首选方法。     

隆突性皮肤纤维肉瘤的广泛切除术

目的 探讨隆突性皮肤纤维肉瘤(dermatofibrosarcoma protuberans,DFSP)经广泛性切除术后的长期临床随访结果,并分析该病经多次手术切除复发后的生物学行为变化.方法 回顾性分析1978年2月至2002年12月收治的109例DFSP患者的临床资料,患者无瘤生存率采用x2检验.结果 所有患者采用广泛性切除术,99例(90.8%)完全切除,7例(6.4%)切缘阳性,另有3例(2.8%)切缘距肿瘤组织＜1 mm.46例原发组中,40例术后直接缝合,6例需游离植皮或转移皮瓣覆盖创面.术后5年无瘤生存率95.7%,10年随访未见远处转移.复发组有43例术后直接缝合,20例需游离植皮或转移皮瓣,5年无瘤生存率为81%,10年随访有4例出现肺转移.两组间5年无瘤生存率比较,P=0.025;10年远处转移率比较,P=0.032,差异均有统计学意义.结论 对于DFSP患者行距肿瘤边缘2.5～3.5 cm的广泛性切除术,可获得较好的局部控制.多次复发的患者,切除术后局部复发和转移率上升.     

头面部皮肤恶性肿瘤手术切除及组织缺损修复探讨

目的:探讨头面部皮肤恶性肿瘤手术切除和组织缺损修复的临床经验。方法:1991年1月～2006年1月共收治56例头面部皮肤恶性肿瘤患者,术后组织缺损根据患者情况分别采用原位缝合12例、皮片移植8例、局部皮瓣25例、邻位皮瓣9例和远位皮瓣2例修复。结果:本组56例,除1例皮瓣远端表皮坏死,经换药治疗伤口II期愈合外,其余皮瓣及植皮均成活,供区均I期愈合。38例患者获随访1～6年,1例复发;复发病例为植皮治疗的鳞状细胞癌患者于术后1年复发,经再次手术扩大切除后采用皮瓣移位修复,随访3年未再复发;随访患者均存活良好,外形及功能满意。结论:头面部皮肤恶性肿瘤早期诊断、彻底切除、及时修复、杜绝复发及取得良好的外观和功能效果是治疗的关键所在。修复方法根据患者具体情况和头面部美学单位或亚单位原理遵循由简至繁的原则,尽可能兼顾缺损区域外形和功能的恢复。     

头面部皮肤恶性肿瘤及癌前病变手术切除和创面修复的方法探讨

目的:探讨头面部皮肤恶性肿瘤及癌前病变手术切除和创面修复的方法。方法:58例头面部恶性肿瘤及癌前病变患者,根据恶性肿瘤手术原则,彻底切除病灶,应用原位缝合9例,游离皮片18例,局部皮瓣31例的方法进行修复。结果:本组58例,除1例皮片移植表皮部分坏死,经换药治疗伤口二期愈合外,其余植皮及皮瓣均一期修复,供区均一期愈合,颜面部外观满意。完成随访的42例中,1例面部鳞癌经局部皮瓣修复术后1年复发,再次扩大切除行皮片移植术后随访3年未见复发,其余41例均未见复发。结论:对于头面部恶性肿瘤及癌前病变应早期诊断,依据恶性肿瘤的治疗原则彻底切除病灶,术中快速冰冻切片可降低复发率,修复缺损应最大程度兼顾缺损区域功能和外形。     

皮肤恶性黑色素瘤手术结合大剂量罗扰素治疗的疗效分析

目的探讨皮肤恶性黑色素瘤手术结合大剂量罗扰素治疗的疗效。方法1998年1月～2005年12月，收治皮肤恶性黑色素瘤患者33例，男20例，女13例；年龄17～79岁。病程2个月～7年，中位病程3．5年。9例Ⅰ期患者行单纯病灶扩大切除结合中厚植皮（或邻位皮瓣）修复创面，23例Ⅱ期患者行病灶扩大切除及区域淋巴结清扫术（或截肢），1例Ⅲ期患者姑息性病灶切除。所有患者术后均辅以大剂量罗扰素生物治疗。结果9例Ⅰ期患者术后切口愈合好，获随访7个月～8年，无复发。Ⅱ期患者中，2例切口愈合延迟，经换药愈合；1例失访，余22例获随访5个月～7年，其中1例复发，部位于大腿原发灶旁，再次予病灶广泛切除后，大剂量罗扰素治疗。1例Ⅲ期患者治疗1年6个月后因肺部转移并发呼吸衰竭死亡。结论手术结合术后大剂量罗扰素综合治疗恶性黑色素瘤疗效满意。     

Mohs显微外科手术治疗皮肤恶性肿瘤23例临床分析

目的：探讨Mohs显微外科手术治疗皮肤恶性肿瘤临床效果。方法：应用Mohs显微外科手术治疗23例皮肤恶性肿瘤患者,观察术后创面愈合、转移及复发情况。结果：23例患者中,切口Ⅰ期愈合22例,Ⅱ期瘢痕愈合1例,其中采用局部转移皮瓣者4例,游离皮片移植者12例,其余患者采用直接缝合。术后随访3～24个月肿瘤无复发、转移。结论：Mohs显微外科手术治疗皮肤恶性肿瘤具有损伤小、美容效果好、复发率低和安全性好的优点。     

Fibrosarcomatous change in dermatofibrosarcoma protuberans

This report describes six patients with dermatofibrosarcoma protuberans (DFSP) that contained fibrosarcomatous areas (FS). The clinical signs and symptoms, ages of the patients, and anatomic distribution of the tumors were similar to those of uncomplicated DFSP. FS was concentrated in the subcutis in each case and comprised more than 50% of the tumor in four cases. The characteristic storiform cellular arrangement of DFSP was replaced by long, gently sweeping fascicles of spindle cells that intersected at various angles, forming the so-called herringbone pattern. Trapped fat cells, characteristic of DFSP when it infiltrates subcutaneous tissue, were absent in five of the six FS and only focally present in one. Two FS were grade 1; their cytologic features were similar to those of DFSP. Four FS were grade 2 and had cytologic atypia exceeding that of DFSP. There was a statistical difference between the mitotic rates of DFSP and FS. Five patients were alive and well at the time of last follow-up (median, 2 years), and one patient had an unexcised recurrence when last examined. Six similar cases from the literature are reviewed; in one of them, the FS metastasized.     

隆凸性皮肤纤维肉瘤的诊断和治疗

目的 探讨隆凸性皮肤纤维肉瘤（DFSP）的诊断和治疗方法。方法 分析第二军医大学长海医院收治的DFSP病人11例,均由手术后病理确诊。其中DFSP纤维肉瘤型（DFSP-FS）4例。肿瘤位于躯干部9例,位于四肢2例。2例行局部常规切除,其余9例均行扩大切除术。3例在术后行放射治疗,平均剂量55Gy（50—65Gy）。结果 切除11例标本,CD34阳性10例,阴性1例。术后随访1—10年（平均4．3年）,失访1例。复发6例,平均复发时间2、6年（10个月至5年）。11例均未见有远处转移,无死亡。结论 DFSP在临床上易与其他软组织肿瘤相混淆。诊断主要依据病理。治疗DFSP最主要的方法是扩大的手术切除,切缘阳性或肿块太靠近切缘的辅以放疗。单独使用放疗可以作为偶见的无法切除肿块的治疗方式。     

Sarcomas arising in dermatofibrosarcoma protuberans: a reappraisal of biologic behavior in eighteen cases treated by wide local excision with extended clinical follow up

There is a prevailing view that sarcomas arising in dermatofibrosarcoma protuberans (DFSP) have a higher risk of metastasis than ordinary DFSP, but these data are based on cases with variable and often suboptimal treatment. There has not been a large study of sarcomas arising in DFSP in which all cases were treated by wide local excision, thereby arguably altering outcome. Clinicopathologic features of 18 cases of sarcomas arising in DFSP treated by wide local excision and having follow up of at least 5 years were analyzed. An estimate of the proportion of sarcoma and DFSP was made. The number of mitotic figures and degree of CD34 immunoreactivity were assessed in each case. The cohort included 13 females and 5 males (age, 23-87 yrs; median, 47 yrs). The tumors involved the trunk (7), scalp (4), extremities (4), and inguinal region (3), and ranged from 1.5 to 7 cm (median, 4 cm). Sarcoma occurred de novo in 15 cases and in a recurrence in three. Sarcomas resembled fibrosarcoma (17) or malignant fibrous histiocytoma (1) and occupied between 20% and 80% of the tumor (median, 60%). Mitotic activity ranged from 2 to 16 per 10 high-power field (HPF; median 7 per 10 HPF) in the sarcomatous component and 0 to 3 per 10 HPF (median, 1 per 10 HPF) in the DFSP component. All tumors expressed CD34 in the DFSP component but only nine (50%) in the sarcomatous component. All patients were treated by wide local excision with negative margins; three additionally received radiation. Four patients (22%) developed recurrences, but none developed metastasis during the follow-up period of 62 months to 17 years (median, 81.5 mos). In contrast to earlier studies, we demonstrate that patients with sarcomas arising in DFSP do not have an increased risk of distant metastasis within a 5-year follow-up period, provided they are treated by wide local excision with negative margins. This probably reflects the fact that wide local excision results in eradication of local tumor, thereby eliminating the source for subsequent dissemination. However, we cannot completely exclude the possibility that tumors in which clear margins are achieved represent a less aggressive subset, as has been suggested for high-grade extremity sarcomas. Previous studies showing increased metastasis for sarcomas arising in DFSP should be re-evaluated to determine if, with treatment stratification, metastatic rate varies.     

Dermatofibrosarcoma protuberans. A clinicopathologic review with emphasis on fibrosarcomatous areas.

We reviewed 75 cases of dermatofibrosarcoma protuberans (DFSP) from the University of Texas M.D. Anderson Cancer Center. All accessions were examined for areas of giant cell fibroblastoma (GCF), but none was found. The 30 cases having a minimum of 5 years follow-up were studied in more detail. The histologic findings were typical of DFSP in 24 cases, whereas in six cases discrete areas with a fascicular or "herringbone" growth pattern, considered to represent fibrosarcomatous change (DFSP-FS), were evident. The mitotic rate was usually but not always higher in fibrosarcomatous areas, and occasional examples of typical DFSP demonstrated relatively numerous mitotic figures (up to 35 per 10 high-power fields). Other histologic findings of interest were the presence of melanin in two cases of DFSP and the focal presence of a distinctive type of multinucleated giant cell similar to those seen in GCF in six cases. Patients with DFSP-FS differed from those with DFSP in that they had a higher median age (56 years vs. 37 years). Tumor location was similar in both groups, with the trunk being the most common site. No significant difference in either the rate of local recurrence or the interval until recurrence between DFSP and DFSP-FS was evident; the only factor strongly related to local recurrence was adequacy of surgical margins. However, the only two patients who died of tumor, including the sole patient with distant metastasis, had DFSP-FS. We conclude that DFSP-FS deserves recognition as a variant of DFSP.     

Myxoid dermatofibrosarcoma protuberans: a rare variant analyzed in a series of 23 cases

The myxoid variant of dermatofibrosarcoma protuberans (DFSPs) is uncommon. It often presents a diagnostic challenge and is important to recognize to prevent both undertreatment and overtreatment. To better characterize this unusual variant of DFSP, 23 myxoid DFSPs (DFSP with greater than 50% myxoid stroma) were retrieved from the authors' consult files. 13 patients were male and 10 were female (median age 40 years; range 9 months to 72 years of age). Tumor size ranged from 1.5 to 11 cm (median 2.8 cm). The most frequent sites were the extremities (9) and head and neck (7), followed by the trunk (4) and anogenital region (3). Grossly, the tumors were white/tan/gray to yellow, firm to gelatinous soft tissue masses. Histologically, tumor stroma ranged from 50 to 100% myxoid (median 80%). The majority of cases displayed an infiltrative sheet-like proliferation of bland spindle cells with palely eosinophilic cytoplasm and stellate nuclei without pleomorphism. The stroma was myxoid with prominent thin-walled vessels. All cases displayed honeycomb infiltration of fat and 16 cases showed cellular areas of more typical DFSP. Four tumors contained pigmented dendritic cells (Bednar variant), 1 showed areas of giant cell fibroblastoma and 1 showed progression to fibrosarcomatous DFSP. Mitoses ranged from 0 to 5 per 10 high power fields. 95% of cases (21 out of 22) were positive for CD34 and all cases were negative for S100 and muscle markers. Clinical follow-up in 8 cases, ranging from 3-21 years, (median follow-up 6 years), revealed local recurrence in 2 cases and no evidence of metastasis. All patients were free of disease following wide excision or excision followed by radiotherapy. In summary, these low-grade lesions are clinically similar to typical DFSP, but their unusual morphology is easily confused with a variety of other tumor types.     

Dermatofibrosarcoma protuberans—a review of 10-year experience on wide local excision

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous sarcoma of low to intermediate grade. Correct diagnosis is very often difficult to make on initial presentation. It is a locally destructive tumour which seldom metastasizes. Excision with an adequate margin is the recommended treatment. However, local recurrence is not uncommon with ranges from 4% to 21% in the literature. Medical records of all patients suffering from DFSP who received operation in our centre were reviewed. The age, gender, location of tumour and method of wound closure were described. Factors that may contribute to tumour recurrence were analysed. Between January 1997 and December 2007, 32 patients (20 men) with DFSP, age ranging between 15 and 78 years, were treated. The lesions (22, 69%) located on the trunk and the lesions (five, 15.5%) located on the extremities were resected with a 3-cm margin, while those located in the head and neck region (5, 15.5%) were excised with a 1.5-cm margin. Intra-operative frozen section was performed in all cases. Final histological examination showed 30 cases of classic DFSP and two cases of DFSP with fibrosarcomatous transformation (FS-DFSP). The positive margin rate was 3.2%. In all cases, tumour resection and reconstruction were performed in a single-stage operation. Adjuvant therapy was given to two cases of FS-DFSP and one case of involved resection margin. With a mean follow-up of 51 months, there was no local recurrence in the classic DFSP group, while the two patients with FS-DFSP developed local recurrence at post-operative 4 and 10 months, respectively. We echo the literature that wide local excision with clear margins is the recommended treatment for the classic DFSP. The achievement of low positive margin rate is crucial for a single-stage operation and to minimise the use of adjuvant therapy.     

隆突性皮肤纤维肉瘤诊断与治疗

目的：探讨隆突性皮肤纤维肉瘤（DFSP）的诊断和治疗方法。方法：对28例经病理证实不同部位隆突性皮肤纤维肉瘤患者的诊治情况进行回顾性分析。躯干部16例（57％）,四肢部8例（28．5％）,头颈部4例（14．2）。5例行局部切除术,23例扩大切除术＋植皮或皮瓣转移修复术。16例在术后行放射治疗,平均照射剂量60Gy（50～70Gy）。结果：切除28例标本,CD34阳性26例,阴性2例。术后随访1～5年（平均2．3年）,失访2例。复发9例,平均复发时间2．6年（8个月～5年）。28例均未见有远处转移,无死亡。结论：隆突性皮肤纤维肉瘤是一种低度恶性肿瘤,行扩大切除术＋辅助放疗是治疗隆突性皮肤纤维肉瘤的主要治疗方法,手术范围大小及术后辅助放疗与否是影响隆突性皮肤纤维肉瘤的独立预后因素,可有效提高患者生存率及生存质量。     

The prognostic significance of fibrosarcomatous transformation in dermatofibrosarcoma protuberans

Dermatofibrosarcoma protuberans (DFSP) is a superficial tumor characterized by high rates of local recurrence and a small risk of metastasis. Fibrosarcomatous (FS) areas rarely arise in DFSP, and considerable controversy exists as to whether these tumors have a higher risk of metastasis than the typical DFSP. The aim of this study was to reappraise the prognostic significance of FS changes in DFSP by analyzing 41 patients from the consultation files of our institution. The study included 23 females and 18 males, with a median age of 48 years (range, 16-100 years). Eighteen lesions were located on the trunk, 16 on the extremities, and 7 on the head/neck region. All tumors were treated with local excision, and the surgical margins were considered positive for tumor in 22 of 39 cases (56%). Fibrosarcomas arose de novo in 38 cases and as a recurrence in 3 cases. All tumors involved the dermis and subcutis, and the FS component comprised 5% to 95% of the tumor area (median, 60%). Mitotic rates of the FS component (median, 20 mitoses/10 high-power fields [HPFs]; range, 5-48/10 HPFs) were considerably higher than those of the neighboring DFSP component (0-2 mitoses/10 HPFs). Immunohistochemical analyses showed that CD34 expression was stronger and more extensive in the DFSP component (97% positive; median intensity, 3+) than in the FS component (81% positive; median intensity, 2+). The MIB-1 labeling index was higher in the FS areas (median, 20%; range, 5%-45%) than in the DFSP areas (<3%). Expression of p53 was present in 92% of the FS areas and in only 3% of adjacent DFSP areas. Follow-up data revealed that 8 patients had local recurrences, 4 patients (10%) had metastases, and 2 patients died of disease. None of the variables evaluated, including margin status, FS proportion, and mitotic count, correlated with disease progression. We demonstrate that FS change in DFSP is a form of tumor progression that carries an increased risk of metastasis over classic DFSP and is associated with gains of p53 mutations and increased proliferative activity.     

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目的 总结转化型隆凸性皮肤纤维肉瘤(DFSP)的临床病理特征,探讨规范化的手术方法和综合治疗途径.方法 对复旦大学上海医学院附属肿瘤医院1985年1月至2006年12月收治的34例转化型DFSP病例,进行临床和病理资料的回顾性分析.结果 34例转化型DESP中,伴有纤维内瘤样转化者(DFSP-FS)32例,伴有恶性纤维组织细胞瘤样转化者(DFSP-MFH)2例,占同期收治手术治疗的260例DFSP的13.1%.经中位随访49个月后,发现其广泛切除手术后局部复发率较传统型DFSP的复发率明显增高(P＜0.0001),且复发灶较 大(P=0.009),复发时间较短(P=0.012),淋巴结和血道等远处转移的发生率高(P＜0.0001),5年和10年存活率明显比传统型DFSP差(P＜0.0001).结论 转化型DFSP的恶性程度较高,预后较差,临床医师必须引起重视并采用更积极的治疗方案.及时和规范化的广泛切除手术非常重要.术后辅助放疗等综合治疗的应用也常需考虑.