Clinicopathological characteristics of melanomas of the hand.

A 25-year clinicopathological review of 19 patients with malignant melanoma of the hand is reported. There were 11 women (median age 73 years) and eight men (median age 70 years). Eleven tumours were subungual, six on the dorsum of the hand, and two had a palmar location. Seven tumours were acral lentiginous melanomas, six were superficial spreading melanomas, and five were of the nodular subtype. Eleven patients presented with localized disease (clinical stage I), four with local spread (clinical stage II), and four with regional lymph node metastases (clinical stage III). Nine of the patients have died of the disease, with a median survival time of 30 months (range, 10-84 months). The subungual melanomas were thicker and the patients were older at presentation compared with the non-subungual sites. Review of our patients emphasized the need for early diagnosis.     

The genetics of malignant melanomas.

A review of the hereditary aspects of the malignant melanomas showed causal heterogeneity and similar pathogenesis based on the dysregulation of the paracrine/autocrine growth mechanisms. The genetically different malignant melanomas have a range of recurrence risks from 1% for the nonfamilial, solitary, malignant melanoma to a risk exceeding 70% for the syndromic melanomas of neurocutaneous melanosis and the nine types of xeroderma pigmentosum. A recurrence risk of 6% is relevant to the members of dysplastic nevus syndrome families without malignant melanomas and the risk increases in excess of 50% for the individuals of families with dysplastic nevi and more than one malignant melanoma.     

Lymphatic mapping for melanomas of the upper extremity.

Over a period of 4 years, 127 consecutive patients with upper extremity melanomas were identified from a prospectively accrued database. A protocol consisting of preoperative lymphoscintigraphy and intraoperative lymphatic mapping and with a vital blue dye and radiocolloid was used; the protocol had a 98% success rate of identifying the sentinel lymph node (SLN). Preoperative lymphoscintigraphy identified unpredictable cutaneous lymphatic flow in 15 (12%) of the patients. These discordant areas would not have been included in classic regional node dissection and possible sites of metastatic disease would not have been identified. Metastatic disease was identified within the SLNs in 12 (9%) of the patients. Of the 12 patients with a positive SLN, 2 (17%) were found on complete node dissection to have metastatic disease in higher nodes in the regional basin. The SLN was the only site of disease in 10 of these 12 patients with documented metastases in the regional basin. Patients with a negative SLN biopsy can be spared the morbidity and expense of a complete lymph node dissection.     

Hemangioma of the hand.

The authors describe the anatomopathological and clinical findings of 24 cases of benign hemangioma of the hand. The instrumental methods used to diagnose hemangioma are discussed, and MRI imaging is given particular importance in the preoperative evaluation of the site, size, extent, and relationship with the surrounding tissues and any multiple locations of the vascular tumor. This evaluation is essential to perform a wide resection of the tumor, which is the only means of avoiding recurrence. After an average follow-up of 33 months (14-54) recurrence was observed in 7% of the cases treated.     

Sacrifice of the unsatisfactory hand.

A hand which compares unfavorably with a prosthesis in function, comfort, and appearance may be better amputated. This decision must be made conjointly by the surgeon and the patient. Contributory factors are severe tissue loss, pain, appearance, infection, functional requirements, sexual reasons, psychological makeup of the patient, economics, safety, the time elapsed since injury, the patient's body image and his desires, and the surgeon's opinion. Fifteen patients elected hand amputation for various combinations of these factors. Eleven were fitted with a prosthesis at the time of operation and three within 3 weeks. All patients expressed satisfaction with their decision and 12 were successful users of the prosthesis.     

Compartmental infections of the hand.

Suppurative conditions of the hand-wrist compartments result in a "vicious circle" of infection and increase in compartmental pressure that reduces perfusion of soft tissues and facilitates spreading of the infection. We have assessed the outcome of such infections in relation to the infecting pathogen, delay in diagnosis, and method of treatment. Fifty-nine patients were treated with drainage, irrigation, and antibiotics and followed up for 6-58 (median 18) months. Staphylococcus aureus was detected in 29 of 39 cultures (74%) that grew pathogens. At the latest follow-up results were excellent in 49 cases. Sixteen required reoperation or readmission. There was a significant association between final range of movement (ROM) and extent of infection (p=0.01). The type of pathogen was also significantly associated with a worse outcome (p=0.03 for ROM, p=0.04 for DASH). These infections have poor results when treatment is delayed or inadequate, as a result of the extended infection, inadequate drainage or inappropriate antibiotic treatment of certain types of bacteria.     

Reconstruction of the mutilated hand.

The experience gained from the reconstruction of sixty-seven severely mutilated hands is applied to the analysis of the procedures of choice in three groups of injury.     

Chondroid syringoma of the hand.

We describe a patient with a benign chondroid syringoma of the little finger of the right hand. She was a 56-year-old pianist who had had the swelling for 25 years without it causing any symptoms. The tumour was excised with an excellent result. Although chondroid syringoma is rare, it should be included in the differential diagnosis of the soft tumours of the hand.     

Metastatic malignancy of the hand.

Metastatic malignancies of the hand are infrequent and seldom initially diagnosed and often taken for infections. They usually occur at the late stage of metastatic generalization and indicate an ominous prognosis and justify surgical amputation. A case of metastasis to the distal phalanx of the left ring finger of a woman who had undergone radical mastectomy for breast cystosarcoma phylloides is reported. The evolution of this lesion, initially taken for a whitlow, lasted 45 days and eventually was treated by amputation. A review of literature confirms the rarity of the lesion, and reveals the pathological, clinical and radiographic characteristics.     

The ageing hand. A study to evaluate the chronological ageing process of the hand.

The rejuvenation of the hand has received increased attention recently. Although many different methods have been advocated, only little is known about the chronological ageing process of the Caucasian hand. A qualitative study was performed to evaluate ageing changes. One hundred and forty-three volunteers were enrolled. Standardised pictures of both hands were obtained and evaluated by one observer in regard to wrinkling pattern, visibility of subcutaneous structures and trophic changes. We found that both males and females showed a distinct progression of the wrinkling pattern. Dorsal veins and age spots increased with age whereas the wrinkle-wrinkle distance decreased. Contrary to common belief, significant joint thickening of the proximal interphalangeal (PIP) joint could not be confirmed. Hand ageing is a three-dimensional process that involves osseous and subcutaneous structures as well as the skin. Despite the increased interest in rejuvenation, a baseline study describing the chronological changes with ageing in the hand is still missing. Our findings will help to define the ageing process in Caucasians.     

Penile melanomas

Melanoma of the penis is a rare, very malignant tumor with poor prognosis. At present improvements of therapeutic results can only be achieved by means of early diagnosis, perhaps also by means of radical surgery. Radiation therapy and chemotherapy are used mostly as adjuvant or palliative therapy. Two cases of malignant melanoma of the penis are presented.