Versatility of vertical rectus abdominis musculocutaneous flaps

The purpose of the study was to demonstrate a variety of indications for the vertical rectus abdominis musculocutaneous (VRAM) flap with respect to donor-site morbidity and alternative procedures. Fifteen VRAM flaps were performed in 15 patients during a 4-year period. The average age of patients was 58 years (range, 34-76 years). Inferiorly based VRAM flaps were used for defect coverage after tumor resection and for penile reconstruction in 7 cases. Superiorly based VRAM flaps were performed in 7 cases for reconstruction of osteocutaneous defects following sternal osteomyelitis and tumor resection. Arterial and venous "supercharging" was necessary in one case. One free VRAM flap was performed in a patient suffering from an osteocutaneous defect after resection of a malignant melanoma metastasis with infiltration of the brain and skull. The reconstructive goals were achieved in all cases using VRAM flap procedures. No total flap loss occurred. Minor complications as well as abdominal wall bulging and hernias were observed in four cases. The pedicled VRAM flap provides a reliable tool for coverage of large soft-tissue defects of the chest wall, groin, hip, and perineum even in a high-risk population, in which a safe and fast forward flap procedure is the primary reconstructive goal. Arterial and/or venous supercharging may be necessary, particularly in superiorly based VRAM flaps. An inferiorly based VRAM flap is a reliable tool for phalloplasty under special circumstances. The indication for free VRAM flaps is given in rare clinical situations. Stabilization of the donor site using artificial mesh is highly recommended.     

The stentless freestyle bioprosthesis: impact of age over 80 years on quality of life, perioperative, and mid-term outcome

Abstract Background: The steadily increasing life expectancy of the population in the Western World, together with the progress in noninvasive diagnostic methods and operating techniques lead to an increase in aortic valve surgery in elderly people. Aim of the study: Is there an increased risk of adverse perioperative and mid‐term outcome for octogenarians and do they benefit from aortic valve replacement (AVR) with stentless bioprostheses?Methods: Between 1996 and 2002, 503 patients older than 60 years underwent AVR with a stentless Freestyle bioprosthesis. Seventy‐six of them were older than 80 years. The risk of operative mortality, perioperative complications, valve‐related morbidity for octogenarians was determined by multivariate logistic regression. Results: In general, risk‐adjusted analyses did not reveal an increased risk of operative mortality (p = 0.4), postoperative atrial fibrillation (p = 0.2), prolonged ventilation (p = 0.5), prolonged stay in the intensive care unit (p = 0.3), or mid‐term valve‐related morbidity as prosthetic valve endocarditis (p = 0.2), reoperation (p = 0.4), bleeding events (p = 0.1), and stroke (p = 0.8) for octogenarians. Continuously increasing age was an independent risk factor for postoperative neurological complications (OR = 1.8 per 10 years, p = 0.04). Quality of life was equal to or better than the general population of the same age. Median survival time of octogenarians was 5.2 ± 0.5 years. Conclusions: Except for postoperative neurological complications, octogenarians receiving stentless bioprostheses had no increased risk of adverse perioperative and mid‐term outcome in comparison to younger patients. As quality of life and life expectancy after AVR with stentless valves were equal to the general population, AVR with stentless bioprostheses should not be withheld from octogenarians.     

Chemotherapie des Hodentumors

Platinum-based polychemotherapy has increased the cure rate in testicular cancer dramatically: at first, chemotherapy was mainly used in advanced disease. Recently it has also become common in low-stage disease, though other therapeutic options are equivalent. Risk factors might help to find the right decision.The success of treatment in patients with metastatic disease results from the combination of chemotherapy and secondary surgery. High-dose chemotherapy for patients with poor prognosis or recurrent disease is being evaluated in clinical trials. Concerning the success in these stages prognostic factors are of special importance. Patients with advanced-stage nonseminoma need residual tumor resection after chemotherapy if no complete remission could be achieved.The therapist should be aware of the indication for and schedule of chemotherapy, its side effects, and supportive care.     

An algorithm for reconstruction of soft tissue defects of the distal lower leg, ankle and heel

AIM: The purpose of the study was to establish an algorithm for the reconstruction of soft tissue defects of the distal lower leg, ankle and heel. METHOD: 81 patients presenting with soft tissue defects in these regions underwent flap coverage. The average age was 44.1 years. Small defects (up to 4 x 4 cm) were covered by local flaps. The neurovascular sural flap was the predominant flap procedure for medium size defects (up to 10 x 15 cm). Free flaps were used for larger defects or in cases of stenosis or occlusion of the peroneal artery. Femoro-crural bypasses were performed in three cases to improve peripheral arterial perfusion. RESULTS: The reconstructive goals were achieved in 95% of the cases by performing reconstruction according to the established algorithm. Minor complications occurred in 29.6% of the cases. CONCLUSION: The results appear to be very good considering a patient population with complex and predominantly contaminated wounds. A preoperative angiography represents an important part of the algorithm for flap reconstruction to detect abnormal arterial vascular conditions and thus to plan vascular reconstruction prior to or simultaneously with free flap coverage. Additionally, a non-patency of the peroneal artery represents a contraindication for sural flaps.     

An analysis of breast cancer risk in women with single, multiple, and atypical papilloma

Breast papillomas may be single or multiple and associated with atypical ductal or lobular hyperplasias (ADH/ALH). The risk of breast carcinoma development in patients with papillomas, particularly those with multiple or atypical lesions, is incompletely defined. Fibrocystic lesions were histopathologically classified in a benign breast disease cohort of 9155 who underwent biopsy from 1967 to 1991, with papilloma assessment in 9108. Individuals with papillomas (N=480) were classified into 4 groups: single papilloma (SP, N=372), single papilloma with ADH or ALH (SP+A, N=54), multiple (>5) papillomas (MP, N=41), and multiple papillomas with ADH or ALH (MP+A, N=13). Those without papillomas were classified as nonproliferative (NP, N=6053), proliferative without atypia (PDWA, N=2308), and ADH/ALH [atypical hyperplasia (AH), N=267]. The relative risk of cancer development within our cohort was compared to that expected in the general population using standardized incidence ratios. The relative risk of breast cancer development associated with SP [2.04, 95% confidence interval (CI) 1.43-2.81] was greater than NP (1.28, 95% CI 1.16-1.42) but similar to PDWA (1.90, 95% CI 1.66-2.16). The risk associated with SP+A (5.11, 95% CI 2.64-8.92) was highly elevated but not substantively different than atypical hyperplasia (4.17, 95% CI 3.10-5.50). Patients with MP are at increased risk compared with PDWA or SP (3.01, 95% CI 1.10-6.55), particularly those with MP+A (7.01, 95% CI 1.91-17.97). There was a marginal increase in breast cancer risk (16%) among patients with proliferative disease if a papilloma was present, but this did not reach statistical significance (P=0.29). The observed frequency of ipsilateral (vs. contralateral) breast cancer development in papilloma subsets was not significantly different than other patient groups. We conclude that SP imparts a cancer risk similar to conventional proliferative fibrocystic change. The presence of papilloma in, or associated with, atypia does not modify the risk connotation of ADH/ALH overall. MP constitutes a proliferative breast disease subset having unique clinical and biologic behavior.     

A human lymph node in vitro--challenges and progress

Extracorporeal human lymphatic organs are expected to be excellent tools in the study of human molecular and cellular bases of the immunologic balance and tissue harmony. A rational approach and process to design a device and a procedure to recreate the human lymph node environment in vitro is described with emphasis on T-cell activation. Based on this approach, a bioreactor and a process supporting self-assembly of human lymphatic tissues due to proper emulation of human architecture and homeostasis could be developed.     

Multifocal urothelial cancers with the mutator phenotype are of monoclonal origin and require panurothelial treatment for tumor clearance

PURPOSE: UC is a disease of the entire urothelium, characterized by multiplicity and multifocality. The clonal relationship among multiple UCs has implications regarding adjuvant chemotherapy. It has been investigated in studies of chromosomal alteration and single gene mutation. However, these genetic changes can occur in unrelated tumors under similar carcinogenic selection pressures. Tumors with high MSI have numerous DNA mutations, of which many provide no selection benefit. While these tumors represent an ideal model for studying UC clonality, their low frequency has prevented their previous investigation. MATERIALS AND METHODS: We investigated 32 upper and lower urinary tract UCs with high MSI and 4 nonUC primary cancers in 9 patients. We used the high frequency and specificity of individual DNA mutations in these tumors (MSI at 17 loci) and the early timing of epigenetic events (methylation of 7 gene promoters) to investigate tumor clonality. RESULTS: Molecular alterations varied among tumors from different primary organs but they appeared related in the UCs of all 9 patients. While 7 patients had a high degree of concordance among UCs, in 2 the UCs shared only a few similar alterations. Genetic and epigenetic abnormalities were frequently found in normal urothelial samples. CONCLUSIONS: Multiple UCs in each patient appeared to arise from a single clone. The molecular order of tumor development varied from the timing of clinical presentation and suggested that residual malignant cells persist in the urinary tract despite apparent curative surgery. These cells lead to subsequent tumor relapse and new methods are required to detect and eradicate them.