Cytology of secondary vulvar Paget's disease of urothelial origin: a case report

BACKGROUND: Primary cutaneous Paget's disease of the vulva is an intraepithelial adenocarcinoma most likely arising from a cutaneous stem cell with sweat gland epithelial differentiation or can be of sweat gland origin. Primary vulvar Paget's disease, however, can be mimicked by an internal noncutaneous neoplasm htat has extended to secondarily involve the vulva. Most commonly, this is due to an anal or rectal adenocarcinoma or a urothelial carcinoma. These malignancies may be detected in a vaginal or vulvar cytologic smear. CASE: An 81-year-old woman with a past history of urothelial carcinoma in situ of the bladder presented severalyears subsequent to treatment for bladder cancer with extensive vulvar and vaginal disease, clinically interpreted as primary vulvar Paget's disease involving the vagina. Vaginal cytology showed a high grade malignancy. The patient subsequently underwent radical (total deep) vulvectomy and vaginal excision. Subsequent investigation of her bladder showed recurrent urothelial carcinoma in situ with extensive spread to the vagina and vulva, simulating primary cutaneous vulvar Paget's disease. CONCLUSION: It is important to recognize secondary vulvar Paget's disease, although uncommon, because of the difference in therapy for primary and secondary vulvar Paget's disease. Certain cytologic characteristics in a vaginal or vulvar smear in a patient with suspected vulvar Paget's disease may aid in distinguishing them.     

Extramammary Paget's disease

Extramammary Paget's disease is an in situ skin and mucosal carcinoma frequently associated with and probably arising in a subjacent or regionally proximate carcinoma. Microscopic spread of tumor cells almost always extends beyond clinically apparent disease. Surgical treatment requires carefully planned, systematic excision under precise histologic control. An ideal treatment method remains to be developed. Inadequate excision usually results in recurrences that can be successfully treated by reexcision. Associated invasive carcinomas occur frequently, and mortality is high in these patients.     

Prevention of an additional surgery for regional lymphadenectomy in melanoma: rapid intraoperative immunostaining of sentinel lymph node imprint smears

Background

Breast spindle cell tumours (BSCTs), although rare, represent a heterogeneous group with different treatment modalities. This work was undertaken to evaluate the utility of fine needle aspiration cytology (FNAC), histopathology and immunohistochemistry (IHC) in differentiating BSCTs.

Methods

FNAC of eight breast masses diagnosed cytologically as BSCTs was followed by wide excision biopsy. IHC using a panel of antibodies against vimentin, pan-cytokeratin, s100, desmin, smooth muscle actin, CD34, and CD10 was evaluated to define their nature.

Results

FNAC defined the tumors as benign (n = 4), suspicious (n = 2) and malignant (n = 3), based on the cytopathological criteria of malignancy. Following wide excision biopsy, the tumors were reclassified into benign (n = 5) and malignant (n = 3). In the benign group, the diagnosis was raised histologically and confirmed by IHC for 3 cases (one spindle cell lipoma, one myofibroblastoma and one leiomyoma). For the remaining two cases, the diagnosis was set up after IHC (one fibromatosis and one spindle cell variant of adenomyoepithelioma). In the malignant group, a leiomyosarcoma was diagnosed histologically, while IHC was crucial to set up the diagnosis of one case of spindle cell carcinoma and one malignant myoepithelioma.

Conclusion

FNAC in BSCTs is an insufficient tool and should be followed by wide excision biopsy. The latter technique differentiate benign from malignant BSCTs and is able in 50% of the cases to set up the definite diagnosis. IHC is of value to define the nature of different benign lesions and is mandatory in the malignant ones for optimal treatment. Awareness of the different types of BSCTs prevents unnecessary extensive therapeutic regimes.     

Limb salvage for soft-tissue malignancies of the foot: an evaluation of free-tissue transfer.

Free flaps may safely allow meaningful ambulation, durable limb preservation, and better quality of life in patients undergoing resections of soft-tissue cancers of the foot. To prove this, the records of a series of patients at The University of Texas M. D. Anderson Cancer Center (n = 67) who underwent limb salvage following tumor-related resection (n = 71 procedures) from 1989 to 1999 were retrospectively reviewed. Eighteen patients who were not candidates for local flaps or skin grafts received a total of 20 free flaps to preserve their limbs. Most defects (mean size, 78 cm2; range, 20 to 150 cm2) were on a weight-bearing surface of the foot (nine on a weight-bearing heel, three on a plantar foot); the remainder were on a non-weight-bearing surface (six on dorsum, two on a non-weight-bearing heel). Melanoma was diagnosed in nine cases (50 percent); soft-tissue sarcoma, in seven (39 percent); and squamous cell carcinoma, in two (11 percent). Fasciocutaneous and skin-grafted muscle flaps were used on both weight-bearing and non-weight-bearing surfaces. Free-tissue transfer was successful in 17 of 20 cases (85 percent); the three flap losses occurred in two patients. Minor complications (i.e., small hematoma, partial skin graft loss, and delayed wound healing) occurred in five patients. In all cases of successful free-tissue transfer, patients began partial weight bearing at a mean of 7.4 weeks (range, 2 to 12 weeks), and all ultimately achieved full weight bearing. Sixty-seven percent still required special footwear. In one patient, an ulceration on the weight-bearing portion of the flap resolved after a footwear adjustment. Only one patient was lost to follow-up (mean, 23 months). In the 17 remaining patients, limb salvage succeeded in 15 (88 percent). Of these, nine (60 percent) were alive without evidence of disease, three (20 percent) were alive with disease, and three (20 percent) had died of disease. Local recurrence developed in two patients but was successfully treated by excision and closure. No late amputations were required for local control. Thus, it seems that free flaps help facilitate limb salvage and that they may preserve meaningful limb function in patients who undergo resection of soft-tissue malignancies of the foot.     

The usefulness of a panel of immunostains in the diagnosis and differentiation of metastatic malignancies in pericardial effusions

Pericardial effusions are not uncommon in patients with an advanced malignancy Rarely malignancies may present initially with a pericardial effusion. Cytological examination of pericardial fluid may be valuable in differentiation of these cases. However, a metastatic tumour in serous effusion may not always show the functional differentiation of the primary tumour. In such a situation, although a wide range of special studies have been suggested for the diagnosis of malignancy we have found the use of a panel of a few common immunostains to be useful in confirming or suggesting the site of a primary tumour. The material for this study consisted of 76 pericardial fluids obtained between January 1991 and October 1998 from 46 males (mean age 59 years) and 30 females (mean age 52 years). Metastatic malignancy was diagnosed in 22 of the 76 patients and in 7/22 cases pericardial effusions were the initial presentation. The subsequent follow-up in the seven cases revealed adenocarcinoma of lung (n = 2), small cell anaplastic carcinoma of lung (n = 1), squamous cell carcinoma lung (n = 1), melanoma leg (n = 1), non-Hodgkin's lymphoma retroperitoneal lymph nodes (n = 1) and carcinoma of the breast (n = 1). Of the remaining 15 cases with a known history of malignancy, eight had cancers (three adeno; two small cell; one poorly differentiated, and two squamous cell types) of the lung; breast (n = 3); colon (n = 1); melanoma (n = 2) and non Hodgkin's lymphoma (n = 1). Immunostains which were useful in the diagnosis were EMA, CEA, cytokeratin, B72.3, HMB45, vimentin, S100, LCA, L26 and kappa and lambda light chains.     

Recurrence following treatment of ductal carcinoma in situ with skin-sparing mastectomy and immediate breast reconstruction

Skin-sparing mastectomy with immediate breast reconstruction can provide an excellent cosmetic result. Despite its increasing popularity, few studies have assessed the risk of recurrence when the procedure is used for the treatment of ductal carcinoma in situ. To evaluate the oncologic safety of skin-sparing mastectomy used for the treatment of ductal carcinoma in situ, the recurrence rate was analyzed. Patients with ductal carcinoma in situ or invasive carcinoma or both who underwent skin-sparing mastectomy with immediate breast reconstruction between 1985 and 1994 and had a follow-up period of at least 6 years were included in this retrospective analysis. The recurrence rates were determined for invasive carcinoma (with or without foci of ductal carcinoma in situ) and ductal carcinoma in situ alone. A total of 221 patients were included, 177 patients with invasive carcinoma and 44 patients with ductal carcinoma in situ alone. The immediate breast reconstructions were performed with transverse rectus abdominis muscle (TRAM) flaps in 62 percent of patients, implants in 34 percent of patients, and latissimus dorsi myocutaneous flaps (with or without implants) in 4 percent of patients. The local recurrence rate was zero of 44 for patients with ductal carcinoma in situ and 5.6 percent (10 of 177) for patients with invasive carcinoma during a mean follow-up period of 9.8 years. There was a 6.8 percent (12 of 177) metastatic recurrence rate in the invasive carcinoma group. All recurrences were invasive ductal carcinoma. Of the patients with ductal carcinoma in situ alone, none developed metastatic disease. The combined metastatic and local recurrence rates for the invasive carcinoma group (n = 177) with each type of reconstruction were 13 percent (14 of 110), 12 percent (seven of 60), and 14 percent (one of seven) for TRAM flaps, implants, and latissimus dorsi flaps, respectively. The risk of recurrence following skin-sparing mastectomy and immediate breast reconstruction for ductal carcinoma in situ is low during this follow-up period. Therefore, skin-sparing mastectomy with immediate breast reconstruction seems to be a safe oncologic treatment option for ductal carcinoma in situ; however, a longer follow-up period is important to determine the long-term risk of recurrence.     

Reconstruction of the internal nasal valve with a splay conchal graft

The internal nasal valve is the narrowest point in the nasal airway and thus is the controlling point that regulates inspiration flow. The cross-sectional area of the internal nasal valve is approximately 40 to 55 mm, and 40 to 50 percent of inspiratory resistance is attributable to internal nasal valve function. Collapse of one or both internal nasal valves can be a consequence of previous surgery, trauma, aging, or primary weakness of the upper lateral cartilage. In this study, autologous conchal cartilage was used as a splay graft for opening and reconstructing the internal nasal valve. Over 3.5 years, 31 patients (18 female patients and 13 male patients) were operated on using the splay graft. Inclusion criteria were positive Cottle sign and modified Cottle sign. Cause of collapse was previous surgery in 12 patients (38.7 percent), primary weakness in 10 patients (32.3 percent), and nasal trauma in nine patients (29 percent). After 10 to 42 months of follow-up, 80.6 percent of patients had good to excellent (stable) subjective respiratory function. There was no major morbidity or complication after surgery. Six patients complained of broadening in the middle nasal vault.     

Presuturing--a new technique for closing large skin defects: clinical and experimental studies

We have developed a new technique termed presuturing for aiding in the closure of large skin defects which may have otherwise required a skin graft or flap. This technique is based on biomechanical properties of skin (creep, stress relaxation) which allow skin to stretch beyond its inherent extensibility. Presuturing is performed under local anesthesia and consists of plicating intact skin over the area of planned excision the night prior to operation. Experimental studies in a pig model showed the decrease in force required to close a standard-sized wound to be 40.1 percent less than control (p less than 0.001). Fourteen patients who underwent wide excision of skin lesions had their wounds presutured. All but one wound could be closed primarily without undermining. Presuturing seems to be an easy and clinically useful technique in aiding the primary closure of large defects.     

Periorbital lymphatic malformation: clinical course and management in 42 patients

Lymphatic malformation in the orbital cavity and surrounding region often causes disfigurement and visual problems. To better clarify the evolution and treatment of this condition, the authors studied a retrospective cohort of 42 consecutive patients seen between 1971 and 2003 and analyzed anatomic features, complications, and management. The ratio of female to male patients was 1:1. Most periorbital lymphatic malformations were noted at birth (59 percent), presenting as either unilateral swelling (60 percent) or a periorbital mass (24 percent). Sixty-two percent of lesions were on the left side. The ipsilateral cheek, temple, and forehead also were involved in 57 percent of patients. Twenty-two percent of lesions were intraconal, 30 percent were extraconal, and 48 percent were in both spaces. Forty-five percent of children had an associated cerebral developmental venous anomaly. Periorbital lymphatic malformation caused major morbidity; 52 percent of patients had intralesional bleeding and 26 percent of patients had a history of infection. Other common complications included intermittent swelling (76 percent), blepharoptosis (52 percent), proptosis (45 percent), pain (21 percent), amblyopia (33 percent), chemosis (19 percent), astigmatism (17 percent), and strabismus (7 percent). Ultimately, 40 percent of children had diminished vision and 7 percent became blind in the affected eye. Management of periorbital lymphatic malformation involved an interdisciplinary team that included an interventional radiologist, a craniofacial surgeon, and an ophthalmologist. The two therapeutic strategies were sclerotherapy (40 percent) and resection (57 percent); most patients required several interventions. A coronal approach was used for subtotal excision of fronto-temporal-orbital lymphatic malformation in 13 patients, whereas a tarsal incision was used for lesions isolated to the eyelid (n = 14). Ocular proptosis was temporarily managed by tarsorrhaphy (n = 9), but expansion of the bony orbit was needed to correct persistent proptosis (n = 8). Orbital exenteration was necessary in two patients.     

Three synchronous primary carcinomas in a patient with HNPCC associated with a novel germline mutation in MLH1: Case report

Background

Adnexal masses are not uncommon in patients with breast cancer. Breast cancer and ovarian malignancies are known to be associated. In patients with breast cancer and co-existing pleural effusions, ascites and adnexal masses, the probability of disseminated disease is high. Nevertheless, benign ovarian masses can mimic this clinical picture when they are associated with Meigs' syndrome making the work-up and management of these patients challenging. To our knowledge, there are no similar reports in the literature and therefore we present this case to highlight this entity.

Case presentation

A 56-year old woman presented with a 4 cm, grade 2, invasive ductal carcinoma of her left breast. Pre-treatment staging investigations showed a 13.5 cm mass in her left ovary, a small amount of ascites and a large right pleural effusion. Serum tumour markers showed a raised CA125 supporting the malignant nature of the ovarian mass. The cytology from the pleural effusion was indeterminate but thoracoscopic biopsy failed to show malignancy. The patient was strongly against mastectomy and she was commenced on neo-adjuvant Letrozole 2.5 mg daily with a view to perform breast conserving surgery. After a good response to the hormone manipulation, the patient had breast conserving surgery, axillary sampling and laparoscopic excision of the ovarian mass which was eventually found to be a benign ovarian fibroma.

Conclusion

Despite the high probability of disseminated malignancy when an ovarian mass associated with ascites if found in a patient with a breast cancer and pleural effusion, clinicians should be aware about rare benign syndromes, like Meigs', which may mimic a similar picture and mislead the diagnosis and management plan.     

A prospective study of the accuracy of the surgeon's diagnosis and significance of positive margins in nonmelanoma skin cancers

Even with a precise preoperative diagnosis, complete excision of nonmelanoma skin cancer is not always achieved. The conundrum remains the decision for appropriate secondary treatment. Many surgeons, regardless of the nature of the lesion, consider re-excision to be the only option. In a prior 4-year prospective study that ascertained the accuracy of our clinical diagnosis of skin lesions removed in an office setting, one-fifth were found to be malignant and 98 percent (n = 415) of the lesions were nonmelanoma skin cancer. Unfortunately, 65 (15.7 percent) of the malignant nonmelanoma skin cancer lesions had positive margins. The outcome of our management for these specific lesions was followed prospectively over the 7.5 years of this study to determine whether aggressive surgical intervention was justified in every case.Of 65 patients with lesions, early and complete re-excision of margin-positive nonmelanoma skin cancer was performed for 34 (52.3 percent), with residual tumor found in 11 (32.4 percent), followed by a later recurrence in one (2.9 percent). The remaining 31 patients agreed to semiannual office visits, with one (3.2 percent) recurrence in this group. Thus, the overall rate of recurrence for margin-positive nonmelanoma skin cancer was 3.1 percent, with a mean follow-up of 3.6 years (range, 0 to 7.5 years).There were no recurrences for basal cell carcinoma in either treatment group, suggesting that, at least for "simple" primary lesions without confounding risk factors, there is some validity to a "wait and see" attitude, in which treatment of a potential recurrence would be straightforward. Despite our observed infrequent local recurrences of squamous cell cancers (13.3 percent), the small risk of metastases still suggests the appropriateness of complete surgical eradication for these tumors whenever feasible.     

What is the appropriate management of tissue extravasation by antitumor agents?

Review of 175 patients sustaining extravasation of an antitumor agent showed that most (89 percent) can be managed immediately with intermittent application of ice (15 minutes four times daily for 3 days) and close wound observation. We consider pain, usually associated with varying degrees of skin involvement, to be the only indication for surgery. Such a procedure should consist of wide, three-dimensional excision of all involved tissue, temporary coverage with a biologic dressing, and simultaneous harvesting and storage of a split-thickness skin graft. Once the wound is clean, delayed application of the graft is performed (usually at 2 to 3 days). Not only will this result in immediate pain relief and provide safe wound coverage, but it also will not interrupt the patient's chemotherapy schedule. Most patients were able to be restarted on their chemotherapy shortly after surgery, and none demonstrated a "recall phenomenon."     

Causes of treatment failure and death in carcinoma of the lung

Studies of patterns of failure and causes of death have been undertaken based upon the WHO histopathologic classification. In a randomized trial of thoracic irradiation +/- chemotherapy (hydroxyurea and CCNU), patterns of failure did not seem to differ by cell type; the largest group was "death without progression." A subsequent clinical trial of thoracic irradiation +/- cranial irradiation permitted a more detailed evaluation. Patients with squamous cell carcinoma had a higher rate of local failure than distant metastasis. Those with small cell carcinoma had a lower local failure rate and a high rate of distant spread. Patients with adenocarcinoma and large cell carcinoma had the lowest local failure rate, but had a high rate of distant metastasis. In 300 consecutive patients with autopsies, 75 percent with squamous carcinoma died of complications of the thoracic tumor and only one-quarter had extrathoracic dissemination; 30 percent with small cell carcinoma died of local tumor complications and 70 percent had carcinomatosis; 40 percent of patients with adenocarcinoma and large cell carcinoma died of intrathoracic complications, and 55 percent had distant metastases. Half the patients with small cell carcinoma, large cell carcinoma, and adenocarcinoma had brain metastases at autopsy. Future clinical trials should emphasize better control of the most common sites of failure.     

Chromogranin A, a member of neuroendocrine secretory proteins as a selective marker for laboratory diagnosis of pheochromocytoma

The function of chromogranin A (CGA) is reviewed, and the radioimmunometric determination of plasma CGA was evaluated as a marker of pheochromocytoma using a comparison of pheochromocytoma patients immediately before surgery (group P, n=25, 635+/-451 ng/ml) with other groups of patients, i.e. pheochromocytoma patients approximately 1 year after removal of tumor (group PP, n=13, 69+/-33 ng/ml), medullary thyroid carcinoma patients (group M, n= 22, 106+/-59 ng/ml), congenital adrenal hyperplasy patients (n=33, 65+/-40 ng/ml), and controls (n=31, 66+/-29 ng/ml). A CGA level above cut off value 130 ng/ml was found in 24 of 25 patients in group P, 1 (relapse) of 13 patients in group PP, and 4 of 22 patients in group M. In the group P we found a significant association between the size of the tumors removed and plasma CGA concentrations (p=0.0016), and also a significant (p=0.0016) relationship between plasma CGA concentrations and PASS score rating the malignity of pheochromocytoma. We can conclude that plasma CGA concentration as determined by radioimmunometric assay (which is simple without the necessity of special laboratory equipment) is an effective marker of pheochromocytoma with association to malignity and tumor mass.     

Hook of hamate fractures: critical evaluation of different therapeutic procedures

The treatment of choice in nondisplaced hook of hamate fractures is conservative, with lower arm splinting. Displaced fractures should be treated operatively, whereby excision of the fragment or open reduction and internal fixation are described. A hamulus ossis hamati fracture was verified in 14 patients (mean age, 42 years; range, 21 to 73 years) including 11 men and three women. In six patients (42.9 percent), conservative treatment was initiated immediately after trauma with a lower arm cast for 6 weeks, and eight patients (57.1 percent) were operated on primarily. In five patients (35.7 percent), the fragment was excised, and in three patients (21.4 percent), an open reduction and internal fixation was performed using a screw. In five of six patients treated conservatively, nonunion of the fracture with persisting clinical symptoms developed. All of those patients were treated operatively, whereby three patients underwent excision and two patients underwent screw fixation, which led to elimination of the symptoms. One patient was asymptomatic despite nonunion of the fracture and rejected surgery. All of the eight patients operated on primarily were asymptomatic 3 months after surgery. Therefore, the success rate of primary surgical treatment (eight of eight) was significantly higher compared with conservative treatment(one of six). Finally, all 14 patients were asymptomatic at late postoperative follow-up. The clinical outcome of patients with hook of hamate fractures treated conservatively was disappointing. Therefore, primary surgical treatment is recommended. In our patients, excision and open reduction and internal fixation led to comparable results.     

Excision margins for nonmelanotic skin cancer

Scientific evidence for advisable excision margins for nonmelanotic skin carcinoma is poorly documented. Recommended excision margins vary from 2 to 15 mm. A prospective study was performed on 150 skin lesions excised over a 9-month period in an outpatient facility at the authors' institution. Primary nonmelanotic skin lesions were clinically diagnosed as either basal cell carcinoma (nodular, superficial, infiltrating, or sclerosing) or squamous cell carcinoma (well, moderately, or poorly differentiated). Macroscopic surgical excision margins were individually assessed, measured, and excised. Histopathologic analysis was then independently performed to determine the correct diagnosis and to measure the actual microscopic lateral and deep excision margins.Sixty-one percent of lesions were basal cell carcinoma, 25 percent were squamous cell carcinoma, and 15 percent were benign or premalignant. Diagnostic accuracy was 81 percent for basal cell and 59 percent for squamous cell carcinoma. The average diameter of the basal cell carcinoma was 12.1 mm; 47 percent of these lesions had a diameter of less than 10 mm. The average diameter of the squamous cell carcinoma was 16.9 mm; 26 percent of these lesions had a diameter of less than 10 mm. The mean surgical margin was 4.2 mm (3.2 mm adjusted for shrinkage), whereas the mean microscopic lateral margin was 3.4 mm. Overall, complete excision was achieved for 98 percent of basal cell carcinoma and 100 percent of squamous cell carcinoma. The raw data were analyzed to assess the suitability of 1-, 2-, 3-, or 4-mm surgical excision margins. A 4-mm surgical margin would give a microscopic lateral margin beyond one microscopic high-power field (0.5 mm) in 96 percent of cases of basal cell carcinoma and in 97 percent of cases of squamous cell carcinoma.The authors recommend a 4-mm surgical margin as the optimal treatment for skin lesions clinically diagnosed as basal cell or squamous cell carcinoma that are suitable for excision in an outpatient facility. Well-demarcated lesions, such as a nodular basal cell carcinoma, may be excised with a 3-mm margin.     

Frontonasal tumors: their diagnosis and management.

Fifty-three patients with frontonasal tumors were seen in a 17 -year period. Of these patients, 33 were females (62 percent) and 50 were caucasians (94 percent). The correct diagnosis was made preoperatively in 87 percent of the cases. Eighty-five percent of the patients were children, and most of the lesions (83 percent) were developmental anomalies rather than true neoplasms. The most common lesions were dermoids (17), hemangiomas (16), and encephaloceles (9), but 13 different types of lesions were encountered. The treatment of all is surgical excision, and a cooperative effort by the neurosurgeon and the plastic surgeon is required in some cases.     

后路椎弓根螺钉内固定结合后外侧植骨融合治疗胸腰椎骨折的临床观察

目的：观察后路椎弓根螺钉内固定结合后外侧植骨融合治疗胸腰椎骨折的临床效果及安全性。方法：回顾性分析2010年6月-2012年4月在我院脊柱骨科住院治疗的71例胸腰脊椎骨折患者,所有患者随机被分成2组,治疗组38例接受采用后路椎弓根螺钉内固定结合后外侧植骨融合治疗,对照组33例接受传统椎弓根螺钉内固定。术后对患者椎体前缘高度、脊柱Cobb’s角、腰背痛、神经功能恢复情况、内固定并发症等方面进行手术效果的评价。结果：治疗组术后及随诊患者的椎体前、后缘高度的比值与对照组相比,均有统计学差异（P〈0．05）;治疗组术后及随诊患者的Cobb’s角较对照组明显减小,差异有统计学意义（P〈0．05）,治疗组手术时间与对照组相比差异有统计学意义（P〈0．05）;两组患者医疗费用、神经功能改善筝级相互比较,无统计学意义咿0．05）。结论：后路复位椎弓根螺钉内固定结合后外侧植骨融合治疗胸腰椎骨折的临床疗效确切。     

The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients

Local muscle flaps, pioneered by Ger in the late 1960s, were extensively used for foot and ankle reconstruction until the late 1970s when, with the evolution of microsurgery, microsurgical free flaps became the reconstructive method of choice. To assess whether the current underuse of local muscle flaps in foot and ankle surgery is justified, the authors identified from the Georgetown Limb Salvage Registry all patients who underwent foot and ankle reconstruction with local muscle flaps and microsurgical free flaps from 1990 through 1998. By protocol, flap coverage was the reconstructive choice for defects with exposed tendons, joints, or bone. Local muscle flaps were selected over free flaps if the defect was small (3 x 6 cm or less) and within reach of the local muscle flap. During the same time frame, the authors performed 45 free flaps (96 percent success rate) in the same areas when the defects were too large or out of reach of local muscle flaps. Thirty-two consecutive patients underwent local muscle flap reconstruction for 19 diabetic wounds and 13 traumatic wounds. All wounds, after debridement, had exposed bone at their base, with osteomyelitis being present in 52 percent of the diabetic wounds and in 70 percent of the nondiabetic wounds. Wounds were located in the hindfoot (47 percent), midfoot (44 percent), and ankle (9 percent). Vascular disease was more prevalent in the diabetic group, in which 42 percent of the affected limbs required revascularization procedures before reconstruction (versus 7 percent in the nondiabetic group). Subsequently, 83 total operations were required to heal the wounds, of which 46 percent were limited to debridement only. Thirty-four pedicled muscle flaps were used: 19 abductor digiti minimi (56 percent), nine abductor hallucis (26 percent), three extensor digitorum brevis (9 percent), two flexor digitorum brevis (6 percent), and one flexor digiti minimi (3 percent). An additional skin graft for complete coverage was required in 18 patients (53 percent). One patient died and one flap developed distal necrosis, for a 96 percent success rate. The complication rate was 26 percent and included patient death, dehiscence, and partial flap or split-thickness skin graft loss. Twenty-nine of the 32 wounds healed. One patient died in the postoperative period; in two others the wounds failed to heal and required below-knee amputations, for an overall limb salvage rate of 91 percent. Diabetes did not significantly affect healing and limb salvage rates. Diabetes, however, did affect healing times (twofold increase), length of stay (2.7 times as long), and long-term survival (63 percent survival in diabetic patients versus 100 percent in the trauma group). Local muscle flaps provide a simpler, less expensive, and successful alternative to microsurgical free flaps for foot and ankle defects that have exposed bone (with or without osteomyelitis), tendon, or joint at their base. Diabetes does not appear to adversely affect the effectiveness of these flaps. Local muscle flaps should remain on the forefront of possible reconstructive options when treating small foot and ankle wounds that have exposed bone, tendon, or joint.     

Treatment of Early Breast Cancer: A Report after Ten Years of a Clinical Trial

A controlled clinical trial has been carried out to compare radical mastectomy with wide excision (extended tylectomy) in the treatment of early breast cancer. Only patients aged 50 and over were included and 370 entered the trial during a period of 10 years. Postoperative radiotherapy was given in each case. In patients with clinically involved axillary nodes there was a significantly higher incidence of local and distant recurrence in those having a wide excision, and the survival of these patients was significantly less than those who had a radical mastectomy. In patients with clinically uninvolved nodes, although there was a significantly higher incidence of local recurrence in those having a wide excision, there was no increased incidence of distant recurrence and the survival rate was similar to those having a radical mastectomy.