Subtotal maxillectomy for melanotic neuroectodermal tumor of infancy.

Melanotic neuroectodermal tumor of infancy is a rare pigmented neoplasm occurring in infants before 1 year of age. It is a rapidly growing tumor that most frequently affects the craniofacial skeleton. Although melanotic neuroectodermal tumor of infancy is benign in the vast majority of cases, inadequate excision, occasional multicentricity, and a small malignant potential result in a fairly high recurrence rate. On the basis of data obtained from the literature and our clinical experience, we advocate an aggressive surgical approach consisting of complete surgical excision when vital structures are not involved. Histopathologic confirmation of complete excision is mandatory to minimize the risk of recurrence and provide the patient with curative treatment and minimal morbidity.     

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.     

Local recurrence of primary non-ampullary adenocarcinoma of duodenum after surgical treatment--a case report and a literature review

Worldwide there is no general attitude on optimal surgical procedure in treatment of primary non-ampullary adenocarcinoma of duodenum, especially for early stage of duodenal cancer. Some authors prefer local excision and segmental resection while others rather perform duodenopancreatic resection, even in the case of early stage of duodenal cancer with aim to avoid tumor recurrence. In this paper we present a rare clinical course of a 60-year-old male patient with an endoscopically and pathohistologically proven early stage duodenal cancer that was treated by wide local excision. Three years after operation, control endoscopy showed "flat" polyp in the duodenum and radical duodenopancreatic resection was performed. Pathohistological examination of resected specimen showed cancer that had spread throughout the duodenal wall with metastases in the regional lymph nodes. According to our findings and literature review we gave some direction concerning the optimal diagnostic and surgical procedure for this rare tumor.     

Treatment of Bowen disease using the ultrasonic surgical aspirator.

In most cases, patients with Bowen disease lesions can be easily treated by surgical excision and direct closure; however, the ultrasonic surgical aspirator, an instrument in common use in many fields, offers a good treatment alternative with few drawbacks for patients with lesions that are large and/or located in joint areas, areas that are hard to heal, or areas that are surgically problematic such as the ears, nose, eyelids, and mucous membranes. The clinical application of the ultrasonic surgical aspirator in the treatment of Bowen disease promises considerable benefit in terms of patient comfort because removal of the lesion is easy, is noninvasive, and does not require hospitalization or result in restricted mobility. All of these factors, although benefiting patients, particularly the elderly, can also substantially lower the cost of treatment.     

Histopathological Changes and Clinical Responses of Buruli Ulcer Plaque Lesions during Chemotherapy: A Role for Surgical Removal of Necrotic Tissue?

Background

Buruli ulcer (BU) caused by Mycobacterium ulcerans is a necrotizing skin disease usually starting with a subcutaneous nodule or plaque, which may ulcerate and progress, if untreated, over months and years. During the currently recommended antibiotic treatment with rifampicin/streptomycin plaque lesions tend to ulcerate, often associated with retarded wound healing and prolonged hospital stays.

Methodology/Principal Findings

Included in this study were twelve laboratory reconfirmed, HIV negative BU patients presenting with plaque lesions at the CDTUB in Allada, Benin. Punch biopsies for histopathological and immunohistochemical analysis were taken before start of treatment and after four to five weeks of treatment. Where excision or wound debridement was clinically indicated, the removed tissue was also analyzed. Based on clinical judgment, nine of the twelve patients enrolled in this study received limited surgical excision seven to 39 days after completion of chemotherapy, followed by skin grafting. Lesions of three patients healed without further intervention. Before treatment, plaque lesions were characterized by a destroyed subcutis with extensive necrosis without major signs of infiltration. After completion of antibiotic treatment partial infiltration of the affected tissue was observed, but large necrotic areas remained unchanged.

Conclusion/Significance

Our histopathological analyses show that ulceration of plaque lesions during antibiotic treatment do not represent a failure to respond to antimycobacterial treatment. Based on our results we suggest formal testing in a controlled clinical trial setting whether limited surgical excision of necrotic tissue favours wound healing and can reduce the duration of hospital stays.     

Surgical treatment of idiopathic megacolon]

The authors discuss own experience in diagnosis and surgical treatment of 32 patients with idiopathic megacolon. Three surgical techniques were compared: 1) partial excision of the colon, 2) nearly complete excision of the colon with cecum-rectal anastomosis, and 3) total colectomy with ileorectal anastomosis. Basing on the authors' own experience and available literature the third approach is recommended as the most appropriate in the treatment of the persistent, chronic constipation accompanying idiopathic megacolon.     

TREATMENT OF MELANOMA—SUCCESS OR FAILURE?

The treatment of melanoma should be by radical surgical excision of the primary lesion and dissection of the regional nodes.Where possible this should be done in anatomic continuity; otherwise in physical discontinuity but at the same time.If maximum salvage is to be achieved the nodal dissection must be effected before there is clinical evidence of involvement by metastasis.Amputation of extremities should be reserved for cases in which there is evident metastasis between the original focus and the regional lymph node areas.     

Treatment of melanoma; success or failure?

The treatment of melanoma should be by radical surgical excision of the primary lesion and dissection of the regional nodes. Where possible this should be done in anatomic continuity; otherwise in physical discontinuity but at the same time. If maximum salvage is to be achieved the nodal dissection must be effected before there is clinical evidence of involvement by metastasis. Amputation of extremities should be reserved for cases in which there is evident metastasis between the original focus and the regional lymph node areas.     

Merkel cell carcinoma: five case reports using sentinel lymph node biopsy and a review of 110 new cases

Merkel cell carcinoma is an uncommon cutaneous tumor that is considered locally aggressive and often spreads regionally through lymphatic channels. Evaluation of surgical treatment methods has been hampered by the low incidence of this tumor. Current standards of treatment include wide surgical excision and regional lymphadenectomy if clinically suspicious nodes are present. However, the development and increasing use of sentinel node imaging and biopsy have expanded the diagnostic options. This article presents information on 110 Merkel cell carcinomas treated in Connecticut between 1990 and 1997. Statistics on gender, age, disease location, treatment, and mortality are reviewed. Using the census data for Connecticut, the annual incidence for this disease was calculated to be 0.42 cases per 100,000 people. A series of five cases treated with wide excision and sentinel lymph node biopsy is also presented.     

Verrucous carcinoma of the skin and its management by Mohs' surgery

Verrucous carcinoma is a low-grade squamous cell cancer that can invade many anatomic sites. Since its clinical appearance is easily confused with several benign conditions, reliable diagnosis is by biopsy and histopathologic examination. The Mohs' histographic surgical technique provides complete surgical excision and a high incidence of cure.     

乳腺癌新辅助化疗疗效评价体系

目前新辅助化疗已广泛应用于乳腺癌的治疗,可降低肿瘤分期,提高手术切除率和增加保乳手术的机会。恰当的新辅助化疗疗效评价不仅可以指导患者治疗方案和预测预后,还可对不同药物的疗效提供可靠的评估。目前新辅助化疗评估主要采用临床检查如触诊、超声、钼靶X线、计算机断层显像、磁共振成像及病理学检查确定肿瘤体积变化,可分为临床评估和病理学评估。两者均有多种体系标准,未形成统一公认的标准。临床试验中采用较多的标准有WHO和RECIST等临床评价标准以及MP标准和JBCS标准等病理学评价标准。本文就乳腺癌新辅助化疗疗效评估体系进行总结。     

Antitumor immunologic reactivity in the relatively early period after cryosurgery: Experimental studies in the rat

An experimental investigation was performed on antitumor immunity in the relatively early postoperative period after cryosurgery, using a metastasizing rat's mammary tumor, MRMT-1. Two weeks after its inoculation, surgical excision of the tumor, cryosurgery, surgical excision plus inoculation with freezing-thawing produced vaccine, or surgical excision plus fasting for 72 hr was performed, and postoperative follow-up was done on incidences of metastases, those of metastatic death, etc. Specific immunologic reactivity was examined in the surgical excision (SE) and cryosurgery (CR) groups.The FTV and fasting groups showed more metastatic deaths as compared with the SE group. The CR and SE groups did not differ significantly from each other in incidences of lung and lymph node metastases.Specific footpad reactivity at 2 and 3 weeks after treatment was lower in the CR group than in the SE group.Winn's neutralization assay showed an inhibition of tumor growth at 1 and 3 week(s) after treatment both in the SE and in the CR groups, the inhibitory effect tending to be lower in the latter.Inactivated serum obtained at 1 week after treatment showed a facilitation of tumor growth in the SE group and a tendency of tumor suppression in the CR group, showing a significant difference between them.A mild reduction in antitumor immunity seen in the relatively early postoperative period following cryosurgery probably was not due to a blocking effect by superfluous antigens. Rather it was considered to be due to activation of suppressor cells, consequent on cryosurgical stress, and/or slow and steady absorption of antigens.     

Review of operative considerations in spinal cord stem cell therapy

Spinal cord injury (SCI) can permanently impair motor and sensory function and has a devastating cost to patients and the United States healthcare system. Stem cell transplantation for treatment of SCI is a new technique aimed at creating biological functional recovery. Operative techniques in stem cell transplantation for SCI are varied. We review various clinical treatment paradigms, surgical techniques and technical considerations important in SCI treatment. The NCBI PubMed database was queried for “SCI” and “stem cell” with a filter placed for “clinical trials”. Thirty-nine articles resulted from the search and 29 were included and evaluated by study authors. A total of 10 articles were excluded (9 not SCI focused or transplantation focused, 1 canine model). Key considerations for stem cell transplantation include method of delivery (intravenous, intrathecal, intramedullary, or excision and engraftment), time course of treatment, number of treatments and time from injury until treatment. There are no phase III clinical trials yet, but decreased time from injury to treatment and a greater number of stem cell injections both seem to increase the chance of functional recovery.     

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.     

Surgical design and algorithm for correction of earlobe ptosis and pseudoptosis deformity

A previously described classification system for earlobe ptosis and criterion for earlobe pseudoptosis deformity was based on height measurements of the two earlobe components: the free caudal segment and the attached cephalic segment. The "ideal" ear lobule free caudal segment was found to be between 1 and 5 mm (grade I ptosis), and the "ideal" attached cephalic segment was 15 mm or less. Earlobe pseudoptosis was defined by an attached cephalic segment measuring greater than 15 mm. Previous studies revealed an association between the elongated free caudal segment and increasing patient age and between the elongated attached cephalic segment and rhytidectomy. Sixteen fresh cadaver earlobes were used to design surgical patterns that would differentially reduce the free caudal segment, the attached cephalic segment, or both. A horizontal, medially based triangular excision pattern was designed. Triangular excisions limited to the attached cephalic segment resulted in 98 +/- 5 percent reduction of excision height from the attached cephalic segment but also resulted in an unexpected 32 +/- 2 percent augmentation of the excision height in the free caudal segment. Triangular excisions limited to the free caudal segment resulted in 88 +/- 4 percent reduction of the excision height from the free caudal segment and negligible reduction of 4 +/- 4 percent of excision height in the cephalic attached segment. An algorithm for correction of earlobe ptosis and pseudoptosis was subsequently derived and implemented in a clinical case. The authors propose that surgical treatment of patients with pseudoptosis be dependent on the ptosis grade. If the ptosis is grade I (1 to 5 mm), then excision of only the attached cephalic segment is recommended. If the ptosis is grade II or higher (more than 5 mm), then a combined attached cephalic and free caudal segment excision is recommended. In cases of isolated ptosis grade II or higher without pseudoptosis, then excision location of only the free caudal segment is recommended. The above simple algorithm and surgical designs will enable plastic surgeons to differentially correct earlobe ptosis and pseudoptosis.     

MEDIASTINAL TUMORS OF THYMIC ORIGIN

Twenty-one cases of mediastinal tumors of thymic origin are presented. Five of these were benign and 16 malignant.Surgical excision is proposed as the treatment of choice for the encapsulated benign tumors or for malignant tumors of limited extent. When surgical excision is not feasible, adequate roentgen therapy amounting to 5,000 to 6,000 r calculated tumor dose may eradicate or control the tumor.No correlation between the histological pattern of the tumor and the survival rate or radiation response could be demonstrated in this small series.     

Entire hemithorax irradiation for Masaoka stage IVa thymomas

Thymomas are rare neoplasms that have an indolent growth with a preferentially intra-thoracic dissemination pattern. Surgery is currently the standard treatment of thymomas; however radiotherapy is often used in an adjuvant setting due to a high sensitivity of these tumors to such treatment. Postoperative entire hemithoracic irradiation has been used in selected Masaoka stage IVa cases after complete surgical excision of metastatic lesions.In the present article, the authors report three cases of Masaoka stage IVa thymoma that underwent entire hemithorax irradiation after surgical excision of metastatic lesions. The first two patients presented as stage IVa thymomas. The third case consisted of a pleural recurrence of a thymoma.Hemithoracic irradiation with low doses has been used by different authors; the available data shows that it is a well-tolerated treatment that could potentially lead to better loco-regional control and increased overall survival.     

Treatment of coronary artery aneurysms by percutaneous sealing with bovine-pericardium-covered stents

The clinical significance of coronary artery aneurysms is briefly discussed. Until recently, surgical excision was the only treatment available. Single-case reports have documented aneurysm exclusion with vein-covered stents using 10 or 11 F. guiding catheters. This paper reports four patients with coronary artery aneurysms which were successfully excluded with the use of a novel pericardium-covered stent which is less invasive and shortens procedure time compared with the use of an autologous vein-grated stent and can be deployed using 8 F. or 9 F. guiding catheters. Short-term (five- to eight-month) clinical follow-up has been event-free in all patients, and in three patients six-month follow-up angiography has shown insignificant luminal loss.     

Succès du repérage isotopique peropératoire dans l’éradication totale de l’ostéome ostéoïde persistant

The osteoid osteoma is a small benign, painful, bony tumour in which the treatment consists of a complete surgical ablation. The cases of recurrence often correspond to an incomplete surgical ablation. We report, in this work, the advantage of isotopic intraoperative marking for an accurate and complete excision of the pathological lesion in a young patient, during his surgical resumption after the short-term failure of the first intervention, which was accomplished without intraoperative location, and completed with a literature review.     

Cutaneous leiomyosarcoma

Cutaneous leiomyosarcoma is a rare soft-tissue sarcoma with negligible metastatic potential, but local recurrence rates after surgical excision have ranged from 14 percent to 42 percent. Unlike other sarcomas, guidelines for the optimal surgical excision margin of cutaneous leiomyosarcoma are not clearly defined in the existing literature. A review of local experience with this condition revealed eight patients over 12 years, none of whom developed local recurrence or distant metastases. This is despite poor prognostic factors in seven patients and excision margins ranging from 1 to 27 mm. These findings are compared with previously published data, and conclusions are drawn based on analysis of the collective results. Complete surgical excision with a narrow margin is recommended, and patients should be observed for a minimum of 5 years after surgery.