Patterns of initial recurrence and prognosis after sentinel lymph node biopsy and selective lymphadenectomy for melanoma

The histologic status of the sentinel lymph node is a highly significant prognostic factor for patients with clinically localized cutaneous melanoma. The patterns of initial treatment failure of patients with positive sentinel lymph node biopsy versus those with negative results have not been well described. The purpose of this study was to determine the relative prognostic importance of sentinel lymph node status and to compare patterns of initial treatment failure and prognosis of node-positive versus node-negative cutaneous melanoma patients staged by sentinel lymph node biopsy and selective lymphadenectomy. The authors reviewed the pertinent demographic and surgical data in a consecutive series of patients with cutaneous melanoma who underwent sentinel lymph node staging of nonpalpable regional nodes. Sentinel lymph node biopsy was performed using a combination of blue dye and radiolocalization. Patients with positive biopsy results underwent selective lymphadenectomy, whereas those with negative results were observed. Site(s) and date(s) of initial recurrence and death were determined, and disease-free and overall survival probabilities were compared between positive and negative groups using the log-rank test and multivariable Cox regression analysis. Between February of 1994 and August of 2000, 408 patients with melanoma underwent sentinel lymph node biopsy to stage 518 regional lymph node basins. Mean Breslow tumor thickness was 2.27 mm (range, 0.2 to 14.0 mm). Eighty-five patients (20.8 percent) had at least one histologically positive sentinel lymph node, and selective lymphadenectomy yielded additional positive lymph nodes in 18 of 84 patients (21.4 percent). Recurrences were noted in 70 patients (17 percent) at a median follow-up period of 31.4 months. Recurrences were more frequent in patients with positive biopsy results (36.5 percent) than in those with negative results (12.1 percent, p < 0.0001). Distant sites of initial recurrence were more likely in the positive group than in the negative group (71 percent versus 49 percent of recurrences, respectively; p = 0.06). The false-negative rate for sentinel lymph node staging was 4.5 percent and overall accuracy was 99 percent compared with clinical follow-up. Disease-free and overall survival correlated significantly with tumor thickness, ulceration, sentinel lymph node status, and the number of tumor-positive lymph nodes (two-sided p < 0.0001 for all comparisons). Multivariable analysis revealed that sentinel lymph node status (p = 0.003), tumor thickness (p = 0.016), ulceration (p = 0.006), and age (p = 0.003) were significant independent predictors of survival for the entire group. Tumor thickness and ulceration were significant predictors of recurrence and survival in sentinel node-negative patients but not in sentinel node-positive patients. Sentinel lymph node histology is possibly the most important negative predictor of early recurrence and survival in patients with American Joint Committee on Cancer stage I and II melanoma. The number of positive lymph nodes provides additional prognostic information. Although sentinel node-negative patients are a prognostically favorable group, various combinations of local and regional recurrences comprise the most common pattern of initial relapse after a negative sentinel lymph node biopsy result.     

Subciliary versus subtarsal approaches to orbitozygomatic fractures

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the anatomic differences in the subciliary versus the subtarsal approach. 2. Discuss the difference between the "skin-only" and the "skin-muscle flap" variations of the subciliary approach. 3. Discuss the potential complications of both approaches. 4. Discuss the advantages of the subtarsal approach versus the subciliary approach. Many incisions have been described for approaches to orbitozygomatic fractures, the most frequently used being the subciliary incision with its modifications, the subtarsal incision, and the transconjunctival incision with or without lateral canthotomy. Each of these approaches has its advantages and disadvantages that may make it more or less appealing to use depending on the patient's age and severity of fracture. A balance must be struck between adequate exposure and acceptable cosmetic result. This article reviews the literature with particular respect to the transcutaneous approaches of subciliary versus subtarsal techniques in the treatment of orbitozygomatic fractures.     

Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction

Gynecomastia, or excessive male breast development, has an incidence of 32 to 65 percent in the male population. This condition has important physical and psychological impacts. Advances in elucidating the pathophysiology of gynecomastia have been made, though understanding remains limited. Recommendations for evaluation and workup have varied and are often arbitrary. A diagnostic algorithm is suggested, with emphasis on a comprehensive history, physical examination, and minimizing unnecessary diagnostic testing. Medical management has had limited success; surgical therapy, primarily through excisional techniques, has been the accepted standard. Although effective, excisional techniques subject patients to large, visible scars. Ultrasound-assisted liposuction has recently emerged as a safe and effective method for the treatment of gynecomastia. It is particularly efficient in the removal of the dense, fibrous male breast tissue while offering advantages in minimal external scarring. A new system of classification and graduated treatment is proposed, based on glandular versus fibrous hypertrophy and degree of breast ptosis (skin excess). The authors' series of 61 patients with gynecomastia from 1987 to 2000 at the University of Texas Southwestern Department of Plastic Surgery demonstrated an overall success rate of 86.9 percent using suction-assisted lipectomy (1987 to 1997) and ultrasound-assisted liposuction (1997 to 2000). The authors have found ultrasound-assisted liposuction to be effective in treating most grades of gynecomastia. Excisional techniques are reserved for severe gynecomastia with significant skin excess after attempted ultrasound-assisted liposuction.     

Metopic synostosis: Defining the temporal sequence of normal suture fusion and differentiating it from synostosis on the basis of computed tomography images

Only the metopic suture normally fuses during early childhood; all other cranial sutures normally fuse much later in life. Despite this, metopic synostosis is one of the least common forms of craniosynostosis. The temporal sequence of normal physiologic metopic suture fusion remains undefined and controversial. Therefore, diagnosis of metopic synostosis on the basis of computed tomography images alone can prove misleading. The present study sought to determine the normal sequence of metopic suture fusion and characterize both endocranial and ectocranial suture morphology. An analysis of computed tomography scans of 76 trauma patients, ranging in age from 10 days to 18 months, provided normative craniofacial data that could be compared to similar data obtained from the preoperative computed tomography scans of 30 patients who had undergone surgical treatment for metopic synostosis. Metopic suture fusion was complete by 6 to 8 months in all nonsynostotic patients, with initiation of suture fusion evident as early as 3 months of age. Fusion was found to commence at the nasion, proceed superiorly in progressive fashion, and conclude at the anterior fontanelle. Although an endocranial ridge was not commonly seen in synostotic patients, an endocranial metopic notch was virtually diagnostic of premature suture fusion and was seen in 93 percent of synostotic patients. A metopic notch was not seen in any nonsynostotic patient. The morphologic and normative craniofacial data presented permit diagnosis of metopic synostosis based on computed tomography images obtained beyond the normal fusion period.     

Conception rates of dairy cows following early not-pregnant diagnosis by ultrasonography and subsequent treatments with shortened Ovsynch protocol

Our objective was to determine the feasibility of prompt reinsemination of dairy cows when diagnosed not pregnant 27-29 days after first-service timed AI (TAI). We assumed that a first-wave dominant follicle was present at that time that would ovulate in response to GnRH once precocious luteal regression was induced after administration of PGF(2alpha). Cows that had not been detected in estrus and reinseminated by Days 27-29 after a first-service TAI were diagnosed not pregnant by ultrasonography. Nonpregnant cows from three herds were assigned randomly to receive either no further treatment until reinsemination (controls; n=189); 25mg i.m. of PGF(2alpha) and then reinsemination according to detected estrus (81 of 108) or at 72-80h after PGF(2alpha) treatment (PGF) in the absence of estrus (27 of 108); or 25mg i.m. of PGF(2alpha) followed by 100 microg i.m. of GnRH 48h later (PGF+GnRH) and then reinsemination after detection of estrus (9 of 160) or at 16-20h after GnRH (151 of 160). Blood samples were collected at the time of the not-pregnant diagnosis and again 48h later. Concentrations of progesterone before treatment with PGF(2alpha) were elevated (<1ng/ml) in 61% of the cows when PGF(2alpha) was administered and 81% of the cows given PGF(2alpha) had low (<1ng/ml) concentrations of progesterone 48h after PGF(2alpha). Treated cows were re-inseminated earlier (P<0.01; 31+/-1days) after first-service TAI than controls (55+/-1days). Conception rates after treatment were not different among treatments: PGF (22%), PGF+GnRH (23%), and control (23%). Average intervals from calving to conception were 22-23 days less (P<0.001) in treated cows than in controls. We concluded that treating nonpregnant cows with PGF(2alpha) on Days 27-29 after insemination produced acceptable conception rates when inseminations were made after detected estrus or when TAI was used after GnRH treatment. Further, both treatments reduced days between first-service TAI and second inseminations, and days from calving to conception.     

Attachment of Listeria monocytogenes to radish tissue is dependent upon temperature and flagellar motility

Outbreaks of listeriosis and febrile gastroenteritis have been linked to produce contamination by Listeria monocytogenes. In order to begin to understand the physiology of the organism in a produce habitat, the ability of L. monocytogenes to attach to freshly cut radish tissue was examined. All strains tested had the capacity to attach sufficiently well such that they could not be removed during washing of the radish slices. A screen was developed to identify Tn917-LTV3 mutants that were defective in attachment to radish tissue, and three were characterized. Two of the three mutations were in genes with unknown functions. Both of the unknown genes mapped to a region predicted to contain genes necessary for flagellar export; however, only one of the two insertions caused a motility defect. The third insertion was found to be in an operon encoding a phosphoenolpyruvate-sugar phosphotransferase system. All three mutants were defective in attachment when tested at 30 degrees C; the motility mutant had the most severe phenotype. However, not all of the mutants were defective when tested at other temperatures. These results indicate that L. monocytogenes may use different attachment factors at different temperatures and that temperature should be considered an important variable in studies of the molecular mechanisms of Listeria fitness in complex environments.