[Primary breast reconstruction in connection with mastectomy for breast cancer. Indication, procedure and immediate surgical results]. / Primaer brystrekonstruktion i forbindelse med mastektomi ved mammacancer. Indikation, procedure og umiddelbare operative resultater.

Mastectomy and immediate reconstruction of 122 breasts were performed in 109 patients in close collaboration between plastic surgeons and general surgeons. In 56 patients reconstruction was performed using tissue expanders including 13 bilateral operations, 29 patients had a latissimus dorsi myocutaneous flap and 24 a free transverse rectus abdominis myocutaneous flap. There were 27 postoperative local complications in 122 reconstructions (22%), in five the reconstruction was lost. Only patients clinically in stage I were considered for reconstruction. After histopathological staging 27 patients received systemic treatment and 10 local radiotherapy as well. There was no complication during systemic therapy related to reconstruction. In 10 cases local radiotherapy was performed in full, with a delay of four weeks in one patient and a need for correction of the radiation field during treatment in one patient.

[Sentinel node biopsy in cutaneous malignant melanoma of the lower extremities]. / "Sentinel node"-biopsi ved kutant malignt melanom på underekstremiteterne.

Although a substantial number of patients with intermediate thickness cutaneous malignant melanoma (> 1.5-4 mm) have non-detectable regional node metastases, elective regional node dissection still remains controversial. One-three specific lymph node(s)--sentinel node(s)--in the first drained regional lymphatic basin can be visualised peroperatively by applying Patent V Blue intradermally at the site of the previous melanoma. Histological examination of the sentinel node can reveal metastases and therefore presumably give a more accurate oncological staging, thus enabling selection of patients who may benefit from elective regional node dissection. The aim of the present study was to describe our experience with this technique in 23 patients treated for cutaneous malignant melanoma of the lower extremity with a thickness > 1.5 mm. We found that sentinel node dissection, through a minimal surgical procedure, was efficient in detecting micrometastases in the regional lymph node(s).

[Sentinel node diagnostics in malignant melanoma]. / "Sentinel node"-diagnostik ved malignt melanom.

New trial have shown that immediate regional lymph node dissection offers increased survival in patients with regional lymph node metastases only. Introduction of isotope technique to identify the first node, the sentinel node (SN), receiving lymph from a tumour area has made it possible to avoid node dissection in SN metastasis negative patients. The feasibility of the technique is illustrated by to examples.

Prognosis of thin cutaneous head and neck melanoma (<1mm).

Thin malignant melanomas, i.e. tumours less than 1 mm, are generally considered to have a good prognosis. The records of 148 patients with thin invasive melanomas located to the head and neck region were reviewed. All patients were followed for the excision of the primary tumour until death, or the closing date of this study (31 December 1989). Follow-up was median 9.6 years, (range: 3 months to 26.5 years). Increasing tumour thickness led to an increasing number of recurrences. However, there was no statistically significant difference in the length of recurrence-free survival or total survival between patients with tumours less than 0.76 mm and patients with tumours measuring between 0.76 mm and 0.99 mm (P>0.08). Tumours located in the scalp, neck and ears did relapse more often than tumours located to the face (P<0.03). No difference in prognosis was found in tumours that were excised with a free margin of <2.0 cm or of > or = 2.0 cm (P>0.29). Sixteen of the patients (11%) developed recurrences, 12 of these 16 patients (75%) died of disseminated melanoma. We conclude that thin head and neck melanomas do not necessarily carry an excellent prognosis. Prognosis is not dependent upon tumour thickness when less than 1.00 mm.

A new silicone rubber dressing used as a temporary dressing before delayed split skin grafting. A prospective randomised study.

In cases of split skin grafting after wide local excision of malignant melanoma or other tumours, the graft is often delayed for one or two days to reduce bleeding underneath it. Paraffin gauze and an absorbent dressing may be used as a temporary dressing before the application of the skin graft. Paraffin gauze, however, has the disadvantage that it often adheres to the wound bed making removal time-consuming and causing pain and bleeding. A new, fine-mesh polyamide netting covered with silicone (Mepitel, Mölnlycke) was therefore tested in a randomised prospective study with paraffin gauze as the control. There were significant differences between the two groups in terms of the adherence of the dressing, the time needed to remove the dressing, pain, and bleeding. Mepitel was superior to paraffin gauze because it adhered less to the wound bed, the time needed to remove the dressing was shorter, and it caused less pain and less bleeding.

Expression of the alpha 6 beta 4 integrin by squamous cell carcinomas and basal cell carcinomas: possible relation to invasive potential?

We have studied the expression of alpha 6 beta 4 integrin, a carcinoma laminin receptor in ten squamous cell carcinomas (SCCs) and ten basal cell carcinomas (BCCs) of the skin in order to examine whether changes in alpha 6 beta 4 integrin expression may be related to invasive and metastatic potential. Monoclonal antibodies specific for each subunit were applied on cryosections, using a three step indirect peroxidase technique. In normal epidermis the basal cells expressed both the alpha 6 and the beta 4 subunits, and the expression was polarized against the basement membrane. In SCCs the expression of the alpha 6 and the beta 4 subunits paralleled each other, showing an increased intensity and loss of polarity. The BCCs, however, showed consistently decreased expression of both the alpha 6 and the beta 4 subunits. The results of our study, as well as those of other studies, support the assumption that the increase and depolarization of alpha 6 beta 4 integrin that occurs in SCCs might be related to the invasive properties of this tumour type.

Wide local excision of recurrent breast cancer in the thoracic wall.

BACKGROUND: Local recurrence is one of the major problems in treatment of breast cancer. Approximately 20% of patients who have radical or modified radical mastectomy have a local recurrence. METHODS: The records of 98 women with locally recurrent breast cancer treated with wide local excision, in the years 1983-1987, were reviewed. The median age at excision was 62 years (range, 32-84 years). All patients were observed until death or December 31, 1989. The median follow-up period was 36 months (range, 2-79 months). RESULTS: At follow-up, 44 of 98 patients (45%) had had a new local relapse and 47 of 98 (48%) were dead. The median duration of local control for all patients was 21 months (range, 1-79 months). The diameter of the local recurrence seemed to influence the duration of local disease control but not total survival. Patients admitted directly for surgery had a longer period of local control compared with patients admitted after unsuccessful oncologic treatment of the local recurrence. The 5-year local control rates were 50% and 24%, respectively (P > 0.92). No statistically significant difference in local control could be shown whether or not the patient received additional oncologic therapy in continuity with the wide local excision. The 5-year local control rate in patients treated only by surgery was 33% compared with 42% in patients also receiving additional oncologic treatment (P > 0.63). CONCLUSIONS: Wide local excision of recurrent breast cancer seems to provide as good or even better local control than other treatment modalities. Surgery should not be postponed in cases of ineffective medical treatment or radiation therapy.

Clinical results after doxorubicin extravasation treated with excision guided by fluorescence microscopy.

Doxorubicin (DR) and epirubicin (ER) produce progressive tissue necrosis when extravasation occurs. Early detection and excision of all affected tissue is important. The clinical experience with fluorescence microscopic guided detection and excision in 24 patients is evaluated. 9 patients with fluorescence negative specimens were kept under observation without excision. None developed necrosis. Wide excision was performed on 15 patients with fluorescence positive specimens. Sequelae, defined as impaired function of the affected limb at the last control examination in the out-patient clinic, were observed in 8 patients. 4 of 5 patients with extravasation in the hand and 2 of 3 with extravasation in the cubital fossa were among these. Delay, defined as time from injury to surgery, was a median of 7 h, range from 3 h to 69 days. Patients developing sequelae had a median delay of roughly 4-fold that of patients without these complications. Patients with extravasation in the cubital fossa were hospitalised for the longest period: 30 days, range 24-45 days, vs. 12 days, range 7-80 days, for those with extravasation at other sites (P < 0.03). Our conclusions are: (1) fluorescence microscopic analysis is a reliable method for the detection and delineation of extravasation of DR or ER. (2) Do not use the cubital fossa or hand for the infusion of these cytostatics. (3) Act promptly if extravasation is suspected--delay leads to sequelae.

[Malignant melanoma of the skin in Denmark--epidemiology, diagnosis and treatment]. / Melanoma malignum cutis i Danmark--epidemiologi, diagnostik og behandling.

About 700 new cases of malignant melanoma of the skin are registered annually in Denmark. The incidence is increasing rapidly and the number of new cases increases by more than 5% per annum. The most important phenotypical risk factors are the number of acquired pigmented naevi and exposure to sunlight is the most important risk factor in the external environment so that severe sunburn in children and intermittent intense exposure to sunlight increase the risk of melanoma. The thickness of the tumour at the time of the diagnosis is the most important prognostic factor. The prognosis deteriorates with increasing thickness. Treatment is primarily surgical. In cases of inoperable local melanoma and regional recurrences, irradiation may be administered. Chemotherapy and/or immunotherapy are of experimental character. In the light of the rapidly increasing incidence, it is important that knowledge of risk factors for development of the disease and the clinical characteristics of early melanoma is spread to not only the medical profession but also to the general public.

The use of autologous fibrin adhesive in skin transplantation.

A method for preparing concentrated fibrinogen for use in autologous fibrin adhesive is described. The adhesive was used in seven patients with eight chronic leg ulcers. The ulcers were divided into two equal sections, and the adhesive was used to seal split-thickness skin grafts in one section, while no adhesive was used to seal the grafts in the other section of the ulcer. The strength of adhesion was measured 3 1/2 minutes after transplantation of a 1-cm2 test split-thickness skin graft. In the sealed grafts, the breaking strength varied from 12 to 26 gm. In the unsealed transplants, the strength was less than 5 gm. The take of the meshed split-thickness skin grafts was equal in the sealed and the unsealed areas, varying from 90 to 100 percent. Biopsies taken on day 7 showed a splitting between graft and recipient bed in half the unsealed grafts; none of the sealed grafts showed splitting, indicating a more stable graft in the sealed areas. Biopsies taken on day 21 showed no difference between sealed and unsealed grafts.

Fluorescence microscopic demonstration and demarcation of doxorubicin extravasation. Experimental and clinical studies.

Extravasation of doxorubicin and its derivative epirubicin, cause severe progressive tissue necrosis that requires early excision of all affected tissues. Doxorubicin and epirubicin are autofluorescent and this characteristic can be used to demonstrate and delineate extravasation by the aid of fluorescence microscopic study. In a rat model doxorubicin was injected intradermally in declining concentrations and the minimal detectable concentration was found to be 0.02 mg/ml. Skin necrosis developed in rats injected with doxorubicin concentrations ranging from 0.02 mg/ml to 2 mg/ml. Clinically, fluorescence microscopic analysis of frozen sections was used in eight patients to assess whether doxorubicin or epirubicin extravasation had taken place. When all fluorescing tissue was removed, no necrosis ensued, but in one patient, where a slightly fluorescing area was ignored, necrosis developed later and excision of the tissue had to be performed.