[Therapy of congenital melanocytic nevi. Excision, dermabrasion, laser]. / Therapie kongenitaler melanozytärer Nävi. Exzision, Dermabrasion, Laser.

Congenital melanocytic nevi are rare lesions which depending on their size and location may cause major cosmetic and psychological problems. Large congenital melanocytic nevi may undergo malignant change and can also be associated with neurocutaneous melanosis. The different treatment approaches reach different levels of the skin. Complete excision is the treatment of choice, but is not always possible with giant nevi. Superficial treatment can reduce the pigmentation, but repigmentation is not uncommon. Incomplete removal of melanocytic nevi does not reduce the melanoma risk. Surgical intervention must be carefully planned; the advantages and disadvantages of the different modalities must be discussed with the parents. The risk of malignant transformation must be weighed up against the expected aesthetic and functional outcomes.

[Current recommendations in the treatment of basal cell carcinoma and squamous cell carcinoma of the skin]. / Aktuelle Therapieempfehlungen für das Basalzellkarzinom und Plattenepithelkarzinom der Haut.

The incidence of the most common tumors of the skin, basal cell carcinoma and squamous cell carcinoma, has risen rapidly in recent years. Dermatologists see in their daily practice many different clinical and histological variants of these tumors. They must be able to develop therapeutic strategies adapted to the tumor and the patient. Surgical excision remains the standard treatment. Micrographic histological evaluation should be employed in difficult locations, for large tumors and when there is increased risk of recurrence or metastasis. For initial or superficial lesions, other approaches such as radiation therapy, as well as curettage, cryosurgery, laser therapy and photodynamic therapy can be employed. An additional option is topical treatment with imiquimod or 5-flourouracil.

Deep subcutaneous application of poly-L-lactic acid as a filler for facial lipoatrophy in HIV-infected patients.

INTRODUCTION: Facial lipoatrophy is a crucial problem of HIV-infected patients undergoing highly active antiretroviral therapy (HAART). Poly-L-lactic acid (PLA), provided as New-Fill/Sculptra, is known as one possible treatment option. In 2004 PLA was approved by the FDA as Sculptra for the treatment of lipoatrophy of the face in HIV-infected patients. While the first trials demonstrated relevant efficacy, this was to some extent linked to unwanted effects. As the depth of injection was considered relevant in this context, the application modalities of the preparation were changed. The preparation was to be injected more deeply into subcutaneous tissue, after increased dilution. MATERIAL AND METHODS: To test this approach we performed a pilot study following the new recommendations in 14 patients. RESULTS: While the efficacy turned out to be about the same, tolerability was markedly improved. The increase in facial dermal thickness was particularly obvious in those patients who had suffered from lipoatrophy for a comparatively small period of time. CONCLUSION: With the new recommendations to dilute PLA powder and to inject it into the deeper subcutaneous tissue nodule formation is a minor problem. However, good treatment results can only be achieved if lipoatrophy is not too intense; treatment intervals should be about 2-3 weeks.

[First experiences with a new radiopharmaceutical for sentinel lymph node detection in malignant melanoma: (99m)Tc colloidal rhenium sulphide]. / Erste Erfahrungen mit einem neuen Radiopharmakon für die Wächterlymphknoten - Detektion beim malignen Melanom: (99m)Tc markiertes kolloidales Rheniumsulfid.

UNLABELLED: AIM of this study was to localize the sentinel lymph node by lymphoscintigraphy using technetium-99m colloidal rhenium sulphide (Nanocis), a new commercially available radiopharmaceutical. Due to the manufacturers' instructions it is licensed for lymphoscintigraphy. PATIENTS AND METHODS: 35 consecutive patients with histologically proved malignant melanoma, but without clinical evidence of metastases, were preoperatively examined by injecting 20-40 MBq Nanocis with (mean particle size: 100 nm; range: 50-200 nm) intradermally around the lesion. Additionally blue dye was injected intraoperatively. A hand-held gamma probe guided sentinel node biopsy. RESULTS: During surgery, the preoperatively scintigraphically detected sentinel lymph nodes were identified in 34/35 (97%) patients. The number of sentinel nodes per patient ranged from one to four (mean: n = 1.8). Histologically, metastatic involvement of the sentinel lymph node was found in 12/35 (34%) patients; the sentinel lymph node positive-rate (14/63 SLN) was 22%. Thus, it is comparable to the findings of SLN-mapping using other technetium-99m-labeled nanocolloides. CONCLUSION: (99m)Tc-bound colloidal rhenium sulphide is also suitable for sentinel node mapping.

Patients with lymphatic metastasis of cutaneous malignant melanoma benefit from sentinel lymphonodectomy and early excision of their nodal disease.

Early versus delayed excision of lymph node metastases is still being assessed in malignant melanoma. In the present retrospective, multicentre study, the outcome of 314 patients with positive sentinel lymphonodectomy (SLNE) was compared with the outcome of 623 patients with delayed lymph node dissection (DLND) of clinically enlarged lymph node metastases. In order to avoid the lead-time bias, survival was generally calculated from the excision of the primary tumour. Survival curves were constructed using the Kaplan-Meier product-limit estimate. Cox's proportional hazards model was used to perform a multivariate analysis of factors related to overall survival. Compared with SLNE and early performed complete lymph node dissection, DLND yielded a significantly higher number of lymph node metastases. Median and mean tumour thickness were nearly identical in the two therapy groups. The estimated 3-year overall survival rate was 80.1+/-2.8% (+/-standard error of the mean (SEM)) in patients with positive SLNs, and 67.6+/-1.9% in patients with DLND (5-year survival rates 62.5+/-5.5 and 50.2+/-5.4%, respectively). The difference between the two survival curves was statistically significant (P=0.002). Using multifactorial analysis, SLNE (P=0.000052), American Joint Committee on Cancer (AJCC) Breslow thickness category (P<0.000001), age (P=0.01) and gender (P=0.028) were independent predictors of overall survival. The location of the primary tumour (P=0.59) was non-significant. Considering only those centres with sufficient data for epidermal ulceration, this risk factor was also significant. In cutaneous malignant melanoma, early excision of lymphatic metastases, directed by the sentinel node procedure, provides a highly significant overall survival benefit.

[Metastases in malignant melanoma despite histologically negative sentinel lymph node: should the concept be changed?]. / Metastasierung beim malignen Melanom trotz histologisch negativem Sentinel Lymph Node: Muss das Konzept in Frage gestellt werden?

AIM: The Sentinel Lymph Node (SLN) is of considerable prognostic relevance, because extended lymph node dissection may not be performed in patients presenting with histologically negative SLN. The aim of the present study was to prove the prognostic value of the SLN-concept in these patients. METHODS: So far the clinical follow-up of 162 patients with histologically proven malignant melanoma and metastatically uninvolved (negative) SLN was investigated. Histological examination included standard methods (HE-Test) and special histochemical techniques (S-100, HMB-45). All patients underwent clinical examination, ultrasonic diagnosis of the regional lymph nodes, and x-ray of the chest every 3 months. RESULTS: Despite of negative SLN-findings in 8/162 patients metastases of the malignant melanoma were found after a time period of 5-27 months. Three patients presented with recurrence in the previously mapped (negative) SLN-basin. In another case the scintigraphically visualized SLN could not be identified intraoperatively by means of the hand-held gamma probe. One patient showed intransit-metastases or skin-metastases, respectively; another patient recurred in the scar area. One patient showed hematogenic dissemination (liver) which is not detectable by lymphoscintigraphy; in another patient metastases were found outside the primary lymphatic basin (cervical). CONCLUSION: In our patient group 4.9% presented with metastases despite negative SLN while published data report up to 11% (observation period 35 months), among them only 3 patients (1.9%) being real concept failures. Our results underline that there is no evidence to change this concept in patients with clinically early stage.

[Lipoma of the forehead]. / Das Lipom der Stirn.

BACKGROUND AND OBJECTIVE: Lipomas should be included in the differential diagnosis of tumors located on the forehead. They require a different operative plan. PATIENTS/METHODS: Lipomas of the forehead were extirpated in ten patients. Dermatohistopathologic investigations confirmed the diagnosis lipoma in each case and exactly identified the anatomic layers surrounding the tumor. RESULTS: Histologic investigations revealed the localization of the lipoma in the submuscular layer in eight patients and in the subgaleal layer in two patients. CONCLUSIONS: Lipomas of the forehead should be differentiated into submuscular and subgaleal lipomas depending on the exact anatomic localization below the frontalis muscle or underneath the galea aponeurotica. This classification is simple and aids in operative planning.

Late metastases of cutaneous melanoma: an analysis of 31 patients.

Analysis of data of 6298 patients with cutaneous melanoma seen at the Department of Dermatology and Allergology at the Ludwig-Maximilians University of Munich between 1977 and 1998 identified 31 patients who first experienced metastatic disease 10 or more years after surgical treatment of the primary melanoma. The mean tumor thickness in patients with late progression of disease was 1.4 mm. There was no sex predominance. Of 31 patients, 15 (48. 3%) were female and included both premenopausal and postmenopausal women at the time of initial diagnosis without any predominance. Sixteen of the 31 patients (51.6%) with late onset of progression had primary tumors located on the trunk. The prognosis after relapse was related to the site of recurrence; survival after local or regional node recurrence was often prolonged, whereas survival after distant metastases usually was limited. Survival after late recurrence did not correlate with disease-free survival. A high-risk group for late recurrence could not be identified. The data emphasize the value of continued clinical follow-up and self-examination for early detection of regional recurrences. We advocate a lifelong follow-up, also to identify other melanocytic lesions at risk (eg, dysplastic nevi, secondary or multiple melanomas).

Fractionated radiotherapy of lentigo maligna and lentigo maligna melanoma in 64 patients.

Between 1987 and 1998, 64 patients with lentigo maligna (LM) (n = 42) or lentigo maligna melanoma (LMM) (n = 22) were treated by fractionated radiotherapy. In all 22 patients with LMM, excision of the nodular part of the LMM was performed before radiation of the residual lentiginous tumor. During the follow-up period of 1 to 96 months (mean, 23 months; median, 15 months), none of the 42 patients with LM displayed any signs of recurrence of LM after radiation therapy alone. Of the 22 patients with LMM, only 2 patients showed local recurrence of the tumor, salvaged by excision in both cases. One patient with LMM suffered from metastatic disease without local recurrence of the melanoma 44 months after radiation therapy. The cosmetic results of radiotherapy were good or excellent in the vast majority of patients, with only a few experiencing hypopigmentation or hyperpigmentation in the irradiated area. Fractionated radiation therapy with superficial x-rays is an effective method of treatment of LM associated with low morbidity and leading to clinical results comparable to those of surgical excision.

[Clinical and epidemiological data of patients with malignant melanoma from the Munich Tumor Center 1977-1997]. / Klinisch-epidemiologische Daten von Patienten mit malignen Melanomen aus dem Bereich des Tumorzentrums München von 1977 bis 1997.

Since 1997, data of patients with malignant melanomas have been systematically documented in the tumor registry of the Tumor Center Munich. Analysis of data of 8071 patients revealed that tumor thickness has steadily declined over the years. While in 1977 the median tumor thickness was 1.45 mm, it is now 0.75 mm. This has been followed by a significant improvement in overall survival. Males and older patients tend to have thicker melanomas than females and younger patients. There has been a relative increase of melanomas of the trunk. At diagnosis, 95% of patients had local disease. Of these patients, 18.3% developed metastastes. At least two-thirds of these patients had progression at the primary tumor site or the regional lymph nodes, both of which can be assessed by clinical or ultrasound examinations. Overall survival of patients with thin melanomas is excellent and does not differ substantially from the overall survival of the general population comparable in sex and age.

[Basalioma terebrans of trunk skin. A neglected tumor]. / Basalioma terebrans der Rumpfhaut. Ein vernachlässigter Tumor.

Small basal cell carcinomas of the trunk are usually regarded as relatively harmless. In contrast, large and ulcerating basal cell carcinomas may become a therapeutic challenge with a less favourable prognosis and high risk of recurrence. The development of mutilating giant basal cell carcinomas appears less due to the biological aggressive character of the tumors, but rather to the patients' attitude of neglect. The case of a 62-year-old patient, featuring such attitude, demonstrates how a common basal cell carcinoma of the trunk can grow over a period of years to a troublesome ulcerating tumor.

[Diagnosis of sentinel lymph node in malignant melanoma: preoperative lymphoscintigraphy and intraoperative gamma probe guidance]. / Diagnostik des "Sentinel Lymph Node" bei malignem Melanom: präoperative Lymphszintigraphie und intraoperative Sondenmessung.

AIM: The sentinel lymph node (SLN) has shown to reflect the histologic features of the remainder of the lymphatic basin in patients with melanoma and is of considerable prognostic relevance. Aim of the study was to localize the SLN pre and intraoperatively by means of lymphoscintigraphy and gamma probe guidance. METHODS: 38 patients with histologically proven malignant melanoma (tumor thickness > 0.75 mm) were preoperatively examined by injecting 40 MBq 99mTc-Nanocoll intradermally around the lesion. The first lymph node identified was marked on the skin. Immediately after scintigraphy patients were referred to the operation room and intraoperatively mapped using a handheld gamma probe. Activity of the SLN and of the adjacent nodes was measured ex vivo. After excision of the SLN, the lymphatic basin was re-checked for radioactivity and activity of the SLN and of the adjacent nodes was re-measured after removal. RESULTS: The hottest reading was found in all patients in vivo and ex vivo in the preoperatively marked lymph node. Morphologically (macroscopically, ultrasound, CT) all nodes were unsuspicious. Histologically, in 8 patients metastatic involvement of the lymph node was found which led to a wide exploration of the lymphatic basin with consecutive lymph node excision in 7 patients. CONCLUSION: The findings suggest that combined preoperative lymphoscintigraphy and intraoperative mapping with a gamma probe is a powerful approach for exact localization of the SLN. Diagnostic detection of the SLN may have considerable impact for patient management, since extended lymph node dissection may be confined to patients presenting with positive SLN.

Pyoderma gangrenosum associated with the secondary antiphospholipid syndrome.

A 64-year-old woman with an 11-year history of systemic lupus erythematosus and amputation of her left lower leg as a consequence of arterial embolism, presented with two large, non-healing ulcers on her right shank. Pyoderma gangrenosum associated with secondary antiphospholipid syndrome was diagnosed based upon the typical clinical features and increased antibodies to cardiolipin. Although an aggressive therapy with corticosteroids and cyclosporine was started, her condition continued to worsen. She finally died as a result of sepsis. We discuss the difficulties in diagnosis and therapy of SLE combined with the antiphospholipid syndrome and pyoderma gangrenosum.

[Granuloma eosinophilicum faciei simulating rhinophyma. Therapeutic long-term outcome after surgical intervention]. / Granuloma eosinophilicum faciei unter dem Bild eines Rhinophyms. Therapeutischer Langzeiterfolg durch chirurgische Intervention.

A 53 year old man presented with a giant variant of granuloma faciale, closely resembling rhinophyma. Therapeutic approaches with cryosurgery and dapsone were unsuccessful. Surgical reconstruction of the nasal skin resulted in an excellent and long lasting effect. We give a short overview of this relatively rare disease, describe an unusual manifestation and discuss the therapeutic possibilities. Surgical procedures seem to offer the best results, despite the inflammatory pathogenesis of the disease.

[Micrographic surgery. A current methodological assessment]. / Mikrographische Chirurgie. Eine methodische Bestandsaufnahme.

Micrographic surgery is one of the most effective methods in the treatment of basal cell carcinoma. In the last 20 years this method has been further developed and modified. Three kinds of micrographic surgery are now available: the Mohs method, the margin strip method ("Tübingen torte") and the "Munich" method. All three variants have the same goal; radical tumour removal with optimal sparing of surrounding tumour-free tissue. They differ, however, in the technique of tumour excision, the preparation of the histological specimens and the interpretation of the slides. In this paper the authors take stock of the methods available and describe the differences, advantages and disadvantages.

[Skin ulcers in rheumatoid arthritis]. / Hautulzerationen bei rheumatoider Arthritis.

The appearance of severe ulceration of the skin in patients with rheumatoid arthritis is often associated with a tendency to progression of the underlying disease, involvement of internal organs and increased mortality. In the pathogenesis of such ulceration there are multiple causes for their development, persistence and tendency to poor healing. They include localized or generalized immune complex vasculitis, treatment with anti-inflammatory drugs and their side effects following the treatment, arterial and venous insufficiency, and mechanical factors. The management of severe ulceration requires stabilization of the underlying autoimmune disease, e.g. with high doses of glucocorticosteroids or other immunosuppressive drugs or plasmapheresis. Adjuvant treatment of pain with analgesics, improvement of blood perfusion and anti-inflammatory drugs should accompany the topical therapy of ulcers. After suppression of the local inflammatory reaction surgical intervention becomes necessary in most of the patients, and vascularized muscle flaps should be used in preference to meshgrafts or split skin grafts for extensive ulceration in rheumatoid arthritis. A hopeful perspective in the treatment of severe rheumatoid arthritis might be opened up with immunotherapy using monoclonal antibodies.

Carbon dioxide laser therapy of a widespread epidermal nevus.

BACKGROUND AND OBJECTIVE: The treatment of epidermal nevi is difficult and often unsatisfactory. Many therapeutic approaches have been tried, of which the surgical methods including lasers aim to avoid recurrences and hypertrophic scarring. Here we report the case of a widespread, life-impairing epidermal nevus, summarize the available treatment modalities, and discuss CO2 laser therapy with respect to the clinically soft variants of these developmental defects. STUDY DESIGN/PATIENTS AND METHODS: A patient with a widespread, recurrent, biopsy-proven epidermal nevus was treated with a 10,600-nm CO2 laser. After test treatments in local anaesthesia, four sessions were performed under general anaesthesia each with a follow-up time of 4 years to date. RESULTS: CO2 laser vaporization resulted in complete removal of the treated nevus without any obvious scarring. The patient is free of recurrence 4 years postoperatively. CONCLUSION: CO2 laser treatment of epidermal nevi is a useful modality in selected variants.

Chronic cutaneous damage after accidental exposure to ionizing radiation: the Chernobyl experience.

BACKGROUND: The hazards of acute radiation exposure are well known. Bone marrow failure from total body gamma or neutron irradiation is the most clinically relevant aspect of acute radiation disease. With nonhomogeneous exposure, as is characteristic in accidents, other organ systems, such as the skin, may be more important in determining clinical prognosis. This became obvious in the two worst radiation accidents since 1945, the Chernobyl accident in April 1986 and the Goiania accident in September 1987. OBJECTIVE: Our purpose was to describe the characteristic chronic sequelae of accidental cutaneous radiation in a group of patients who survived the Chernobyl nuclear power plant accident. METHODS: Fifteen patients with the delayed type of the cutaneous radiation syndrome were examined between September 1991 and January 1992. All patients had a history of acute radiation disease. The exposure pattern was characterized by partial body exposure with high doses of beta and gamma irradiation from radioactive water, steam, or dust. RESULTS: Radiation-induced lesions were confined primarily to the legs and distal arms, but sometimes involved up to 50% of the total body surface. In addition to telangiectases, radiation keratoses, and radiation ulcers, hemangiomas, hematolymphangiomas, splinter hemorrhages in the distal nail bed, lentiginous hyperpigmentation, and severe subcutaneous fibrosis were noted. No malignant transformation could be detected. Associated diseases included cataracts, chronic hepatitis, and recalcitrant bacterial and herpesvirus infections. CONCLUSION: After accidental partial body exposure to high doses of beta and gamma irradiation, the predominant involvement of the skin, described as the cutaneous radiation syndrome, can become the characteristic feature. This causes longlasting, serious diagnostic and therapeutic problems.