[Umbilical endometriosis]. / Endometriose ombilicale.

Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity. Involvement of the umbilical region is rare. We present the case of a woman with ovarian endometriosis associated with extragenital umbilical endometriosis. The umbilical lesion was completely removed. We take the opportunity of this case to give a short survey with consideration to histopathological and therapeutic aspects as well as possible differential diagnostics.

Locoregional cutaneous metastasis in patients with therapeutic lymph node dissection for malignant melanoma: risk factors and prognostic impact.

In patients with lymph node metastasis of malignant melanoma, the incidence of additional locoregional cutaneous metastases has not been well documented. More importantly, the prognostic impact of locoregional cutaneous metastases appearing prior to therapeutic lymphadenectomy is unclear. Using Kaplan-Meier estimations and a Cox proportional hazards model, we addressed these questions in 224 patients with palpable lymph node metastases to the axilla or the groin. The 10 year overall probability to develop regional cutaneous metastasis, calculated from primary tumour excision, was 38.7%. Using univariate and multivariate analysis, Breslow thickness was a significant risk factor of in-transit disease in node-positive patients. In 24 patients (10.7%) locoregional cutaneous metastases had appeared before therapeutic lymphadenectomy, but this was not associated with a survival disadvantage. In conclusion, locoregional cutaneous metastases amenable to surgical excision do not significantly influence the survival prognosis after therapeutic lymphadenectomy. In the subpopulation of patients with lymph node metastasis, Breslow thickness predicts the probability of additional locoregional cutaneous metastasis.

[Arteriovenous fistula: an uncommon cause of leg ulcers]. / Arteriovenöse Fistel als seltene Ursache eines Ulcus cruris.

A 69-year-old woman presented with a therapy-resistant ulcer on the medial aspect of her left ankle present for 2 years. Previously there had been a blood vessel tumor at the same site, but it had regressed almost completely in adolescence following a bacterial infection. A whirring flow sound was e heard over the ulcer. Numerous arteriovenous connections in the area of the ulcer were shown in the form of vascular convolutions with duplex sonography and angiography. The diagnosis of arteriovenous fistula was made. In addition, there was calcinosis around the ulcer. Successful therapy consisted of excision of the ulcer and the underlying calcinosis, and of ligature of the multiple arteriovenous connections. Our patient demonstrates that smaller arteriovenous fistulas may exist for decades without symptoms. The classification, clinical patterns, diagnostic approach, possible complications (bleeding, ulceration) and therapy of the rare arteriovenous fistulas are discussed.

Standardized axillary lymphadenectomy improves local control but not survival in patients with palpable lymph node metastases of cutaneous malignant melanoma.

BACKGROUND: The aim of the present study was to investigate whether consistent application of standard surgical techniques contributes to improved local control or improved survival in melanoma patients with palpable lymph node metastases to the axilla. METHOD: Using Kaplan-Meier estimations and the Cox proportional hazards model, 120 axillary dissections were assessed. The data from 63 patients who had received standardized axillary lymphadenectomy were compared to those of 57 patients operated on before the introduction of standardized lymphadenectomy. RESULTS: The introduction of standardized axillary lymphadenectomy led to a significant decrease in 5-year local recurrence probability from 43.1% to 13.1% ( P=0.0008). Using multifactorial analysis, the standardized operative procedure resulted in a significantly lower risk of recurrence in the dissected axilla ( P=0.009). The development of intransit metastases was also related to recurrence in the nodal basin ( P=0.03). No significance was accorded to the number of metastatic lymph nodes, tumor thickness, epidermal ulceration, site of primary melanoma, age, sex, or adjuvant chemotherapy. Notably, no differences in the survival rates were observed between the two treatment groups. CONCLUSION: In patients with palpably enlarged axillary lymph node metastases, the introduction of a complete lymphadenectomy, standardized according to the currently acknowledged principles of oncological surgery, improves local disease control without improving overall survival.

Superficial inguinal and radical ilioinguinal lymph node dissection in patients with palpable melanoma metastases to the groin--an analysis of survival and local recurrence.

The present study addresses the question whether an extended ilioinguinal dissection as compared to an only superficial inguinal dissection improves survival and/or local tumour control after the appearance of palpable melanoma metastases to the groin. We retrospectively analysed the data of 104 patients with 69 ilioinguinal and 35 superficial inguinal dissections (median follow up 127 months). Prognostic factors of survival and groin recurrence were assessed using Kaplan-Meier estimation and Cox proportional hazards model. By multifactorial analysis, metastatic involvement of two lymph nodes or less was associated with a significantly better survival rate than involvement of > 2 or pelvic nodes (p = 0.0002). After radical ilioinguinal dissection, patients with extremity-located primaries had a better prognosis than patients with truncal primaries (p = 0.03). Tumour infiltration of the ilio-obturator compartment was found to be an independent factor of poor prognosis (p = 0.0009). The probability of recurrence in the dissected groin paralleled the number of positive nodes and significantly increased if intransits were observed (p = 0.0002). The extent of surgery, Breslow thickness, epidermal ulceration, sex, age and adjuvant chemotherapy neither significantly influenced survival nor local control rates. In summary, when metastatic inguinal nodes become palpable, the presence of pelvic metastases indicates systemic disease. After therapeutic groin dissection, local recurrence and survival depend rather on regional tumour burden than on the extent of surgery.

Prognostic factors of overall survival in patients with delayed lymph node dissection for cutaneous malignant melanoma.

To date, no study of melanoma patients who have undergone delayed lymph node dissection (DLND) has focused on the independent prognostic factors of overall survival, as calculated from surgery on the primary. Using Kaplan-Meier estimates and Cox's proportional hazard model, the significance of prognostic factors was evaluated in 173 patients who developed clinically apparent regional lymph node metastases. When calculated from excision of the primary tumour (median Breslow thickness 3.0 mm), the median survival was 38 months. When calculated from DLND, the median survival was 19 months. Multifactorial analysis revealed that the number of nodes involved at the time of DLND significantly affected both survival calculated from primary tumour excision (P = 0.0002) and survival calculated from DLND (P < 0.0001). In contrast, the well-known risk factors of primary melanoma did not significantly influence overall survival or survival after DLND. However, the remission duration between surgery on the primary and DLND clearly depended on epidermal ulceration (P = 0.001), Breslow thickness (P = 0.009) and the site of the primary melanoma (P = 0.048). Thus, in patients submitted to DLND, the risk factors of primary melanoma influence the early period of the disease, until metastatic lymph nodes become palpable. With regard to overall survival, only the extent of nodal disease determines the prognosis of these patients.

[Acne inversa (hidradenitis suppurativa): early deetection and curative surgery]. / Die Acne inversa (Hidradenitis suppurativa): Frühzeitig erkennen und kurativ operieren.

Acne inversa (synonyms are hidradenitis suppurativa, pyodermia fistulans sinifica) is a chronic inflammatory disorder of the terminal hair follicles of the intertrigines. Abscesses and fistules develop mostly in both axillae, in the anogenital region, and under the breasts. The disease is common, but the right diagnosis is often missed. Local incision gives only a short relief of pain. The therapy of choice is wide local excision. We report on 12 patients with acne inversa who were surgically treated from 1991-1999 in our department. Surgical results and patient satisfaction were assessed on an average of 4.2 years. In all, 20 excisions in the axillae and 5 excisions anogenital were done. Seven patients were treated preoperatively with isotretinoin over at least 2 months. All patients could move their limbs without trouble. The cosmetic result was good in nine patients and three expressed dissatisfaction. Nine patients did not develop new lesions in the treated area. Three patients had new inflammations in both treated and previously uninvolved and therefore not resected regions. Wide local excision gives very good functional and cosmetic results. It usually heate long-lasting disease for nearly disabled patients. Isotretinoin reduces the disease activity and allows radical surgical treatment.

[Inguinal recurrence after therapeutic lymphadenectomy in malignant melanoma]. / Das inguinale Rezidiv nach therapeutischer Lymphadenektomie beim malignen Melanom.

In a retrospective study, 73 stage-II melanoma patients with 22 superficial and 51 deep groin dissections were observed over a maximum of 9 years of follow up (median 67.5 months). The 5-year survival rate of 29.8% was consistent with that yielded by comparable analyses of other investigators. However, the probability of recurrence in the node dissection field was as high as 35%. All groin recurrences occurred in the first 29 months after lymph node clearance (median 6 months). Patients with groin recurrence following lymph-node dissection had a poor prognosis (median survival 12 months). In a multifactorial analysis (Cox model), the only prognostic factor of probability of recurrence was the development of regional in-transit cutaneous metastases (p = 0.0028). Factors that did not affect the appearance of recurrent metastases in the node dissection field were: site of primary melanoma, tumor thickness, epidermal ulceration, degree of lymph node involvement (p = 0.2) age, sex, degree of surgery (superficial or deep groin dissection) and adjuvant chemotherapy. Because regional in-transit cutaneous metastases mostly occur synchronously with groin recurrence or later, they are a typical concomitant phenomenon rather than a prognostic factor of recurrence.

[Axillary recurrence after lymph node excision in malignant melanoma]. / Das axilläre Rezidiv nach Lymphadenektomie beim malignen Melanom.

In a retrospective study 143 patients with 155 axillary lymphadenectomies were observed with a maximum of 8 years of follow-up (mean 51.9 +/- 25.8 months). At the time of their lymphadenectomies, 39 patients had histologically negative nodes (stage I), 85 patients lymph-node metastases (stage II), 19 patients axillary node involvement and distant metastases (stage III). The estimated 5-year survival rates were 77.5% in stage I and 28.6% in stage II. Axillary recurrence after dissection of tumor-free lymph nodes rarely happened, but in stage II the probability of recurrence was as high as 30.7%. All axillary recurrences occurred in the first 20 months after lymphadenectomy. In a multivariate analysis (Cox model), the only prognostic factor of probability of recurrence in stage II was the development of regional in-transit cutaneous metastases (p = 0.048). Factors that did not affect the appearance of recurrent metastases in the node dissection field were: epidermal ulceration, vascular invasion, tumor thickness, degree of lymph-node involvement, age, sex, and adjuvant chemotherapy. Median survival after axillary recurrence following therapeutic lymph-node excision (5 months) was comparable with survival after lymphadenectomy in stage III (7 months). There was a high incidence (> 30%) of regional in-transit cutaneous metastases in both groups. Regardless of the poor prognosis, we found 15% axillary recurrences after lymph-node clearance in stage III.