Prognostic features in angiosarcoma of the head and neck: a retrospective monocenter study.

BACKGROUND: Cutaneous angiosarcoma of the head and neck (cAS-HN) is a rare malignancy with poor survival. Most of the histological markers and grading were not proven to be significant for prediction of outcomes in cAS-HN. This study aimed to find prognostic clinical features and histologic markers for cAS-HN. MATERIAL AND METHODS: We retrospectively analysed primary cAS-HN's seen in a single institution between 1980 and 2009. Clinical data and specific histologic characteristics were assessed. Outcome parameters were analysed using uni- and multivariate statistics. RESULTS: 80 patients (mean age 71.4 (SD 14.4) years, average follow-up time 55.3 (SD 74.4) months) were included. 5-year DSS rate was 62%. Univariate analysis revealed the extent of primary tumour (affecting more than one anatomical region), incomplete resection and initial metastatic disease as significant (p < 0.05) predictors for unfavourable disease specific survival (DSS) rates and time. Multivariate analysis confirmed age over 70 years, incomplete resection and initially distant metastasis influencing outcome adversely. Analysis of specific histological markers in 37 cases found patterns of growth (solid areas greater than 80%) associated with better survival (p = 0.011). CONCLUSION: In conclusion age, number of affected regions, initial metastasis, complete initial resection and pattern of growth significantly affected mortality rates.

Primary mucosal malignant melanoma of the head and neck.

Diagnosis, therapy, and prognosis of 40 patients with malignant melanoma of the mucous membranes, treated at one hospital from 1971 to 2006, were evaluated in a retrospective study. The survival rate was compared with that established by the German-Austrian-Swiss Study Group on Tumors of the Head and Neck (DÖSAK) for 121 cases. The cumulated 5-year survival rate amounting to 33% (DÖSAK study 35%) emphasizes the unfavorable prognosis of this tumor. Age, sex, or tumor location had no significant impact on a patient's survival. A modified surgical concept has been developed for the treatment of the primary tumor and its lymphatic drainage area to maintain a patient's quality of life. The entire tumor should be resected under histologic control ensuring a 5-mm safety margin of healthy tissue. Bone should only be resected if invaded by the tumor. Large resections of the upper or lower jaw should be avoided. A neck dissection does not improve the prognosis and should be performed only in the case of histologically confirmed invasion of lymph nodes.

One-stage reconstruction of nasal defects: evaluation of the use of modified auricular composite grafts.

Complex nasal defects in the distal regions of the nose are cosmetically difficult to repair. In 70 patients over a period of 10 years, defects of the nasal ala and the soft triangle, nasal tip, columella, and columellar-lobular junction were reconstructed with modified auricular composite grafts. A randomized group of 40 of these patients was assessed after a mean of 55.5 months to evaluate the method's functional and cosmetic long-term results. The majority of the patients (60%, N = 48) had been treated primarily for basal cell carcinoma. Of all defects, 57% ( N = 46) measured 2 to 3 cm in width and 43% ( N = 34) 1 to 2 cm. Seventy-five percent ( N = 60) of all defects were composite lesions involving skin, cartilage, and vestibular mucosa, in contrast to 25% ( N = 20) involving skin and cartilage with intact vestibular skin. Two crucial technical modifications seemed to have improved survival for larger grafts: first, the use of hinge flaps from the margins of the defect to obtain a well-vascularized recipient bed and optimization of the raw contact surface; second, postoperative gentle scarification of the graft in combination with a constantly applied heparin solution decongests venous stasis normally seen in such grafts. This maneuver establishes a stable and early blood supply enhancing graft take. With this type of treatment, 67 (84%) grafts healed well without further complications, whereas 13 (16%) grafts developed complications, resulting in partial ( N = 9) and total ( N = 4) necrosis of the transplant. Six of these patients underwent a secondary reconstruction using another auricular composite graft. Long-term results of this method have turned out to be very satisfying in terms of functional and cosmetic outcome and patient acceptance.

Soft tissue reconstruction of the nose.

Soft tissue repair of skin defects of the nose-being in the middle of the face-is very demanding with regard to its functional and aesthetic outcome to allow successful rehabilitation of the patient concerned. In the majority of these cases, soft tissue reconstruction using local and regional flaps is indicated after individual therapy planning considering location and size of the defect, the patient's age, and his or her wishes. Flaps from nasal skin, glabella, forehead, as well as nasolabial fold provide good possibilities to cover the defect externally and ensure matching color and texture. Full-thickness skin grafts and healing by secondary intent are second-choice therapies. In the case of partial amputation of the nose, a nasolabial rotation flap can be used for inner lining, if necessary supported by septal cartilage or a composite graft building a stable nasal scaffold from the inside for the outside. The possibilities of facial plastic surgery, the exact knowledge of vascular supply, and flaps adjusted to individual requirements allow achievement of an outcome that is aesthetically and functionally satisfying for the patient.

Surgical reconstruction of eyelids.

Tumors of the eyelid region are a special entity within the tumors of head and neck. Their early recognition and histologic classification helps to avoid extensive and destructive surgery, which is particularly challenging with regard to the surgical repair of those defects. In 58% of the patients with eyelid tumors treated at Fachklinik Hornheide between 2002 and 2006, a malignant neoplasia was diagnosed. In eyelid surgery, particular principles need to be observed. Provided those guidelines are strictly observed, even extensive defects of the upper or lower eyelid can be repaired in an aesthetically acceptable manner. When reconstructing a lower eyelid, not only restoration of the original structure of the margin of the lower eyelid including the ciliary edge is aimed at but also stabilization of the eyelid especially in reconstruction of the lateral angle of the eye. Static reconstruction is not sufficient in many cases with extensive defects of the upper eyelid. It is necessary not only to replace skin, mucosa, and tarsus, but also to restore mobility and function of the upper eyelid to enable complete eyelid closure to protect the cornea. In the current study, the experience with various techniques of eyelid reconstruction and their functional and aesthetic implications are presented and discussed.

Invasive basal cell carcinoma of the head and neck (basalioma terebrans).

In a retrospective study, initial diagnosis and method of treatment were evaluated in 118 patients with invasive basal cell carcinoma (formerly basalioma terebrans) of the head and neck. In 97 of the total 118 patients, radical surgery with resection of important organs had to be performed, and the follow-up results of 107 patients were recorded. In 44 (41%) of the latter 107 cases, recurrences were observed despite radical tumor excision, and only 63 (59%) patients were free of tumor. In 20 patients a second recurrence and in 12 patients a third recurrence was found. The recurrence rate amounted to only 1.9% in a comparative study group of 6932 patients with "simple" basal cell carcinoma. The findings reveal that healing without recurrence was achieved in only half of the patients with invasive basal cell carcinoma (basalioma terebrans). In cases in which bony structures had been invaded by the tumor, the recurrence rate was 71.4%. Despite the hypothesis of primary incurability of invasive basal cell carcinoma, it is pointed out that radical surgery may still improve a patient's quality of life. Although definite healing seems impossible, surgery may contribute to an acceptable quality of life for several years.

Gab2-mediated signaling promotes melanoma metastasis.

Metastatic melanoma is a disease with a poor prognosis that currently lacks effective treatments. Critical biological features of metastasis include acquisition of migratory competence, growth factor independence, and invasive potential. In an attempt to identify genes that contribute to melanoma pathogenesis, a genome-wide search using bacterial artificial chromosome array comparative genomic hybridization and single nucleotide polymorphism arrays in a series of 64 metastatic melanoma samples and 20 melanoma cell lines identified increased copy numbers of Gab2 located on 11q14.1. Gab2 is an adaptor protein that potentiates the activation of the Ras-Erk and PI3K-Akt pathways and has recently been implicated in human cancer; however, its role in melanoma has not been explored. In this study, we found that Gab2 was either amplified (approximately 11%) and/or overexpressed (approximately 50%) in melanoma. Gab2 protein expression correlated with clinical melanoma progression, and higher levels of expression were seen in metastatic melanomas compared with primary melanoma and melanocytic nevi. We found that overexpression of Gab2 potentiates, whereas silencing of Gab2 reduces, migration and invasion of melanoma cells. Gab2 mediated the hyperactivation of Akt signaling in the absence of growth factors, whereas inhibition of the PI3K-Akt pathway decreased Gab2-mediated tumor cell migration and invasive potential. Gab2 overexpression resulted in enhanced tumor growth and metastatic potential in vivo. These studies demonstrate a previously undefined role for Gab2 in melanoma tumor progression and metastasis.

Increased expression of the tumor suppressor PLZF is a continuous predictor of long-term survival in malignant melanoma patients.

Promyelocytic leukemia zinc finger (PLZF) is a transcriptional repressor and tumor suppressor inhibiting melanoma cell growth in vitro and in vivo in animal models. In this study, we analyzed the impact of in vivo primary tumor gene expression of PLZF on the long-term survival of malignant melanoma patients. PLZF expression was assessed by using DNA microarray and real-time polymerase chain reaction analysis of 41 primary malignant melanomas from patients with a defined histology and a close to 20-year clinical follow-up, of 29 melanoma metastases, and of 6 different melanoma cell lines. Kaplan-Meier survival analyses, log-rank statistics and Cox regression analysis were employed to identify the impact of PLZF expression on long-term survival. We detected PLZF expression in 92% of primary melanoma tumors in vivo but not in melanoma cell lines in vitro. By univariate analysis, we identified: (1) PLZF mRNA expression < or = 10,000 mRNA copies/mug total tumor RNA, (2) Breslow tumor thickness >4 mm, and (3) American Joint Committee on Cancer stages IIC, IIIB, IIIC, and IV as statistically significant pretreatment risk factors. We defined a continuous prognostic index (i.e., risk score) for primary melanoma patients based on the regression coefficient of PLZF mRNA expression. Applying a cutpoint to the prognostic index at - 1.65, patients were assigned to one of two risk groups: low-risk patients (n = 28) with a median overall survival of 79 months (5-year survival of 61%) and high-risk patients (n = 13) with a median overall survival of 32 months (5-year survival of 23%) (p < 0.05). This is the first time that PLZF mRNA expression has been linked to a prognostic model for primary malignant melanoma patients to derive prognostic groups for clinical purposes (e.g., improved melanoma immunotherapies).

Management of lower lid ectropion.

BACKGROUND: Ectropion repair is a challenge in plastic surgery. Depending on the etiology of the underlying problem, a variety of surgical techniques are available. The etiology, operative management, and recurrence rate are presented. OBJECTIVE: An improvement of the deformity or, in the ideal case, a functional and aesthetic restoration should be accomplished. MATERIALS AND METHODS: In this study, 58 patients with ectropion treated from June 2002 until March 2004 were analyzed, 33 with scar contractures, 13 with a tumor of the lid margin, 8 with facial paralysis, and 4 with senile ectropion. Surgical procedures included lateral or medial canthopexy, lateral tarsorrhaphy, wedge excision, skin graft, local flaps, cartilage graft, fascial slings, and combined procedures in one-third of the patients. RESULTS: Postoperative complications included incomplete correction and others in 18.9% of the patients. Eight patients (13.8%) had to be reoperated. CONCLUSION: Correction of the lower lid area including restoration of the lid margin in terms of shape and position is the surgical end point. The preoperative analysis is mandatory for a surgical solution to this severe problem, which is associated with a high incidence of recurrence, especially in difficult reconstructive cases. An individual sophisticated strategy combined with experience in the variety of surgical techniques is mandatory. Frequently, multiple procedures are necessary.