ECE-1 overexpression in head and neck cancer is associated with poor tumor differentiation and patient outcome.

BACKGROUND: Endothelin-converting enzyme-1 (ECE-1) primarily converts big endothelins (ETs) into active endothelin-1 (ET-1). However, the expression pattern and prognostication status of ECE-1 in head and neck cancer (HNC) are enigmatic. In this study, we investigated ECE-1 expression and assessed the roles of ECE-1 as a predictor for HNC differentiation and prognosis. MATERIALS AND METHODS: ECE-1 expressions were evaluated by immunohistochemical analysis using a tissue microarray (TMA) composed of 100 cases of head and neck squamous cell carcinoma. The correlation of ECE-1 expression with clinicopathologic variables and patient outcomes was analyzed. RESULTS: ECE-1 may be overexpressed in HNC carcinoma cells. Higher ECE-1 level was detected more frequently in moderately to poorly differentiated tumors and showed a lower differentiation category compared to the G1 cases (p = 0.015); this finding was further confirmed by an adjusted odds ratio (OR) of 4.071 (p = 0.042). Moreover, Kaplan-Meier survival analyses showed that a higher ECE-1 expression was associated with a poorer survival in patients with HNC (p < 0.0001). On multivariate Cox proportional hazards models analysis, ECE-1 of high expression proved to be an independent prognostic factor with a hazard ratio (HR) of 3.985 (p < 0.001). CONCLUSION: Our data provide the first evidence that overexpression of ECE-1 in HNC is a predictor of poor tumor differentiation and prognosis.

Vascularized lymph node transfer based on the hilar perforators improves the outcome in upper limb lymphedema.

BACKGROUND: Maintenance of the blood supply to the lymph nodes is necessary for survival and function. We report the outcome of vascularized lymph node transfer with hilar perforators compared with the conventional technique. PATIENTS: A total of 21 patients affected by early stage II upper limb lymphedema were included in this study. Of them, 11 patients received a free groin flap containing lymph nodes, and 10 patients received vascularized inguinal lymph nodes with hilar perforators. Mean follow-up was 46 and 40 months, respectively. Complications, secondary procedures, circumference of the limb, and subjective symptomatology were registered. The differences were evaluated statistically. RESULTS: The limb circumferences decreased significantly in the new group. The number of secondary procedures was significantly higher in the standard group. There were 2 cases of partial flap loss and donor site lymphorrhea in the standard group. In both the groups, visual analog scale scores improved after the operation. CONCLUSIONS: Transfer of vascularized inguinal lymph nodes based on the hilar perforators improves the outcomes in the treatment of early lymphedema of the upper extremity.

Optimizing outcome of charles procedure for chronic lower extremity lymphoedema.

BACKGROUND: The Charles procedure for late-stage lower limb lymphoedema (LLL) is often criticized for its unpredictable and poor results. We have adopted a systematic approach to optimize outcome of patients treated with this excisional surgery. METHODS: From June 2004 to March 2009 we performed the Charles procedure on 1 lower limb of 19 women and 8 men with late-stage LLL. Mean age and follow-up was 48 (range, 16.5-77.8) years and 21.6 (range, 1.5-48) months, respectively. RESULTS: Average inpatient stay was 27 (range, 11-54) days. After discharge, 16 (59.3%) patients underwent further minor surgery. The most frequent complication was a single, short episode of cellulitis, affecting 5 (18.5%) patients. Self-reported mobility was either the same or improved at 6 months, and appearance of their limbs satisfactory. CONCLUSIONS: The Charles procedure is an effective treatment for selected patients and by applying our systematic approach, a positive outcome can be achieved.

Elective amputation of the toes in severe lymphedema of the lower leg: rationale and indications.

Entry lesions at the toes interdigital spaces, in the setting of chronic lymphedema, are strongly associated with repetitive infective episodes which cause significant morbidity. A prospective study was designed to evaluate the outcome in 2 groups of patients affected by end stage III lymphedema of the lower extremity, treated with the Charles procedure with or without simultaneous amputation of the toes. At a mean 3 years of follow-up, 20% of the patients receiving elective toes amputation experienced recurrence of the infection and none required more proximal amputations. Among the patients not desiring elective toes amputation; 83% suffered multiples attacks of cellulitis and in 88% the toes were eventually amputated. The difference in the number of infective episodes between the 2 groups was highly significant. No cases of recurrent lymphedema were registered. Elective toes amputation in combination with the Charles procedure reduces recurrent cellulitis and long-term morbidity in stage III lymphedema of the lower leg.

Anterolateral thigh perforator flap: varying perforator anatomy.

The anterolateral thigh (ALT) perforator flap is based on the septocutaneous or musculocutaneous perforators from the lateral circumflex femoral vessels. Each perforator artery should be accompanied by 2 veins. Anomalies of the perforator anatomy in the subfascia and intramuscular layer are rarely reported. This study analyzed 6 anatomic perforator variations from subfascial to intramuscular level out of 1043 ALT perforator flaps performed from 2005 to 2007 in China Medical University Hospital in Taichung, Taiwan and from 2004 to 2007 in E-Da Hospital in Kaohsiung, Taiwan. The perforator flaps included (1) 1 perforator artery and 4 accompanying veins, (2) 1 perforator artery and 1 accompanying vein, (3) 1 tortuous perforator artery and 1 accompanying vein, (4) 1 perforator artery with no accompanying vein, (5) 2 veins with no accompanying perforator artery, and (6) 1 vein only. These variations in perforator anatomy were believed to be the causes of total or partial flap failure after excluding all the other possibilities such as vessel kinking or perforator injury during intramuscular dissection. Further, the nearby anteromedial thigh or tensor fasciae lata flaps were considered alternative flaps in cases of unusual perforator anatomy. The contralateral ALT flap was also necessary in some cases. However, anatomic variations in perforators from subfascial to intramuscular layer must be considered if the flap is to be used safely and reliably.

Treatment of dyspareunia by creation of a pseudojoint in rigid bone following total penile reconstruction with fibular osteocutaneous flap.

INTRODUCTION: Gender reassignment requires total penile reconstruction, which is commonly performed with autologous tissue. One option for reconstruction is the free fibula osteocutaneous flap, which provides a long segment of vascularized bone that is less susceptible to infection and allows for deep penetration into the vagina during sexual intercourse. One problem, however, is that their sexual partner may suffer from pain (dyspareunia) because of the long and rigid bone. AIMS: Our intent is to elucidate the treatment of female dyspareunia by surgically modifying the reconstructed penis with segmental osteotomies and fascia interposition within the rigid bone stock resulting from gender reassignment with a free fibula osteocutaneous flap. METHODS: In order to improve their sexual relations and alleviate dyspareunia, a semirigid penis was created by forming a pseudojoint at the junction of the proximal and distal third of the fibula bone stock with osteotomies and fascia interposition. MAIN OUTCOME MEASURES: Alleviation of dyspareunia by surgical modification of a previously reconstructed penis for the couple to continue to have sexual relations. RESULTS: The created pseudojoints in the reconstructed penis allowed for pain-free vaginal intercourse between the patient and his wife because of its now semirigid structure. CONCLUSIONS: The surgical modification presented in this case report addresses the treatment of dyspareunia by creating a more malleable penile reconstruction, which will now allow for a pain-free vaginal intercourse.