A comparison of local recurrence and resection margins for stage I primary cutaneous malignant melanomas.

A retrospective review of 552 patients with clinical stage I primary cutaneous malignant melanomas was undertaken comparing margins of resection and local recurrence between 1966 and 1981. The overall local recurrence rate was 8 per 552 (1.45 percent). We observed no instances of local recurrence in lesions less than 1.40 mm thick with resection margins of at least 1 cm. A comparison of resection margins greater than 2 cm versus less than 2 cm for lesions less than 1.00 mm thick showed no difference at the 0.05 level of significance for local recurrence (0 per 228 versus 2 per 154; 1.3 percent) or survival. While narrower margins of resection for thinner, low-risk stage I malignant melanomas appear safe, the exact minimum margin of resection needed to satisfy both oncologic and cosmetic considerations, whether 1 or 2 cm, will need to be determined by a large prospective, randomized study.

Intersphincteric proctectomy.

Conventional proctectomy for inflammatory bowel disease is followed by delayed perineal wound healing in 20% to 63% of patients and sexual dysfunction in up to 17%. Although described several times since 1967, intersphincteric proctectomy is a technique used by very few surgeons in the United States. Accurate and safe rectal mobilization is easily accomplished by dissection within the intersphincteric plane, resulting in minimal damage to the pelvic floor and pelvic nerves and a much smaller perineal wound. The records of 58 patients who underwent rectal excision were examined. Proctectomy was performed in a conventional fashion for 30 patients and an intersphincteric proctectomy was performed for 28 patients. Of the 30 conventional procedures, 20 were for ulcerative colitis and 10 were for Crohn's disease. There was complete healing of the perineal wound in 70% of the patients at 6 months and in 73% at 1 year. There were four residual deep sinus tracts. Of the 15 men, three developed impotence, one permanently. Of the 28 patients who underwent intersphincteric proctectomy, 17 had ulcerative colitis, eight had Crohn's disease, two had incapacitating proctitis, and one had cancer of the midrectum. There was complete healing of the perineal wound in 84% of the patients at 6 months and in 84% at 1 year. There were no residual deep sinus tracts. Of the 15 men, one developed impotence that resolved after 1 year. Only one patient complained of persistent anal discomfort. The morbidity rate from intersphincteric proctectomy is low and we recommend more widespread use of this technique.

Rectal carcinoid tumors--treatment and prognosis.

Because of their location, rectal carcinoid tumors present a special therapeutic challenge for the surgeon. Only about 15% of these tumors manifest metastases and the others can be cured by complete local excision; hence performing a low anterior resection or an abdominoperineal resection for all patients would result in excessive rates of morbidity and death. Present-day treatment programs call for radical cancer resections only for lesions 2 cm in diameter or larger and local resection for all others. However, in a review of 595 patients, including 29 from the University of Chicago Hospitals, it was determined that this practice results in undertreatment of 24% (19/78) of all rectal carcinoid tumors that were associated with metastases, for 5% of all lesions smaller than 2 cm also had metastases. Invasion of the muscularis propria, we found, was an excellent additional prognostic sign for tumor progression. If the criteria for radical cancer resection included both size (all tumors 2 cm or larger and invasion of the muscularis propria in all smaller lesions, only 6% (5/78) of all aggressive tumors would have been missed and only 1.2% of all individuals with rectal carcinoid tumors would have received too limited an operation. It is hoped that the use of these new criteria will improve present-day survival statistics for patients with rectal carcinoid tumors.

Carcinoid tumors: a 37-year experience.

We analyzed 101 cases of carcinoid tumor in patients treated at the University of Chicago hospitals between 1942 and 1979. Tumors occurred most commonly in the rectum (29%) and ileum (28%). Only 12% were appendiceal. More than 60% were less than 1 cm, and 43% were confined to the submucosa. These factors led to favorable prognoses. Twenty-three percent of the tumors were greater than 2 cm in diameter; 70% of them had metastasized, compared with only 6% of lesions less than 1 cm. Metastases were present in 46% of ileal and 40% of colonic lesions. None of 13 bronchial and only one of 12 appendiceal lesions demonstrated this spread. Carcinoid syndrome was noted in three cases. A second neoplasm was present in 22%. The corrected five-year survival rate was 87% overall, 95% without metastases, 83% with positive regional lymph nodes, and only 40% with distant spread.