Fistula and stenosis after 135 (pharyngo)laryngectomies.

BACKGROUND: Despite progress made with reconstruction, morbidity is still elevated after (pharyngo)laryngectomy. The present study was designed to determine the incidence and predisposing factors of the complications following (pharyngo)laryngectomy. METHODS: Primary surgical treatment was delivered in 60 patients. Seventy-five patients underwent surgical salvage following radiotherapy. Different factors were evaluated as potentially predisposing to fistula formation. RESULTS: Stenosis is rare: 5.1% in the present series. A pharyngocutaneous fistula developed in 48.8% of patients. After a multivariate analysis, the site of the tumour was defined as a significant risk factor for pharyngocutaneous fistula formation. CONCLUSIONS: Despite progress made with reconstruction, morbidity is still elevated after major resection of the phary golarynx. Stenosis, a frequent complication when partial pharyngectomy is needed, is rare: 5.1% in the present series. Fistulas are relatively frequent but the majority resolved either with local irrigation or with subsequent flaps. The site of the tumour was a significant risk factor for pharyngocutaneous fistula formation, as defined by a multivariate analysis.

Wide localized excision and reconstruction for minor salivary gland tumours.

BACKGROUND: Insufficient excision is one of the main factors leading to recurrence of minor salivary gland tumours. Our aim is to perform large resections with immediate reconstruction in order to provide local control, as well as to achieve better cosmetic and functional results. METHODS: Four consecutive patients suffering from minor salivary gland tumours of the upper aerodigestive tract were treated: two had adenoid cystic carcinomas (one of the lateral oropharyngeal mucosa, one of the retromolar area); one had a polymorphous low-grade carcinoma (at the base of the tongue); and one had mucoepidermoid carcinoma (on the floor of the mouth). Two radial forearm free-flaps, a trapezius myocutaneous pedicled flap (including an adjacent osseous part of the scapula), and a sternocleidomastoid muscular pedicled flap were used, respectively, for reconstruction. Additional external radiation was used for three patients (60 cGy). RESULTS: The postoperative course was uneventful for each patient, and the ability to chew and swallow was rapidly restored. Two patients, locally controlled, with adenoid cystic carcinomas died: one from brain metastases (four years post-surgery), the other with pulmonary metastases (eight-years post-surgery). One patient is alive with a recurrent tumour of the pterygomaxillary fossa (without trismus) sixteen years after the original operation; another patient is free of recurrent disease at the base of the tongue but has recently undergone surgery, with success, for two pulmonary metastases sixty months after the initial surgery. CONCLUSIONS: For minor salivary gland carcinoma of the head and neck, large resection with immediate reconstruction affords fast recovery and long-lasting locoregional control. Additional radiotherapy is feasible.

Immediate breast reconstruction with implants and adjuvant chemotherapy: a good option?

Immediate breast reconstruction using implants is a currently practiced intervention. However, it is exposed to the potential adverse effects of adjuvant therapies necessitated for cancer control. Patients with implants, receiving adjuvant chemotherapy, were compared with those not necessitating chemotherapy to evaluate the real impact of this combination of treatment modalities on the final outcome. Cosmetic results were not influenced by the adjunction of chemotherapy, but a higher rate of implant infection was observed in the chemotherapy group (10.7% versus 1.5% p = 0.0084). This observation needs to be kept in mind when selecting patients for immediate breast reconstruction with implants.

Lethal cutaneous verrucous carcinoma.

Verrucous carcinoma is a rare subtype of well-differentiated squamous cell carcinoma that may occur anywhere on the skin. It is slow growing, enlarging relentlessly and invading locally. Some cases were reported to occur on chronic scar tissue but demonstrated the same clinical course than in other locations. Herein, we report on a very unusual case of cutaneous verrucous carcinoma arisen from a long-standing (40 years old) burn scar and which involved the pleura five years after the initial surgical resection. To our best knowledge, this is the first case of pleural involvement by a verrucous carcinoma originating from the skin.

Basal cell carcinoma of the external auditory canal.

Carcinomas of the external auditory canal are rare, nevertheless they are associated with a relatively poor prognosis. Among these tumours, basal cell carcinomas are less frequent than squamous cell carcinomas. Anyway, it is difficult to determine if their prognosis is better, as in other localizations on the body. We reviewed six patients, presenting locally advanced basal cell carcinomas of the external auditory canal and considered the history of their disease, the treatment procedures and final oncological outcome. Four of the patients died of the disease within five years from surgery. They presented local recurrences even after radical surgical excision in free tissue margins. From these findings we have the impression that basal cell carcinoma of the external auditory canal behave, even after radical surgery, as an aggressive tumour associated with a really poor prognosis.

Bednar tumor of the foot: a case report.

Pigmented dermatofibrosarcoma protuberans (Bednar tumor) is a rare neoplasm accounting for approximately 1-5% of all cases of dermatofibrosarcoma protuberans. The majority occurs on the trunk, and the remainders are more or less equally distributed in the upper and lower extremities and the head and neck. Microscopically it is characterized by spindled cells arranged in a tight storiform pattern and admixed with a small population of melanin-containing dendritic cells. The dendritic cells are the primary feature that distinguish this lesion from conventional dermatofibrosarcoma protuberans. We report here a case of Bednar tumor occurring on the dorsal aspect of the foot in a young female.

Immediate breast reconstruction with saline-filled implants: no interference with the oncologic outcome?

The possible adverse effects on cancer control due to immediate breast reconstruction have been addressed recently for both silicone-filled implants and flap reconstruction. To evaluate those possible effects after immediate breast reconstruction with saline-filled implants, 49 patients reconstructed with saline-filled breast implants at the Jules Bordet Cancer Institute were studied. Selection was only based on the possibility to find a matched patient. These patients were matched with a control group of 49 matched women with breast cancer treated in the same center by mastectomy without any type of breast reconstruction. The two groups were comparable according to age at diagnosis (within 3 years), year of diagnosis (same year), stage of the tumor, histology, and nodal status. The only difference between the two groups was that radiation therapy was applied to some of the patients who were not reconstructed (due to tumor location). The results show, in terms of local recurrences, distant metastasis, and deaths, no significant difference between the two groups, even for the irradiated patients, within a mean follow-up period of 72 months (range, 24 to 108) months.

Cutaneous verrucous carcinoma.

Verrucous carcinoma is a rare, low-grade, well-differentiated squamous cell carcinoma most commonly seen on mucosa. It has been infrequently reported to occur on the skin, where it is a slow-growing and locally aggressive tumour. It is not uncommon for cutaneous verrucous carcinomas to be mistaken for the more frequent verruca vulgaris and treated accordingly. Three cases of cutaneous verrucous carcinoma are presented with the medical history and follow-up data. Surgery is the treatment of choice; these lesions may sustain a potentially anaplastic transformation after radiation therapy.

[Reconstructive surgical techniques after palliative tumor excision]. / Techniques de reconstruction apres exerese tumorale palliative.

Palliative care is more and more of concern in medical information. If there is no exact definition about the real place of surgery in this concept, the rule of reconstructive surgery is even less clear. The goal of this paper is to try to define, on one hand the general characteristics of palliative surgery, and on the other hand, to underline the role of reconstructive surgery in four specific indications: the head and neck area, the thorax, the pelvis and the extremities. The resection surgery, associated with flap coverage, may seems an excessive treatment in such palliative indications. Nevertheless, the results presented here tend to demonstrate that, after careful patient selection a better quality of life could be obtained with an acceptable surgery-induced morbidity (regarding preoperative disability). More than technical aspect, it is by a different approach of the problem that this type of surgery is to be distinguished.

Cutaneous malignant melanoma in children.

UNLABELLED: Although rare, malignant melanoma does occur in children. As in adults, prognosis clearly depends on rapid diagnosis and early treatment. This paper describes eight cases of confirmed malignant melanoma in children, with full case history and pathological findings. Mean follow-up was 109.8 months. Early diagnosis and low Breslow indices provide good results in the form of absence of recurrence and long-term survival prognosis. The paper also includes a discussion of specific risk factors affecting children. In order to encourage earlier diagnosis and improved prognosis, it must be kept in mind that in children too, the skin as an organ should be included in any physical examination. CONCLUSION: As for adult patients, early clinical detection, speedy histological confirmation and prompt surgery is the only way to achieve a long survival period for children suffering from malignant melanoma.

Radiation therapy after immediate breast reconstruction with implants.

The use of implants in immediate breast reconstruction is presently a common option. However, the practice should be evaluated in consideration of possible adjuvant therapies needed to control disease and to rule out negative interactions. This article discusses the effects of radiotherapy on breast implants with regard to the final cosmetic result. Six out of 124 cases of immediate breast reconstruction with implants were followed and evaluated in terms of capsular contracture and final aesthetic result after adjuvant radiotherapy and compared with the results of 118 patients who did not require irradiation. All of the patients who received irradiation demonstrated poor to fair results, with grade III to IV capsular contracture. Two patients received radiation therapy for local recurrences, which worsened their capsular contracture, emphasizing the deleterious effect of irradiation on breast implants. Statistical analysis of the results demonstrated a significant difference between the two groups in terms of capsular contracture and breast symmetry. In the selection of patient candidates for immediate breast reconstruction with implants, adjuvant radiation therapy must be considered as a contraindication, at least from an aesthetic point of view.

Current guidelines in melanoma treatment. Melanoma Working Group of Gent and Bordet.

This article focuses on the actual management of cutaneous melanoma, dealing both with established, internationally well-accepted standard procedures and interventions which are still being investigated. It wants to offer a global picture to the dermatologist of what is currently available in the therapeutic arsenal against melanoma.

Early surgical suction and washout for treatment of cytotoxic drug extravasations.

This case report is presented to assess safety and efficiency of early suction and saline washout of extravasated cytotoxic drugs. Through multiple small skin incisions, the area of extravasation is first suctioned and subsequently extensively washed out with saline. Incisions are left open and the arm is elevated for 24 hours. A complete healing was obtained in five days without any skin or soft tissue loss. No additional treatment was needed. Early referral and surgical treatment by suction and washout is a safe and reliable treatment protocol for major cytotoxic drug extravasation injuries.

Extravasation injuries and emergency suction as treatment.

To evaluate the efficiency of emergency suction in extravasation injuries of contrast medium, records of 11 patients treated for extravasation injuries with a combination of suction and saline washout were reviewed. All of the patients were treated in the first 2 hours after injury. The mean extravasated volume was 55 cc. There were no surgery-related complications, and all the patients experienced a relief of their preoperative pain. Except for two patients with blisters at admission, none of them suffered skin or soft-tissue necrosis. Mean time to complete healing was 9 days. Emergency suction therapy is safe and effective in preventing the skin and soft-tissue necrosis associated with extravasation injuries of hyperosmolar contrast medium.

In vivo study of electrolyte exchanges through membranes of saline-filled breast implants.

Saline-filled breast implants are currently used in breast reconstruction and augmentation. Free diffusion of electrolytes through these implants has been questioned recently and is of potentially high importance. Many questions are still unanswered about this phenomenon. Eighteen prostheses were reviewed and tested for diffusion and exchange of electrolytes and glucose in vivo. None of these implants demonstrated major variation of the inner contents from the original saline used to fill them, emphasizing the real innocuousness of such implants in terms of possible ionic pooling. Extrapolation of these results to all implants made by different manufacturers is not possible according to the sample size in the present study.

alpha-Melanotropin immunoreactivity in human melanoma exudate is related to necrosis.

We have previously reported high immunoreactive alpha-MSH (IR-alpha-MSH) concentrations in melanoma patients' plasma, as well as significant amounts in melanoma metastases and cells grown in culture. Necrosis within the melanoma tumour leads to a massive proteolysis of intracellular proteins and release of cell content: this might significantly contribute to the elevated IR-alpha-MSH plasma levels measured in melanoma patients. To test this hypothesis, we studied the necrosis-related release of MSH from human melanoma cells, using a specific radioimmunoassay. The studies of fine-needle biopsies indicated that most of the human melanoma tumour exudates tested contained very high MSH concentrations (> 500 pg/ml; 14/15), while plasma levels were generally normal (< or = 25 pg/ml; 10/15). The level in an exudate from a non-melanoma tumour type was < 40 pg/ml. In vitro studies showed that release of the IR-alpha-MSH was time- and temperature-dependent, and related to cell death.