Measuring the quality of melanoma surgery - Highlighting issues with standardization and quality assurance of care in surgical oncology.

In an attempt to ensure high standards of cancer care, there is increasing interest in determining and monitoring the quality of interventions in surgical oncology. In recent years, this has been particularly the case for melanoma surgery. The vast majority of patients with melanoma undergo surgery. Usually, this is with combinations of wide excision, sentinel lymph node biopsy and lymphadenectomy. The indications for these procedures evolved during a time when no effective systemic adjuvant therapy was available, and whilst the rationale has been sound, the justification for differences in extent and thoroughness has generally been supported by inadequate or low-level evidence. This has led to a substantial variation among melanoma centres or even among surgeons within a centre in how these procedures are done. With recent rapid progress in the efficacy of systemic treatments that are impacting on overall survival, the prospect of long-term survival in these previously high risk patients means that more than ever long-term locoregional control of melanoma is imperative. Furthermore, the understanding of effects of systemic therapy on locoregional disease will only be interpretable if surgeons use standardized, high quality techniques. This article focuses on standardization and evolution of quality indicators for melanoma surgery and how these might have a positive impact on patient care.

Bowel complications after prolene hernia system (PHS) repair: a case report and review of the literature.

The advent of mesh devices allowed for tension-free inguinal hernia repairs and a subsequent reduction in the rate of recurrences. In 1993, Rutkow and Robbins introduced the plug-and-patch repair method whereby the hernia defect is filled with a mesh plug. This new procedure led to new technique-specific complications. Here, we report the case of a man who presented with obstructive symptoms and pain at the site of his inguinal hernia repair performed with the Prolene Hernia System((R)) 18 months prior. At laparotomy, he was found to have a small bowel obstruction and perforation due to mesh contact with the small bowel and colon. The literature is reviewed for cases of bowel complications due to mesh plugs. Based on reported complications, three recommendations can be made to avoid or reduce the risk of this complication. First, the pre-peritoneal dissection should be performed carefully with particular attention to identify and repair any tears of the peritoneum. Secondly, the mesh plug should not be placed too deep within the defect. Finally, the plug should be secured to reduce the possibility of mesh migration.

The tumor suppressor protein menin interacts with NF-kappaB proteins and inhibits NF-kappaB-mediated transactivation.

Multiple endocrine neoplasia type 1 is an autosomal dominant tumor syndrome. Manifestations include neoplasms of the parathyroid glands, enteropancreatic neuroendocrine cells, and the anterior pituitary gland. The MEN1 tumor suppressor gene encodes menin, a 610 amino acid nuclear protein without sequence homology to other proteins. To elucidate menin function, we used immunoprecipitation to identify interacting proteins. The NF-kappaB proteins p50, p52 and p65 were found to interact specifically and directly with menin in vitro and in vivo. The region of NF-kappaB proteins sufficient for binding to menin is the N-terminus. Furthermore, amino acids 305-381 of menin are essential for this binding. Menin represses p65-mediated transcriptional activation on NF-kappaB sites in a dose-dependent and specific manner. Also, PMA (phorbol 12-myristate 13-acetate)-stimulated NF-kappaB activation is suppressed by menin. These observations suggest that menin's ability to interact with NF-kappaB proteins and its modulation of NF-kappaB transactivation contribute to menin's tumor suppressor function.