Nonoperative treatment of anterior interosseous nerve paralysis.

Although the current recommendation for the treatment of spontaneous anterior interosseous nerve paralysis is surgical decompression, there has been recent evidence in the neurologic literature that these lesions are examples of a neuritis. We followed 10 cases of spontaneous partial anterior interosseous nerve paralysis. All patients were seen initially with a typical history of pain. Seven had signs of other nerve involvement either on physical examination or electromyogram analysis. Eight patients treated by observation had signs of recovery in 6 months and full recovery within 1 year. Surgical decompression did not affect recovery time in the other patients. Our findings suggest that anterior interosseous nerve paralysis is a form of neuritis and can safely be treated without operation. These patients will achieve complete recovery.

Treatment considerations in the complicated rheumatoid hand.

The rheumatoid patient with complex involvement or multiple deformities of the hand and wrist can be a challenge to the hand surgeon. A systematic and orderly approach is used to formulate and execute a treatment plan that is realistic and that can result in modest, but significant improvement in overall hand function. The evaluation and treatment philosophy which is described can help turn a complicated and seemingly overwhelming situation into smaller components which can be treated in one or more surgical stages.

Dupuytren's (subungual) exostosis.

Because it may produce a bewildering array of histologic patterns, the clinical entity of subungual exostosis (Dupuytren's exostosis), is sometimes confused with chondrosarcoma. However, this lesion is a distinct entity. It begins as a reactive growth of cellular fibrous tissue and metaplastic cartilage, which undergoes enchondral ossification. The rate of growth may be exuberant, but it is limited. We present a series of 15 cases as well as a review of the literature. Postadolescents and young adults are most commonly affected, and the majority of cases (80%) occur on the dorsal-medial aspect of the great toe. Trauma, whether chronic or acute, and infection are frequent inciting factors. The radiologic picture is consistent and can be diagnostic. In more than half our cases, chondrosarcoma was suspected initially. However, if the entire clinical picture is evaluated, the histologic findings should not lead to confusion with a malignant process. This acquired exostosis is benign; local excision is curative. However, recurrence is common (53%) after incomplete excision or when the lesion has not achieved full maturation.

Ultrastructure of myofibroblasts and decidualized cells in leiomyomatosis peritonealis disseminata.

A case of leiomyomatosis peritonealis disseminata studied by light and transmission electron microscopy is reported. The lesion, from a pregnant woman, was found to contain predominantly myofibroblasts and decidualized cells in a rich collagen stroma, while relatively few leiomyocytes and fibroblasts were observed. The development and fate of this entity are discussed in view of the present findings and those previously reported.

Prognostic factors in the treatment of cutaneous melanoma.

The incidence of metastasis in cutaneous melanoma is proportional to maximal tumor thickness. The relationship is linear for extremity melanoma but not for tumors from all body sites, probably due to intrinsic differences in tumors from different sites. The level of invasion of the tumor is an indirect measure of tumor thickness and is not as accurate in predicting metastases because of the marked variation in thickness within each level. The implications of these observations for the treatment of melanoma are discussed.

Stage I melanoma of the limbs: assessment of prognosis by levels of invasion and maximum thickness.

The prognostic significance of 2 histological parameters, level of invasion and maximum thickness is evaluated in 248 cases of malignant melanoma of the limbs staged T1-3NoMo which were collected for Trial No. 1 of the W.H.O. Collaborating Centres for the Evaluation of Methods of Diagnosis and Treatment of Melanoma between September 1967 and December 1974. There is a linear relation of tumor thickness to mortality with a high statistical significance (P = 0.0002). Mortality also increases with progression of the level of invasion. The incidence of occult metastases to the regional lymph nodes increases with increasing thickness or level of invasion. Moreover the age and sex corrected survival curves are also dependent on both parameters. The comparison of the 2 methods revealed that maximal tumor thickness is a more powerful measure of prognosis than is the determination of the level of invasion.

Evaluation of prognosis in Stage I cutaneous melanoma.

A review of the literature on melanoma indicates that age, sex, size, ulceration, presence of satellites, absence of melanin, and whether or not the tumor is markedly raised above the surface of the surrounding skin are all useful criteria in evaluating the prognosis in Stage I cutaneous melanoma. Histological factors include the tumor type, the mitotic rate, and the maximum thickness of the tumor. The last is accurate for prognosis--objective, reproducible, and directly proportional to the mortality rate. Tumors less than 0.76 mm thick rarely, if ever, metastasize--and it appears that the size of the resection margin can safely be reduced for such thin tumors. The level of invasion (Clark) is less accurate in predicting the mortality.

Optimal size of resection margin for thin cutaneous melanoma.

The width of the resection margin for 62 melanomas less than 0.76 millimeter thick ranged from 0.10 to 5.50 centimeters, with 32 per cent being 1.0 centimeter or less. None of these patients has a local recurrence or metastases develop. It appears that these thin tumors should be treated conservatively, the size of the resection margin being dependent upon the anatomic location of the tumor. In most instances, skin grafting should not be necessary.

Malignant melanoma: correlation of long-term follow-up with clinical staging, level of invasion and thickness of the primary tumor.

Sixty melanoma patients were followed 20 to 30 years after primary therapy, and survival rates were reviewed with reference to clinical and histological staging. All but one of the patients with clinically positive regional nodes died of metastatic disease. Two of nine patients with nonenlarged nodes that were clinically negative but histologically positive are alive 25 years after node dissections. Ten of 17 patients with negative nodes survived their operations by 20 to 30 years. Another series of 138 patients with stage 1 cutaneous melanoma were reviewed at the George Washington University Medical Center and tumor thickness was found to be a better measurement of prognosis than clinical or histologic staging, or the tumor's level of invasion. Prophylactic lymph node dissection appeared to double the survival of patients with lesions greater than 1.5 millimeters thick, but had no effect on those with thinner lesions. Thirty-nine per cent of the patients had lesions less than 0.76 mm thick, and all survived free of disease for five or more years. Of the tumors in the intermediate range of 0.76 to 1.50 mm thick, 33% metastasized or recurred; no clinical or pathologic discriminant could be detected that differentiated those patients who would have the recurring lesions from the others with tumors in this range of intermediate thickness who did well.