A 5-year follow-up study of 633 cutaneous SCC excisions: Rates of local recurrence and lymph node metastasis.

BACKGROUND: A 5-year follow-up study of 633 cutaneous squamous cell cancer (SCC) excisions was performed by collecting data on rates of local recurrence (LR) and lymph node (LN) metastasis. METHODS: A retrospective analysis of patients was performed across four regional plastic surgery centres (Stoke Mandeville Hospital, Aylesbury; John Radcliffe Hospital, Oxford; Salisbury District Hospital, Salisbury and Queen Alexandra Hospital, Portsmouth) assessing rates of LR and LN metastasis. RESULTS: We report 5-year outcomes from 598 SCCs (95% follow-up rate). The total recurrence rate (LR and LN metastasis) was 6.7% (n = 40) at 5 years, with 96% of these occurring within 2 years. Median time to LR was 9 months (1-57), with 76.9% (n = 20) undergoing further wide local excision. Median time to LN metastasis was 5.5 months (1-18 months). There were two cases of disease-related death. Only 15% (n = 6) of incomplete excisions recurred. Interestingly, 19.1% (n = 9) of 47 SCCs with perineural invasion on original histopathology recurred versus only 5.6% (n = 31) of the 551 SCCs without perineural invasion (p = 0.005). CONCLUSIONS: This study is one of the largest studies to date following up 598 SCC excisions at 5 years with total recurrence rates comparable to those in current published literature. We report perineural invasion as a significant predictor of recurrence and that 96% of total recurrence occurred within 2 years. This is in contrast to current UK guidelines (75% at 2 years, 95% at 5 years), thus suggesting that shorter length of hospital follow-up may be reasonable.

Melanoma in buckinghamshire: data from the inception of the skin cancer multidisciplinary team.

Background. Melanoma incidence is increasing faster than any other cancer in the UK. The introduction of specialist skin cancer multidisciplinary teams intends to improve the provision of care to patients suffering from melanoma. This study aims to investigate the management and survival of patients diagnosed with melanoma around the time of inception of the regional skin cancer multidisciplinary team both to benchmark the service against published data and to enable future analysis of the impact of the specialisation of skin cancer care. Methods. All patients diagnosed with primary cutaneous melanoma between January 1, 2003 and December 3, 2005 were identified. Data on clinical and histopathological features, surgical procedures, complications, disease recurrence and 5-year survival were collected and analysed. Results. Two hundred and fourteen patients were included, 134 female and 80 males. Median Breslow thickness was 0.74 mm (0.7 mm female and 0.8 mm male). Overall 5-year survival was 88% (90% female and 85% male). Discussion. Melanoma incidence in Buckinghamshire is in keeping with published data. Basic demographics details concur with classic melanoma distribution and more recent trends, with increased percentage of superficial spreading and thin melanomas, leading to improved survival are reflected.

Guidelines for the excision of cutaneous squamous cell cancers in the United Kingdom: the best cut is the deepest.

Surgical excision remains the gold standard for the management of cutaneous squamous cell cancers (SCC) and national guidelines for operative radial margins predict 95% oncological clearance with a margin of 4 mm for low-risk and 6 mm for high-risk tumours. We retrospectively analysed all cutaneous SCC excisions performed across 4 regional Plastic surgical units in England over a consecutive 24-month period and collected data on tumour characteristics, operative and histological margins and completeness of excision. We identified 633 eligible SCC excisions of which 265 (42%) were over 2 cm in diameter with 37 recurrent tumours (5.8%). The mean radial operative margin was 6.5 mm across all tumours and 8.4 mm for tumours greater than 2 cm. The mean histological tumour diameter was 21 mm. The overall incomplete excision rate was 7.6% (7.9% for tumours >2 cm). Ninety-four percent (45/48) of incomplete excisions involved the deep margin and only 3 out of 633 excisions (0.47%) were incomplete at a radial margin only. No differences were observed in tumour size or excision margin between incompletely and completely excised tumours. Incomplete excisions were most common on the ear, nose and cheek. In summary our analysis demonstrates that despite adherence to recommended surgical margins for cutaneous SCCs the incomplete excision rate remains higher than expected. We believe that this is because most incomplete excisions are incomplete at the deep margin and question the utility of performing increasingly wide excisions, and, the generalisability of the evidence upon which recommendations for radial margins are based.

Pyogenic granuloma - the quest for optimum treatment: audit of treatment of 408 cases.

Pyogenic granuloma is a common, acquired, benign vascular lesion of skin and mucous membranes which may occasionally present intravascularly or subcutaneously. Pyogenic granuloma occur in all age groups and although they may eventually regress, removal of unsightly, bleeding or uncomfortably positioned lesions is usually sought before this takes place. This is a retrospective study of 408 cases of pyogenic granuloma that were analysed by the Stoke Mandeville Histopathology laboratory between 1994 and 2004. This study was carried out to review the sex, age and anatomic distribution of the lesions and to assess the most successful form of treatment on the basis of recurrence risk and other measures such as aesthetic result, acceptability and appropriateness of the procedure with respect to the patient. There was a slight male preponderance especially among children. The exception to this was lesions on mucous membranes, which were more common in women. Head and neck was the most common anatomical location, in particular the cheek and intraoral locations. Fewest recurrences were noted following excision and direct closure although all techniques investigated showed an acceptably low recurrence rate. Whatever technique is used it must yield material for histopathological analysis to ensure the exclusion of differential diagnoses.

Male breast cancer in World War II aviation: a case report and review.

Increased incidence of malignancies within aviators is well documented. Commercial female flyers have been found to have a higher risk of developing breast cancer. However, there has not been any report of male breast cancer related to flying either alone or where malignant melanoma and other primary cancers are also associated. We report two male World War II, British Royal Air Force pilots with primary breast carcinoma associated with two other primary cancer sites.

Pregnancy as an autologous tissue expander for closure of an abdominal-wall defect.

We report the reconstruction of a complex abdominal-wall defect using expanded skin from pregnancy. Wound closure was achieved using a vertical abdominoplasty.

Hair thread tourniquet syndrome.

Tourniquet of hair and thread fibres may become tightly wrapped around a child's digit. The resultant ischaemia may lead to tissue necrosis and autoamputation. Experience with two patients is reported. The need for prompt recognition and complete removal of all fibres is stressed. The possibility of non-accidental injury should be born in mind.

Domestic iron burns in children: a cause for concern?

The case notes of 26 children with contact thermal burns to the hand who were treated in the Burn Unit at Stroke Mandeville Hospital as inpatients during the period 1987-92 have been reviewed. The burns were found to be caused by a variety of injuring agents, although the domestic iron was the single commonest cause accounting for 46 per cent of cases. Mechanisms of iron injuries were variable although leaving a hot iron on the floor or on a low table were identified as being two important causes. Fifteen children (58 per cent) underwent either primary or tangential excision of the burn skin and grafting. The majority of the children had a satisfactory outcome, although five children (19 per cent) developed hypertrophic scars. The results of this study demonstrate the relatively high incidence of domestic iron burns as a causative factor for contact hand burns in children. Parental vigilance and leaving a hot iron in a secure place are two factors which will help to reduce the incidence of this potentially serious injury.

Pretibial injuries in the elderly: a prospective trial of early mobilisation versus bed rest following surgical treatment.

Pretibial lacerations are a common form of injury of the elderly population. With respect to graft healing, controversy exists regarding rehabilitation by early ambulation, following debridement and split skin grafting. In a prospective, randomised trial comparing early mobilisation (n = 21) with the traditional method of a period of in-patient bed rest after surgical treatment (n = 40), no statistically significant difference has been found in the percentage area of skin graft take at either 1 or 3 weeks postoperatively. The method of anaesthesia (local or general) has no significant effect on the outcome of healing. Prolonged bed rest has a detrimental effect on return to independent mobility in one third of cases. Complications related to the wound site are similar in both groups. Hospital stay averaged 12 days in those confined to bed, compared to an average of 2 days in those who were allowed to walk immediately.

The estimation of blood loss during burns surgery.

The estimations of blood loss and transfusion requirements during burns surgery are notoriously difficult. This clinical study investigated the effectiveness of estimates made by junior and senior burns surgeons and senior anaesthetists by comparing them with calculated blood losses. Regression analysis shows good correlation between these methods (r-value range 0.75-0.97), although 'eye-balling' the losses tends to underestimate the transfusion requirements (regression slope coefficients ranged between 0.56 and 0.87). In only five out of 46 procedures was there a need for late transfusion for an unacceptably low haemoglobin level (< 10 g/dl). This provides further empirical evidence for the clinical value of each member of the team voicing an estimate of the loss at the end of the procedure. The mean blood loss for 1 per cent of burn excised or split skin donor site harvested was 117 ml in adult cases. Blood loss can also be expressed as a mean percentage of the patient's calculated total blood volume for each 1 per cent burn excised or autograft harvested, giving figures of 2.6 per cent for adults and 3.4 per cent for children. Gravimetric analysis of soiled swabs underestimates the blood loss by approximately 50 per cent.

Localized nodular synovitis: a rare cause of ulnar nerve compression in Guyon's canal.

A rare case of ulnar nerve entrapment at the wrist by a nodule of localized nodular synovitis is presented. The literature is reviewed with particular reference to the causes of ulnar tunnel syndrome, the uncertainty over the origin of this type of tumor, and its tendency to recur after incomplete excision.

Contact burns due to thermoplastic road paint.

Thermoplastic road markings are used at similar temperatures to tar and bitumen and spillage onto skin causes similar contact burns. Most of these occupational burn injuries can be avoided by adherence to the manufacturer's recommendations about the wearing of protective clothing. Management and foremen of contractors using these materials need to ensure that their workers comply with safe procedures and wear the specified protective clothing.