Clinicopathological characteristics, diagnosis and treatment of melanoma in Serbia--the Melanoma Focus Study.

BACKGROUND/AIM: Treatment options for metastatic melanoma in Serbia are limited due to the lack of newly approved biologic agents and the lack of clinical studies. Also, there is a paucity of data regarding the treatment approaches in different tertiary centers and efficacy of available chemotherapy protocols. The aim of this study was to obtain more detailed data about treatment protocols in Serbia based on structured survey in tertiary oncology centers. METHODS: Data about the melanoma patients treated in 2011 were analyzed from hospital databases in 6 referent oncology centers in Serbia, based on the structured survey, with the focus on metastatic melanoma patients (unresectable stage IIIC and IV). RESULTS: A total of 986 (79-315 in different centers) patients were treated, with 320 (32.45%) newly diagnosed patients. There were 317 patients in stage IIIC/IV, 77/317 aged < 50 years. At the time of diagnosis 47.3% of patients were < 60 years of age (24.2% < 40 years, 23% 50-59 years, 52.6% > 60 years). At initial diagnosis 12.5% of patients were in stage III and 4.5% in stage IV. The most common type was superficial spreading melanoma (50-660), followed by nodular melanoma (23.5-50%). Apart from the regional and distant lymph node metastases, the most frequent organs involved in stage IV disease were distant skin and soft tissues (12-55%), lungs (19-55.5%), liver (10-60%), and bones (3-10%). The first line therapy in stage IV metastatic melanoma was dacarbazine (DTIC) dimethyl-triazenoimidozole-carboxamide in 61-93% of the patients, while the second line varied between the centers. Disease control (complete response + partial response + stable disease) was achieved in 25.7% of the patients treated with the first line chemotherapy and 23.1% of the patients treated with the second line therapy, but the duration of response was short, in first-line therapy 6.66 +/- 3.36 months (median 6.75 months). More than 90% of patients were treated outside the clinical trials. CONCLUSION: Based on this survey, there is a large unmet need for the new treatment options for metastatic melanoma in Serbia. The development of national guidelines, and greater involvement in international clinical studies could lead to widening of treatment options for this chemotherapy resistant disease.

A 5-year retrospective analysis of necrotizing fasciitis--a single center experiences.

BACKGROUND/AIM: Necrotizing fasciitis (NF) is usually an acute infection of superficial fascia with rapid progression in around soft tissue. If not promptly recognized and aggressively treated NF usualy leads to sepsis and multiorgan failure with fatal outcome, thus early diagnosis and prompt surgical treatment are crucial for healing of these patients. The aim of this article was to evaluate the clinical presentation of all patients with acute NF diagnosed and treated in surgical clinics of Clinical Center of Vojvodina, Novi Sad, Serbia. METHODS: The medical records of patients treated for acute NF localized on a different parts of the body in Clinical Center of Vojvodina, Novi Sad, Serbia, during a 5-year period (from January 2008 to December 2012) were retrospectively evaluated. This study enrolled patients admitted via Emergency Center of Vojvodina with the diagnosis of acute NF either as the primary diagnosis or with the diagnosis at discharge after surgical treatment. RESULTS: During a 5-year period there were 216 patients with final diagnosis of acute NF. Most of our patients (140-64.81%) were admitted with the initial diagnosis of cellulitis, abscesses, phlegmons or sepsis. Unfortunately, the clinical symptoms of acute NF were atypical at time of initial examination. Pain and swelling of the affected localization were the most presented bias of symptoms (183-84.72%). The majority of our patients were male (164-75.92%). Among the 216 patients, the most common pre-existing single factor was drug abuse (39-18.05%), followed by obesity (38-17.59%) and diabetes mellitus (31-14.35%). Trauma was most common etiological factor (22-10.8%) in infected wounds, followed by abdominal (15-6.94%) and orthopedic (11-5.09%) surgical intervention. In the present study idiopathic acute NF was diagnosed in 22 (10.18%) patients and more than one etiological factor were diagnosed in 20 (9.25%) patients. The majority of our pa- tients had type I acute NF (172-79.62%) with Streptococcal species as the most common microorganism (125-71.02%). The most common localization was an extremity (151-69.90%). The minority of our patients had head and neck lo- calization of infection (7-3.24%). Surgical treatment was performed in all the patients and most of them (183-84.72%) received the first surgery within 24 h. Other patients (23-10.64%) received operation after stabilization of general status or after getting the diagnosis of acute NF (unclear diagnosis on admission). During hospitalization, the most common complication among our patients was sepsis (156-72.22%). The mortality rate was 14.35%. CONCLUSION: Acute NF is a rare but very difficult and sometimes life-threatening disease of superficial fascia and around soft tissue. If acute NF is suspected, early radical excision of all the affected tissue with exploration and excision of superficial fascia with pathological and microbiological assessment are most significant for treatment. Appropriate antibiotics and intensive care set ting to manage other organ failure of NF are recommended at the same time with surgery.

Estimating disability and quality of life after different degrees of hand and forearm trauma.

BACKGROUND/AIM: Hand injuries comprise up to one fourth of all injuries and require excellent skills and aggressive physical therapy with still a high potential to cause long term physical and functional disability which affects one's quality of life. The aim of this study was to evaluate disability and quality of life in patients with different degrees of hand and forearm injuries using the two different scoring sistems and to examine the correlation between them. METHODS: This retrospective study was performed among patients operated on at our clinic due to acute hand and forearm trauma during the period of two years. Four groups of patients were made according to the Modified Hand Injury Severity Score (MHISS). One year after the treatment, phone interviews were made with those patients to answer to the Disability of Arm Shoulder and Hand (quick-DASH) score for estimating disability and to the World Health Organization Quality of Life BREF (WHOQoL-BREF) score to estimate the quality of life regerding four domains: physical, social, environmental and psychological. RESULTS: Out of 182 patients who satisfied the inclusion criteria, only 60 completely answered to the questionnaires, 46 (17%) men and 14 (23%) women. Most of the patients were in the group with moderate injuries according to the MHISS, followed by the group with major and severe injuries. A weak correlation was found between the MHISS and quick DASH score in the group with minor injuries, compared to no correlation between these parameters in other groups. The lowest quality of life was registered in the physical domain, while the highest in the social one. A negative correlation was found among the four domains of the WHOQoL BREF score and quick-DASH score in all the groups. CONCLUSION: Severity of hand and forearm injuries does not necessarily correlate with patient's perception of disability. The quality of life was less affected by severity of injury than by the patient's per- ception of disability.

Melanoma risk prediction models.

BACKGROUND/AIM: The lack of effective therapy for advanced stages of melanoma emphasizes the importance of preventive measures and screenings of population at risk. Identifying individuals at high risk should allow targeted screenings and follow-up involving those who would benefit most. The aim of this study was to identify most significant factors for melanoma prediction in our population and to create prognostic models for identification and differentiation of individuals at risk. METHODS: This case-control study included 697 participants (341 patients and 356 controls) that underwent extensive interview and skin examination in order to check risk factors for melanoma. Pairwise univariate statistical comparison was used for the coarse selection of the most significant risk factors. These factors were fed into logistic regression (LR) and alternating decision trees (ADT) prognostic models that were assessed for their usefulness in identification of patients at risk to develop melanoma. Validation of the LR model was done by Hosmer and Lemeshow test, whereas the ADT was validated by 10-fold cross-validation. The achieved sensitivity, specificity, accuracy and AUC for both models were calculated. The melanoma risk score (MRS) based on the outcome of the LR model was presented. RESULTS: The LR model showed that the following risk factors were associated with melanoma: sunbeds (OR = 4.018; 95% CI 1.724-9.366 for those that sometimes used sunbeds), solar damage of the skin (OR = 8.274; 95% CI 2.661-25.730 for those with severe solar damage), hair color (OR = 3.222; 95% CI 1.984-5.231 for light brown/blond hair), the number of common naevi (over 100 naevi had OR = 3.57; 95% CI 1.427-8.931), the number of dysplastic naevi (from 1 to 10 dysplastic naevi OR was 2.672; 95% CI 1.572-4.540; for more than 10 naevi OR was 6.487; 95%; CI 1.993-21.119), Fitzpatricks phototype and the presence of congenital naevi. Red hair, phototype I and large congenital naevi were only present in melanoma patients and thus were strongly associated with melanoma. The percentage of correctly classified subjects in the LR model was 74.9%, sensitivity 71%, specificity 78.7% and AUC 0.805. For the ADT percentage of correctly classified instances was 71.9%, sensitivity 71.9%, specificity 79.4% and AUC 0.808. CONCLUSION: Application of different models for risk assessment and prediction of melanoma should provide efficient and standardized tool in the hands of clinicians. The presented models offer effective discrimination of individuals at high risk, transparent decision making and real-time implementation suitable for clinical practice. A continuous melanoma database growth would provide for further adjustments and enhancements in model accuracy as well as offering a possibility for successful application of more advanced data mining algorithms.

Psychosocial characteristics and motivational factors in woman seeking cosmetic breast augmentation surgery.

BACKGROUND/AIM: There are various opinions regarding the factors motivating women to undergo breast augmentation. The aim of this study was to estimate motivation for augmentation mammaplasty (AM), self-esteem and body image perception in breast augmentation patients. METHODS: This prospective study involved AM patients operated in the Clinical Center of Vojvodina during a 3-year period. A total of 45 patients responded to our package of questionnaires designed to assess motivation for surgery, self-esteem level and body image perception. Those patients were compared to the control group of women who did not want to change their breast size, and who were similar in their age, social status and education level. Our package of questionnaires included a general questionnaire, Photographic Figure Rating Scale (PFRS) and Rosenberg's Self-Esteem Scale. RESULTS: Differences in marital status, educational level, habitation and employment status were statistically insignificant, but there was a significantly lower body mass index (BMI) in the operated women. Considering motives for surgery, a few factors were distinguished: desire to feel more feminine (82.2%), confident (75.5%) and attractive (73.3%), to feel less shy with men (64.4%), to improve their sex life (46.5%), teasing history (42.2%) and easier to find a partner (11.1%) and job (2.2%). Both groups demonstrated a high self-esteem level, but in the the AM group results were lower than in the control group. The mean current self-rating by the PFRS in the group AM was lower than in the control group (4.28 +/- 1.3 vs 5.12 +/- 1.23, respectively) and this coincided with lower BMI in the AM group. The women in the AM group had chosen significantly smaller body size as maximally attractive, and had chosen a narrower attractive body size range than the women in the control group. CONCLUSION. Preoperative evaluation of patients' motives for surgery can help surgeons to exclude woman with unrealistic expectations and different psychological problems.

Clinical and pathological features of the giant, invasive basal cell carcinoma of the scalp.

BACKGROUND: The giant, invasive basal cell carcinoma of the scalp is a rare clinical form of this tumor that appears on the skin, but may spread to some of the following structures: soft tissues of the scalp, bones, meninges, and the brain. In literature, so far, it is known as the GBCC. It is caused by aggressive BCC subtypes. METHODS: We will present here a research of clinical and pathological features of 47 pathological specimens in 31 patients where the following features were examined: the dimension of the tumor, the dimension of the tissue segment, tumor area, segmentation area, resection margin width, microscopic resection margin status, tumor invasion level, and the outcome. RESULTS AND CONCLUSIONS: We have concluded that microscopic resection margin dimensions from 1 to 10 mm are safe and that relapse occurrences in giant, invasive BCCs of the scalp depend on microscopic resection margin dimensions, resection margin status, tumor invasion levels, risky occupation, and risky behavior of the patient.

Burns treatment in ancient times.

Discovery of fire at the dawn of prehistoric time brought not only the benefits to human beings offering the light and heat, but also misfortune due to burns; and that was the beginning of burns treatment. Egyptian doctors made medicines from plants, animal products and minerals, which they combined with magic and religious procedures. The earliest records described burns dressings with milk from mothers of male babies. Goddess Isis was called upon to help. Some remedies and procedures proved so successful that their application continued for centuries. The Edwin Smith papyrus (1500 BC) mentioned the treatment of burns with honey and grease. Ebers Papyrus (1500 BC) contains descriptions of application of mud, excrement, oil and plant extracts. They also used honey, Aloe and tannic acid to heal burns. Ancient Egyptians did not know about microorganisms but they knew that honey, moldy bread and copper salts could prevent infections from dirt in burns healing. Thyme, opium and belladona were used for pain relief. In the 4th century BC, Hippocrates recorded that Greek and Roman doctors used rendered pig fat, resin and bitumen to treat burns. Mixture of honey and bran, or lotion of wine and myrrh were used by Celsus. Honey was also known in Ayurveda (Indian medicine) time. Ayurvedic records Characa and Sushruta included honey in their dressing aids to purify sores and promote the healing. Burn treatment in Chinese medicine was traditional. It was a compilation of philosophy, knowledge and herbal medicine. The successful treatment of burns started in recent time and it has been made possible by better knowledge of the pathophysiology of thermal injuries and their consequences, medical technology advances and improved surgical techniques.

The analysis of reasons for malignant skin tumors late diagnosis.

INTRODUCTION: Timely diagnosis is a prerequisite for the successful treatment of malignant skin tumors. Late diagnosis leads a patient into a situation of losing valuable time and chance for cure. MATERIAL AND METHODS: A prospective study was conducted from February 2006 until August 2011 which analyzed the reasons that led to establishing the diagnosis of malignant skin tumors in 220 patients. Patients were divided into two groups: Group A (102 patients), patients with diagnosed melanoma, and group B (118 patients) of patients suffering from basocellular (BCC) and planocellular cell (PCC) skin cancer. Parameters for comparison of analysis results were the reasons for coming to examination and reasons for not coming to the examination, because of which skin cancers were not diagnosed in time. GOAL: To determine the factors that influences the establishment of late diagnosis and treatment of skin tumors. RESULTS: It was confirmed that the prejudices of patients that tumors of the skin "should not be operated because it is dangerous" is the main reason for late diagnosis. At the same time it is confirmed that the belief that it is unnecessary to operate congenital changes of the skin is the second most important reason for delayed diagnosis of malignant skin tumors.

[Plantar fibromatosis and Dupuytren's contracture in an adolescent].

BACKGROUND: Fibromatosis represents a wide group of benign, locally proliferative disorders of fibroblasts. Dupuytren's disease is a benign proliferative disease of palmar aponeurosis which usually affects adults between 40 and 60 years of age. Ledderhose's disease or plantar fibromatosis is plantar equivalent of Dupuyten's disease most often affecting middle-aged and older men, usually bilateral, represented with painless nodule in the medial division of plantar fascia. CASE REPORT: We presented a 19-year old adolescent that turned to a plastic surgeon complaining to his small finger contracture. He noticed palmar thickening with nodule over the metacarpophalangeal joint of small finger of his right hand when he was 16 years old. A year later a finger started to band. During physical checkup we noticed plantar nodule that also had his father and grandmother. Magnetic resonance and tumor biopsy confirmed a suspicion on plantar fibromatosis - Ledderhose's disease. Clinical exam of the hand clearly led to a conclusion that the patient had Dupuytren's contracture with pretendinous cord over the small finger flexor tendons and lack of extension of proximal interphalangeal (PIP) joint. On the extensor side of the PIP joints there were Garrod's nodes. The patient refused surgical treatment of plantar tumor, but agreed to surgical correction of finger contracture. CONCLUSION: Despite the fact that Dupuytren's disease and plantar fibromatosis are diseases of adults, the possibility of conjoint appearance of these forms of fibromatosis in adolescent period of life should be kept in mind especially in patients with strong genetic predisposition.

Dysplastic nevus--a risk factor of developing skin melanoma clinical and epidemiological study with retrospective review of literature.

Dysplastic nevus is a risk factor for developing skin melanoma. The aim was to analyze patients with both skin melanoma and dysplastic nevi. A 10-year retrospective analysis (1999-2009) was conducted at the Department for Plastic and Reconstructive Surgery, Clinical Centre Vojvodina. During the observed time interval, of 482 patients treated for skin melanoma, 165 (34.2%) had also dysplastic nevi. Melanoma developed more often de novo (67.9%) and 32.1% by malignant alteration. The most dominant type of melanoma was nodular one (70.3%), the most frequent depth being 3.1-4mm (40.6%). The highest incidence of melanoma (32.1%) was in patients aged from 51 to 60 years. The 5- and 10-year survival rates were 72.7% and 50.3%, respectively. Our results correspond to those found in literature except for the fact that the majority of diagnosed melanomas were of nodular type with worse prognosis.

[Specificities of hand trauma in agriculture].

BACKGROUND/AIM: Hand injuries in agriculture are characterized by massive destruction of all tissues, frequent amputations of finger, hand and often the whole extremity. These injuries are mutilant and can cause death. The aim of this paper was to show the specificities of hand injuries in agriculture in regard to hand injuries of other etiology. METHODS: We analyzed patients that were treated in the Departement for Plastic and Reconstructive Surgery, Clinical Center Vojvodina, during a five-year period (2003-2007) because of hand injuries. RESULTS: In a five-year period there were 366 patients hospitalized because of hand injuries, out of whom 36 injuries were related to agricultural machinery use. In both groups the number of patients trended to increased, with male gender being dominant. Most of the patients were young or middle-aged men. In agricultural injuries most of the patients were in the group of 41-50-year old (30%), while in the other group, the patients were younger (21-30-year old). Hand injuries in agriculture resulted in finger amputation in 92%, while in the other group that number was much smaller (13%). Skin defect reconstruction in agricultural injuries required complex methods of skin grafting or skin flaps in more than 71%, while this was necessary in only 10% of other hand injuries. CONCLUSION: Hand injuries in agriculture are very mutilant and often result in conquassation and finger amputation. A possibility to preserve tissue damaged in this way is very limited, and skin closer usually requires complex methods.

Mechanical cornpicker hand injuries.

Mechanical cornpicker hand injuries are not frequent in comparison to general hand trauma, but they have a specific mechanism of occurrence and are very severe. This investigation included 221 hand injuries. The sex distribution shows a general male dominance (85.25%) in their active age (84.44%). These are, seasonal injuries mostly occurring in October (75.11%). By type of injuries, mutilating crush injuries are most frequent (64.25%). After completing the treatment, in most cases the functional result were estimated as bad (50.68%). Data concerning education and trainig for operating agricultural machines (96.38%--patients without training) and carrying out safety measures (63.35% of injured patients did not apply any protection measures) are devastating. The number of these injuries, as well as consequent permanent disabilities, may be considerably reduced by preventive measures, inclulding public health services and media. Use of contempoarary agricultural machinery, as well as obligatory training for operating these machines and application of protective measures, may also reduce the incidence of hand injuries during corn picking.

[Reconstruction of the esophagus with a jejunal segment--case report]. / Rekonstrukcija jednjaka jejunalnim reznjem--prikaz slucaja.

INTRODUCTION: Portions of gastrointestinal tract may be used as microvascular transfers for reconstruction of hypopharynx and esophagus. Colon, jejunum and portions of stomach have also been successfully used. Intestinal transfer by revascularization was reported by Seidenberg in 1959, long before the development of other free tissue transfers. MATERIAL AND METHODS: When an appropriate piece of jejunum is being selected for transfer, the important considerations are its shape and its vascular supply. Because of multiple curves of jejunum, it is difficult to obtain straight lengths longer than 12-15 cm without separating it from its mesentery at both ends. DISCUSSION: Mucous production is very important in the first postoperative days. When edema decreases and patients can swallow fluids well, oral intake can gradually be increased to full fluids and eventual regular diet. It is important to monitor jejunum following its transfer. Anastomosis thrombosis and unrecognized gangrene of jejunum may cause serious neck infections. CONCLUSION: Portions of gastrointestinal tract may be used as microvascular transfers for reconstruction of hypopharynx and esophagus. Intestinal transfer by revascularization was reported by Seidenberg in 1959. It is important to monitor jejunum following its transfer.

[Principles of management of high-energy injuries of the leg]. / Principi zbrinjavanja visokoenergetskih povreda potkolenice.

INTRODUCTION: High-energy traumas are open or closed injuries caused by force (missile, traffic injuries, crush or blust injuries, falling from heights), affecting the body surface and transferring high amount of kinetic energy inducing great damage to the tissue. Management of such lower extremity injuries has evolved over past several decades, but still remains a difficult task for every surgical team. Specific anatomic and functional characteristics combined with extensive injuries demands specific treatment protocols. MULTIPLE INJURIES: In a multiple injured patient the first priority is management of life-threatening trauma. Despite other injuries, surgical treatment of limb-threatening injuries must start as soon as life-threatening condition has been managed. TREATMENT ALGORITHMS: Algorithms are especially beneficial in management of severely injured, but salvageable extremities and in making decision on amputation. Insight into mechanisms of injury, as well as systematic examination of the affected limb, should help us understand the extensiveness of trauma and make an adequate management plan. PREVENTION OF INFECTION AND SURGICAL APPROACH: Prevention of wound infection and surgical approach to high-energy limb trauma, which includes wound extension, wound excision, skeletal stabilization and if necessary muscle compartment release, should be done in the first 6 hours after injury. METHODS OF SOFT TISSUE RECONSTRUCTION: Commonly used methods for soft tissue defects must provide wound coverage in less than five days following injury. REHABILITATION: Early passive and active mobilization and verticalization of patients is very important for successful treatment. CONCLUSION: Good and timely evaluation of the injured and collaboration between plastic and orthopaedic surgeons from the beginning of treatment, are crucial for final outcome.