Clinical significance of intra-nodal naevi in sentinel node biopsies for malignant melanoma.

BACKGROUND: Intra-nodal naevi (INN) identified during assessment of a sentinel lymph node for melanoma are not an uncommon finding. Little is known about their clinical significance. Patients with INN are treated as sentinel node biopsy (SNB) negative currently. Our aim was to assess the significance of INN in patients who undergo SNB for melanoma. METHODS: 353 melanoma patients who underwent a SNB between November 1999 and June 2012 were retrospectively analysed from a prospectively collected database. The patients were divided into SNB negative, INN, isolated tumour cells (ITC) and SNB positive groups. Outcome measures of nodal recurrence, distal recurrence and survival were used to assess the differences between the groups. RESULTS: 203 patients were SNB negative, 103 were positive of which 13 had ITC, 47 had INN (13%). Overall median follow up was 2.3 years (range 0.1-14.1 years). Our data demonstrated a statistically significant survival benefit for patients who had an INN compared to the SNB positive and ITC group. INN patients also had significantly better nodal and regional recurrence compared to SNB positive patients. There was no difference between INN and SNB negative patients. CONCLUSION: We have clinically demonstrated that patients with INN on SNB can be adequately treated as SNB negative patients.

Attitudes to contralateral risk reducing mastectomy among breast and plastic surgeons in England.

INTRODUCTION: Rates of contralateral risk reducing mastectomy (CRRM) are rising despite a paucity of data to support this practice. Surgeons work as part of the multidisciplinary team (MDT). They may counsel women on these requests without the benefit of established guidelines or agreed protocol. This study assessed the practices and perceptions of breast and plastic surgeons in England on CRRM. METHODS: A postal questionnaire was sent to 455 breast and 364 plastic surgeons practising in England. Basic demographics, trends in CRRM, risk assessment, role of the MDT and knowledge base were assessed. RESULTS: The response rate among breast surgeons was 48.3% (220/455) and 12.6% (46/364) among plastic surgeons. Nearly half (44%) of the respondents felt there had been an increase in rates of CRRM over the last three years. Seventy-one per cent of those surveyed performed 1-5 CRRMs annually while sixteen per cent did not perform this procedure at all. A third (32%) of respondents correctly quoted their patients an annual risk of 0.5-0.7%. Funding was refused in 4% of cases and 43% of the surgeons felt that in the future they would have to apply to relevant clinical commissioning groups. Over half (58%) of all respondents reported that decisions for CRRM are always discussed in the MDT meeting but 6% stated that these cases are never discussed by the MDT. BRCA mutation was perceived as the main risk factor for contralateral breast cancer by 81% of respondents. Surgeons felt that women requested CRRM mainly to alleviate anxiety. The next most common reasons were carriage of BRCA mutation and a desire to have reconstructions match. CONCLUSIONS: A wide variation of surgical practices and perceptions exist in assessing women for CRRM. Guidelines to standardise practices are required.

The Manchester guidelines for contralateral risk-reducing mastectomy.

BACKGROUND: Rates of contralateral risk-reducing mastectomy (CRRM) are rising, despite a decreasing global incidence of contralateral breast cancer. Reasons for requesting this procedure are complex, and we have previously shown a variable practice amongst breast and plastic surgeons in England. We propose a protocol, based on a published systematic review, a national UK survey and the Manchester experience of CRRM. METHODS: We reviewed the literature for risk factors for contralateral breast cancer and have devised a 5-step process that includes history taking, calculating contralateral breast cancer risk, cooling off period/counselling, multi-disciplinary assessment and consent. Members of the multi-disciplinary team included the breast surgeon, plastic surgeon and geneticist, who formulated guidelines. RESULTS: A simple formula to calculate the life-time risk of contralateral breast cancer has been devised. This allows stratification of breast cancer patients into different risk-groups: low, above average, moderate and high risk. Recommendations vary according to different risk groups. CONCLUSION: These guidelines are a useful tool for clinicians counselling women requesting CRRM. Risk assessment is mandatory in this group of patients, and our formula allows evidence-based recommendations to be made.

Contralateral risk-reducing mastectomy: review of risk factors and risk-reducing strategies.

Rates of contralateral risk-reducing mastectomy have increased substantially over the last decade. Surgical oncologists are often in the frontline, dealing with requests for this procedure. This paper reviews the current evidence base regarding contralateral breast cancer, assesses the various risk-reducing strategies, and evaluates the cost-effectiveness of contralateral risk-reducing mastectomy.

Challenges and new horizons in the management of advanced basal cell carcinoma: a UK perspective.

Basal cell carcinoma (BCC) is a common malignancy with a good prognosis in the majority of cases. However, some BCC patients develop a more advanced disease that poses significant management challenges. Such cases include locally advanced, recurrent or metastatic BCC, or tumours that occur in anatomical sites where surgical treatment would result in significant deformity. Until recently, treatment options for these patients have been limited, but increased understanding of the molecular basis of BCC has enabled potential therapies, such as hedgehog signalling pathway inhibitors, to be developed. A clear definition of advanced BCC as a distinct disease entity and formal management guidelines have not previously been published, presumably because of the rarity, heterogeneity and lack of treatment options available for the disease. Here we provide a UK perspective from a multidisciplinary group of experts involved in the treatment of complex cases of BCC, addressing the key challenges associated with the perceived definition and management of the disease. With new treatments on the horizon, we further propose a definition for advanced BCC that may be used as a guide for healthcare professionals involved in disease diagnosis and management.

Gluteal fold flaps for perineal reconstruction.

Defects of the perineum are created during ablative procedures for gynaecological, urological and colorectal malignancies. The gluteal fold flap is a reliable means of reconstructing these defects. We retrospectively reviewed case notes of gluteal fold flaps performed for perineal reconstruction over four years (2007-2010) in our institution. 77 perineal defects were reconstructed using unilateral or bilateral gluteal fold flaps (127 flaps in total). 50% of all patients are discharged before 11 days, and 90% were discharged within one month. Mean time to discharge was 13.2 days. 70% of all patients were completely healed at 2 months, and 85% completely healed at three months. Pre-operative radiotherapy was found to have a prolonging effect on the time to discharge (P<0.05) but did not reach statistical significance when considering the eventual time to healing. The number of co-morbidities that each patient had at the time of surgery had a prolonging effect on both time to discharge and time to healing (P<0.03). The type of resected areas that required reconstruction did not have a statistically significant effect on the time to discharge, but defects where the anus had been resected did eventually take longer to heal than those were the anus was not resected (P<0.01). 124 flaps were successful (97.6%) with total or partial flap loss occurring in three. Complications were seen in 34 of the 77 patients (44%), with simple wound breakdown resulting in delayed healing seen most frequently (30%). The gluteal fold fasciocutaneous flap is a versatile option for reconstructing a wide range of pelvic and perineal defects. Patients with multiple co-morbidities, cases with radiotherapy and instances where the anus has been resected are more likely to experience longer healing times. We present our algorithm for management for perineal defects after tumour resection.

One stage breast reconstruction following prophylactic mastectomy for ptotic breasts: the inferior dermal flap and implant.

INTRODUCTION: Immediate reconstruction following prophylactic mastectomy for larger ptotic breasts is difficult. Tissue expansion in these patients often results in poor cosmetic outcomes. Autologous options may not be possible due to clinical unsuitability or patient choice. Using the inferior dermal flap with implant achieves lower pole fullness and allows a one-stop reconstruction in the larger ptotic breast. METHODS: The inferior dermal flap and implant was performed on ten patients (20 breasts). Average age was 43 (range 36-53). The average BMI was 37 (range 32-43). The distance from nipple to IMF varied from 15 cm to 26 cm. The average implant size was 533 (range 390-620). Complications were minimal with one patient experiencing delayed wound healing at the T-junction and one patient developing inferior pole erythema postoperatively that settled with antibiotics. CONCLUSION: The inferior dermal flap and implant provides a one-stop reconstructive option. It is reliable, safe and maintains the breast envelope while giving excellent size, shape and symmetry in the larger ptotic patient.

Breast reconstruction following prophylactic mastectomy for smaller breasts: the superiorly based pectoralis fascial flap with the Becker 35 expandable implant.

INTRODUCTION: Immediate reconstruction using tissue expander/implants following prophylactic mastectomy for smaller breasts is a reliable means of providing similar size, shape and symmetrical reconstructions. The superiorly based pectoralis fascial flap allows an immediate reconstruction of the inferior pole and may eliminate the need for tissue expansion. METHODS: The superiorly based pectoralis fascial flap and implant was performed on 5 patients (10 breasts). The Becker 35 expandable implant was used in all cases and average size was 349 (range 290-400cc). Average age was 33 (range 21-43). The average BMI was 23 (range 20-26). One patient underwent further tissue expansion of the Becker 35 postoperatively. One patient developed a seroma in the abdominal fascial flap donor site that settled without the need for drainage. There were no other complications. CONCLUSION: The superiorly based pectoralis fascial flap provides a one-stop reconstruction of the lower pole and can eliminate the need for tissue expansion in patients with small breasts.

The use of a combined radial forearm flap and radial fascial flap for layered dural lining and an orbital defect reconstruction.

Variable reconstruction methods for craniofacial tumour resections have been devised with the primary purpose to improve quality of life and disease control. The reconstructive aims are to provide a watertight seal, cranial base support while allowing a cosmetically pleasing result. For defects involving the orbit, maintenance of the depth of the orbital socket remains important for prosthetic fitting and a bulky flap is not advisable for this purpose. This case demonstrates the use of a combination pericranial flap, radial forearm fascial flap and cutaneous radial forearm flap. We have been able to achieve a watertight seal of dura in multiple layers, provide adequate support to the cranial base while giving a non bulky reconstruction of the orbit.

Supraorbital neuroma masquerading as local recurrence from a previously excised microcystic adnexal carcinoma.

We present a case of a 53 year old gentleman with a previous history of a microcystic adnexal carcinoma in the supraorbital region who represented with pain and tenderness 3 years postoperatively. Although this was thought to represent local recurrence, it proved to be a supraorbital neuroma.

Joint practice guidelines for radionuclide lymphoscintigraphy for sentinel node localization in oral/oropharyngeal squamous cell carcinoma.

Involvement of the cervical lymph nodes is the most important prognostic factor for patients with oral/oropharyngeal squamous cell carcinoma (OSCC), and the decision of whether to electively treat patients with clinically negative necks remains a controversial topic. Sentinel node biopsy (SNB) provides a minimally invasive method for determining the disease status of the cervical node basin, without the need for a formal neck dissection. This technique potentially improves the accuracy of histologic nodal staging and avoids overtreating three-quarters of this patient population, minimizing associated morbidity. The technique has been validated for patients with OSCC, and larger-scale studies are in progress to determine its exact role in the management of this patient population. This document is designed to outline the current best practice guidelines for the provision of SNB in patients with early-stage OSCC, and to provide a framework for the currently evolving recommendations for its use. Preparation of this guideline was carried out by a multidisciplinary surgical/nuclear medicine/pathology expert panel under the joint auspices of the European Association of Nuclear Medicine (EANM) Oncology Committee and the Sentinel European Node Trial (SENT) Committee.

Micrometastases and isolated tumour cells in sentinel lymph nodes in oral and oropharyngeal squamous cell carcinoma.

BACKGROUND: The occurrence of micrometastases (MMs) and isolated tumour cells (ITCs) in oral sentinel lymph node (SLN) biopsy is poorly known, and the definitions and clinical significance of MMs and ITCs in SLN biopsy are controversial. We compared the UICC/TNM definitions of MMs and ITCs with our previously published sentinel node protocol to assess how the adoption of the UICC/TNM criteria would affect the staging of nodal micrometastatic disease. METHODS: Of 107 patients who had a SLN biopsy and pathology at 150 microm intervals, 35 with metastatic tumour were included. Eighty-six SLNs were reassessed using the UICC/TNM definitions for MMs and ITCs. Findings were linked to the final pathology in the subsequent neck dissection. RESULTS: Initial H&E sections showed metastases in 24 patients (in 34 out of 61 SLN), 8 of whom (9 SLNs) had MMs. Additional step serial sections revealed metastatic deposits in a further 11 patients (15 out of 25 SLNs were positive) which were reassessed as MMs (6 patients) or ITCs (5 patients). Subsequent neck dissection revealed additional metastases in 46% of patients with MM, whilst one of the ITC patients had subsequent neck metastases (20%). CONCLUSION: Despite some limitations, the UICC/TNM classification provides an objective, uniform method of detecting MMs and ITC's. Unlike in cases with ITC, metastases in other non-SLNs were common when a micrometastasis was detected in a SLN, indicating need for further treatment of the neck.

Bevacizumab for recurrent malignant gliomas: efficacy, toxicity, and patterns of recurrence.

BACKGROUND: Bevacizumab, a humanized monoclonal antibody against vascular endothelial growth factor, may have activity in recurrent malignant gliomas. At recurrence some patients appear to develop nonenhancing infiltrating disease rather than enhancing tumor. METHODS: We retrospectively reviewed 55 consecutive patients with recurrent malignant gliomas who received bevacizumab and chemotherapy to determine efficacy, toxicity, and patterns of recurrence. Using a blinded, standardized imaging review and quantitative volumetric analysis, the recurrence patterns of patients treated with bevacizumab were compared to recurrence patterns of 19 patients treated with chemotherapy alone. RESULTS: A total of 2.3% of patients had a complete response, 31.8% partial response, 29.5% minimal response, and 29.5% had stable disease. Median time to radiographic progression was 19.3 weeks. Six-month progression-free survival (PFS) was 42% for patients with glioblastoma and 32% for patients with anaplastic glioma. In 23 patients who progressed on their initial therapy, bevacizumab was continued and the concurrent chemotherapy agent changed. In no case did the change produce a radiographic response, but two patients had prolonged PFS of 20 and 31 weeks. Recurrence pattern analysis identified a significant increase in the volume of infiltrative tumor relative to enhancing tumor in bevacizumab responders. CONCLUSIONS: Combination therapy with bevacizumab and chemotherapy is well-tolerated and active against recurrent malignant gliomas. At recurrence, continuing bevacizumab and changing the chemotherapy agent provided long-term disease control only in a small subset of patients. Bevacizumab may alter the recurrence pattern of malignant gliomas by suppressing enhancing tumor recurrence more effectively than it suppresses nonenhancing, infiltrative tumor growth.

A comparison of the views of patients and medical staff in relation to the process of informed consent.

INTRODUCTION: The quality and quantity of information required in the consent process is well documented, but there is little extant literature regarding timing of either information about the proposed procedure or the act of consent itself. With the recent introduction of a new NHS-wide consent form, we wished to determine the preferences of both patients and staff to ascertain whether any concordance of views existed. PATIENTS AND METHODS: A 10-point questionnaire, developed in conjunction with the department of clinical psychology was completed by 242 patients selected for surgery over a 4-month period. Identical questionnaires were completed by local staff (n = 50) and national consultant plastic surgeons (n = 56). RESULTS: The cumulative majority (61.8%) preferred information at the specialist out-patient appointment (OPA). There was a significant difference (P < 0.001) between patients and staff as to information provision by the specialist as compared to non-specialists; staff indicating it much more strongly. As to the timing of consent form signature, 40.2% preferred signature on admission with no statistically significant difference between subgroups. An additional pre-operative clinic, for consent form signing, was selected by 27.3%. Staff expressed this view more often than patients (P < 0.001). CONCLUSIONS: Patients prefer information about a planned surgical procedure at their specialist OPA and final consent for surgery when admitted to the ward. Staff had quite definite views and felt an additional pre-operative out-patient appointment to be beneficial, more so than the patients themselves.

Variations in the postoperative management of free tissue transfers to the head and neck in the United Kingdom.

Reliable assessment of the perfusion of free tissue transfers has always been a challenge for reconstructive microsurgeons. The complexities of flap microcirculation are often difficult to assess despite all the subjective and objective examination techniques available today, particularly when the free tissue transfer is buried, and not visible for monitoring. We investigated the post-operative management of free tissue transfers to the head and neck in the United Kingdom. Selected results from our survey show that the majority of units performed between two and five free tissue transfers to the head and neck region per month (n=60, mean=4.13, range<1-12). Clinical tests were used to monitor the flaps post-operatively in all units questioned. Hand held doppler was the most commonly used adjunctive technique, being routinely used for post-operative monitoring by twenty six units, and available for use in eighteen other units with the most common indications for use were, slow capillary refill and pale colour. Frequency and location of monitoring post-operatively was highly variable. Nurses were responsible for the routine monitoring of flaps in almost every unit. Thirty four units (57%) had a written protocol in place governing the monitoring of free tissue transfers post-operatively. We note the wide variation in practice on a national level, and make certain recommendations.

The nodal neck level of sentinel lymph nodes in mucosal head and neck cancer.

Sentinel node biopsy is emerging as a successful means of identifying subclinical lymph node disease in mucosal head and neck cancer. Sentinel node studies in melanoma and breast cancer have identified sentinel nodes at unusual sites and the technique is redefining our understanding of dynamic lymphatic flow. In this study, the sentinel nodes in mucosal head and neck malignancies were mapped according to their site within the neck and this was correlated with tumour site within the oral cavity. Fifty-two necks were explored for sentinel nodes from tumours located in the tongue (23 cases), floor of mouth (12 cases), palate (six cases), retromolar trigone (five cases), alveolus (three cases), buccal mucosa (two cases), tonsil (two cases) and lip (one case). In total, 124 sentinel nodes were found in levels I-V. Two hot spots were found in the tonsils and were not excised, two nodes were located in level IIB, four nodes were found in level IV, three in the contralateral neck and one in level V. The sentinel nodes located at unusual sites would not have been excised in a supraomohyoid neck dissection and the study has improved our understanding of dynamic lymph flow from tumours.