Efficacy of immune checkpoint inhibitors for in-transit melanoma.

BACKGROUND: The efficacy of immune checkpoint inhibitors (ICI) in metastatic melanoma is well established. However, there are limited data regarding their efficacy in in-transit melanoma (ITM). This study assessed the efficacy of ICI in patients with ITM. METHODS: A retrospective review of patients with ITM commenced on an ICI between March 2013 and February 2018 at three tertiary centers in Australia. Patients were excluded if they had previous or synchronous distant metastases. Overall response rate (ORR), progression-free survival (PFS) and overall survival (OS) were based on a composite of radiological and clinical assessments. RESULTS: Fifty-four patients were included: 27 (50%) female; median age 75 (range 26-94); 12 (22%) stage IIIB, 40 (74%) stage IIIC and 2 (4%) stage IIID; 10 (19%) BRAF mutant. Forty (74%) received single-agent anti-PD-1 (pembrolizumab or nivolumab), 8 (15%) single agent anti-CTLA-4 (ipilimumab), 5 (9%) combination anti-PD-1/anti-CTLA-4 (ipilimumab and nivolumab or pembrolizumab) and 1 (2%) combination anti-PD-L1 (atezolizumab) and MEK inhibitor (cobimetinib). The median follow-up was 15 months (2-46).ORR to ICI was 54%: 14 (26%) complete responses; 15 (28%) partial responses; 9 (17%) stable disease; 16 (30%) progressive disease. Thirteen (46%) responders had only one ITM lesion. ORR was 58% for single-agent anti-PD-1, 38% for single-agent anti-CTLA4 and 40% for anti-PD-1/anti-CTLA-4. The median PFS was 11.7 months (6.6-not reached). 1-year and 2-year PFS were 48% and 39%, respectively,. Fourteen progressed locoregionally and 11 progressed distantly. The median OS was not reached. 1-year and 2-year OS were 85% and 63%, respectively. No clinicopathological features were associated with ORR. CONCLUSIONS AND RELEVANCE: ICI produce objective responses in ITM and should be considered in patients with unresectable ITM or disease recurrence.

The removal of cranial springs used in the treatment of scaphocephaly: A minimal access approach.

The treatment of non-syndromic scaphocephaly with spring-activated cranioplasty offers acceptable outcomes with the potential for reduced surgical morbidity when compared with cranial vault remodelling procedures. A disadvantage of this technique is the need for a second operative intervention to remove the implanted devices. There are many descriptions of the surgical technique for performing spring-activated cranioplasty available in the literature; however, little is documented regarding the procedures used for device removal. The published accounts of spring removal demonstrate a wide range of approaches, from the reopening and dissection of the entire previous surgical field, to attempts to limit the incisions and dissection. In this study we describe our technique for the minimally invasive removal of cranial springs used in the treatment of scaphocephaly. Our technique focuses on minimal soft tissue disruption and uses a Kirschner wire cutter to divide the spring at its mid-point so as to relieve any residual internal forces acting on the footplates.

Orthognathic Surgery for Patients with Cleft Lip and Palate.

Cleft orthognathic surgery is an important component of a comprehensive cleft care plan. Applying combined orthodontic and orthognathic treatment principles to a cohort of patients with cleft lip and palate raises many challenges not encountered in conventional orthognathic care. Cleft patients share a commonality in their midfacial anatomy that is characterized by a 3-dimensionally deficient maxilla. The residual sequelae of multiple previous surgeries along with dental differences and unhealed fistulae are considerations when embarking on treatment. This article describes many of these challenges and highlights approaches that are used to address the specific needs of this special group of patients.

Pigmented lesions of the nail bed - Clinical assessment and biopsy.

BACKGROUND: Subungual melanoma is an uncommon type of melanoma that can be difficult to diagnose. Patients often present with advanced primary lesions and have an associated increased risk of nodal disease. Delays in diagnosis are believed to contribute to poor patient outcomes. OBJECTIVE: The objective of this article is to offer an approach to assessing and managing patients who present with subungual pigmented lesions. We describe the anatomy of the nail bed to offer a rationale for our technique of nail bed biopsy, and warn of the potential to cause permanent nail dystrophy through other approaches. DISCUSSION: Many clinicians have limited experience in assessing lesions of the nail apparatus.Subungual pigmentation has extremely broad differential diagnoses, which include a variety of benign pathologies. A systematic approach to assessment, and early referral of patients with suspicious lesions to a specialist unit, has the potential to improve patient outcomes.

The 2009 Sydney shark attacks: case series and literature review.

BACKGROUND: There were 59 unprovoked shark attacks worldwide in 2008. Twelve of these occurred in Australia, ranking it as second only to the USA. In February 2009, two attacks occurred within 72 h in Sydney, Australia. METHODS: The two patients involved survived severe limb trauma. Case 1 suffered bite trauma to the lower limb and hand and underwent staged debridement and early amputation. Case 2 presented with a hand severed at the level of the wrist that was initially replanted. However, it would succumb to progressive necrosis after 12 days. We discuss the aspects of these cases that contributed to the patients' survival and ultimately good functional outcomes. DISCUSSION: New paradigms for the management of major trauma patients have emerged over the last decade. We consider recent advances in the understanding of pre-hospital tourniquet use, rapid transit to the operating suite and damage control surgery, and examine how they impacted on the management of our patients. Very little is known about the microbiology of shark bites. Organisms from sea water, the patient's skin and the shark's mouth must all be considered when selecting appropriate antimicrobial prophylaxis. The planning of definitive surgery in severe limb trauma is dependent on the interactions of a number of factors including physical, psychological and social issues. The decision to ultimately replant or amputate the effected limb is best made in union with the patient and their family.