Negative pressure wound treatment (NPWT) in vulva and groin wounds in gynaecologic oncology.

Secondary healing of complicated vulvar and groin wounds is a major challenge due to its moist condition and at risk of contamination by colonic flora. Vacuum assisted closure is the controlled application of sub-atmospheric pressure to the local wound environment using a sealed dressing connected to a vacuum pump. MATERIALS AND METHODS: The NPWT consists of an open-pore polyurethane ether foam sponge, an adhesive cover, fluid collection system, and suction pump that generates negative pressure. Direct application of sponge to blood vessels, bone, nerves or intact skin is avoided. The dressing and tubing are changed every 48-72 hours. RESULTS: Eight patients had NPWT following the vulva and/or groin surgery. Pain during removal of the sponge was the main adverse event requiring narcotic analgesia. All wounds healed completely. One patient is dead of disease progression. Others are alive without disease at four to 48 months. CONCLUSION: Wound breakdown in vulvar and groin surgery is an infrequent occurrence because of the rarity of full radical excision for vulva cancer and infralevator pelvic exenterative surgery. The present experience with NPWT was favourable.

Selective arterial embolisation for intractable vaginal haemorrhage in genital tract malignancies.

PURPOSE OF INVESTIGATION: Embolisation of the internal iliac artery has been described as an effective and safe method of treating massive vaginal haemorrhage in small series of advanced uterine cancer and case reports of cervical cancer. Selective embolization of the bleeding vessel is potentially less morbid. The aim of this study was to assess the efficacy of selective arterial embolisation (SAE) in controlling intractable haemorrhage due to gynaecological malignancy. MATERIALS AND METHODS: This retrospective observational study comes from in a tertiary cancer center with 300 new gynecologic cancers per annum. The authors reviewed all gynecology cancer patients who had intractable major vaginal haemorrhage in the first five years following the introduction of selective arterial embolisation at their unit. The outcomes measured were the control of acute haemorrhage and discharge to planned pathway of treatment. RESULTS: SAE was successful in all cases. Identification of the bleeding point facilitated highly selective embolisation in more than half of the patients. The uterine arteries were embolised in the remaining cases. Bleeding stopped immediately. The expedient control of haemorrhage facilitated early discharge to commencement/continuation of radiation treatment or palliative care as appropriate. CONCLUSIONS: Since the introduction of SAE the authors have avoided emergency radiotherapy, surgery, and repeat vaginal packing in patients with intractable vaginal bleeding due to gynaecological cancer. Patients were discharged to their appropriate treatment pathways in a timely manner. The authors recommend the application of SAE.

Whole-body [18F]fluoro-2-deoxyglucose positron emission tomography scan as combined PET-CT staging prior to planned radical vulvectomy and inguinofemoral lymphadenectomy for squamous vulvar cancer: a correlation with groin node metastasis.

Surgery is the mainstay of treatment for vulvar cancer. FIGO staging requires histopathological detail of the primary tumor and inguinofemoral lymph nodes but groin node dissection carries a substantial risk of short and long-term morbidity. The trend in current practice is towards sentinel lymphadenectomy for cancers with a low risk of metastases. Full lymphadenectomy is undertaken if the sentinel lymph node contains metastasis. The predictive value of 18F-FDG-PET in preoperative assessment of the groin in vulvar squamous cancer was assessed in retrospect at a single institution. A period of three years prior to the introduction of sentinel lymph node mapping was chosen in order to have full histopathological assessment of inguinal and femoral lymph nodes available as the gold standard for correlation with positron emission tomography-computerized tomography (PET-CT) to determine the accuracy of the enhanced radiological technique. In patients with histologically proven metastases to groin nodes, comparisons between PET-CT positive (True-positive/TP) and negative (False-negative/FN) groups vis-à-vis histology showed a tendency towards higher FDG avidity in the vulvar lesions, more bilateral nodes, multiple metastases, larger metastases and more extra-capsular extension in the TP group. Calculations per patient for PET-CT yielded a sensitivity of 50% and specificity at 100%. The positive predictive value (PPV) was 100% and the negative predictive value (NPV) was 57.1%. The test accuracy was 70% per patient. The high positive predictive value of PET-CT can be used to advance treatment planning prior to surgical staging of patients identified with Stage III disease. The poor sensitivity makes it unsuitable as a substitute for staging lymphadenectomy.

Opportunistic and interventional salpingectomy in women at risk: a strategy for preventing pelvic serous cancer (PSC).

OBJECTIVE: Salpingectomy is proposed as a prophylactic measure to reduce the incidence of tubo-ovarian/pelvic serous cancers. We surveyed the attitudes of obstetrician/gynecologists to incorporating salpingectomy opportunistically into surgery for benign conditions, and electively for young BRCA mutation carriers. STUDY DESIGN: A questionnaire, designed to assess current standard clinical practice and willingness to perform salpingectomy for female sterilization at abdominal hysterectomy for benign disease (ABH), vaginal benign hysterectomy (VBH) and electively for women with BRCA mutations who wish to postpone oophorectomy was mailed to obstetrician/gynecologists working in Irish hospitals. RESULTS: In their current practice of interval female sterilization 96% of gynecologists applied clips at laparoscopy and 4% performed salpingectomy, and 73% were willing to consider salpingectomy. Eighty-one percent were willing to consider salpingectomy for sterilization at cesarean section. Gynecologists performing hysterectomy (without oophorectomy) for benign conditions did salpingectomy in 26% at ABH and 5.4% at VBH, and now 90% would consider salpingectomy at ABH and 66% at VBH. Two-thirds of respondents would consider salpingectomy for women at genetic risk of ovarian cancer who want to postpone oophorectomy. CONCLUSION: Changing general gynecological practice to include more opportunistic salpingectomy has the potential to reduce the incidence of serous cancers. The majority of gynecologists are willing to incorporate more salpingectomies into their surgical practices and consider elective salpingectomy as an interim measure for women with defined genetic risk of pelvic serous cancer.

Rare variations of the mylohyoid muscle: case study.

The mylohyoid is a muscular diaphragm in the floor of the oral cavity. Its superficial and deep surfaces have important anatomical relationships. The submandibular gland is uniquely related to both surfaces at the posterior free edge of the muscle. It is here that the submandibular and sublingual tissue spaces become continuous. This case report describes an unusual range of anatomical variations of the mylohyoid muscle and reviews their clinical significance.

Insulin-receptor binding characteristics in perfused SHR and WKY rat hearts.

This work uses a new heart-perfusion technique to measure 125I-insulin binding on capillary endothelium and myofiber cell membranes in Wistar-Kyoto and spontaneously hypertensive rats. Ringer-Lock buffer was infused at a rate of 1 ml min-1 in the presence of 20 meq l-1 K+ and 125I-insulin through an aortic cannula. The effluent was collected through a catheter introduced into the right atrium. The capillary endothelial lining was removed by detergent treatment to expose the cardiac myocyte surfaces. A physical model describing a 1:1 binding stoichiometry of 125I-insulin with its receptors is proposed and the derived mathematical equations allow for the calculation of binding constants (kn), unbinding constants (k-n), dissociation constants (kd), and residency time constants (tau). The results showed that in the spontaneously hypertensive rats' hearts significant alterations were not noticed in the kinetics of insulin binding with its receptor at the capillary endothelial site compared to hearts of the normotensive control Wistar-Kyoto rats. However, at the myocyte site and in the spontaneously hypertensive rats, steric, configurational, and/or structural modifications for insulin binding with the receptor were observed as indicated by changes in insulin affinity for its receptor. Hence, alterations in insulin binding rather than reduction in insulin receptor number due to hyperinsulinemia, can be considered among the peculiarities of insulin resistance in the spontaneously hypertensive rats. Hyperinsulinemia, therefore, may be considered an upregulatory process as a consequence of insulin-resistance. The results support the hypothesis that insulin-resistance on the myocytes could be a pathophysiologic defect in insulin-receptor structure, function and affinity, and therefore myocardial function.

Blood supply of the tensor fasciae latae muscle.

The tensor fasciae latae (TFL) muscle has been successfully harvested as a myocutaneous flap in reconstructive surgery. Reports on the vascular supply of this muscle, however, are incomplete or inconclusive. Therefore the arterial pattern was examined by dissection in 100 injected human cadaveric specimens. It was observed that whereas 67 muscles were supplied exclusively by a single vessel derived from the ascending branch of the lateral circumflex femoral (LCF) artery, 13 were supplied by a secondary vessel derived from the same branch, while 20 muscles were supplied by two vessels, the larger one arising as before and the smaller from the descending branch of the LCF. Our observations reveal that although the majority of TFL muscles are clinically Type I (one vascular pedicle) according to the classification of Mathes and Nahai (1981), 20% are actually Type II (major and minor vascular pedicles).

Fos-like immunoreactivity induced by intraplantar injection of endotoxin and its reduction by morphine.

C-Fos-like immunoreactivity (FLI) in the central nervous system, has been associated with the processing of nociceptive information in acute and chronic pain animal models. The aim of this study was to investigate whether intraplantar (i.pl.) injections of endotoxin (ET, 1.25 microg) can induce FLI in the lumbar spinal cord of rats and to assess the effects of morphine injection on c-fos expression. FLI was studied in various groups of rats at 2, 3, 4, 6, 9 and 24 h following ET injections. Labeled neurons were mainly detected in the lumbar segments ipsilateral to the ET-injected leg, with a major peak (71.01 +/- 4.79 positive neurons) at 4 h and a second peak (29.87 +/- 5.97 positive neurons) at 9 h followed by a recovery to the baseline at 24 h after ET injections. Within the laminae, the majority of positive neurons was observed at 2-3 h in laminae I and II and in deep laminae (V and VI mainly) starting at 4 h after ET injections. Rostrocaudally, labeled neurons were observed initially in L4-L5 segments (2-3 h post-ET) after which they extended to L2-L6 segments at 4 h after ET. Morphine injections either i.p. (1 or 2 mg/kg) or i.pl. (50 microg) significantly reduced ET-induced hyperalgesia and simultaneously the FLI. The maximum effect was observed on labeled neurons in the deep laminae (V and VI mainly). We conclude that local injections of ET can induce FLI in the lumbar spinal cord with a temporal and spatial patterns comparable to the described hyperalgesia, and that both FLI and hyperalgesia are reduced by morphine in a dose-dependent manner with a maximal effect shown by the local i.pl. morphine injections.

Binding of 125I-insulin on capillary endothelial and myofiber cell membranes in normal and streptozotocin-induced diabetic perfused rat hearts.

A heart-perfusion technique was employed to measure 125I-insulin binding on capillary endothelial and myocyte cell membranes in Sprague-Dawley rats. Animals were anesthetized, and the anterior chest wall excised to expose the mediastinal contents. The right and left superior and inferior venae cavae were dissected and tied, and another tie was passed around the aorta. A polyethylene catheter was introduced into the aortic lumen from cephalad to caudad to sit with its tip above the aortic valve. Another catheter was introduced into the cavity of the right atrium and both were anchored by sutures. Oxygenated Ringer-Lock buffer containing 20 mM/L K+ and 125I-insulin was perfused at a rate of 1 mL/min via the aortic catheter. Concomitantly, the distal ascending aorta and venae cavae were ligated. The effluent was collected from the right atrial catheter at the same infusion rate. Animals were divided into two groups, the normal group and streptozotocin-induced diabetic group. Heart perfusion was done on both groups either without or after treatment with detergent (CHAPS) to remove the capillary endothelial lining. A physical model for 125I-insulin sequestration as a ligand to its receptors on endothelial and/or myocyte plasma membranes was proposed. The model described a reversible binding of ligand on cellular surface receptor concentration to fit a conservation equation and a first order Bessel function. The binding constants (kn), reversal constants (k-n), dissociation constants kd = k-n/kn, and residency time constants tau = 1/k-n of 125I-insulin in normal untreated, normal CHAPS-treated, diabetic untreated, and diabetic CHAPS-treated hearts were estimated using a theoretically generated curve-fit to the data. Since insulin receptor binding on the capillary endothelial cell surfaces may serve to transport insulin from the intravascular to the subendothelial space, and since streptozotocin-induced diabetes was shown to diminish receptor autophosphorylation and kinase activity and hence internalization of insulin, then one can conclude the following from the data. In the normal heart, removal of the capillary endothelial lining with CHAPS did not alter kn, k-n, kd, and tau of insulin binding as compared to the normal untreated, whereas in the diabetic untreated heart these constants were altered, compared to the diabetic treated. Furthermore, the kn and k-n values in the diabetic CHAPS-treated hearts were the same as for the normals untreated and CHAPS-treated, respectively. In conclusion, the dissociation constants and residency time constants of all groups indicated the possible existence of two types of insulin receptors: the capillary endothelial cell surface insulin receptors with lower residency time (low affinity receptor or combination of insulin and IGF-1 receptors) and the myocyte plasma membrane insulin receptors with higher residency times (high affinity).

Anterior tibial artery: variation in origin and branching.

In a combined radiographic-anatomic study, the anterior tibial artery in a stillborn male was a branch of the posterior tibial at about its midpoint. It gave off an unusual lateral calcaneal vessel that coursed initially in the musculoperoneal canal. The variations are discussed in the context of the complex embryologic development of the blood supply to the lower limb.

Fascial layers of the scalp. A study of 48 cadaveric dissections.

The arrangement and structure of the fascial layers of the scalp were studied in 48 red neoprene latex-injected cadavers with the aid of an operating microscope. The galea aponeurotica was continuous with a superficial temporal fascia. Deep to the galea, the subaponeurotic connective tissue was bilaminar. There was an outer, vascular, areolar layer, and an inner, avascular, membranous layer. Underlying the temporalis muscle, the pericranium was thinner and more adherent than elsewhere with no subpericranial tissue.

Direct branch of external carotid: a masseteric artery.

An additional branch of the right external carotid in the form of an unusual direct artery to m. masseter is described. It arose as a terminal branch along with the maxillary and superficial temporal arteries, ran in the substance of the parotid gland to supply the muscle on its lateral aspect. The pertinent anatomical literature is reviewed.

Cutaneous arterial patterns in the scapular region.

The scapular and parascapular cutaneous branches of the circumflex scapular artery were studied in 28 cadaver sides using red latex dissection or lead oxide radiography. 2 vascular patterns have emerged depending on the dominant artery. The 2 patterns have important anatomical implications in reconstructive surgery.

A doubled flexor carpi radialis muscle.

A doubled flexor carpi radialis muscle was observed in the right forearm of an embalmed adult male cadaver. The extra muscle took origin from intermuscular septa and inserted on the 3rd metacarpal. It shared the nerve supply and the synovial sheath of the regular muscle. The pertinent anatomical literature is reviewed.

An unusual accessory flexor (opponens) digiti minimi muscle.

An accessory flexor (opponens) digiti minimi muscle is described with an origin from antebrachial fascia. In the same limb, a reversed palmaris longus muscle was noted inserting into the deep aspect of the flexor retinaculum.

A bifid piriformis muscle with dual insertion.

A bifid piriformis muscle is described with the aberrant fascicle inserting into the trochanteric fossa along with the obturator internus and gemelli muscles. The sciatic nerve split to enclose the aberrant fascicle between its common peroneal and tibial components.

Anomalous fascicle and high origin of latissimus dorsi compensating for absence of serratus anterior.

The unilateral absence of the right serratus anterior muscle was found in a 78 year old white male subject. In addition, on the same side, a high origin (5th thoracic level) of latissimus dorsi with an accessory muscle fascicle which covered the inferior angle of the scapula and fused with teres major and with the deep fascia of infraspinatus was also found. The structural arrangement suggests that the absence of serratus anterior was compensated for by the anomalous latissimus dorsi.

Absence of the coronary sinus.

The rare absence of the coronary sinus is described in a 78 year old male cadaver. The veins of the posterior surface of the heart, including the marginal and small cardiac veins, drained into the right atrium through an ostium guarded by a valve. The great cardiac vein drained into the superior vena cava after passing upward and beneath the left coronary artery.

Doubled palmaris longus muscle (with accessorius ad flexorem minimi digiti).

An unusual combination of variations is described in a palmaris longus muscle. The muscle was completely doubled with a tendinous cross slip. Insertion was on the hypothenar and thenar fasciae, and carpal bones. One of the 2 tendons formed the origin of an accessorius ad flexorem minimi digiti muscle.

An aberrant psoas major muscle fascicle.

An aberrant psoas major muscle fascicle is described in a human male cadaver. It arose by a tendinous arch spanning the body of L4 and the transverse process of L5, ran an independent course along the pelvic brim to blend with psoas major fibers proximal to the inguinal ligament.