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Summary Background Selection of implant pocket and size is a dilemma for surgeons especially if radiation therapy is envisaged after implant based immediate breast reconstruction (IBR). The aim of this study is to compare complication rates between subpectoral and the dual plane polyglactin mesh supported IBR after nipple-areola sparing mastectomy. Patients and method Reconstructive analysis of 208 breasts of 190 patients with breast cancer undergoing implant based IBR at a single university hospital were evaluated. The patients were reconstructed with either dual-plane polyglactin mesh supported (n = 91) or subpectoral (n = 117) implant based IBR after nipple-areola sparing mastectomy. Demographic data, and postoperative complications were compared. Results The mean age was 43.3 years. Early complications encountered in 12% (n = 25) and late complications occurred in 18% (n = 37) of breasts. Both early (13,7% vs 9.9%, P = 0.406) and late complications (24.8% vs 8.8%, P = 0.003) were more common in subpectoral group, but only late complication occurrence rate was statistically significant. Capsular contracture (P = 0.000), inframammary fold problems (P = 0.010), bottoming-out (P = 0.370), mechanical shift (P = 0.036) and animation deformity (P = 0.007) were all more common in subpectoral group. Only rippling deformity (P = 0.011) was more common in dual plane group. Conclusions Dual plane IBR has acceptable complication rates compared to subpectoral IBR. It is associated with less capsular contracture, fewer animation and bottoming-out deformity and better inframammary fold appearance.

Background: Even though anxiety and depression are two mood disorders encountered commonly in cancer patients only few trials have been carried out so far in melanoma patients. The aim of the study was to determine the clinical prevalence of these disorders in Turkish cutaneous melanoma patients and to clarify possible clinicopathological factors influencing them. Material and methods: A total of 100 consecutive outpatient melanoma patients were enrolled and asked to complete the Hospital Anxiety and Depression Scale (HADS) questionnaire immediately after scheduled visits. Results: A total of 24 participants had clinical anxiety and 8 were diagnosed with borderline anxiety. Fifteen were diagnosed with clinical depression and 20 with borderline depression. Prior to melanoma diagnosis the majority of the patients, 93 and 86, were assessed as normal in terms of their anxiety and depression status, respectively (p

Background The aim of this study was to analyze the potential utilization of external jugular vein (EJV) cutdown approach for totally implantable venous access device (TIVAD) placement. Methods This is a prospective, non-randomized, observational, uni-institutional study. All patients (n = 451) were first subjected to attempted subclavian vein (SV) percutaneous approach. If SV percutaneous approach was unsuccessful after multiple puncture in group A and maximum two puncture in group B, an ipsilateral EJV cutdown approach was attempted. Results Four hundred four patients (89.6%) underwent TIVAD placement via SV percutaneous approach. Of those 47 patients in which SV percutaneous approach was not successful, 8 patients in group A and 39 patients in group B, TIVAD was placed via ipsilateral EJV cutdown approach. The avarage of operative time was 17.9 ± 8.5 min in group A and 18 ± 7.3 min in group B (P > 0.05). The early complications of group A were significantly higher than that of group B (P = 0.02). Conclusions TIVAD placement by the SV percutaneous approach is safe and fast, and its success rate is very high. By avoiding the immediate complications associated with the percutaneous approach, the EJV cutdown has to be considered a valid, safe, and suitable alternative when the SV percutaneous approach unsuccessful after two needle puncture. J. Surg. Oncol. 2009;100:279–283. © 2009 Wiley-Liss, Inc.

Background: Non-HIV related Kaposi sarcoma (NHKS) is a rare indolent neoplasm which is more common around Mediterranean origin. Data concerning factors that influence progression-free survival (PFS) for NHKS are insufficient. The purpose of present retrospective analysis was to distinguish the factors affecting PFS in patients with NHKS. Methods: A hundred and twenty-eight consecutive patients with NHKS who were treated or observed between 1997 and 2014 at Istanbul University Institute of Oncology were included into the study. Treatment response and progression definitions were determined according to different treatment modalities administered at first line. Results: Majority of patients were male (n = 97, 75.8%). Median age of the whole group was 66 years (28-85). Of the patients, 15 patients were immunosuppressant, whereas 113 patients had no disease that caused immunosuppression. Patients were treated with local excision (n = 57, 44.5%), chemotherapy (n = 32, 25.0%) and/or radiotherapy (n = 13, 10.2%) or observed without treatment (n = 26, 20.3%). At a median follow-up of 28 months, 71 (55.5%) patients had progression, while 3 patients (2.3%) died of NHKS. On univariate analysis, patients who had hypertension (HT) had poorer PFS compared with others (19 +/- 12 versus 41 +/- 22 months; p = 0.03), whereas plaque formation was associated with better outcome (25 +/- 9 versus 54 +/- 12 months; p = 0.03). In addition, heavy smoking (>= 40 pack-years) had a borderline significance regarding better PFS time (23 +/- 24 versus 45 +/- 38 months, p = 0.06). On multivariate analysis, none of factors evaluated had any impact on PFS. Conclusions: HT was correlated with poorer outcome among NHKS patients. Patients with plaque formation and >= 40 pack-years of smoking had better PFS than others.

Interferon is widely used as the most effective agent in the adjuvant therapy of patients with melanoma. However, little is known about the effect of intermediate dose interferon (IDI) in adjuvant therapy. We conducted this study to determine whether intermediate doses of interferon-alpha 2 could be beneficial for these patients. A series of 84 melanoma patients with high-risk relapse potential (stage II-III) after excisional biopsy were enrolled for adjuvant therapy with IDIs, either IFN-alpha 2a, 9 MU or IFN alpha 2b, 10 MU per day, subcutaneously, for 1 yr consisted of an induction period (5d/wk for 4 wk) followed by 48 wk of same dose administered three times per week. The median follow-up was 25.9 mo with range 4-90.4 mo. Thirty-three (39%) patients had progressed; 18 (55%) of them while on treatment. The median (range) time of the failure occurrence was 9.1 mo (1.7-47.3 mo). Distribution of failure site was identical and the majority of the recurrences were found as single metastasis. For distant metastasis-free interval, mean (+/- SE) value was 28.8 +/- 3.6 mo: 1- and 2-yr survival rates were 87.8 +/- 5.7% and 61.6 +/- 9.3%, respectively. Twenty-two deaths were observed. Five-year survival rates of progression-free survival and overall survival were 50% and 60%, respectively. Generally, the treatment was found well-tolerated; drug-induced dose reduction or treatment discontinuation due to toxicity was minimal. Severe toxicity was rare. In conclusion, the small number of patients and the short follow-up does not permit any conclusion. However, the preliminary data seem to show that treatment with IDI was usually well tolerated with low toxicity of the patients during the adjuvant therapy.

Amifostine is an organic thiophosphate compound, which has both cytoprotective and radioprotective effects. An experimental study was undertaken to investigate the effects of its use on reconstructive surgery in cancer treatment. One hundred and twenty guinea pigs were divided into three equal groups to investigate flap survival and healing, patency of microvascular anastomoses, and nerve regeneration, respectively. The groups were subdivided in such a way that they were given either preoperative or postoperative radiotherapy, with or without amifostine treatment. Macroscopic and planimetric examination, light and electron microscopy, and histomorphometric analyses were performed to evaluate flap survival and healing, patency of arterial anastomoses, and nerve regeneration. Although flap survival rates were not affected, significantly better flap healing was observed in the postoperative radiotherapy subgroup with amifostine treatment. However, amifostine treatment did not result in a statistically significant difference in terms of anastomotic patency and nerve regeneration with either preoperative or postoperative radiotherapy.

Malignant melanoma is one of the most rapidly increasing cancer types, and patients with metastatic disease have a very poor prognosis. Detection of metastatic melanoma cells in circulation may aid the clinician in assessing tumor progression, metastatic potential, and response to therapy. Tyrosinase is a key enzyme in melanin biosynthesis. The gene is actively expressed in melanocytes and melanoma cells. Melan A is a differentiation antigen that is expressed in melanocytes. The presence of these molecules in blood is considered a marker for circulating melanoma cells. In this study, we analyzed the usefulness of this marker combination in evaluating the response to therapy in the blood of 30 patients with malignant melanoma. Circulating cells were detected by a reverse-transcriptase-polymerase-chain reaction. The tyrosinase expression was observed in 9 (30%) patients and Melan A in 19 (63.3%) patients before therapy. Following treatment, the tyrosinase mRNA was detected in only one patient, while Melan A transcripts were still present in 14 patients. We suggest that this molecular assay can identify circulating melanoma cells that express melanoma-associated antigens and may provide an early indication of therapy effectiveness.

This analytic (phase II) study aimed to investigate the hypothesis that the decline in serum melanoma-inhibiting activity (MIA) levels following initiation of treatment might have prognostic value. The mean serum lactate dehydrogenase (LDH), MIA and S100 levels in patients with malignant melanoma before treatment were higher than in the control group. Patients with visceral dissemination had much higher mean serum MIA levels than patients with nodal spread only. A regression model was constructed to analyse the prognostic factors in patients with advanced stage malignant melanoma. Therapy included surgical excision or lymph node dissection, hypofractionated radiotherapy, and immunotherapy or chemotherapy. Blood samples were collected within 24 h before the initiation of systemic treatment and two or three times more at 20-28 day intervals. Overall survival was investigated by univariate analysis, and correlation with clinical factors was compared using the log-rank test. Gender, primary tumour site, surgery, radiation therapy, serum S100 levels before systemic treatment and choice of chemotherapy were not correlated with the outcome. In addition to the stage of disease, low serum LDH levels before systemic treatment and a decline in serum MIA levels following initiation of systemic treatment predicted a favourable outcome. Metastasis to visceral organs was associated with higher serum MIA levels. Persistence of high serum MIA levels despite systemic treatment predicts an unfavourable prognosis. (C) 2001 Lippincott Williams & Wilkins.

The incidence of malignant melanoma has been steadily increasing over the past decades. CD 44 is a transmembrane glycoprotein which is implicated in a number of adhesive and migratory events. Downregulation of CD 44 is implicated in the metastatic process. P-Selectin is a member of the selectin family of cell surface molecules. The levels of P-Selectin in biological fluids may be elevated in subjects with a variety of pathological conditions. In malignant melanoma, elevation of the plasma level of soluble intercellular adhesion molecule-1 (sICAM-1) has been associated with a reduction in disease-free survival. This study was performed to investigate the differences in the serum concentrations of the adhesion molecules in patients with malignant melanoma. The study group consisted of 52 patients with malignant melanoma and 20 healthy subjects. No meaningful difference was observed for P-selectin and sICAM 1 levels. A statistically significant decrease was observed in the cancer patients for serum CD 44 levels.

Merkel cell trabecular carcinoma of the skin has a prognosis poorer than expected for a small skin lesion. An early diagnosis and prompt treatment can contribute to improve survival in cases of this aggressive skin tumor. A wide local excision is indicated for localized disease. Elective lymph node dissection is controversial. The authors report a rare case of Merkel cell tumor treated with wide local excision and sentinel lymph node biopsy.

The aim of this study was to identify the axillopectoral muscle anomaly commonly known as Langer's axillary arch, and to understand its importance in surgical procedures of the axilla.Between 2009 and 2011, 758 patients underwent sentinel lymph node biopsy, axillary dissection, or both. Patients with Langer's axillary arch were identified and assessed retrospectively. The decision to cut or preserve the axillary arch was made based on clinical judgment, and patients were followed-up accordingly to monitor for adverse outcomes.Of the 758 patients who underwent axillary procedures, 9 (1.2%) were found to have a Langer's axillary arch. In 2 patients the arch was cut, and in 7 patients it was preserved. No adverse outcomes were identified in any of the patients upon follow-up.Langer's axillary arch is a unique anatomic anomaly of the axillary region that may be problematic due to the potential risks of lymphedema and vascular or nerve compression. It is important for surgeons and radiologists alike to be aware of this anatomic variation in order to properly identify it and respond appropriately based on clinical judgment, and to complete close follow-up of the patient due to the potentially increased risk of adverse outcomes.Ziel dieser Studie war es, die axillopektorale Muskelanomalie bekannt als Langerscher Achselbogen zu identifizieren und ein Verständnis potentieller Auswirkungen dieser Struktur auf chirurgische Eingriffe an der Axilla zu gewinnen.Zwischen 2009 and 2011 wurde bei 758 Patientinnen eine Sentinelknotenbiopsie, eine axilläre Lymphknotendissektion oder beides durchgeführt. Patientinnen mit einem Langerschen Achselbogen wurden identifiziert und retrospektiv bewertet. Die Entscheidung, den Achselbogen zu durchtrennen bzw. zu erhalten, wurde basierend auf der klinischen Gesamtlage getroffen, und die Patientinnen wurden entsprechend weiterverfolgt und hinsichtlich eines nachteiligen Behandlungsausgangs nachbeobachtet.Von den 758 Patientinnen, bei denen ein Eingriff an der Axilla vorgenommen wurde, hatten 9 (1,2%) einen Langerschen Achselbogen. Bei 2 Patientinnen wurde die Struktur durchtrennt, bei 7 Patientinnen wurde sie erhalten. Keine der Patientinnen zeigte einen nachteiligen Behandlungsausgang in der Nachbeobachtung.Der Langersche Achselbogen ist eine einzigartige anatomische Anomalie der Achselhöhle, die auf Grund des potentiellen Risikos der Lymphödementstehung bzw. Einklemmung von Gefäßen oder Nerven zu Problemen führen kann. Sowohl Chirurgen als auch Radiologen sollten sich dieser anatomischen Variation bewusst sein, um sie korrekt zu identifizieren und basierend auf der klinischen Situation entsprechend auf sie reagieren zu können. Der Nachbeobachtung kommt ebenfalls große Wichtigkeit zu, da das Risiko eines nachteiligen Ausgangs potentiell erhöht ist.

Reconstructive surgery in previously irradiated areas is more difficult than in non-irradiated cases. A retrospective analysis of the outcome of 200 previously irradiated patients who had skin graft or flap reconstruction performed by the same surgeon is presented, and the most suitable surgical technique in irradiated areas is discussed. One hundred and fifty-six patients had skin and oral cavity cancer, and were operated on after local recurrence. Twenty patients had breast cancer; 15 were operated on for local recurrence and five for breast reconstruction. Twenty-four patients had soft tissue sarcomas. Eighty-five patients had a skin graft (group 1), 35 had a skin flap (group 2), 10 had a fascia/muscle flap plus skin graft and 70 had a myocutaneous flap (group 3). Analysis of complications revealed statistically significant differences in terms of incomplete graft/flap necrosis between group 1 and 2 (P0.001) and groups 1 and 3 (P0.001), and in terms of infection between groups 1 and 3 (P0.01). We conclude that the method of reconstruction is determined by the characteristics of the defect such as size and localization; the quality, fractionation, total dose, and energy of radiation used; skin and subcutaneous tissue changes due to radiation; and operation time. However, it is reasonable to choose fascia/muscle or myocutaneous flaps for reconstruction in previously irradiated areas. These methods are more resistant to bacterial inoculation, more prone to clean residual infection, and provide better vascularized tissue and volume replacement for contour defects.

Background This study evaluated whether prophylactic treatment with a cefazolin could prevent infections in patients who had a surgically inserted totally implantable venous access device (TIVAD). Methods We conducted a prospective, randomized, double-blind, placebo-controlled trial comparing wound infection rates in 404 patients (203 received prophylactic cefazolin, 201 received a placebo) undergoing TIVAD insertion. Infections were evaluated 3, 7, 14, and 30 days after discharge and outcomes were compared and analyzed. Results Groups were well matched for all preoperative variables studied, including comorbid conditions. Superficial surgical site infection developed in 5 patients (2.5%) from the antibiotic group and 6 (3%) from the placebo group ( P = .75). One from each group developed deep surgical site infection. Both patients were readmitted and underwent repeated debridement, which eventually resulted in port loss in 1 patient. Conclusions We do not recommend the use of prophylactic antibiotics in TIVAD insertion because they will not decrease the already low rate of postoperative infectious complications. Registration number NCT00867295 ( http://www.clinicaltrials.gov ).

The aim of this study was to analyze the potential utilization of external jugular vein (EJV) cutdown approach for totally implantable venous access device (TIVAD) placement.This is a prospective, non-randomized, observational, uni-institutional study. All patients (n = 451) were first subjected to attempted subclavian vein (SV) percutaneous approach. If SV percutaneous approach was unsuccessful after multiple puncture in group A and maximum two puncture in group B, an ipsilateral EJV cutdown approach was attempted.Four hundred four patients (89.6%) underwent TIVAD placement via SV percutaneous approach. Of those 47 patients in which SV percutaneous approach was not successful, 8 patients in group A and 39 patients in group B, TIVAD was placed via ipsilateral EJV cutdown approach. The average of operative time was 17.9 +/- 8.5 min in group A and 18 +/- 7.3 min in group B (P0.05). The early complications of group A were significantly higher than that of group B (P = 0.02).TIVAD placement by the SV percutaneous approach is safe and fast, and its success rate is very high. By avoiding the immediate complications associated with the percutaneous approach, the EJV cutdown has to be considered a valid, safe, and suitable alternative when the SV percutaneous approach unsuccessful after two needle puncture.

Primary melanoma of the anal region is a rare pathological entity and its prognosis is generally poor. The aim of this report is to demonstrate the feasibility of the sentinel lymph node (SLN) procedure with combined technique in patients with anal melanoma. We report of two cases with anal melanoma that had wide local excision of the primary lesion and was referred for further evaluation. After diagnostic metastatic work-up, SLN procedure consisted of a combination of preoperative lymphoscintigraphy with technetium-99m nanocolloid injected around the tumor, and intraoperative detection of SLN with gamma probe (combined technique) was performed. In addition, patent blue dye was injected at the periphery of the tumor to facilitate direct identification of the blue-stained lymph node. In the first case, SLN identified both inguinal and iliac lymph node basins, both of which were histologically negative on both frozen and paraffin sections. In the other case, SLN removed from the inguinal lymph node basin showed micrometastasis by paraffin section. In both cases SLN procedure with combined technique was performed sufficiently without significant complications. Consequently, we suggest that SLN procedure with combined technique is also a useful technique in malignant melanomas similar to other anal canal cancers.

Penile involvement has been implicated as a metastatic site in several tumors; approximately 300 cases have been reported. Of these, only two cases showed cutaneous melanoma as the primary site. Our patient presented with a painless mass on the penile shaft together with other distant metastases. A magnetic resonance image demonstrated two sites of deposit in the subcutaneous tissue on the radix penis, and fine needle aspiration cytology of the mass confirmed the presence of melanoma cells. The patient died of systemic disease without any further treatment for penile involvement. This unusual involvement is presented with a review of the related literature.

Stage T1 through T3 lip cancers can be treated primarily by brachytherapy (BRTX), with or without external radiotherapy (ERT), with adequate safety margins and good results. In this study, the outcomes of BRTX were reviewed for patients treated at the Brachytherapy Department of the Istanbul University Oncology Institute (IUOE). The medical records of 41 patients registered at IUOE with a diagnosis of lip cancer between 1988 and 2003 were reviewed. The median follow-up time was 88 months (24–160 mo). Among these patients, 21 patients with a primary tumor, 14 with tumors arising postoperatively, and 6 with postoperative recurrence of tumor were treated using BRTX. A total of 33 patients (80%) received BRTX alone and 8 (20%) received BRTX and ERT. The 10-year local control rate was 100%, 93%, and 67% for patients treated with BRTX alone, BRTX and surgery, and those treated for postoperative recurrence, respectively (P < .02). For patients treated with BRTX only and BRTX plus surgery, specific disease-free survival was 95% and 94%, respectively, and overall survival was 93% and 100%, respectively; these differences were not statistically significant. One patient with a postoperative recurrence who had been treated with BRTX died as a result of lip cancer. No patients developed any ulcerations, intra-oral complications, or mandibular necrosis. In the BRTX only group, 83% had excellent or good cosmetic results. In the surgery group, 62% had a contour deformity. In lip cancer management, BRTX results were comparable for local control, survival, and minimal late effects in normal tissue. This is in accordance with current reports in the medical literature. Satisfactory results were observed in patients with stage T1 and T2 lesions who had been treated with BRTX only and in patients with stage T3 lesions who had been treated with BRTX plus ERT, without a need for additional treatment modalities.

Background: The breast is associated with a large number of diseases. Besides being the host of many benign and malignant tumors, breast skin and parenchyma are also metastatic sites for various tumors such as leukemia, lung cancer and melanoma. Methods: Malign melanoma has different manifestations in the breast. All these manifestations are important not only as initial presentations of the disease, but also as indicators of the progression period of the disease. Results: This study reports on 12 cases of cutaneous malignant melanoma in breast skin and tissue. Nine of these cases are primary cutaneous melanomas, while the others are breast metastases from a distant site cutaneous melanoma. In two of the nine primary cutaneous melanomas in-transit metastasis to the breast developed during the follow-up period. Conclusions: In this paper, the diagnostic and surgical approach to primary and metastatic melanoma of the breast, and the importance of the breast during the follow-up period are reviewed.

Amifostine is an organic thiophosphate compound, which has both cytoprotective and radioprotective effects. An experimental study was undertaken to investigate the effects of its use on reconstructive surgery in cancer treatment. One hundred and twenty guinea pigs were divided into three equal groups to investigate flap survival and healing, patency of microvascular anastomoses, and nerve regeneration, respectively. The groups were subdivided in such a way that they were given either preoperative or postoperative radiotherapy, with or without amifostine treatment. Macroscopic and planimetric examination, light and electron microscopy, and histomorphometric analyses were performed to evaluate flap survival and healing, patency of arterial anastomoses, and nerve regeneration. Although flap survival rates were not affected, significantly better flap healing was observed in the postoperative radiotherapy subgroup with amifostine treatment. However, amifostine treatment did not result in a statistically significant difference in terms of anastomotic patency and nerve regeneration with either preoperative or postoperative radiotherapy.

Degradation of basement membranes and extracellular matrix is an essential step in cancer invasion and metastasis. Matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) play key roles in this step. The present study was conducted to investigate the levels of MMP-3 and TIMP-1 in serum of patients with malignant melanoma and the relationship to tumor progression and known prognostic parameters. Seventy patients with cutaneous malignant melanoma were investigated. Serum samples were obtained on first admission before any adjuvant and metastatic treatment was given or follow-up of patients. Serum TIMP-1 and MMP-3 levels were determined by the solid-phase sandwich ELISA (Oncogene Science Inc.) method. The elevation of serum MMP-3 and TIMP-1 levels between the patients with malignant melanoma and healthy controls were not significantly different (p0.05). The serum levels of MMP-3 were significantly different in males and females (p = 0.001) and serum TIMP levels were influenced by age (p = 0.047). Except for the ulceration status of the tumor, serum levels of MMP-3 and TIMP-1 were not related to the known prognostic factors such as tumor histology, localization, stage of the disease, Breslow thickness, Clark invasion, mitosis, TIL, and regression of tumor (p0.05). In patients with ulceration positive, the serum levels of MMP-3 were higher (p = 0.04) and TIMP-1 were lower (p = 0.008) than those in patients without ulceration. No significant relationship was found between serum levels of MMP-3 and TIMP-1. In conclusion, these results suggest that neither of the serum levels of MMP-3 and TIMP-1 could be a good indicator of invasion and metastasis nor can be recommended as a tumor marker in the management of melanoma patients owing to lack of sensitivity and specificity. However, much research still continues in this field and exciting new knowledge will ultimately emerge.

In this study, total vermilionectomy, indications and technique are discussed. The results of 33 cases are presented with review of the literature.

Totally implantable venous-access ports (TIVAPs) are valuable instruments for long-term intravenous treatment of patients with cancer, but implantation and use of these devices are each associated with complications. In addition to the perioperative problems, long-term complications can arise; these can be classified in five categories-catheter malfunction, catheter-related venous thrombosis, catheter-related infection, port-related complications, and extravasation injury. Such complications reduce the benefits of reliable access to the venous system in patients with malignant tumours. The vast majority of such disadvantages are attributable to inexpert handling of ports and, therefore, should be avoidable. TIVAP placement procedures and TIVAP complications are discussed in this review, with special emphasis on local problems and extravasation injuries. To obtain maximum benefit from TIVAPs, all health-care personnel must be familiar with the use and routine maintenance procedures of the devices and treatment options for catheter-related complications.

We present a new, simple technique for umbilical positioning in abdominoplasty. The technique is concluded to be a practical one, especially for staff in training.