Carl H. Manstein

How accurate is frozen section for skin cancers

Frozen section analysis has been used to increase the likelihood of complete excision of skin cancers and to minimize the risk for recurrence. The question of its accuracy has been addressed in many studies and this article adds data to the discussion. A retrospective study was performed of 60 consecutive cases in which frozen section diagnoses were compared with permanent sections. It was found that in 85% of the cases the frozen sections were accurate compared with the permanent sections, but in 13% of the total cases the margins were less than 1 mm. These results concur with the literature. The surgery and pathological examinations were performed in a community hospital in which there was no dermatopathologist. The authors review the limitations of frozen section diagnosis in skin cancers and show that frozen section may be necessary in select cases but not in most skin cancers.

Keratoacanthoma: is it a real entity?

Keratoacanthoma of the skin and well-differentiated squamous cell carcinoma are two cutaneous neoplasms that most often occur in sun-exposed sites of light-skinned persons. It is often difficult to distinguish these two from each other either clinically or histologically. The view that these two cutaneous neoplasms are part of the same disease entity is not new. We reviewed 150 patients with these two diseases in an effort to see whether any specific criteria for diagnosis and treatment could be achieved. It is our hypothesis that they are not separate diseases but within the spectrum of the same disease. Keratoacanthoma may be some sort of aborted malignancy or hyperplastic premalignant lesion within the squamous cell carcinoma spectrum. The incidence of metastases from squamous cell carcinoma of the skin may be as high as 3%. We do not have the courage to wait 3 months to see if a potentially invasive and metastatic neoplasm is indeed involutional. Incision biopsy may be wrought with significant histopathological inconsistencies. We believe that early, complete excision is the treatment of choice for all skin neoplasms thought to be keratoacanthoma.

Paraspinous Muscle Flaps

Coverage of midline posterior wounds presents a challenge to the reconstructive surgeon, especially when spinal stabilization hardware has been present and exposed in the wound. Most commonly those wounds that involve the mid to upper thoracic spine have been covered by latissimus dorsi muscle or musculocutaneous flaps. Lower midline wounds, especially in the thoracolumbar region, have needed more complex means of coverage. These have included reversed latissimus dorsi flaps, free flaps, extended intercostal flaps, or fasciocutaneous rotation flaps. We have utilized a far simpler and effective muscle flap: the paraspinous muscle flap. We have raised paraspinous muscle flaps bilaterally and have been able to cover a number of difficult wounds. The wounds were presented by 8 patients with exposed Harrington rods, 3 patients with cerebrospinal fluid leaks, and 1 patient with exposed spinous processes. The wounds in 5 of these 12 patients were in the upper thoracic region, where a latissimus flap was utilized as an additional layer of muscle coverage. The other seven patients had wounds in the lower midline region below the potential reach of the latissimus dorsi. In the latter patients the only flaps employed were paraspinous muscle flaps. We had only one failure in all patients, which involved a recurrent cerebrospinal fluid leak in which there was no decompression of the cerebrospinal fluid pressure utilized in the immediate postoperative period to protect the dural repair. In that instance, a leak recurred. This paper presents the method of flap elevation and the results of our series.

Giant basal cell carcinoma: a series of seven T3 tumors without metastasis.

Basal cell carcinoma accounts for 65 to 80 percent of all reported cases of nonmelanoma skin cancer. It is the most common malignancy in the United States, with approximately 800,000 tumors treated each year. It is a disease that affects a myriad of patients crossing all age boundaries as well as all ethnicities. Giant basal cell carcinoma is defined as a lesion greater than 5 cm at its greatest diameter. By the TNM classification, these tumors are termed T3. They are quite rare. In Betti et al.’s study of 1093 cases, only five were classified as the giant type (0.5 percent).1 The importance of size has been implicated as a determinant of metastatic potential. Although only 0.03 percent of basal cell carcinomas are found to have metastasis, giant basal cell carcinoma is reported to be more aggressive.2 Sahl studied 11 patients with giant basal cell carcinoma, of whom three had metastatic disease and subsequently died of their disease.3 The mean survival following the discovery of metastatic basal cell cancer is only 8 to 10 months.4 Our study includes seven patients with giant basal cell carcinoma with no evidence of metastatic disease. Our results lead us to predict that wide local excision is recommended treatment in these T3 lesions. Depth of invasion did not appear to be an issue or have any prognostic implication. Reconstruction to repair the surgical defect following excision is at the preference of the surgeon. We used split-thickness skin grafts exclusively.

Obtaining projection in the amputation free nipple/areolar graft breast reduction without a vertical scar: using breast parenchyma to create a new mound.

Multiple techniques for breast reduction in the giant breast have been used. The amputation technique with the free nipple/areolar graft has been the mainstay for severe macromastia since 1921. Traditional methods for amputation of the inferior pole of the breast have created fairly flat breast mounds. Projection of the mound was enhanced by an inferior pleat with a resulting vertical scar. A new technique employing a superiorly based dermal fat flap folded back behind the residual breast to improve projection and roundness has been developed. It has not only eliminated the vertical scar but improved the shape of the mound. It has also given patients who were not previously good candidates for reduction with other techniques an option for surgery despite the presence of old scars or the need for lumpectomy in the lower third of the breast. A clinical series is presented.

Rejection of cultured keratinocyte allografts in the rat

We have made a detailed analysis of the fate of Langerhans cell-free cultured keratinocyte allografts in two rat strain combinations, DA-to-PVG and DA-to-LEW, and compared the results with the rejection of conventional skin allografts in these strain combinations. The cultured keratinocyte layers were grafted both to the body surface using a technique to prevent wound contraction, and to the renal subcapsular site. Histological examination of grafts was made on days 2, 7, 10, 14, and 28 after transplantation. Donor-specific anti-class I MHC monoclonal antibodies were used to verify the donor origin of the keratinocytes. We report that the keratinocyte allografts are acutely rejected but, in contrast to the conventional allografts, do not evoke alloantibody responses. Rejection of the keratinocytes at the renal subcapsular site was as rapid as that of conventional skin grafts. However, rejection of keratinocyte grafts on the body surface was delayed by a few days when compared with conventional skin grafts. Immunosuppression with cyclosporine prevented the rejection of DA keratinocyte layers placed at the renal subcapsular site of PVG rats, but rejection followed soon after cessation of cyclosporine therapy. These data suggest that rejection is a major constraint for the clinical application of cultured keratinocytes, and that autografts must be used if permanent cover is required. Moreover, the findings have interesting theoretical implications relating to the much greater vulnerability to rejection of skin grafts compared with organ grafts. Our current and previous data also suggest that class II positive dendritic cells are the major stimulus to alloantibody production after tissue transplantation.

Use of pectoralis minor muscle in immediate reconstruction of the breast.

A technique is described in which the pectoralis minor muscle is rotated as a muscle pedicle flap to be used in immediate reconstruction of the breast. The advantages of this procedure are that it provides additional muscle coverage over the prosthesis as well as preventing lateral displacement. Seven patients have undergone this technique with excellent results.

Giant basal cell carcinoma: 11-year follow-up and seven new cases.

Basal cell carcinoma is the most common malignancy of the body and the most common skin cancer, and is seen most often on the head and neck. Histopathologically, most basal cell carcinomas arise from the epidermis and hair follicles.1 The most common factor involved in the pathogenesis of skin cancer is ultraviolet light,2 which explains why three-quarters of these tumors are in the head and neck.3 Metastasis of basal cell carcinoma is rare, with an incidence as low as 0.0028 percent.4 Regardless of size, all basal cell carcinomas arise in the basal layer of the epidermis and the pilosebaceous follicle units (Figs. 1 and 2). Basal cell carcinoma usually grows solely by local extension in both horizontal and vertical directions; local extension can continue into the deeper tissues, such as cartilage and bone. Perineural extension is often insidious in its development. In 2000, we presented a series of seven patients with giant basal cell carcinoma—tumors larger than 5 cm in diameter—without any clinical evidence of metastases.5 At the time of our original publication, the tumor, node, metastasis system classified these tumors ( 5 cm) as T3.6 The American Joint Committee on Cancer recently released the seventh edition of the Cancer Staging Manual7; this updated manual includes several changes, including a revision of the tumor, node, metastasis staging system for basal cell carcinomas. Until this latest edition, basal cell carcinoma with a diameter greater than 5 cm was classified as a T3 tumor; however, the new T staging has eliminated the 5-cm diameter cutoff. Two-centimeter diameter continues to differentiate T1 and T2 with certain high-risk features that increase the T stage: depth of tumor, anatomical site, perineural invasion, histopathologic grade or differentiation, and bony invasion. We would like to present an additional seven patients with these large tumors, now classified as T2, and reassert the notion that depth of invasion of giant basal cell carcinoma does not have any prognostic implication. This study followed the Declaration of Helsinki guidelines for research involving human individuals. The nature of the study was explained and all patients gave written consent to participate. Treatment for these large basal cell carcinomas is the same for any other size basal cell carcinoma: surgical excision. With a 1-cm margin of normal tissue as part of the resection margin, we found it most expeditious and practical to reconstruct all surgical defects with split-thickness skin grafts. We found that reconstructive options other than split-thickness skin grafts were not necessary or indicated, unlike other authors.8,9 We have not had any experience with Metvix photodynamic therapy as a preoperative means of shrinking the size of the tumor.10 Our practice has accumulated over 5000 specimens of surgically excised basal cell carcinoma over the past 20 years. Regardless of size or any prior treatments, we have yet to see one case of metastasis, which is consistent with the new classification in the seventh edition of the Cancer Staging Manual by the American Joint Committee on From the Division of Plastic Surgery, Ambulatory Surgery Center, Holy Redeemer Hospital. Received for publication March 3, 2011; accepted March 30, 2011. Follow-up to: Manstein CH, Gottlieb N, Manstein ME, Manstein G. Giant basal cell carcinoma: A series of seven T3 tumors without metastasis. Plast Reconstr Surg. 2000; 106:653–656. Copyright ©2011 by the American Society of Plastic Surgeons

Management of thyroid nodules in children

Estimates of the prevalence of thyroid nodules in children depend on the method of detection, ranging from 1 to 1.5% for detection by palpation to 3% for detection on ultrasound scans. Several risk factors are associated with a higher risk of developing thyroid nodules. These factors include puberty, iodine insufficiency, family history of thyroid disease, thyroid diseases, whether autoimmune (Hashimoto thyroiditis, Grave’s disease) or congenital (congenital hypothyroidism with organification defects), genetic syndromes (such as familial adenomatous polyposis, Carney’s complex or Cowden disease) and a history of exposure to radiation after medical treatment (before bone marrow transplantation or in patients with Hodgkin’s lymphoma) or through the environment [1]. Thyroid nodules occur in a broad range of thyroid disorders, including solitary nodule formation, multinodular goiter, chronic lymphocytic thyroiditis (Hashimoto disease) and Graves’disease. They may also reflect the formation of cysts in the thyroglossal duct.

Selective digital venous hypertension: A rare complication of hemodialysis arteriovenous fistula

We report and document angiographically a case of selective venous hypertension, masquerading as an infection, which involved the three middle digits of the right hand in a patient with an access arteriovenous (AV) fistula. This complication arose following hemodialysis and was resolved after resection of the right radial artery at the site of AV fistula and re-anastomosis.