Christen Krag

Psychoeducational intervention for patients with cutaneous malignant melanoma: a replication study.

PURPOSE In 1993, a randomized intervention study among patients with malignant melanoma showed a significant decrease in psychological distress and increased coping capacity 6 months after the intervention and enhanced survival 6 years later. We applied a similar intervention with a few modifications in a randomized controlled trial among Danish patients with malignant melanoma and evaluated results on immediate and long-term effects on psychological distress and coping capacity. PATIENTS AND METHODS A total of 262 patients with primary cutaneous malignant melanoma were randomly assigned to the control or intervention group. Patients in the intervention group were offered six weekly sessions of 2 hours of psychoeducation, consisting of health education, enhancement of problem-solving skills, stress management, and psychological support. The participants were assessed at baseline before random assignment and 6 and 12 months after surgery. The analyses of the main effects of the intervention were based on analyses of covariance. RESULTS The patients in the intervention group showed significantly less fatigue, greater vigor, and lower total mood disturbance compared with the controls, and they used significantly more active-behavioral and active-cognitive coping than the patients in the control group. The improvements were only significant at first follow-up. CONCLUSION The findings of this study support the results of an earlier intervention study among patients with malignant melanoma and indicate that a psychoeducational group intervention for such patients can decrease psychological distress and enhance effective coping. However, this effect is short term and the clinical relevance is not obvious.

Wide local excision of recurrent breast cancer in the thoracic wall.

Background. Local recurrence is one of the major problems in treatment of breast cancer. Approximately 20% of patients who have radical or modified radical mastectomy have a local recurrence.

Survival After a Psychoeducational Intervention for Patients With Cutaneous Malignant Melanoma: A Replication Study

PURPOSE The results of a randomized, intervention study done in 1993 of psychoeducation for patients with early-stage malignant melanoma showed a beneficial effect on recurrence and survival 6 years after the intervention. In the present study, we replicated the study with 258 Danish patients with malignant melanoma. We also compared recurrence and survival among the participants in the randomized study with 137 patients who refused to participate. PATIENTS AND METHODS We randomly assigned 262 patients with primary malignant melanoma to a control or an intervention group. Patients in the intervention group were offered six weekly 2-hour sessions of psychoeducation. Participants and nonparticipants were followed up for vital status and recurrence 4 to 6 years after surgical treatment. Prognostic factors (thickness of the tumor and lymph node status), sex, and age were adjusted for in a Cox regression model (proportional hazards regression) to derive an adjusted survival rate ratio and an adjusted relapse-free survival rate ratio, with 95% CIs. RESULTS The hazard ratio was 1.30 (95% CI, 0.5 to 3.5) for survival and 0.73 (95% CI, 0.3 to 1.9) for recurrence. Being a nonparticipant increased the risk for death by more than two-fold (hazard ratio, 2.26; 95% CI, 1.0 to 5.2) over that of participants. CONCLUSION Psychoeducation did not increase survival or the recurrence-free interval among patients with malignant melanoma; however, nonparticipants had a statistically significantly greater risk for death than participants.

Melanoma and Pregnancy

In the last half-century the incidence of cutaneous malignant melanoma has increased all over the world according to available reports. No association between risk of melanoma and age at menarche, first birth, menopause or duration of reproductive period has been proven so far. Studies on the effect of parity on relative risk and survival have given divergent results with multiparous women possibly having a better prognosis than nullipara. Women with melanoma diagnosed during pregnancy tend to have thicker tumours, shorter disease-free interval and, maybe, lower 10-year survival rate than non-pregnant matched controls. There is no conclusive evidence that therapeutic abortion improves the cure rate. Multivariate analysis has failed to unveil impaired prognosis in women who become pregnant subsequent to diagnosis.

The Latissimus Dorsi Flap: An Overview

In the recent past, the latissimus dorsi musculocutaneous flap has added a significant tool to the armamentarium of the reconstructive surgeon. The history of its clinical use is reviewed with emphasis on embryological, anatomical and hemodynamic aspects.

Experience with transplantation of composite tissues by means of microsurgical vascular anastomoses. I. Indications, techniques and early results.

The clinical experience with 65 transplantations of composite tissues by means of microsurgical vascular anastomoses is reported with emphasis on indications, operative techniques, vascular complications and soft tissue healing. Donor tissues, comprising 28 latissimus dorsi flaps, 20 groin flaps, 2 saphenous flaps, 4 fibular flaps, 9 dorsalis pedis artery flaps and 2 second toes, were transplanted to recipient sites in the head and neck area (18), upper extremity (8), torso (2) and lower extremity (37) in sixty-two patients with defects caused by traumata (45), tumor excisions (16) or congenital malformations (1) in which on average 3 therapeutic attempts had been unsuccessful. The reconstruction failed in 3/65 (5%) cases due to vascular thrombosis at the anastomotic sites. Early circulatory impairment (less than 1 week postoperatively) in the transplanted tissues was seen in 16/65 (25%) cases, thirteen of which were successfully managed by evacuation of a haematoma (9) and/or by resection of the anastomotic site and reconstruction of vascular continuity (5). Late circulatory impairment (greater than 1 week postoperatively) secondary to local infection was seen on 2 occasions and resulted in total loss of one flap. In one case persistent posttraumatic ostitis resulted in partial loss of a flap necessitating further reconstructive attempts. Altogether the reconstructive attempt failed in the early postoperative period (less than 3 months) in 5 cases (8%). It is concluded, that difficult reconstructive problems may be solved in a single stage using microsurgical composite tissue transplantation in patients who otherwise would have faced prolonged multistaged reconstructions and/or major limb amputations. Microsurgical composite tissue transplantation has widened the possibilities of reconstructive surgery and seems to be a reliable method, at least as safe as conventional reconstructive flap procedures.

Experience with the Latissimus Dorsi Flap

A review of 65 applications of the latissimus dorsi flap based on the thoraco-dorsal vessels to recipient sites in the head and neck area (10), on the torso (22), in the upper extremity (9) and in the lower extremity (24) in 62 patients with malignancies (28) and congenital deformities (6) is presented. Thirty-five flaps were transplanted with microsurgical vascular technique, while 30 flaps were pedicled. Vascular thrombosis at the anastomotic site was seen in 4/35 free tissue transplants and was successfully managed in 3 cases with an overall survival rate of 97% in this group, while all pedicled flaps survived. Healing complications including haematomas and wound infections were related to the nature of the recipient site and most commonly seen in the lower leg after resection of infected bone. In 3 cases leg amputations were performed within 6 months after the reconstruction, while 6 patients had secondary operations for tibial pseudoarthroses. Donor site morbidity was insignificant, without permanent, functional losses. It is concluded, that the thoracodorsal unit is a versatile and safe flap for reconstructive purposes.

Experience with Transplantation of Composite Tissues by Means of Microsurgical Vascular Anastomoses: II. Late Results and Comments

In a series of 65 composite tissue transplantations the results were evaluated 6-68 (median 28) months postoperatively. The donor tissues, comprising skin flaps (7), neurovascular skin flaps (2), musculocutaneous flaps (26), tendinocutaneous flaps (2), muscle flaps (2), osteocutaneous flaps (18), bone grafts (6), and digits (2), were transplanted to recipient sites in the head and neck area (18), upper extremity (8), torso (2) and lower extremity (37) in sixty-two patients with defects caused by traumata (45), tumor excisions (16) or congenital malformations (1) in which on average 3 therapeutic attempts had been unsuccessful. In 5 cases the reconstruction failed within the first two postoperative weeks while the reconstructed part was included in lower extremity amputations 6-24 months postoperatively in 3 cases. The intended purpose was achieved in 27/34 cases of soft tissue reconstruction, 3/3 cases of combined tendon and skin repair, 18/19 cases of combined skin coverage and bone reconstruction, 4/5 cases of segmental bone reconstruction, 2/2 cases of thumb reconstruction and in 2/2 cases of facial reanimation. In 21 cases of 37 lower extremity reconstructions a major amputation would have been the alternative. Four of these patients were in fact amputated above the knee (1) or below the knee (3). Altogether, the reconstructions were successful in 56/65 (= 86%) cases. It is concluded that difficult reconstructive problems, especially those related to head and neck surgery, orthopaedic surgery and hand surgery may be amenable to successful reconstruction using microsurgical composite tissue transplants with an expected success rate averaging 9 out of 10 cases.

The Effect of Pulsed Electromagnetic Energy (Diapulse®) on the Survival of Experimental Skin Flaps: A Study on Rats

Experimental skin flaps in rats were treated with an active/non-active Diapulse unit in a double-blind trial to clarify whether or not pulsed electromagnetic energy had any effect on the surviving length of flaps. The observed differences in surviving flap areas between the Diapulse treated group and the untreated group as compared to the predicted survival by fluoresceine and/or vital capillary television microscopy were not statistically significant (p less than 0.10) in a set up, that on a significance level of 5%, would have detected an enhancement of flap survival of greater than or equal to 10% in 98% of trials.

Late Patency of Clinical Microvascular Anastomoses to Free Composite Tissue Transplants: I. Angiographical Aspects

In a series of sixty-five free composite tissue transplantations by means of microsurgical techniques, 37 transplantations were performed to recipient sites in the lower extremity in 34 patients. Twenty-eight of these patients with 31 composite transplants were examined by femoral arteriography to assess the patency of 33 arterial anastomotic lines 6-45 months, median 12 months, postoperatively. Angiography showed patency in 32 of 33 arterial anastomotic lines, one arteriography being inconclusive. The results suggest that microsurgical techniques in small vessel anastomosis (ext. diam, 3/4-3 1/2 mm) are essential prerequisites for long-term vascular patency.