Cristina Chiarugi

FIRST RECURRENCE ANALYSIS OF 840 CUTANEOUS MELANOMAS : A PROPOSAL FOR A FOLLOW-UP SCHEDULE

Aims and background A correct follow-up schedule for patients who underwent an excision for stage I cutaneous melanoma might allow the early detection of local and distant metastases. At present, there is no general agreement on follow-up protocols. In order to work out a follow-up guide, we have retrospectively evaluated the records of 840 stage I cutaneous melanoma patients surgically treated and followed during the postoperative period in the Division of Plastic Surgery of the University of Florence from 1975 to 1992. Methods We evaluated the patients’ records by analyzing time, pathway and site of any first recurrence in relation to the main prognostic factors such as patient sex, site, histological type and depth of invasion of each primary melanoma. A statistical analysis was performed. Results To summarize, the salient results were the following: 80% of relapses occurred in the first 3 years and they occurred significantly earlier when the primary melanoma was localized in the trunk and significantly later when the melanoma was localized in the lower limbs and for < 1.5 mm lesions. The first recurrence occurred earlier by the lymphatic than by the hematic pathway regarding the overall number of patients. The hematic pathway was the most frequent (with respect to the overall percentage of hematic metastases) for the melanomas localized in the head and neck region and for lentigo malignant melanomas, whereas the lymphatic pathway was most frequent for melanomas of the lower limbs and > 3 mm in thickness. Conclusions We suggest a follow-up schedule taking into consideration the postoperative behavior of stage I cutaneous melanoma patients (in terms of time and pathway of the first recurrence) in relation to the site and depth of invasion of the tumor.

The Use of High Resolution Ultrasound in Preoperative Evaluation of Cutaneous Malignant Melanoma Thickness

High resolution ultrasound (HRUS) was tested in 58 cutaneous malignant melanomas to check its validity in evaluating tumor thickness in vivo before surgery. The values obtained with this method were compared with histologic values (measured according to Breslow); a highly significant correlation was found (r = 0.895, p < 0.001). The accuracy of HRUS in distinguishing between low- and high-risk cutaneous malignant melanoma was also found to be quite high. Our data therefore justify the use of such a technique in the preoperative staging procedure.

Reconstruction of a Medial Canthus Defect with a Myocutaneous Flap

Defects in the inner canthal area are generally repaired by full-thickness skin grafts, V-Y advancement flap, or frontal flap. Each of these techniques may give some problems in restoring the functional or aesthetic features of that region, or both. To avoid these inconveniences, we performed the reconstruction of the medial canthal area after tumor excision by using a myocutaneous rotation flap from the upper lid joined to a rotation flap from the lower lid and cheek. No scar resulted inside the aesthetic unit and a fine result was achieved from both the functional and the aesthetic point of view.

Infusion of in vitro expanded tumour-infiltrating lymphocytes and recombinant interleukin-2 in patients with surgically resected lymph node metastases of malignant melanoma: A pilot study

A pilot study was set up in order to evaluate the feasibility and safety of infusing in vitro expanded tumour-infiltrating lymphocytes (TILs) and recombinant interleukin-2 (rlL-2) in a group of patients with advanced melanoma after radical resection of lymph node metastases. Twenty-four patients were eligible for the study and proliferating TILs were collected in 16. These patients were infused with TILs and then treated with rlL-2 and a-interferon. Short-term toxic effects (such as fever) were in general controlled by symptomatic drugs, whereas chronic toxicities were absent. The median follow-up period was 19 months; at present, 13 patients are alive and disease free, one patient is in progression and two patients have died. The approach was feasible and safe and the clinical results observed are comparable to those obtained by long-term treatment with other biological response modifiers.

Sonographic evaluation of dermis and subcutaneous tissue during and after skin expansion

Soft-tissue thickness modifications were evaluated by high-resolution ultrasound sonography in six patients undergoing skin expansion, with the aim of investigating the possible use of this noninvasive method in the routine monitoring of soft tissues during and after skin expansion. Both during expansion (decrease) and in the postoperative period (increases up to 100 percent or more of the baseline preoperative value), changes in fat thickness occurred faster and were greater in magnitude than those in dermal tissue, overall gradual and limited. In our series, the values of fat thickness ranged between 44 (at full-expansion time) and 140 percent (2 months after expander removal), with a highly significant difference (p = 0.0003), while dermis thickness values ranged between 83 and 114 percent, respectively, showing no significant difference (p = 0.71). Some echostructural dermal modifications were found by the 20-MHz probe at full skin expansion only. High-resolution ultrasound sonography may be proposed as a noninvasive method in the routine monitoring of soft tissues during and after skin expansion. (Plast. Reconstr. Surg. 93: 1050, 1994.)

A rare case of anal porocarcinoma treated by electrochemotherapy

We report the case of an old woman with an eccrine porocarcinoma unusually localized in the perianal area treated by electrochemotherapy, a new technique, emerging as a very effective local treatment of different skin metastases and selected primary tumors. Electrochemotherapy was performed taking into account patient wishes and refusal of demolitive surgery. The electrochemotherapy treatment was well tolerated by the patient, it gave an excellent clinical response and a complete clinical regression with no sphincter dysfunction and signs of relapse observed during follow-up. The case is of particular interest for the exceptional localization of porocarcinoma for the first time treated by electrochemotherapy in this area. Electrochemotherapy could be considered as an alternative option for selected cases of cutaneous tumors.

Saddle tailored upper eyelid island myocutaneous flap to repair full-thickness lower eyelid defects after melanoma excision.

Purpose: To perform an early melanoma diagnosis and to repair the full-thickness lower eyelid defect with an island upper eyelid myocutaneous flap tailored into a new shape. Methods: Two patients with pigmented lesion involving skin and tarsus of the lower eyelid were reported. Histologic examination, performed after diagnostic punch biopsy, confirmed the diagnosis of in situ melanomas in both cases. A full-thickness excision was done and a single pedicle island myocutaneous flap from the upper eyelid was performed. The flap was designed in a blepharoplastic manner and tunnelized to reach the lower eyelid defect. The flap was tailored into a “saddle” shape, doubled, and folded to restore both the internal and external eyelid walls in a single-stage procedure. Results: Good functional and aesthetic results were obtained with no complications. Interestingly enough, the tissue of the internal layer lost the features of skin epithelium due to metaplasia processes and appeared similar to the conjunctiva. After 3 years, no sign of melanoma recurrence was noted. Conclusions: Early diagnosis was performed in both reported lower eyelid melanoma cases. For the reconstruction, a modified upper eyelid island myocutaneous flap tailored into a “saddle” shape was used, which had the advantages of being a single-stage procedure and avoiding mucosa grafts. The technique could also be used to repair full-thickness lower eyelid defects from other causes.

Comparison of results with CO2 laser and traditional surgical treatment of stage I malignant melanoma.

The follow-up data on 39 cases of stage I malignant melanoma treated with CO2 laser are compared to those of an analogous group of cases treated by traditional surgical methods and selected for their clinical and pathologic similarities with the laser-treated group. The findings were expressed in terms of tumor-free time and were evaluated by variance analysis. The data showed that traditional methods gave better results. CO2 laser surgery requires longer healing time, which may have a negative effect on the course of the disease.