Erkki Suominen

Microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients.

Objective:Postoperative lymphedema after breast cancer surgery is a challenging problem. Recently, a novel microvascular lymph node transfer technique provided a fresh hope for patients with lymphedema. We aimed to combine this new method with the standard breast reconstruction. Methods:During 2008–2010, we performed free lower abdominal flap breast reconstruction in 87 patients. For all patients with lymphedema symptoms (n = 9), we used a modified lower abdominal reconstruction flap containing lymph nodes and lymphatic vessels surrounding the superficial circumflex vessel pedicle. Operation time, donor site morbidity, and postoperative recovery between the 2 groups (lymphedema breast reconstruction and breast reconstruction) were compared. The effect on the postoperative lymphatic vessel function was examined. Results:The average operation time was 426 minutes in the lymphedema breast reconstruction group and 391 minutes in the breast reconstruction group. The postoperative abdominal seroma formation was increased in patients with lymphedema. Postoperative lymphoscintigraphy demonstrated at least some improvement in lymphatic vessel function in 5 of 6 patients with lymphedema. The upper limb perimeter decreased in 7 of 9 patients. Physiotherapy and compression was no longer needed in 3 of 9 patients. Importantly, we found that human lymph nodes express high levels of endogenous lymphatic vessel growth factors. Transfer of the lymph nodes and the resulting endogenous growth factor expression may thereby induce the regrowth of lymphatic network in the axilla. No edema problems were detected in the lymph node donor area. Conclusion:Simultaneous breast and lymphatic reconstruction is an ideal option for patients who suffer from lymphedema after mastectomy and axillary dissection.

Donor-Site Lymphatic Function after Microvascular Lymph Node Transfer

Background: Lymphedema remains a challenging clinical problem that often lacks curative treatment options. Recent reports have shown that microvascular lymph node transfer from the groin area into axillas of lymphedematous patients may improve lymphatic drainage, but the effect on donor-site lymphatic flow has not been studied. These patients may be more prone to develop lymphedema at donor sites as well; therefore, the authors aim was to evaluate postoperative donor-site lymphatic function. Methods: The authors performed lymphatic groin flap transfer to the axilla in 13 lymphedema patients. In 10 patients, the lymph node transfer was performed simultaneously with lower abdominal breast reconstruction. Postoperative lymphatic vessel function of the donor site was evaluated by lymphoscintigraphy and limb circumference measurements. For semiquantitative evaluation of lymphatic drainage, a numerical transport index was used. Results: In six of 10 patients, postoperative lymphoscintigraphy revealed minor changes in lymphatic flow of the donor-site limbs. The transport index was considered slightly abnormal in two of 10 patients. None of the 13 patients had changes in lower limb circumferences during the 8- to 56-month follow-up. Conclusions: Lymph node transfer can be easily combined with lower abdominal breast reconstruction, and the popularity of this technique is increasing rapidly. Even though none of our patients had developed symptoms of postoperative lymphedema, the results of the first lymphoscintigrams show that it is important to reduce the surgical trauma to the lymphatic flap donor site. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Sentinel Lymph Node Biopsy in Cutaneous Melanoma: A Case-Control Study

AbstarctBackgroundSentinel lymph node biopsy (SLNB) is the most precise method for staging invasive cutaneous melanoma, but its therapeutic effect has been difficult to assess, and SLNB is not routinely used in all melanoma treatment centers.MethodsThis case-control study of 305 prospective SLNB patients compared them with 616 retrospective patients who had not undergone invasive nodal staging at diagnosis. Thin melanomas were included in both study groups.ResultsA total of 50 SLNB patients were sentinel positive (16.4%) and 255 were sentinel negative (83.6%). A total of 49 of the 50 sentinel-positive patients underwent completion lymph node dissection, and 9 of them (18%) had additional metastases in the nonsentinel nodes. The false-negative rate was 1.6% (five same-basin nodal recurrences during follow-up). There was a significant difference in melanoma-related overall survival (OS) between sentinel-positive and sentinel-negative patients (Pxa0<xa0.001). The tumor burden of the sentinel nodes was a significant prognostic factor for melanoma-related OS (Pxa0<xa0.001). There was no significant difference in melanoma-related OS or disease-free survival between the study groups, but the nodal disease-free survival was significantly longer among the SLNB patients (Pxa0=xa0.004).ConclusionsSLNB is recommended for routine use in the treatment of cutaneous melanoma because the sentinel node status carries unique prognostic information on the survival of melanoma patient. Improved regional disease control is an obvious therapeutic advantage of SLNB and immediate completion lymph node dissection.

FREE MICROVASCULAR TRAM FLAPS: REPORT OF 185 BREAST RECONSTRUCTIONS

The free TRAM flap is the most elegant technique currently available for breast reconstruction. We describe here the surgical technique, the complications, the possible effects of the prognosis of the breast cancer, and the learning curve of the surgical team. From December 1990 to the end of 1995 we reconstructed 185 breasts (10 bilateral) in 175 patients with free TRAM flaps; 27 were immediate reconstructions. We harvested the flap based on the inferior epigastric pedicle on the opposite side to the affected breast. To dissect the rectus muscle we used a muscle-sparing technique. The flap was designed and de-epithelialised while still on the abdomen, and was anastomosed to the thoracodorsal or circumflex scapular vessels with loupes only. In the immediate reconstructions we removed the breast tissue through a periareolar incision; we dissected the group I axillary lymph nodes and exposed the recipient vessels through a separate incision. The areolar complex was autotransplanted as a free skin graft. Only two flaps were lost. Eight patients were reoperated on for thrombosis of the vessels. The complication rate was nearly 50% among the first 50 patients. However, as surgical experience grew, the figure was reduced, eventually being down to 20%-25%. Of the patients who had delayed reconstructions only two died during the follow-up period of 48 months. One patient had a local recurrence above the TRAM skin. During the last eight years the free TRAM flap has been our main method of breast reconstruction. Free flaps today are reliable and the reconstruction does not seem to worsen the prognosis of breast cancer.

Return of Sensibility and Final Outcome of Breast Reconstructions Using Free Transverse Rectus Abdominis Musculocutaneous Flaps

Thirty-nine patients who had had free transverse rectus abdominis musculocutaneous (TRAM) flaps were studied and interviewed 5 months to 2.3 years after the procedure. The main reason why the patients had wanted the reconstruction in the first place was difficulty with the external prosthesis. Thirty three of 39 would have had the operation again; three were hesitant, and three had regrets for reasons other than that the breast was not satisfactory. All patients considered that the symmetry of the breasts was good or satisfactory with bras; without bras, one patient thought that the symmetry was poor, and the physician thought that the symmetry was poor in nine patients. Two-point discrimination turned out to be too delicate for studying the sensitivity of the breast. When pressure sensitivity was studied with von Frey monofilaments, the threshold values were significantly lower on the lateral and medial side and under the reconstructed breast than on the opposite side. In 22 patients the lateral part, and in 23 the medial part, of the reconstructed breast was insensate. There was good or satisfactory pressure sensitivity on the lateral side in nine patients and on the medial side in eight. The return of sensitivity to the autogenous breast reconstruction was variable among the patients studied, but it did not affect their satisfaction with the reconstruction.

Whole body positron emission tomography in follow-up of high risk melanoma

The aim of this study was to determine the clinical impact of whole body positron emission tomography (FDG PET) to detect clinically silent metastases in the follow-up of patients with high risk melanoma. FDG PET was performed to 30 asymptomatic melanoma patients (AJCC stage IIB–IIIC) 7–24 months after the primary surgery and sentinel node biopsy. FDG PET was able to detect six of seven recurrences, constituting 20% of all study patients. One patient presented with a negative FDG PET finding at the very first scanning, but was positive later in a repeated scan after manifestation of palpable mass in the axilla. The positive PET finding had an impact on treatment decisions in every case: three patients underwent surgical resection and four patients received chemotherapy or interferon. The mean follow-up time was 27 months (range, 12–48 months) and during that time the other 23 patients with true negative FDG PET were disease-free. One of the seven recurrences was in remission after surgical metastasectomy. In conclusion, whole body FDG PET is a valuable follow-up tool in high risk melanoma to diagnose recurrences and to select the patients, who are suitable for surgical metastasectomy.

Desire for Body Contouring Surgery After Bariatric Surgery

BACKGROUNDnThere is disparity between the number of postbariatric surgery subjects who desire body contouring and those who receive it due to lack of resources or insurance criteria.nnnOBJECTIVESnThe authors evaluate the desire for body contouring after bariatric surgery and its relationship with demographic patient characteristics.nnnMETHODSnThree hundred sixty patients who had undergone bariatric surgery procedures >1 year previously completed a questionnaire designed by the surgical team to analyze each patients desire for body contouring by area (face, upper arm, upper back, chin/neck, chest/breast, waist/abdomen, lower back, rear/buttock), scored from 0 to 3 (do not want, want somewhat, want, want a great deal). Data were compared with patient characteristics, postoperative body mass index (BMI), amount of weight loss, and BMI difference (ΔBMI).nnnRESULTSnMost patients desired body contouring surgery, with high or very high desire for waist/abdomen (62.2%), upper arm (37.6%), chest/breast (28.3%), and rear/buttock (35.6%) contouring. Many patients (36.4%) cited very high expectations for how body contouring might change their appearance. Patients >50 years old and >3 years postsurgery had a significantly lower desire. Patients with a ΔBMI >10 and with a weight loss >20 kg showed a significantly stronger overall desire for body contouring compared with other groups.nnnCONCLUSIONSnMost patients desire body contouring surgery after bariatric surgery, and our multivariate analysis showed a significant positive association between female sex, younger age, amount of weight loss, and ΔBMI with desire for body contouring.

Physical discomfort due to redundant skin in post-bariatric surgery patients

Massive weight loss after bariatric surgery leads to excess skin with functional and aesthetic impairments. The aim of this study was to evaluate the prevalence of excess skin after bariatric surgery and identify any relationship with pre- and postoperative characteristics. A total of 360 patients who had undergone bariatric surgery procedures were asked to complete a questionnaire designed by the surgical team at least 1 year after surgery. This questionnaire was planned to estimate any impairment due to redundant skin, which was graded according to a visual analogue scale (VAS, 0--0). Mean (standard deviation, SD) age of 110 males and 250 females was 51.2 (10.8) years. Mean preoperative body mass index (BMI) was 45.7 (6.4) kg m(-2) and mean postoperative BMI at follow-up was 33.6 (6.0) kg m(-2). After a mean follow-up of 56.1 (43.6) months, the mean weight loss was 35.2 (18.8) kg. Most patients (92.8%) reported problems with redundant skin, especially on the abdomen, upper arms and rear/buttocks, which impaired daily physical activity in half of them. Excess skin was associated with female gender (β=-13.56, 95% confidence interval (CI) -16.81 to -10.32, p<0.0001), weight loss (β=0.21, 95% CI 0.12-0.29, p<0.0001) and ΔBMI (β=0.21, 95% CI 0.12-0.29, p<0.0001) at multivariate analysis. Patients with a ΔBMI>20 kg m(-2) showed a significantly surplus skin discomfort compared to ΔBMI≤5 and 550 kg showed a significantly redundant skin discomfort compared to weight loss<20 kg (p<0.001). Weight loss after bariatric surgery reduces the medical risks of obesity but psychosocial and functional problems often remain due to the surplus skin. Our data suggest that a ΔBMI≤10 kg m(-2) and weight loss>20 kg, not BMI alone, might be taken into consideration as cut-off values for developing score systems with the intention to apply evidence-based indications for the surgical management of post-bariatric impairments.

Hailey–Hailey disease and tight junctions: Claudins 1 and 4 are regulated by ATP2C1 gene encoding Ca2+/Mn2+ATPase SPCA1 in cultured keratinocytes

Mutations in the ATP2C1 gene encoding Ca2+/Mn2+ ATPase SPCA1 cause Hailey–Hailey disease (HHD, OMIM 16960). HHD is characterized by epidermal acantholysis. We attempted to model HHD using normal keratinocytes, in which the SPCA1 mRNA was down‐regulated with the small inhibitory RNA (siRNA) method. SiRNA inhibition significantly down‐regulated the SPCA1 mRNA, as demonstrated by qPCR, and decreased the SPCA1 protein beyond detectable level, as shown by Western analysis. The expression of selected desmosomal, adherens and tight junction (TJ) proteins was then studied in the SPCA1‐deficient and control keratinocytes cultured in low (0.06 mm) or high (1.2 mm) calcium concentration. The mRNA and protein levels of most TJ components were up‐regulated in non‐treated control keratinocyte cultures upon switch from low to high calcium concentration. In contrast, SPCA1‐deficient keratinocytes displayed high levels of TJ proteins claudins 1 and 4 even in low calcium. ZO‐1 did not, however, follow similar expression patterns. Protein levels of occludin, beta‐catenin, E‐cadherin, desmoplakin, desmogleins 1–3, desmocollin 2/desmocollin 3 and plakoglobin did not show marked changes in SPCA1‐deficient keratinocytes. Indirect immunofluorescence labelling revealed delayed translocation of desmoplakin and desmoglein 3 in desmosomes and increased intracellular pools of TJ and desmosomal components in SPCA1‐inhibited keratinocytes. The results show that SPCA1 regulates the levels of claudins 1 and 4, but does not affect desmosomal protein levels, indicating that TJ proteins are differently regulated. The results also suggest a potential role for claudins in HHD.

Lymphatic vessel function and lymphatic growth factor secretion after microvascular lymph node transfer in lymphedema patients.

Background: Recent reports have shown that microvascular lymph node transfer may improve lymphatic drainage in lymphedema patients. Lymphatic anastomoses are expected to form spontaneously in response to lymphatic growth factor [vascular endothelial growth factor C (VEGF-C)] secreted by the transferred lymph nodes. Methods: We have analyzed the results of 19 lymph node transfer patients operated on 2007–2012. Postoperat ive lymphatic function of the affected arm was evaluated using semiquantitative lymphoscintigraphy (transport index) and limb circumference measurements. To investigate the postoperative VEGF-C secretion, we examined axillary seroma fluid samples after different surgical operations, including lymph node transfer. Results: The transport index was improved postoperatively in 7 of 19 patients. Ten of the 19 patients were able to reduce or even discontinue using compression garments. Arm circumferences were reduced in 12 of 19 patients. Six of the 7 patients with preoperative erysipelas infections have not had infectious episodes postoperatively during 15–67 months follow-up. Neuropathic pain was relieved in 5 of 5 patients. VEGF-C protein was detected in the axillary seroma fluid both after lymph node transfer and normal breast reconstruction. Conclusions: Reconstructing the lymphatic anatomy of the axilla with a lymph node flap may offer possibilities that other reconstructive options are lacking. However, we will need further reports and comparative studies about the clinical efficacy of this new promising technique. In addition to the transferred lymph nodes, lymphatic growth factor production may also be induced by other factors related to microvascular breast reconstruction.