Fa-Lai Yeh

Primary Cutaneous Leiomyosarcoma

Primary cutaneous leiomyosarcomas are rare malignant tumors. They can occur at any age, but most commonly between the fifth and seventh decade of life. Because of the small number of patients treated, treatment recommendations are still evolving. We report the results of a retrospective study of 12 patients treated for leiomyosarcomas through a thirty year period (from 1973 to 2002). Five males and seven females (mean age, 54.4 years; age range, 22-81 years), more than 58% of the patients were at least 50 years old. The tumors presented mainly as solitary lesions and were located on the upper and lower extremities (seven lesions), trunk (three lesions), and the head and neck (two lesions). The main treatment of choice was surgical wide excision. Clinical follow-up revealed local recurrences in four patients after a period ranging from 3 to 72 months after surgical excision. No distant metastases have been observed in our series. We reviewed published articles. The clinical findings, pathologic examinations and treatments were analyzed. We believe primary cutaneous leiomyosarcoma should be considered biologically benign with regard to distant metastases, despite the malignant histologic appearance. Wide local excision is recommended, and it would seem that narrow margins with a tumor-free plane should be sufficient.

Interaction of genetic polymorphisms in cytochrome P450 2E1 and glutathione S-transferase M1 to breast cancer in Taiwanese woman without smoking and drinking habits

P450 (CYP) and glutathione S-transferase (GST) are involved in the activation and detoxification of many potential carcinogens. Although, the interaction between environmental exposure and genetic polymorphisms of cytochrome P450 2E1 (CYP2E1) and glutathione S-transferase M1 (GSTM1) in breast cancer has been assessed, the gene–gene interactions between CYP2E1 and GSTM1 related to breast cancer have not been focused on and reported. We conducted a hospital-based case-control study to investigate whether the genetic interaction effects of CYP2E1 and GSTM1 modify the risk of developing breast cancer independent of the effect of cigarette smoking and alcohol consumption. Individuals with the C2/C2 genotype of CYP2E1 had a lower risk (ORxa0=xa00.24, 95% CIxa0=xa00.08–0.74) when compared with those with the C1/C1 genotype. However, there was no significant difference (ORxa0=xa01.05, 95% CIxa0=xa00.73–1.50) in the GSTM1 genotype frequency between the cases with breast cancer and that of the controls. When individuals with the genotype of C1/C1 or C1/C2 of CYP2E1 and the wild-type of GSTM1 were compared with those of C2/C2 of CYP2E1 and the null-type of GSTM1 however, we found a significantly increased risk (ORxa0=xa03.50, 95% CIxa0=xa01.01–16.55) in the breast cancer patients. Our findings indicated a gene–gene interaction between CYP2E1 and GSTM1 was accessible to developing breast cancer in Taiwanese women without the habits of cigarette smoking and alcohol consumption even though independent effects of CYP2E1 and GSTM1 were weak or non-significant and suggest that environmental carcinogen besides cigarette and alcohol consumption could induce breast cancer.

The use of “composite dressing” for covering split-thickness skin graft donor sites

To evaluate the effect of a new dressing method for clean wound coverage, two kinds of dressing materials are combined together to cover nine wounds in nine patients. All the wounds are split-thickness skin graft donor sites located in the anterior thighs. The size of the wounds ranges from 6 cm x 4 cm to 10 cm x 8 cm (42 cm(2) on average). A central fenestration is created in the polyurethane film layer for draining the wound discharge, and a piece of 2.5 cm x 2.5 cm carboxymethyl cellulose dressing is fixed on top of the fenestration for protecting the underlying wound. Dry gauze is used to cover the composite dressing, which is replaced daily. The wound condition is checked and recorded everyday until the patient is discharged. Further management and follow-up for the wound is performed at the outpatient department or by telephone. All wounds healed smoothly on the postoperative 6th to 7th day. No wound infection was noted, including one patient who had diabetes mellitus. Five patients responded to follow-up for at least 5 months and no hypertrophy scar formation was noted. From clinical experiences, we know that this new method is practical and cost-effective for covering small-sized, split-thickness skin graft donor-site wounds.

Delayed dilated cardiomyopathy for major burn injuries

PURPOSEnThe early impact on the heart of severe burns has all been well documented previously. Here, we report on the late effects of burns upon the heart, and dilated cardiomyopathy, such aspects having been little reported previously in the literature.nnnMETHODSnOver the past 8 years (June 1991 to December 1998), 55 scalded or flame-burnt patients for whom the total burnt body surface area (TBSA) exceeded 50% were treated. Seventeen patients survived and were followed up. The mean age was 44 years. The mean follow-up period was 47.3 months; four patients displayed a previous history of heart disease. We used several parameters to evaluate and follow cardiac status to see the late effect of burns upon the heart.nnnRESULTSnOf 17 patients, 3 patients (17.7%) were found to exhibit dilated cardiomyopathies after a mean time of 6 months post-injury. A dramatic recovery from symptoms and roentgenographic findings were observed for all patients following symptomatic treatment.nnnCONCLUSIONnHere we report three cases of delayed dilated cardiomyopathy, a condition that has been little reported in the past. There may be many causating factors. Several recommendations are described.

Benign symmetric lipomatosis

Background: Madelungs disease, benign symmetric lipomatosis, is a rare proliferative disease predominantly seen in middle-aged male patients. The disorder is characterized by multiple symmetrical, painless deposits of non-encapsulated fat around the neck, upper arms and upper part of the thorax. No clear etiology has been recognized while a close correlation to alcohol and metabolic disturbances has been observed. Aim and Objectives: To evaluate the clinicopathologic, morphologic and biochemical findings in this disease, we present and discuss various factors in this disease of 5 cases and give a survey of the literature. Materials and Methods: Five patients with benign symmetric lipomatosis were reviewed. All were male, aged 38 to 73 years, with a history of disease ranging from 6 months to 7 years. Patients usually complain of their cosmetic appearance, limited range of motion of the neck, difficulty in swallowing and compression of the airway. We performed the surgical excision via lipectomy with or without liposuction in all patients for the neck tumors. Results: The mean follow-up period was 88.6 months. The functional results were satisfactory in all patients. A recurrence was observed in one of our patients six months after the operation. Severe complications were not observed. Conclusions: According to our experience, surgical removal of lipomatous tissues in BSL can yield satisfactory functional and cosmetic results.

Dermatofibrosarcoma Protuberans (DFSP) of the Scalp with Left Neck Lymph Node Metastasis-A Case Report

Dermatofibrosarcoma protuberans (DFSP) is an unusual skin malignancy, which is locally invasive and rarely metastasizes. According to the literature, DFSP with distant metastasis is more often than regional lymph node involvement. Treatment of local DFSP is mainly surgical. A patient was noted with scalp DFSP when aged 4. Then he sustained four times of local recurrences, and left neck lymph node metastasis happened at age 19. No concurrent scalp DFSP was identified when the neck metastatic lesion was found. The previously recurred tumors were all excised, while we removed the metastatic lesion by radical neck dissection. Neither radiotherapy nor chemotherapy was done. We followed the patient for up to three years and no evidence of disease was found. DFSP with regional lymphatic metastasis is rarely seen, and literature is reviewed for the management of such patients.

Tracheal Stenosis after Inhalation Burn Injury-A Case Report

Tracheal stenosis is most commonly the result of mechanical trauma from endotracheal intubation. Other known causes of acquired tracheal stenosis are external trauma, infection, inflammation and thermal or caustic injuries. Inhalation injury itself has the potential risk of tracheal stenosis. Patient with tracheal stenosis may present with dyspnea, stridor, and even lift-threatening airway obstruction. We report a case of severe tracheal stenosis following an inhalation burn injury. The patient experienced progressively dyspnea and stridor one month after his injury. The CT scan of neck demonstrated severe subglottic and tracheal stenoses. He was successfully treated by the insertion of a tracheal T-tube. The patient has been symptom-free and no restenosis could be detected for the last 30 months.

Primary Mucinous Carcinoma of the Scalp-A Case Report

Primary mucinous carcinoma of the skin is a rare tumor with only cases reported in the literature since the first description of a case by Lennox et al. in 1952. This tumor is a histologic subtype of sweat gland carcinoma. Because of the histopathologic appearance, primary mucinous carcinoma of skin can be mistaken for metastasis from extracutaneous sites. Most cases occur mainly between the fifth and the seventh decade of life. They are growing slowly with a propensity for local recurrence and metastasis. This tumor has not been widely reported in the plastic surgery literature. We describe a 59-year-old woman with a tumor on the right scalp. This lesion enlarged progressively and showed a reddish, elevated, dome-shaped surface. Excisional biopsy of the tumor revealed mucinous carcinoma. Further treatment involved wide local excision and reconstruction. In attempt to improve the recognition of this clinical entity, we discuss the histopathology, clinical course, surgical management and prognosis. Mucinous carcinoma can occur in noncutaneous visceral sites and metastasize to the skin. Systemic investigation were undertaken to exclude the possibility of metastatic mucinous carcinoma.

The Application of Integra Artificial Dermis for Skin Reconstruction

Autologous skin grafts are used as one of the standard treatment modalities for deep skin defects. However, skin grafts exist some disadvantages such as donor site morbidities, limited donor site areas, and recipient site contractures. Hoping to eliminate all the above-mentioned problems, several skin substitutes have been developed in recent years and commercialized for temporary or permanent use^1. From April 1997 to November 2000, ten artificial dermis (Integra) followed with ultrathin split thickness skin grafts (STSG) or cultured epithelium autografts (CEA) were performed in seven patients. The indications of operation include hypertrophic scar/keloids; immediate full-thickness skin defects due to burn injury; and excision of full thickness skin lesion. One patient died of distant metastasis of melanoma four months after resurfacing surgery. Two Integra infections were identified (2/10). In the hypertrophic scar/keloids group, three of the six recipient sites developed unwanted scars again. From the limited experiences in this series, Integra artificial dermis used in hypertrophic scar/keloids might decrease the recurrence of keloid formation in some patients. For the skin resurfacing patients, Integra showed promising results and is one of the treatment alternatives for these patients.

The Internal Fixation in Maxillofacial Bone Fractures-A Clinical Analysis

We review the internal fixation in maxillofacial fractures over the past 10 year period from 1987 Jan. to 1996 Dec. in Veterans General Hospital-Taipei, Taiwan, R.O.C. Patients who presented with maxillofacial fractures received titanium miniplate or wire internal fixation treatment within 14 days of injury and were followed for one year. The fractures were divided into superior, middle and inferior portions for evaluation of causes, frequency, age, sex, and the difference between miniplate and wire internal fixation. There were 296 patients who received miniplate or wire internal fixation management. A total of 327 operations were performed: superior portion 17, middle portion 206 and inferior portion 104. The male to female ratio was 4.4:1. The age was ranged from 14 to 84 years with the mean of 35.5. The highest incidence of trauma was in the 20-29 year age group (32.1% of all patients), similar to other reports. In addition, there was another peak incidence in the 60-69 year age group of males (15.4%). The most common cause of fracture was traffic accident (82.8%), which was followed by falling down accident (9.4%) and assault (7.8%). Of all operative patients, the middle portion was the most common fracture site (63%). The overall complication rate was 11.4% for miniplate and 3.6% for wire. The complications of operation were infection (3.7%), facial deformity (2.4%), malocclusion (2.4%), temporomandibular joint dysfunction (1.5%), and ectropion (1.2%). Miniplate exposure was noted in 3 cases (1.1% of miniplate patients). There was no difference in complication rate between miniplate and wire fixations (p=0.089). Using miniplate for internal fixation, there were significant infection (p=0.0047) and malocclusion (p=0.007) rates in the inferior portion, compared to the middle and superior portions. Further investigation is required for improvement of complications.