Hidekazu Fukamizu

Sentinel lymph node detection in skin cancer patients using real-time fluorescence navigation with indocyanine green: preliminary experience

BACKGROUND Sentinel lymph node (SLN) biopsy has become the most widely used procedure to determine the regional lymph node status of patients with cutaneous malignant melanoma, and its application has spread rapidly to other malignancies such as squamous cell carcinoma of the skin, breast cancer and gastric cancer. OBJECTIVE SLN detection was performed in skin cancer patients using a newly developed real-time fluorescence navigation system with indocyanine green (ICG). METHODS SLN biopsy was performed by this method in 10 skin cancer patients (seven with melanoma and three with squamous cell carcinoma). After ICG was injected intradermally around the tumours, the lymphatic drainage was detected and the SLNs were identified by real-time fluorescence imaging. RESULTS The SLNs and their associated subcutaneous lymphatics were successfully identified in all patients. Fluorescence from SLNs was detected by this system for at least 3 hours after the injection of ICG. CONCLUSION SLN biopsy using ICG fluorescence achieves a high identification rate and allows effective observation for several hours. This method may become a useful option for the detection of SLNs in patients with skin cancer.

Mechanical Stretching Increases Prostaglandin E2 in Cultured Human Amnion Cells

Mechanical stretching increases synthesis and release of prostaglandin E2 (PGE2) in cultured amnion cells. The maximum level of PGE2 in stretched amnion cells is three times higher than that in nonstretched amnion cells. The maximum level of PGE2 in stretched cell medium is nine times higher than the maximal level of PGE2 in nonstretched cell medium. 3H-thymidine incorporation into DNA is 211 +/- 25 cpm/10(5) cells in nonstretched groups; that in stretched groups is 582 +/- 94 cpm/10(5) cells. There is a significant difference between the two groups. These results suggest that stretch stimulation facilitates prostaglandin production in fetal membranes, which may contribute to uterine contraction in labor.

Applicability of radiocolloids, blue dyes and fluorescent indocyanine green to sentinel node biopsy in melanoma

Patients with primary cutaneous melanoma underwent sentinel node (SN) mapping and biopsy at 25 facilities in Japan by the combination of radiocolloid with gamma probe and dye. Technetium‐99m (99mTc)‐tin colloid, 99mTc‐phytate, 2% patent blue violet (PBV) and 0.4% indigo carmine were used as tracers. In some hospitals, 0.5% fluorescent indocyanine green, which allows visualization of the SN with an infrared camera, was concomitantly used and examined. A total of 673 patients were enrolled, and 562 cases were eligible. The detection rates of SN were 95.5% (147/154) with the combination of tin colloid and PBV, 98.9% (368/372) with the combination of phytate and PBV, and 97.2% (35/36) with the combination of tin colloid or phytate and indigo carmine. SN was not detected in 12 cases by the combination method, and the primary tumor was in the head and neck in six of those 12 cases. In eight of 526 cases (1.5%), SN was detected by PBV but not by radiocolloid. There were 13 cases (2.5%) in which SN was detected by radiocolloid but not by PBV. In 18 of 36 cases (50%), SN was detected by radiocolloid but not by indigo carmine. Concomitantly used fluorescent indocyanine green detected SN in all of 67 cases. Interference with transcutaneous oximetry by PVB was observed in some cases, although it caused no clinical trouble. Allergic reactions were not reported with any of the tracers. 99mTc‐tin colloid, 99mTc‐phytate, PBV and indocyanine green are useful tracers for SN mapping.

GIANT BASAL CELL CARCINOMA: IMPROVEMENT IN THE QUALITY OF LIFE AFTER EXTENSIVE RESECTION

We describe a rare case of giant basal cell carcinoma which invaded the orbital tissue and the anterior skull base. Though the eyeball in the right orbit was preserved with the tumour at the patients request, the improvement in the quality of the patients life was achieved.

Roxithromycin antagonizes catagen induction in murine and human hair follicles: implication of topical roxithromycin as hair restoration reagent

Roxithromycin (RXM) is a 14-member macrolide antibiotics, with a variety of bioregulatory functions including anti-apoptotic activity to keratinocytes. Therefore, RXM has been used for many kinds of skin diseases. In this study, human and murine hair follicles were treated with RXM in order to find the possibility to cure hair loss disease such as androgenetic alopecia (AGA). In AGA, dihydrotestosterone signals apoptosis in dermal papilla cells in susceptible individuals, resting in premature termination of anagen and early entry into catagen. Therefore, anti-apoptotitic drug has a possibility of new candidate for AGA. This study revealed RXM antagonized the in vitro inhibitory effect of IFN-γ on proliferation of keratinocytes and induction of apoptosis in murine and human hair bulb. RXM increases hair elongation and inhibits catagen-like changes induced in vitro with IFN-γ in murine and human hair follicles. Furthermore, topical 5% RXM solution effectively restores hair growth in about half of individuals with AGA without any local and systemic adverse effects. Therefore, RXM is new candidate as a hair restoration drug for AGA.

Delayed distally based sural flap with temporary venous supercharging.

The distally based sural flap has become popular for reconstruction of the foot and leg. However, this flap often fails due to venous congestion. In this report, we developed a new modification of the distally based sural flap. The procedure comprised three stages. In the first stage, the flap was raised cephalad to the midpoint of the posterior aspect of the leg, involving reanastomosis of the short saphenous vein (SSV) at the proximal end of the flap. In the second stage, ligature of the SSV was performed. In the third stage, the entire flap was raised. We treated eight patients with the flap. All flaps survived completely. Duplex scanning indicated that venous drainage of the flap was provided by the tenuous venae comitantes (VCs) surrounding the SSV. Reanastomosis of the SSV may prevent rapid venous overloading of the VCs. Our new modification may be useful to avoid venous congestion.

Treatment of giant congenital nevus of the back by convergent serial excision

Dear Editor, Giant congenital nevus (GCN) is a disfiguring and potentially malignant pigmented nevus that is present at birth. Various methods for the treatment of GCN have been reported, but the best procedure is still controversial and it remains difficult to achieve both complete excision and a good cosmetic result in these patients. Serial excision is one of the treatment options for giant nevus. In conventional serial excision, the central part of the nevus is removed (as much as can be excised safely). The site of excision becomes soft and pliable by 3 months to 1 year after the first operation. At this time, more of the nevus and the initial scar are excised, and the procedure is repeated until eventually the entire lesion is removed. Because the base of the residual nevus needs to be undermined in patients with an extremely large nevus treated by the conventional method, the residual part of the lesion is subjected to tension and tends to expand. One of the most common locations of giant nevus is on the posterior trunk. Chrétien-Marquet et al. reported a new method of serial excision, in which a nevus on the back was excised concentrically from the periphery to the center. With their method, the base of the residual nevus (located at the center of the lesion) is not undermined. Therefore, the residual nevus is unlikely to expand postoperatively. The goal of their method is to achieve the expansion of healthy skin, but not expansion of the nevus. However, no further reports of this method have been seen since. The elasticity of the skin is greatest during infancy and gradually declines with increasing age. Among healthy male subjects ranging in age from 3 months to 73 years, skin elasticity was maximal in the age group of less than 2 years old. In our experience, a larger nevus can be excised surgically after the subcutaneous fat becomes thicker. The thickness of subcutaneous fat shows an early peak at 6 months of age and then decreases gradually from approximately 6 years old. Therefore, the optimum timing for serial excision could be from approximately 6 months to 2 years old. In our patient with GCN of the back (Fig. 1a,b), serial excision was started at 6 months of age when the patient was wearing a diaper. Wound infection due to contamination by feces or urine could lead to serious postoperative complications at this age. Therefore, we modified the method of ChrétienMarquet et al. to avoid such wound infection by avoiding surgery near the perineum. The operative procedure was as follows. Excision of the nevus was done full-thickness down to the muscle fascia, and was started at the periphery of the lesion, except that the distal part was not treated. The healthy skin at the edge of the nevus was undermined along the suprafascial plane so as not to disturb the cutaneous blood supply. We also excised part of the central portion of the nevus and left the distal part of the lesion without undermining (Fig. 1c–e), so that a suture line was not placed near the anus to avoid infection by fecal or urinary contamination. The residual part of the nevus was never undermined. The wound edges were approximated by convergent mobilization, and sutures were either placed between different parts of the skin edges or between the skin and the residual nevi (Fig. 1c–e). Anchoring sutures were placed in the deep fascia using 2-0 absorbable material. A suction drain was inserted, and the incisions were closed. The interval until the second operation was 7 months. At the time of the second operation, the patient was no

Twist1 as a possible biomarker for metastatic basal cell carcinoma.

Basal cell carcinoma (BCC), a common tumour of epithelial origin, is locally invasive and has a low risk of metastasis, estimated to range from 0.028% to 0.1% (1). However, once BCC metastasizes to distant organs, the effective therapeutic options are limited, leading to poor patient outcome. Recent studies have shown that epithelial-mesenchy-mal transition (EMT) suppresses epithelial features, and induces mesenchymal traits to epithelial cells in several pathological conditions (2, 3). Of note is that tumours of epithelial origin can express transcription factors Snail and Twist1, or the cell adhesion molecule N-cadherin as a mesenchymal marker. We have previously shown that N-cadherin is up-regulated in invasive tumours, but not in carcinoma in situ of extramammary Pagets disease, and that EMT is associated with distant organ metastasis, leading to poor patient survival (4, 5). However , it remains unclear whether EMT plays a key role in the development of highly invasive phenotype and potential metastasis in BCC. We report here the first case of morphoeic and metastatic BCC showing the induction of Twist1 and the epithelial-to-mesenchymal conversion of cadherins in association with multiple organ metastases. A 51-year-old Japanese man presented with a 3-cm ulcerated nodule with peripheral focal pigmentation on the upper back (Fig. 1a). A biopsy specimen disclosed the proliferation and invasion of epithelial strands with mesenchymal transition and rich stroma, indicating a diagnosis of morphoeic BCC (Fig. 1b). The patient underwent a tumour resection, and the defect was reconstructed with the trapezius musculocutaneous flap. After 4 years of follow-up, a subcutaneous mass appeared in the patients supraclavicular fossa. Under the histological diagnosis of metastatic BCC, the tumour was surgically resected with subsequent reconstruction using the pectoral major musculo-cutaneous flap, followed by a total of 60 Gy radiation to the local region. However, multiple foci of tumour metastasis were found in the left levator scapulae muscle and the pleura of the left lung by magnetic resonance imaging. The patient underwent systemic chemotherapy with a combination of cisplatin and doxorubicin. However, the therapeutic effect was minimal, and at the time of writing, the tumours were disseminated in the lung. To clarify the potential role of EMT in metastatic BCC, we investigated the tumour by immunohisto-chemical analyses. Formalin-fixed paraffin-embedded sections of the index case showed that the tumour cells were positive for Twist1 at the invasive front of the primary tumour (Fig. 1c), whereas the tumour cells centrally were negative for Twist1. In …

Free hemiback flap with surgical delay for reconstruction of extensive soft tissue defect: a case report.

A delay procedure allows for reliable tissue transfer in random pattern flaps and axial pattern flaps. However, delay procedures have not been studied in free flaps. In this report, we present a case involving the use of a free extended latissimus dorsi musculocutaneous flap (hemiback flap) that included half of the total back skin and was based on thoracodorsal vessels for reconstruction of an extensive soft tissue defect of the flank and waist. The flap was tailored in combination with a delay procedure. Intraoperative indocyanine green fluorescence angiography indicated profuse perfusion except for the most inferomedial part of the flap, which was discarded. The flap survived. A free hemiback flap may offer a valuable option for reconstruction of extensive soft tissue defects. To our knowledge, this is the first report to demonstrate a free flap made in combination with a delay procedure.

Reconstruction of lateral mandibular defect: a comparison of functional and aesthetic outcomes of bony reconstruction vs soft tissue reconstruction - long-term follow-up.

Abstract Conclusion: Reconstruction with a vascularized bone flap provided superior postoperative outcomes compared with reconstruction with a soft tissue free flap. However, patients obtained acceptable long-term functional outcomes even with a soft tissue free flap and this method is an option in selected patients. A multidisciplinary approach involving dental treatments and nutrition education is important to improve postoperative function. Objective: To assess the postoperative outcomes of two different options for reconstruction of the lateral mandible using bony or soft tissue reconstruction. Methods: We divided 25 patients into 2 groups on the basis of the type of reconstruction following lateral mandibulectomy. Twelve patients underwent reconstruction using a vascularized fibular flap and 13 patients received a soft tissue free flap. We compared the postoperative functional and aesthetic outcomes and examined the time-dependent change in functional outcomes in both groups. Results: Reconstruction with a vascularized bone flap was significantly superior to reconstruction with a soft tissue free flap in deglutition and aesthetic results. There was no significant difference in speech function between the groups. Deglutition in both groups improved markedly over time and all but one patient tolerated a normal or soft diet, including those in the soft tissue reconstruction group. Denture fabrication and recreating occlusion explained the improved deglutition.