Jonathon M. Pleat

Response to Article “Plantar Verrucous Carcinoma: Report of A Case Treated with Boyd Amputation Followed by Reconstruction with A Free Foream Flap (J Dermatol, 28, 226–230, 2001)”

To the Editor: We read the report by Yoshitatsu and colleagues with interest (1). The authors are correct to highlight this unusual lesion, with apparently bland histology and cytology but marked potential for local invasion. Recently we had a similar case of verrucous carcinoma of the forefoot. The patient, a 45-year-old man with spina bifida, developed a verrucous ulcer on the sole that was resistant to standard medical treatment. Multiple incision biopsies failed to demonstrate any significant pathology. As a result of overriding clinical suspicion and previous knowledge of the condition, a full-thickness biopsy was performed, including the interface between lesional and normal tissue. This demonstrated verrucous carcinoma. Complete surgical excision was an achieved and the defect reconstructed with a extended perforator flap based on the medial aspect of the foot instead of the free flap option chosen by Yoshitatsu. The flap was delayed to allow time for detailed histology and proof of clearance before reconstruction was completed. Verrucous carcinoma is a rare tumour with contradictory, benign histological features but invasive clinical behaviour. Whilst the pathophysiology is poorly understood, a number of theories have been proposed, including repeated mechanical trauma (2). We believe that, as in the case presented, repeated trauma may have been a factor in the development of the lesion in our patient. We commend the authors’ attempt to demonstrate a viral aetiology. Although more commonly seen in laryngeal lesions, it has been postulated that in verrucous carcinoma a tumour suppressor gene may be nullified by types of human papilloma virus (3). We agree that surgery is the primary mode of treatment for verrucous carcinoma. Excision should be adequate to ensure clear surgical margins. The relative radioresistance seen in this type of squamous cell carcinoma may be a reflection of the low rate of proliferation of all but the deepest advancing margin (4). It has been suggested that anaplastic transformation with possible lymph node invasion may occur after radiotherapy (5). However this has been reported after surgery and other treatment modalities. Post-treatment progression of disease may instead represent progression of a poorly differentiated element within a hybrid squamous cell carcinoma. Unlike conventional squamous cell carcinoma, lymph node metastasis is rare. However regional lymphadenopathy is often seen but almost invariably represents an inflammatory response to the tumour. This inflammation is often florid, maybe due to the production of tumour-derived cytokines, such as interleukin-8 by dyplastic keratinocytes (6).

Plastic surgery beyond the human genome.

We read with interest the article by Cole and Isik on the Human Genome Project, microarrays, and the implications for plastic and reconstructive surgery (Plast. Reconstr. Surg. 110: 849, 2002). The authors present a lucid account of a powerful screening technique, but we believe that their emphasis is misplaced. Genes provide the instruction template for cellular structure and function. RNA molecules act as intermediaries. However, the true intracellular and extracellular workhorses are proteins.

Breast augmentation should be on the NHS: a discussion of the ethics of rationing

We read this article with interest and applaud the attemptto argue a difficult case; however, we have some concernsabout the use of breast augmentation in the argument.First, the discussion centres around the term ‘seriousdysfunction’. As rightly stated, GMC guidelines proposethat treatment priorities should be on the basis of clinicalneed; therefore, a term such as ‘serious dysfunction’ haslittle meaning without clinical context. Second, it is statedthat it is considered inappropriate to offer surgery towomen suffering distress due to the social stigma attachedto small breasts. This is not true. These women are offeredsurgery on the NHS after thorough evaluation by thesurgeon, together with a psychiatrist for the protection ofall parties involved. Psychiatric evaluation forms animportant part of the decision-making process as it enablesthe GMC guidelines on clinical need to be adhered to.Third, some of the women who attend requesting breastaugmentation do not have ‘small’ breasts, and therefore thequestion of social stigma is not raised. It is the patient’sperception of body image that requires treatment. Finally,in the conclusion it is stated that: ‘I have shown that whenconsidering the priority a treatment should receive, weoften begin with assumptions and performed valuejudgements’. To state that you have ‘shown’ impliesevidence- or research-based practice. In fact, what youhave done is to assume that ‘we begin with assumptions’and we would suggest that you are, therefore, a victim ofyou own argument.