Jörg Wehner-Caroli

Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study

BACKGROUND Cutaneous squamous-cell carcinomas (SCC) are among the most common cancers capable of metastasis. Current Tumour Node Metastasis (TNM) staging includes horizontal tumour size, involvement of extradermal structures, and degree of differentiation. The aim of this study was to prospectively analyse the key factors predicting metastasis and local recurrence in cutaneous SCC. METHODS We assessed prospectively investigated potential risk factors for metastasis or local recurrence of SCC, previously suggested by retrospective studies and small case series, in 615 white patients. Between Jan 1, 1990, and Dec 31, 2001, all patients underwent surgery for cutaneous SCC with complete histological examination of the three-dimensional excision margins (3D-histology) in one centre. Univariate and multivariate analysis included tumour thickness, horizontal size, body site, histological differentiation, desmoplastic growth, history of multiple SCC, and immunosuppression. Primary endpoints were time to metastasis and time to local recurrence, defined as the time from date of diagnosis of the primary tumour to the date of diagnosis of metastasis or local recurrence, respectively. FINDINGS 653 patients were enrolled in the study. 38 patients were lost to follow-up leaving 615 assessable patients (median age 73 years [range 27-98]). During a median follow-up period of 43 months (range 1-165), 26 (4%) of 615 patients developed metastases and 20 patients developed local recurrence (3%). Tumours 2.0 mm or less in thickness did not metastasise. Metastases occurred in 12 (4%) of 318 tumours between 2.1 mm and 6.0 mm in thickness, and in 14 (16%) of 90 tumours with a thickness greater than 6.0 mm. On multivariate analysis, key prognostic factors for metastasis were increased tumour thickness (hazard ratio 4.79 [95% CI 2.22-10.36]; p<0.0001), immunosuppression (4.32 [1.62-11.52]; p=0.0035), localisation at the ear (3.61 [1.51-8.67]; p=0.0040), and increased horizontal size (2.22 [1.18-4.15]; p=0.0128). The risk of local recurrence depended on increased tumour thickness (6.03 [2.71-13.43]; p<0.0001) and desmoplasia (16.11 [6.57-39.49]; p<0.0001). INTERPRETATION Only SCC greater than 2.0 mm in thickness are associated with a significant risk of metastasis. Tumours greater than 6.0 mm are associated with a high risk of metastasis and local recurrence. Desmoplastic growth is an independent risk factor for local recurrence. Studies should assess the role of follow-up visits and sentinel-lymph-node biopsy in high-risk patients.

Double-blind, placebo-controlled study of intralesional interferon gamma for the treatment of localized scleroderma

BACKGROUND Localized scleroderma is characterized by circumscribed fibrotic plaques and may progress to widespread skin involvement and fibrosis. Interferon gamma (IFN-gamma) has been shown to be a potent inhibitor of collagen synthesis and of the migration and proliferation of dermal fibroblasts. OBJECTIVE Our purpose was to determine whether IFN-gamma is effective in the treatment of localized scleroderma. METHODS A double-blind, randomized, placebo-controlled, multicenter study was conducted. Twenty-four patients with progressive lesions received 100 micrograms of IFN-gamma or placebo subcutaneously on 5 consecutive days for 2 weeks followed by 100 micrograms of IFN-gamma or placebo once weekly for 4 weeks. Thereafter patients were observed for 18 weeks. To determine whether improvement could be related to an altered level of collagen messenger RNA (mRNA), biopsy specimens were taken from uninvolved and involved skin before and after therapy. RESULTS The patients treated with IFN-gamma or placebo showed no significant difference in size or fibrosis of lesions or collagen type I mRNA synthesis. However, a reduction in the number of new lesions was observed in the IFN-gamma-treated group. The biopsy specimens obtained from involved skin showed a moderate increase of type I collagen and a significant decrease in the small proteoglycan decorin mRNA levels. CONCLUSIONS The results indicate that IFN-gamma is ineffective in the treatment of localized scleroderma, but may inhibit the development of new lesions.

SLOW INFUSION TUMESCENT ANESTHESIA

background. Dermatologic surgery is usually possible under local anesthesia, even when large amounts of highly diluted anesthetic solutions are required (tumescent anesthesia). Although special pumps now render such large injections effortless, it is usually still necessary to hold and guide the injection cannula. objective. We have found it possible to overcome this handicap by injecting anesthetic solutions slowly with a common infuso‐mat, as in paravenous infusion, into the subcutaneous layer. methods. The method consists of slow, automated tumescent anesthesia by means of infusion. The speed of injection varies between 50 and 1500 mL per hour depending on the location, the size of the operation, and the needle size. Volumes usually range from 2 to 500 mL but may rise as high as 1000 mL if necessary (maximum, 12 mg/kg). We use 30‐ to 20‐gauge needles with a length of 1.5–10 cm and butterfly infusion cannulas. We customarily use an anesthetic solution of pri‐locaine (Xylonest); the dilution liquid is original Ringers solution with epinephrine (1:1,000,000) in 500‐mL bottles. The concentration of the solution varies between 0.4% and 0.1%. After setting up the system during pulsoxymetry, the physician can usually leave the room. This is calming, especially for children and very anxious patients. We used the slow infusion tumescent anesthesia (SITA) in our department to treat 502 patients ranging in age from 3 to 92 years (mean age, 51 years). We performed all kinds of tumor operations (n= 213), dermabrasions (n= 5), scar revisions (n= 21), stripping of the long and short saphenous veins (n = 82), sentinel node dissection (n= 27), complete lymph node dissection of the axilla (n= 12) and groin (n= 17), and 125 minor operations as well. results. There were no severe complications. One hundred ten (91%) of 121 patients who had previously experienced general or regional anesthesia for the same kind of surgery and all who had previously had conventional syringe injection preferred SITA. conclusions. SITA is an economical, safe, and comfortable technique for nearly all skin operations, even for children and very sensitive patients. Choosing the most suitable concentration, needle, needle position, flow and volume requires some experience.© 1998 by the American Society for Dermatologic Surgery, Inc.

Pustular psoriasis exacerbation under intoxication with mercury

Zusammenfassung. Unter einer 3wöchigen systemischen Therapie mit einem quecksilberhaltigen Präparat exazerbierte eine seit 4 Jahren bestehende Psoriasis pustulosa palmaris. Es entwickelte sich eine Psoriasis pustulosa generalisata ohne Schleimhautbeteiligung. Die Hg-Spiegel in Blut und Urin waren deutlich erhöht. Nach Absetzen des Hg-haltigen Präparates wurden das Quecksilber-Antidot DMPS (2,3-Dimercapto-1-propan-sulfonsäure) sowie kurzzeitig ein aromatisches Retinoid und PUVA angewendet. Innerhalb weniger Tage waren die Hg-Spiegel deutlich rückläufig, die Hauterscheinungen heilten fast vollständig ab.Abstract. A patient suffering from long-standing pustular psoriasis of the palms was treated for 3 weeks with a mercury-containing drug. Exacerbation into generalized pustular psoriasis developed. Mercury levels in blood and urine were increased. After withdrawal of the mercury preparation, therapy with DMPA (2,3-Dimercapto-1-propane-sulfonic acid), a mercury antidote, was initiated, together with short-term treatment with aromatic retinoids and PUVA. Within a few days mercury levels decreased significantly and the skin lesions practically disappeared.

Bullöses Pemphigoid als paraneoplastisches Syndrom Eine Falldarstellung bei einem Nierenzellkarzinom

ZusammenfassungParaneoplasien können obligat oder fakultativ und im frühen bis späten Tumorstadium auftreten. Kontrovers wird dies in der Literatur beim bullösen Pemphigoid diskutiert. Die Assoziation eines bullösen Pemphigoids mit einem Nierenzellkarzinom ist bisher selten beschrieben worden. Vorgestellt wird die Kasuistik einer 74jährigen Patientin mit einem bullösen Pemphigoid. Im Rahmen der Untersuchungen wurde ein Nierenzellkarzinom mit multiplen Metastasen in Lymphknoten, Leber, Lunge und Skelett diagnostiziert. Die Patientin verstarb elf Wochen nach Auftreten des bullösen Pemphigoids.SummaryParaneoplastic markers in tumor patients may occur at various stages of the disease. While some disorders almost invariably herald an underlying malignancy (obligative marker), most only occasionally do so (facultative marker). The association of bullous pemphigoid with malignancy is controversial. There are only a few reports of bullous pemphigoid associated with a renal cell carcinoma. We diagnosed a renal cell carcinoma in a 74 year old female patient, admitted to the hospital because of bullous pemphigoid. Multiple metastases were found in her lymph nodes, liver, lung and skeleton. The patient died eleven weeks after the first symptoms of bullous pemphigoid appeared.

Anaphylactic reaction to bovine serum albumin after embryo transfer

OBJECTIVE To increase the awareness of bovine serum albumin (BSA) sensitivity as a potentially lethal complication during ET. DESIGN Case report. SETTING Routine ET in university hospital. PATIENT(S) A 26-year-old woman who was undergoing her first ET. INTERVENTION(S) ET with BSA containing standard fluid medium. MAIN OUTCOME MEASURE(S) Specific immunoglobulin (Ig) E antibodies and skin tests. RESULT(S) The patient demonstrated increased levels of specific IgE antibodies to BSA and a clearly positive scratch test for BSA. CONCLUSION(S) Anaphylactic reactions to BSA can occur during ET. The risk can be reduced substantially if a detailed medical history is obtained.

Ausgedehntes Ulcus terebrans (Typ: solides Basalzellkarzinom)

ZusammenfassungEin über 15 Jahre bestehendes solides Basalzellkarzinom am Rücken einer 52jährigen Patientin führte zu einem ausgedehnten Ulcus terebrans von 27 cm Durchmesser mit osteolytischer Wirbelkörperdestruktion, Umschließung des Conus medullaris, beginnender spinaler Kompression und einer bis an das Retroperitoneum heranreichenden Weichteilmanifestation. Erste neurologische Ausfälle sind beobachtbar. Jetzt erfolgte die großzügige Tumorexzision im Hautbereich und eine plastische Defektdeckung durch Verschiebeschwenklappenplastiken um das Zielvolumen einer notwendigen Folgeradiatio zu verkleinern und um eine Verbesserung der Lebensqualität durch Wiederherstellung einer intakten Hautoberfläche zu erreichen. Im weiteren wurde eine palliative Radiatio gezielt nach CT- und NMR-Befunden durchgeführt. Eine Querschnittslähmung ist bis heute nicht aufgetreten.SummaryA 52 year old female had a large destructive basal cell carcinoma of the back measuring 27 cm in diameter. There was destruction of the vertebral bodies, envelopment of the medullary cone, early spinal compression and soft tissue spread into the retroperitoneum. Early neurological defects were present. The tumor was excised, covered with two large rotation flaps and post operatively irradiated. The patients quality of life has improved, the tumor has not progressed and there is no sign of paraplegia.

Die Tübinger „Video-Live”-Tagungen: Beispiele für moderne interaktive und multimediale Fortbildung

aktiven Markierung (mit intraoperativer Anwendung einer Gamma-Sonde) am günstigsten. Alle Operateure konnten „ihren“ Lymphknoten detektieren und extirpieren. In einem Fall wurde ein zuvor schon sonographisch verdächtiger inguinaler Lymphknoten, der sich mit der szintigraphischen und Patentblau-Markierung deckte, nach Exstirpation einer Schnellschnittuntersuchung durch Herrn Prof. Horny (Pathologisches Institut Tübingen) zugeführt. Die Befundung erfolgte am Mikroskop des histologischen Arbeitsplatzes des OP und wurde per Kamera live mit entsprechenden Kommentaren in den Hörsaal übertragen. Nachdem sich eine Lymphknotenmetastase zeigte, erfolgte noch am gleichen Tag eine radikale inguinale Lymphadenektomie. Es zeigte sich bei diesem Verfahren, daß bei Schnellschnittbiopsaten eine vorhergehende Patentblau-Anfärbung störend sein kann.