Oliver Cassell

Surgical management of metastatic inguinal lymphadenopathy

Inguinal lymphadenectomy, or groin dissection, has a key role in the management of patients with penile, vulval, anal, and cutaneous malignancy. About 500 procedures are performed in the United Kingdom each year by general, gynaecological, plastic, and urological surgeons. Groin dissection is associated with high postoperative morbidity, chiefly related to wound healing and lymphoedema. As the preoperative diagnosis and postoperative care of these patients may also involve general practitioners, oncologists, dermatologists, and specialist nurses, this review is aimed at providing a concise yet comprehensive summary of the key aspects of managing inguinal lymph nodes. We searched the Cochrane Library and Medline online databases, using the terms “inguinal lymphadenectomy”, “groin dissection”, and “sentinel lymph node biopsy”, combined with “melanoma”, or “carcinoma” and either “vulva”, “penis”, or “anus”. We reviewed abstracts and selected relevant articles. ### Tumours of the male genital tract Squamous cell carcinoma is the most common tumour of the penis (table 1, accounting for 95% of primary penile malignancies.w1 Relatively uncommon in developed countries, it accounts for up to 17% of all male malignancies in developing countries.1 2 Penile malignancy affects about 800 men per annum in the United Kingdom.1 The mean age of affected individuals is 64.1 Palpable inguinal lymphadenopathy at presentation may represent metastatic disease or secondary inflammation, so a four to six week course of oral antibiotics is usually prescribed, followed by re-evaluation of the lymphadenopathy. However, studies have shown that up to 20% of patients with no palpable lymphadenopathy will have nodal metastasis.w2 View this table: Table 1 Pathology of tumours commonly metastasising to the inguinal lymph nodes ### Tumours of the female genital tract Tumours arising from the vulva and lower third of the vagina metastasise to the inguinal lymph nodes. Vaginal tumours are rare and will not be considered further here. Squamous cell carcinoma is the most common tumour of the vulva (table 1), and 1996 …

Sentinel lymph node biopsy in melanoma: The Oxford ten year clinical experience *

Sentinel lymph node biopsy (SLNB) has become an established investigation for assessing microscopic nodal metastasis in melanoma. The American Joint Committee on Cancer (AJCC) incorporates the sentinel node status in its staging criteria for melanoma. We present our clinical evaluation of performing SLNB in a single UK centre between 1998 and 2008. There were 697 patients with a mean age 53 years (range 13-92). We were able to surgically harvest at least one sentinel node in 694 patients of which 532 (76%) were negative. Of the 162 positive patients, 129 underwent further completion lymphadenectomy with 29 showing further pathologically positive nodes. At median follow up of 46 months, mortality from melanoma for SLN positive and negative patients was 32% and 4%, respectively. Disease recurrence was noted in 10% of the SLN negative group. Survival curves showed significant difference (p<0.001) in outcomes for patients grouped by Breslow thickness. Postoperative complications were noted in 6% of patients. No life-threatening complications were noted. Our results are comparable to other national and international studies. We await the outcomes of ongoing trials to assess the therapeutic value of SLNB for melanoma.

Closure of the radial forearm donor site using a local hatchet flap: analysis of 45 consecutive cases.

Background The radial forearm free flap (RFFF) is widely used in reconstructive surgery. Traditional donor-site closure by grafting may be associated with significant aesthetic and functional morbidity. We report our experience with primary closure using a local hatchet flap. Methods In all, 45 consecutive patients who underwent RFFF reconstruction in the head and neck during an 8-year period were retrospectively assessed with regards to their donor-site morbidity. Results The mean age of the patients was 54, with 23 being female. The mean RFFF area harvested was 37.7 cm2; mean width, 7.6 cm (5.5–11 cm); and mean length, 4.7 cm (3.5–6.5 cm). All patients had their donor site closed primarily utilizing a local hatchet flap. At the time of follow-up, there were 33 surviving patients, of which 31 patients were available for assessment. Conclusions We recommend this technique of primary closure of the RFFF donor site: it is well tolerated by the patient, with good cosmesis and is associated with no discernable functional morbidity.

Sentinel lymph node biopsy for external ear melanoma: A 17 year experience with long term survival data

Melanoma of the external ear is an uncommon tumour, sparsely reported, with contrasting data regarding its prognosis. A recent letter from the Department of Plastic Surgery at St George’s Hospital, London has suggested that external ear melanoma has a lower rate of sentinel lymph node positivity which might correlate with a favourable outcome, but these data did not reach statistical significance. The study lacked long term survival data which the authors suggested was important to further interpret this result. We performed a 17-year (2000e2017) analysis of patients undergoing sentinel lymph node biopsy (SLNB) for melanoma at our department, using prospectively collected data. We identified 41 patients undergoing SLNB for external ear melanoma from a total of 1799 (2%). The median age of these patients was 61 years, which was not significantly different from patients undergoing SLNB for melanoma in any other body site. Those with external ear melanoma were more likely to be male (73%) than those with melanoma at other body sites (49%, pZ 0.0026) (Table 1). Neither the proportion of SSMM (superficial spreading malignant melanoma) nor the proportion of nodular melanoma differed significantly between groups. The median Breslow thickness in the external ear group was 1.90 (cf. 1.70 in all other sites and 1.90 in other head and neck sites). There were no significant differences in the proportions of tumours staged as T1, T2, T3 or T4 between our external ear group and those with melanoma at any other body site, however we did note a higher proportion of T4 melanomas in non-ear head and neck sites (21%) compared to the external ear (5%, p Z 0.016). There was no significant difference in the proportion of melanomas

Inter-operator variability in the sensitivity of sentinel lymph node biopsy for melanoma

INTRODUCTION AND AIMS Plastic surgery trainees, in some circumstances, can progress to consultant level having performed only 15 generic lymph node surgeries, with no mention specifically of sentinel lymph node biopsy (SLNB) on the training log. The majority of SLNBs carried out for melanoma at our centre since 1999 have been performed by eight surgeons, six of whom had been formally trained and mentored in our unit or previously completed skin cancer fellowships. Two surgeons started performing the procedure without formal training or specialist fellowships. We analysed the first 40 cases performed by each consultant hypothesising that those with more extensive training would achieve higher sensitivities. METHODS Using our centres prospectively collected data set we studied 320 procedures. Sensitivities were calculated and compared between surgeons with less extensive and more extensive training. RESULTS The two surgeons without formal training had a combined sensitivity of 85% (80 cases, 17 positive results, 3 false negative results). The six surgeons who had been practising after extensive training had a combined sensitivity of 94% (240 cases, 44 positive results, 3 false negative results). SLNBs in the head and neck region accounted for 17% of total cases, but 50% of false positive results. CONCLUSIONS There is likely to be a learning curve for this operation, and in the era of adjuvant therapy a false negative result may affect survival. Training requirements may not be enough to ensure consistency amongst newly qualified plastic surgeons. We advocate a similar level of experience to that required of breast surgeons before performing the procedure independently.

Cartilage-sparing surgery for melanoma of the external ear

BACKGROUND The excision of melanoma of the external ear poses a challenge to surgeons, who must achieve adequate oncological control while minimising impact on form and function. Cartilage-preserving surgery is an attractive option, as it leaves behind a scaffold for immediate reconstruction with a variety of techniques including full-thickness skin grafts (FTSGs) and local flaps. This manuscript will review the literature comparing cartilage-sparing surgery with composite excision of the skin and the cartilage for the treatment of auricular melanoma. We report the results of a 17 year experience of using both techniques, together with sentinel node biopsy at our centre. METHODS A structured review of MEDLINE and EMBASE was conducted to evaluate all studies reporting local recurrence or survival rates for melanoma of the external ear treated with cartilage-preserving surgery. A retrospective review of all patients undergoing wide local excision (WLE) and sentinel lymph node biopsy (SLNB) for auricular melanoma at our centre between 2000 and 2017 was performed. RESULTS Of 40 patients identified, 29 underwent cartilage-preserving surgery with no local recurrences or evidence of perichondral involvement. There was one local recurrence out of 11 patients who had their cartilage excised. There were no significant differences in recurrence rates or melanoma-specific survival rates when comparing cartilage-preserving and cartilage-sparing surgery. Our results are supported by the literature review, which suggests that cartilage-sparing surgery is gaining acceptance as a safe practice.

Letter in response to article – “Estimating the positive predictive value and sensitivity of the clinical diagnosis of basal cell carcinoma.”

We read with interest the recent study entitled “Estimating the positive predictive value and sensitivity of the clinical diagnosis of basal cell carcinoma.” We appreciate the difficulties in clinically assessing skin lesions with the naked eye. Clinical experience is very difficult to substitute, with evidence to show that training plays a significant role in the accuracy of diagnosis of skin lesions. However, the consequences of unnecessary excision cannot be ignored. In general, the majority of excisions are on the head and neck and can give cosmetic sequelae. The patient population is older and with co-morbidities, and hence more complications. It is therefore important that clinical diagnosis is as accurate as possible. This study reports 204 false positives for the diagnosis of BCC. Accounting for the 15 non-BCC lesions which would have necessitated excision independent of this diagnosis (lentigo maligna melanoma, squamous cell carcinoma), and the 15 cases of Bowen’s disease, for which surgery is an option, there were 174 non-indicated excisions. If extrapolated across all plastic surgery units, then this obviously has financial and logistical implications, in addition to the risks posed to the individual patient. As previously published in this journal, dermoscopy is a sensitive addition to naked eye examination. The use of dermoscopy reduces unnecessary excision, increases diagnostic accuracy, and is very cost effective. Even with a very short, one-day course in dermoscopy, the relative odds ratio of increased accuracy in diagnosis when using dermoscopy was 5.2, when compared with the naked eye