Oliver J. Smith

Clinical significance of intra-nodal naevi in sentinel node biopsies for malignant melanoma

BACKGROUND Intra-nodal naevi (INN) identified during assessment of a sentinel lymph node for melanoma are not an uncommon finding. Little is known about their clinical significance. Patients with INN are treated as sentinel node biopsy (SNB) negative currently. Our aim was to assess the significance of INN in patients who undergo SNB for melanoma. METHODS 353 melanoma patients who underwent a SNB between November 1999 and June 2012 were retrospectively analysed from a prospectively collected database. The patients were divided into SNB negative, INN, isolated tumour cells (ITC) and SNB positive groups. Outcome measures of nodal recurrence, distal recurrence and survival were used to assess the differences between the groups. RESULTS 203 patients were SNB negative, 103 were positive of which 13 had ITC, 47 had INN (13%). Overall median follow up was 2.3 years (range 0.1-14.1 years). Our data demonstrated a statistically significant survival benefit for patients who had an INN compared to the SNB positive and ITC group. INN patients also had significantly better nodal and regional recurrence compared to SNB positive patients. There was no difference between INN and SNB negative patients. CONCLUSION We have clinically demonstrated that patients with INN on SNB can be adequately treated as SNB negative patients.

Sentinel Node Biopsy

The presence of cervical lymph node metastases remains one of the most important prognostic factors for various solid tumours of the head and neck, including melanoma, squamous cell carcinoma and Merkel cell carcinoma. In patients with clinically evident neck involvement, the regional lymphatics clearly require directed treatment, and this may involve therapeutic neck dissection or radiotherapy. However, the decision whether or not to electively treat patients with clinically uninvolved cervical lymphatics is usually less clear-cut. On the one hand, elective neck dissection simultaneously allows for accurate pathologic neck staging and definitive surgical management of patients found to harbour occult metastatic disease. On the other hand, the majority of patients with clinically negative necks do not harbour occult disease and would therefore be overtreated by an elective neck dissection. The significant morbidity associated with neck dissection means that this is a real concern, and efforts to minimise the extent of surgical intervention while maintaining oncologic safety are ongoing.

The use of combined radial forearm cutaneous and radial forearm fascial flaps in head and neck reconstruction: a case series.

INTRODUCTION Reconstruction of complex head and neck cases involving bony and dural defects poses many issues. The primary aims of reconstruction are to provide a tight dural seal with good cranial support while also achieving a satisfactory cosmetic result. AIMS This study describes the use of combined radial forearm cutaneous flap and radial forearm fascial flaps for reconstruction of complex skull defects where each component is used for a distinct reconstructive purpose. The benefits of this technique are illustrated in the cases of three patients requiring reconstruction following tumor resection. METHODS The fascial component was used as a seal for dural defects. The cutaneous flap was then used to reconstruct the concomitant cutaneous defect. CONCLUSION The combined use of the fascial and cutaneous components of the radial forearm flap, where each is used for a distinct reconstructive purpose, increased the reconstructive versatility of this commonly used flap. The fascial flap was a thin, pliable, and highly vascularized piece of tissue that was effectively used to provide a watertight seal for the dural defect. The simultaneous use of the cutaneous flap gave support to the bony defect while providing a good cosmetic result.