Paul R.W. Stanley

Accuracy in skin lesion diagnosis and the exclusion of malignancy

The accuracy of clinical diagnosis of skin lesions has important ramifications for treatment selection and importantly prioritisation for treatment. The objective of this study was to assess the accuracy of diagnosis of skin lesions within our department with an emphasis placed on whether there were any negative consequences of a missed malignant diagnosis. The study was conducted retrospectively. Accuracy of diagnosis was judged on 2 criteria. The first, if the clinical diagnosis matched the histological diagnosis. The second, if the malignancy was diagnosed correctly. 1186 lesions were excised. 57% of patients were female and the mean age was 56 (range 6-94). 25% were invasive malignancies. Clinical diagnosis was correct in 700 (66%) cases. 89% BCCs and 33% of SCCs excised were correctly diagnosed preoperatively. Misdiagnosis of BCCs or SCCs as benign was associated with a stastically significant delay in treatment (BCC 6.2 vs 10.7 weeks, p=0.02) (SCC 3.7 vs 9.5 weeks p=0.004). 100% of correctly diagnosed vs 79% of misdiagnosed SCCs were completely excised. The sensitivity and specificity of the diagnosis of MM were 87% and 97.7% respectively. The mean waiting time for patients correctly diagnosed preoperatively was 2.4 weeks vs 3 weeks (p=0.39). For malignant diagnoses sensitivity was 91%, specificity 84%, PPV 65% and NPV 96%. Misdiagnosis of skin lesions results in delays in treatment and may increase the rate of incomplete excision. The high NPV rate suggests that few malignancies are missed but those that are may have serious consequences if discharged untreated.

Risk Factors for Complications Following Breast Reduction: Results from a Randomized Control Trial

Reduction mammoplasty has been shown to benefit physical, physiological, and psycho‐social health. However, there are some recognized complications. It would be beneficial if one could identify and modify the factors which increase the rate of complications. To determine the effects of resection weight, BMI, age, and smoking on complication rates following reduction mammoplasty. Data were gathered as a part of randomized control trial (RCT) examining psycho‐social & QOL benefits of reduction mammoplasty. Sixty‐seven consecutive female patients referred to either the Hull Breast Unit or Hull Plastic and Reconstructive Surgery Unit and underwent Inferior pedicle reduction mammoplasty were recruited. Complications were recorded prospectively. Data gathered included resection weight, BMI, age, and smoking status. Smoking status was categorized into current; ex; and never. Prospective records of all complications were noted. SPSS was used for purposes of statistical analysis. Of the 67 patients, 16 (23.9%) had complications. Higher resection weight, increased BMI, and older age are associated with high rate of complications with significance reaching p‐values of p < 0.001, p = 0.034, and p = 0.004, respectively. Among the 67 women who had surgery, nine (13.4%) were current smokers, 20 (29.9%) were ex‐smokers, and 38 (56.7%) never smoked. The incidence of complications was highest among current smokers and lowest among those who had never smoked. When comparing the current smokers with those who are not currently smoking, there is a 37% difference in the occurrence of complication. The chi‐squared test shows that this is a significant difference (p < 0.01) at the 99% confidence interval. Higher resection weight, increased BMI, older age, and smoking are risk factors for complications. Patients should be adequately counseled about losing weight and stopping smoking.

Surgical excision margins for melanoma in situ

INTRODUCTION Melanoma in situ (MIS) is a non-invasive lesion accounting for up to 27% of all melanomas by Coory et al. (2006).(1) MIS may be a precursor to invasive disease. The Lentigo Maligna (LM) subgroup of MIS carries upto a 4.7% lifetime risk of developing an invasive component by Agarwal-Antal et al. (2002).(2) Surgical excision is recommended however other modalities of treatments are possible. In this study we aim to assess whether histological margins following excision of in situ melanoma has any bearing on recurrence or progression to malignancy. METHOD We retrospectively reviewed data accumulated on all melanomas referred to the hospital between the dates of February 2001 to February 2009. We identified all patients with melanoma in situ and for these patients recorded age, sex, anatomical site of lesion, histological type, histological excision margin, recurrence after excision and transformation to malignant melanoma. RESULTS A total of 2121 patents were identified having been diagnosed and treated for melanoma of which 192 cases were identified with melanoma in situ representing 9.1% of all melanomas treated. 38% of all the lesions were of the LM subgroup. We noted a higher incomplete excision rate in this subgroup (p < 0.01) compared to the non-LM subgroup. We only noted two recurrences following complete excision (1.1%) and one recurrence in lesions completely excised with histological margins less than 2 mm (1.4%). Both of the lesions that recurred following complete excision were LM lesions. Recurrence following complete excision of LM was 2.9%. CONCLUSION Our data suggests that MIS lesions that were not LM and adequately excised even with narrow margins are unlikely to recur therefore reducing the need for wider excision. LM however poses a more challenging clinical problem not only with the higher inadequate primary excision and higher recurrence rates following excision but also the fact that it occurs in much older patients who may be less able to tolerate more extensive surgery. In keeping with the literature we would suggest treating LM lesions more aggressively if possible.

Fibroma of a tendon sheath at the wrist: a rare cause of compression of the median nerve

We report a case of fibroma of a tendon sheath, a rare benign tumour, which presented as a painless swelling at the wrist and caused symptoms of median nerve compression. We have also reviewed similar cases.

Evaluation of sentinel lymph nodes positive for melanoma for features predictive of non-sentinel nodal disease and patient prognosis: A 49 patient series

Sentinel lymph-node biopsy (SNB) is an established staging tool for malignant melanoma. It aims to identify the first draining node(s) in the nodal basin draining the tumour-bed. The node(s) are submitted for histological evaluation and if malignant cells are identified, the remainder of the nodal basin is cleared. It aims to spare completion lymph-node dissection (CLND) in patients without nodal disease, but the rate of melanoma-negative CLND remains as high as 70%. Studies have aimed to identify features of the SNB predictive of the CLND.

Sorafenib enhances the in vitro anti-endothelial effects of low dose (metronomic) chemotherapy

Angiogenesis inhibitors may enhance the effects of low dose (metronomic) chemotherapy. However, there is a wide range of novel angiogenesis inhibitors which must be tested in combinations with oral chemotherapy agents to assess the anti-endothelial and anti-cancer effects. This preliminary testing is most suited to high throughput in vitro models, rather than clinical trials. We aimed to establish an in vitro model and test the anti-endothelial and anti-cancer effects of the multi-kinase inhibitor sorafenib when used as a single agent and in combination with oral chemotherapy agents used at low concentrations. Micro-vascular endothelial cells and 3 cancer cell lines were utilised and an extended treatment strategy (96 h) was employed in order to mimic a continuous low dose anti-angiogenic chemotherapy regimen. Sorafenib significantly enhanced the anti-endothelial effect of low dose etoposide, paclitaxel and temozolomide. Sorafenib also significantly enhanced the anti-cancer effect of low dose etoposide, paclitaxel and temozolomide in SK-MEL-2 melanoma cells, producing an additive effect on inhibition of cell growth in all cases. These combinations appear to be the most promising for in vivo pre-clinical studies, with a view to testing in melanoma patients as a continuous dosing strategy, due to the in vitro additive inhibitory effect on growth seen in both endothelial and cancer cells.

Macromastia and Carpal Tunnel Syndrome: Is There an Association?

Macromastia is a disorder commonly reported by women. The prevalence of electrophysiologically confirmed, symptomatic carpal tunnel syndrome is 3% among women. A consecutive series of 31 patients with macromastia requesting breast reduction between August 2002 and April 2003 was recruited. The physical characteristics recorded included age, body mass index, and breast size. Clinical and electrophysiologic assessments of the upper limb were performed. Electrophysiologic testing showed that 7 (22%) of the 31 women had a prolonged median nerve latency conduction time longer than 0.40 ms. Age, chest circumference, and the ratio of nipple-to-inframammary line to chest circumference was associated with carpal tunnel syndrome. The prevalence of carpal tunnel syndrome among patients with macromastia was shown to be higher than in previous epidermiologic studies investigating the prevalence of carpal tunnel syndrome among women. Age, chest circumference, and breast size, but not body mass index, have a positive correlation with the increased prevalence of carpal tunnel syndrome in macromastia cases.

Cutting or Round-Bodied Needles for Tendon Repair

We carried out a biomechanical study comparing tensile strength after using round-bodied or cutting needles for tendon repair. Swine tendons were repaired in three groups: Group 1 core suture repair only; group 2 core and circumferential suture repair; and group 3 isolated circumferential suture repair. The tendons were tested at longitudinal stress to failure at 5 mm/minute. No significant differences were found between the round-bodied and cutting needles in any group. Equal numbers in the core suture repair group failed by suture pullout when comparing cutting and round-bodied needles. We conclude that the choice of needle has no effect on the outcome of tendon repair if there is consistency of surgeon’s skill and experience.

Use of topical negative pressure in the treatment of chronic osteomyelitis. A case report.

The use of topical negative pressure is now an established practice among many surgeons for the treatment of difficult wounds, both as a frontline therapy and as a salvage procedure. Among difficult wounds, few present more of a challenge to the reconstructive surgeon than chronic osteomyelitis of the lower limb. Acutely, persistent sinuses and fistulas typically involve the whole length of the bone, necessitating extensive debridement that often results in extensive skin loss. Exposed bone and, frequently, exposed medullary cavities, leave a surface unsuitable for skin-grafting or conventional dressings. It is well recognized that the muscle flap is the optimal treatment following adequate debridement and antibiotic coverage. Despite an often initially excellent clinical result, some surgeons remain cautious about the long-term outcomes of treatment with either local or free flaps because of the recurrent nature of chronic osteomyelitis1,2. Treatment options for the lower limb are often further limited by the difficult anatomical constraints, making amputation always a possibility. We present a case of chronic osteomyelitis in a thirty-nine-year-old man who had recurrences, with failed skin grafts, pedicled flaps, and free flaps, over a period of more than thirty years. Topical negative pressure was used as a salvage procedure before a planned amputation. Following split-thickness skin-grafting, the wound healed and the patient had virtually full use of the limb for the next three years. The patient was informed that data from the case would be submitted for publication. We treated a thirty-nine-year-old man in whom acute hematogenous osteomyelitis of the left tibia had developed in 1963, when he was nine years old. At that time, he was treated with a cross-leg flap, but the infection recurred at the age of fourteen. Multiple debridement procedures and courses of antibiotic therapy were used until he …

Effects of reduction mammoplasty on upper-limb nerve conduction across the thoracic outlet in women with macromastia: a prospective randomized study.

Macromastia is a common problem. The physical complaints include upper body pain and aches. There have been anecdotal reports of neurologic deficits in the nerves emanating from the lower trunk of the brachial plexus. This is thought to be due to pressure on the lower trunk from both the first rib and tilting forward of the coracoid process. Other anecdotal reports have centered on the correction of neuropraxia of the ulnar nerve following bilateral breast reduction (BBR). We investigate the effect of BBR on the electrophysiological function of the nerve supply to the upper limbs in women with macromastia. Methodology: Consecutive patients undergoing BBR were randomized into 2 groups, depending on time of surgery. None had any prior neurologic disorder. Each patient had a comprehensive neurologic assessment and 2 electrodiagnostic neurophysiologic tests. Group 1 had 2 tests, one before surgery and a second 3 months postsurgery, while Group 2 had 2 sets of tests, one initially and a second test 4 months later (control). The outcome measures include somatosensory evoked potential (SSEP) (median and ulnar), F-wave median and ulnar latencies. The F waves measure the integrity of neural conduction time from the anterior horn cells to the hypothenar and thenar muscles reflecting lower trunk function. The SSEP of the median nerve measure the integrity of the nerve fibers traversing the upper trunk of the brachial plexus and the ulnar nerve SSEP that of the lower trunk. There was no statistical difference in the conduction times. BBR does not have any effect on the upper limb nerve conduction times.