Ralph Hamilton

The role of lymph node dissection for clinical stage I malignant melanoma of intermediate thickness (1.51—3.99 mm)

The survival times of patients who had an elective regional lymph node dissection was compared with that of those who did not undergo the procedure in a database of 72 patients with clinical Stage I melanoma of intermediate thickness (1.51–3.99 mm). All of the patients had been followed for 5 years or longer or until death. No significant differences were found in other reported prognostic factors, suggesting that the two groups were comparable. By multivariate analysis, a low mitotic rate, intermediate patient age, and the presence of an infiltrative lymphocytic response were found to be associated with favorable survival. There did not appear to be any association of elective regional lymph node dissection with survival; and it was concluded that such therapy should not be regarded as “standard” for clinical Stage I melanoma of intermediate thickness.

Successful lymph node transplantation in rats, with restoration of lymphatic function.

After doing a popliteal lymphadenectomy in rats, we were able to transfer a mass of inguinal nodes to the area, either on an island pedicle of the superficial epigastric vessels, or as a free flap by microvascular anastomoses. The transplants survived and at 7 days were able to entrap india ink particles, or particles of radioactive gold, injected in the distal part of the extremity.

A comparison of local recurrence and resection margins for stage I primary cutaneous malignant melanomas.

A retrospective review of 552 patients with clinical stage I primary cutaneous malignant melanomas was undertaken comparing margins of resection and local recurrence between 1966 and 1981. The overall local recurrence rate was 8 per 552 (1.45 percent). We observed no instances of local recurrence in lesions less than 1.40 mm thick with resection margins of at least 1 cm. A comparison of resection margins greater than 2 cm versus less than 2 cm for lesions less than 1.00 mm thick showed no difference at the 0.05 level of significance for local recurrence (0 per 228 versus 2 per 154; 1.3 percent) or survival. While narrower margins of resection for thinner, low-risk stage I malignant melanomas appear safe, the exact minimum margin of resection needed to satisfy both oncologic and cosmetic considerations, whether 1 or 2 cm, will need to be determined by a large prospective, randomized study.

Utility of frozen section analysis on follicular lesions of the thyroid

The experience of one surgeon (R.H.) with intraoperative frozen sections (FS) performed on thyroid nodules over a 10-year period was studied to assess the utility of FS in follicular thyroid lesions. One hundred and ten patients with dominant or solitary nodules demonstrating a follicular growth pattern were evaluated. The FS slides and subsequently the permanent sections of the nodules were reviewed by the pathologists in the study (M.P.B., VAL.) without knowledge of the original diagnoses. Our results indicate: (1) if the FS was definitively benign (58 patients), the final diagnosis was benign [these lesions consisted of adenomatous nodule, nodular goiter, follicular adenoma, and Hürthle cell adenoma); (2) if an FS diagnosis of malignancy was rendered (4 patients), it was confirmed on permanent sections (follicular variant of papillary carcinoma in all 4); and (3) if the FS diagnosis was deferred (48 patients), the final diagnosis was benign in all but 10 (21 %) (of these 10, 6 had minimally invasive follicular carcinoma [2 of the Hürthle cell type], and 4 had follicular variants of papillary carcinoma). Overall, sensitivity, specificity, and accuracy rates for FS diagnoses were 29, 100, and 91%. Because unilateral lobectomy may be acceptable therapy for well-differentiated thyroid cancers, and because the efficiency of FS evaluation in diagnosing malignancy is low (only 4 malignancies of 110 total patients were diagnosed at FS, or 3.6% overall), we conclude that in this era of cost-containment, FS is not useful in the evaluation of follicular thyroid nodules identified preoperatively as follicular lesions by fine-needle aspiration cytology. Several recommendations concerning the 3 categories of FS diagnosis (i.e., definitively benign, definitively malignant—especially the follicular variant of papillary carcinoma—and deferred) are also put forward.

Melanoma of the Male Urethra: Surgical Approach and Pathological Analysis

AbstractPrimary urethral melanoma in male subjects is rare and optimum therapy has not been established. We describe a male patient with a primary urethral melanoma that arose in a precursor nevus and was treated by excision, bilateral groin dissections and postoperative radiation therapy. Urinary and sexual functions have been maintained. We review the previously reported cases of urethral melanoma in male subjects. The biologic relationship of melanoma to precursor lesions in mucosal sites is discussed.

Successful localization of parathyroid adenomas by magneticresonance imaging

Exploration of the neck for primary hyperparathyroidism is facilitated if the parathyroid glands can be localized preoperatively. Magnetic resonance imaging is a noninvasive and relatively safe procedure that is capable of distinguishing and differentiating small soft-tissue structures. Ten patients with primary hyperparathyroidism underwent preoperative diagnostic magnetic resonance imaging followed by cervical exploration. In 9 of these patients (90 percent), imaging correctly predicted the location of a single enlarged parathyroid gland, and in one patient the findings were misleading. All 10 patients proved to have single adenomas in orthotopic locations. Based on this early experience, magnetic resonance imaging appears to be a promising technique for preoperative localization of an enlarged parathyroid gland.

Successful preservation of canine small intestine by freezing

Abstract Five of fourteen canine intestinal autografts frozen at −196°C for 7 days were surviving 2 wk after reimplantation. The mucosal epithelium sloughed immediately, but repopulated from surviving crypt cells over the ensuing 3–5 days. Absorptive and peristaltic functions were present at 2 wk after reimplantation.

The use of microvascular free skin-muscle flaps in management of avulsion injuries of the lower leg.

The authors used microvascular free skin-muscle flaps to cover avulsion wounds in the lower leg of ten patients. There were three children and seven adults, ranging in age from 5 to 54 years. Vessels supplying gracilis (four) and tensor fascia lata (six) skin-muscle units were anastomosed to the anterior tibial (nine) and posterior tibial (one) vessels. The tensor fascia lata unit has a more constant anatomy and is preferred. Principles of management include: 1) early adequate, but conservative, debridement; 2) continuous bony stabilization; 3) preoperative arteriography; 4) anticoagulation; 5) recipient vessel identification in healthy uninjured tissue; 6) appropriate timing; 7) delayed bone grafting.

Management of cutaneous melanomas of the female breast.

Primary melanomas of the skin of the breast are uncommon lesions. Fifty-four patients were surgically treated for this lesion during a 13-year period, accounting for 3.8 percent of a total of 1431 patients with cutaneous melanoma. Nineteen patients were female and 35 were male. Most recently, in patients with high-risk lesions, such as those exhibiting an aggressive vertical growth phase or a Clark level IV or V, attempts at curative resection have utilized wide and deep excision to the level of the pectoralis fascia with axillary lymph node dissection in selected cases. Reconstruction of the significant breast deficit in five female patients utilized the latissimus dorsi myocutaneous flap. This technique results in an improved aesthetic appearance when compared to primary closure or skin grafting. Donor-site morbidity is minimal. Long-term cancer surveillance is not impeded, and all five patients expressed satisfaction with the reconstruction. Four of the five female patients are currently alive with no evidence of disease at a mean follow-up of 55 months after definitive therapy.

Ultrastructural changes in the mucosa of frozen-preserved canine ileum*†

Summary Serial ultramicroscopic observations were made on four segments of canine ileum frozen to −50°C after use of 10% glycerol solution as a cryoprotectant. The observed alterations in cellular structure were progressive in degree during the perfusion, frozen and thawed, and revascularized stages. Normal fine structure was evident in the cells studied 1 month after freezing. There was a wide variation in the response of individual cells to the freezing process. Changes observed in the epithelial cells included swelling of mitochondria, distention and vesiculation of the endoplasmic reticulum, and rounding with dilation of the cisternal profiles of the Golgi apparatus. In the terminal stages prior to cell disruption, fragmentation of the microvilli was observed. Consistent or typical changes in the nuclei were not identified in this study. In the lamina propria, the capillary endothelium retained its integrity during perfusion but showed mitochondrial swelling. Late changes following freezing included disruption of endothelial cytoplasm. Minimal changes in smooth muscle cells were observed but included decrease in peripheral myofibrills and increase in condensed nuclear chromatin. Plasma cells were relatively unaffected by perfusion but showed vesiculation of the endoplasmic reticulum after freezing and thawing. It would appear that the morphological changes observed after freezing and thawing first appear after perfusion. The one ultrastructural change which may prove most useful in evaluating improved storage procedures is the gradual alteration in the rough endoplasmic reticulum, which develops over a broad range of experimental conditions.