Sidika Kurul

Totally implantable venous-access ports: local problems and extravasation injury

Totally implantable venous-access ports (TIVAPs) are valuable instruments for long-term intravenous treatment of patients with cancer, but implantation and use of these devices are each associated with complications. In addition to the perioperative problems, long-term complications can arise; these can be classified in five categories-catheter malfunction, catheter-related venous thrombosis, catheter-related infection, port-related complications, and extravasation injury. Such complications reduce the benefits of reliable access to the venous system in patients with malignant tumours. The vast majority of such disadvantages are attributable to inexpert handling of ports and, therefore, should be avoidable. TIVAP placement procedures and TIVAP complications are discussed in this review, with special emphasis on local problems and extravasation injuries. To obtain maximum benefit from TIVAPs, all health-care personnel must be familiar with the use and routine maintenance procedures of the devices and treatment options for catheter-related complications.

The role of antibiotic prophylaxis in totally implantable venous access device placement: results of a single-center prospective randomized trial

BACKGROUND This study evaluated whether prophylactic treatment with a cefazolin could prevent infections in patients who had a surgically inserted totally implantable venous access device (TIVAD). METHODS We conducted a prospective, randomized, double-blind, placebo-controlled trial comparing wound infection rates in 404 patients (203 received prophylactic cefazolin, 201 received a placebo) undergoing TIVAD insertion. Infections were evaluated 3, 7, 14, and 30 days after discharge and outcomes were compared and analyzed. RESULTS Groups were well matched for all preoperative variables studied, including comorbid conditions. Superficial surgical site infection developed in 5 patients (2.5%) from the antibiotic group and 6 (3%) from the placebo group (P = .75). One from each group developed deep surgical site infection. Both patients were readmitted and underwent repeated debridement, which eventually resulted in port loss in 1 patient. CONCLUSIONS We do not recommend the use of prophylactic antibiotics in TIVAD insertion because they will not decrease the already low rate of postoperative infectious complications. Registration number NCT00867295 (http://www.clinicaltrials.gov).

Lymphatic mapping for Merkel cell carcinoma.

Merkel cell trabecular carcinoma of the skin has a prognosis poorer than expected for a small skin lesion. An early diagnosis and prompt treatment can contribute to improve survival in cases of this aggressive skin tumor. A wide local excision is indicated for localized disease. Elective lymph node dissection is controversial. The authors report a rare case of Merkel cell tumor treated with wide local excision and sentinel lymph node biopsy.

Modification of approach for totally implantable venous access device decreases rate of complications

The aim of this study was to analyze the potential utilization of external jugular vein (EJV) cutdown approach for totally implantable venous access device (TIVAD) placement.

Serum levels of the soluble adhesion molecules in patients with malignant melanoma.

The incidence of malignant melanoma has been steadily increasing over the past decades. CD 44 is a transmembrane glycoprotein which is implicated in a number of adhesive and migratory events. Downregulation of CD 44 is implicated in the metastatic process. P-Selectin is a member of the selectin family of cell surface molecules. The levels of P-Selectin in biological fluids may be elevated in subjects with a variety of pathological conditions. In malignant melanoma, elevation of the plasma level of soluble intercellular adhesion molecule-1 (sICAM-1) has been associated with a reduction in disease-free survival. This study was performed to investigate the differences in the serum concentrations of the adhesion molecules in patients with malignant melanoma.The study group consisted of 52 patients with malignant melanoma and 20 healthy subjects. No meaningful difference was observed for P-selectin and sICAM 1 levels. A statistically significant decrease was observed in the cancer patients for serum CD 44 levels.

Serum matrix metalloproteinase-3 and tissue inhibitor of metalloproteinase-1 in patients with malignant melanoma.

Degradation of basement membranes and extracellular matrix is an essential step in cancer invasion and metastasis. Matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) play key roles in this step. The present study was conducted to investigate the levels of MMP-3 and TIMP-1 in serum of patients with malignant melanoma and the relationship to tumor progression and known prognostic parameters. Seventy patients with cutaneous malignant melanoma were investigated. Serum samples were obtained on first admission before any adjuvant and metastatic treatment was given or follow-up of patients. Serum TIMP-1 and MMP-3 levels were determined by the solid-phase sandwich ELISA (Oncogene Science Inc.) method. The elevation of serum MMP-3 and TIMP-1 levels between the patients with malignant melanoma and healthy controls were not significantly different (p>0.05). The serum levels of MMP-3 were significantly different in males and females (p=0.001) and serum TIMP levels were influenced by age (p=0.047). Except for the ulceration status of the tumor, serum levels of MMP-3 and TIMP-1 were not related to the known prognostic factors such as tumor histology, localization, stage of the disease, Breslow thickness, Clark invasion, mitosis, TIL, and regression of tumor (p>0.05). In patients with ulceration positive, the serum levels of MMP-3 were higher (p=0.04) and TIMP-1 were lower (p=0.008) than those in patients without ulceration. No significant relationship was found between serum levels of MMP-3 and TIMP-1. In conclusion, these results suggest that neither of the serum levels of MMP-3 and TIMP-1 could be a good indicator of invasion and metastasis nor can be recommended as a tumor marker in the management of melanoma patients owing to lack of sensitivity and specificity. However, much research still continues in this field and exciting new knowledge will ultimately emerge.

Sentinel lymph node biopsy for the staging of anal melanoma: Report of two cases

Primary melanoma of the anal region is a rare pathological entity and its prognosis is generally poor. The aim of this report is to demonstrate the feasibility of the sentinel lymph node (SLN) procedure with combined technique in patients with anal melanoma. We report of two cases with anal melanoma that had wide local excision of the primary lesion and was referred for further evaluation. After diagnostic metastatic work-up, SLN procedure consisted of a combination of preoperative lymphoscintigraphy with technetium-99m nanocolloid injected around the tumor, and intraoperative detection of SLN with gamma probe (combined technique) was performed. In addition, patent blue dye was injected at the periphery of the tumor to facilitate direct identification of the blue-stained lymph node. In the first case, SLN identified both inguinal and iliac lymph node basins, both of which were histologically negative on both frozen and paraffin sections. In the other case, SLN removed from the inguinal lymph node basin showed micrometastasis by paraffin section. In both cases SLN procedure with combined technique was performed sufficiently without significant complications. Consequently, we suggest that SLN procedure with combined technique is also a useful technique in malignant melanomas similar to other anal canal cancers.

Axillary Arch May Affect Axillary Lymphadenectomy

Background: The aim of this study was to identify the axillopectoral muscle anomaly commonly known as Langers axillary arch, and to understand its importance in surgical procedures of the axilla. Patients and Methods: Between 2009 and 2011, 758 patients underwent sentinel lymph node biopsy, axillary dissection, or both. Patients with Langers axillary arch were identified and assessed retrospectively. The decision to cut or preserve the axillary arch was made based on clinical judgment, and patients were followed-up accordingly to monitor for adverse outcomes. Results: Of the 758 patients who underwent axillary procedures, 9 (1.2%) were found to have a Langers axillary arch. In 2 patients the arch was cut, and in 7 patients it was preserved. No adverse outcomes were identified in any of the patients upon follow-up. Conclusion: Langers axillary arch is a unique anatomic anomaly of the axillary region that may be problematic due to the potential risks of lymphedema and vascular or nerve compression. It is important for surgeons and radiologists alike to be aware of this anatomic variation in order to properly identify it and respond appropriately based on clinical judgment, and to complete close follow-up of the patient due to the potentially increased risk of adverse outcomes.

Can Steroids plus Surgery Become a First-Line Treatment of Idiopathic Granulomatous Mastitis?

Background: The aim of this study is to compare the clinical course of idiopathic granulomatous mastitis (IGM) treated with low-dose oral corticosteroid therapy alone as opposed to treatment with low-dose corticosteroid therapy followed by surgery. Patients and Methods: 37 patients were treated with an approach that consisted of methylprednisolone at a dose of 0.5 mg/kg/day followed by wide excision, and 23 patients were treated with an approach that consisted only of methylprednisolone. The treatment efficacy was compared between the two groups. Results: Clinical and radiological regression was reported in all patients with steroid therapy, and the regression rate had a median of 75% (25-100%). No recurrence was observed in patients who were treated with wide surgical excision after steroid therapy during the median follow-up period of 38 (22-78) months. The control group of 23 patients was treated only with steroid therapy, and 7 (30%) of these patients experienced recurrence in the follow-up period (p < 0.001). Conclusions: Steroid therapy was effective in the treatment of IGM by reducing the lesion size and extent. With regard to the current treatment options available for IGM, surgical excision after steroid therapy seems the better treatment option compared to steroid therapy without surgical excision. This treatment sequence reduces the rate of recurrence.

Successful treatment of triple primary tumor

INTRODUCTION The occurrence of multiple primary tumors is rare. Only limited number of cases with triple malignancy have been reported. We report here a rare case of a woman presented synchronous triple tumors, in her lung, breast, skin. PRESENTATION OF CASE A 56-year-old woman presented with invasive ductal carcinoma of breast, non-small cell lung cancer and malignant melanoma. The patient undergone mastectomy and malignant melanoma tumor excision on-site. After operation stereotactic radiotherapy was given to her lung tumor. Six course of chemotherapy was given to her. She is alive with no progression. DISCUSSION The patient was diagnosed with melanoma and staging by FDG/PET. There is not any study about routine using PET/CT in the melanoma staging. CONCLUSION This is a very rare synchronous triple tumor case.