Vygintas Kaikaris

Measurement of melanoma thickness ― comparison of two methods: Ultrasound versus morphology

OBJECTIVE The aim of our study was to investigate the association between non-invasive ultrasound examination and morphologic test results in the measurement of cutaneous melanoma thickness influencing surgical treatment strategy. METHODS Our prospective clinical study has been conducted in the Clinic of Plastic and Reconstructive Surgery of Kaunas University of Medicine Hospital (KUMH) since January 2004 until October 2008. A total of 100 patients with a clear clinical diagnosis of stage I-II cutaneous melanoma were enrolled in this study. Melanoma depth was measured using a linear 14-MHz frequency ultrasound sensor (Toshiba Xario XG). Surgically removed fragments of skin-subcutaneous tissue were fixated using 10% formalin solution in the operating theatre, and sent to KUMH Clinic of Pathological Anatomy. The most informative sections were analysed for tumour thickness, according to Breslow, as well as tumour type, vascular and lymphatic invasion and dissemination. A comparative data analysis of melanoma thickness measured by ultrasound (T) preoperatively and histologically estimated cutaneous melanoma (CM) thickness according to Breslow (pT) using the Bland-Altman method was performed. RESULTS Higher mean difference of melanoma thickness (60 μm) between T and pT measurements was found when tumour thickness matched pT1 and pT2 categories. In cases of CM depth exceeding 2mm, mean difference of measurements between CM thickness determined by ultrasound and histological examination was lower (30 μm). Data regression analysis showed that correlation between T and pT measurements was lower when CM was thinner (1-2 mm) (Pearsons correlation coefficient, r: 0.283). In cases of thicker melanoma (>2 mm), strong and statistically significant (p<0.0001) correlation (r: 0.869) was observed. CONCLUSIONS Correlation between melanoma thickness measured using a linear 14-MHz frequency ultrasound sensor and histologically estimated melanoma thickness according to Breslow was lower if melanoma was thinner (1-2 mm). However, in cases of thicker melanoma (>2 mm), very strong correlation between measurements was observed.

Sentinel lymph node biopsy for high-risk cutaneous squamous cell carcinoma: Analysis of recurrence-free survival.

BACKGROUND AND AIM Cutaneous squamous cell carcinoma (CSCC) is a malignant epithelial cell tumor. CSCC has a tendency to spread via lymphogenic pathway. Metastases are found in 2%-6% of cases. Prognosis of patients with CSCC is directly related to the morphology and localization of primary tumor. The aim of this study was to evaluate the recurrence-free survival of patients with CSCC after tumor excision and SLNB as well as to analyze morphologic CSCC features related to patient recurrence-free survival. MATERIALS AND MATERIALS A retrospective analysis of 51 patients with CSCC, who underwent surgical treatment between January 1, 2012, and December 31, 2014, in the Clinic of Plastic and Reconstructive Surgery, Hospital of the Lithuanian University of Health Sciences, was done. The diagnosis of CSCC was verified on a histological examination, and all patients had no clinical evidence of nodal or distant metastases on a physical examination or imaging studies. Sentinel lymph node biopsy (SLNB) was performed for low- and high-risk CSCC patients. RESULTS A total of 51 patients were enrolled into the study (34 women and 17 men). Total of 68 lymph nodes were removed during sentinel lymph node biopsy. No micrometastases were identified. Until April 1, 2015, no relapse event was documented. The mean time after operation was 27.5 months. During the follow-up period, no distant metastases were identified. CONCLUSIONS No patient who had no micrometastases in sentinel lymph nodes developed local and distant CSCC metastases during the follow-up period. Our report supports the concept that SLNB can be applied for CSCC. It is obvious that larger prospective studies with longer follow-up period are needed to establish the efficacy of SLNB and define the optimal treatment of occult nodal metastasis for CSCC.

Free musculocutaneous and muscle flaps for foot reconstruction: a clinical and gait analysis study

Abstract Between 1986 and 1995, 48 microvascular flaps (14 fasciocutaneous, 13 muscle, and 21 musculocutaneous) were performed on 47 patients with foot defects. The study group consisted of 19 patients who successfully underwent weightbearing surface reconstruction with free musculocutaneous flaps or muscle flaps with a skin graft. The groups were identified on the basis of the free flap used. Group 1: Latissimus dorsi musculocutaneous flaps (11 patients); group 2: Skin grafted muscle flaps (8 patients: latissimus dorsi - 6, gracilis - 1, rectus abdominis - 1). The follow-up period was 1–11 years (average: 8.3 years). Follow-up included documentation of foot pain, presence of ulceration, sensory recovery, the ability to wear normal shoes, and the need for a second operation. In group 1, debulking operations were necessary (8 patients, 72.7%). Debulking was not required in group 2. Ulceration occurred in four (36.4%) group 1 patients and in one (12.5%) group 2 patient. All patients had good deep pressure sensation. All the group 2 patients could wear normal shoes. Four (36.4%) of the group 1 patients had to wear special orthopedic shoes. The gait analysis consisted of two parts: footprint analysis with the Harris mat technique and plantogram of Parotec system by Kraemer. Foot analysis with the Harris mat showed that the pressure on the muscle flap is less than the pressure on the musculocutaneous flap. Gait analysis by the Parotec system showed that in patients with musculocutaneous flaps, static load distribution on the reconstructed bare foot is nearly normal, but dynamic load distribution is pathological. In patients with muscle flaps, both static and dynamic load distribution were close to normal.

Importance of sentinel lymphatic node biopsy in detection of early micrometastases in patients with cutaneous squamous cell carcinoma

BACKGROUND Cutaneous squamous cell carcinoma (CSCC) is the second most common malignant skin cancer with a tendency to spread through the lymphogenic pathway. Metastases are found in 2-6% of cases. The aim of this study was to determine CSCC micrometastases when non-invasive examination methods do not detect them. METHOD A total of 88 patients were included in the study with clinically diagnosed, histologically confirmed CSCC and no distant or regional lymph node metastases detected during instrumental tests. The patients were grouped into low- and high-risk CSCC groups. They underwent one-stage surgery - radical tumour excision and sentinel lymph node/nodes biopsy (SLNB). Significance level of 0.05 was chosen for testing statistical hypotheses. RESULTS One hundred and fifty-three sentinel lymph nodes (SLNs) were detected and excised in 88 patients. Micrometastases were found in five SLNs of three patients with high-risk CSCC. The rate of micrometastases was 3.4%; however, in the high-risk group it was 6.5%. The mean diameter of CSCC with micrometastases in SLN was 5.6 ± 3.5 cm, and that without micrometastases was 1.5 ± 1.1 cm (p = 0.003). The depth of CSCC according to Breslow in the patients with detected micrometastases in SLN was 3.5 ± 1.2 mm, and that without detected micrometastases was 2.2 ± 1.4 mm (p = 0.047). Patients with micrometastases in sentinel lymphatic nodes underwent radical lymphadenectomy. There was neither recurrence of CSCC metastases in regional lymph nodes nor distant metastases during the research period detected. CONCLUSIONS In patients with CSCC the rate of micrometastases directly correlates with the depth and diameter of the tumour. In patients with high-risk CSCC the rate of micrometastases is 6.5%.