RESUMEN
PURPOSE: Recurring keloids are a clinical challenge. Interdisciplinary treatments are required in most cases. Owing to the wide variety of concepts, the optimal treatment regime remains unclear. Our clinic established a protocol of perioperative interstitial high-dose-rate brachytherapy with three fractions of 6 Gy and achieved an excellent 2-year local control rate of 94% (In search of the optimal treatment of keloids: Report of a series and a review of the literature). This report is an update on our long-term results of prospective study. Twenty-nine patients were included with a median followup of 5 years. METHODS AND MATERIALS: From 2009 to 2015, 29 patients with 37 recurrent keloids were treated with perioperative interstitial high-dose-rate brachytherapy; 3 patients had been previously treated with adjuvant external beam radiotherapy and presented with recurrences in the pretreated area. Brachytherapy was given in three fractions with a single dose of 6 Gy in 5-mm tissue depth and covered the scar in total length. Followup visits were scheduled at 6 weeks, 3 months, 6 months, 1 year, and annually thereafter. Therapeutic outcome was assessed in terms of recurrence, acute and late complications, and cosmetic results. RESULTS: No procedure-related complications occurred. Improvement of keloid-related symptoms was noticed in all patients after treatment. After a median followup of 49.7 months (range: 7.9-91.9 months), three keloid recurrences and two hypertrophied scars were observed. CONCLUSIONS: Our results suggest that brachytherapy may be advantageous in the management of high-risk keloids, even after failure of external beam radiotherapy and other treatment procedures. Our three-fraction treatment schedule reduces the treatment period to 2 days and is therefore convenient for the patients.
Asunto(s)
Braquiterapia/métodos , Queloide/radioterapia , Adulto , Anciano , Anciano de 80 o más Años , Braquiterapia/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Dosificación Radioterapéutica , Radioterapia Adyuvante/efectos adversos , Radioterapia Adyuvante/métodos , Recurrencia , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
PURPOSE: To prospectively evaluate high-dose-rate brachytherapy in the treatment of therapy-resistant keloids and report first results, with emphasis on feasibility and early treatment outcome. METHODS AND MATERIALS: From 2009 to 2014, 24 patients with 32 recurrent keloids were treated with immediate perioperative high-dose-rate brachytherapy; 3 patients had been previously treated with adjuvant external beam radiation therapy and presented with recurrences in the pretreated areas. Two or more different treatment modalities had been tried in all patients and had failed to achieve remission. After (re-)excision of the keloids, a single brachytherapy tube was placed subcutaneously before closing the wound. The target volume covered the scar in total length. Brachytherapy was given in 3 fractions with a single dose of 6 Gy in 5 mm tissue depth. The first fraction was given within 6 hours after surgery, the other 2 fractions on the first postoperative day. Thus, a total dose of 18 Gy in 3 fractions was administered within 36 hours after the resection. RESULTS: The treatment was feasible in all patients. No procedure-related complications (eg, secondary infections) occurred. Nineteen patients had keloid-related symptoms before treatment like pain and pruritus; disappearance of symptoms was noticed in all patients after treatment. After a median follow-up of 29.4 months (range, 7.9-72.4 months), 2 keloid recurrences and 2 mildly hypertrophied scars were observed. The local control rate was 94%. Pigmentary abnormalities were detected in 3 patients, and an additional 6 patients had a mild delay in the wound-healing process. CONCLUSIONS: The early results of this study prove the feasibility and the efficacy of brachytherapy for the prevention of keloids. The results also suggest that brachytherapy may be advantageous in the management of high-risk keloids or as salvage treatment for failure after external beam therapy.
Asunto(s)
Braquiterapia/métodos , Queloide/radioterapia , Adulto , Anciano , Anciano de 80 o más Años , Profilaxis Antibiótica , Braquiterapia/efectos adversos , Estudios de Factibilidad , Femenino , Humanos , Radioisótopos de Iridio/uso terapéutico , Queloide/cirugía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Dosificación Radioterapéutica , Radioterapia Adyuvante , Recurrencia , Resultado del Tratamiento , Cicatrización de Heridas/efectos de la radiación , Adulto JovenRESUMEN
PURPOSE: Thoracic wall reconstructions have become a standard procedure for the reconstructive plastic surgeon in the larger hospital setting, but detailed reports about long-term results including pulmonary function and physical examination are rare. MATERIALS AND METHODS: The data of 92 consecutive patients with full thickness chest wall resections were acquired from patient's charts and contact to patients, their relatives or general practitioners, with special reference to treatment and clinical course. At a mean follow-up of 5.5 years, 36 patients were examined physically and interviewed. Twenty-seven of them underwent additional pulmonary function tests. Kaplan-Meier method was used to calculate survival. Regression tests were undertaken to identify factors influencing the outcome. RESULTS: Postoperative complications were observed in 42.4%, but neither mesh implantation nor the size of the defect contributed significantly. The 5-year mortality was worse for patients with recurrent mamma carcinoma (90.6%) than for patients with soft tissue sarcoma (56.3%). No medical history or operation parameter (resection size and localization) besides the general patients' conditions increased mortality. Pulmonary function parameters were only moderately reduced and not significantly affected by the resections' size or its localization. Majority of patients suffer from sensation disorders and motion-dependent pain, which contributed significantly to hypoxemia. Quality-of-life parameters were significantly reduced compared to the healthy control group but similar to the control group with cancer according to the Short Form-36 protocol. We could not detect a relevant decrease in quality of life comparing post- to preoperative values. CONCLUSIONS: Thoracic wall reconstruction provides sufficient thoracic wall stability to maintain pulmonary function, but postoperative pain and sensation disorders are considerable. However, chest wall repair can contribute to palliation and even cure after full-thickness resections.
Asunto(s)
Neoplasias Óseas/cirugía , Neoplasias de la Mama/cirugía , Procedimientos de Cirugía Plástica/métodos , Sarcoma/cirugía , Pared Torácica/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Niño , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/cirugía , Prótesis e Implantes , Calidad de Vida , Pruebas de Función Respiratoria , Colgajos Quirúrgicos , Infección de la Herida Quirúrgica/epidemiología , Adulto JovenRESUMEN
Porous PEGT/PBT implants with different physico-chemical characteristics were evaluated to identify its potential as biodegradable and biofunctional soft tissue filler. Implants (50 x 10 x 5 mm3) were implanted subcutaneously in mini-pigs and tissue response, tissue volume generated and its consistency were assessed quantitatively with a 52 weeks follow-up. The absence of wound edema, skin irritation, and chronic inflammation demonstrated biocompatibility of all implants evaluated. The hydrophobic implants induced the mildest foreign body response, generated highest amount of connective tissue and demonstrated a decrease in copolymer MW of 34-37% compared to 90% decrease of the hydrophilic implants. The rate and extent of copolymer fragmentation seems to be the determining factor of success of soft tissue augmentation using porous PEGT/PBT copolymer implants.
Asunto(s)
Implantes Absorbibles , Materiales Biocompatibles/química , Tejido Conectivo/cirugía , Tejido Conectivo/ultraestructura , Regeneración Tisular Dirigida/instrumentación , Poliésteres/química , Polietilenglicoles/química , Animales , Materiales Biocompatibles/efectos adversos , Diseño de Equipo , Análisis de Falla de Equipo , Regeneración Tisular Dirigida/efectos adversos , Regeneración Tisular Dirigida/métodos , Estudios Longitudinales , Ensayo de Materiales , Poliésteres/efectos adversos , Poliésteres/uso terapéutico , Polietilenglicoles/efectos adversos , Polietilenglicoles/uso terapéutico , Porosidad , Porcinos , Porcinos EnanosRESUMEN
Sclerosing (pseudovascular) rhabdomyosarcoma in adults has been described as a rare variant of rhabdomyosarcoma characterized by extensive hyaline fibrosis and pseudovascular growth patterns. We describe another case of this rhabdomyosarcoma subtype including ultrastructural and genetic findings-the lesion presented in a 62-year-old male patient in the left lower leg. The tumor was located within the deep soft tissue with maximum diameter of 11.8 cm and skin ulceration. Ultrastructural analysis revealed irregularly distributed disorganized filaments without clear evidence of Z-bands and a richly collagenized matrix. Using comparative genomic hybridization, a sharply delineated loss of chromosomal region 10q22, loss of chromosome Y, and a gain of chromosome 18 (trisomy) were detected. Reciprocal translocations t(1;13) and t(2;13)(q35;q14) which are characteristic of alveolar rhabdomyosarcoma could be excluded. These findings, while showing a relation to other rhabdomyosarcoma subtypes, represent a relatively circumscribed genetic defect pattern in sclerosing (pseudovascular) rhabdomyosarcoma that is somewhat different from patterns described in most other rhabdomyosarcoma subtypes. Six months after tumor resection, the patient presented with metastatic disease. Further studies should concentrate on the identification of genes especially on chromosomal region 10q22 to elucidate more aspects in the pathogenesis of this rhabdomyosarcoma subtype.
Asunto(s)
Aberraciones Cromosómicas , Rabdomiosarcoma/patología , Neoplasias de los Tejidos Blandos/patología , Cromosomas Humanos Par 10 , Humanos , Inmunohistoquímica , Masculino , Persona de Mediana Edad , Hibridación de Ácido Nucleico , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Rabdomiosarcoma/química , Rabdomiosarcoma/genética , Rabdomiosarcoma/ultraestructura , Esclerosis , Neoplasias de los Tejidos Blandos/química , Neoplasias de los Tejidos Blandos/genética , Neoplasias de los Tejidos Blandos/ultraestructuraRESUMEN
Changes in hematopoiesis that occur in humans after a burn injury may have important effects on morbidity and mortality. In patients with a variety of severe diseases, the presence of erythroblasts in peripheral blood is known to be indicative of a poor prognosis. However, the prognostic significance of erythroblasts in peripheral blood of burn patients has not yet been estimated. This study included 464 consecutive burn patients, of whom 81 did not survive their injuries (17.5 percent). Together with erythroblasts in blood, data on age, sex, total burn surface area, third-degree burn, inhalation trauma, white blood cell count, C-reactive protein, and hemoglobin were studied. The mortality rate of patients with erythroblasts in peripheral blood (n = 53) amounted to 56.6 percent (n = 30; total burn surface area, 39 percent), which is significantly higher (p < 0.001) than the mortality rate of patients without erythroblasts (12.4 percent, n = 51; total burn surface area, 18.69 percent). None of the 10 patients with more than 1000 erythroblasts x 10/liter survived. The detection of erythroblasts in the peripheral blood of burn patients is highly predictive of death, with the odds ratio after adjustment for the other known prognostic factors being 8.3 (95 percent confidence interval, 4.5 to 15.3). Erythroblasts were detected for the first time on average 10 +/- 4 days (median, 6 days) after admission and 13 +/- 6 days (median, 7 days) before death. Detection of erythroblasts in burn patients is of high prognostic power with regard to in-hospital mortality, providing physicians with a strong prognostic method with which to identify seriously threatened patients. It seems attractive to think about an incorporation of erythroblasts into further refinements of burn scores.
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Recuento de Células Sanguíneas , Quemaduras/sangre , Quemaduras/mortalidad , Eritroblastos/fisiología , Adulto , Anciano , Quemaduras/fisiopatología , Quemaduras por Inhalación/sangre , Quemaduras por Inhalación/mortalidad , Proteína C-Reactiva/análisis , Femenino , Alemania/epidemiología , Hematopoyesis , Hemoglobinas/análisis , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Valor Predictivo de las Pruebas , Pronóstico , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
The development of Fournier's gangrene after Milligan-Morgan hemorrhoidectomy of a previously healthy 76-year-old female patient is described. After such a common surgical procedure, the patient developed full-thickness skin necrosis of the perianal region including the rectum. Immediate radical debridement was mandatory. Because of rectal involvement, a diverting sigmoid colostomy was required. The rectum had to be removed by abdominoperineal resection. This disastrous complication was completely unexpected and unpredictable after Milligan-Morgan hemorrhoidectomy because of the lack of predisposing factors.
Asunto(s)
Gangrena de Fournier/etiología , Hemorroides/cirugía , Recto/cirugía , Infección de la Herida Quirúrgica , Anciano , Canal Anal/patología , Anastomosis Quirúrgica , Colostomía , Desbridamiento , Femenino , Gangrena de Fournier/patología , Humanos , Necrosis , Recto/patologíaRESUMEN
The recovery of skin function is the goal of each burn surgeon. Split-skin graft treatment of full-thickness skin defects leads to scar formation, which is often vulnerable and instable. Therefore, the aim of this study was to analyze wound healing and scar tissue formation in acute full-thickness wounds treated with clinically available biopolymer dermal regeneration templates. Full-thickness wounds (3 x 3 cm) on both flanks of Gottingen mini pigs (n= 3) were treated with split-thickness skin graft alone or in combination with a 1-ethyl-3-(3-dimethylaminopropyl)-carbodiimide (EDC) cross-linked-collagen scaffold, Integra, or a polyethyleneglycol terephthalate-polybutylene terephthalate (PEGT/PBT) scaffold. The wounds (n= 12 per group) were examined weekly for six weeks to evaluate graft take, contraction (planimetry), and cosmetic appearance. Histologic samples taken after one and six weeks were used to assess scaffold angiogenesis, biocompatibility, and scar tissue quality. In all wounds, one week postwounding graft take was between 93 and 100 percent. The control wound, treated with split-skin graft, showed little granulation tissue formation, whereas the EDC-collagen treated wounds showed two to three times more granulation tissue formation. The collagen scaffold was completely degraded within one week. The Integra and PEGT/PBT scaffolds showed angiogenesis only through two-thirds of the scaffold, which resulted in loss of integrity of the epidermis. Only basal cells survived, proliferated, and regenerated a fully differentiated epidermis within three weeks. Granulation thickness was comparable to collagen scaffold-treated wounds. After six weeks, control wounds showed a wound contraction of 27.2 +/- 6.1 percent, Integra-treated wounds 34.6 +/- 6.4 percent, collagen scaffold-treated wounds 38.1 +/- 5.0 percent, and PEGT/PBT scaffold-treated wounds 54.5 +/- 3.9 percent. The latter wounds had significantly more contraction than wounds of other treatment groups. Microscopically, the control and collagen scaffold-treated wounds showed an immature scar tissue that was two times thicker in the EDC-collagen treated wounds. The Integra-treated wounds showed nondegraded collagen scaffold fibers with partly de novo dermal tissue formation and partly areas with giant cells and other inflammatory cells. The PEGT/PBT scaffold was almost completely degraded. Scaffold particles were phagocytosized and degraded intracellularly by clusters of macrophages. The scar tissue was in the early phase of ECM remodeling. In conclusion, this study showed that the rate of dermal tissue formation and scarring is influenced by the rate of scaffold angiogenesis, degradation, and host response induced by the scaffold materials.
Asunto(s)
Cicatriz/patología , Piel Artificial , Heridas y Lesiones/patología , Heridas y Lesiones/cirugía , Animales , Vendajes , Modelos Animales de Enfermedad , Femenino , Inmunohistoquímica , Masculino , Apósitos Oclusivos , Probabilidad , Distribución Aleatoria , Factores de Riesgo , Sensibilidad y Especificidad , Fenómenos Fisiológicos de la Piel , Trasplante de Piel/métodos , Porcinos , Cicatrización de Heridas/fisiologíaRESUMEN
Poly(ether ester) block-copolymer scaffolds of different pore size were implanted into the dorsal skinfold chamber of balb/c mice. Using intravital fluorescent microscopy, the temporal course of neovascularization into these scaffolds was quantitatively analyzed. Three scaffold groups (diameter, 5 mm; 220-260 thickness, microm; n = 30) were implanted. Different pore sizes were evaluated: small (20-75 microm), medium (75-212 microm) and large pores (250-300 microm). Measurements were performed on days 8, 12, 16, and 20 in the surrounding normal tissue, in the border zone, and in the center of the scaffold. Standard microcirculatory parameters were assessed (plasma leakage, vessel diameter, red blood cell velocity, and functional vessel density). The large-pored scaffolds showed significantly higher functional vessel density in the border zone and in the center (days 8 and 12) compared with the scaffold with the small and medium-sized pores. These data correlated with a larger vessel diameter and a higher red blood cell velocity in the large-pored scaffold group. Interestingly, during the evaluation period the microcirculatory parameters on the edge of the scaffolds returned to values similar to those found in the surrounding tissue. In the center of the scaffold, however, neovascularization was still active 20 days after implantation. Plasma leakage and vessel diameter were higher in the center of the scaffold. Red blood cell velocity and functional vessel density were 50% lower than in the surrounding tissue. In conclusion, the dorsal skinfold chamber model in mice allows long-term study of blood vessel growth and remodeling in porous biomedical materials. The rate of vessel ingrowth into poly(ether ester) block-copolymer scaffolds is influenced by pore size and was highest in the scaffold with the largest pores. The data generated with this model contribute to knowledge about the development of functional vessels and tissue ingrowth into biomaterials.