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BACKGROUND: The clinical relevance of RT-PCR positivity for melanoma markers in the sentinel node remains controversial. Our purpose was to determine whether patients with a histologically negative but RT-PCR positive node were at an increased risk for recurrence than their RT-PCR negative counterparts. METHODS: Thirty-nine adult patients underwent sentinel node biopsies for melanoma between 1998 and 2000. Each sentinel node was bivalved. Half was serially sectioned and examined by routine hematoxylin and eosin (H&E) and immunohistochemistry (IHC; S100, HMB-45, melanA, and tyrosinase). The other half was analyzed by a nested RT-PCR assay for tyrosinase. RESULTS: Patients were followed for recurrence with a mean follow-up of 71.1 months. The odds ratio of recurrence for RT-PCR positive versus RT-PCR negative patients was 1.39 (0.34, 5.62; p = 0.73). Within the histology negative subgroups, the risk of recurrence in the RT-PCR positive group (26.7%) was not significantly different from the risk of recurrence in the RT-PCR negative group (22.2%) (p = 0.33 chi-squared). RT-PCR of the sentinel node was not a predictor for recurrence on multivariate analysis (p = 0.65). CONCLUSION: Sentinel node RT-PCR positivity did not risk stratify histologically negative melanoma patients beyond routine pathologic examination in this series.

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BACKGROUND AND OBJECTIVES: Neoadjuvant protocols in the management of upper extremity sarcoma have improved local control rates but have been associated with high complication rates. We present a refinement of the Eilber protocol using judicious preoperative chemoradiation, limb salvage surgery, and flap coverage to achieve high local control rates with acceptable wound healing complications. METHODS: Patients presenting with upper extremity neoplasms from 1986 to 2002 were treated with a modified Eilber protocol, consisting of 3 days of adriamycin (30 mg/day) and sequential radiotherapy (300 cGy/day for 10 days). Limb salvage surgery with flap coverage where needed was performed 4-8 weeks later. Patients were followed prospectively for recurrence. RESULTS: Fifty-three consecutive patients with upper extremity tumors were treated and followed for a mean of 6.1 years. This cohort included 44 sarcomas and nine non-metastasizing, locally aggressive tumors. There were two local recurrences (3.8%). Limb salvage was achieved in all patients. Flaps were required in 43.4% of patients. Major complications occurred in 11%, were all flap related (partial flap loss, venous congestion), and went on to heal promptly with treatment. CONCLUSION: This modified Eilber protocol achieved 96% local control for upper extremity tumors with a wound complication rate of 11%. The liberal use of flaps of resulted in healed, stable wounds in all patients.

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The latissimus dorsi (LD) muscle has been previously described to repair diaphragmatic defects, but as a "reverse" flap, relying on secondary blood supply from the perforating lumbar vessels rather than primary inflow from the dominant thoracodorsal artery. We report resection of a retroperitoneal synovial sarcoma, with reconstruction of the hemidiaphragm using the LD rotated on its primary neurovascular bundle. By using the dominant pedicle, the vascularity of the flap is improved, minimizing the chance of flap tip loss. Maintaining an intact nerve supply prevents atrophy. As the distal origin of the LD is broad and flat, it is ideally suited for diaphragm repair. A latissimus-sparing thoracotomy incision is required to enable this method of diaphragm reconstruction.

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One potential cause of suboptimal results after nerve repair is disruption or gapping of the neurorrhaphy in the postoperative period. This study assesses the biomechanical strength of five nerve repair techniques: fibrin glue, simple epineurial sutures, and three other novel neurorrhaphy methods. Fifty rabbit sciatic nerve segments were divided and repaired utilizing one of five different methods, producing five groups of ten specimens. Fibrin glue and four epineurial suture techniques (simple, horizontal mattress, "Tajima," "Bunnell") were employed. Repaired nerve segments were ramp-loaded to failure on an Instron 8300 materials-testing machine at a displacement rate of 5 mm/min. Gapping at the repair site was captured using high-resolution video. Differences among the five groups were assessed for significance using ANOVA and Fisher's protected least squares differences post-hoc testing. The mean force to produce disruption was higher for mattress suture repairs relative to simple repairs, but not significantly so (p = 0.31). Both were significantly stronger than fibrin glue repairs (p < 0.0001). "Tajima" and "Bunnell" repairs were both statistically stronger than glue (p < 0.0001), simple (p < 0.0001), or mattress (p = 0.0004) repairs, but not significantly different from one another (p = 0.48). Data for gapping at the repair site were similar with all suture techniques outperforming fibrin glue (p = 0.003). "Bunnell" repairs demonstrated the most resistance to gapping, compared to glue (p < 0.0001), simple (p = 0.0001), mattress (p = 0.007) and "Tajima" repairs (p = 0.01). These data demonstrate that repairs done utilizing fibrin glue are significantly weaker than all types of suture repairs. Two novel techniques for nerve repair (epineurial "Tajima" and "Bunnell") are significantly more resistant to disruption and gapping. Further evaluation to assess the effect of these repair techniques on function is required.

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Although the time required for a nerve to gain sufficient strength to withstand normal physiologic forces of joint motion is unknown, typically nerve repairs are protected up to 3 weeks postoperatively. The authors investigated the mechanical strength of a nerve repair as a function of time. Fifty adult Sprague-Dawley rats underwent sciatic nerve division and repair, and were sacrificed in groups of 10 at 0, 1, 2, 4, and 8 weeks. Repaired nerves were then mechanically loaded at 5 mm/min to failure. Gapping across the repair site was captured on high-resolution video. The contralateral sciatic nerve served as a control. A significant increase in tensile strength was gained between 0 and 1 week and between 2 and 4 weeks. Healing nerves achieved 63 percent of the strength of the control by 8 weeks. Controls showed no gain in strength over the testing period. Gapping occurred at lower forces at all time increments. From 0 to 1 week, a significant increase in load necessary to produce gapping was found, which did not increase significantly again until 8 weeks. These results may have implications for postoperative rehabilitation protocols in patients with nerve injuries.

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STUDY DESIGN: The use of vacuum-assisted therapy to close upper thoracic and thoracolumbar spinal wounds was studied retrospectively. Two patients whose wounds failed conservative management were successfully treated by negative pressure therapy. OBJECTIVES: The authors evaluated the efficacy of applying vacuum therapy on patients with exposed spinal hardware and summarized current knowledge about this treatment. SUMMARY OF BACKGROUND DATA: Vacuum therapy was applied three times on two patients. METHODS: Success was defined as a stable, closed wound that required no future surgery and had no signs of chronic infection. RESULTS: Both patients' wounds were closed successfully and have received follow-up treatment for up to 10 months with no sign of recurrence. CONCLUSIONS: The cases illustrate the usefulness of vacuum-assisted therapy as an adjunct in closing complex back wounds with exposed spinal hardware. In the authors' experience, it helps establish a soft tissue envelope for wound healing and simplifies the need for future surgery.

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Nodal metastases in patients with melanoma identify a reduction of survival by 50%; however, elective lymph node dissection (ELND) has not been shown clearly to improve survival. Morton's technique of sentinel node biopsy, using preoperative lymphoscintigraphy and intraoperative blue dye, addresses elegantly the controversy regarding ELND. Sentinel node biopsy has been shown to stage the patient accurately because metastases from melanoma follow an orderly progression from the sentinel node to the remainder of the basin. Fifty-six consecutive patients with American Joint Committee on Cancer stage 1b or 2 melanoma seen at the London Health Sciences Center between July 1998 and January 2000 were enrolled prospectively to undergo sentinel node biopsy. Preoperative lymphoscintigraphy was conducted in the nuclear medicine department. A total of 10 to 15 MBq (0.27-0.41 mCi) of technetium 99m (99mTc) rhenium colloid or filtered sulfur colloid was injected intradermally around the biopsy scar. Images were obtained to localize all draining nodal basins. The location of the sentinel node was marked on the skin. The patient was taken to the operating room and anesthetized. Isosulfan blue dye was injected intradermally around the biopsy scar. A hand-held gamma probe was used intraoperatively as a guide to the first draining node. Blue-stained lymphatic channels aided in the dissection. Sentinel node localization was successful in 55 of 56 patients, for an overall success rate of 98%. Preoperative lymphoscintigraphy identified a sentinel node in an unpredictable location in 32% of patients. On average, 2.3 sentinel nodes per patient were identified on the initial scan, and 2.2 sentinel nodes per patient were recovered at surgery. Both 99mTc rhenium and filtered sulfur colloid showed no substantial differences in tracer uptake and retention in the sentinel node. Twelve patients had a positive sentinel node on routine histology, and 11 patients subsequently underwent completion lymphadenectomy. The mean thickness of the primary melanoma in the 12 patients with positive sentinel nodes was 3.7 mm compared with a mean tumor thickness of 1.8 mm in the remaining 41 patients with negative biopsies (p = 0.0003). Two patients experienced recurrence in a regional basin after negative pathological evaluation of the sentinel node. Reverse transcription-polymerase chain reaction analysis of both of these patients was positive. Two patients are alive with metastatic disease and 54 patients are alive without disease, with a mean follow-up of 1 year (range, 2-24 months). Complications occurred at a substantially higher rate (45%) after completion lymphadenectomy than after sentinel node biopsy alone (9%). Sentinel node biopsy is a feasible technique with a high success rate (98%), but it requires a multidisciplinary approach. This study validates the clinical usefulness of 99mTc rhenium colloid for lymphoscintigraphy.

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Pneumomediastinum as a consequence of injection injury to the hand has not been previously reported. We present a 22-year-old male who developed pneumomediastinum when a high pressure hose injected air into his hand. The anatomic continuity between peripheral ulnar neurovascular bundle and the hilar vessels provided the route for air entering the hypothenar eminence to penetrate the mediastinum. After ruling out life-threatening causes of pneumomediastinum such as esophageal perforation, his management included observation and serial radiographs. By one week there was complete resolution of the mediastinal air. This report demonstrates that pneumomediastinum may be associated with air injection injury of the hand, and that expectant management is appropriate.

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The belief that breast hypesthesia is an expected consequence of reduction mammaplasty is based on past reports that failed to objectively quantify breast sensibility. Forty-five women undergoing reduction mammaplasty by one plastic surgeon using a single operative technique were followed prospectively for change in breast sensation. Pressure threshold measurements were taken preoperatively and at 2 and 6 weeks postoperatively, by using Semmes-Weinstein monofilaments. Areas tested included the nipple, four points on the areola, and four points 1 cm from the areola on the breast skin. The data were nonparametric and were analyzed by using the Wilcoxon signed rank test. For all areas tested, sensation significantly improved from preoperatively to 2 weeks (i.e., nipple: 33.1 versus 29.3, p<0.0004) and again from 2 to 6 weeks (i.e., nipple: 29.3 versus 19.3, p<0.002). Relief of chronic nerve traction injury is conjectured as the reason for sensibility improvement. Numb nipples persisted in 2 percent of breasts at 6 weeks.

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BACKGROUND: 1994 marked a decade since the inception of a prospective population-based study on the value of neoadjuvant approach for soft tissue sarcomas of head, neck, and limbs at the Tom Baker Cancer Centre, Calgary, Alberta. To date, 42 patients have been followed for a minimum of 5 years or until death. METHODS: Each patient received a protocol of 60 mg to 90 mg of Adriamycin infused intra-arterially or intravenously over 3 days into a vessel feeding the involved area, 30 Gy of radiotherapy given over 10 days, and complete resection of the sarcoma 4 to 6 weeks later. The lower dose was used empirically for smaller limbs (e.g., arm). RESULTS: Two of the 42 patients were immediate failures of protocol, with one requiring amputation and one requiring later reexcision. In the 38 appendicular lesions, the ultimate limb salvage rate was 97.5%. All tumors were associated with a high risk of local recurrence with 15 being previous local failures. The rest were deep and grade 2 or 3 lesions. Serious local complications were seen in one patient (2.5%) who had wound necrosis requiring reoperation. Minor wound complications were seen in five patients (12.5%) (one wound infection, one resolved edema, three long-term drainage). There was one local recurrence; thus 5-year local control was 97%. No patient had long-term morbidity related to the treatment. No effect on systemic control was suggested. CONCLUSION: Our report demonstrates that this combined modality approach provides superior local control of soft tissue sarcomas with low postoperative morbidity.

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OBJECTIVE: The authors relate prehospital delay and in-hospital delay to the incidence of perforation of appendicitis. SUMMARY BACKGROUND DATA: Quality assurance studies use perforation rate as an index of quality of care. This is based on the assumption commonly presented in retrospective reports that in-hospital delay to surgery influences the incidence of perforation. Only one limited study prospectively found that prehospital delay increased the perforation rate. METHODS: During a 6-month period, 95 consecutive adults undergoing appendectomies at Foothills Hospital in Calgary, Alberta, were questioned as to onset and type of first symptom (i.e., epigastric discomfort, anorexia nervosa, vomiting, and abdominal pain). Time of emergency room (ER) arrival, surgery consultation, and operating room start were taken from the chart. Surgical and pathology reports were used to identify status of appendix (normal, inflamed, suppurative, gangrenous, perforated) and presence of abscess cavity. The status of appendix was related to prehospital and in-hospital delay to establish significance. RESULTS: There were 13 (14%) normal, 67 (70%) inflamed, and 15 (16%) perforated appendices. Patients with perforated appendices waited 2.5 times longer before reporting to the ER, compared with patients with inflamed appendices (57 hours vs. 22 hours, p < 0.007). Once in the hospital, patients with perforated appendices were identified and treated faster than those with inflamed appendices (7 vs. 9 hours, p < 0.039). Analysis by ER physician was 3 hours whether the appendix was normal, inflamed, or perforated. Analysis by the surgeon was significantly shorter in patients with perforated appendices than patients with inflamed appendices (4 vs. 6 hours, p < 0.039). CONCLUSIONS: This prospective study identifies that delay in presentation accounts for the majority of perforated appendices. Clinical evaluation is effective for identifying patients with more advanced disease. Indiscriminate appendectomy as an attempt to decrease perforation is not supported by these data. Hospital perforation rates likely reflect patient factors, illness attitude, and access to medical care.

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