April 1985, Volume 35, Issue 4

Special Communication

Selected Abstracts

Are Pinch Grafts of Historical Jnterest Only?  D.F.M.Cochran and J.C. McGregor. J.R. Coll. Surg. Ed/nb., 1982, 27: 204-208.
ADMITTING that pinch grafts should not be used indiscriminately and that more conventional techniques should be used first, the authors present a retrospective 15 year review of 96 patients who have undergone pinch grafting. Most of the wounds treated thusly were gravitational wounds of the lower extremity, and many were instances in which split grafts had failed. While conceding that appearances of the recipient site were not aesthetically pleasing, the use of elliptically excised and closed groin donor sites were said to minimize their aesthetic morbidity. Patients which a paucity of suitable donor site tissue, such as those with subtotal body surface burns, psoriasis or neurofibrornatosis, are cited as ideal candidates.
John Bostwick III

Metastasis from Squamous Cell Cancer of the Extremities. Frederick C. Ames and Robert C. Hickey. South. Med. J. 1982, 75: 920-923.
THIRTY-FIVE THOUSAND PATIENTS with carcinoma of the skin were treated at M.D. Anderson Hospital and Tumor Institute in Houston from 1944 to 1976; 1, 118 had localized squamous cell carcinoma of the skin of the extremities. Only 16 of these patients, 1.4 per cent, later had distant metastases develop,; an additiona 90 patients were first seen when metastases developed after treatment elsewhere for the primary lesion. Thirty per cent of these 106 patients had associated conditions predisposing to a malignant condition, including thermal burns in 11 patients and radiation dermatitis in six. Thirty patients, 20 per cent, had a second instance of carcinoma of the skin, and eight patients 8 percent had visceral carcinoma in addition to the carcinoma of the skin that metastasized. Seventy-eight patients had lesions of the hand or fingers, eight had lesions of the arm, and 20 had lesions of the lower extremities. Forty-two patients had local failure of treatment of the primary lesion at some time. The most common sites of first distant metastases were the skin of the trunk; adjacent extraregional nodes and the ribs. Ninety-eight per cent of the recurrences were noted within 36 months. The over-all five year crude survival rate was 14 per cent, and the actual survival rate was 39 per cent, results which are compatible with those associated with squamous cell carcinoma of the head and neck. Several patients underwent radiation therapy.
It is concluded that successful initial treatment is important to reduce the incidence of metastases and that close follow-up visits during the first 36 months after operation are important. The authors believe that adequate dissection of the lymph nodes, with adjuncitive radiation therapy of at least 5,000 rads in five weeks, is beneficial.
Bruce M. Achauer

Malignant Melanoma and Exposure to Fluorescent Lighting at Work. Valerie Beral, Susan Evans, Helen Shaw and Gerald Milton. Lancet, 1982, 2: 290-293.
RESULTS of this study of 274 female patients with melanoma and control patients demonstated that those exposed to fluorescent light had a greater relative risk for having melanoma develop. Although a twofold increase in risk was associated with any exposure to fluorescent light, office workers were more at risk than others. Paradox ically, those who were exposed to fluorescent light had a relative cxcess of lesions of the trunk. Measures of the exposure to sunlight, which has a broader spectrum of ultraviolet light than fluorescent light, failed to reveal any consistent relation to risk for melanoma. Although the postulated association between melanoma and exposure to fluorescent light is plausible, the authors caution that these results must be viewed cautiously.
John Bostwick III

The Evolution of Techniques for Reconstruction of Full Thickness Cheeck Defects. Juris Bunkis, John B. Mulliken. Joseph Upton and Joseph E. Murray. Plast. Reconstr. Surg., 1982, 70: .319-327.
A RETROSPECTIVE ANALYSIS of 17 patients treated for fulithickness defects of the cheek during a 21 year period is presented to illustrate the change in methods of reconstruction used. Random tube flap reconstruction required an average of 11 operations, 11 8 days in the hospital and eight admissions during a period of 18 months Later reconstructions done with axial pattern flaps required three operations, 45 hospital days and two admissions during a period of two months The authors also present a modification of the latissimus dorsi flap which allows a one-stage, watertight closure of through and through defects of the cheek.
Robert G. Brown

Controlled Trial of the Antigonadotropin Danazol in Painful Nodular Benign Breast Disease.R.E. Mansel, J.R. Wisbey and L.E. Huges Lancet, 1982, 1: 928-930.
IN THIS REPORT, the authors describe the results of a doubleblind crossover study of the effects of two dose levels of danazol in 28 women with cyclical mastalgia. Objective and subjective responses were recorded for all women, including those who received placebo. It was found that, compared with the placebo, danazol produced a significant and progressive decrease in pain and nodularity in the breast. The testing period lasted six months, and a 21 per cent dropout rate occurred. The principal side-effects of danazol were weight gain and irregular menstruation. it is concluded that danazol is useful for suppressing symptoms related to severe, hormone dependent, benign disease of the breast.
Joseph A. Caprini

Predicting the Risk of Cancer at the Time of Breast Biopsy; Variation in the Benign to Malignant Ratio. Gary H. Spivey, bruce W. Perry, Vigginia A. Clark and others. Am. Suig., 1982, 48: 326-332.
BASED upon the results of approximately 7,200 biopsies of the breast, the risk of the results of such a biopsy showing malignant disease may be assessed more realistically. In evaluating the data, the authors examined a number of variables. including race, socioeconomic status and age. The risk of malignant findings from biopsy was lower ip the group of Hispanic patients. Age, however, was the most significant factor in predicting the ratio of benign-to-malignant findings from biopsy of the breast. These age groupings reflect the risk of results of biopsy of the breast revealing a malignant condition: 20 to 29 years, I per cent; 30 to 39 years, 9 per cent; 40 to 49 years, zu per cent; 50 to b9 years, 3/ per cent; 60 to 69 years, 60 per cent. 70 to 79 years, 64 per cent, and 80 to 89 years, 70 per cent.
It is concluded that the “average odds” given to women regarding the risk of biopsy findings showing malignant disease do not necessarily reflect the true risk involved. Indeed, estimated odds specific to the age of the patient represent the most accurate information the surgeon can give.
Philip W. Susann

Role of Gallium 67 Thoracic Scinfigraphy in the Diagnosis and Staging of Patients Suspected of Bronchial Carcinoma. R. Pannier, I Verlinde, I.Puspowidjond and J.P. Willeniot. Thorax, 1982, 37: 264-269.
GALLIUM 67 lung scanning was performed upon 100 consecutive patients who, because of history, clinical data or abnormal radiologic findings, were suspected of having bronchial carcinoma. The results of this study allow the conclusion to be drawn that a normal as well as an abnormal scan is an important element in the diagnosis of some instances of bronchial carcinoma. The method is most helpful in the preoperative diagnosis of circumscribed peripheral shadows and in the assessment of suspected hilar enlargement; it may even allow the visualization of hidden malignant tumors. Gallium 67 scanning is also valuable in the assessment of hilar and mediastinal involvement in the presence of a proved jrimary tumor of the lung. The results of this study support the view that, in the presence of a normal scan of the mediastinum, the patient may be spared a mediastinoscopic procedure and be referred directly for operation.
Malcolm R. Lewis

Adult Respiratory Distress Syndrome in Children. Jorg Pfenninger, Andreas Gerber, Heinz Tschap­peler and Arthur Zimmerman. f. Pediatr., 1982, 101: 352-357.
TWENTY CHILDREN who were two weeks to 15 years old and had adult respiratory distress syn­drome were treated by the authors criteria for being diagnosed as having respiratory distress syndrome were: previously normal lungs; presence of acute triggering illness or injury; need for mechanical ventilation with a minimal positive end expiratory pressureof 6 cm. of water with 72 hours after the triggering event; the need for continuous positive pressure ventilation for at least five days for survivors and for at least 48 hours for nonsurvivors and diffuse bilateral alveolar infiltrates in the acute stages of the illness.
All patients with pre-existing disease of the lung, abnormal car diorespiratory adaptation to extrauterine life, cardiovascular disease or extra-corporeal circulation, rapid fatal course or classical pulmonary disease, such as pneumonia and atelectasis, were excluded from the study. The underlying disease of seven patients was septic intra-abdominal infection or septemia; other patients had hypovolemic shock, near drowning, closed space burn of cardiogenic shock caused by nupercaine intoxication.
The mean time of artificial ventilation with positive end expiratory pressure was 18 days, and the mean fraction time of inspiratory pressure was 18 days, and the mean fraction time of inspirated oxygen greater than 0.5 during continuous positive pressure ventilation was 39 hours. Positive end expiratory pressure levels were most often between 8 and 1 5 cm. of water. Eight patients, 40 per cent, died; almost all of the deaths were related to unresolved basic medical surgical problems and failure of multiple organs. Treatnient of adult respiratory distress syndrome includes elimination of the cause of the syndrome, early institution of mechanical ventilation with positive end expiratory pressure, prompt recognition and treatment of superimposed infections and bareful management of failures of additional organs.
Steven J. Phillips

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