Metastatic basal cell carcinoma of the upper extremity.
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Aged↗
Biomedical subjects
C W Cruse
Publications and source records attributed to C W Cruse.
Treatment of the primary in malignant melanoma of the skin.
Surgical excisional therapy of malignant melanoma is the primary method of treatment for malignant melanoma. The exact size of the excisional therapy depends on the depth and location of the tumor. At the University of South Florida (Tampa, FL), tumors less than 0.76 mm in depth are resected with a 1-cm margin and tumors greater than 0.76 mm in depth are resected with a 3-cm margin. The location of the tumor also determines the exact margin of excision. Maximal reconstructive efforts following general principles of plastic and reconstructive surgery are noted and used for producing an optimal functional and aesthetic result.
Esthetics↗
Etiology and prognosis of local recurrence in malignant melanoma of the skin.
All patients with stage I and stage II malignant melanoma of the skin were analyzed for stage; time of local, regional, or systemic recurrence, or two or more of these events; presence or absence of ulceration of the primary tumor; thickness of the primary tumor; level of invasion according to Clark; and margins of resection. Local recurrence had a significant negative impact on the long-term survival of patients. Our data revealed that local recurrence had the same poor prognostic effect as regional or systemic recurrence, or both. Factors significant in predicting local recurrence included the primary tumor characteristics of ulceration of the primary tumor and thickness of the primary tumor. Margins of resection and level of invasion were not noted significant in predicting local recurrence.
Florida↗
Lymphoscintigraphy in malignant melanoma.
The development and rationale for the use of lymphoscintigraphy in the preoperative evaluation of patients with malignant melanoma being considered for elective lymph node dissection is reviewed. This overview is updated by an analysis of 135 patients with early stage malignant melanoma involving the head, neck, shoulders, and trunk at Moffitt Cancer Center and Research Institute at the University of South Florida (Tampa, FL). High discordancy rates (overall, 41%) were seen between drainage patterns predicted from historical anatomical guidelines and those revealed by the lymphoscintigraphic examination. The high discordancy rate was most pronounced in the head (64%) and the neck (73%). Surgical management was changed in 33% of the patients, overall. A preoperative lymphoscintigram is recommended for all patients with melanoma with head, neck, and truncal lesions evaluated for elective lymph node dissection as the lymphatic drainage patterns are often unpredictable and variable.
Decision Making↗
The concept of lymph node dissections in patients with malignant melanoma.
Therapeutic lymph node dissections in patients with grossly palpable metastatic melanoma are performed to control regional disease, to salvage a small percentage of patients, and to obtain staging information. Patients with malignant melanoma may undergo elective lymph node dissections, when the basin is clinically negative, for three reasons. There is some evidence based on large retrospective studies that survival is increased in patients with intermediate thickness melanoma if elective lymph node dissections are performed as part of the initial treatment of the primary melanoma. Second, in a small percentage of patients, a previous elective lymph node dissection may have helped control disease in the regional lymphatics, so that more extensive procedures, including amputations, are not necessary. Another important reason is to obtain staging and prognostic information for the patient because most adjuvant protocols are based on the presence or absence of disease in the regional basin. During a 3-year period, 115 patients have undergone a regional nodal dissection at the Moffitt Cancer Center and James Haley VA Hospital as part of their surgical treatment. With a follow-up of 3 years, patients with 1 node positive do significantly better than those with more than 1 node positive in their dissection (p = 0.06). The percentage of nodes positive is also important. Those patients who have less than 10% of their nodes involved with metastatic melanoma have a better survival than those patients whose percentage is greater than 10% (p = 0.07).
Adolescent↗
Isolated limb perfusion for recurrent melanoma of the extremity.
Recent reports in the literature suggest that hyperthermic isolated limb perfusion (HILP) may be effective in preventing local recurrence in patients with deeply invasive melanoma or in patients with recurrent disease confined to the extremity. It has been used in the past as an adjuvant treatment after resection of the primary melanoma or recurrence, or as a therapeutic measure if all the disease on the extremity cannot be resected. A prospective, nonrandomized trial of 16 patients with melanoma with recurrent disease confined to the extremity underwent HILP. The protocol involved the wide local excision of all recurrent disease when possible, elective or therapeutic node dissection when indicated, and HILP using cisplatin. In 11 patients in whom all recurrent disease could be resected and the HILP was considered prophylactic, only 1 patient's disease has recurred in the perfusion circuit. Before the perfusion, the 11 patients had a total of 19 local or intransit recurrences. Of the 5 patients in whom all recurrent disease could not be resected, disease persisted in 4 patients. When compared with a concurrent control population of patients with extremity melanoma who had a local recurrence and were not perfused, the patients with melanoma who underwent HILP had a significant prolongation of disease-free survival (p less than 0.05), but a similar actuarial survival. In this study, we demonstrate that HILP can prevent local regional recurrences in patients with metastatic melanoma who are at high risk for further recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)
Arm↗
The evaluation of putative tumor markers for malignant melanoma.
Biomarkers have long held out the promise that malignancies might be diagnosed early and that patients could be monitored more confidently during their clinical course to more reliably predict recurrence and the effect of therapy. Reliable tumor markers have been described for colon carcinoma, hepatomas, and other tumors, but no reliable marker has been identified to monitor the course of malignant melanoma. Recently, the plasma level of lipid-bound sialic acid (LASA-P) has been described as reflecting an alteration in the surface membrane of cancer cells. An attempt was made to correlate the LASA-P level, along with the serum level of neuron-specific enolase, a glycolytic enzyme specific to cells of neuroectoderm origin including melanocytes, with clinical disease activity with a follow-up to at least 2 years. Two hundred seventy patients had blood samples drawn at various times during their clinical course for assay of LASA-P and neuron-specific enolase. Eighty of the patients (30%) sampled developed a recurrence sometime during their clinical course, whereas another 10 patients had active disease noted at diagnosis with evaluative tumor markers. The sensitivity and specificity of neuron-specific enolase was 27% and 77%, respectively, and cannot be recommended as a marker for melanoma. LASA-P showed a sensitivity of 65%, with 55 patients recurring and having active disease with abnormally high markers and 35 patients recurring or having active disease with normal markers. Specificity of the LASA-P test was 76%. When recurrence was associated with elevated LASA-P levels, the elevated level preceded recurrence by a median of 9.3 months. LASA-P may be a useful marker to follow patients with malignant melanoma.
Biomarkers↗
Adjuvant chemotherapy in malignant melanoma using dacarbazine, carmustine, cisplatin, and tamoxifen: a University of South Florida and H. Lee Moffitt Melanoma Center Study.
A prospective, nonrandomized trial was performed of the four-drug chemotherapy protocol consisting of dacarbazine, carmustine, cisplatin, and tamoxifen citrate given to high-risk patients for recurrence of melanoma after local regional treatment. The treated patients were consecutively registered and 6 patients who did not elect to be treated served as the control population. Criteria for inclusion in the trial were the presence of four or more lymph nodes positive for metastatic melanoma on regional modal dissection, the presence of metastatic disease in second station lymph node areas such as the iliac basin, greater than 5 cm in maximal diameter tumor burden in the nodal basin, and patients who had resected stage 4 (systemic metastases) disease with clear margins and were rendered free of disease. Actuarial survival curves for the treated group and the control subjects were similar (p = 0.91). There was a definite trend toward an increased disease-free survival for the group receiving adjuvant chemotherapy (p = 0.09). The mean disease-free survival for the control population was 200 days and for the treated group, 600 days. The study suggests a therapeutic benefit for adjuvant chemotherapy treatment of patients with metastatic melanoma who have been rendered free of disease but are at high risk for recurrence.
Adult↗
Treatment of stage IV malignant melanoma with dacarbazine, carmustine, cisplatin, and tamoxifen regimens: a University of South Florida and H. Lee Moffitt Melanoma Center Study.
Fourteen consecutive patients with stage IV metastatic melanoma with measurable disease were treated between January 1989 and August 1990 with combination chemotherapy. The chemotherapy regimen (DBPT) included dacarbazine (DTIC) 200 mg/m2/i.v. on days 1 through 3, carmustine (BCNU) 150 mg/m2/i.v. on day 1, cisplatin 25 mg/m2/i.v. on days 1 through 3, and tamoxifen citrate 10 mg p.o. twice daily. This cycle was repeated every 4 weeks. BCNU was given every other cycle. A total of six cycles of chemotherapy were delivered. Patients were then restaged to assess the response. Six concurrent patients during the study period did not elect to undergo chemotherapeutic approach and served as control subjects. When evaluated at 300 days of follow-up, 4 patients had response (3 complete response and 1 partial response), 3 had stable disease, and 7 showed progression. At 300 days of evaluation after chemotherapy, survival appeared significantly increased between treated and nontreated groups, that is, 48% in the chemotherapy group versus 27% in the control group (p = 0.03). Actuarial survival was significantly increased between those who responded to chemotherapy versus the nonresponders. At 300 days follow-up, survival was at 83% in the responders and 22% in nonresponders (p = 0.0002). This study shows that in stage IV disease, systemic chemotherapy appears to make a difference in survival. Attempts to discover better chemotherapy regimens to improve response in patients with stage IV malignant melanoma should continue to be rewarded.
Adult↗
Detection of occult lymph node metastases in malignant melanoma.
An accurate prediction of the prognosis of melanoma is dependent on the ability to determine the presence or absence of malignant cells in lymph nodes. Our laboratory has developed a method for screening lymph node sections for the presence of micrometastatic disease. The nodes obtained from regional lymphadenectomies are dissected free from surrounding tissue and divided into halves. One-half is subjected to routine histopathological evaluation and the other one-half is disrupted into a single cell suspension and placed into cell culture. Lymph nodes from 19 patients with malignant melanoma were evaluated by tissue culture. Tumor cells were isolated in 125 of the 173 nodes examined. In contrast, only 14 of these nodes were initially found positive for melanoma by routine pathological evaluation. All lymph nodes positive for melanoma by pathological evaluation were also culture positive. Examination by cell culture has led to an upgrade in the stage of disease in 58% of the histologically node-negative patients. In addition, 43% of the patients who were histologically node negative but culture positive have recurred, suggesting some clinical correlation. These results indicate that the tissue culture method for detecting micrometastatic lymph node disease may prove more reliable and sensitive than current techniques for determining the presence of occult melanoma.
Antigens, Neoplasm↗
Metastatic melanoma with an unknown primary.
An infrequent initial presentation for malignant melanoma is the diagnosis of metastatic disease without a history of an obvious primary lesion. Confusion exists in the literature concerning the workup, treatment, and prognosis of the unknown primary melanoma. A retrospective, computer-aided chart review of 580 consecutively registered patients with melanoma at the University Treatment Center (Tampa, FL), identified 18 patients with an unknown primary presentation. There were 10 males and 8 females with a mean age of 38.4 years. Ninety-four percent of the patients were diagnosed with metastatic disease in a nodal basin, whereas 1 patient had a resected isolated lung mass as the initial presentation. In the patients who presented after having a biopsy of a single positive node for diagnosis, more disease was recovered in the nodal basin with a formal node dissection in 59% of the patients. Actuarial survival curves were constructed for the group with unknown primary melanoma. As a control population, survival curves were constructed of the subpopulation of patients with melanoma who had a known primary and had stage III (regional nodal disease) at diagnosis. There was no difference in survival between those with known and unknown primary melanoma (p = 0.96).
Adolescent↗
The current management and prognosis of acral lentiginous melanoma.
A computer-aided retrospective analysis was performed on 359 patients with stage I and II melanoma at the time of diagnosis (disease confined to the primary melanoma), at the University of South Florida (Tampa, FL). Eighteen patients were identified with primary melanoma in acral locations, most being acral lentiginous melanoma. A comparison of actuarial survival curves of patients with melanoma in four different locations (acral, head and neck, trunk, and other extremity site) was performed. The patients with melanoma in acral locations did not have a statistically different actuarial survival than those with primary melanoma in other sites. When actuarial disease-free survival curves were constructed, however, acral primary melanoma had a shorter interval to recurrence than those located on the trunk or other extremity sites. Differences between actuarial disease-free survival for the head and neck and for acral primary sites were not significant. To identify prognostic factors responsible for the decreased disease-free survival of the acral lentiginous population, a regression analysis was performed. Three prognostic factors were analyzed for stage I and II melanoma, including Breslow tumor thickness, ulceration of the primary lesion, and primary site location. In the univariate analysis, with each prognostic factor acting independently, tumor thickness (p less than 0.01) and ulceration (p = 0.02) were significant variables influencing the disease-free interval. Primary site did not, however, add prognostic information to the model (p = 0.54). A stepwise multivariate analysis confirmed this finding.
Female↗
A myocutaneous flap for closure of upper arm amputations for uncontrolled axillary tumors.
Tumor spread or recurrence in the axilla is usually treated with nodal dissections. At times disease recurrence is uncontrolled, causing significant morbidity including pain, bleeding, lymphedema, and neurologic symptoms. Previously, forequarter amputation has been the treatment for this problem, resulting in a significant cosmetic and functional deficit. This report describes a novel myocutaneous flap that can be used to cover soft tissue defects after major disarticulations of the upper extremity. The deltoid myocutaneous flap has been used to successfully treat three patients with uncontrolled tumors in the axilla and preserve the shoulder structures to lessen the functional deficit.
Amputation, Surgical↗
Redefinition of cutaneous lymphatic drainage with the use of lymphoscintigraphy for malignant melanoma.
Lymphoscintigraphy was performed on 82 patients with melanoma registered at the University Melanoma Clinic. From these data, precise lymphatic drainage basins could be drawn for the head, neck, shoulder, and trunk. These drawings differed significantly from the classic anatomic studies, providing a functional look at the cutaneous lymphatic drainage. This new method correlates much better with clinical experiences and demonstrates much larger areas of ambiguous drainage than previously reported. Data from the lymphoscintigrams also emphasize the individuality of cutaneous lymphatic flow. The implications of these data in planning elective node dissections for intermediate thickness melanomas are obvious, since it is estimated that up to 59% of the dissections for trunk and head and neck primary melanomas may be misdirected if based on classic anatomic studies. The data indicate that all patients with head, neck, and shoulder lesions should undergo lymphoscintigraphy to define possible drainage basins at risk for metastatic disease. Similarly, truncal lesions require scintigrams except when they are within four well-defined areas with an extremely low probability of ambiguous drainage. Lesions in these areas show very reliable and predictable drainage to a single nodal group.
Antimony↗
Burn injuries from small airplane crashes.
Because a large amount of general aviation activity occurs in Central Florida, we reviewed our admissions for victims of small airplane crashes. We identified 13 burn victims of small aircraft accidents over a 7-year period. Of the 13, 12 survived their burn injuries, an overall survival rate of 92%. The extent of burn injury, Abbreviated Burn Severity Index (ABSI), complications, other injuries and rehabilitation potential are reviewed. Burn injury resulting from small airplane crashes is usually survivable if the patient arrives at the Burn Center alive. These burn victims generally are highly motivated individuals, are easily rehabilitated, and continue productive lives. Small airports and local hospitals should be aware of burn center availability because of the usual major extent of the burn injury.
Abbreviated Injury Scale↗
Minor burns: treatment using a new drug delivery system with silver sulfadiazine.
We investigated a new product for treatment of burn wounds in outpatients. The product is a drug delivery system composed of polyethylene glycol 400, poly-2-hydroxyethyl methacrylate, and dimethyl sulfoxide into which silver sulfadiazine is incorporated for sustained release. It is applied to the wound and changed every four to five days until the wound has epithelialized. Of the 20 patients we treated by this method, none had wound infections. Most patients had partial-thickness injuries that epithelialized without difficulty. One patient with full-thickness injuries required subsequent excision and grafting. Application of the product over joint surfaces facilitated range of motion. The product was easy to apply, it diminished pain, and it produced no abnormal effects except for an occasional bad odor.
Acrylates↗
Current concepts in management of the burned patient.
Management of the burned patient requires great skill and understanding of the burn wound. Knowledge of the wound has increased rapidly over the past few years and management of patients has progressively changed. The resuscitation formulae are widely recognized and "burn shock" rarely occurs in the acute phase. More often the patient receives excessive amounts of fluid due to over-estimation of the body surface involved.
Biological Dressings↗
Bilateral upper extremity ischemia after administration of dihydroergotamine-heparin for prophylaxis of deep venous thrombosis.
Prolonged arterial spasm as a complication of ergot-containing medications has been reported since antiquity. This article describes our experience with a patient who had severe bilateral arterial spasm in the upper extremities 6 days after the initiation of a regimen of dihydroergotamine and heparin for prophylaxis against deep venous thrombosis. The spasm was refractory to oral calcium channel blocking agents and direct intraarterial infusion of tolazoline (Priscoline). However, intraarterial nitroglycerin produced a prompt and dramatic improvement in symptoms and in physical and arteriographic findings. This experience suggests that intraarterial nitroglycerin may be an appropriate first choice for ergot-induced arterial spasm.
Arm↗