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Multimodality management of merkel cell carcinoma
J Oral MaxillofacSurg 58:119 123, 2000
Abstracts M u l t i m o d a l i t y Management o f Merkel Cell C a r c i n o m a , Ott MJ, Tanabe KK, Gadd MA. Arch Surg 134:388, 1999
Reprint requests to: Dr Matrassaro: 1009 Park Ave, New York, NY 10028.
Merkel cell c a r c i n o m a is a rare dermal n e u r o e n d o c r i n e c a r c i n o m a w h o s e optimal t r e a t m e n t a n d prognostic factors are poorly defined. The authors believe that high-risk patients w i t h Merkel cell c a r c i n o m a are best treated w i t h multimodality therapy. This study relied o n the retrospective r e v i e w of all p a t i e n t s w i t h Merkel cell c a r c i n o m a treated at the Massachusetts General Hospital from January 1, 1980 to August 24, 1997. Median follow-up time was 37 m o n t h s (range, 6 to 157 m o n t h s ) . A d e q u a t e data for evaluation was available for 31 patients. Male to female distribution was 14 m e n and 17 w o m e n , w i t h a m e d i a n p a t i e n t age of 68 years. T h e r e w e r e 12 extremity, 11 h e a d a n d neck, a n d 8 truncal tumors. T h e r e w e r e 22 isolated primary tumors, 8 w i t h additional clinically positive l y m p h nodes, and 1 w i t h distant disease. T h e r a p y was local excision w i t h or w i t h o u t radiation therapy (XRT) in 19 patients, local r e s e c t i o n a n d l y m p h a d e n e c t o m y w i t h or w i t h o u t XRT in 8 patients, and XRT alone in 4 patients w i t h h e a d a n d n e c k tumors. Fifteen patients had recurrences. Median time for r e c u r r e n c e was 8 m o n t h s . T h e r e w e r e 7 tumor-related deaths, 6 of w h i c h w e r e associated w i t h truncal lesions. No locoregional recurrences o c c u r r e d in patients w i t h margins of r e s e c t i o n of 2 c m or greater or a d e q u a t e XRT. A f u r t h e r analysis of the data selected truncal lesions a n d nodal disease as predictors of mortality. Merkel cell c a r c i n o m a is an aggressive dermal c a n c e r w i t h f r e q u e n t nodal metastases. T h e authors believe that truncal t u m o r s have the w o r s t prognosis. They also state that locoregional r e c u r r e n c e s correlate w i t h inadequate margin and lack of XRT w i t h possible remission if multimodality t h e r a p y is u s e d . - - H . PATINO
H y d r o x y a p a t i t e C e m e n t i n C r a n i o f a c i a l T r a u m a Surg e r y : Indications and E a r l y E x p e r i e n c e . Reddi SP, Stevens MR, Kline SN, et al. J Craniomaxillofac Trauma 5:7, 1999 Hydroxyapatite c e m e n t (HAC) is a n o n c e r a m i c type of hydroxyapatite created by direct crystallization in vivo that results in a structurally stable product. T h e paste sets, w i t h a c o m p l e t e l y isothermic reaction, in 10 to 15 m i n u t e s at b o d y t e m p e r a t u r e and maintains a pH of 6.5 to 8. T h e final p r o d u c t has limited shear s t r e n g t h b u t maintains a compressive s t r e n g t h in t h e range of 60 Mpa. The p o r e size of t h e set c e m e n t is 2 to 5 nm. In this article t h e authors p r e s e n t t h e i r e x p e r i e n c e using a resorbable HAC (Bonesource; Osteogenics, Richardson, TX) to r e c o n s t r u c t craniofacial defects s e c o n d a r y to trauma. The authors designed a classification system b a s e d o n indications for HAC use in craniofacial defects: Type I - - d e l a y e d r e c o n s t r u c t i o n of small craniofacial defects 0 e s s t h a n 5 x 5 cm); type I I - - i m m e d i a t e reconstruction of cranial vault d o n o r site; type I l l - - d e l a y e d r e c o n s t r u c t i o n , in c o m b i n a t i o n w i t h b o n e grafts in large defects; a n d type I V - - i m m e d i a t e craniofacial r e c o n s t r u c t i o n a n d / o r frontal sinus obliteration. HAC was used for a total of 10 cases that u n d e r w e n t s u b s e q u e n t follow-up for a minim u m of 6 m o n t h s . They p r e s e n t e d 4 cases, e a c h of w h i c h r e p r e s e n t 1 of the 4 categories. T h r e e complications w e r e o b s e r v e d in 2 patients out of 10. A type III patient w h o u n d e r w e n t internal repair using a large frontal b o n e graft a n d several smaller grafts in c o m b i n a t i o n w i t h HAC to r e c o n s t r u c t a large defect d e v e l o p e d a p o s t o p e r a t i v e infection; the graft and all nonvascularized material w e r e removed. The s e c o n d p a t i e n t was a type 1V a n d u n d e r w e n t immediate r e c o n s t r u c t i o n a n d frontal sinus obliteration w i t h HAC. Subsequently, t h e p a t i e n t d e v e l o p e d scalp abscess and b e c a u s e of r e c u r r e n t fistula t h e c e m e n t was r e m o v e d 1 year postoperatively. T h e same patient also d e v e l o p e d sepsis that resolved w i t h o u t immediate removal of t h e c e m e n t . The authors suggest that type I a n d II indications a p p e a r to b e the m o s t predictable. In type III indications t h e r e may b e p r o b l e m s w i t h the c e m e n t contamination b e c a u s e HAC may play a h o s t role for pathogens. In addition, HAC may interfere w i t h t h e graft revascularization. Type IV indications p r e s e n t a diagnostic challenge especially if p o s t o p e r a t i v e sepsis occurs. For all indications, t e c h n i c a l issues s u c h as c e m e n t setting time, h a r d n e s s of t h e final product, a n d dryness of the surgical field m u s t still b e improved. The e x p e r i e n c e of t h e authors indicates that application of HAC in areas of c o m p r o m i s e d vascularity, large free-bone grafts, o p e n sinus fractures, and patients w i t h possible increased risk of sepsis may b e subject to m o r e complications. HAC appears to b e an ideal material for elective delayed r e c o n s t r u c t i o n of small defects w i t h stable soft tissue a n d for r e c o n t o u r i n g of d o n o r harvest sites in n o n s t r e s s areas of the cranium.--F.F. KATAm
Reprint requests to Dr Ott: Division of Surgical Oncology, Departmerit of Surgery, Massachusetts General Hospital, 626 Cox Bldg, 100 Blossom St, Boston, MA 02114. B o t u l i s m A E x o t o x i n f o r the Management o f P l a t y s m a l B a n d s . Matrassaro A, Matrassaro S, Brandt FS, et al. Plast Reconstr Surg 103:645, 1999 Injections of Botulism A toxin are successfully used to treat rhytids of t h e u p p e r facial regions. This study is an e x a m i n a t i o n of t r e a t m e n t of h y p e r t r o p h i c muscle b a n d i n g s e e n in the aging neck. A classification system I t h r o u g h IV was designed to categorize the degree of deformity a n d serve as a guideline for dosages of toxin. A total of 1,500 patients w e r e treated by 3 i n d e p e n d e n t practices. Visual analog scales d e t e r m i n e d that over 98% of the p a t i e n t s w o u l d evaluate their result as g o o d to excellent. Skin bruising was t h e m o s t c o m m o n side effect, o c c u r r i n g in 20% of the patients. Ten p e r c e n t of the patients r e p o r t e d transient mild n e c k discomfort lasting for 2 to 5 days post-treatment. O n e p e r c e n t of the p a t i e n t s r e p o r t e d n e c k w e a k n e s s w h i l e lifting t h e i r h e a d and 1 case of dysphasia o c c u r r e d 3 days after injection. This resolved s p o n t a n e o u s l y w i t h i n 2 weeks. Conclusions d r a w n by t h e authors are that botulism toxin is a safe a n d effective t r e a t m e n t for n e c k rhytids.--J. BROKLOFF
Reprints requests to Dr Stevens: Division of Oral and Maxillofacial Surgery, University of Miami, School of Medicine, 1611 NW 12th Ave, D-44, Ace E, Second Floor, Miami, FL 33136.
119
Abstracts M u l t i m o d a l i t y Management o f Merkel Cell C a r c i n o m a , Ott MJ, Tanabe KK, Gadd MA. Arch Surg 134:388, 1999
Reprint requests to: Dr Matrassaro: 1009 Park Ave, New York, NY 10028.
Merkel cell c a r c i n o m a is a rare dermal n e u r o e n d o c r i n e c a r c i n o m a w h o s e optimal t r e a t m e n t a n d prognostic factors are poorly defined. The authors believe that high-risk patients w i t h Merkel cell c a r c i n o m a are best treated w i t h multimodality therapy. This study relied o n the retrospective r e v i e w of all p a t i e n t s w i t h Merkel cell c a r c i n o m a treated at the Massachusetts General Hospital from January 1, 1980 to August 24, 1997. Median follow-up time was 37 m o n t h s (range, 6 to 157 m o n t h s ) . A d e q u a t e data for evaluation was available for 31 patients. Male to female distribution was 14 m e n and 17 w o m e n , w i t h a m e d i a n p a t i e n t age of 68 years. T h e r e w e r e 12 extremity, 11 h e a d a n d neck, a n d 8 truncal tumors. T h e r e w e r e 22 isolated primary tumors, 8 w i t h additional clinically positive l y m p h nodes, and 1 w i t h distant disease. T h e r a p y was local excision w i t h or w i t h o u t radiation therapy (XRT) in 19 patients, local r e s e c t i o n a n d l y m p h a d e n e c t o m y w i t h or w i t h o u t XRT in 8 patients, and XRT alone in 4 patients w i t h h e a d a n d n e c k tumors. Fifteen patients had recurrences. Median time for r e c u r r e n c e was 8 m o n t h s . T h e r e w e r e 7 tumor-related deaths, 6 of w h i c h w e r e associated w i t h truncal lesions. No locoregional recurrences o c c u r r e d in patients w i t h margins of r e s e c t i o n of 2 c m or greater or a d e q u a t e XRT. A f u r t h e r analysis of the data selected truncal lesions a n d nodal disease as predictors of mortality. Merkel cell c a r c i n o m a is an aggressive dermal c a n c e r w i t h f r e q u e n t nodal metastases. T h e authors believe that truncal t u m o r s have the w o r s t prognosis. They also state that locoregional r e c u r r e n c e s correlate w i t h inadequate margin and lack of XRT w i t h possible remission if multimodality t h e r a p y is u s e d . - - H . PATINO
H y d r o x y a p a t i t e C e m e n t i n C r a n i o f a c i a l T r a u m a Surg e r y : Indications and E a r l y E x p e r i e n c e . Reddi SP, Stevens MR, Kline SN, et al. J Craniomaxillofac Trauma 5:7, 1999 Hydroxyapatite c e m e n t (HAC) is a n o n c e r a m i c type of hydroxyapatite created by direct crystallization in vivo that results in a structurally stable product. T h e paste sets, w i t h a c o m p l e t e l y isothermic reaction, in 10 to 15 m i n u t e s at b o d y t e m p e r a t u r e and maintains a pH of 6.5 to 8. T h e final p r o d u c t has limited shear s t r e n g t h b u t maintains a compressive s t r e n g t h in t h e range of 60 Mpa. The p o r e size of t h e set c e m e n t is 2 to 5 nm. In this article t h e authors p r e s e n t t h e i r e x p e r i e n c e using a resorbable HAC (Bonesource; Osteogenics, Richardson, TX) to r e c o n s t r u c t craniofacial defects s e c o n d a r y to trauma. The authors designed a classification system b a s e d o n indications for HAC use in craniofacial defects: Type I - - d e l a y e d r e c o n s t r u c t i o n of small craniofacial defects 0 e s s t h a n 5 x 5 cm); type I I - - i m m e d i a t e reconstruction of cranial vault d o n o r site; type I l l - - d e l a y e d r e c o n s t r u c t i o n , in c o m b i n a t i o n w i t h b o n e grafts in large defects; a n d type I V - - i m m e d i a t e craniofacial r e c o n s t r u c t i o n a n d / o r frontal sinus obliteration. HAC was used for a total of 10 cases that u n d e r w e n t s u b s e q u e n t follow-up for a minim u m of 6 m o n t h s . They p r e s e n t e d 4 cases, e a c h of w h i c h r e p r e s e n t 1 of the 4 categories. T h r e e complications w e r e o b s e r v e d in 2 patients out of 10. A type III patient w h o u n d e r w e n t internal repair using a large frontal b o n e graft a n d several smaller grafts in c o m b i n a t i o n w i t h HAC to r e c o n s t r u c t a large defect d e v e l o p e d a p o s t o p e r a t i v e infection; the graft and all nonvascularized material w e r e removed. The s e c o n d p a t i e n t was a type 1V a n d u n d e r w e n t immediate r e c o n s t r u c t i o n a n d frontal sinus obliteration w i t h HAC. Subsequently, t h e p a t i e n t d e v e l o p e d scalp abscess and b e c a u s e of r e c u r r e n t fistula t h e c e m e n t was r e m o v e d 1 year postoperatively. T h e same patient also d e v e l o p e d sepsis that resolved w i t h o u t immediate removal of t h e c e m e n t . The authors suggest that type I a n d II indications a p p e a r to b e the m o s t predictable. In type III indications t h e r e may b e p r o b l e m s w i t h the c e m e n t contamination b e c a u s e HAC may play a h o s t role for pathogens. In addition, HAC may interfere w i t h t h e graft revascularization. Type IV indications p r e s e n t a diagnostic challenge especially if p o s t o p e r a t i v e sepsis occurs. For all indications, t e c h n i c a l issues s u c h as c e m e n t setting time, h a r d n e s s of t h e final product, a n d dryness of the surgical field m u s t still b e improved. The e x p e r i e n c e of t h e authors indicates that application of HAC in areas of c o m p r o m i s e d vascularity, large free-bone grafts, o p e n sinus fractures, and patients w i t h possible increased risk of sepsis may b e subject to m o r e complications. HAC appears to b e an ideal material for elective delayed r e c o n s t r u c t i o n of small defects w i t h stable soft tissue a n d for r e c o n t o u r i n g of d o n o r harvest sites in n o n s t r e s s areas of the cranium.--F.F. KATAm
Reprint requests to Dr Ott: Division of Surgical Oncology, Departmerit of Surgery, Massachusetts General Hospital, 626 Cox Bldg, 100 Blossom St, Boston, MA 02114. B o t u l i s m A E x o t o x i n f o r the Management o f P l a t y s m a l B a n d s . Matrassaro A, Matrassaro S, Brandt FS, et al. Plast Reconstr Surg 103:645, 1999 Injections of Botulism A toxin are successfully used to treat rhytids of t h e u p p e r facial regions. This study is an e x a m i n a t i o n of t r e a t m e n t of h y p e r t r o p h i c muscle b a n d i n g s e e n in the aging neck. A classification system I t h r o u g h IV was designed to categorize the degree of deformity a n d serve as a guideline for dosages of toxin. A total of 1,500 patients w e r e treated by 3 i n d e p e n d e n t practices. Visual analog scales d e t e r m i n e d that over 98% of the p a t i e n t s w o u l d evaluate their result as g o o d to excellent. Skin bruising was t h e m o s t c o m m o n side effect, o c c u r r i n g in 20% of the patients. Ten p e r c e n t of the patients r e p o r t e d transient mild n e c k discomfort lasting for 2 to 5 days post-treatment. O n e p e r c e n t of the p a t i e n t s r e p o r t e d n e c k w e a k n e s s w h i l e lifting t h e i r h e a d and 1 case of dysphasia o c c u r r e d 3 days after injection. This resolved s p o n t a n e o u s l y w i t h i n 2 weeks. Conclusions d r a w n by t h e authors are that botulism toxin is a safe a n d effective t r e a t m e n t for n e c k rhytids.--J. BROKLOFF
Reprints requests to Dr Stevens: Division of Oral and Maxillofacial Surgery, University of Miami, School of Medicine, 1611 NW 12th Ave, D-44, Ace E, Second Floor, Miami, FL 33136.
119