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Melanoma-in-situ (MIS) represents 45% of all melanomas. The margins of MIS are often poorly defined with extensive subclinical disease. Standard fusiform excision with 5-mm margins results in positive margins in up to a third of cases. To decrease the incidence of involved margins, we use a staged excision approach for MIS. First, patients undergo excision under local anesthesia of a 2- to 3-mm “contoured” rim of tissue optimally 5 mm beyond the visible extent of the lesion. Formalin-fixed paraffin-embedded en face sections from this excision are then evaluated, if necessary with the aid of immunohistochemical stains. Any positive margins are further excised. When all margins are negative, the central area is then excised and reconstructed. A total of 61 patients with MIS or lentigo maligna melanoma underwent staged contoured excisions from 2004 to 2007 at Moffitt Cancer Center. We analyzed data only from patients with MIS of the head and neck. Patients with known invasive melanoma or non–head and neck primary disease were excluded. Demographics, tumor characteristics, margin status, number of stages, and type of reconstruction and recurrences were evaluated. Forty-nine patients with MIS of the head and neck, 28 (57%) male and 21 (43%) female, 42 to 88-years-old (median 72; mean 70), underwent staged contoured margin excision before definitive central tumor excision and reconstruction. The final surgical defect size ranged from 2 to 130 cm 2 (median 16 cm 2 ). Twelve patients (24%) required reexcision of at least one margin; the median number of reexcisions was 1 (range 1–2). There seemed to be a positive association between lesion size and margin status (as well as number of excisions needed to clear the margin). Unsuspected invasive melanoma was found in the central specimen in six patients (12%). Even small tumors could have unsuspected invasive melanoma: invasive cancer was seen in 4 (21%) of 19 tumors ≤2 cm in greatest dimension and 2 (7%) of 30 > 2 cm, respectively. Surgical defects were reconstructed with flaps in 18 (37%), full-thickness grafts in 20 (41%), and split-thickness grafts in 10 patients (20%). Median time from first margin excision to completion/final reconstruction was 7 days (range 7–63 days). No local recurrences have been reported at a median follow-up of 14 months (range 1–36 months). This technique allows for careful margin analysis and subsequent central tumor excision with simultaneous reconstruction. This approach minimizes the need for a second major operation, which would have been necessary in 24% of our patients if treated by a one-stage excisional approach. It is noteworthy that 12% of MIS patients had invasive melanoma in the final excision specimen. This reinforces the importance of adequate full-thickness biopsies of suspicious pigmented lesions before any type of surgical management. With short follow-up, local control has been achieved by this technique in 100% of cases.

Acellular dermal matrix (ADM) use in prosthetic breast reconstruction has become increasingly popular. Several benefits have been reported with this technique including diminished donor-site morbidity and improved aesthetic outcomes. Recently, in an effort to ascertain the overall safety and efficacy of this approach, an emphasis has been placed on identifying potential postoperative complications. This report describes a unique complication experienced with ADM use in which ADM conceals the detection of recurrent breast carcinoma.

Hepatic artery infusional (HAI) chemotherapy has been shown to favorably impact outcome in patients with metastatic colorectal cancer, but complications often preclude complete treatment. The purpose of this study was to determine whether HAI complications impact survival in these patients. Patients undergoing HAI pump placement at our institution from September 2001 to July 2004 were separated into terciles based on the number of treatments completed: ≤1 (none), 2 to 4 (partial), and ≥5 (complete). Complications relating to pump placement or treatment were recorded for each and their impact on survival was determined. Kaplan-Meier survival in 15 patients receiving no treatment was significantly shorter than 7 patients completing therapy (P = 0.02). Thirty-three per cent of patients receiving no therapy were alive at 26 months, whereas 63 per cent of partially and 86 per cent of completely treated patients were alive at 32 and 30 months, respectively. Patients receiving no treatment had more overall complications (80%) and significantly (P < 0.05) more pump-related complications (60%) than those completing therapy (43% and 0%, respectively). Cox regression revealed a significant correlation to gender (hazard ratio, 3.9), tumor size (hazard ratio, 1.17), and carcinoembryonic antigen level (hazard ratio, 1.02) to survival. Patients receiving complete HAI treatment survive longer than those receiving no treatment. Potentially preventable pump-related complications not only impacted the patients’ ability to continue therapy, but survival times as well.

In our patient, the surrounding tissue of the sternal section was free of tumor, with the mass demonstrating a similar histological presentation to the primary tumor. [...] the diagnosis of metastatic lesion of primary insular carcinoma of the thyroid seems appropriate.