Orbital Venous Malformations: Current Multidisciplinary Treatment Approach
Objective: To evaluate the clinical, radiological, and histopathological features, treatment, and outcome of a series of orbital venous flow malformations (OVMs) with the aim of delineating a more systematic approach for treatment.
Methods: A 38-year retrospective review of 22 patients with OVMs followed up at 1 institute.
Results: Eighteen of 22 patients (13 women and 9 men) showed clinical or radiological evidence of distensibility. The mean age at the initial manifestation was 28.3 and 50.7 years in patients with distensible and nondistensible OVMs, respectively. Eight patients (36.3%) had deep orbital lesions, 6 (27.3%) had superficial orbital lesions, and 8 (36.3%) had combined orbital lesions. All 3 patients with deep nondistensible OVMs had a sudden onset of proptosis and pain or diplopia secondary to thrombosis or hemorrhage. Seventeen patients required treatment. All 4 nondistensible lesions were treated by surgical excision. A variety of techniques were used to treat distensible OVMs including carbon dioxide laser ablation, percutaneous alcohol sclerotherapy, or embolization with Guglielmi detachable coils after surgical exposure and surgical excision. Of the 14 patients with follow-up, 8 had complete resolution of the signs and symptoms and 6 patients showed marked improvement following surgery. Mean follow-up was 57.8 months.
Conclusion: If intervention is indicated, less invasive methods such as carbon dioxide laser ablation and percutaneous alcohol sclerotherapy for superficial and combined orbital lesions and endovascular treatment by Guglielmi detachable coil embolization for deep orbital lesions should be considered before proceeding with more invasive procedures.
Arat YO, Mawad ME, Boniuk M
Effect of Carbon Dioxide Laser Resurfacing on Epidermal p53 Immunostaining in Photodamaged Skin
Objective: To quantitatively examine changes in p53 tumor suppressor gene immunostaining after carbon dioxide (CO2) laser resurfacing of photodamaged skin to assess the potential value of this treatment in reducing the risk of progression to cutaneous carcinoma.
Design: Serial in vivo immunohistochemical analyses after laser therapy.
Setting: Academic referral center, Department of Dermatology, University of Michigan, Ann Arbor.
Other Participants: Volunteer sample of 11 adults, 51 to 76 years old, with clinically evident photodamage of the forearms.
Intervention: Focal CO2 laser resurfacing of photodamaged forearms and serial biopsies at baseline, 3 weeks, and 6 months after treatment.
Main Outcome Measures: Because keratinocytes with mutations in p53 or altered p53 expression stain via immunohistochemical techniques, image analysis of immunohistochemically stained sections was used to quantify p53 expression.
Results: Positive immunostaining for p53 in the interfollicular epidermis was noted in 8 of 11 subjects at baseline, with an average staining density of 250 cells/mm2. Average staining decreased to 3 cells/mm2 3 weeks after treatment. This decrease was sustained at 5 cells/mm2 6 months after resurfacing.
Conclusions: There was a consistent decrease in p53 immunostaining in the interfollicular epidermis lasting for at least 6 moths after CO2 laser resurfacing of photodamaged skin. Since p53 mutation or overexpression is observed in a majority of cases of cutaneous carcinoma, the posttreatment repopulation of the epidermis with p53-negative keratinocytes should theoretically decrease the risk of malignant progression. Further study of laser resurfacing as a prophylactic procedure in patients at high risk for skin cancer development appears warranted.
Orringer JS, Johnson TM, Kang S, et al
Surgical Margins for Lentigo Maligna and Lentigo Maligna Melanoma: The Technique of Mapped Serial Excision
Objectives: To assess the margins required for excision of lentigo maligna (LM) and lentigo maligna melanoma (LMM) by the technique of mapped serial excision (MSE), and to assess the efficacy of MSE.
Design: An interventional, prospective, noncontrolled case series.
Setting: Tertiary referral, dermatologic surgery unit.
Patients: Consecutive patients with head and neck LM or LMM who underwent MSE between March 1, 1993, and October 31, 2002.
Intervention: The MSE of LM or LMM.
Main Outcome Measures: The number of 5-mm levels for excision of LM and LMM and recurrence.
Results: One hundred sixty-one LMs or LMMs in 155 patients were treated. Thirty percent (37 of 125) of LMs required more than 5-mm margins. For LMMs less than 1 mm in Breslow thickness, 12% (4/32) required more than 10-mm margins. For primary tumors, 20% of LMs (18 of 91) required more than 5-mm margins, while 10% of LMMs less than 1 mm in Breslow thickness (2 of 21) required more than a 10-mm margin. For recurrent tumors, 56% of LMs (19/34) required more than a 5-mm margin. Mean follow-up of 38 months (range, 5-100 months) showed 4 recurrences (2%) after MSE. The extrapolated recurrence at 5 years was 5.0%.
Conclusions: The current recommendations of 5-mm margins for LM and 10-mm margins for LMM less than 1 mm in Breslow thickness are often insufficient. Our results demonstrate the importance of margin-controlled excision, particularly in recurrent lesions. The use of MSE offers a high cure rate, in conjunction with tissue conservation.
Huilgol SC, Selva D, Chen C, et al
Double-blind Placebo-Controlled Study of Autologous Transplanted Epidermal Cell Suspensions for Repigmenting Vitiligo
Objectives: To investigate the efficacy of epidermal noncultured cellular grafting in patients with vitiligo and the role of postinflammatory, spontaneous, or UV-induced pigmentation in obtaining repigmentation.
Design: A prospective, randomized, double-blind, placebo-controlled study.
Setting: Ambulatory patients in an institutional practice. Patients were followed up for 3 to 12 months.
Patients: A total of 33 paired, symmetrically distributed leukodermic lesions, all resistant to therapy, were observed in 28 patients. Nineteen patients appeared to have a stable vitiligo (group 1), whereas there was doubt about the stability of the disease in 9 patients (group 2).
Intervention: After laser ablation, a hyaluronic acid-enriched cellular graft was applied to 1 lesion while the paired lesion received placebo. Three weeks later all lesions were exposed to UV irradiation twice per week for approximately 2 months.
Main Outcome Measures: Primarily, the percentage of repigmentation was assessed after 3, 6, and 12 months using a digital image analysis system. The repigmentation pattern was also evaluated after 1 and 3 months.
Results: A strongly significant difference between cellular grafts and placebo was observed after 3, 6, and 12 months (P<.001, P = .002, and P = .002, respectively). In group 1, repigmentation of at least 70% of the treated area was achieved in 55%, 57%, and 77% of the actively treated lesions 3, 6, and 12 months after treatment, whereas in group 2 repigmentation of at least 70% of the treated area was not observed at any time point. The repigmentation pattern was diffuse in 94% of the responding patients.
Conclusions: After a strict preoperative selection for disease stability, transplantation resulted in repigmentation of at least 70% of the treated area in most actively treated vitiligo lesions. Repigmentation was primarily caused by the transplanted melanocytes.
van Geel N, Ongenae K, De Mil M, Haeghen YV, Vervaet C, Naeyaert JM
Abstracts: In Other AMA Journals. Arch Facial Plast Surg. 2005;7(1):63–64. doi: