Faculty Bibliography

One hundred eighty-two patients undergoing initial surgical therapy for primary malignant melanoma were evaluated for delayed hypersensitivity using a battery of recall antigens prior to surgery. Fifty-six patients were also sensitized with 2, 4-dinitrochlorobenzene. All tumors were classified by Clark-Mihm levels and the patients were clinically staged. They were followed up for an average period of 55 months. There was no significant difference in the ability of patients with varied Clark-Mihm level lesions to mount a delayed hypersensitivity response to the recall battery or to 2, 4-dinitrochlorobenzene. Thirteen stage I melanoma patients in whom recurrence developed at a distant site exhibited no difference in immune responsiveness when compared to 148 patients in whom recurrence did not develop when both groups were tested with recall antigens. No difference was noted in patients with stage II disease in whom recurrence developed, as measured by reaction to these same antigens. Twelve patients demonstrated anergy to recall antigens, in none of whom has recurrence developed to date. Fifty-six patients who were tested with 2, 4-dinitrochlorobenzene showed no difference in reactivity with tumors classified at any of the Clark-Mihm levels. Anergy demonstrated by delayed hypersensitivity skin testing appears to reflect increasing tumor burden, rather than a preexisting deficiency that can be used to predict patients at high risk for the development of recurrent disease

The case history of a 29-yr-old woman with a mole of 4-5 yr duration on the anterior chest wall is briefly described. The woman was 5 mo pregnant, and the mole had recently become darker, larger, and sensitive to touch. A superficial spreading melanoma invasive to Clark's level III, 1 mm, was excised. Two wk later, wide, local excision of the melanoma site was performed, and no residual melanoma cells were found. Recommendations for follow-up treatment and prognosis are made by a consultant

Thirteen patients with sarcomas of the extremities have been treated with radical en bloc resection requiring vascular reconstruction as initial treatment. In one instance, vascular reconstruction failed. Eight patients are currently alive and free of disease. There were two instances of a local recurrence. Each of the remaining five patients who died had distant metastases develop, none of whom had a local recurrence. Vascular reconstruction with prosthetic bone replacement, when indicated, offers an alternative approach to the treatment of tumors which, because of attachment to major vascular structures, might be considered for radical amputation

A technic for total mastectomy with complete axillary dissection has been described. The procedure utilizes division of the pectoralis major muscle between its clavicular and sternal portions, perservation of its innervation, and reconstruction after completion of the dissection. The pectoralis minor muscle is resected. This modification facilitates a thorough axillary dissection, particularly at the apex, while preserving the cosmetic and functional benefits of the Patey operation

Over a ten year period, four patients with inflammation or perforation of non-Meckelian, small intestinal diverticula were treated on the surgical services of Bellevue Hospital. This entity remains uncommon but may be increasing in incidence. The patients presented with a short history of severe abdominal pain, usually accompanied by nausea and vomiting. Each patient also gave a longer preceding history of less well defined abdominal symptoms. The pathogenesis of the small intestinal diverticula is uncertain but may be related to disturbed muscular peristalsis in the small bowel analogous to the changes implicated in esophageal and colonic diverticular disease. The diverticulum may be difficult to demonstrate at operation, and careful exploration for this possibility should be carried out at the time of operation for peritonitis of obscure origin. Segmental resection and end-to-end anastomosis is the treatment of choice

A series of 94 patients with cutaneous malignant melanoma of the head and neck region has been studied. Fifty-three of the patients had regional lymph node dissections performed and the results in 37 performed more than 5 years ago are presented. The policy of elective lymph node dissection for invasive melanoma of the head and neck is strongly endorsed, although not proven by the data presented in this limited series. Whenever possible, a total excisional biopsy should be performed to establish the diagnosis. It is recommended that all melanomas be classified by the method of Clark and Mihm and that the level of invasion also be determined. There is an appreciable error in the clinical evaluation of lymph nodes for metastases. In general, it is suggested that elective regional lymph node dissections be performed for invasive melanoma (levels III, IV and V). The literature pertaining to cutaneous melanoma of the head and neck has been reviewed and surgical and pathological problems peculiar to lesions of this region are emphasized