Abstract Aim It is commonly known that women have better prognosis than men after diagnosis of primary cutaneous melanoma. However, few studies have investigated whether histopathological prognostic factors are associated with this difference. This study aimed to investigate if there were sex-specific differences in prognostic features of primary melanoma at time of diagnosis in a large clinical series. Method This was a records-based observational study of unselected patients treated for melanoma in a major tertiary oncology centre in the United Kingdoms, 2002–2016. Prognostic features (age at diagnosis; thickness of primary melanoma; ulceration and mitotic count) were extracted from histological reports and sex-specific differences tested for significance using X2 test. Results Among 1323 melanoma patients of median age 61 years (range 15–99), and roughly equal proportions of males (640, 48%) and females (683,52%), females had significantly earlier age of presentation on average than males (58 vs 64 years) (p<0.001). Comparing Breslow thickness of <2mm vs ≥2mm, significantly more females (414, 67%) than males (282, 55%) had melanomas <2mm (p<0.001). Other key histopathological factors namely presence of ulceration (p=0.073) and mitotic rate (p=0.618) were not significantly different by sex. Conclusions We found that female melanoma patients presented at an earlier age and with thinner primary melanomas than males, but mitotic rate (speed of tumour growth) was not significantly different. These data suggest that females’ better prognosis is explained by their tendency to present earlier with suspicious skin lesions than males.

The lower limb is a common site for melanoma in women, but the reason for this is not fully understood. To investigate this phenomenon in more detail, we assessed the specific subsites of primary melanoma occurring on the lower limbs of females compared with males across age groups. In a records-based study at an oncology hospital in north-west of England, among an unselected sample of patients with primary invasive melanoma treated between 2002–2015, information was collected on patient age at diagnosis, sex, and co-morbidities, and the tumor thickness and anatomical subsite (thigh, lower leg, foot for lower limb). Of a total sample of 1,522 patients, 316 (227, 72% female) had lower limb melanoma. The most common subsite was lower leg (142 cases with F:M ratio =3.74), followed by thigh (55 cases with F:M = 1.83) and feet (30 cases with F:M = 1.15). At ages <40 years the odds of thigh to foot melanoma was 20 times higher in females than in males (OR 20.0, 95% CI 2.6-152.6) and 7.5 times higher on the lower limb (OR 7.5, 95% CI 1.1–49.2). For ages 40+ years, the odds of females developing thigh melanoma compared to foot melanoma was similar in males versus females (OR 0.8), while the corresponding odds of lower leg melanoma in females versus males remained significantly increased at ages 40–59 and 60+ (OR 4.2 and 2.8 respectively). Our study demonstrates the female predilection for lower limb melanoma persists over most but not all subsites.However, there is heterogeneity in the female to male occurence of lower limb melanoma across subsites and at different ages, which may be linked to relative influence of genetic and environmental risk factors.

BACKGROUND The advent of effective adjuvant therapies for patients with resected melanoma has highlighted the need to stratify patients based on risk of relapse given the cost and toxicities associated with treatment. Here we assessed circulating tumor DNA (ctDNA) to predict and monitor relapse in resected stage III melanoma. PATIENTS AND METHODS Somatic mutations were identified in 99/133 (74%) patients through tumor tissue sequencing. Personalized droplet digital PCR (ddPCR) assays were used to detect known mutations in 315 prospectively collected plasma samples from mutation-positive patients. External validation was performed in a prospective independent cohort (n = 29). RESULTS ctDNA was detected in 37 of 99 (37%) individuals. In 81 patients who did not receive adjuvant therapy, 90% of patients with ctDNA detected at baseline and 100% of patients with ctDNA detected at the postoperative timepoint relapsed at a median follow up of 20 months. ctDNA detection predicted patients at high risk of relapse at baseline [relapse-free survival (RFS) hazard ratio (HR) 2.9; 95% confidence interval (CI) 1.5-5.6; P = 0.002] and postoperatively (HR 10; 95% CI 4.3-24; P < 0.001). ctDNA detection at baseline [HR 2.9; 95% CI 1.3-5.7; P = 0.003 and postoperatively (HR 11; 95% CI 4.3-27; P < 0.001] was also associated with inferior distant metastasis-free survival (DMFS). These findings were validated in the independent cohort. ctDNA detection remained an independent predictor of RFS and DMFS in multivariate analyses after adjustment for disease stage and BRAF mutation status. CONCLUSION Baseline and postoperative ctDNA detection in two independent prospective cohorts identified stage III melanoma patients at highest risk of relapse and has potential to inform adjuvant therapy decisions.

Background: Adjuvant immunotherapy and BRAF-targeted therapies have shown improved relapse-free survival (RFS) in patients (pts) with resected melanoma. There is a critical need to develop biomarkers to stratify pts based on risk of relapse given the cost and toxicities with these therapies. Methods: Droplet digital PCR was used to detect known mutations in circulating tumour DNA (ctDNA) from 112 pts with resected stage II-III melanoma who consented to prospective serial plasma and risk-adapted F-18-fluoro-deoxyglucose positron emission tomography (FDG-PET) monitoring. External validation was performed in a prospective independent cohort. Results: In 92/112 pts who did not receive adjuvant therapy, 55/92 (60%) pts relapsed at a median follow-up of 21 months. Plasma samples were available in 67/92 pts at baseline and 59/92 pts postoperatively (median 2 weeks post surgery). ctDNA was detected at baseline and postoperatively in 21/67 (31%) pts and 15/59 (25%) pts respectively. 19/21 and 14/15 pts with ctDNA detected at baseline and the postoperative visit relapsed. Detection of ctDNA predicted patients at high risk of relapse at baseline (RFS hazard ratio [HR] 4.7; 95% confidence interval [CI] 2.3-9.6; p < 0.0001) and postoperatively (HR 9.3; 95% CI 4-22; p < 0.0001). Inferior distant metastasis-free survival (DMFS) was associated with ctDNA detection at baseline (HR 5.3; 95% CI 2.5-11; P < 0.0001) and postoperatively (HR 14; 95% CI 5.4-37; P < 0.0001). These findings were validated in an independent cohort. Postoperative ctDNA detection remained an independent predictor of both RFS (HR 8; 95% CI 3-20; P < 0.0001) and DMFS (HR 11; 95% CI 4-30; P < 0.0001) after adjustment for disease stage and BRAF mutation status. In 20/112 pts who received adjuvant therapy, 3/18 pts with a postoperative plasma sample had detectable ctDNA. Serial plasma samples were available in 2 of 3 cases and showed clearance of ctDNA post immunotherapy. At a median follow-up of 7 months, none of the pts with detectable ctDNA who received adjuvant therapy have relapsed. Conclusions: Detection of ctDNA at baseline and after surgical resection in two independent prospective cohorts identifies pts with stage II/III melanoma at highest risk of relapse with potential to guide adjuvant therapy decisions. Legal entity responsible for the study: Peter MacCallum Cancer Centre. Funding: National Health and Medical Research Council, Cancer Research UK, Wellcome Trust. Disclosure: S.K. Sandhu: Honorarium: Merck, Bristol-Myers Squibb. M. Shackleton: Travel support: BMS, Merck; Consultancy: BMS, Merck, MSD; Honoraria: BMS, Merck, MSD Research support: BMS. A. Haydon: Advisory board: Novartis, MSD. D. Gyorki: Advisory board: Amgen; Honorarium: Amgen. P. Lorigan: Consultancy/ Advisory work: Amgen, GSK, Roche, BMS, Merck, Novartis; Speaker bureau: Merck, BMS, Novartis, Roche; Support for travel: Merck, BMS, Roche. R. Marais: Research funding: Basilea Pharmaceuticals. All other authors have declared no conflicts of interest.

Since its inception nearly 30 years ago, the pedicled TRAM flap has remained a reliable technique of breast reconstruction. However, venous congestion of the flap in the early postoperative period is well recognised and may lead to partial or total flap loss. This study describes a simple technique routinely employed by the senior author over 15 years involving intraoperative cannulation of the deep inferior epigastric vein and externalisation into an ileostomy bag, in order to facilitate drainage and reduce the likelihood of venous congestion. In addition to its role in breast reconstruction, this technique may be a useful adjunct to any form of free or pedicled tissue transfer.

Defects of the perineum are created during ablative procedures for gynaecological, urological and colorectal malignancies. The gluteal fold flap is a reliable means of reconstructing these defects. We retrospectively reviewed case notes of gluteal fold flaps performed for perineal reconstruction over four years (2007-2010) in our institution. 77 perineal defects were reconstructed using unilateral or bilateral gluteal fold flaps (127 flaps in total). 50% of all patients are discharged before 11 days, and 90% were discharged within one month. Mean time to discharge was 13.2 days. 70% of all patients were completely healed at 2 months, and 85% completely healed at three months. Pre-operative radiotherapy was found to have a prolonging effect on the time to discharge (P<0.05) but did not reach statistical significance when considering the eventual time to healing. The number of co-morbidities that each patient had at the time of surgery had a prolonging effect on both time to discharge and time to healing (P<0.03). The type of resected areas that required reconstruction did not have a statistically significant effect on the time to discharge, but defects where the anus had been resected did eventually take longer to heal than those were the anus was not resected (P<0.01). 124 flaps were successful (97.6%) with total or partial flap loss occurring in three. Complications were seen in 34 of the 77 patients (44%), with simple wound breakdown resulting in delayed healing seen most frequently (30%). The gluteal fold fasciocutaneous flap is a versatile option for reconstructing a wide range of pelvic and perineal defects. Patients with multiple co-morbidities, cases with radiotherapy and instances where the anus has been resected are more likely to experience longer healing times. We present our algorithm for management for perineal defects after tumour resection.

Introduction: The operating theatre can be a dreaded experience not only for the patient but also occasionally for the surgeon. We sought to investigate the prevalence of pain experienced by surgeons while operating.Methods: One hundred and thirty anonymous questionnaires were sent to surgical consultants in the Britain.Results: The response rate was 60% and 63 experienced pain while operating. The back and neck were the most common areas of pain (36 & 30 consultants respectively), followed by the hand (24 consultants). Nearly 80% described pains on a regular basis. Table height was the most common cause of pain (35%), followed by the use of microscopes (27%) and standing (22%). Nearly 43% of the consultants will take a break from surgery because of their symptoms, and 4 took sick leave in direct relation to pain experienced as a result of operating. However only 27% took measures to reduce their symptoms and 65% never sought any help or advice and only one consultant informed the occupational health department.Conclusion: Many surgeons will experience pain while operating due to positioning or the instruments they use, however there are no guidelines from occupational health departments or training courses to help minimise these symptoms. (C) 2009 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Cutaneous squamous cell carcinoma (cSCC) remains the second most common skin malignancy worldwide. 1 Goldman G.D. Squamous cell cancer: a practical approach. Semin Cutan Med Surg. 1998; 17: 80-95 Crossref PubMed Scopus (80) Google Scholar In order to harmonise the management of cSCC, the British Association of Plastic Surgeons (BAPS) and the British Association of Dermatologists (BAD) published guidelines for the management of primary cSCC. 2 Motley R. Kersey P. Lawrence C. Multiprofessional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma. Br J Plast Surg. 2003; 56: 85-91 Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar The aim of this work was to find out, and for the first time, to what extent these guidelines have been accepted into practice by plastic surgeons in the UK.

TECHNIQUE While preparing the tibial plateau for resection, the knee is fully flexed with retraction of the distal femur and soft tissues to expose the area adequately. This is generally done using a singleand double-pronged retractor held by an assistant. In our technique, the double-pronged retractor is held using a pair of Kocher’s forceps passed through the proximal hole in the retractor and attached to the drapes. The single-pronged retractor may then be positioned to retract the lateral soft tissues. This is held in position by a second pair of Kocher’s forceps, the jaws of which are closed around the double-pronged retractor, with the single-pronged retractor held between the two handles, against the ratchet mechanism of the forceps (Fig. 1). DISCUSSION With the advent of the European Working Time Directive, it has become increasingly difficult to acquire the services of an assistant in theatre. Joint exposure is an extremely important step in total knee arthroplasty that requires adequate retraction to show the tibial plateau. We feel that when assistance is unavailable, the described technique provides reliable exposure during this vital step in the procedure.

Department of Plastic Surgery, Royal Preston Hospital, Preston, United Kingdom Correspondence to Dr. Khan, Department of Plastic Surgery, Royal Preston Hospital, Preston, Lancashire PR2 9HT, United Kingdom, [email protected]

Pereira, Clifford F.R.C.S.; Oudit, Deemesh M.R.C.S.Ed.; McGrouther, D A. F.R.C.S. Author Information

Department of Plastic and Reconstructive Surgery, Lancashire Teaching Hospitals, Preston and Birmingham, United Kingdom Correspondence to Dr. Oudit, Department of Plastic and Reconstructive Surgery, Royal Preston Hospital, Sharoe Green Lane North, Fulwood, Preston PR2 9HT, United Kingdom, [email protected]

Oudit, Deemesh M.R.C.S.Ed.; Ellabban, M F.R.C.S.; Eldafl, D; Crawford, Louise M.R.C.S.Ed.; Juma, Ali F.R.C.S.(Plast.) Author Information

We describe the use of a modified V-Y advancement flap from the lateral aspect of the outer canthus to cover a defect with three components on the lateral aspects of the upper and lower eyelids and the outer canthus of the eye.

Scholten, Erik M.D., Ph.D.; Nanhekhan, L V. M.D.; Oudit, D M.R.C.S.Ed.; Hage, J J. M.D., Ph.D. Author Information