Limb Lesions Research Articles

TNF receptor-associated periodic syndrome (TRAPS): Description of a novel TNFRSF1A mutation and response to etanercept

TRAPS is the most common of the autosomal dominant periodic fever syndromes. It is caused by mutations in the TNFRSF1A gene, which encodes for the type 1 TNF-receptor (TNFR1). We describe here a Brazilian patient with TRAPS associated to a novel TNFRSF1A de novo mutation and the response to anti-TNF therapy. The patient is a 9-year-old girl with recurrent fevers since the age of 3 years, usually lasting 3 to 7 days, and recurring every other week. These episodes are associated with mild abdominal pain, nausea, vomiting and generalized myalgia. Recurrent conjunctivitis and erysipela-like skin lesions in the lower limbs also occur. Laboratory studies show persistent normocytic normochromic anemia, thrombocytosis, elevated erythrocyte sedimentation rate and C-reactive protein. IgD levels are normal. Mutational screening of TNFRSF1A revealed the association of a novel C30F mutation with the common R92Q low-penetrance mutation. The R92Q mutation is seen in 5% of the general population and is associated with an atypical inflammatory phenotype. The patient had a very good response to etanercept, with cessation of fever and normalization of inflammatory markers. Our report expands the spectrum of TNFRSF1A mutations associated with TRAPS, adding further evidence for possible additive effects of a low-penetration R92Q and cysteine residue mutations, and confirms etanercept as an efficacious treatment alternative.

Un lymphome musculaire : à propos d’une observation

Skeletal muscle involvement is uncommon in lymphoma, occurring in less than 1.5% of patients. We report the original case of a 61-year-old man who presented with pseudotumoral muscle lesions of the lower limbs, revealing non-Hodgkin T-cell lymphoma. In our patient, magnetic resonance imaging (MRI) was useful in clearly revealing the detailed anatomic extent of muscle change; indeed, MRI showed muscle enhancement after intravenous administration of gadolinium on T1-weighted images as well as high-signal intensity on T2-weighted images. Moreover, MRI was helpful in guiding the optimal site for muscle biopsy.

Lymph drainage in patients with joint immobility due to chronic ulcerated lesions

The fibrous process of chronic ulcerated lesions of lower limbs can impair the mobility of the affected limb. The aim of this work was to assess the benefits of lymph drainage in patients who suffer from this disease. Twenty female and five male patients with ages ranging from 53 to 69 years (mean age 60.6 years) were evaluated. All had a history of at least 10 years of varicose veins and/or ulcerated lesions of the lower limbs with initial dermatofibrosis, with the positive Godet sign during the physical examination of the limb. Patients with intermittent claudication, diabetes and trauma were excluded from the study, as well as patients with chronic dermatofibrosis, and in whom positive Godet sign was not seen. Patients with immobility or very limited movement of the ankle and with some limitation in the toe joints were selected. The patients were randomly divided into group A comprising 15 individuals, and group B 10. All the individual treatments were established before the start of the evaluation period. Lymph drainage was performed on the patients of group A four or five times per week. Group B was subjected to a type of massage for the same period and at the same frequency. The mobility of the ankle joints was evaluated using goniometry before the start and after 30 days of treatment. In all the patients who underwent lymph drainage, an improvement of the joint mobility was seen, whereas in the control, group B, there was no obvious change. In conclusion, lymph drainage gave an improvement in the mobility of the ankle joint after impairment due to initial dermatofibrosis in patients with chronic ulcerated lesions.

Cutaneous melanoma: descriptive epidemiological study.

Cutaneous melanoma represents around 3% of all skin tumors. About 20% of such patients will have advanced disease and will die before reaching five years of survival. The aim of this paper was to describe the clinical and histopathological variables and their correlations. Retrospective, descriptive, epidemiological study at the Melanoma Unit, Dermatological Clinic, Irmandade da Santa Casa de Misericórdia, São Paulo. Records from 364 cases between May 1993 and January 2006 were analyzed. The frequencies of all study variables and their 95% confidence intervals were determined. The chi-squared test was used to evaluate associations among the variables, adopting a significant level of 0.05. Females predominated, with 1.4 women for each man. The patients mean age was 58.9 years. Nonwhite patients represented 13.7% of the sample. The prevalent anatomical sites for cutaneous melanoma were the trunk and feet, for both men and women. Acral lentiginous melanoma represented 22.3% of the cohort. In situ primary lesions were observed in few cases and a high percentage of thick cutaneous melanoma was detected. Ulceration was found in 13.4% of the thin tumors (< 1.0 mm). Thicker and ulcerated lesions predominated in male patients (p = 0.011 and p < 0.001 respectively) and in elderly patients (p = 0.021 and p = 0.015). The cohort mostly presented thick and ulcerated tumors, denoting late diagnosis and bad prognosis. Also, the sample was characterized by considerable prevalence of female patients, nonwhite patients, limb lesions and acral lentiginous melanoma.

Welfare and performance of yearling dairy heifers out-wintered on a wood-chip pad or housed indoors on two levels of nutrition

Wood-chip pads represent a low-cost alternative to housing for cattle during the winter. Considering the negative welfare implications associated with housing indoors on concrete, they may also offer welfare benefits to replacement dairy heifers. However, these animals may not be able to withstand winter weather conditions on a grass silage diet. The aim of this experiment was to evaluate behaviour, limb injuries, dirtiness scores, performance and climatic energy demand (CED) of yearling dairy heifers on two levels of nutrition kept outdoors on a wood-chip pad or indoors in cubicles during the winter. Ninety-six 10-month-old heifers were blocked and assigned in groups of eight, to one of the following four treatments in a 2 × 2 factorial design: (a) indoors, silage only; (b) indoors, silage plus concentrate; (c) outdoors, silage only; and (d) outdoors, silage plus concentrate. There were three replicate groups per treatment. All animals were inspected for skin lesions and were weighed and body condition scored (BCS) at the beginning and end of the trial. Instantaneous scan sampling and continuous all-occurrence behaviour sampling were used to collect behaviour data during two 24-h periods. Animals were also dirtiness scored and group feed intakes were recorded during the trial. Significantly more comfort, social and play behaviours were recorded outdoors (P < 0.05) while trips, slips and falls were only recorded indoors (P < 0.001). Groups outdoors had significantly lower limb lesion scores at the end of the experiment (P < 0.05) and fewer groups outdoors were affected by all categories of limb lesions. However, they were consistently dirtier than animals indoors (P < 0.001). Low-nutrition animals had lower feed intakes, smaller BCS changes and lower average daily weight gains than high-nutrition animals (P < 0.01). Heifers outdoors had significantly lower average daily weight gains and BCS changes (P < 0.05) explained by lower feed intakes (P < 0.01). However, outdoor heifers on both the high- and low-nutrition diets and indoor animals on the low-nutrition diet had lower UFL (feed unit for maintenance and lactation (Irish Republic)) intakes (−0.36, −0.35 and −0.22, respectively) than that required to meet the daily live-weight gains they achieved. Heifers indoors on the high-nutrition diet gained 0.98 kg per day but consumed 0.17 UFL more than what would be recommended to achieve a daily weight gain of 1.0 kg. The CED for outdoor heifers was higher than that of indoor heifers (6.18 v. 5.47 MJ/day per m2 body surface area; P < 0.001, s.e.d. 0.044). However, CED did not exceed heat production in any treatment. Although animal performance was reduced outdoors, the wood-chip pad was associated with welfare benefits compared with cubicle housing.

Full thickness skin graft cover for lower limb defects following excision of cutaneous lesions

Excision of cutaneous lesions in the lower limb often results in defects that cannot be closed primarily. In comparison to split-skin grafts, full-thickness skin grafts achieve a better cosmetic outcome but take with more difficulty. We aimed to study the outcome of full-thickness graft resurfacing of such defects. This study included 28 patients who underwent excision of a total of 30 lesions with full-thickness skin grafts. The data gathered included site and size of the lesion, level of excision, method of fixation of the graft, histology results, graft take and presence of donor and recipient complications. The median age of the patients was 87 years. The mean size of the defect was 18.03 cm(2) (roughly 6 x 4 cm(2)). The graft take was good (>80%) in 18 full-thickness skin grafts, while it was partial (50-75%) in 7 patients and was poor (25% or less) in 5 patients. All excision wounds healed without any need for further surgery. Donor site complications occurred in 2 patients. We conclude that, following excision of lower limb lesions, primary full-thickness skin grafting is an effective and safe method of resurfacing defects in the lower limbs with a very low incidence of donor site complications.

Efficacy of the Nd YAG Laser in the treatment of superficial cutaneous vascular lesions

On the basis of accumulated clinical experience, there is some information available about the treatment of vascular lesions with lasers especially the pulse dye laser. Our study aims to assess the efficacy of Nd YAG lasers in the management of cutaneous vascular lesions and compare results with previously published work on the Nd YAG laser, the Pulse Dye Laser, and Intense Pulsed Light (IPL). The apparatus used was the Combined IPL–Nd YAG Laser system from AK lasers. Fifteen patients volunteered with thread veins, spider naevi, and telangectasia. The treatments were given on an outpatient basis, and results were reassessed at 1 month. The results were generally disappointing at 1 month. Ten patients had no improvement. Five patients treated on the face had minimal to moderate improvement. Although the Nd YAG laser showed dramatic immediate results, in the long run, its use proved disappointing for cutaneous venous lesions of the lower limbs, although the results for facial lesions are better and in keeping with previous studies.

Autologous peripheral blood stem cell transplantation in a patient with POEMS syndrome

Dear Editor, A 32-year-old woman was admitted because of progressive numbness in the lower limbs for 15 months, accompanied with pains in the breastbone, spine, and pelvis for 6 months before hospitalization. There was no prior history of exposure to neurologic toxins and no family history of neuropathy. Physical examination revealed splenomegaly, and no hyperpigmentation or other skin changes were observed. Neurological examination demonstrated moderate sensory disturbance of both lower limbs, with disappearance of deep tendon reflexes. Laboratory analysis showed that full blood count and urine routine test are normal. Other normal or negative results include hepatic and renal functions test, folate and VitB12 levels, and auto-antibody screen. Ophthalmoscopy revealed bilateral papilledema. Endocrinologic investigations showed low levels of FT3, FT4, testosterone, and estrogen. Electromyographic analysis demonstrated peripheral motor and sensory nerves demyelinating lesions in upper and lower limbs. Multiple osteosclerotic lesions in ribs, breastbone, spine, and pelvis were disclosed by CT scan (Fig. 1), together with a few lytic lesions in pelvis. Monoclonal IgG (κ) (20.3 g/l)(normal, 7.0–17.0 g/l) was detected in the serum by electrophoresis. There was no Bence-Jones proteinuria. Bone marrow aspiration revealed 2% of mature plasma cell with normal cytogenetics. Normal levels of protein, glucose and cells were detected in the cerebrospinal fluid (CSF). The patient met the criteria for the diagnosis of POEMS syndrome described by Dispenzieri [1]. She was initially treated with two cycles of chemotherapy with MP regimen (melphalan 6 mg/day days 1–7, Dexamethasone 40 mg/day, days 1–4, days 9–12, days 17–20). A minor improvement of numbness in the lower limbs was observed after chemotherapy, with disappearance of splenomegaly and papilledema, but the patient started to present with mild distal weakness of both lower limbs and toes. Bone pains in the breastbone, spine, and pelvis remained, but were stable. As she developed motor deficiency despite systemic chemotherapy, 5 months after diagnosis, she received autologous peripheral blood stem cell transplantation (autoPBSCT). Peripheral blood stem cell collection was performed after mobilization by chemotherapy (intravenous cyclophosphamide 60 mg/kg/day × 2 days), plus subcutaneous granulocyte colony-stimulating factor (rhG-CSF, 5 mg/kg/day) 6 days after chemotherapy and lasted for 3 days. The number of collected mononuclear cells (MNC) was 6.70×10/kg, and the CD34 cells were 7.51×10/kg. High-dose chemotherapy and autoPBSCT were performed 44 days after PBSC collection. She was conditioned using 200 mg/m melphalan, and the PBSC were infused 3 days later. Standard supportive care with prophylactic antibiotics was used before transplantation. Growth factor support was provided 3 days after stem cell transfusion. The transplantation course was uneventful except for a transient neutropenic fever and mucositis, which were settled with broad-spectrum antibacterial therapy. The patient was engrafted and the time to neutrophil count above 0.5×10/ l and platelets above 20×10/l was +10 and +11 days, respectively. Numbness in lower limbs improved gradually, and the area of sensory disturbance of numbness was limited in the bottoms of feet 6 months after transplantation, although Ann Hematol (2008) 87:247–248 DOI 10.1007/s00277-007-0379-2

Isolamento e perfil de suscetibilidade de bactérias de pé diabético e úlcera de estase venosa de pacientes admitidos no pronto-socorro do principal hospital universitário do estado de Goiás, Brasil

CONTEXTO: Lesões infectadas de membros inferiores (úlceras diabéticas e úlceras de estase venosa) são causa de grande sofrimento e incapacitação funcional com impacto social, econômico e aumento do risco de complicações severas. OBJETIVO: Caracterizar a microbiota e determinar o perfil de suscetibilidade antimicrobiana das bactérias isoladas de lesões de membros inferiores secundárias a úlcera de estase venosa e pé diabético. MÉTODOS: Foram incluídos no estudo pacientes portadores de lesões de membros inferiores, sendo diabéticos, e pacientes com úlcera de estase venosa, atendidos em um serviço de urgência de um hospital universitário de Goiânia (GO), no período de fevereiro de 2005 a agosto de 2006. A coleta de material foi realizada com swab de algodão para realização de cultura e teste de sensibilidade antimicrobiana, empregando-se técnicas preconizadas. RESULTADOS: Das amostras analisadas, foi detectada a presença de bactérias em 88,46%. Os cocos gram-positivos foram caracterizados como Staphylococcus aureus e Staphylococcus epidermidis. Dentre os bastonetes gram-negativos, detectou-se Pseudomonas aeruginosa,Escherichia coli,Proteus mirabilis e Enterobacter sp. CONCLUSÕES: Os microrganismos isolados das lesões de membros inferiores (pé diabético e úlcera de estase venosa) incluíram bactérias gram-positivas e negativas, sendo Staphylococcus aureus,Pseudomonas aeruginosa e Escherichia coli as mais freqüentes, com elevada resistência a diversos antimicrobianos.

Multi-slice CT (MSCT) angiography for assessment of traumatic lesions of lower limbs peripheral arteries

The aim of this study was to evaluate the feasibility and effectiveness of multi-slice computed tomography (MSCT) angiography for the assessment of traumatic lesions involving the arteries of the lower limbs. Forty-seven patients with suspected arterial post-traumatic lesions of lower limbs underwent MSCT angiography (4 x 2.5-mm collimation, 3-mm slice width). The standards of reference were: digital subtraction angiography (DSA; patients with inconclusive/doubtful or positive MSCT angiography indicating a need for intravascular treatment), surgical findings (patients with positive MSCT angiography indicating a need for surgery), or clinical/investigational follow-up (patients with negative MSCT angiography and no need for further diagnostic procedures or surgery). All CT exams were technically adequate. Sensitivity, specificity, and overall diagnostic accuracy of MSCT angiography were 96.3, 90, and 93.6%, respectively, relative to the reference of standard findings. In 44 out of 47 patients, MSCT angiography allowed a correct continuation of the diagnostic work-up. MSCT angiography is a reliable fast tool for diagnosing traumatic vascular lesions, providing results comparable to DSA.

Female patients with atherosclerotic lesions of the lower limbs. Not all are alike

Data on female patients with atherosclerotic peripheral arterial disease (PAD) are scarce, and limited primarily to the elderly population with multilevel disease. In this longitudinal observational study we compare female patients below 60 years of age with isolated lesions at the aortic bifurcation or focal superficial femoral artery disease. Analysis is based on consecutive series of 43 female patients with PAD limited to the aortoiliac bifurcation (n = 28, group I) or an isolated femoral segment at the adductor channel (n = 15, group II) seen in a tertiary referral center between 1998 and 2000. The first assessment provided baseline data, with follow up data obtained at this study. Traditional risk factors, carotid artery disease and clinical outcome (mortality, cardiovascular events, vascular re-intervention rate, PAD progression) were evaluated over an interval of 5 (2 to 8) years. Female patients with aortic disease [group I] were younger (51.8 +/- 7.7 vs. 56.7 +/- 7.6 years in group II; p = 0.048), presented a more masculine phenotype, and smoked significantly more often (82% vs. 40%; p = 0.007). Arterial hypertension and diabetes mellitus were more common in group II, though it missed statistical significance (p = 0.068 and p = 0.085). Cardiovascular and limb outcome were comparable in both groups of female patients, while carotid artery disease was more severe in group I (i.e., carotid plaques in 71 vs. 53%). Our data support previous findings that cigarette smoking is a stronger risk factor for aortic disease as compared to femoral disease in younger female patients, with the strongest effect of smoking on a localized region of the aortic bifurcation.

Assessment of the behaviour and welfare of laying hens on free-range units

The aims of this study were twofold: to develop and test an animal-based protocol for the assessment of the physical and emotional elements of the welfare of laying hens on...

Primary investigation of the value of multi-voxel 1H-MRS in differential diagnosis of benign and malignant musculoskeletal lesions of limbs

目的 探讨多体素氢质子MR波谱(1H-MRS)在鉴别良恶性肌骨病变方面的应用价值.方法 搜集经病理证实的骨与软组织良恶性病变患者47例,男28例,女19例.良性病变9例,恶性病变38例.所有病例在1H-MRS检查前均行动态和延迟增强扫描.统计动态增强扫描中MR信号强度-时间(SI-T)曲线最大线性斜率(5.06)鉴别良恶性病变的敏感度、特异度和准确度.将1H-MRS谱线分为2型:Ⅰ型,谱线中3.2 ppm(×10-6)处有明显的胆碱(Cho)峰;Ⅱ型,谱线中3.2 ppm处无明显的Cho峰.统计良恶性病变出现2种谱线的例数,并计算诊断良恶性病变的敏感度、特异度和准确度.结果 9例良性病变的SI-T曲线最大线性斜率范围为0.07～8.54,平均为3.48±2.30.38例恶性病变最大线性斜率范围为2.89～32.50,平均9.56±5.16,以5.09作为SI-T曲线最大斜率的良恶性病变界值时,诊断的敏感度为97.30%,特异度为80.00%,准确度为93.62%.47例中有42例多体素1H-MRS效果满意,9例良性病变中出现Ⅰ型谱线2例,Ⅱ型谱线7例;33例恶性肿瘤中出现Ⅰ型谱线27例,Ⅱ型谱线6例,良恶性谱线类型例数比较,x2=9.13,P＜0.01.Ⅰ型谱线诊断恶性肿瘤的敏感度为93.10%,特异度为53.80%,准确度为80.95%;若不计钙化、骨化成分较多的6例,则敏感度为93.10%,特异度为100%,准确度为94.44%.结论 1H-MRS谱线的类型对评价肌骨病变的生物学活性价值较高,对钙化和骨化较少的病变良恶性的鉴别效果与MR动态增强扫描的效果相当。

Metastatic Breast Tumor Arising from Synovial Sarcoma: Report of a Case

We report a case of metastatic breast tumor arising from a synovial sarcoma of the lower limb. A 27-year-old Japanese woman was diagnosed to have synovial sarcoma 14 months prior to finding a mass in her left breast. An excisional biopsy was performed and a metastatic synovial sarcoma to the breast was confirmed. Eight months after the resection of the breast lesion, the patient developed local recurrences in both her knee and breast. A tumor resection of the limb lesion and a simple mastectomy for the huge lesion, which was diagnosed to be a metastatic breast tumor without lymph node metastasis, were performed. After the operation, the patient received adjuvant systemic chemotherapy. To the best of our knowledge, this is only the second reported case of a solitary metastatic breast tumor arising from synovial sarcoma.

Pulmonary Aspergillosis and Ischemic Distal Limb Necrosis Associated with Enteric Salmonellosis in a Foal

A 5-month-old mixed-breed filly presented with diarrhea due to Salmonella typhimurium infection and subsequently developed pneumonia in addition to ischemic necrosis of distal limbs. Pulmonary lesions were characterized by numerous discrete, disseminated pyogranulomas with intralesional fungal hyphae. The morphologic characteristics of fungal hyphae were consistent with Aspergillus spp., and large numbers of A fumigatus were isolated from lung tissue via fungal culture. Lesions in all 4 limbs were similar in distribution, duration, and severity and were characterized by coagulation necrosis accompanied by occasional thrombi in small vessels without evidence of thrombosis of larger limb arteries. Thus, limb lesions are consistent with symmetrical peripheral gangrene, a potential complication of sepsis.

VACTERL anomalies in patients with esophageal atresia: an updated delineation of the spectrum and review of the literature

The VACTERL complex refers to anomalies of the bony spinal column (V), atresias in the gastrointestinal tract (A), congenital heart lesions (C), tracheoesophageal defects (TE), renal and distal urinary tract anomalies (R) and limb lesions (L). The incidence of each of these components has not been precisely quantified in the recent literature and the full array of anomalies within each systemic class of the VACTERL complex has not been well described. Therefore, we reviewed our most recent 20-year experience of patients born with esophageal atresia to comprehensively delineate and accurately describe the type and incidence of associated lesions. A retrospective review was then conducted on all patients diagnosed with esophageal atresia between 1985 and 2005. Patient demographics recorded included gestational age, weight and gender. The specific types of lesions were carefully cataloged. The outcome measure recorded was survival. One hundred and twelve patients were diagnosed with esophageal atresia were identified during the study period. The gestational age range was 28-41 weeks with an average of 36.5 weeks. Average birth weight was 2,557 g (range 1,107-3,890). A male predominance was seen with 62 males and 50 females. The overall survival was 92.9%. The categorical breakdown of anomalies were vertebral (24.1%), atresia (14.3%), cardiac (32.1%), tracheoesophageal fistula (95.5%), urinary (17.0%), skeletal (16.1%) and other (10.8%). VACTERL anomalies are common in patients with esophageal atresia, however, they appear to have little impact on overall survival.

The “Safari” Technique to Perform Difficult Subintimal Infragenicular Vessels

The purpose of this study was to describe the efficacy of planned combined subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) to obtain the precise recanalization of the patent portion of a distal runoff vessel in critical limb ischemia (CLI) patients presenting long occlusions involving the popliteal trifurcation. Four patients at risk of limb loss due to long occlusions involving the leg vessel tree and not suitable for a surgical bypass were treated by the subintimal antegrade and retrograde (posterior tibial or anterior tibial artery) approach. The patent portion of the runoff vessel was previously assessed by magnetic resonance angiography (MRA) and directly punctured under Doppler ultrasound (US) guidance. A subintimal channel rendezvous was performed to allow snaring of the guidewires. Subsequently, a balloon dilatation was performed without stent deployment. All patients were successfully recanalized and had complete healing of the limb lesions. At the 12-month follow-up all patients showed clinical improvement with no major complications related to the procedure. This combined antegrade and retrograde subintimal approach is currently an excellent endovascular option in patients with long occlusions extending onto the leg vessels trifurcation and at risk of limb loss.

Escorbuto e ictiosis adquirida asociadas a enfermedad de Whipple

The skin manifestations, except for hyperpigmentation, are uncommon in Whipple's disease (WD). We present the case of a 48-year-old male with chronic diarrhea and long course general syndrome associated to neurological manifestations. Skin examination revealed lesions in the lower limbs and gums that were clinically consistent whit scurvy and were confirmed by histological study and measurement of blood vitamin C levels. Furthermore, he had lesions that were clinically and histologically consistent with acquired ichthyosis. The digestive tract biopsy study showed non-necrotizing epithelioid granulomas without the presence of PAS positive macrophages. The patient was diagnosed of Whipple's disease through the identification of genomic fragments of Tropheryma Whippelii by PCR in duodenal samples. He was treated with antibiotics for two years with resolution of the cutaneous and digestive picture but with partial improvement of the neurological symptoms. In the literature reviewed, we did not find any case of acquired ichthyosis associated to WD and only one of scurvy secondary to this rare disease.

Basal cell carcinoma histological clearance margins: an analysis of 1539 conventionally excised tumours. Wider still and deeper?

An analysis of peripheral and deep margins of histological clearance around 1539 consecutive basal cell carcinomas excised by conventional surgery showed that 81 lesions (5.3%) were incompletely excised peripherally; 36 lesions (2.3%) were incompletely excised deeply; 13 lesions (0.8%) were incompletely excised peripherally and deeply. Nine hundred and ninety-six lesions (65%) were excised with a peripheral histological clearance margin<5mm (0.1-4.9mm), whereas 1303 lesions (85%) were excised with a deep histological clearance margin<5mm (0.1-4.9mm). Four hundred and eight lesions (27%) had a peripheral histological clearance margin of 5.0-9.9mm, whereas 170 lesions (11%) had a deep histological margin of 5.0-9.9mm. Peripheral histological clearance margins exceeded 10mm in 41 lesions (3%) and deep histological margins exceeded 10mm in 17 lesions (1%). Thus 30% of peripheral histological margins were 5mm or more but only 12% of deep histological margins were 5mm or more. Despite a relative sparing of deep tissue, incomplete excision in depth affected only 36 lesions compared with 81 incomplete peripheral excisions. Peripheral histological clearance was <5mm (0.1-4.9mm) for 55% of temple lesions, 50% of scalp lesions and 43% for limb lesions. In the cosmetically sensitive areas of peri-orbital region, nose, cheek, lip, neck and chin more than 70% of lesions were excised with a peripheral histological margin<5mm. This study of conventional surgical excision of basal cell carcinomas with an incomplete excision rate of 8% has shown that 65% of lesions were excised with <5mm histological clearance peripherally and 85% with <5mm deep clearance. These figures for 'normal tissue sacrifice' are not excessive when compared with those of 'tissue sparing' Mohs' micrographic surgery in which the operator may take a margin of several millimetres of normal tissue in the initial 'slice', or in the subsequent 'safety margin' beyond the eventual tumour free plane. However, peripheral margins did exceed 5mm in more than 30% of lesions of scalp, temple and forehead, and for these sites where even with loupe magnification the tumour edge could be difficult to define, either frozen section control or Mohs' technique, might with benefit be more often used in order to minimise normal tissue sacrifice.

Interdigital skin lesions of the lower limbs among patients with lymphoedema in an area endemic for bancroftian filariasis

An estimated 15 million persons suffer from lymphoedema of the leg in filariasis-endemic areas of the world. A major factor in the progression of lymphoedema severity is the incidence of acute dermatolymphangioadenitis (ADLA), which is triggered by bacteria that gain entry through damaged skin, especially in the toe web spaces ('interdigital skin lesions'). Little is known about the epidemiology of these skin lesions or about patients' awareness of them. We interviewed and examined 119 patients (89% women) with lymphoedema of the leg in Recife, Brazil, an area endemic for bancroftian filariasis. We detected 412 interdigital skin lesions in 115 (96.6%) patients (mean, 3.5 lesions per patient, range 0-8). The number of interdigital skin lesions was significantly associated with lymphoedema stage (P<0.001) and frequency of ADLA (P<0.0001). Only 20 (16.8%) patients detected their own interdigital skin lesions or considered them abnormal. Patients reported a mean of 3.6 ADLA episodes during the previous 12 months (range, 0-20); reported ADLA incidence was associated with lymphoedema stage (P<0.0001) and the number of interdigital skin lesions detected by the examining physician (P<0.0001). These data suggest that interdigital skin lesions are a significant risk factor for ADLA and that persons with lymphoedema in filariasis-endemic areas are unaware of their presence or importance. Prevention of ADLA through prompt recognition and treatment of interdigital skin lesions will require that patients be taught to identify lesions, especially between the toes and to recognize them as abnormal.