ECZEMA VACCINATUM
ECZEMA VACCINATUM
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DOI：
10.1136/bmj.2.5414.906
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发表时间：
1964-01-01
影响因子：
--
通讯作者：
WALLACE, HJ
中科院分区：
文献类型：
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作者：
COPEMAN, PWM;WALLACE, HJ
讨论恶性黑色素瘤的治疗，特别是在没有临床转移证据的情况下（可能被称为“I期”病例），在过去很难计划。 Fortner 等人（1964）在切除原发淋巴结后对区域淋巴结进行了常规块切除。他们发现这些患者中有 38% 有淋巴结受累的显微镜证据。在没有临床证据的情况下，其他人对是否进行常规预防性块切除犹豫不决。块切除后伤口愈合差，伤口败血症发生率高。不可避免地会出现畸形和疤痕，而且常常会出现严重的淋巴水肿。事实上，许多患者拒绝接受这样的手术。另一种治疗计划是切除原发灶，并在进行块解剖之前观察淋巴结是否临床受累。这避免了一部分不必要的手术，但几乎肯定会导致发生淋巴结转移的患者结果较差。手术治疗的另一个缺点是难以处理原发病变和区域淋巴结之间的淋巴管中可能出现的继发性淋巴管生长，因为仅偶尔可以在单个块中切除原发灶和淋巴结。仅通过传统的外部方法，甚至通过超电压X射线或钴伽马射线，以破坏这些恶性细胞所需的高剂量照射该组织块，通常不可能不存在广泛的辐射发病率的风险。这可能需要广泛的手术切除来修复。内淋巴治疗不会出现这种并发症；高剂量集中在淋巴管中，并且正如已经表明的那样，如果发生放射坏死，则其是局部的并且带来相对较小的手术问题。
DiscussionThe treatment of malignant melanoma, particularly in cases where there is no clinical evidence of metastasis-what might be termed" stage I" cases-has been difficult to plan in the past. Fortner et al.(1964) have performed routine block dissection of regional lymph nodes after removing the primary. They found that 38% of these patients had microscopical evidence of node involvement. Others have hesitated to perform routine prophylactic block dissections in the absence of clinical evidence of involvement. Wound-healing is poor after block dissection and the incidence of wound sepsis is high. There is inevitable deformity and scarring and very often severe lymphoedema. Indeed, many patients decline to have such an operation. An alternative plan of management is to excise the primary and wait to see if nodes become clinically involved before performing block dissection. This avoids a proportion of unnecessary operations but almost certainly leads to poorer results in the patients who do develop nodemetastases. Another disadvantage of surgical treatment is the difficulty of dealing with the possible growth of secondaries in the lymphatics intervening between the primary lesion and the regional nodes, for it is only occasionally possible to excise primary and nodes in a single block. Irradiation of this block of tissue by conventional external methods only, even by supervoltage x-ray or cobalt gamma-ray, to the high dosage required for destruction of these malignant cells, is often impossible without the risk of widespread radiation morbidity. This might require extensive surgical excision to repair. This complication does not occur in endolymphatic therapy; the high dose is concentrated in the lymphatics, and, as has been shown, radio-necrosis, should it occur, is localized and presents a relatively minor surgical problem.