Malignant melanoma (MM), the most common cause of skin cancer deaths, metastasises to regional lymph nodes. In animal models of other cancers, lymphatic growth is associated with metastasis. To assess if lymphatic density (LD) was increased in human MM, and its association with metastasis, we measured LD inside and around archival MM samples (MM, n ¼ 21), and compared them with normal dermis (n ¼ 11), basal cell carcinoma (BCC, n ¼ 6) and Merkel cell carcinoma (MCC), a skin tumour thought to metastasise through a vascular route (MCC, n ¼ 6). Lymphatic capillary density (mm À2 ), as determined by immunohistochemical staining with the lymphatic specific marker LYVE-1, was significantly increased around MM (10.072.5 mm À2 ) compared with normal dermis (2.470.9 mm À2 ), BCC (3.070.9 mm À2 ) and MCC (2.471.4 mm À2 ) (Po0.0001). There was a small decrease in LD inside MM (1.170.7 mm À2 ) compared with normal dermis, but a highly significant decrease in BCC (0.1470.13) and MCC (0.1272.4) (Po0.01 Kruskal -Wallis). Astonishingly, LD discriminated between melanomas that subsequently metastasised (12.871.6 mm À2 ) and those that did not (5.471.1 mm À2 , Po0.01, Mann -Whitney). Lymphatic invasion by tumour cells was seen mainly in MM that metastasised (70% compared with 12% not metastasising, Po0.05 Fisher's Exact test). The results show that LD was increased around MMs, and that LD and tumour cell invasion of lymphatics may help to predict metastasis. To this end, a prognostic index was calculated using LD, lymphatic invasion and thickness that clearly discriminated metastatic from nonmetastatic tumours.

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A vascularised bone segment of the distal radius was harvested as a distally based flap to treat segmental metacarpal bone loss in three patients. One reconstruction followed resection of a giant cell tumour excision and the other two were to replace traumatic bone loss. The bone defects were in the second metacarpal in two cases and in the second and third metacarpal in one case and included three shaft and one distal metacarpal reconstruction. The mean length of the metacarpal defects was 6 cm. All of the flaps survived and no complications occurred at the donor site. Clinical and radiological union was established in all cases after an average of 3 months.

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