Endometriosis-associated clear cell carcinoma arising in caesarean section scar: a case report and review of the literature

Background

Malignant transformation has been reported in approximately 1% of the endometriosis cases; herein, we report a case of clear cell endometrial carcinoma arising from endometriosis foci located within a caesarean section scar.

Case presentation

In November 2014, a Caucasian, 44-year-old woman was transferred to our institution because of severe respiratory failure due to massive lung embolism and rapid enlargement of a subcutaneous suprapubic mass. Abdomino-pelvic magnetic resonance showed a 10.5 × 5.0 × 5.0 cm subcutaneous solid mass involving the rectus abdominis muscle. Pelvic organs appeared normal, while right external iliac lymph nodes appeared enlarged (maximum diameter = 16 mm). A whole-body positron emission tomography/computed tomography scan showed irregular uptake of the radiotracer in the 22 cm mass of the abdominal wall, and in enlarged external iliac and inguinal lymph nodes. In December 2014, the patient underwent exploratory laparoscopy showing normal adnexae and pelvic organs; peritoneal as well as cervical, endometrial and vesical biopsies were negative. The patient was administered neo-adjuvant chemotherapy with carboplatin and paclitaxel, weekly, without benefit and then underwent wide resection of the abdominal mass, partial removal of rectus abdominis muscle and fascia, radical hysterectomy, bilateral salpingo-oophorectomy, and inguinal and pelvic lymphadenectomy. The muscular gap was repaired employing a gore-tex mesh while the external covering was made by a pedicled perforator fasciocutaneous anterolateral thigh flap. Final diagnosis was clear cell endometrial adenocarcinoma arising from endometriosis foci within the caesarean section scar. Pelvic and inguinal lymph nodes were metastatic. Tumor cells were positive for CK7 EMA, CKAE1/AE3, CD15, CA-125, while immunoreaction for Calretinin, WT1, estrogen, and progesterone receptors, cytokeratin 20, CD10, alpha fetoprotein, CDX2, TTF1, and thyroglobulin were all negative. Liver relapse occurred after 2 months; despite 3 cycles of pegylated liposomal doxorubicin (20 mg/m², biweekly administration), the death of the patient disease occurred 1 month later.

Conclusions

Attention should be focused on careful evaluation of patient history in terms of pelvic surgery, and symptoms suggestive of endometriosis such as repeated occurrence of endometriosis nodules at CS scar, or cyclic pain, or volume changes of the nodules.

A Snapshot on the On-Label and Off-Label Use of the Interleukin-1 Inhibitors in Italy among Rheumatologists and Pediatric Rheumatologists: A Nationwide Multi-Center Retrospective Observational Study

Background: Interleukin (IL)-1 inhibitors have been suggested as possible therapeutic options in a large number of old and new clinical entities characterized by an IL-1 driven pathogenesis.

Objectives: To perform a nationwide snapshot of the on-label and off-label use of anakinra (ANA) and canakinumab (CAN) for different conditions both in children and adults.

Methods: We retrospectively collected demographic, clinical, and therapeutic data from both adult and pediatric patients treated with IL-1 inhibitors from January 2008 to July 2016.

Results: Five hundred and twenty-six treatment courses given to 475 patients (195 males, 280 females; 111 children and 364 adults) were evaluated. ANA was administered in 421 (80.04%) courses, CAN in 105 (19.96%). Sixty-two (32.1%) patients had been treated with both agents. IL-1 inhibitors were employed in 38 different indications (37 with ANA, 16 with CAN). Off-label use was more frequent for ANA than CAN (p < 0.0001). ANA was employed as first-line biologic approach in 323 (76.7%) cases, while CAN in 37 cases (35.2%). IL-1 inhibitors were associated with corticosteroids in 285 (54.18%) courses and disease modifying anti-rheumatic drugs (DMARDs) in 156 (29.65%). ANA dosage ranged from 30 to 200 mg/day (or 1.0–2.0 mg/kg/day) among adults and 2–4 mg/kg/day among children; regarding CAN, the most frequently used posologies were 150mg every 8 weeks, 150mg every 4 weeks and 150mg every 6 weeks. The frequency of failure was higher among patients treated with ANA at a dosage of 100 mg/day than those treated with 2 mg/kg/day (p = 0.03). Seventy-six patients (14.4%) reported an adverse event (AE) and 10 (1.9%) a severe AE. AEs occurred more frequently after the age of 65 compared to both children and patients aged between 16 and 65 (p = 0.003 and p = 0.03, respectively).

Conclusions: IL-1 inhibitors are mostly used off-label, especially ANA, during adulthood. The high frequency of good clinical responses suggests that IL-1 inhibitors are used with awareness of pathogenetic mechanisms; adult healthcare physicians generally employ standard dosages, while pediatricians are more prone in using a weight-based posology. Dose adjustments and switching between different agents showed to be effective treatment strategies. Our data confirm the good safety profile of IL-1 inhibitors.

One year in review 2016: pathogenesis of rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune disease characterised by chronic synovial inflammation leading to joint destruction and bone erosions. Although the pathogenic mechanisms underlying the disease are not fully elucidated, it is known that genetic susceptibility and environmental factors trigger an abnormal autoimmune response. Potentially, any organ and tissue could be affected by RA and the increased cardiovascular (CV) risk represents the major complication responsible for a worse prognosis. In this setting, the shared pathogenic mechanisms between RA pathogenesis and accelerated atherosclerosis further strengthen the rationale for a treat-to-target strategy with synthetic and biologic disease modifying anti-rheumatic drugs. The aim of this review is to provide the novel insights, regarding the pathogenesis of RA, published over the last year.

Surgical therapy of vulvar cancer: how to choose the correct reconstruction?

Objective

To create a comprehensive algorithmic approach to reconstruction after vulvar cancer ablative surgery, which includes both traditional and perforator flaps, evaluating anatomical subunits and shape of the defect.

Methods

We retrospectively reviewed 80 cases of reconstruction after vulvar cancer ablative surgery, performed between June 2006 and January 2016, transferring 101 flaps. We registered the possibility to achieve the complete wound closure, even in presence of very complex defects, and the postoperative complications. On the basis of these experience, analyzing the choices made and considering the complications, we developed an algorithm to help with the selection of the flap in vulvoperineal reconstruction after oncologic ablative surgery for vulvar cancer.

Results

We employed eight types of different flaps, including 54 traditional fasciocutaneous V-Y flaps, 23 rectus abdominis myocutaneous flaps, 11 anterolateral thigh flaps, three V-Y gracilis myocutaneous flaps, three free style perforators V-Y flaps from the inner thigh, two Limberg flaps, two lotus flaps, two deep inferior epigastric artery perforator flap, and one superficial circumflex iliac artery perforator flap. The structures most frequently involved in resection were vulva, perineum, mons pubis, groins, vagina, urethra and, more rarely, rectum, bladder, and lower abdominal wall.

Conclusion

The algorithm we implemented can be a useful tool to help flap selection. The key points in the decision-making process are: anatomical subunits to be covered, overall shape and symmetry of the defect and some patient features such as skin laxity or previous radiotherapy. Perforator flaps, when feasible, must be considered standard in vulvoperineal reconstruction, although in some cases traditional flaps remain the best choice.

Abdominal Subcutaneous Mass After Laser-Assisted Lipolysis and Immediate Multiple Treatments with a Dual-Wavelength Laser, Vacuum and Massage Device

Body contouring by means of minimally invasive procedures is a growing trend. Current approaches to body contouring often involve a combination of surgical techniques (eg, laser-assisted liposuction) and a series of noninvasive device-based treatments aimed at accelerating recovery and improving aesthetic outcomes. In this case study, we describe a 38-year-old woman who presented with an abdominal-wall mass that resembled a tumor when assessed with magnetic resonance imaging. Twenty-six months before presenting to our office, the patient had undergone laser lipolysis and a series of treatments with a device that delivered dual-wavelength laser energy and vacuum-assisted massage. To address the patient's concerns, we removed the mass and performed abdominal dermolipectomy. No postoperative complications occurred, and the patient was highly satisfied with the aesthetic outcome. The results of histologic studies indicated that the mass was pseudocystic and fluid-filled, surrounded by a fibrous capsule, and characterized as a foreign-body granuloma. Further analysis is warranted regarding the safety of laser lipolysis without aspiration combined with a device delivering dual-wavelength laser energy and vacuum-assisted massage.

LEVEL OF EVIDENCE

5 Risk.

Short-course radiotherapy in elderly patients with early stage non-melanoma skin cancer: a phase II study

AIM

To evaluate outcome of an accelerated radiotherapy (RT) regimen in elderly patients with an early stage non-melanoma skin cancer (NMSC).

METHODS

Total RT dose was 30 Gy in 5 Gy fractions in six consecutive days.

RESULTS

Thirty-one patients were enrolled. Fourteen were aged ≥80 years. Acute skin and observed late toxicity were exclusively of grade 1. Thirty patients showed a complete response (median follow-up 30 months). Two-year actuarial local control was 93.2%. The cosmetic result was mostly judged as good or excellent.

CONCLUSIONS

Short-course RT in elderly NMSC patients produces >90% local control of disease.

Acral melanoma of the hallux

OBJECTIVE

A case of misdiagnosed acral melanoma of the hallux and its diagnostic challenge are herein presented. Acral melanoma is insidious and subtle. A methodic approach to any suspicious lesions is mandatory. A case of misdiagnosed acral melanoma of the hallux is herein reported in a 66-year-old healthy man. Suggestions concerning similar non-healing lesions are herein presented.

MATERIALS AND METHODS

It was firstly clinically diagnosed and treated as a micosis at another centre. The absence of any amelioration after three years pushed us to perform a biopsy.

RESULTS

An acral melanoma was revealed, treated by amputation.

CONCLUSIONS

In case of a non-healing ulcer of the lower extremities, melanoma should be taken into consideration. Even in absence of any suggestive risk factors or clear signs of melanoma, the lack of any improvement after treatment should raise doubts about diagnosis. In particular, biopsy is advisable as a first attempt to guide the management.

Postabdominoplasty Wound Dehiscence in Bariatric Patients: Biliopancreatic Diversion Versus Gastric Bypass: A Preliminary Study

BACKGROUND

Surgical procedures with an extended follow-up and therefore recognized as safe in literature are classified into 2 categories: procedures limiting the introduction of food mechanically (restrictive interventions such as adjustable gastric banding, vertical banded gastroplasty, and sleeve gastrectomy) or functionally (mini gastric bypass or gastric bypass) and procedures limiting absorption (mainly biliopancreatic diversion [BPD]).

MATERIALS AND METHODS

Seventy-nine patients who underwent postbariatric abdominoplasty to correct serious flaws resulting from weight loss surgery were included in this retrospective study. Dehiscence of the surgical wound was carefully investigated between the population previously submitted to BPD and gastric bypass. The data were analyzed by correlating the incidence of postoperative dehiscence by Fisher exact test, with a statistical significance level of P<0.05.

RESULTS

Among the 42 abdominoplasties after BPD, dehiscence rate was 33% (14 patients), whereas in the group of 37 patients who underwent gastric bypass, the occurrence of dehiscence was 8% (3 patients).The Fisher exact test highlighted previously performed BPD as statistically significant for the onset of postoperative dehiscence (P=0.012).

CONCLUSIONS

There is a great need to validate these data on large or multicentric studies. The previous bariatric surgery procedure may play a role similar to so many other widely investigated risk factors such as smoking and body mass index, and some categories of patients should require even more attention in the preoperative, intraoperative, and postoperative management.

Multiple lipomatosis after stem cell trasplant and chemotherapy: a case report

BACKGROUND

Lipomas are the most common type of soft tissue benign tumor. They can be either isolated entities or involved in a multiple lipomatosis, which may have a familial basis or be an acquired condition.

AIM

Chemotherapy and/or blood stem cell transplantation may be plausible causes of multiple lipomatosis.

MATERIALS AND METHODS

A 28 year-old patient was diagnosed with non-seminomatous germ cell left testicular cancer. The patient was addressed to chemotherapy and peripheral blood stem cell chemomobilization. After stem cells collection, the patient underwent autologous peripheral blood stem cell transplant.

RESULTS

A subsequent de novo multiple lipomatosis onset developed.

CONCLUSIONS

Although this is a preliminary study and further elaborations are needed, dermatologists and surgeons facing with multiple lipomatosis should consider previous chemotherapy and peripheral blood stem cell mobilization/transplant as possible causes of its onset.

A simple procedure to facilitate chin implants placement via submental approach

In order to facilitate chin implants placement by submental incision, the use of two threads is described. They are separately passed through the extremities of the implant and inserted into the previously created subperiosteal pocket using a grooved guide. Once the landmarks of dissection have been reached, the tip of the needle exits through the skin just a few centimetres laterally to the augmentation area and, only by pulling the free ends of the threads, the implant can easily be inserted into the pocket and the sutures cut and removed. This procedure was successfully performed in 79 patients of both sexes presenting with deficiencies in the sagittal dimension at the pogonion and in width, laterally to the symphysis. Therefore, in the authors' opinion, the before-described technique could be a useful tool that facial plastic surgeons can employ to facilitate alloplastic chin implants placement, by minimising the invasiveness of the procedure, reducing the operative time, and greatly improving the aesthetic result, without sacrificing the safety of the operation.

"Inverted-Y": a modified vest-over-pants abdominoplasty pattern following bariatric surgery

BACKGROUND

The post-bariatric surgery patient presents several challenges to the surgeon. Correction of skin and subcutaneous redundancy can be difficult, particularly in massive-weight-loss patients with horizontal laxity, upper abdominal or flank laxity, and "double-roll" deformities. The aim of our study was to propose our modification of the "vest-over-pants" abdominoplasty technique to exploit all the advantages of the Planas technique in bariatric surgery patients and to solve the problem of extreme epigastric skin redundancy in difficult abdominal contour cases.

METHODS

Sixteen post-bariatric surgery patients (10 females and 6 males, nonsmokers) with moderate to severe epigastric skin laxity were enrolled in the study. They all had undergone a biliopancreatic diversion (BPD) by laparotomy and had undergone this body-contouring procedure from 2006 to 2010.

RESULTS

After the inverted-Y abdominoplasty, 12 patients (75 %) had an uneventful recovery. On the other hand, one subject (6.25 %) had a seroma and four (25 %) had wound dehiscence and delayed wound healing. No skin necrosis was reported. In one patient (6.25 %) scar revision in areas that had delayed healing was performed. The addition of a vertical incision has not led to an increased rate of postoperative complications, but the rates are in line with the satisfactory results described with the Planas technique in bariatric surgery patients. In addition, various advantages have been observed compared to traditional vertical resection patterns.

CONCLUSION

This case series has quantitative limitations and further investigations are needed. However, this study suggests that inverted-Y abdominoplasty could be a good compromise between the need to minimize complication rates and ensure an optimum aesthetic result and patient satisfaction rate in some abdominal defects in massive-weight-loss patients.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article.