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.

"Vest over pants" abdominoplasty in post-bariatric patients

Obesity has become a worldwide metabolic disease, necessitating appropriate treatment. Conservative therapy has shown lack of success long term on managing weight loss and comorbidities. On the other hand, bariatric surgery has demonstrated effectiveness. Unfortunately, bariatric patients experience significant skin excess, laxity, and ptosis which may lead to postural, functional, hygienic, dermatologic, and aesthetic impairments. These can be corrected only with body-contouring surgery. Among these procedures, abdominoplasty is one of the most commonly performed operations. In 1977, Planas presented his "vest over pants" abdominoplasty, which had several advantages over the previous approaches. In this study, the technique was tested on post-bariatric patients. From 2005 to 2008, subsequent to laparoscopic biliopancreatic diversion, a tummy tuck was performed on 35 patients (28 females; 7 males). The patients were followed up for a mean period of 5 years. After abdominal contouring, 22 patients had an uneventful recovery and local complications were reported in the other 13 patients. Several advantages of this abdominal lipectomy method were recorded: minimal infection rate and single flap weight; high vascular safety; excellent matching of the flaps' thickness and scar position on the abdomen; minimal cumbersome maneuver and traction of the tissues; relatively short operating and lead time; and discrete comfort for the assistants and surgeon. In conclusion, the "vest over pants" abdominoplasty in post-bariatric patients has been demonstrated to be effective, fast to perform, comfortable for the surgeon, and safe.

Abdominoplasty in patient with penile implant

BACKGROUND

In the United States, one third of adult men are obese (BMI > 30 kg/m²) and profound sexual dysfunction is quite common in them. Penile prostheses have proved to be an effective and widespread therapeutic option, with approximately 30,000 devices implanted annually worldwide.

METHODS

A 54-year-old weight-loss male patient came to our practice for body contouring. Upon admission we discovered the presence of a three-piece inflatable prosthesis, placed many years before.

RESULTS

We decided to perform an abdominoplasty plus pubic lift supported by ultrasound in order to better localize the implant reservoir, to exclude tractions or distortions of the connecting system or pump damage, and also to locate and draw the corresponding new position of the reservoir and the pump on the skin.

CONCLUSION

Our case reminded us that we should always suspect the presence of penile prostheses in bariatric patients in order to avoid intraoperative damage and subsequent medicolegal problems. Their precise detection is crucial and ultrasound is a safe, inexpensive, and useful method for accurate pre-, intra-, and postoperative localization of genital prostheses.

The "triple-plane technique" for breast augmentation

Breast augmentation is one of the most frequently performed aesthetic surgery procedures. In the United States, it is the second most commonly performed aesthetic surgery procedure among women, according to the American Society of Aesthetic Plastic Surgery statistics. Different choices available to the surgeon deal with the pocket plane, the skin incisions, and the type of implant. This report describes the results from a retrospective review of the authors' experience with the "triple-plane technique" and its different indications according to breast types. Findings have shown that this technique is suitable for many different types, shapes, and sizes of breasts; that it offers very good and natural results; and particularly, that these results last over time.

Up-regulation of pro-inflammatory genes as adaptation to hypoxia in MCF-7 cells and in human mammary invasive carcinoma microenvironment

The role of tumor cells in synthesizing pro-inflammatory molecules is still controversial. Here we report that hypoxic treatment of the MCF-7 human mammary adenocarcinoma cell line induced activation of hypoxia-inducible factor 1alpha (HIF-1alpha) and nuclear factor-kappa B (NF-kappaB). Importantly, hypoxia regulated expression of alarmin receptors such as the receptor for advanced glycation end products (RAGE) and the purinoreceptor (P2X7R), and up-regulated inflammatory response (IR) genes such as the inducible enzymes nitric oxide synthase (NOS2), cycloxygenase (COX2), and the acute-phase protein pentraxin-3 (PTX3). Hypoxia also stimulated chemokine (C-X-C motif) receptor 4 (CXCR4) mRNA synthesis. In fact, the CXCR4 ligand stromal-derived factor-1alpha (SDF-1alpha) increased invasion and migration of hypoxic MCF-7 cells. Inhibition of HIF-1alpha by chetomin and NF-kappaB by parthenolide reduced mRNA and protein expression of the studied molecules and prevented invasion of hypoxic MCF-7 cells. Moreover, solid invasive mammary tumor microenvironment was analyzed after laser-capture microdissection (LCMD) comparing tumor versus host normal tissue. Nuclear translocation of HIF-1alpha and NF-kappaB and up-regulation of IR, CXCR4, estrogen receptor alpha (ERalpha), and epithelial growth factor receptor (EGFR) was observed in tumor but not in host normal tissue in the absence of a local inflammatory leukocyte infiltrate. We conclude that under hypoxic conditions MCF-7 cells acquire a pro-inflammatory phenotype, and that solid human mammary carcinoma evidenced a similar activation of HIF-1alpha, NF-kappaB, and IR genes in malignant tumor cells as compared to the normal host tissues. We suggest a role for IR activation in the malignant progression of transformed cells.

Association between cutaneous melanoma, Breslow thickness and vitamin D receptor BsmI polymorphism

BACKGROUND

Literature data report an association between some vitamin D receptor (VDR) polymorphisms and different kinds of tumours, including malignant melanoma (MM). Only three VDR polymorphisms (FokI, TaqI and A-1012G) have been investigated in association with the presence of cutaneous MM or the development of metastases.

OBJECTIVES

The present paper analyses for the first time the association between BsmI polymorphism and MM prevalence together with Breslow thickness. In addition, the FokI single nucleotide polymorphism was also determined.

METHODS

One hundred and one patients with MM and 101 healthy donors matched for age and sex were enrolled. Molecular VDR typing was performed by means of restriction fragment length polymorphism analysis.

RESULTS

All cases and controls were in Hardy-Weinberg equilibrium for BsmI, FokI and A-1012G. Significant associations were found between the BsmI bb genotype frequency and MM (P = 0.02) along with Breslow thickness (P = 0.001). This same behaviour was not observed for the FokI or A-1012G polymorphisms. Multivariate logistic regression analysis confirmed these significant results after correction for age, gender, skin type and MM localization.

CONCLUSIONS

Although the biological meaning of the effects exerted by BsmI polymorphism is still under debate, the statistical association found in the present study suggests that further work should be done to verify this variant as a possible risk marker for MM and its aggressiveness, also considering that the real association may be due to other unknown genes linked to the BsmI b allele.

Duplication of the glans penis manifested at puberty

We report the case of a complete duplication of the glans, with prepuce and a blind end urethra just proximal to the dorsal aspect of the balanopreputial fold. The malformation was not evident at birth and during childhood, and became manifest only at puberty, with the growth of the external genitalia. It was not associated with other urinary malformations. Surgical excision was easy and uneventful.

Comparison between three molecular methods for detection of blood melanoma tyrosinase mRNA. Correlation with melanoma stages and S100B, LDH, NSE biochemical markers

BACKGROUND

The molecular monitoring of circulating tumor cells by reverse transcriptase-PCR (RT-PCR) for patients with melanoma, is still under debate. It may be affected by: a) pre-analytical variability, b) frequency of melanoma-associated gene transcripts and c) the reliability of the methods employed. Few commercial methods are available for the detection of tyrosinase mRNA in blood.

OBJECTIVE

Comparison between two RT-PCR-nested methods with a third one based on real-time methodology, for detection and quantitation of tyrosinase transcripts, respectively.

METHODS

Sixty-two melanoma patients with different AJCC stages and 20 healthy subjects were enrolled. All blood samples were extracted in duplicate with two different methods. Two nested-PCR methods (one commercial and one in house) plus a real time commercial kit were employed.

RESULTS

The two nested PCR methods employed were overimposable, specific and sensitive, at least in the stage III, where there was a concordance between sentinel lymph nodes detection and blood tyrosinase positivity. The different extraction methods did not affect the quality of results, while the commercial real-time kit cannot be used.

CONCLUSION

Tyrosinase mRNA detection may be therefore employed to monitor the melanoma patients over time in function of response to therapy.

A simple way to choose the right implant volume in breast augmentation

In planning a breast augmentation, the choice of an appropriate breast implant volume is sometimes a problem, particularly for unskilled surgeons. The authors have used a little trick to make the choice easier for both the surgeon and the patient.