Advanced cutaneous squamous cell carcinoma of the trunk and extremity: analysis of prognostic factors

Precision laparoscopic sentinel node navigation surgery for femoral skin cancer

Navigation surgery using indocyanine green (ICG) fluorescence imaging has been used in thoracoabdominal surgery, and its usefulness has been reported in many cases. In this study, laparoscopic lateral lymph node dissection was performed using ICG fluorescence imaging in a patient with left femoral spinous cell carcinoma with inguinal and external iliac lymph node metastases. Spinous cell carcinoma is classified as a rare cancer in Japan, and there is a scarcity of evidence for pelvic lymph node dissection, as well as a lack of studies that mention the dissection area. We hypothesized that visualization of lymph nodes and lymph flow using intraoperative ICG fluorescence imaging would indicate the area of dissection and lead to more efficient dissection. In conclusion, intraoperative ICG fluorescence imaging may be useful in this area where there is limited evidence, although there are some limitations.

Beyond the dermis-high-risk invasive squamous cell carcinoma: a retrospective review

OBJECTIVE

Most cutaneous squamous cell carcinomas (cSCC) are low risk and can be treated with simple excision or ablation. High-risk cSCC require invasive treatment, including radical surgery. We present our experience in treating invasive cSCC of the pelvis and extremities.

METHOD

A retrospective review of the data of patients with invasive cSCC, indicated for surgery between 2014 and 2018, from a single institution was carried out.

RESULTS

A total of 19 patients (nine men, 10 women) were included in the study. Mean age was 62 years; mean tumour size was 8.6cm). Of the 19 patients, five patients with paraplegia with cSCC arising from hard-to-heal ulcers died of infection or bleeding after surgery or systemic therapy. Also, nine patients with localised cSCC underwent margin-negative resection with or without radiation; one patient experienced disease relapse. Of the participants, two patients with previous transplants and multifocal aggressive cSCC underwent numerous resections but succumbed to disease, and two patients who presented with locally recurrent disease after previous positive margin resection and radiation underwent re-resection but developed recurrent disease.

CONCLUSIONS

Prognosis for invasive cSCC largely depends on clinical setting. Tumours arising from ulcers in patients with paraplegia have a poor prognosis regardless of treatment. Invasive cSCC in transplant patients are often multifocal and often recur. Debulking procedures are associated with local recurrence despite radiation. Patients presenting with localised disease have a favourable prognosis with wide resection, flap coverage and adjuvant therapy.

Japanese Dermatological Association Guidelines: Outlines of Guidelines for Cutaneous Squamous Cell Carcinoma 2020

In consideration of the development of treatment options for squamous cell carcinoma (SCC), the Japanese Skin Cancer Society issued the first guidelines of SCC in 2007 and revised them in 2015. Here, we report the English version of the 2020 edition of the Japanese SCC guidelines. The first half of this article is an overview of SCC including actinic keratosis and Bowen's disease, and the second half discusses three clinical questions: (i) treatment of actinic keratosis; (ii) determination of the resection margin of the primary lesion; and (iii) treatment of radically incurable cases, as contemporary problems encountered in treating SCC. In these evaluations, all processes were implemented according to the Grading of Recommendations, Assessment, Development, Evaluation system. Also, items of recommendation concerning each clinical question were determined by a multidisciplinary expert panel consisting of dermatologists, plastic/reconstructive surgeons, radiologists, and oncologists through a comprehensive literature search and systematic reviews.

Primary Invasive Squamous Cell Carcinoma of the Foot

Malignant transformation of wounds is a rare complication that if missed can lead to loss of life or limb. This case report presents a rare invasive variant of squamous cell carcinoma presenting in the setting of a chronic wound complicated by osteomyelitis. This aggressive form of squamous cell carcinoma has a high growth rate and a high propensity for metastasis and recurrence. Early intervention greatly decreases the risk of metastasis and recurrence. We present the systematic evaluation and surgical management of an aggressive primary tumor occurring in the forefoot.

Squamous Cell Carcinoma with Regional Metastasis to Axilla or Groin Lymph Nodes: a Multicenter Outcome Analysis

BACKGROUND

Cutaneous squamous cell carcinoma (cSCC) of the trunk/extremities with nodal metastasis represents a rare but significant clinical challenge. Treatment patterns and outcomes are poorly described.

PATIENTS AND METHODS

Patients with cSCC who developed axilla/groin lymph node metastasis and underwent curative-intent surgery between 2005 and 2015 were identified at four Canadian academic centers. Demographics, tumor characteristics, treatment patterns, recurrence rates, and mortality were described. Overall survival (OS) and disease-free survival (DFS) were calculated using Kaplan-Meier analysis. Predictors of survival and any recurrence were explored using Cox regression and logistic regression models, respectively.

RESULTS

Of 43 patients, 70% were male (median age 74 years). Median follow-up was 38 months. Median time to nodal metastasis was 11.3 months. Thirty-one and 12 patients had nodal metastasis to the axilla and groin, respectively. A total of 72% and 7% received adjuvant and neoadjuvant radiation, respectively, while 5% received adjuvant chemotherapy. Following surgery, 26% patients developed nodal and/or distant disease recurrence. Crude mortality rate was 39.5%. Mean OS was 5.3 years [95% confidence interval (CI) 3.9-6.8 years], and 5-year OS was 55.1%. Mean DFS was 4.8 years (95% CI 3.3-6.2 years), and five-year DFS was 49.3%. Any recurrence was the only independent predictor of death [p = 0.036, odds ratio (OR) = 29.5], and extracapsular extension (p = 0.028, OR = 189) and age (p = 0.017, OR = 0.823) were independent predictors of recurrence.

CONCLUSIONS

This represents the largest contemporary series to date of outcomes for patients with axilla/groin nodal metastases from cSCC. Despite aggressive treatment, outcomes remain modest, indicating the need for a continued multidisciplinary approach and integration of new systemic agents.

Isolated limb perfusion for unresectable extremity cutaneous squamous cell carcinoma; an effective limb saving strategy

Background

A small minority of patients present with locally advanced cutaneous Squamous Cell Carcinoma (cSCC). The aim of this study was to evaluate the effectiveness of Tumour necrosis factor α (TNF) and melphalan based isolated limb perfusion (TM-ILP) as a limb saving strategy for locally advanced extremity cSCC.

Methods

A retrospective search from prospectively maintained databases, at two tertiary referral centers, was performed to identify patients treated with TM-ILP for locally advanced cSSC of an extremity between 2000 and 2015.

Results

A total of 30 patients treated with TM-ILP for cSCC were identified, with a median age of 71 years (36–92) and 50% female. Response could not be evaluated in 3 patients. After a median follow up of 25 months, the overall response rate was 81% (n = 22), with 16 patients having a complete response (CR, 59%). A total of 7 patients developed local recurrence, with a median time to recurrence of 9 months (Interquartile Range 7–10). Progressive disease was observed in 5 patients (19%). Limb salvage rate was 80%. The overall 2-year survival was 67%.

Conclusions

TM-ILP should be considered as an option in patients with locally advanced cSCC in specialised centers, resulting in a high limb salvage rate.

The Effect of Differentiation Grade of Cutaneous Squamous Cell Carcinoma on Excision Margins, Local Recurrence, Metastasis, and Patient Survival: A Retrospective Follow-Up Study

BACKGROUND

The incidence of cutaneous squamous cell carcinoma (SCC) is increasing worldwide. Despite a growing body of literature on prognostic factors, it remains unclear how tumor differentiation grade influences patient survival. The aim of this study was to investigate a possible correlation between cutaneous SCC differentiation, local recurrence, metastasis, and patient survival.

MATERIALS AND METHODS

All consecutive patients treated for cutaneous SCC between 2001 and 2008 were retrospectively analyzed. Univariate survival analysis was used to assess the association of different tumor characteristics with survival.

RESULTS

One hundred thirty-one patients with 155 SCCs were included (median follow-up, 81 months; range, 27-125 months). Although no significant correlation between tumor differentiation grade and local recurrence could be found, it was an independent prognostic factor for metastatic disease and overall survival (OS). Metastasis-free survival at 5 years was significantly higher in well-differentiated tumors (70%) compared to moderately (51%) and poorly differentiated SCCs (26%; P = 0.012); identical percentages were found for OS (P = 0.005). Furthermore, patients with incomplete excision of the first tumor showed an increased relative risk of dying of SCC of 4.0 (95% confidence interval, 2.4-6.6; P < 0.001) compared to excision with clear margins.

CONCLUSIONS

Studies that investigated the relationship between SCC differentiation grade and patient survival are scarce and inconsistent. The present study indicates tumor differentiation grade is an independent prognostic factor for OS. This finding suggests poor differentiation of cutaneous SCC alone is sufficient to upstage the primary tumor in the TNM classification system.

Dermatology clinics: what's new in dermatopathology: news in nonmelanocytic neoplasia

This article reviews the recent dermatopathology literature involving nonmelanocytic neoplasia, with a focus on important work done over the last 5 years. The discussion includes advances in the understanding of Merkel cell carcinoma pathogenesis and prognosis; changes in the seventh edition of the American Joint Committee of Cancer staging manual in reference to staging of squamous cell carcinoma and Merkel cell carcinoma; newly described or rare histopathologic patterns and entities including squamoid eccrine ductal carcinoma, rippled-pattern adnexal neoplasms, onychomatricoma, spindle cell predominant trichodiscoma/neurofollicular hamartoma, and myoepithelioma; and microsatellite instability in sebaceous neoplasms of Muir-Torre syndrome and other tumors.

LC3A-positive "stone-like" structures in cutaneous squamous cell carcinomas

This study was set to investigate the relation between autophagic activity and the aggressiveness of cutaneous squamous cell carcinomas (SCC), as indicated by tumor thickness and proliferative activity. The anti-LC3A antibody, recognizing both the soluble and the autophagosome-bound forms of the protein, and a standard immunohistochemical technique were applied to 75 cutaneous SCC of variable tumor thickness. The study was complemented by staining for MIB1. Three patterns of LC3A reactivity were recognized: diffuse cytoplasmic, cytoplasmic/perinuclear, and "stone-like" structures (SLS), that is, large, rounded, densely stained amorphous material, 5 μm on average, enclosed within cytoplasmic vacuoles. Higher numbers of SLS were counted in >6-mm-thick SCC compared with the intermediate-thickness tumors (2.1-6 mm) and the <2-mm-thick tumors; the mean recorded values, being 8.8, 4.55, and 1.55, respectively, were statistically significant. The diffuse cytoplasmic staining showed a nearly inverse trend, whereas the perinuclear pattern, expressed in <10% of the total, was not evaluated. With regard to MIB1 proliferation index, this increased with tumor thickness and, in linear regression analysis, was directly linked with SLS counts and inversely with the cytoplasmic pattern. These data suggest that autophagic activity in SCC, when expressed as high LC3A/SLS counts, can be regarded as an indicator of tumor aggressiveness.

Sentinel lymph node biopsy for high-risk cutaneous squamous cell carcinoma: clinical experience and review of literature

High-risk cutaneous squamous cell carcinoma (SCC) is associated with an increased risk of metastases. The role of sentinel lymph node (SLN) biopsy in these patients remains unclear. To address this uncertainty, we collected clinical data on six patients with clinical N0 high-risk SCC that underwent SLN biopsy between 1999 and 2006 and performed a literature review of SLN procedures for SCC to study the utility of SLN biopsy. There were no positive SLN identified among six cases and there was one local and one distant recurrence on follow-up. Literature review identified 130 reported cases of SLN biopsy for SCC. The SLN positivity rate was 14.1%, 10.1%, and 18.6%; false negative rate was 15.4%, 0%, and 22.2%; and the negative predictive value was 97.8%, 100%, and 95.2% for all sites, head/neck, and truncal/extremity sites, respectively. SLN biopsy remains an investigational staging tool in clinically node-negative high-risk SCC patients. The higher false negative rate and lower negative predictive value among SCC of the trunk/extremity compared to SCC of the head/neck sites suggests a more cautious approach when treating patients with the former. Given the paucity of long-term follow up, an emphasis is placed upon the need for close surveillance regardless of SLN status.

Prognostic and risk factors in patients with locally advanced cutaneous squamous cell carcinoma of the trunk and extremities

55 patients with advanced cutaneous squamous cell carcinoma (CSCC) of the trunk and extremities were studied. A Tissue Microarray was constructed using immunohistochemistry to quantify expression of the HER family, E-cadherins, and podoplanin. Clinical and histopathological factors related to lymph node metastasis and prognosis were also established. Primary tumor positivity was 25.5% for EGFR, 87.3% for HER-3, and 48.1% for HER-4. Metastases were positive for EGFR in 41.7%, for HER-3 in 83.3%, and HER-4 in 43.5%. HER-2 was negative in all samples. Membrane E-cadherin and cytoplasmic E-cadherin were positive in 47.3% and 30.2% of primary tumors and 45.5% and 27.3% of metastases, respectively. Podoplanin was positive in 41.8% of primary tumors and 41.7% of metastases. Intratumoral lymphocytic infiltrate was associated with lymph node metastasis. Patients with T3 tumors had better cancer-specific survival (CSS) than those with T4 tumors; patients with no lymph node involvement had better CSS than patients with N1 tumors. Undifferentiated tumors and hyperexpression of podoplanin were negative prognostic indicators on multivariate analysis.

Hemipelvectomy and Reconstruction in a Patient With Advanced Marjolin’s Ulcer: A Case Report

Patients with squamous cell carcinoma of the lower limb may exhibit locally advanced or metastatic disease. Surgical resection to control the primary tumor is often extensive.The case of a 51-year-old man with squamous cell carcinoma on Marjolin’s ulcer affected, rapidly growing, and involving soft and bone tissues is described. Treatment required performing a hemipelvectomy. Immediate reconstruction was chosen as surgical procedure planning the harvest of 4 superficial muscles and 1 deep muscle of the abdomen to protect the pelvic content and to eliminate the dead spaces.The chosen technique minimized postoperative complications, and at 7 years follow-up, the patient is disease free.

Human papillomavirus-associated squamous cell carcinoma of the nail bed in African-American patients

BACKGROUND

Human papillomavirus (HPV) has been implicated in the development of digital squamous cell carcinoma (SCC). Case reports in the literature mostly identify HPV type 16 present in tumors, but HPV types 2, 31, 34, 35, and 73 have also been isolated.

METHODS

Two cases of digital SCC associated with HPV 16 in young African-American men are presented.

RESULTS AND CONCLUSIONS

Digital SCC associated with HPV may be difficult to evaluate and treat, particularly in African-Americans and patients with human immunodeficiency virus (HIV). We discuss the need for careful evaluation, treatment, and follow-up of these individuals.

Prognostic factors for lymph node metastasis from advanced squamous cell carcinoma of the skin of the trunk and extremities

Background

Squamous cell carcinoma (SCC) of the skin of the trunk and extremities may present lymph node metastasis with difficult disease control and poor survival. The purpose of this study was to identify risk factors for lymph node metastasis and outcome.

Patients/Methods

Retrospective review of 57 patients with locally advanced SCC of the trunk and extremities was performed and several clinical variables including age, gender, ethnicity, previously injured skin (burns, scars, ulcers and others), patient origin (rural or urban), anatomic site and treatment were studied.

Results

Fifteen patients presented with previous skin lesions. Thirty-six were classified as T3 tumors and 21 as T4; 46 were N0, and 11, N1. Eleven N0 patients presented lymph node metastasis during follow up. Univariate analysis identified previous skin lesions (ulcers and scars) as risk factor for lymph node metastasis (p = 0.047). Better survival was demonstrated for T3 (p = 0.018) classification. N0 patients who presented lymph node metastasis during follow up (submitted to lymphadenectomy) had similar survival to patients without lymph node recurrence (p = 0.219).

Conclusion

Local advanced tumors are at risk of lymph node metastasis. Increased risk is associated to previous lesions at tumor site. T4 classification have worse prognosis. Lymph node recurrences in N0 patients, once treated, did not affect survival. For these patients, we propose close follow up and prompt treatment of lymph node metastasis. These results do not support indication for elective lymphadenectomy or sentinel node mapping. Further prospective studies must address this issue.

Subungual squamous cell carcinoma of the toe: working toward a standardized therapeutic approach

Subungual squamous cell carcinoma (SCC) is a rare malignancy with very few reported cases that occur on the toe. The etiology of these lesions is not known, and although this location is generally considered low risk for metastasis, cases of inguinal lymph node metastasis after toe amputation have been reported. Patients with subungual disease may meet criteria other than location that increase their risk for metastasis. Currently, no standardized approach to therapy for these patients has been established. In this article, we describe a patient with SCC of the right fourth toe with no clinical evidence of lymph-node metastasis. This patient underwent toe amputation and has done well for 2.5 years with no evidence of recurrence. We discuss this case of subungual SCC of the toe along with others in the literature to propose an optimal standardized approach for therapy and follow-up. In so doing, we aim to advance medical knowledge of subungual SCC and to improve patient care.

High-Risk Cutaneous Squamous Cell Carcinoma without Palpable Lymphadenopathy: Is There a Therapeutic Role for Elective Neck Dissection?

PURPOSE

The beneficial role of elective neck dissection (END) in the management of high-risk cutaneous squamous cell carcinoma (CSCC) of the head and neck remains unproven. Some surgical specialists suggest that END may be beneficial for patients with clinically node-negative (N0) high-risk CSCC, but there are few data to support this claim. We reviewed the available literature regarding the use of END in the management of both CSCC and head and neck SCC (HNSCC).

METHODOLOGY

The available medical literature pertaining to END in both CSCC and HNSCC was reviewed using PubMed and Ovid Medline searches.

RESULTS

Many surgical specialists recommend that END be routinely performed in patients with N0 HNSCC when the risk of occult metastases is estimated to exceed 20%; however, patients who undergo END have no proven survival benefit over those who are initially staged as N0 and undergo therapeutic neck dissection (TND) after the development of apparent regional disease. There is a lack of data regarding the proper management of regional nodal basins in patients with N0 CSCC. In the absence of evidence-based data, the cutaneous surgeon must rely on clinical judgment to guide the management of patients with N0 high-risk CSCC of the head and neck.

CONCLUSIONS

Appropriate work-up for occult nodal disease may occasionally be warranted in patients with high-risk CSCC. END may play a role in only a very limited number of patients with high-risk CSCC.

Sentinel Lymph Node Biopsy in Cutaneous Squamous Cell Carcinoma: A Systematic Review of the English Literature

BACKGROUND

Although most cutaneous squamous cell carcinoma (SCC) is curable by a variety of treatment modalities, a small subset of tumors recur, metastasize, and result in death. Although risk factors for metastasis have been described, there are little data available on appropriate workup and staging of patients with high-risk SCC.

OBJECTIVE

We reviewed reported cases and case series of SCC in which sentinel lymph node biopsy (SLNB) was performed to determine whether further research is warranted in developing SLNB as a staging tool for patients with high-risk SCC.

METHODS

The English medical literature was reviewed for reports of SLNB in patients with cutaneous SCC. Data from anogenital and nonanogenital cases were collected and analyzed separately. The percentage of cases with a positive sentinel lymph node (SLN) was calculated. False negative and nondetection rates were tabulated. Rates of local recurrence, nodal and distant metastasis, and disease-specific death were reported.

RESULTS

A total of 607 patients with anogenital SCC and 85 patients with nonanogenital SCC were included in the analysis. A SLN could not be identified in 3% of anogenital and 4% of nonanogenital cases. SLNB was positive in 24% of anogenital and 21% of nonanogenital patients. False-negative rates as determined by completion lymphadenectomy were 4% (8/213) and 5% (1/20), respectively. Most false-negative results were reported in studies from 2000 or earlier in which the combination of radioisotope and blue dye was not used in the SLN localization process. Complications were reported rarely and were limited to hematoma, seroma, cutaneous lymphatic fistula, wound infection, and dehiscence.

CONCLUSIONS

Owing to the lack of controlled studies, it is premature to draw conclusions regarding the utility of SLNB in SCC. The available data, however, suggest that SLNB accurately diagnoses subclinical lymph node metastasis with few false-negative results and low morbidity. Controlled studies are needed to demonstrate whether early detection of subclinical nodal metastasis will lead to improved disease-free or overall survival for patients with high-risk SCC.

Invasive Squamous Cell Carcinoma of the Skin: Defining a High-Risk Group

BACKGROUND

Unlike its more common non-invasive form, invasive squamous cell carcinoma (SCC) of the skin can be biologically aggressive and is prone to recur. The objectives of this study were to identify relevant clinicopathologic prognostic factors associated with the outcomes of patients with invasive SCC in order to define a high-risk group.

METHODS

We retrospectively reviewed the records of patients with invasive cutaneous SCC of the trunk or extremities who received surgical treatment at a tertiary care cancer center over the past 10 years. We examined the patterns of presentation, all known clinical and histological risk factors for recurrence, and their association with survival.

RESULTS

136 patients were identified, of whom 102 (74%) were male. Patterns of presentation included primary (n = 91), locally recurrent (n = 16), regional nodal (n = 24), and distant (n = 5) disease. Univariate analysis identified poorly differentiated carcinomas (hazard ratio [HR] = 2.92, P = .016), scar carcinomas (HR = 3.12, P = .008), tumor size > 2 cm (HR = 3.79, P = .006), and regional nodal disease (HR = 5.77, P < .0001) as significant risk factors for recurrence or death. On multivariate analysis, however, only regional nodal disease at presentation (HR = 7.64, P < .0001) was found to be significant.

CONCLUSIONS

Patients with invasive SCCs metastatic to regional nodes constitute a group at high risk for recurrence and death. Such patients should be considered for adjuvant therapy trials.

Prognostic factors for metastasis in squamous cell carcinoma of the skin

BACKGROUND

Squamous cell carcinoma (SCC) of the skin exhibits a significant propensity to metastasize. A number of variables have been reported to influence the tendency of SCC to metastasize. Because of the increasing incidence of skin cancer, it is becoming increasingly important to identify those neoplasms which are biologically more aggressive. We report 25 cases of metastatic SCC and compare them to 175 cases of nonmetastasizing SCC treated during the same period.

OBJECTIVE

To characterize tumors with the greatest tendency to metastasize.

METHODS

A tumor registry from the Dermatologic Surgery Unit at the Medical University of South Carolina was accessed to obtain records on 200 patients diagnosed with invasive SCC managed by Mohs surgery from 1988 to 1998. A retrospective analysis was conducted. The characteristics of patients with metastatic SCC and those with nonmetastatic SCC were compared using the chi-squared test and Fisher's exact test.

RESULTS

Of 200 tumors, 25 (12.5%) metastasized. Size, Clark's level, degree of differentiation, the presence of small tumor nests, infiltrative tumor strands, single-cell infiltration, perineural invasion, acantholysis, and recurrence all correlated strongly with metastasis. Location, ulceration, inflammation, and Breslow depth did not correlate with the development of metastasis.

CONCLUSION

Patients with tumors that exhibit certain clinical and histologic features are more likely to metastasize and need close follow-up to detect recurrence and metastasis early, allowing for appropriate life-saving intervention. Sentinel lymph node biopsy should be considered in patients with high-risk SCC.

Subcutaneous adipocytes promote the differentiation of squamous cell carcinoma cell line (DJM-1) in collagen gel matrix culture

Cancer cell-stromal cell interaction plays a crucial role in the malignant growth of cancer cells. In the skin, the main stromal cell types consist of dermal fibroblasts and subcutaneous adipocytes. Fibroblasts are shown to promote the invasive growth of various cancer cell types. The interaction between cancer cells and stromal adipocytes, however, has not been sufficiently studied even in cutaneous carcinoma. To address the effects of adipocytes on the biologic behavior of cancer cells, we examined the growth and differentiation of a squamous cell carcinoma cell line of the skin (DJM-1), using a three-dimensional collagen gel matrix culture with a cutaneous environmental factor, air exposure. The growth was estimated by the uptake of bromodeoxy-uridine (BrdU) for 24 h. The BrdU indices of DJM-1 cells in stromal-cell-free, fibroblast-containing, and adipocyte- containing conditions were 19.7 +/- 1.9%, 19.8 +/- 2.8%, and 4.7 +/- 1.4%, respectively, whereas the BrdU index on the gel containing both fibroblasts and adipocytes was 10.4 +/- 3.3%. In terms of differentiation, DJM-1 cells cocultured with adipocytes constructed the best-organized stratified layer with a cornified-like structure in all conditions above. The differentiation markers involucrin and cytokeratin 10 were immunohistochemically detected in this structure of DJM-1 cells. Adipocyte-induced phenomena were not affected distinctively by air exposure. These results indicate that adipocytes, but not fibroblasts, promote the differentiation of squamous cell carcinoma cells (DJM-1) and inhibit their growth. These adipocyte-induced phenomena were not completely inhibited by fibroblasts. In conclusion, we suggest that stromal adipocytes may be involved in the differentiating mechanisms of cutaneous carcinoma cells.

Amputation and the prevention of phantom pain

Although it has been proposed that preoperative analgesia with epidural administration of analgesics may prevent long-term phantom pain, published results to date have been contradictory and controversial. In this case report, we describe a 41-year-old man with local recurrence of squamous cell carcinoma of the anus who underwent a hemipelvectomy. Preoperatively he had a significant neuropathic pain syndrome requiring oxycodone 60 mg every 4 hours. An epidural infusion of morphine and bupivacaine was started 24 hours preoperatively and discontinued on the third postoperative day. Over the next 10 days the oxycodone was gradually decreased and eventually discontinued prior to discharge. A review of the literature reveals conflicting reports on the benefit of preoperative epidural pain management in the prevention of postoperative pain syndromes. Conflicting research and conclusions of commentators leaves unanswered questions for clinicians. Nevertheless, we do know that we need to provide the best pain relief for patients both before and after amputation. This may require a combination of the oral, subcutaneous or intravenous, and epidural routes.

Closure of hemicorporectomy with bilateral subtotal thigh flaps

Hemicorporectomy is typically performed with a circumferential truncal incision, and the wound is closed primarily. Wound disruption is a common complication, especially at the base of the wound closure and posteriorly at the lumbar vertebral level. We report a case of the use of bilateral subtotal thigh flaps for the closure of a hemicorporectomy wound in a patient with a defect extending up to the high lumbar region. The subtotal thigh flap is a well-vascularized thick flap that provides a firm support for the abdominal viscera and is a large flap that can be used to close even a high lumbar defect.

Recognition and management of high-risk cutaneous tumors

The majority of cutaneous malignancies can be treated by the military dermatologist in a clinical setting. Recognition of tumors at high risk for recurrence or metastasis is important for any dermatologist but especially list care. Providing optimal care includes knowledge about which patients should be medavacced to larger medical centers for advanced surgical and medical treatments.