Neoplastic wounds and degenerescence

En-bloc excision of sacral squamous cell carcinoma with immediate reconstruction

Sacral squamous cell carcinoma is an uncommon condition that may arise in scars following burns or in chronic wounds, such as an untreated pilonidal cyst. The aim of the present technical note is to describe a surgical technique aimed at minimizing local recurrence rates by en-bloc resection as well as providing immediate plastic reconstruction: 1. right-sided extended vertical rectus abdominis myo-cutaneous (VRAM) flap; 2. abdomino-perineal excision of the rectum with end colostomy; 3. en-bloc excision of the mass inclusive of gluteus maximus muscles and distal sacrectomy; 4. sacrectomy defect covered with VRAM flap; 5. bilateral gluteal defects covered with single-layer dermal substitute of bovine collagen and elastin hydrolysate followed by immediate split-thickness skin grafting from bilateral thigh donor sites, and negative pressure wound therapy dressings. This approach resulted in a favorable outcome at 2-year follow-up in a male patient presenting with a large locally advanced sacral squamous cell carcinoma involving the external anal sphincter muscle.

Approach to the Atypical Wound

The heterogeneity of atypical wounds can present diagnostic and therapeutic challenges; however, as the prevalence of atypical wounds grows worldwide, prompt and accurate management is increasingly an essential skill for dermatologists. Addressing the underlying cause of an atypical wound is critical for successful outcomes. An integrated approach with a focus on pain management and patient engagement is recommended to facilitate enduring wound closure. Advances in treatment, in addition to further research and clinical training, are necessary to address the expanding burden of atypical wounds.

Malignant wound aetiology, diagnosis and management: a case series and literature review

OBJECTIVE

Malignant wounds develop when neoplastic cells invade the skin either locally or by lymphatic and haematogenous spread. They can present as hard-to-heal wounds and underlying causes include: primary skin cancer; metastasis of extracutaneous primary malignancy; malignant transformation of a hard-to-heal wound; iatrogenic injury; and cutaneous forms of cancers of non-skin origin. High clinical suspicion for a malignant wound should be confirmed with skin biopsy. The aim of this case series is to highlight a combination of both clinically clear cutaneous malignancies and not-so-obvious wounds caused by malignancy.

METHOD

This case series examines patients with malignant wounds of varying aetiology and appearance. For each case, we explain the pathophysiology, atypical features, diagnostic approach and treatment. We also discuss types of wound biopsy and general wound management principles.

RESULTS

Among the 11 cases analysed using descriptive statistics, median wound duration before presentation at our clinic was one year, while median age at presentation was 65 years. Our case series included the following diagnoses: cutaneous metastasis of invasive ductal carcinoma of the breast (n=2); cutaneous metastasis of colorectal adenocarcinoma (n=1); Marjolin's ulcer (n=1), basal cell carcinoma (BCC) (n=2), primary cutaneous squamous cell carcinoma (SCC) (n=1), metastatic malignant melanoma (n=1), cutaneous T-cell lymphoma (n=1), cutaneous angiosarcoma (n=1), Kaposi sarcoma (n=1) and recurrent tonsillar SCC with osteoradionecrosis (n=1); one case had both BCC and SCC.

CONCLUSION

Punch and excisional biopsies were the most frequently used diagnostic techniques. Local wound therapy addressed bleeding, malodour, exudate, pain and infection. However, wound healing is usually achieved once the underlying malignancy is treated. In advanced or metastatic disease, palliative wound care aims to prevent exacerbation of existing wounds and focuses on patient comfort.

Management of malignant cutaneous wounds in oncologic patients

PURPOSE

Neoplastic wounds may develop as a result of primary tumor growth in the skin, due to metastasis, or due to skin invasion by tumors emerging from deeper levels. Malignant wounds may present as a crater-like ulcer, or as raised nodules with a cauliflower-like appearance. They are associated with malodor, necrosis, pain, bleeding, and secondary infection. The aim of our study is to better characterize fungating wounds and their management.

METHODS

We retrospectively reviewed the database of the Wound Care Unit of the University of Bologna in order to identify individuals affected by neoplastic wound, between January 2019 and February 2021.

RESULTS

We identified 9 females and 2 males with a mean age of 63 years; all were referred by the Oncology Unit. Management differed depending on the characteristics of the patients and the ulcers. Complete healing of the wound, following the parallel complete remission of the lymphoproliferative neoplasia, was observed in one individual. Among the others, one died because of breast cancer, while cutaneous lesions in 2 individuals deteriorated after 1 year of follow-up. Remission/relapse of the ulcer following the treatment course administered for the lymphoma were observed in one patient.

CONCLUSIONS

Treatment of malignant fungating wounds is challenging. Considering the neoplastic nature of the wounds, complete healing or improvement cannot be expected with the application of classically prescribed dressing for wounds. A mostly palliative treatment, focusing on maintaining the patient's quality of life, is a reasonable choice.

Comparison of Curative Complications between Mammotome-Assisted Minimally Invasive Resection and Conventional Open Resection for Breast Neoplasm: A Retrospective Clinical Study

Background

To know the clinical value of mammotome-assisted minimally invasive resection (MAMIR) in the treatment of patients with breast neoplasm, we performed a retrospective clinical study for the patients treated with the MAMIR and conventional open resection (COR).

Methods

Postoperative complications were compared between 40 patients treated with the MAMIR and 40 patients treated with the COR. The postoperative complications mainly included intraoperative blood loss, hospitalization days, operative time, surgical scar, and incidence of postoperative complications.

Results

We found that the amount of intraoperative blood loss, hospitalization days, operative time, surgical scar, and incidence of postoperative complications in the MAMIR group were significantly lower than those of patients in the COR group.

Conclusion

Our results indicated that patients with breast neoplasm treated with the MAMIR had better outcomes, which reinforced the advantage of this approach.

Marjolin Ulcer: A Comprehensive Review

GENERAL PURPOSE

To provide a comprehensive review of Marjolin ulcer (MU) to assist clinicians in understanding the epidemiology, etiology, pathogenesis, diagnosis, and treatment of MU.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Describe the epidemiology, pathogenesis, and clinical manifestations of MU.2. Summarize the diagnostic and treatment approaches for patients who have an MU.

ABSTRACT

This article aims to provide a comprehensive review of Marjolin ulcer (MU) to assist clinicians in understanding the epidemiology, etiology, pathogenesis, diagnosis, and treatment of MU. Marjolin ulcer presents with clear signs and symptoms of malignant degeneration in chronic wounds. It can be prevented by raising awareness and educating wound care providers appropriately about its signs and symptoms.

[Diagnostic pitfall: Early arising, multiple and recurrent Marjolin's ulcer. About 8 patients (16 tumors) and literature review]

INTRODUCTION

Marjolin's ulcer (MU) is a large entity representing skin cancers resulting from the transformation of chronic wounds of a heterogeneous nature. Burn scars are the most at risk of degeneration, in particular because there are the sites of important skin tension. Atypical forms are not uncommon. The objective of this study is to present these exceptions which are underestimated.

MATERIALS AND METHODS

All patients with UM in our centre between January 2011 and February 2019 have been included permitting to report the initial pathology, the location, the latency time, the histology and the management carried out.

RESULTS

Eight patients were treated in our center for MU, they developed 16 skin cancers. Fourteen were squamous cell carcinomas (SCC). The shortest latency period was 2 months. The youngest patient was 22 years old when she was diagnosed with MU. Three patients had at least 2 synchronous SCC. One patient had a recurrence after a split-thickness skin grafting on artificial dermis and 2 patients had second locations.

CONCLUSION

Atypic forms are not rare. MU is commonly recurrent, multiple, early arising and may appear in young people. The treatment of chronic wounds cannot be dissociated from the treatment of contractures, otherwise the wound will inevitably reappear.

Late-onset anorectal disease and psychosocial impact in survivors of childhood cancer: A report from the Childhood Cancer Survivor Study

BACKGROUND

The prevalence and associated psychosocial morbidity of late-onset anorectal disease after surgery and radiotherapy for the treatment of childhood cancer are not known.

METHODS

A total of 25,530 survivors diagnosed between 1970 and 1999 (median age at cancer diagnosis, 6.1 years; age at survey, 30.2 years) and 5036 siblings were evaluated for late-onset anorectal disease, which was defined as a self-reported fistula-in-ano, self-reported anorectal stricture, or pathology- or medical record-confirmed anorectal subsequent malignant neoplasm (SMN) 5 or more years after the primary cancer diagnosis. Piecewise exponential models compared the survivors and siblings and examined associations between cancer treatments and late-onset anorectal disease. Multiple logistic regression with generalized estimating equations was used to evaluate associations between late-onset anorectal disease and emotional distress, as defined by the Brief Symptom Inventory 18 (BSI-18), and health-related quality of life, as defined by the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36).

RESULTS

By 45 years after the diagnosis, 394 survivors (fistula, n = 291; stricture, n = 116; anorectal SMN, n = 26) and 84 siblings (fistula, n = 73; stricture, n = 23; anorectal neoplasm, n = 1) had developed late-onset anorectal disease (adjusted rate ratio [RR] for survivors vs siblings, 1.2; 95% confidence interval [CI], 1.0-1.5). Among survivors, pelvic radiotherapy with ≥30 Gy within 5 years of the cancer diagnosis was associated with late-onset anorectal disease (adjusted RR for 30-49.9 Gy vs none, 1.6; 95% CI, 1.1-2.3; adjusted RR for ≥50 Gy vs none, 5.4; 95% CI, 3.1-9.2). Late-onset anorectal disease was associated with psychosocial impairment in all BSI-18 and SF-36 domains.

CONCLUSIONS

Late-onset anorectal disease was more common among childhood cancer survivors who received higher doses of pelvic radiotherapy and was associated with substantial psychosocial morbidity.

The Point Prevalence of Malignancy in a Wound Clinic

The aim of this study was to determine the prevalence of malignant leg ulcers and to identify the most frequent characteristics of such wounds. This study was a retrospective investigation of patients with chronic leg ulcers in a North American tertiary wound clinic. Between January 2011 and September 2013, a total of 1189 patients with lower extremity wounds, including 726 patients with leg wounds, were identified. A total of 124 of the 726 had undergone a biopsy of their atypical wound, 16.1% (20/124) of which were malignant. Patients with malignant wounds were older than patients with nonmalignant leg wounds (P < .0001), and the common location of the malignant wound was the anterior shin (odds ratio = 3.5). The limitation of this analysis is the lack of distinction between malignant transformation of wounds and de novo presentation of malignancies as chronic nonhealing wounds. Three distinguishing morphological features in malignant wounds were irregular borders (P = .0002), presence of hypergranulation tissue (P < .0001), and friable/bleeding wound surface (P < .0001). The frequency of malignant wounds in patients with chronic leg ulcers highlights the need for a systematic approach, which would involve biopsy of wounds to identify malignancy in this patient population early on.

Induction of delayed wound healing by irradiation with optional mechanical compression in swine

A chronic wound or non-healing wound is one that fails to heal for at least 30 days after injury. This study was designed to create delayed wound healing induced by irradiation and mechanical compression using silicone block. Two female pigs received a single fraction of 20 Gy with 6-MeV electrons to a 22 × 60 cm field on the dorsal body skin 7 weeks before experimentation. A 30 × 30 mm sized wounds were created with preservation of muscle fascia on the dorsum. In groups of six, wounds were designated to be control (C) or test areas of irradiation only (T0), irradiation with silicone blocks for 1 week (T1), irradiation with silicone blocks for 2 weeks (T2), and irradiation with silicone blocks for 3 weeks (T3). Wound contraction, bacterial culture, and histological analysis were performed at 1-week intervals for 4 weeks. Control wounds displayed complete re-epithelialization at Weeks 4; however, all experimental groups (T0, T1, T2, and T3 groups) showed necrosis and delayed healing at Week 4. The number of bacterial strains in control wounds differed significantly from values recorded for all experimental groups from Weeks 1-3 (p < 0.05). However, in comparing the various test wounds (T0, T1, T2, and T3 groups), the numbers of strains did not differ significantly from Weeks 1-4. In the histological analysis, the control wound showed a peak influx of acute and chronic inflammatory cell and diminished inflammation thereafter. However, all experimental groups showed no peak in inflammatory score and prolonged chronic inflammation. In conclusion, radiation exposure alone, which triggers intense inflammation and extensive recruitment of inflammatory cells, proved sufficient to prevent re-epithelialization of skin at 30 days. Insertion of silicone blocks had limited effects on promoting delayed wound healing. Consequently, we now recommend using irradiation alone to simulate delayed wound healing in an experimental setting.

Ephrin-Bs Drive Junctional Downregulation and Actin Stress Fiber Disassembly to Enable Wound Re-epithelialization

For a skin wound to successfully heal, the cut epidermal-edge cells have to migrate forward at the interface between scab and healthy granulation tissue. Much is known about how lead-edge cells migrate, but very little is known about the mechanisms that enable active participation by cells further back. Here we show that ephrin-B1 and its receptor EphB2 are both upregulated in vivo, just for the duration of repair, in the first 70 or so rows of epidermal cells, and this signal leads to downregulation of the molecular components of adherens and tight (but not desmosomal) junctions, leading to loosening between neighbors and enabling shuffle room among epidermal cells. Additionally, this signaling leads to the shutdown of actomyosin stress fibers in these same epidermal cells, which may act to release tension within the wound monolayer. If this signaling axis is perturbed, then disrupted healing is a consequence in mouse and man.

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Ephrin-B/EphBs are upregulated in the migrating wound epidermis in mouse and man

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Ephrin-B/EphB signaling drives junction loosening, thus enabling re-epithelialization

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Ephrin-B/EphB signaling also leads to dissolution of stress fibers and tension release

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In human chronic wounds ephrin-Bs are misregulated and may be a therapeutic target

Inverted verrucous carcinoma of the buttock mimicking abscess and gossypiboma: MR and pathologic correlation

Verrucous carcinoma (VC) is an uncommon, low-grade variant of squamous cell carcinoma. Its benign histologic appearance and indolent course may lead to a delayed diagnosis. We report a rare case of an inverted verrucous carcinoma of the buttock presenting as a slow-growing subcutaneous lesion with a draining sinus and no exophytic component, clinically mimicking abscess and gossypiboma, with magnetic resonance imaging (MRI) and pathologic correlation. Biopsy of the lesional base is mandatory for accurate diagnosis. An enhancement pattern with a convoluted undulating appearance in a subcutaneous lesion displayed on MRI should raise a consideration of inverted VC in the differential diagnosis.

Cancers mimicking fungal infections

Primary and metastatic malignancies may occasionally mimic or coexist with cutaneous fungal infections. The authors report 3 cases of cancers that were initially presumed to be cutaneous fungal infections. Dermatologists should maintain a low threshold for skin biopsy in patients with persistent or refractory fungal infections.