A multidisciplinary team approach to hydroxyurea-associated chronic wound with squamous cell carcinoma

Head and Neck Reconstruction in Patients with Polycythemia Vera: Case Series and Literature Review

Background  Polycythemia vera (PV) is a myeloproliferative disease with overproduction of erythrocytes, leukocytes, and platelets causing an increased risk of both thrombosis and hemorrhage. There are limited reports and no established guidelines for managing such patients undergoing reconstructive surgery. Methods  We present four patients with PV and head and neck cancer who required reconstruction after resection and provide a review of the current literature. Results  Preoperatively, patients on cytoreductive therapy continued with their treatment throughout their hospital course and had hematologic parameters normalized with phlebotomy or transfusions if needed. Two patients who underwent free flap surgery (cases 1 and 2) had postoperative courses complicated by hematoma formation and persistent anemia, requiring multiple transfusions. Cases 3 and 4 (JAK2+ PV and JAK2- PV, respectively) underwent locoregional flap without postoperative complications. Conclusion  Concomitant presentation of PV and head and neck cancer is uncommon and presents unique challenges for the reconstructive surgeon. Overall, we recommend that patients should have hematologic parameters optimized prior to surgery, continue ruxolitinib or hydroxyurea, and hold antiplatelet/anticoagulation per established department protocols. It is essential to engage a multidisciplinary team involving hematology, head and neck and reconstructive surgery, anesthesia, and critical care to develop a standardized approach for managing this unique subset of patients.

A Multidisciplinary Approach for Tophi Wounds Caused by Glycogen Storage Disease Type 1a: A Rare Case

ABSTRACT

Glycogen storage diseases (GSDs) are a group of rare inherited metabolic disorders caused by enzyme deficiencies in glycogen catabolism. The more common type, GSD type Ia, is caused by glucose-6-phosphatase deficiency and often complicated by gout from hyperuricemia. Here, the authors report a rare case of a tophi wound caused by GSD type Ia in a Chinese patient. Difficulties in this case included the control of abnormal blood markers, especially uric acid; removal of tophi deposited in the tissues; restoration of hand function after wound healing; and patient adherence to treatment and follow-up. A multidisciplinary team was set up consisting of experts from the authors' wound care center and the departments of endocrinology, orthopedics, and rehabilitation. The wound healed in 53 days and was followed up for about 7 months. During follow-up, the patient's hand function returned to normal, and no new tophi formed. Because GSDs are a congenital lifelong condition, regular follow-ups are especially important.

Drug-Related Cutaneous Adverse Events in Philadelphia Chromosome-Negative Myeloproliferative Neoplasms: A Literature Review

Since myeloproliferative neoplasms (MPN) pose a significant risk for vascular and thrombotic complications, cytoreductive therapies, such as hydroxyurea (HU), interferon (IFN) inhibitors, and Janus kinase (JAK) inhibitors are recommended for patients at high risk. However, these agents also place patients at increased risk for drug-related cutaneous adverse events. Herein, we review the literature on skin toxicity related to the use of drugs for the treatment of MPN. Overall, the cytoreductive agents used for MPN are generally well tolerated and considered to be safe, except IFN, for which dropout rates as high as 25% have been reported. While IFN is known to give rise to flu syndrome, it rarely leads to hematological alterations. The most common hematological side effects of HU are mild and include granulocytopenia, anemia, and thrombocytopenia. The JAK inhibitor ruxolitinib has been associated with cytopenia and a higher incidence of viral infections, as well as increased risk for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Based on the present analysis, it can be concluded that cutaneous toxicity is not a negligible complication of commonly used treatments for MPN. While further research is needed, patients on these agents, and especially those with a history of cutaneous malignancies, should undergo thorough skin examination before and during therapy. In addition, detailed history is critical since many patients who develop non-melanoma skin cancer have multiple preexisting risk factors for cutaneous carcinogenesis.

Hydroxyurea-induced cutaneous squamous cell carcinoma: A case report

BACKGROUND

Hydroxyurea (HU) is a non-alkylating antineoplastic agent that is active in the S-phase of the cell cycle and inhibits the enzyme ribonucleoside reductase. HU is currently used to treat leukemia, sickle cell anemia, psoriasis, and chronic myeloproliferative disorders. Although HU is easy to use and effective and has high tolerance, there have been numerous reports of cutaneous complications during long-term therapy with HU.

CASE SUMMARY

We report a 67-year-old woman on long-term HU therapy for primary myelofibrosis who developed concurrent skin lesions during treatment. The first skin lesion appeared on the dorsum of her right hand in 2015. Despite continuous use of HU, her cutaneous changes were neglected. Approximately 3 years ago, she had multiple nodular and keratotic lesions on both hands with sharp margins, branny desquamation, and dotted hyperpigmentation. Furthermore, she developed acutely numerous ulcerative lesions on her hands and legs. Topical wound therapy with dressing changes and parenteral antibiotics was applied for management of the lesions. Most of the wounds healed after HU withdrawal. Lesions on both hands were replaced by scabs. Nevertheless, the wound on her left ankle reached 9 cm × 7 cm in size in January 2018. Pathology confirmed well-differentiated squamous cell carcinoma at the ulcer area. In addition, her left foot was severely affected and radical surgery with a below-the-knee amputation was suggested followed by preventive right groin nodal dissection.

CONCLUSION

In patients receiving continuous HU therapy, close dermatologic follow-up is critical for the early diagnosis and selection of appropriate treatment for cutaneous lesions.

Successful Treatment of Chronic Lower Extremity Ulcers with Allogeneic Platelet-Rich Plasma and Artificial Dermis: A Case Report

Hydroxyurea is an oral medication associated with painful, nonhealing ulcers, for which there is no effective treatment but permanent discontinuation of hydroxyurea. The authors present a case of leg ulcers that likely occurred as a result of hydroxyurea use in a patient with essential thrombocythemia. Topical treatment with allogeneic platelet-rich plasma and artificial dermis completely healed the leg ulcers without hydroxyurea cessation.

Nonmelanoma skin cancer associated with Hydroxyurea treatment: Overview of the literature and our own experience

Nonmelanoma skin cancer is the most common malignant tumor in the fair skin population, with each year several millions of diagnosed cases. Their most common risk factors are fair skin, a history of excessive ultraviolet light exposure, chronic inflammatory skin conditions, exposure to radiation, and contact with arsenic. Certain drugs can also be associated with a higher risk of nonmelanoma skin cancer. These include hydroxyurea, which acts as a metabolic inhibitor of ribonucleotide reductase and a potent nonalkylating myelosuppressive agent. It is used for the treatment of various myeloproliferative disorders, including chronic myeloid leukemia, polycythemia vera, and essential thrombocytopenia. Several publications describe an increased occurrence of skin manifestations following hydroxyurea treatment. A growing body of evidence indicates a possible role of hydroxyurea in skin cancer progression. In this review article, we summarize some relevant observations about the association of hydroxyurea and skin cancer, and we describe our own clinical experiences to provide up to date recommendations about the care of patients on hydroxyurea therapy.

Successful treatment of hydroxyurea-associated chronic leg ulcers associated with squamous cell carcinoma

Hydroxyurea (HU) is an antineoplastic drug used in the treatment of chronic myeloproliferative neoplasms (MPNs). HU is associated with cutaneous adverse effects, whereas severe complications such as leg ulcers and non-melanoma skin cancers (NMSCs) are rare and only observed after long-term treatment. We herein report a patient with essential thrombocythemia (ET) treated chronically with HU, and who developed refractory bilateral leg ulcers complicated by squamous cell carcinoma (SCC) over both heels. The patient was successfully managed by multiple debridement stages and skin grafting surgeries.

Differential diagnosis of leg ulcers

Leg and foot ulcers are symptoms of very different diseases. The aim of this paper is to demonstrate the differential diagnosis of leg ulcers. The majority of leg ulcers occur in the lower leg or foot. In non-venous ulcers the localization in the foot area is more frequent. The most frequent underlying disease is chronic venous disease. In 354 leg ulcers, Koerber found 75.25% venous leg ulcers, 3.66% arterial leg ulcers, 14.66% ulcers of mixed venous and arterial origin and 13.5% vasculitic ulcers. In the Swedish population of Skaraborg, Nelzen found a venous origin in 54% of the ulcer patients. Each leg ulcer needs a clinical and anamnestic evaluation. Duplex ultrasound is the basic diagnostic tool to exclude vascular anomalies especially chronic venous and arterial occlusive disease. Skin biopsies help to find a correct diagnosis in unclear or non-healing cases. In conclusion, chronic venous disease is the most frequent cause of leg ulcerations. Because 25% of the population have varicose veins or other chronic venous disease the coincidence of pathological venous findings and ulceration is very frequent even in non-venous ulcerations. Leg ulcers without the symptoms of chronic venous disease should be considered as non-venous.