Extended Scalp Flaps for Extensive Soft Tissue Scalp Defects as a Day Surgery Procedure Under Local Anesthetic: A Single Centre Experience

Background  Cutaneous malignancies are on the rise, associated with an increased number in scalp cancers that require wide local excision (WLE) to ensure clearance; the inelastic nature of the scalp poses a particular challenge when dealing with such large defects. Case presentation  A series of 68 cases with large scalp defects following WLE for the clearance of squamous cell carcinoma, atypical fibroxanthoma, dermatofibrosarcoma protuberans, and melanoma skin cancers are presented. These cases were treated in one center under local anesthesia and underwent extended scalp flaps to close the resulting defect primarily without the use of skin grafts for the flap donor site on the scalp. Conclusion  Extended scalp flap is a safe and reproducible solution for extensive scalp defects, which results in quicker wound healing with cosmetically superior results, and can be performed safely and comfortably under local anesthesia in the day case setting.

Steady-state pharmacokinetics of hydroxychloroquine in patients with cutaneous lupus erythematosus

Background Hydroxychloroquine (HCQ), a 4-aminoquinolone antimalarial, is regarded as the oral therapy of choice for cutaneous and systemic lupus erythematosus (SLE). It is also licensed for rheumatoid arthritis (RA). Studies of HCQ-treated patients with SLE or RA have demonstrated a positive correlation between whole-blood HCQ levels and clinical response. Such studies have involved measuring whole-blood concentrations at any given time point after HCQ ingestion assuming that steady-state concentrations would undergo limited fluctuation over a daily interval because HCQ has a long half-life. This approach might not sufficiently take into account the potential intra-patient variation in HCQ blood levels that can occur over a 24-hour period. Such variation, if significant, could affect the credibility of any concentration-response relationship provided from these previous studies. Objectives The objectives of this report are to: (a) investigate the intra-patient variation in HCQ whole-blood levels and (b) suggest an optimum time for sampling patients for future studies. Methods Six patients were recruited with cutaneous lupus erythematosus who had each been on HCQ 200 mg twice daily for at least six months, so that they were at steady-state. Each patient was fasted overnight and had standardized meals and dosing schedule. Whole blood was sampled at seven time points over 24 hours. Whole-blood HCQ levels were measured with high-performance liquid chromatography using gradient elution, fluorimetric detection and chloroquine as an internal standard. The assay had a mean inter- and intra-day coefficient of variation of 10% and 5% respectively and a limit of detection of 5ng/ml. Results HCQ levels appeared to follow a biphasic pattern over the sampling period. Maximum levels were noted a median of four hours (range 2-6) after ingestion. Median intra-patient variation between trough and peak levels, 'Cmax' ((peak - trough)/trough × 100%), was 27% (range 8-150%). Conclusions This study demonstrated that whole-blood HCQ levels vary 27% (median, range 8-150%) within an individual over a 12-hour period. Drug levels might differ between individuals because of multiple factors, including variable adherence to medication. Measuring HCQ levels for assessment of drug adherence could be valuable in the 'real-world' clinical setting. This could be assessed by taking a blood sample at any time following HCQ ingestion. If patients were found to have very low or undetectable levels of HCQ, non-adherence to HCQ should be suspected.

Mohs micrographic surgery for dermatofibrosarcoma protuberans (DFSP): a single-centre series of 76 patients treated by frozen-section Mohs micrographic surgery with a review of the literature

Dermatofibrosarcoma protuberans (DFSP) is a rare low-grade sarcoma that typically presents with local invasion but rarely metastasises. Surgical excision remains the first-line treatment for DFSP. There are no randomised controlled or prospective studies comparing wide local excision (WLE) with Mohs micrographic surgery (MMS), but available evidence from the retrospective studies and case series available has consistently shown higher recurrence rates for standard surgery and WLE than for MMS. Combined recurrence rates of data within the last 20 years for WLE have been reported at 7.3% compared with 1.1% for MMS. Our aim was to review the clinical details and recurrence rates of DFSP cases treated with frozen-section MMS in our centre between 1996 and February 2013. The relevant data were collected from the case notes. It involved 76 patients with nine of these patients lost to follow-up. In the remaining 67 (67/76) cases, the recurrence rate was 1.5% during the mean follow-up period of 50 months (2-132). This is comparable to recurrence rates for the MMS in the literature [20,21]. Our series is the largest series for frozen-section MMS reported to date. Based on these findings and the current literature evidence, we advocate MMS as the treatment of choice for DFSP in all locations.

Clinical value of immunohistochemically detected lymphovascular space invasion in early stage cervical carcinoma

BACKGROUND

This study investigates the clinical significance of lymphovascular space invasion (LVSI) as detected by hematoxylin and eosin (LVSI-H&E) and immunohistochemistry (LVSI-IHC) in early stage cervical carcinoma.

METHODS

Single representative sections from 97 patients with early stage squamous cell cervical cancer were immunostained with pancytokeratin and CD31 endothelial cell marker antibodies. The H&E sections and their corresponding immunostained sections were reexamined to identify LVSI. Associations between LVSI with clinicopathological factors were sought.

RESULTS

Overall, LVSI was present in 29 (29.9%) and absent in 68 (70.1%) by IHC, as compared with 18 cases (18.6%) and 79 cases (81.4%), respectively, by H&E. Statistical analysis revealed a significant association between LVSI-H&E and nodal metastasis (P = .004). Follow-up data were available for 76 patients. The median follow-up period was 64 months. During follow-up, 7 of 24 patients with recurrent disease had evidence of LVSI-H&E as opposed to 3 of 52 cases with no recurrence. There was a significant association between tumor recurrence and LVSI-H&E (P = .009). The 5-year recurrence-free survival was 30% for the group with LVSI-H&E compared with 73% without. There was a significant difference in the recurrence-free survival between the two groups (P = .002). In contrast LVSI-IHC was found to be associated with no pathological factors, and survival analysis revealed no statistically significant association with recurrence or survival.

CONCLUSION

LVSI-H&E in early stage cervical cancer remains an important predictive factor of recurrent disease and reduced disease-free interval. Immunohistochemically detected LVSI is a common event and seems to be of no clinical value.