Postmastectomy upper limb lymphedema: Combined vascularized lymph node transfer and scar release with fat graft expedites surgical and patients' related outcomes. A retrospective comparative study

INTRODUCTION

Lymphedema resulting from breast cancer treatment is a chronic condition that can significantly compromise quality of life. Several works have documented the efficacy of vascularized lymph node flap transfer (VLNT) for the treatment of advanced-stage lymphedema. Given that the axillary scar may contribute to the patient's existing lymphedema, the authors assumed that combining VLNT and scar release with fat graft could be an effective strategy of treatment. The purpose of this study is to compare the efficacy in the reduction of limb circumference and health-related quality of life between a combined strategy, namely, VLN transfer (VLNT) and axillary scar release with fat grafting, and only VLNT for patients affected by postmastectomy upper limb lymphedema. The idea.

MATERIALS AND METHODS

All patients with stage II and III breast cancer-related lymphedema operated between January 2012 and January 2016 were retrospectively identified, and only those treated by combined VLNT and scar release (Group A) or only VLNT (Group B) were included. The outcomes were assessed clinically by limb circumference measurement and radiologically by lymphoscintigraphy. Lymphedema-related quality of life was evaluated preoperatively and at 1 year follow-up through the LYMQOL questionnaire.

RESULTS

Thirty-nine patients met inclusion criteria (Group A = 18; Group B = 21). Mean follow-up was 29 months for Group A and 32 months for Group B. Flap survival rate was 100%, with no donor site morbidity in all patients. A statistically significant difference between the circumference reduction rates (RR) at above elbow level was observed at 3 and 6 months of follow-up comparing the two groups (p<0.00001), with higher values in Group A than in Group B. No significant difference was detected comparing RR values at above and below elbow at 12 and 24 months postoperatively. LYMQOL metrics showed significantly better scores (p<0.0001) in all domains at all follow-up appointments in Group A.

CONCLUSIONS

Patients with postmastectomy upper limb lymphedema can benefit from combined lymph node transfer and axillary scar release with fat graft, as this approach seems to fasten the onset of improvement and to have a positive impact on patients' quality of life.

Letter to editor: Surgical-site infection following lymph node excision indicates susceptibility for lymphedema: A retrospective cohort study of malignant melanoma patients

Following the reading of the original article "Surgical-site infection following lymph node excision indicates susceptibility for lymphedema: A retrospective cohort study of malignant melanoma patients", the authors reviewed the literature for the discussed therapeutic value of complete lymph node dissection (CLND), the major complications and the current treatment for lymphedema. The authors also share their experience and protocol for CLND, and treating lymphedema using lymph node flap transfer and multiple lymphatic-venous anastomoses.

Robotic inguinal lymph node dissection for melanoma: a novel approach to a complicated problem

Following the interesting reading of the article "Robotic inguinal lymph node dissection for melanoma: a novel approach to a complicated problem", the authors review the pros and cons of a minimally invasive technique for lymph node dissection, the consequences of complete lymph node dissection and the possible treatments for lymphedema, such as lymph node flap transfer and multiple lymphatic-venous anastomoses. The authors also review the possible benefits of applying the robotic technique to anatomical sites other than the inguinal one.

The use of Nexobridtm in debriding chronic ulcers: a preliminary observational study

Nexobrid is a highly selective enzymatic debriding agent used in the acute management of burns to perform escharectomy. From October 2016 to April 2017, we treated 6 patients affected with lower limb chronic ulcers of different etiologies with Nexobrid in order to perform eschar removal by enzymatic debridement. For all patients, a dosage of Nexobrid, calculated as 2gr per 1% TBSA, was applied in a 2-3 mm thick uniform layer on the ulcer eschar and fibrin tissue and left for 4 hours, covered with an occlusive dressing. Patients were assessed in terms of ulcer cleansing 24 hours and 7 days post Nexobrid debridement, by wound bed score (WBS) and % of remaining necrotic tissue. A patient pain VAS was also recorded at 24 hours and 7 days post debridement. Adverse events at these time points were also noted. The results documented a complete removal of necrotic tissue in a time frame of 4 hours. At 24 hours, all lesions were completely debrided. At 7 days, there was a partial recurrence of necrotic tissue, as also documented by decreased WBS. All patients reported none to mild pain, and no adverse events were noted, except for mild erythema along the edges of the lesion on healthy skin in one case. This is a preliminary observation. Optimal dosage and application of Nexobrid in this indication needs to be validated by further controlled data.

Spontaneous healing and scar control following enzymatic debridement of deep second-degree burns

Scarring after a burn injury remains the greatest unmet challenge in the treatment of functional and psychosocial sequelae of burns. The hypertrophic scar represents the most common type of cicatrix after burns, and it has a prevalence of up to 70%. We present a case of upper and lower extremity partial-thickness burns in a female patient treated in two different modalities. Superficial seconddegree burns on the upper extremities were treated with conservative dressing with fairly early wound closure but they developed hypertrophic scars. Deeper, lower extremity burns were debrided with a new bromelain-based debriding agent, resulting in scar-free healing. The pathophysiology of hypertrophic scar formation is based on the perturbation of collagen production or degradation or both. The duration and magnitude of the inflammatory phase of wound healing also appears to play a role in hypertrophic scarring. Bromelain has demonstrated an anti-angiogenic effect in various cancer cell lines and it has been shown to regulate a variety of pro-angiogenic growth factors. This case raises the classical question of the relationship between time to healing and formation of hypertrophic scars after burn injury, pointing to other potential factors that may play an important role in burn healing.

Unusual presentation of carpal tunnel syndrome with cutaneous signs: a case report and review of the literature

Carpal tunnel syndrome (CTS) is a neurological impairment caused by compression of the median nerve throughout the carpal tunnel, which consequently induces ischemia and mechanical disruption, dysfunctional axonal transport, and epidural blood flow. Most common symptoms include numbness, rather than pain, with a typical night exacerbation, weakness, paresthesia, and loss of sensitive discrimination. In rare cases, such syndrome may present with cutaneous manifestations localized on the distal phalanges of the hands, even without the above mentioned neurological symptoms. We describe a case of a woman who came to our attention complaining of the appearance of recurrent bullous eruptions involving the distal phalanges innervated by the median nerve. She did not report any neurological signs whatsoever. After excluding a bullous disease, we further investigated through additional analysis that revealed a CTS. Hence, physicians should consider CTS as a differential diagnosis when assessing cutaneous lesions of the first three fingers of the hands.

Pemphigus vulgaris with circulating anti-desmoglein 3 and anti-BP180 antibodies: a case report and brief review of cases with coexistence of pemphigus vulgaris and bullous pemphigoid

Pemphigus vulgaris (PV) and bullous pemphigoid (BP) are two autoimmune blistering diseases involving the skin and the mucous membranes characterized by circulating autoantibodies directed against desmosomal cadherins or antigens expressed in the basement membrane zone, respectively. The simultaneous presence of clinical and/or immunopathological features of PV and BP in the same patient has been reported in very few cases in the literature to date. Most of these cases had exclusive cutaneous involvement, while a minority showed concomitant oral lesions. We describe the case of a 59-year-old female patient with a 10-year history of refractory PV lesions limited to mucous membranes (conjunctiva, oral cavity and genital mucosa), which were controlled by the addition of mycophenolate sodium to oral prednisone. Immunofluorescence studies revealed findings consistent with PV, whereas enzyme-linked immunosorbent assay revealed circulating anti-BP180 antibodies in association with anti-desmoglein 3 antibodies. The significance and relevance of this finding are briefly discussed, in light of the literature data.

Methyl-aminolevulinate photodynamic therapy for the treatment of actinic keratoses and non-melanoma skin cancers: a retrospective analysis of response in 462 patients

AIM

Topical photodynamic therapy (PDT) with methyl-aminolevulinate (MAL) is widely used for the management of actinic keratoses (AK) and non-melanoma skin cancers (NMSCs). The authors report the results of a retrospective chart review showing the cumulative four-year experience with MAL-PDT in a hospital outpatient setting.

METHODS

The medical records selected concerned all patients who completed the MAL-PDT regimen (one single session for AK and two sessions one week apart for NMSCs) and who underwent post-treatment assessments over a follow-up period of at least 12 months.

RESULTS

Present case series included a total of 462 patients: 210 patients with AK, 228 subjects with 348 basal cell carcinomas (BCCs), 213 of nodular type (nBCC) and 135 of superficial type (sBCC), 17 patients with Bowen's disease and seven with squamous cell carcinoma. On the whole, following a single session, complete clearance of AK was achieved in 79% of patients at three months and in 68.1% at 12 months. As concerns BCCs, regardless of the clinical type, a complete response was observed in 71% of lesions at three months, with a rate of recurrence at 12 months of 15%. The risk of both initial treatment failure and recurrence was higher for nBCCs than sBCCs. Our results, even if obtained in very few cases, indicate that Bowen's disease is very responsive to MAL-PDT, unlike microinvasive or invasive SCC. Treatment was generally well tolerated.

CONCLUSIONS

Our experience confirms that MAL-PDT is a valid approach to patients with AK, BCC and Bowen's disease, with an acceptable tolerability profile and a very low risk of complications.