Surgical management of giant skin tumor - A case report

INTRODUCTION

Malignant non-melanoma skin cancers (NMSC) are of two main types: basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). In rare occasions, some of the malignant skin lesions show histopathological characteristics of both BCC and SCC and are known as basosquamous carcinomas (BSC). In some cases of large tumors, extensive reconstructive surgery might be needed to correct the skin defect after the primary excision.

PRESENTATION OF CASE

We report a case of a 76-year-old Bulgarian male patient who presented with a neglected giant cutaneous tumor with more than a 15-year history of a growing mass in the right deltoid area. On physical exam an enormous exophytic ulcerated and crusted skin lesion measuring around 11×11cm was found. Wide local excision of the lesion with 10-mm resection margins and partial resection of the underlying deltoid muscle were performed due to signs of infiltration. A full-thickness total skin graft from the left inguinal area was harvested to cover the skin defect. Final histopathological examination showed metatypical carcinoma with mixed characteristics of SCC and BCC - BSC, with infiltration of the fatty tissue, deltoid muscle and clear margins of resection, staged as T4R0. Two and a half years after surgery there are no signs of upper arm motor dysfunction and no evidence of local recurrence and distant metastasis on a follow-up PET/CT.

DISCUSSION

Following current National Comprehensive Cancer Network's guidelines for primary treatment of BCC, surgical candidates should undergo standard excision with wider surgical margins, postoperative margin assessment and second intention healing, linear repair, or skin graft. Therapeutic strategy for non-operable cases includes administration of radiotherapy or system therapy in the face of Hedgehog pathway inhibitors and programmed cell death protein 1 inhibitor. They can provide an alternative solution to unresectable or difficult-to-treat locally advanced cases of BSC.

CONCLUSION

Similarly to BCC and SCC, the first-line treatment option for BCS is surgical excision, but surgical margins should be wider than those for low-risk BCC due to the infiltrative growth pattern of this tumor. Favorable esthetic outcome requires precise planning of the reconstructive technique.

Dietary Intake and Adherence to the Recommendations for Healthy Eating in Patients With Type 1 Diabetes: A Narrative Review

Background: Medical nutrition therapy is essential for all people with diabetes, of any type or severity. Compliance with the recommended nutrition is an integral part of the treatment of type 1 diabetes (T1D). It remains unclear to what extent the dietary intake of patients with type 1 diabetes adheres to the recommendations for healthy eating.

Objective: The primary aim of our study is to collect and analyze published articles on the nutrition of T1D patients in comparison with the general population and recommendations.

Research Strategy and Methods: A literature search for articles, published between January 2006 and July 2021 was conducted, using electronic databases (PubMed and Google Scholar) for all available publications in English and Bulgarian. The process of study selection, identification, screening, eligibility and inclusion followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations for a flowchart. Based on the keywords search, 425 titles were retrieved, of which 27 were selected based on title and abstract. All papers were crosschecked and reviewed for selection by 3 independent reviewers. As a result, 19 titles were eligible and met inclusion criteria for a full review.

Results: Energy intake tends to be lower in T1D patients or comparable to controls and in most cases within the general recommendations. The percentage of calories from protein is within the recommendations for children, adolescents and adults. Only two studies showed that T1D patients consume significantly less than the recommendation for total fat intake (<35E%). The median intake of carbohydrates is in the lower end of the recommended 45 to 60E%. The median intake of dietary fiber adjusted for total energy is too low for T1D patients and the general population.

Conclusion: Study findings suggested a lack of knowledge or misunderstanding of diabetes dietary management. Patients with T1D, who are being consulted with a dietician as a part of their treatment plan may have better compliance to their recommended diet and as a result, are likely to have better health outcomes. Nutritional therapy should focus not only on glycemic control and pure carbohydrate counting but also on healthy eating and complication prevention.

Adipocytokines during pregnancy and postpartum in women with gestational diabetes and healthy controls

BACKGROUND

This study aims to explore the changes in maternal serum adipocytokines during pregnancy and post partum in normal and complicated with gestational diabetes (GDM) pregnancies and to investigate the relationship between serum adipocytokines and some of major metabolic parameters.

MATERIALS AND METHODS

236 pregnant women (127 with GDM and 109 control group) and 50 postpartum women (30 with GDM during pregnancy and 20 controls). Using ELISA and EIA kits, serum levels of adipocytokines were tested during pregnancy and post partum. Maternal adipocytokines levels were correlated with some metabolic parameters.

RESULTS

Women with GDM had lower values of adiponectin and higher values of leptin during pregnancy (p<0.001; 0.0001) and post partum (p<0.002; 0.0001). Serum apelin was significantly lower in GDM group (p<0.009). However, we did not find significance for resistin (p<0.317) and apelin (p<0.218). Positive correlation for leptin and negative for adiponectin was found for pre-pregnancy and pregnancy body mass index, glycated hemoglobin and homeostasis model assessment of insulin resistance index. Using cut point of 8.2 μg/ml for adiponectin and 28.7 ng/ml for leptin could exclude GDM with a sensitivity of 83.6%/81.2% and specificity of 56.6%/64.2% (area under the curve 0.702 and 0.827).

CONCLUSION

There are constant differences in adiponectin and leptin levels between GDM and control group during pregnancy and post partum. Apelin was decreased in our GDM group and no differences were found for resistin and visfatin. Further studies are required to verify the mechanism of this alteration and whether the adipocytokines can be predictors for GDM at an early stage of pregnancy.

[Metformin efficiency for the adolescent PCOS treatment]

PCOS is a polyglandular heterogenic metabolic condition, which frequency in adolescence is defined between 11-26%. There are some aspects of PCOS which can be seen in a regular puberty and vice versa. This makes the adolescent PCOS a condition which is rather complicated to diagnose as well as to treat. The pathophysiology of PCOS is not fully clarified, but is well established the fundamental role of the insulin resistance and the hyperinsulinemia. This fact explains the detailed investigations of the insulin sensitizers use for the PCOS treatment. Nevertheless there is insufficient experience with this medication group for the adolescent PCOS treatment in Bulgaria.

OBJECTIVE

To evaluate the Metformin efficiency for the adolescent PCOS treatment.

MATERIAL AND METHODS

This is a prospective study including 55 girls with menstrual irregularities aged between 13 and 18 years. None of the subjects had previously been diagnosed with any endocrine pathology or had received any hormonal treatment for at least three months prior to their evaluation. They have been evaluated according to the diagnostic criteria for PCOS in adolescence accepted in 2010.

RESULTS

The incidence of PCOS in our research was 38.9%. In 66.7% of them the body mass index was higher than normal. Insulin resistance was diagnosed in 90.5%. The insulin resistance was improved in 80% of the PCOS patients after six months therapy with Metformin 2 x 850 mg/p.d. The menstrual function was regulated in 77.8% of the cases.

[Short-term and long-term risks for children born from patients with gestational diabetes]

The risk of developing type 2 diabetes and cardiovascular disease in women who had previously been diagnosed with gestational diabetes (GDM) is well established. A growing body of literature suggests that chronic disease has much of its origins in the fetal response to the intrauterine environment, a concept known as "fetal programming". Longitudinal studies have demonstrated that higher rates of obesity impaired glucose tolerance, hypertension, and dyslipidemia are evident in the offspring of diabetic women. Furthermore, distinct differences in regional populations, lack of routine screening and treatment of GDM worldwide, and long follow-up periods for offspring represent a challenge in assessing the risk for development of these abnormalities in the offspring of women who have had GDM.

[Myoinositol--alternative treatment of insulin resistance in adolescents]

Myo-inostitol is a part of inositolphosphoglycan (IPG) mediators, which are known as putative mediators of insulin. One of the theories for insulin resistance is any deficiency in Myo-inositol. Presumably a substitution therapy with exogenous Myo-inositol could be effective for treatment of insulin resistance and PCOS. This is well established in women in reproductive age, but there is insufficient data for adolescence.

[Our and foreign experience in surgical treatment of CIN III-cold knife conisation versus LLETZ]

AIM

Our aim was to assess the treatment results of patients with CIN III- surgically treated with cold knife cone biopsy compared with the results of treatment with LLETZ and laser conisation.

MATERIALS AND METHODS

600 patients were assessed and researched for 10 years period. Some of them were from the Specialized Hospital for Active Treatment in Oncology-Sofia, some from RHW and some from the Medical University of Varna-Cathedra of Obstetrics and Gynaecology. 350 patients were operated by the classical method- cold knife conisation, 200 by LLETZ and 50 by laser cone biopsy.

RESULTS

We didn't find any difference in patients age, their cytological results and the results of their treatment. The LLETZ showed good results according to resected margins. The same good results were observed with laser conisation. Invasive disease and recurrence were observed in 150 patients--50 of them having adenocarcinoma in situ.

CONCLUSIONS

Our research showed that there is no difference in the results of both groups- treated by the classical way--cold knife conisation or by LLETZ and laser conisation.