Anatomical variants of the intercostobrachial nerve and its preservation during surgery, a systematic review and meta-analysis

BACKGROUND

The anatomic variants of the intercostobrachial nerve (ICBN) represent a potential risk of injuries during surgical procedure such as axillary lymph node dissection and sentinel lymph node biopsy in breast cancer and melanoma patients. The aim of this systematic review and meta-analysis was to investigate the different origins and branching patterns of the intercostobrachial nerve also providing an analysis of the prevalence, through the analysis of the literature available up to September 2023.

MATERIALS AND METHODS

The protocol for this study was registered on PROSPERO (ID: CRD42023447932), an international prospective database for reviews. The PRISMA guideline was respected throughout the meta-analysis. A systematic literature search was performed using PubMed, Scopus and Web of Science. A search was performed in grey literature through google.

RESULTS

We included a total of 23 articles (1,883 patients). The prevalence of the ICBN in the axillae was 98.94%. No significant differences in prevalence were observed during the analysis of geographic subgroups or by study type (cadaveric dissections and in intraoperative dissections). Only five studies of the 23 studies reported prevalence of less than 100%. Overall, the PPE was 99.2% with 95% Cis of 98.5% and 99.7%. As expected from the near constant variance estimates, the heterogeneity was low, I2 = 44.3% (95% CI 8.9%-65.9%), Q = 39.48, p = .012. When disaggregated by evaluation type, the difference in PPEs between evaluation types was negligible. For cadaveric dissection, the PPE was 99.7% (95% CI 99.1%-100.0%) compared to 99.0% (95% CI 98.1%-99.7%).

CONCLUSIONS

The prevalence of ICBN variants was very high. The dissection of the ICBN during axillary lymph-node harvesting, increases the risk of sensory disturbance. The preservation of the ICBN does not modify the oncological radicality in axillary dissection for patients with cutaneous metastatic melanoma or breast cancer. Therefore, we recommend to operate on these patients in high volume center to reduce post-procedural pain and paresthesia associated with a lack of ICBN variants recognition.

European e-Delphi process to define expert consensus on electrochemotherapy treatment indications, procedural aspects, and quality indicators in melanoma

BACKGROUND

Skin metastases are an important co-morbidity in melanoma. Despite broad adoption, electrochemotherapy implementation is hindered by a lack of treatment indications, uncertainty regarding procedural aspects, and the absence of quality indicators. An expert consensus may harmonize the approach among centres and facilitate comparison with other therapies.

METHODS

An interdisciplinary panel was recruited for a three-round e-Delphi survey. A literature-based 113-item questionnaire was proposed to 160 professionals from 53 European centres. Participants rated each item for relevance and degree of agreement on a five-point Likert scale, and received anonymous controlled feedback to allow revision. The items that reached concordant agreement in two successive iterations were included in the final consensus list. In the third round, quality indicator benchmarks were defined using a real-time Delphi method.

RESULTS

The initial working group included 122 respondents, of whom 100 (82 per cent) completed the first round, thus qualifying for inclusion in the expert panel (49 surgeons, 29 dermatologists, 15 medical oncologists, three radiotherapists, two nurse specialists, two clinician scientists). The completion rate was 97 per cent (97 of 100) and 93 per cent (90 of 97) in the second and third rounds respectively. The final consensus list included 54 statements with benchmarks (treatment indications, (37); procedural aspects, (1); quality indicators, (16)).

CONCLUSION

An expert panel achieved consensus on the use of electrochemotherapy in melanoma, with a core set of statements providing general direction to electrochemotherapy users to refine indications, align clinical practices, and promote quality assurance programmes and local audits. The residual controversial topics set future research priorities to improve patient care.

Is Pediatric Melanoma Really That Different from Adult Melanoma? A Multicenter Epidemiological, Clinical and Dermoscopic Study

PURPOSE

To improve the diagnostic accuracy and optimal management of pediatric melanomas.

METHODS

We conducted a retrospective descriptive, multicenter study of the epidemiological, clinical, and dermoscopic characteristics of histopathologically proven melanomas diagnosed in patients less than 18 years old. Data on sociodemographic variables, clinical and dermoscopic characteristics, histopathology, local extension, therapy and follow-up, lymph node staging, and outcome were collected from the databases of three Italian dermatology units. We performed a clinical evaluation of the morphological characteristics of each assessed melanoma, using both classic ABCDE criteria and the modified ABCDE algorithm for pediatric melanoma to evaluate which of the two algorithms best suited our series.

RESULTS

The study population consisted of 39 patients with a histologically confirmed diagnosis of pediatric melanoma. Comparing classic ABCDE criteria with the modified ABCDE algorithm for pediatric melanomas, the modified pediatric ABCDE algorithm was less sensitive than the conventional criteria. Dermoscopically, the most frequent finding was the presence of irregular streaks/pseudopods (74.4%). When evaluating the total number of different suspicious dermoscopy criteria per lesion, 64.1% of the lesion assessments recognized two dermoscopic characteristics, 20.5% identified three, and 15.4% documented four or more assessments.

CONCLUSIONS

Contrary to what has always been described in the literature, from a clinical point of view, about 95% of our cases presented in a pigmented and non-amelanotic form, and these data must be underlined in the various prevention campaigns where pediatric melanoma is currently associated with a more frequently amelanotic form. All the pediatric melanomas analyzed presented at least two dermoscopic criteria of melanoma, suggesting that this could be a key for the dermoscopic diagnosis of suspected pediatric melanoma, making it possible to reach an early diagnosis even in this age group.

A rare case of polypoid primary anorectal melanoma with subsequent giant stomach metastasis: a gastrointestinal involvement of both primary and metastatic mucosal melanoma

Introduction: Melanoma can involve the gastrointestinal apparatus as both primary and metastatic lesions. Primary anorectal mucosal melanoma (ARMM) and metastatic gastric melanoma are rare entities and usually resulted in a poor prognosis. Case: We presented a case of a 61-year-old man who after the complete excision of an ARMM developed a gastric metastasis after almost three years form the complete tumour excision. Upon esophagogastroduodenoscopy, a giant ulcered mass resulted in melanoma metastasis. The patient underwent a near-total gastrectomy. After five months of follow-up, the patient is disease-free. Conclusion: The incidence of ARMMs is increasing, highlighting the necessity of new prevention and treatment strategies in order to achieve a better prognosis for these patients. There are no known risk factor for ARMMs but surgery, together with the combination of anti-CTLA-4 and anti-PD-1 antibodies, are promising therapeutic options. Early and aggressive treatments are required, together with a strict multidisciplinary approach.

Clinical and Dermoscopic Features of Vulvar Melanosis Over the Last 20 Years

Importance

Vulvar melanosis is a common pigmentary change that accounts for most pigmented vulvar lesions. It presents as single or multiple asymptomatic macules or patches of varying size and color that may be asymmetric with poorly defined borders. The differential diagnosis of melanocytic lesions includes melanoma, which creates anxiety for patients and the physicians who diagnose the condition and treat the patients.

Objective

To evaluate the clinical and dermoscopic features of vulvar melanosis and their changes over time.

Design, Setting, and Participants

In this cohort study, patients with vulvar melanosis were recruited and followed up in the Department of Dermatology, University of Florence, Florence, Italy, between January 1, 1998, and June 30, 2019. Data on patient characteristics and on both the clinical and dermoscopic features of the vulvar lesions were collected. Each lesion was photographed clinically and dermoscopically at initial evaluation and at annual follow-up visits.

Main Outcomes and Measures

The clinical, dermoscopic, and histopathologic features of vulvar melanosis and their changes over time.

Results

This cohort study included 129 women (mean age at diagnosis, 46 years [range, 19-83 years]) with vulvar melanosis. A total of 87 patients (67%) with vulvar melanotic lesions were premenopausal, and 84 patients (65%) had received some type of hormone therapy. The most frequent location for vulvar melanosis was the labia minora (55 [43%]), followed by the labia majora (33 [26%]). In 39 of 129 cases (30%), the lesions increased in size and changed color after initial evaluation but ultimately stabilized. No malignant evolution was documented in any patient during a median follow-up of 13 years (range, 5-20 years).

Conclusions and Relevance

This study suggests that vulvar melanosis was a benign entity, and changes in lesions over time did not signify malignant transformation. An association between hormonal status and vulvar melanosis may be hypothesized.

Ilioinguinal Nerve Neurectomy is better than Preservation in Lichtenstein Hernia Repair: A Systematic Literature Review and Meta-analysis

OBJECTIVE

This study aimed to evaluate the incidence of chronic groin pain (primary outcome) and alterations of sensitivity (secondary outcome) after Lichtenstein inguinal hernia repair, comparing neurectomy with ilioinguinal nerve preservation surgery. The exact cause of chronic groin postoperative pain after mesh inguinal hernia repair is usually unclear. Section of the ilioinguinal nerve (neurectomy) may reduce postoperative chronic pain.

METHODS

We followed PRISMA guidelines to identify randomized studies reporting comparative outcomes of neurectomy versus ilioinguinal nerve preservation surgery during Lichtenstein hernia repairs. Studies were identified by searching in PubMed, Scopus, and Web of Science from April 2020. The protocol for this systematic review and meta-analysis was submitted and accepted from PROSPERO: CRD420201610.

RESULTS

In this systematic review and meta-analysis, 16 RCTs were included and 1550 patients were evaluated: 756 patients underwent neurectomy (neurectomy group) vs 794 patients underwent ilioinguinal nerve preservation surgery (nerve preservation group). All included studies analyzed Lichtenstein hernia repair. The majority of the new studies and data comes from a relatively narrow geographic region; other bias of this meta-analysis is the suitability of pooling data for many of these studies. A statistically significant percentage of patients with prosthetic inguinal hernia repair had reduced groin pain at 6 months after surgery at 8.94% (38/425) in the neurectomy group versus 25.11% (113/450) in the nerve preservation group [relative risk (RR) 0.39, 95% confidence interval (CI) 0.28-0.54; Z = 5.60 (P < 0.00001)]. Neurectomy did not significantly increase the groin paresthesia 6 months after surgery at 8.5% (30/353) in the neurectomy group versus 4.5% (17/373) in the nerve preservation group [RR 1.62, 95% CI 0.94-2.80; Z = 1.74 (P = 0.08)]. At 12 months after surgery, there is no advantage of neurectomy over chronic groin pain; no significant differences were found in the 12-month postoperative groin pain rate at 9% (9/100) in the neurectomy group versus 17.85% (20/112) in the inguinal nerve preservation group [RR 0.50, 95% CI 0.24-1.05; Z = 1.83 (P = 0.07)]. One study (115 patients) reported data about paresthesia at 12 months after surgery (7.27%, 4/55 in neurectomy group vs. 5%, 3/60 in nerve preservation group) and results were not significantly different between the two groups [RR 1.45, 95% CI 0.34, 6.21;Z = 0.51 (P = 0.61)]. The subgroup analysis of the studies that identified the IIN showed a significant reduction of the 6th month evaluation of pain in both groups and confirmed the same trend in favor of neurectomy reported in the previous overall analysis: statistically significant reduction of pain 6 months after surgery at 3.79% (6/158) in the neurectomy group versus 14.6% (26/178) in the nerve preservation group [RR 0.28, 95% CI 0.13-0.63; Z = 3.10 (P = 0.002)].

CONCLUSION

Ilioinguinal nerve identification in Lichtenstein inguinal hernia repair is the fundamental step to reduce or avoid postoperative pain. Prophylactic ilioinguinal nerve neurectomy seems to offer some advantages concerning pain in the first 6th month postoperative period, although it might be possible that the small number of cases contributed to the insignificancy regarding paresthesia and hypoesthesia. Nowadays, prudent surgeons should discuss with patients and their families the uncertain benefits and the potential risks of neurectomy before performing the hernioplasty.

The use of cisplatin electrochemotherapy in nonmelanoma skin cancers: A single-center study

Electrochemotherapy (ECT) is a well-known nonconventional skin cancer ablative method that was shown to be safe and effective for treating both locoregional disease spreading and disseminated cutaneous and subcutaneous lesions from different types of cancer. The most common medications used are bleomycin and cisplatin. In the last years many studies were performed on ECT, lead it to be a valid therapeutic option in many international guidelines. Nevertheless, there are still no clear indications regarding timing of its use. The main aim of this study was first to assess the safety and effectiveness of intralesional cisplatin ECT for treating different types of nonmelanoma skin cancer in a group of eligible patients. The second endpoint was to assess patients' tolerability and symptoms improvement through the treatment. A single-center prospective study was performed. Patients with squamous cell carcinoma, basal cell carcinoma, or skin metastases were selected during 1 month. The ideal setting was the presence of two or three lesions with a maximum diameter of 2 cm. Both primary, recurrent, and metastatic lesions were included. Before and 8 weeks after treatment, all patients were evaluated to assess the number, measurement, and anatomical site of skin lesions using photography and metric notation. The medical device for membrane electroporation was the CLINIPORATOR EPS02 model. The cisplatin concentration was at least 1 mg/mL. The dose for each single lesion was calculated based on its volume, as is the standard procedure for ECT. Local or systemic adverse events and changes in symptoms were evaluated with a questionnaire based on a visual analog scale that was administrated before and after ECT. Eight patients with a total of 18 lesions underwent the procedure (six men and two women). Four out of eight (50%) patients had a complete response to the treatment. However, all eight patients had an overall tumor response (100%), experiencing an improvement in symptoms including less pain and bleeding from the tumor. Our study clearly show that ECT with intralesional cisplatin is a valuable and safety procedure for nonmelanoma skin cancer and cutaneous tumor metastasis. ECT with cisplatin was able to achieve a good local disease control leading to complete response in an half of cases. The results were stable after 1 year of follow-up. The outer ear area displayed a really good response, due to both ear's anatomical configuration and intralesional cisplatin pharmacological characteristics.

Accuracy and feasibility of SentiMag technique for localization of non-palpable breast lesions

BACKGROUND

Non-palpable breast lesions are more frequent now than in the past due to the attention toward the mammary pathology and the screening diffusion; the marking of such lesions is very important for a successful surgery. The SentiMag System uses a magnetic marker that is inoculated transdermal in the breast through an 18-gauge needle.

METHODS

Between April 1^st and June 30^th, 2018, 16 patients with non-palpable breast lesions were selected and subjected to surgery using the SentiMag System in our Unit. They were women with a mean age of 52 years (range 30-84 years). Seven of 16 (43.7%) had a borderline preoperative histological or cytological diagnosis (C3/B3), and nine (56.3%) a diagnosis of carcinoma (C5/B5). Six (37.5%) were marked on ultrasound guidance and 10 (62.5%) on a mammography stereotaxic guide.

RESULTS

The time for the marker positioning ranged from 2 to 10 minutes. The radiological control of the surgical specimen always showed the presence of both the lesion and the marker, both centered within the specimen and intact. The pathology revealed seven benign lesions, one in-situ, and eight infiltrating carcinomas.

CONCLUSIONS

The SentiMag represents a fast and safe preoperative marking system of non-palpable breast lesions, cutting the radio exposure for personnel and patients. The marker is not displaced over time and it is rapid to place and easy to locate intraoperatively, allowing a clear dissection plane around the lesion. Thus, this reduces the amount of gland removed, improving the aesthetic result mostly in small breasts.

Reduction of postoperative lymphorrhoea in patients undergoing radical lymphadenectomy for stage III melanoma: prospective study using collagen-fibrin patches

BACKGROUND

Radical lymph nodes dissection (RLND) is the standard procedure for regional control of disease in patients with metastatic melanoma (stage III). Because of its aggressiveness, lymphorrhoea is a constant problem in postoperative.

METHODS

In this prospective nonrandomized study with a retrospective analysis of data, patients undergoing surgical treatment of axillary or iliac-inguinal RLND received standard treatment plus a collagen-fibrin sealant patch (TachoSil) (N.=50) or standard treatment alone (N.=50). The first endpoint was the comparison between the treated population and the control group, in terms of persistence of drainage and average daily volume of lymphorrhoea. The second aim was to relate patients' BMI, volume of lymphorrhoea and time of drainage in the two groups.

RESULTS

In the comparison between the two groups receiving or not the treatment with collagen-fibrin patch, we found an average difference both in the volume of daily lymphorrhoea (42.91±6.61 cc) and in the persistence of drainage (9.292±1.644 days) with P value <0.0001. Besides, the collagen-fibrin patch was actually effective in reducing lymphorrhoea and time of drainage, regardless of patients' BMI.

CONCLUSIONS

The results of this study confirm and support the starting thesis: TachoSil is an effective tissue sealant able to reduce lymphorrhoea and drainage removal times following a radical lymphadenectomy, independently from the BMI.

Appearance of cutaneous melanoma and subcutaneous metastases in metastatic gastric carcinoma undergoing chemotherapy with oral 5-fluorouracil prodrug

Metastatic skin lesions of gastric cancers usually appear as nonspecific, firm, and hyperpigmented nodules. However, they occasionally present as unusual skin manifestations that mimic other skin disorders. We describe a case of multiple cutaneous metastases from gastric cancer resembling sebaceous cysts with a synchronous melanoma, in a patient after fluoropyrimidine-based systemic chemotherapy. Melanoma occurring as a second cancer has been recognized in patients having undergone previous chemotherapy or radiation for another cancer. We can assume that the capecitabine-based chemotherapy may have played a role in the development of the melanocytic neoplasm. Our observation adds extra evidence to the link between fluoropyrimidine-based immunosuppression and the induction of melanocytes' proliferation and transformation. For these reasons, it is advisable to require dermatological checkups for patients undergoing chemotherapy treatments in order to identify suspicious melanocytic lesions as soon as possible.

Retained sponges in abdomen: an analysis of the judgments of the Italian Supreme Court

The administration of justice in Italy includes first, second and third instance. The first and second instances are represented by the Court of First Instance and the Court of Appeal: these are judgment of Romamerit. The court of last appeal for both the civil and the criminal jurisdiction is the Court of Cassation, the Italian Supreme Court. It is a court of legitimacy that should provide for a consistent and uniform interpretation of the law and that only on points of law, not on factual evidence. The Court of Cassation can confirm the sentence of second instance, can dismiss it without referral, can deciding and closing the trial definitively, or dismiss it referring the case to the judge of merit that must decide according to the principles set out in the legitimacy. The aim of this study is to analyze the Supreme Cassation Court's judgments on the legal proceedings about retained sponges in abdomen.

Palliative Electrochemotherapy in Vulvar Carcinoma: Preliminary Results of the ELECHTRA (Electrochemotherapy Vulvar Cancer) Multicenter Study

Vulvar cancer (VC) is a rare disease of which recurrence poses management problems due to patients' advanced age and comorbidities, and to the localization of the disease. Palliative treatments, allowing local disease control in patients previously treated with multimodal therapies or with comorbidities, are lacking. In this study we tested electrochemotherapy (ECT) on recurrent VC refractory to standard therapies to assess the tumor response and to define the selection criteria for patient's candidate to ECT. This is a multicenter observational study carried out in five Italian centers. Data about patients and tumor characteristics, treatment, toxicity, and clinical response were recorded. In all procedures, intravenous bleomycin was administered according to European Standard Operative Procedure ECT (ESOPE) guidelines. Sixty-one patients, with a median age 79 years (range: 39-85) and mainly affected by squamous cellular carcinoma (91.8%), were treated with ECT. No serious adverse events were reported. Patients were discharged after three days (median, range: 0-8 days). Two months after ECT, the clinical response rate was 83.6% and was not related to age, body mass index, International Federation of Gynecology and Obstetrics (FIGO) stage, number of treated nodules, or previous treatments. ECT is a safe procedure with a favorable cost-effectiveness ratio and should be considered as a treatment option for local disease control in patients unsuitable for standard therapies.

Three-dimensional versus two-dimensional laparoscopic right colectomy: a systematic review and meta-analysis

BACKGROUND

Three-dimensional (3D) vision technology has recently been validated for the improvement of surgical skills in a simulated setting. Clinical studies on specific operations have been published in the field of general, urologic, and gynecologic laparoscopic surgery. We hypothesized that 3D vision laparoscopic right colectomy has better intra and short-term postoperative outcomes than two-dimensional (2D) vision.

AIM

The outcomes of this review and meta-analysis were to compare the 3D vision and the 2D vision laparoscopic right colectomy.

METHODS

A systematic search of the literature was performed on Pubmed, WOS, Google Scholar, and Scopus databases (Prospero reg. nr. 42016047704) for comparative studies between 2D and 3D laparoscopic right colectomy. Primary endpoints were safety issues and secondarily patients' related and surgeons' comfort outcomes. Meta-analyses, when possible, were conducted with a random-effects model.

RESULTS

Two retrospective comparative studies (for a total of 56 patients in the 2D arm and 52 patients for the 3D arm) were selected out of 680 screened records. Methodological quality was fair. Three-dimensional laparoscopic right colectomy has similar safety and secondary outcomes when compared to 2D, with not statistically significant shorter operating times (mean difference 11.81 min). The results are comparable also for anastomosis leakage. The results for other outcomes were not aggregated for heterogeneity.

CONCLUSIONS

3D laparoscopic right colectomy shows equivalent patients' outcomes compared to 2D operation, but the scarce clinical data and the potential amelioration of surgeons' skills, especially on difficult intracorporeal tasks like suturing, suggest the publication of further trials.

Surgical treatment of gastrointestinal stromal tumors of the duodenum: a literature review

Background

Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumours in the digestive tract. The duodenal GIST (dGIST) is the rarest subtype, representing only 4-5% of all GIST, but up to 21% of the resected ones. The diagnostic and therapeutic management of dGIST may be difficult due to the rarity of this tumor, its anatomical location, and the clinical behavior that often mimic a variety of conditions; moreover, there is lack of consent for their treatment. This study has evaluated the scientific literature to provide consensus on the diagnosis of dGIST and to outline possible options for surgical treatment.

Methods

An extensive research has been carried out on the electronic databases MEDLINE, Scopus, EMBASE and Cochrane to identify all clinical trials that report an event or case series of dGIST.

Results

Eighty-six studies that met the inclusion criteria were identified with five hundred forty-nine patients with dGIST: twenty-seven patients were treated with pancreatoduodenectomy and ninety-six with only local resection (segmental/wedge resections); in four hundred twenty-six patients it is not possible identify the type of treatment performed (pancreatoduodenectomy or segmental/wedge resections).

Conclusions

dGISTs are a very rare subset of GISTs. They may be asymptomatic or may involve symptoms of upper GI bleeding and abdominal pain at presentation. Because of the misleading clinical presentation the differential diagnosis may be difficult. Tumours smaller than 2 cm have a low biological aggressiveness and can be followed annually by endoscopic ultrasound. The biggest ones should undergo radical surgical resection (R0). In dGIST there is no uniformly adopted surgical strategy because of the low incidence, lack of experience, and the complex anatomy of the duodenum. Therefore, individually tailored surgical approach is recommended. R0 resection with 1-2 cm clear margin is required. Lymph node dissection is not recommended due to the low incidence of lymphatic metastases. Tumor rupture should be avoided.

Clinical and Dermoscopic Features of Lichenoid Keratosis: A Retrospective Case Study

BACKGROUND

Lichenoid keratosis is a benign cutaneous lesion exhibiting many clinical faces and different dermoscopic features.

OBJECTIVE

This study aims to determine the pattern of different clinical subtypes of lichenoid keratosis and to establish whether there is any correlation between the clinical variants of lichenoid keratosis and their dermoscopic appearance.

METHODS

We retrospectively analyzed the medical records and clinical database of patients who had received a histological diagnosis of lichenoid keratosis. Based on the literature review and the clinical-dermoscopic features of lichenoid keratosis, we divided the lesions into 6 clinical subtypes to evaluate potential correlations between clinical and dermoscopic features in all subtypes.

RESULTS

Fifty-one lesions were included in this clinical study. Preoperatively, only 1.9% of cases were clinically diagnosed as lichenoid keratosis, and the most common misdiagnosis was basal cell carcinoma (52.9%). We identified 6 subtypes of lichenoid keratosis and their corresponding dermoscopic features and clues.

CONCLUSION

Since lichenoid keratosis has no pathognomonic dermoscopic clues and it is commonly misdiagnosed as malignant skin neoplasms, such as basal cell carcinoma and melanoma, improving the knowledge of both clinical and dermoscopic variability of lichenoid keratosis may help dermatologists to reduce unnecessary surgery and to reduce health care spending.

Cytogenetic/mutation profile of chronic lymphocytic leukemia/malignant melanoma collision tumors of the skin

Background

Collision tumors are rare entities that consist of two histologically distinct tumor types arising in the same anatomic site. An association between chronic lymphocytic leukemia (CLL) and malignant melanoma (MM) has been already described. Up to now, they have been documented only at positive regional lymph nodes while we focused on collision tumor in a skin lesion.

Case presentation

We characterized the genomic profile of a skin CLL/MM collision tumor in a patient with a 9-years story of CLL. Typical high-grade genomic biomarkers featured the CLL: the immunoglobulin heavy variable genes were unmutated; a clonal del(11q), involving ATM and BIRC3, was present in the peripheral blood (PB) and skin lesion, while a subclonal large del(13q)/D13S319-RB1 was detected only in the PB. Interestingly, the del(13q) clone, increased from 10% to 46% from diagnosis to relapse. NOTCH1, SF3B1, and TP53 were wild type. The MM lesion carried a BRAF^V600E and a TERT promoter mutation.

As the family story was consistent with a genetic predisposition to cancer, we performed mutational analysis of genes involved in familial melanoma and CLL, and of BRCA1 and BRCA2. No germinal mutation known to predispose to CLL, MM, or breast cancer was found. Interestingly, conventional cytogenetic detected a constitutional t(12;17)(p13;p13).

Conclusions

Our data are consistent with distinct genetic landscape of the two tumors which were characterized by specific disease-related abnormalities. CLL cells carried poor prognostic imbalances, i.e. large deletions of the long arm of chromosomes 11 and 13, while in MM cells two functionally linked mutations, i.e. BRAF^V600E and a TERT promoter occurred. Although, known germline variations predisposing to MM and/or CLL were ruled out, genetic counseling suggested the proband family was at high risk for MM.

Role of BMI and hormone therapy in melanoma risk: a case-control study

BACKGROUND

Currently, the association between body mass index (BMI) and hormone therapies and Cutaneous Melanoma (CM) development is strongly debated. This study was carried out to assess the association between BMI, hormone therapies, and CM risk.

METHODS

The present study is a hospital-based case-control study with 605 consecutive CM patients and 592 controls treated for non-neoplastic conditions at the Department of Dermatology in Florence. The associations of melanoma risk with BMI and hormone therapies were assessed performing unconditional logistic regression to estimate odds ratios (OR) and their 95% confidence intervals, adjusting for potential confounders.

RESULTS

We found a significant interaction of BMI with age (P < 0.0001): being overweight significantly increased CM risk among individuals less than 50 years old (OR = 1.85 with 95% CI 1.14-2.94), whereas the association was not significant for individuals over 50 years old (OR = 1.15 with 95% CI 0.77-1.71). For oestrogen therapy, women taking oral contraceptives (OCs)/hormone replacement therapy (HRT) showed a lower CM risk than men (OR = 0.63, 95% CI 0.44-0.89), with risk estimates significantly lower (P < 0.0001) than in non OCs/HRT users, which had an increased risk compared to men (OR = 1.81, 95% CI 1.29-2.53).

CONCLUSIONS

Being overweight was significantly associated with CM risk, and this relationship was highly age-conditioned; the second finding was the protective effect of oestrogen therapies for women. Both findings may have a significant impact on melanoma prevention, as the prevalence of obesity and hormone therapy use is increasing worldwide.

Clinical and dermoscopic features of truly amelanotic plantar melanoma

Currently, there are no specific clinical and dermoscopic features for diagnosing truly amelanotic plantar melanoma (TAPM). The present study aimed to investigate the dermoscopic features of all clinical variants of TAMPS and to evaluate their histopathological correlations. A retrospective analysis of prospectively collected data was carried out during a 10-year period (2003-2013). We analyzed the clinical data of 1321 patients, who had received a histological diagnosis of melanoma at the Melanoma Unit of the University of Florence. We selected the clinical and dermoscopic images of TAPMs and analyzed the presence of dermoscopic parameters. Incorrect preoperative diagnoses were analyzed to highlight peculiar dermoscopic features of pinkish plantar melanomas, the clinical diagnosis of which is extremely challenging for the dermatologist. Of all 1321 patients, 29 (24%) had TAPMs. Importantly, only 20.7% of patients with TAPMs had a correct preoperative diagnosis of suspicious melanocytic lesion. On the basis of the initial misdiagnosis, TAPMs were categorized as eczema-like, verruca-like, angioma-like lesions. Dermoscopically, all TAPMs showed the presence of a well-defined 'erythematous homogeneous area' with an atypical polymorphous vascular pattern with dotted, globular, and glomerular vessels. Our study highlights a crucial dermoscopic feature of TAPMs, the 'erythematous homogeneous area' that is characteristic of the plantar region, and, to our knowledge and experience, has not been described in nonacral amelanotic melanomas.

Trichilemmal cystis in metastatic melanoma: a case report

The malignant melanoma is a neoplasm associated with a wide variety of cutaneous paraneoplastic syndromes, as dermatomyositis, systemic sclerosis, paraneoplastic pemphigus. We describe a case of four multiple trichilemmal cystis arising on frontal region in the same patient with brain metastasis and unknown primary melanoma and discuss their relationship.

Electrochemotherapy with intravenous bleomycin for advanced non-melanoma skin cancers and for cutaneous and subcutaneous metastases from melanoma

BACKGROUND

The treatment of cutaneous advanced non-melanoma skin cancers (NMSC) and multiple cutaneous and subcutaneous melanoma metastases (Mm) represents a main therapeutic challenge. Electrochemotherapy (ECT) is an anticancer procedure that facilitates the penetration of cytotoxic drugs into cancer cells by means of the application of electrical pulses. The aim of our study was to evaluate efficacy and tolerability of ECT in the treatment of advanced NMSC and Mm.

METHODS

Thirteen patients with a total of 88 cutaneous and subcutaneous tumour lesions were selected (69 Mm in 6 patients and 19 NMSC in 7 patients). The lesions were divided into "Target" (NMSC: 7; Mm: 9) and "Non -target" (NMSC: 12; Mm: 60) lesions according to RECIST criteria 1.1. All patients underwent ECT under mild general anaesthesia. Eight minutes following intravenous bleomycin, electrical pulses were delivered to the tumour nodules using a square wave pulse generator (CliniporatorTM, IGEA S.p.A., Carpi, Italy).

RESULTS

A complete response of "Target" NMSC lesions and "Target" Mm nodules was observed in 85.7% (6/7) and 33.3% (3/9), respectively. Only one NMSC underwent two courses of treatment, achieving a complete response 1 month after the second ECT session. Among Mm, 6 of 9 "Target" lesions received more than one ECT session, achieving a size reduction in 3 of 6 lesions. This improvement, however, was not classified as partial response because the size reduction was lower than 30%. In 1 patient, one Mm "Target" lesion increased in volume while other two "Target" lesions appeared stable. No statistically significant difference was observed, between the size of the lesions before treatment and after treatment, nevertheless statistical significance was achieved in the "Target" lesions comparing the response to ECT of NMSC group vs. Mm group (P<0.05).

CONCLUSIONS

Our study confirms the potential therapeutic role of ECT. This procedure could represent the 1st line treatment for advanced NMSC, especially in elderly patients not suitable for surgery or radiotherapy. As already described in literature, we hereby validate the effective role of ECT in the palliation of Mm.

Experimental Model of Lymphedema

The authors describe a new exper imental model for lymphedema of rabbit ear. The method proved to be reliable and easily reproducible. The dilatation of lymph vessels after ex perimental provocation of lymphe dema permits study of the physio pathologic basis of lymphovenous shunts created by means of micro surgery and proves to be helpful for the microsurgeon's practice.

Teledermoscopy in doubtful melanocytic lesions: is it really useful?

INTRODUCTION

The diagnosis of cutaneous pigmented lesions remains a challenge for both dermatologists and pathologists. Our aim was to determine the diagnostic concordance between the conventional face-to-face diagnosis and the telediagnosis of 10 dermatologists with expertise in dermato-oncology of 10 challenging pigmented lesions.

METHODS

Using a store-and-forward teledermatology method, clinical and dermoscopic digital images of all selected lesions were transmitted via e-mail to 10 dermatologists. Dermatologists were called to provide their telediagnoses with a step-by-step approach. When the dermatologists responded with their first clinical telediagnosis, they received a second email that contained dermoscopic images of the 10 cases. Final histopathological diagnosis was considered the gold standard for comparison with face-to-face and teledermatology diagnoses in statistical analysis.

RESULTS

Face-to-face results indicated moderate agreement between clinical and histopathological diagnoses (K = 0.6). After the first clinical step, interobserver concordance of telediagnosis was lower than face-to-face diagnosis (K = 0.52). After the second dermoscopy step, the concordance declined further (K = 0.38).

CONCLUSIONS

Teledermatology was inferior to face-to-face dermatology. Moreover, the diagnostic concordance of telediagnosis decreased after the teledermoscopic step. This finding may be justified by the dermoscopic difficulty of the selected lesions, including Spitzoid proliferations and atypical melanocytic nevi of the elderly. These lesions may represent a potential diagnostic pitfall given their confounding dermoscopic aspects.

Axillary Lymph Node Metastases of Melanoma: Management of Third-level Nodes

AIM

To state the limits of axillary lymphadenectomy in patients with metastatic melanoma.

PATIENTS AND METHODS

We performed a prospective study on patients submitted to axillary dissection for stage III melanoma. At surgery, the third-level nodes were separately dissected to be examined by the pathologist.

RESULTS

We analyzed 86 patients. In 93%, the third-level nodes were disease-free; none of the patients with previous positive sentinel nodes (SN) showed nodal metastases at level III. Patients (7%) found to have positive level III nodes had undergone therapeutic lymphadenectomy for bulky nodal disease.

CONCLUSION

Our data show that axillary non-sentinel nodes of level III are usually disease-free in cases of previously positive SN, while they can be involved in the presence of bulky disease. A prerequisite allowing sparing of level III nodes after a positive SN biopsy is the meticulous research of all level I and II lymph nodes.

Therapeutic options for body packers: surgical or conservative treatment? A single center experience and review of literature

Body packing is a way to deliver packages of drugs hidden in body cavities. In Europe, as noted the latest report coming from the Brussels observatory, there are 74 million drugs consumers. Italy is in pole position and Perugia was considered as a "capital city" in the drug market. Body packers usually swallow the drug packets, although their insertion into the rectum and vagina has also been reported. The management depends on whether or not the patient becomes symptomatic. Surgery is indicated in presence of repeated bouts of drug toxicity not controlled by medical treatment, radiological evidence of packet retention in the stomach, intestinal obstruction or perforation. It is also important to emphasize that, in a multidisciplinary context, the patient's management before reaching the operating theater if symptomatic, is aimed to stabilization and is usually demanded to Intensive Care Unit (ICU) physicians. We present our center recent experience with body packers, managed both with surgical and conservative treatments.

KEY WORDS

Body packers, Drugs, Emergency surgery, Foreign bodies.

A rare nosological entity: the perforated solitary cecal diverticulum. Research article

AIM

To describe three cases of solitary cecal diverticulum, and trying to evaluate the better method of diagnosis and treatment with analysis of the literature.

MATERIAL OF STUDY

Description of three cases of solitary cecal diverticulum's perforation admitted in the Department of General and Oncologic Surgery, Santa Maria della Misericordia Hospital, Perugia, during the period January 2011 - January 2012.

RESULTS

In all patients the clinical presentation was very similar to that of acute appendicitis. Preoperative diagnosis was achieved in one case through abdominal CT scan, other two cases were identified at final pathology. At one year from the treatment all patient are still alive.

DISCUSSION

Cecal diverticulum is a rare condition, often diagnosed either casually or because of inflammatory or perforative complications. The highest incidence is found in Western population. Because of the clinical presentation, very similar to the appendicitis, and the inflammatory reaction involving the colon and its surrounding tissues, the pre- and intra-operative diagnosis are very difficult. The diagnosis is almost always histological. The treatment may vary from simple expectant medical management, carried out with bowel rest, parenteral support and antibiotics as for left-sided diverticulitis, to surgical approach, performed through simple diverticulectomy or by classical right hemicolectomy.

CONCLUSION

Pre-surgical and, also intra-operative, diagnosis of perforated solitary cecal diverticulum is clearly difficult. CT scan represents the gold standard for the differential diagnosis. Right hemicolectomy is an effective and safe approach, allowing accurate control, preventing complications and recurrences, and it represents the optimal management of the disease.

Current status of robotic bariatric surgery: a systematic review

Background

Bariatric surgery is an effective treatment to obtain weight loss in severely obese patients. The feasibility and safety of bariatric robotic surgery is the topic of this review.

Methods

A search was performed on PubMed, Cochrane Central Register of Controlled Trials, BioMed Central, and Web of Science.

Results

Twenty-two studies were included. Anastomotic leak rate was 8.51% in biliopancreatic diversion. 30-day reoperation rate was 1.14% in Roux-en-Y gastric bypass and 1.16% in sleeve gastrectomy. Major complication rate in Roux-en-Y gastric bypass resulted higher than in sleeve gastrectomy ( 4,26% vs. 1,2%). The mean hospital stay was longer in Roux-en-Y gastric bypass (range 2.6-7.4 days).

Conclusions

The major limitation of our analysis is due to the small number and the low quality of the studies, the small sample size, heterogeneity of the enrolled patients and the lack of data from metabolic and bariatric outcomes. Despite the use of the robot, the majority of these cases are completed with stapled anastomosis. The assumption that robotic surgery is superior in complex cases is not supported by the available present evidence. The major strength of the robotic surgery is strongly facilitating some of the surgical steps (gastro-jejunostomy and jejunojejunostomy anastomosis in the robotic Roux-en-Y gastric bypass or the vertical gastric resection in the robotic sleeve gastrectomy).

The integrated role of ultrasonography in the diagnosis of soft tissue metastases from melanoma: preliminary report of a single-center experience and literature review

Currently melanoma has the fastest growing incidence of all cancers in men and the second in women (after lung cancer) in Western countries. Since prognosis of skin melanoma is excellent in early stages but dramatically worsens in advanced stages, an early diagnosis is fundamental in granting patients a favorable outcome. Sentinel node (SN) biopsy represents the gold standard for accurately staging melanoma, but other tests are commonly endorsed both in the initial staging work-up and in the follow-up, such as ultrasonography, computed tomography (CT)-scan and positron emission tomography (PET)-CT. PET-CT, among others, has high sensitivity and specificity for the study of distant metastases, the assessment of soft tissues and lymph node involvement, and for the guidance of surgical biopsies. Ultrasonography (US) is a non-invasive procedure whose use has recently expanded in our service, both preoperatively, intraoperatively and postoperatively, thanks to its wide availability, low costs and easy and fast reproducibility; ultrasonography even surpassed the reliability of PET-CT or CT-scan in the seven cases presented herein. US is operator-dependent, and this is probably the major limitation of the procedure, together with lack of prospective studies validating its strength, but our preliminary study demonstrates that ultrasound can assume an important role in melanoma, both for staging and the follow-up of patients, especially with lymph nodal or subcutaneous involvement.

Oncologic reliability of nipple-sparing mastectomy for selected patients with breast cancer

BACKGROUND

Nipple sparing mastectomy (NSM) is the current surgical alternative to conventional techniques, when mastectomy is required. This less invasive procedure safeguards the integrity of the nipple areola complex (NAC), whose removal is recognized as a factor that exacerbates the patient's feeling of mutilation, however ensuring oncological radicality for women with breast cancer.

PATIENTS AND METHODS

From January 2003 to January 2011, 77 patients underwent Nipple Sparing Mastectomy (NSM). Patients were carefully selected according to specific criteria. When requested, postoperative radiotherapy on the residual glandular tissue was performed within 6 months of surgery. Patients were on close clinical and instrumental follow-up every 4 months for 2 years and every 6 months for the remaining 3 years.

RESULTS

Of the 77 patients who underwent NSM, 10 suffering from bilateral cancer were subjected to bilateral procedure, for a total of 87 performed procedures. Furthermore, in the same group, 13 NSMs were carried out for preventive purposes. The average diameter of resected tumors was 13.5 mm, with a range of 2 to 25 mm. During the follow-up (range 23-115 months, mean 50.33 months) 2 locoregional recurrences in the NAC were observed, identified through instrumental check, and surgically treated by NAC removal after 33 and 37 months respectively.

CONCLUSION

According to the litterature data and confirmed by our experience, we consider NSM as an oncologically safe technique that, in the respect of inclusion criteria may be performed in any patient with indication to mastectomy. A careful selection of patients by a multidisciplinary team according to strict criteria is the key in determining feasibility as well as oncological safety and should lead the general acceptance and widespread use of such surgical technique.

Optimizing therapeutic timing in patients undergoing mastectomy through use of the Tiloop® synthetic mesh: single-step surgery

Patients undergoing mastectomy for breast cancer have to face a long and elaborated therapeutic path, very often burdened by reoperation to replace the temporary expander, used to enlarge the submuscular pouch, with a definitive implant. Postoperative planning represents a critical moment of care, as it requires the integration of multiple treatments (chemotherapy, radiotherapy, hormonotherapy) each with a specific deadline. We believe that in such a complex multidisciplinary approach, coordination among the different therapeutic phases should be the key to success. The aim of the Breast Unit is to manage rapidly the ad hoc paths set out for each patient in order to guarantee compliance with adequate therapeutic timing. With this purpose in mind we tested the advantage of immediate reconstruction with definitive implants, by using a polypropylene mesh which, prolonging the inferolateral profile of the pectoralis major muscle (PMM), allows for direct accommodation of the desired implant volume. This leads to a single-step surgical approach, guaranteeing at the same time reduced interference with adjuvant therapies and good aesthetic results. We applied this technique to 4 patients, one of which was bilateral and, in spite of the restricted number of cases, our results seem to be promising.

Surgical solutions for the reconstruction of the lower eyelid: canthotomy and lateral cantholisis for full-thickness reconstruction of the lower eyelid

The lower eyelid is the most common site of tumors of the orbital region, usually of basocellular skin carcinoma, whose incidence is increasing with population aging in Western countries. The treatment must achieve the complete removal of the neoplasm in order to prevent recurrences, thus requiring eyelid and periocular reconstruction. Several techniques are described for eyelid defect reconstruction, aiming for direct suture eased by flaps, or considering the use of grafts. We report our experience with 22 patients operated on for basocellular carcinoma of the lower eyelid, for wich defects were repaired by means of a full-thickness reconstruction using a canthotomy and lateral cantholisis; in 13 patients the canthotomy was combined with a lateral-canthal flap. We achieved good results in terms of orbital function and aesthetic outcome, as long as radical removal of the tumor without local recurrences was attainable.