Corrado Rubino

BRAF/NRAS Mutation Frequencies Among Primary Tumors and Metastases in Patients With Melanoma

PURPOSE The prevalence of BRAF, NRAS, and p16CDKN2A mutations during melanoma progression remains inconclusive. We investigated the prevalence and distribution of mutations in these genes in different melanoma tissues. PATIENTS AND METHODS In all, 291 tumor tissues from 132 patients with melanoma were screened. Paired samples of primary melanomas (n = 102) and synchronous or asynchronous metastases from the same patients (n = 165) were included. Tissue samples underwent mutation analysis (automated DNA sequencing). Secondary lesions included lymph nodes (n = 84), and skin (n = 36), visceral (n = 25), and brain (n = 44) sites. RESULTS BRAF/NRAS mutations were identified in 58% of primary melanomas (43% BRAF; 15% NRAS); 62% in lymph nodes, 61% subcutaneous, 56% visceral, and 70% in brain sites. Mutations were observed in 63% of metastases (48% BRAF; 15% NRAS), a nonsignificant increase in mutation frequency after progression from primary melanoma. Of the paired samples, lymph nodes (93% consistency) and visceral metastases (96% consistency) presented a highly similar distribution of BRAF/NRAS mutations versus primary melanomas, with a significantly less consistent pattern in brain (80%) and skin metastases (75%). This suggests that independent subclones are generated in some patients. p16CDKN2A mutations were identified in 7% and 14% of primary melanomas and metastases, with a low consistency (31%) between secondary and primary tumor samples. CONCLUSION In the era of targeted therapies, assessment of the spectrum and distribution of alterations in molecular targets among patients with melanoma is needed. Our findings about the prevalence of BRAF/NRAS/p16CDKN2A mutations in paired tumor lesions from patients with melanoma may be useful in the management of this disease.

Toxic epidermal necrolysis (Lyell's disease)

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe adverse drug reactions, characterized by a low incidence but high mortality, initially described as separate entities, but today considered variants of the same pathologic process and differing only for severity. The majority of cases appear to be related to idiosyncratic drug reactions. The drugs most commonly involved are: antibiotics such as sulfonamides, beta-lactam, tetracyclines and quinolones; anticonvulsants such as phenytoin, phenobarbital and carbamazapine; antiretroviral drugs; nonsteroidal anti-inflammatory drugs, allopurinol. There is common agreement to consider TEN as the manifestation of a disregulated immune reaction against epithelial cells. During the first stages of TEN, apoptosis mediates keratinocyte death and the pivotal role of Fas-FasL pathway activation during TEN is undoubted. T cell cytotoxicity, demonstrated during TEN, has been shown to be mediated by the perforin-granzyme pathway. It seems, also, clear that a peculiar cytokine pattern plays an important role in TEN pathogenesis. The cutaneous findings result in an acute macular erythematous rash with bullae. These lesions rapidly exhibit Nikolskys sign and a separation of large sheets of epidermis from the dermis and a subsequent localised shedding develops rapidly, which can become very extensive. When feasible, admission in burn or intensive care unit, positioning the patients in air-fluidised beds, is universally considered crucial in TEN treatment. The prompt withdrawal of the suspected drug, fluid and electrolyte replacement and topical wound care are the first line of therapy. The use of corticosteroids has been abandoned and the role of immunosuppressants, despite some success, is not well defined and is not considered as a standard. A trial comparing thalidomide versus placebo in TEN patients was suspended because mortality rate increased in the treated group. Infliximab, a chimeric monoclonal antibody to TNF-alpha, has been administered to a patient, in single infusion, with a favourable outcome. Plasmapheresis is reported to lead to some success in TEN treatment, with improvement of clinical conditions and high percentage of survival. Different authors reported good results in terms of decreasing mortality and morbidity or improving clinical conditions of the use of human intravenous immunoglobulins (IVIGs). Regardless, the true utility of this treatment remains controversial. In 2005, the authors (ML and RC), dealing with a number of severe TEN cases, proposed a new protocol based on the combination of these last two techniques reporting their preliminary results in the treatment of severe TEN patients.

Effects of zafirlukast on capsular contracture: controlled study measuring the mammary compliance.

Capsular contracture is a highly distressing, difficult complication after breast augmentation for both the patient and the surgeon. Although capsular contracture is a multifactorial process, one common denominator in the successful treatment of this complication is believed to be the abatement of inflammation. Leukotriene antagonists have recently emerged as effective prophylactic agents in reactive airway diseases. Anecdotal reports have indicated that zafirlukast (Accolate, AstraZeneca) effectively reverses capsular contracture. A prospective study of capsular contracture in 120 female patients in whom a total of 216 prostheses were implanted was performed. The hardness of capsular contracture was assessed by means of the mammary compliance method (Anton Paar Mammacompliance system). The patients were divided into two groups: patients in group A received zafirlukast for a 6-month period, while those in group B received vitamin E. The results show a significant decrease of the values of breast compliance after 6 months in group A but not in group B and that the variation in compliance after 6 months in group A compared to group B is statistically significant. In zafirlukast-treated patients, we observed a reduction in mammary compliance of 7.69% after 1 month, 16.78% after 3 months and 24.01% after 6 months. The present study suggests that zafirlukast may be effective in reducing pain and breast capsule distortion in patients with longstanding contracture who are either not surgical candidates or who do not wish to undergo surgery.

Ultrastructural anatomy of contracted capsules around textured implants in augmented breasts

The development of a capsule around an implant is part of the physiological response to a foreign body. Capsular contracture is the most specific and frustrating complication of augmentation mammaplasty, and a lot of studies have been devoted to it. The aim of the current study is to examine the fine architecture of the contracted capsule around textured implants in humans. Eight capsules from augmented and contracted breasts with gel-filled, textured-surface silicone implants were studied after standard preparation for light and scanning electron microscopy, and after partial digestion in sodium hydroxide. Two capsules from contracted breasts around smooth implants and two noncontracted capsules around textured implants were prepared and studied in the same fashion as controls. A multilayer structure of the contracted capsule was seen, and the architecture of the various layers is described. The inner surface presents irregular craterlike depressions. The arrangement of collagen fibers varies in capsule layers. The effect of a textured-surface implant on the mechanism of capsule contraction based on the observed capsular architecture is that only part of the capsule is effective mechanically in producing a contracting force. A thin vascular layer was identified near the inner surface in contracted capsules around textured implants, and the authors’ think that this layer is probably the key structure in the histological development and growth of the capsule.

Flap size/flow rate relationship in perforator flaps and its importance in DIEAP flap drainage ☆

The vascular architecture within a perforator flap is different from a conventional muscle or myocutaneous flap. The purpose of this paper is to understand the correlation between flow rate and flap size in perforator flaps. With extrapolation of these data, we have provided an indirect analysis of the venous drainage and its correlation with flap size. A prospective study was planned. Twenty-five patients were enrolled in this study: six patients were operated on using an anterolateral thigh (ALT) flap and 19 using a deep inferior epigastric artery perforator (DIEAP) flap. One month postoperatively, echo-colour-Doppler measurements were performed on pedicle and perforator arteries to calculate blood flow rate in the flaps. A correlation between weight and flow rate was analysed. Spearman rho statistic was calculated. A linear regression model was made from patient data of flow rate/flap weight and predicted values of flow per flap weight were calculated. Then, flow rate values of veins of various diameters were estimated using Hagen-Poiseuilles formula. Our data show that flow rate measured postoperatively on flap arteries is significantly correlated with flap weight [rho(23 d.f.)=0.725, P<0.01 (two-tailed)]. Moreover, we have calculated the minimum size of veins able to drain flaps of increasing weights with different patterns, i.e. our data show that veins of 1.30, 1.50 and 1.75 mm diameter could safely drain flaps of, respectively, 300, 500 and 900 g in weight. This can be useful preoperatively to estimate the risk of flap congestion and in planning additional drainage.

Innervated island pedicled anterolateral thigh flap for neo-phallic reconstruction in female-to-male transsexuals

Many techniques have been described to create an aesthetic and functional neo-phallus after penile amputation or in female-to-male transsexuals. Microsurgical free-flap phalloplasty seems to be the preferred method of penile reconstruction. For many years the radial forearm free flap has been considered the best procedure, but other flaps have been attempted to minimize donor site morbidity and optimize outcome. Pedicled flaps are considered to be reliable and to decrease the risk of total failure. Recently, a one-stage non-microsurgical technique was described for phallic reconstruction in a young male patient. We report successful total phallic reconstruction in a female-to-male transsexual patient using an island pedicled anterolateral thigh (ALT) flap. Urethral reconstruction was left as a possible further procedure due to patients preference. A malleable soft silicone penile prosthesis was inserted within the flap and the lateral cutaneous femoral nerve stump was sutured to the dorsal clitoris branch from the pudendal nerve for flap sensation. After 6 months, the patient demonstrated successful aesthetic and functional reconstruction referring to satisfactory sexual activity. To our knowledge, this is the first report of an innervated island pedicled ALT flap used for female-to-male penile reconstruction in a transsexual patient. The pedicled ALT flap may be a reliable option to avoid visible scarring at the donor site on exposed parts of the body, and reduce the risk of total flap failure from microsurgical procedures for reconstruction of a neo-phallus in this increasing population of patients.

Island chondro-mucosal flap and skin graft: a new technique in eyelid reconstruction

We report a new technique of large full thickness eyelid defect reconstruction using an axial island chondro-mucosal flap from the lateral aspect of the nose and a full-thickness skin graft. The flap is harvested undermining the skin and the subperiosteal plane and taking a strip of upper lateral cartilage and nasal mucosa. It is transposed to reconstruct the tarso-conjunctival plane of the missing eyelid and the skin defect repaired with a skin graft. The donor defect is repaired by direct closure. Satisfactory results were obtained in 3 patients. In our opinion, the technique is a reliable choice when dealing with large full thickness defects of the upper eyelid, and, in selected cases, of the lower eyelid.

The propeller flap for chronic osteomyelitis of the lower extremities: a case report

The goals of the treatment of chronic osteomyelitis are infection eradication with systemic antibiotic therapy and local management with radical excision of the infected tissue and obliteration of the remaining dead space. Adequate debridement and coverage with a well-vascularised tissue are mandatory for successful outcomes. Use of muscle covering for chronic osteomyelitis in the lower extremities is considered the best procedure. However, there have been instances where debridement of the bone tissue did not leave a deep cavity along the leg bones and fasciocutaneous flaps can be used in these instances to cover the defect and to restore function without recurrence of the disease. Recently, free non-muscle flaps have been used and assessed for chronic osteomyelitis or covering of exposed bone. Perforator flaps have been shown to be well vascularised due to a structural haemodynamic enhancement. In the light of these findings we report a successful case of chronic osteomyelitis of the right fibula treated with excision of the affected tissue and covering with a propeller flap. Instead of free flap covering, in order to optimise surgical reconstruction, reducing the operative time, donor and recipient site morbidity and risk of total flap failure, local perforator flaps and particularly the propeller flap may be indicated in the treatment of chronic osteomyelitis in selected patients when the defect is limited and there is no need to fill a deep bone cavity or a dead space. To our knowledge, this the first report of the use of a propeller flap in the treatment of chronic osteomyelitis in the lower extremities.

An objective assessment of botulinum toxin A effect on superficial skin texture.

The botulinum toxin A (BTX-A) role on elimination of hyperkinetic wrinkles is consolidated, although relying on subjective methods of assessment. A prospective open-label study was performed on 10 patients to objectively analyze superficial skin texture changes caused by BTX-A in the glabellar area. Skin areas were reproduced by silicon replica technique at baseline, 1 month, and 6 months after treatment. Takahashis parameters (roughness, anisotropy, microsulcus number, and width) were obtained from scanning electron microscopy (SEM) analysis and compared using the Wilcoxon signed rank test. SEM images showed skin texture changes, and software analysis gave parameters for statistical analysis, allowing an objective evaluation. Statistically significant parameter modifications were evidenced. BTX-A effectiveness in wrinkle treatment was confirmed, and no differences in skin texture parameters from baseline to toxin action end were noted.

Hemodynamic changes in the microcirculation of DIEP flaps.

Perforator flaps are widely used in reconstructive surgery, but little is known about the hemodynamic changes within these flaps. Recently, the blood velocity in the perforator artery was shown to be higher than that at the source vessel. This study was carried out to demonstrate the effect of this increased velocity within the perforators in the cutaneous microcirculation of the perforator flap. Twenty-six consecutive patients who underwent unilateral immediate breast reconstruction with deep inferior epigastric perforator (DIEP) flaps were selected. A 3-stage prospective study using 2 laser Doppler probes was carried out. Stage 1: preoperative measurements; Stage 2: immediate postoperative measurements; Stage 3: postoperative measurements after 3 months. Statistically significant increase of blood velocity in the microcirculation of DIEP flaps was demonstrated in stages 2 and 3 when compared with stage 1 (P < 0.01, Friedman and Wilcoxon tests). The higher blood velocity within the perforator flap microcirculation may be a favorable rheologic feature of perforator flaps.