Diego Ribuffo

APLASIA CUTIS CONGENITA OF THE SCALP, THE SKULL, AND THE DURA

A newborn baby boy presented with a full thickness defect of the scalp, skull, and dura measuring 6 x 7 cm caused by aplasia cutis congenita. Full thickness loss is extremely rare and to our knowledge this case is the twenty-first reported. It has an established mortality of up to 55%. An encephalocele forced us to do an emergency operation with a single large scalp flap based on the supratrochlear and superficial temporal arteries. After revision the child is now 9 months old and progressing well. There are several ways to treat these rare and delicate cases.

Detection of melanoma cells in sentinel lymph nodes by reverse transcriptase-polymerase chain reaction: prognostic significance.

Background: Recently reverse transcriptase-polymerase chain reaction (RT-PCR) has been proposed as a new sensitive method for the detection of submicroscopic melanoma nodal metastases. Sentinel lymph node (SLN) status is considered the most important prognostic factor for melanoma patients. Thus, in recent years, melanoma research has been focused on identifying new molecular markers of micrometastases.Methods: In this study, 129 SLNs were collected and analyzed by RT-PCR for tyrosinase and melanoma inhibitory activity (MIA) messenger RNA (mRNA) expression. Results from PCR analysis were then compared with those obtained by hematoxylin and eosin and immunohistochemistry and related to progression of disease.Results: MIA gene expression was positive by RT-PCR in 27% of the tyrosinase-positive SLNs. When the correlation between tyrosinase and/or MIA mRNA expression and disease-free survival was evaluated by the Kaplan-Meier exact test, there was a statistically significant correlation between simultaneous tyrosinase and MIA gene expression in SLNs and progression of disease.Conclusions: RT-PCR analysis for both MIA and tyrosinase mRNA may identify a subset of melanoma patients with a worse prognosis whom the routine methods, such as histology and immunohistochemistry, fail to identify because of the poor sensitivity of these methods.

Basal cell carcinoma of the penis and scrotum with cutaneous metastases

A 75-year-old man presented with a multicentric basal cell carcinoma (BCC) of the penis and scrotum with skin metastases. The lesion was large, affecting the whole shaft, the scrotum, and the pubic and inguinal areas. The patient was operated on and the defect covered with a split thickness skin graft. At six months followup, the patient was well, with no evidence of recurrence. This site is extremely rare (we know of 24 cases described) but seems to metastasise widely. Surgery is the best treatment option in these cases, and must be aggressive, considering the particular biological behaviour of BCC of the genital region.

The effect of post-mastectomy radiation therapy on breast implants: Unveiling biomaterial alterations with potential implications on capsular contracture

Post-mastectomy breast reconstruction with expanders and implants is recognized as an integral part of breast cancer treatment. Its main complication is represented by capsular contracture, which leads to poor expansion, breast deformation, and pain, often requiring additional surgery. In such a scenario, the debate continues as to whether the second stage of breast reconstruction should be performed before or after post-mastectomy radiation therapy, in light of potential alterations induced by irradiation to silicone biomaterial. This work provides a novel, multi-technique approach to unveil the role of radiotherapy in biomaterial alterations, with potential involvement in capsular contracture. Following irradiation, implant shells underwent mechanical, chemical, and microstructural evaluation by means of tensile testing, Attenuated Total Reflectance Fourier Transform InfraRed spectroscopy (ATR/FTIR), Scanning Electron Microscopy (SEM), high resolution stylus profilometry, and Time of Flight Secondary Ion Mass Spectrometry (ToF-SIMS). Our findings are consistent with radiation-induced modifications of silicone that, although not detectable at the microscale, can be evidenced by more sophisticated nanoscale surface analyses. In light of these results, biomaterial irradiation cannot be ruled out as one of the possible co-factors underlying capsular contracture.

The anteromedial thigh free flap anatomy: a clinical, anatomical, and cadaveric study.

Background: Perforator flaps have become the choice of most reconstructive surgeons because they have decreased donor-site morbidity. Among these flaps, the free anteromedial thigh flap has not yet become a first-choice flap because of the inconstant anatomy of its pedicle. This study aimed to describe the anatomy from different perspectives to highlight common patterns and simplify the flap’s application in clinical cases. Methods: The study started in 2004 and took 9 years to complete. It was performed on 12 clinical anteromedial thigh flap cases, 48 clinical cases of anterolateral thigh flap in which the vascular anatomy of the anteromedial thigh flap was studied, and 48 cadaver dissections. Results: In “type of perforators,” the authors found an almost total consistency between clinical cases (group 1) and dissections in patients (group 2) (&khgr;2 = 0.164 and p = 0.92), whereas the cadaver dissections (group 3) were minimally homogeneous (&khgr;2 = 13.7 and p = 0.0082). Then, taking into account the parameter “origin of perforators,” they noticed the same trend with a clear alignment between the first two groups (&khgr;2 = 1.84 and p = 0.87) and a strong inhomogeneity in relation to the third group (&khgr;2 = 19.8 and p = 0.03). Conclusions: Anatomical study of the anteromedial thigh flap pedicle showed a marked variability that makes preoperative planning difficult, and thus more stressful to realize. This evidence confirms that the flap can be used as a second choice or simultaneously with the anterolateral thigh flap. In addition, the authors strongly suggest a preoperative radiological study to minimize the possible anatomical variabilities during surgery.

Fibronectin and laminin expression in sentinel lymph nodes of patients with malignant melanoma

SIR, Malignant melanoma (MM) has shown an alarming increase in incidence over the last few decades; currently it represents roughly 5% of skin cancers and 1% of all malignant tumours, with an annual increase in incidence and mortality of 2–3% during the last 30 years. Sentinel lymph node (SLN) biopsy has greatly improved the staging and prognostic evaluation of primary cutaneous MM; in particular, the Reverse Transcriptase–Polymerase Chain Reaction (RT-PCR), which is able to detect melanoma cells expressing tyrosinase mRNA, offers an additional technique to the histopathological examination. The remodelling of cell adhesion molecules during the process of tumour progression is known to play a key functional role in cancer progression and metastasis. To date, although there have been several attempts to identify molecular markers among cell adhesion molecules in melanoma lesions and in peripheral blood from patients with MM, few studies have focused on the involvement of cell adhesion molecules in SLNs of such patients. Fibronectin and laminin are two adhesion molecules that have been shown to be involved in melanoma progression even though their role in SLNs has been poorly investigated. Recently, our group investigated the molecular profile of SLNs, suggesting a role as prognostic indicators for survivin, tyrosinase, MIA and Mart-1 expression. In this study we investigated the role of fibronectin and laminin mRNA expression as prognostic indicators in SLNs of patients with MM and correlated the results to progression of disease in a median follow-up of 51Æ5 months. The presence of capsular naevus cells in SLNs was tested and the positive samples were excluded from the study. We analysed 72 SLNs from 48 patients (mean age 58Æ3 years) with MM; informed consent was obtained from each patient. There were 22, 20 and six patients with stage I, II and III disease, respectively. Sections of each lymph node were stained with haematoxylin and eosin, and immunohistochemistry was performed by using antibodies to HMB-45 antigen and S100 protein that were detected with the avidinbiotin-peroxidase technique. Negative controls were obtained by using normal animal serum instead of specific primary antibodies. The results are shown in Table 1. After surgical excision the SLNs were frozen in liquid nitrogen and stored at –80 C until use in the RT-PCR assay. One microgram of total RNA extracted from the frozen tissues was reverse transcribed in a final volume of 20 lL, then 5 lL of cDNA was amplified in PCR buffer containing 25 pmol each of upstream and downstream specific primers. All the recommended precautions were taken to avoid the possibility of false-positive results. Each RT-PCR experiment included a sample without RNA as negative control and RNA extracted from the SK-MEL 5 melanoma cell line as positive control. The amplification products were separated by electrophoresis on 2% agarose gel: those showing specific amplification products were considered positive. The suitability of all samples was investigated by an RT-PCR with b-actin-specific primers. Laminin expression was found to be positive in 45 of 72 and negative in 27 of 72 samples examined. Positive expression was associated with death or disease progression in 20 of 45 cases, whereas negativity was associated with disease progression in 16 of 27 cases; 11 of 27 remain disease free. Fibronectin gene expression was found in 61 of 72 specimens: positivity was associated with disease progression in 26 of 61 positive samples, while 35 of 61 were disease free. Eleven of 72 samples did not have fibronectin gene expression: negativity was associated with death or disease progression in 10 of 11 cases, whereas one of 11 is currently disease free. The features of patients and the results obtained by the RT-PCR assay are listed in Table 1. Agarose gel electrophoresis of RT-PCR products is shown in Figure 1. In order to verify the statistical significance of our results we first determined the correlation between overall survival, Clark level and fibronectin and laminin expression by the Kaplan– Meier method. We failed to find a statistically significant correlation for the expression of laminin (P = 0Æ57); in contrast, a significant correlation was found between the Clark level and overall survival (P = 0Æ0036) and between negativity for fibronectin and overall survival (P = 0Æ0024). The log-rank test showed a strong correlation between absence of fibronectin expression and Clark level (Spearman correlation P = 0Æ35). The Cox proportional hazards model was applied to the multivariate survival analysis and demonstrated that absence of fibronectin expression and Clark level are statistically significant negative prognostic factors (P = 0Æ012 and P = 0Æ030, respectively).

Application of extended bi-pedicle anterolateral thigh free flaps for reconstruction of large defects: A case series

The anterolateral thigh flap is a workforce flap in reconstructive surgery, however, variations in it is vascular anatomy are not uncommon. These variations may affect flap design and survival, especially when large flaps are required. In some anatomical variants the anterolateral thigh flap is supplied by two separate dominant pedicles, and in these cases a bi‐pedicle modification may be necessary to ensure complete flap viability. The aim of this report is to evaluate the outcomes, and present our approach in using bi‐pedicle anterolateral thigh flaps as a method to reduce the risk of partial flap necrosis when reconstructing sizeable soft tissue defects.

Laparoscopic harvest of ileocolon flap in pharyngoesophageal reconstruction.

Dear Sir, The ileocolon flap is a well-known technique used for pharyngoesophageal reconstruction (Perrone et al., 2013). The cecum and part of the ascending colon are used to reconstruct the esophagus, while a segment of the terminal ileum is connected to the trachea, shunting air from the main airway to the neo-esophagus and making it resonate (Lo Torto et al., in press). Traditionally, it is a major procedure requiring a laparotomy and usually a long postoperative hospitalization. The aim of this letter is to report the first laparoscopic harvest of ileocolon flap for pharyngoesophageal reconstruction. Pharyngolaryngectomy with immediate reconstruction using an ileocolon flap was planned for a 57-year-old patient presenting with hypopharyngeal cancer (Figure 1A). The flap harvest was performed laparoscopically through 4 trocars. The intestines were mobilized from the terminal ileum up to the transverse colon. After division of the ileocolic pedicle and the right branch of the middle colic artery, the umbilical port was enlarged to deliver the specimen (Figure 1B). The proximal and distal ends of the flap were divided and intestinal continuity was restored with a functionally end-to-end stapled ileocolonic anastomosis. The recipient vessels for revascularization of the flap were the thoracoacromial artery and cephalic vein, as no other suitable vessels were found in the neck. The flap was inset in an isoperistatltic fashion. The cecum was anastomosed to the pharyngeal stump superiorly, while the asccending colon was anastomosed to the upper end of thoracic esophagus inferiorly. The ileal segment of the flap was then used for voice reconstruction with anastomosis to the side of tracheal stump. The total operative time was six hours including the one hour spent for the laparoscopic harvest of the flap. The postoperative course was uneventful. The patient was discharged at one month after tolerating oral feeding. Voice rehabilitation was initiated at 2 months. No perioperative donor or recipient site complication was noted. While the free ileocolon flap provides simultaneous restoration of speech and swallowing function, the traditional open approach might be associated with high donor site morbidity (Karri et al., 2011). The laparoscopic harvest can be a promising alternative that can avoid a large abdominal wound with its associated potential complications and decrease pain and hospitalization time (Ding et al., 2013). This is very important in this patient group due to their short life expectancy (Beauvillain et al., 1997). Laparoscopic harvesting of ileocolon flap is expected to provide all the advantages of a minimally invasive

Surgical treatment of nasal non-melanoma skin cancer in elderly patients using dermal substitute.

Abstract Conclusions: The nose is often involved by non-melanoma skin cancer (NMSC) and the increase in the incidence of such tumors, the morbidity and treatment-related costs represent a significant burden to healthcare systems. A bioresorbable dermal substitute (Hyalomatrix®) has been used for immediate dermal coverage and nose restoration after excision of infiltrating nasal NMSCs in elderly ASA III patients. Further studies on dermal substitutes are needed to improve benefit to patients. Objective: Surgical treatment of nasal non-melanoma skin cancer (NMSC) in elderly patients. Materials and methods: Ten elderly ASA III patients with nasal defects after resection of infiltrating NMSC were reconstructed in a two-stage strategy. The surgical protocol targeted an initial wide tumor excision and apposition of a dermal induction template (Hyalomatrix®) and successive full thickness skin autograft. Results were documented by photography, visual analog scale for patient satisfaction, and Vancouver scar scale for evaluation of final graft characteristics. Results: All patients were tumor-free during the 2 years follow-up. The procedure achieved acceptable nose reshaping and graft scarring evolution. Patient satisfaction was good-to-high.

CONTROVERSIAL ISSUES IN DIAGNOSIS OF LIPOSARCOMAS OF THE THIGH: A report of 18 cases

Liposarcoma is a common soft tissue neoplasm mainly found in the thigh. Early diagnosis and appropriate treatment are essential for survival, but clinical diagnosis may not be easy, and the importance of imaging is controversial as it often fails to indicate the presence of liposarcoma so that treatment is delayed. We report our experience of 18 cases of liposarcoma (16 of which in the thigh). This experience has led us to revise our opinions about imaging, clinical, and histopathological diagnosis, and the surgical and medical treatment. We now suggest that any hard, subfascial mass in an adult should be considered as a soft tissue neoplasm. Of these neoplasms, liposarcoma is the most common type, after malignant fibrous histiocytoma. Diagnosis by imaging techniques is rarely possible, so that integration with clinical data is essential. Among the various imaging techniques, computed tomography and ultrasound seem to be most useful.