Eleonora Nacchiero

Interval sentinel lymph nodes in melanoma: a digital pathology analysis of Ki67 expression and microvascular density

AbstractnThe presence of interval sentinel lymph nodes in melanoma is documented in several studies, but controversies still exist about the management of these lymph nodes. In this study, an immunohistochemical evaluation of tumor cell proliferation and neo-angiogenesis has been performed with the aim of establishing a correlation between these two parameters between positive and negative interval sentinel lymph nodes. This retrospective study reviewed data of 23 patients diagnosed with melanoma. Bioptic specimens of interval sentinel lymph node were retrieved, and immunohistochemical reactions on tissue sections were performed using Ki67 as a marker of proliferation and CD31 as a blood vessel marker for the study of angiogenesis. The entire stained tissue sections for each case were digitized using Aperio Scanscope Cs whole-slide scanning platform and stored as high-resolution images. Image analysis was carried out on three selected fields of equal area using IHC Nuclear and Microvessel analysis algorithms to determine positive Ki67 nuclei and vessel number. Patients were divided into positive and negative interval sentinel lymph node groups, and the positive interval sentinel lymph node group was further divided into interval positive with micrometastasis and interval positive with macrometastasis subgroups. The analysis revealed a significant difference between positive and negative interval sentinel lymph nodes in the percentage of Ki67-positive nuclei and mean vessel number suggestive of an increased cellular proliferation and angiogenesis in positive interval sentinel lymph nodes. Further analysis in the interval positive lymph node group showed a significant difference between micro- and macrometastasis subgroups in the percentage of Ki67-positive nuclei and mean vessel number. Percentage of Ki67-positive nuclei was increased in the macrometastasis subgroup, while mean vessel number was increased in the micrometastasis subgroup. The results of this study suggest that the correlation between tumor cell proliferation and neo-angiogenesis in interval sentinel lymph nodes in melanoma could be used as a good predictive marker to distinguish interval positive sentinel lymph nodes with micrometastasis from interval positive lymph nodes with macrometastasis subgroups.

Dual plane breast implant reconstruction in large sized breasts: How to maximise the result following first stage total submuscular expansion

Introduction Women who were good candidates for a skin reducing mastectomy, but were instead treated with a skin-sparing mastectomy and reconstruction with expanders, show discrepancy of volume and form between the healthy breast (voluminous and ptotic) and the expanded mastectomy envelope and muscle, which has a smaller size as well as excessive amount of skin at the lower pole. Methods From January 2014 to March 2015, we recruited 18 women with breasts of medium to large volume and with moderate to severe ptosis, already treated at a different centre with a one-side mastectomy and reconstruction by means of an expander. These women were treated at our unit for the second reconstructive step with a dual plane technique and a contralateral reduction/mastopexy. Results The minimum duration of follow-up was 2 years (range 24–30 months). The average volume of the implants was 613u2009g. The reconstructive outcome at the final follow-up (at least 24 months) was judged by the specialist as excellent in 5 cases, very good in 10 cases and good in 3 cases. Breast Q average score was 87.08. Discussion The disinsertion of the expanded muscle dome and the use of a dual plane technique for the placement of the definitive implant provide a solution to the skin-volume mismatch problem. The subcutaneous placement of the implant at the level of the lower pole extends the excessive amount of skin and gives the reconstructed breast fullness and natural ptosis. Further validation of our results is needed.

The effects of the introduction of a chronic care model-based program on utilization of healthcare resources: the results of the Puglia care program

BackgroundAgeing is continuously increasing the prevalence of patients with chronic conditions, putting pressure on the sustainability of Healthcare Systems. Chronic Care Models (CCM) have been used to address the needs of frail people in the continuum of care, testifying to an improvement in health outcomes and more efficient access to healthcare services. The impact of CCM deployment has already been experienced in a selected cohort of patients affected by specific chronic illnesses. We have investigated its effects in a heterogeneous frail cohort included in a regional CCM-based program.Methodsa retrospective population-based cohort study was carried out involving a non-oncological cohort of adult subjects with chronic diseases included in the CCM-oriented program (Puglia Care). Individuals in usual care with comparable demographic and clinical characteristics were selected for matched pair analysis. Study cohorts were defined by using a record linkage analysis of administrative databases and electronic medical records, including data on the adult population in the 6 local area health authorities of Puglia in Italy (approximately 2 million people). The effects of Puglia Care on the utilizations of healthcare resources were evaluated both in a before-after and in a case-control analysis.ResultsThere were 1074 subjects included in Puglia Care and 2126 matched controls. In before-after analysis of the Puglia Care cohort, 240 unplanned hospitalizations occurred in the pre-inclusion period, while 239 were registered during follow-up. The incidence of unplanned hospitalization was 10.3 per 100 person/year (95% CI, 9.1–11.7) during follow-up and 12.1 per 100 person/year (95% CI, 10.7–13.8) in the pre-inclusion period (IRR, 0.84; 95% CI, 0.80–0.99). During follow-up a significant reduction in costs related to unplanned hospitalizations (IRR, 0.92; 95% CI, 0.91–0.92) was registered, while costs related to drugs (IRR, 1.14; pxa0<u20090.01), out-patient specialist visits (IRR, 1.19; pxa0<u20090.01), and planned hospitalization (IRR 1.03; pu2009<u20090.01) increased significantly. These modifications can be related to the aging of the population and modifications to healthcare delivery; for this reason, a case-control analysis was performed. The results testify to a significantly lower number (IRR, 0.79; 95% CI, 0.68–0.91), length of hospital stay (IRR, 0.80; 95% CI, 0.76–0.84), and costs related to unplanned hospitalizations (IRR, 0.80; 95% CI, 0.80–0.80) during follow-up in the intervention group. However, there was a higher increase in costs of hospitalizations, drugs and out-patients specialist visits during follow-up in Puglia Care when compared with patients in usual care.ConclusionIn a population-based cohort, inclusion of chronic patients in a CCM-based program was significantly associated with a lower recourse to unplanned hospital admissions when compared with patients in usual care with comparable clinical and demographic characteristics.

Suprafascial versus traditional harvesting technique for free antero lateral thigh flap: A case‐control study to assess the best functional and aesthetic result in extremity reconstruction

Clinical applications of ALT flap have currently extended to extremity (hand and foot) as well as oral cavity reconstruction. In these anatomical areas, the traditional harvesting technique presents a few disadvantages such as bulkiness of the recipient site and potential donor site morbidity including damage to the deep fascia and skin graft adhesions. The purpose of the present study was to compare the functional and aesthetic outcomes of upper and lower extremity reconstruction with either suprafascial or subfascial harvested anterolateral (ALT) flaps.

Reply to “melanoma pattern of care in ontario: A call for strategic alignment of multidisciplinary care)”

We read with great interest the recent article entitled “Melanoma patterns of care in Ontario: a call for strategic alignment of multidisciplinary care” by Look Hong NJ et al. In this article, the authors did an extremely valuable work in collecting data related to patterns of melanoma diagnosis and treatment in Ontario. Although melanoma is the sixth most commonly diagnosed malignancy across North America, the authors stated that one patient out of nine is inadequately treated and it seems that referral to sub-specialized providers is critical for ensuring appropriate care. Inspired by the authors, wewould like to express some comments. In particular, we would like to report how someMelanoma Centers are been trying to achieve the “strategic alignment of care” in Italy and to present the experience of amultidisciplinary network that has been set in Puglia with our Melanoma Center as a plastic surgery component. First, the authors collectedmelanoma cases from theOntario Cancer Registry (OCR) and linked data to other administrative databases to perform a retrospective analysis. Since the incidence of melanoma has been increasing also in Italy, in 2013 the Italian Melanoma Intergroup (IMI) promoted the creation of aNational Registry (CNMR) to collect data related to melanoma current treatments, results and costs. The primary objective for IMI was to document the variation in melanoma management, especially in advanced stages. Secondary endpoints were the assessment of a quality index in melanoma surgery and evaluate treatment outcomes. Referring to the wide variations in melanoma treatment mentioned by the authors of the article, in 2015 Sommariva et al published a consensus of the Italian Melanoma Intergroup to standardize some aspects of care related to surgery and define a quality assurance programs in melanoma surgery. In this regard, in consideration of the extensive series reported by the authors, it would be interesting to know their percentage of post-operative complications. Our interest is mainly on lymphedema that could be caused both by sentinel node biopsy and lymphadenectomy procedures. It is the most disabling complication but we are able now to offer to patients preventive and curative surgical solutions. Second, our understanding of melanoma continues to improve, and we can now differentiate low-risk from high-risk patients on the basis of multifactorial analyses from several series of large patients. It is not reasonable that some patients still receive inappropriate treatment andwe strongly agreewith the authors stating that there is a need to create multidisciplinary networks to promote the access to melanoma specialists. In this regard, we would like to underline that this objective can be easily achieved through multimedia communication. Most patients search for medical information through a “Google research” before consulting the family doctor. OurMelanomaCenter is part of a multidisciplinary network together with other specialists (Oncologists, Dermatologists, Pathologists, etc.) with an online domain. Patients can easily collect information about melanoma diagnosis and treatment by the website consultation. Thus, we think that the strength of the online portal is the possibility for family doctors or melanoma patients to book directly a consultation with a specialist and the analysis made by the authors of the article supports the idea that this makes the difference.

Lymphatic-venous anastomosis in a rat model: A novel exercise for microsurgical training: LEUZZI et al.

Lymphedema is a condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system. Lymphaticovenular anastomoses (LVA) and multiple lymphatic‐venous anastomoses (MLVAs) have been recognized as efficient methods to treat chronic lymphedema. Because few models for lymphatics microsurgical training have been described, the aim of this study is to present a new training model for MLVA in a rat.

Use of the Stromal Vascular Fraction in Intermediate-Deep Acute Burns: A Case With Its Own Control

We present a case of symmetrical thermal intermediate-deep burns treated in a case-control fashion with the stromal vascular fraction (SVF) obtained with the MyStem™ device and a scaffold of hyaluronic acid. After enzymatic debridement and SVF harvesting and application, we observed quicker healing (as assessed by wound area histogram planimetry) in the case area as opposed to the control one, which eventually underwent skin grafting. At the 3 months follow-up, the Vancouver Scar Scale was 9 for the case side and 10 for the control side, with a tendency to hypertrophic scarring in both areas, while patient satisfaction Visual Analogue Scale was 7 for the case side and 2 for the control side. CD31 expression, a marker of neoangiogenesis, was significantly higher in the case area as compared to the control one. SVF could potentially represent a valid alternative to the current standard of care, with a decreased need of invasive surgery and consequent improved patients quality of life.

Breast cancer cutaneous metastases mimicking Papilloma Cutis Lymphostatica. Biopsy to avoid pitfalls

Highlights • We present a singular case of secondary lymphedema is the most frequent long-term complication of axillary lymphadenectomy. It can result in complication as erysipelas, warts, Papilloma Cutis Lymphostatica (PCL), or angiosarcomas. Moreover, in women affected by breast cancer an accurate differential diagnosis among these conditions or complication related to radiation dermatitis or cutaneous metastasis is essential. We report the case of a 60-year-old postmenopausal Caucasian woman affected by secondary lymphedema following complete mastectomy for breast cancer. These lesions had clinical typical features of PCL, but histopathological analysis revealed dermo-hypodermic metastasis of breast carcinoma.• The presence of skin lesions in secondary lymphedema after oncological lymphadenectomy requires an accurate differential diagnosis. In fact, these lesions can emulate degenerative or infective skin diseases; anyway, in patients affected by secondary lymphedema other less common conditions - as PLC, nodular-type lichen myxedematosus or Gottron’s carcinoid papillomatosis - should be taken into account.• Our case reports the possibility that metastases of breast cancer might also mimic these conditions.

Single-stage excision and sentinel lymph node biopsy in cutaneous melanoma in selected patients: a retrospective case–control study

Sometimes, diagnostic excision of a primary melanoma would already necessitate skin grafting or transposition skin flaps, especially in areas with an esthetic or functional importance. The utility of sentinel lymph node biopsy (SLNB) after skin reconstruction is controversial. We carried out a single-institution retrospective case–control study. In patients with a wide primary lesion at high clinical–dermatoscopic suspicion for invasive melanoma in anatomical region in which a reconstruction with a skin graft or a flap is required, we proposed the performance of a confocal microscopy examination and an incisional biopsy of the primary lesion. If these diagnostic methodologies confirmed the suspicion of melanoma, lymphatic mapping was performed before the wide excision (WE) of the primary lesion, and WE and SLNB were performed during the same operative procedure. The database evaluation showed 496 patients who had undergone a previous complete local excision and a subsequent SLNB (two-stage group), whereas 61 patients underwent WE and SLNB during the same surgical time (one-stage group). Histological results of the excisional biopsy confirmed the diagnosis of melanoma in all patients of the one-stage group. The false-negative rate was lower in the one-stage group (5.5%) than in the two-stage group (16.7%). Patients of the two groups showed a similar recurrence-free and overall survival period even when corrected for clinic-demographical variables. The concomitant execution of SLNB and WE after confocal microscopy examination and incisional biopsy appears to be a safe and accurate procedure in patients with a wide primary melanoma that requires a skin flaps or a skin graft to cover the residual defect.