Guidelines for the diagnosis and treatment of cutaneous squamous cell carcinoma: a GRADE approach for evidence evaluation and recommendations by the Italian Association of Medical Oncology.

Cutaneous squamous cell carcinoma (CSCC) accounts for ∼20%-25% of all skin tumors. Its precise incidence is often challenging to determine due to limited statistics and its incorporation with mucosal forms. While most cases have a favorable prognosis, challenges arise in patients presenting with locally advanced or metastatic forms, mainly appearing in immunocompromised patients, solid organ transplantation recipients, or those facing social difficulties. Traditionally, chemotherapy and targeted therapy were the mainstays for advanced cases, but recent approvals of immunotherapeutic agents like cemiplimab and pembrolizumab have revolutionized treatment options. These guidelines, developed by the Italian Association of Medical Oncologists (AIOM) using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach, aim to guide clinicians in diagnosing, treating, and monitoring patients with CSCC, covering key aspects from primitive tumors to advanced stages, selected by a panel of experts selected by AIOM and other national scientific societies. The incorporation of these guidelines into clinical practice is expected to enhance patient care and address the evolving landscape of CSCC management.

Guidelines for the diagnosis and treatment of basal cell carcinoma: a GRADE approach for evidence evaluation and recommendations by the Italian Association of Medical Oncology.

Basal cell carcinoma (BCC) is the most common form of cancer, with a high impact on the public health burden and social costs. Despite the overall prognosis for patients with BCC being excellent, if lesions are allowed to progress, or in a small subset of cases harboring an intrinsically aggressive biological behavior, it can result in local spread and significant morbidity, and conventional treatments (surgery and radiotherapy) may be challenging. When a BCC is not amenable to either surgery or radiotherapy with a reasonable curative intent, or when metastatic spread occurs, systemic treatments with Hedgehog inhibitors are available. These guidelines were developed, applying the GRADE approach, on behalf of the Italian Association of Medical Oncologists (AIOM) to assist clinicians in treating patients with BCC. They contain recommendations with regard to the diagnosis, treatment and follow-up, from primitive tumors to those locally advanced or metastatic, addressing the aspects of BCC management considered as priorities by a panel of experts selected by AIOM and other national scientific societies. The use of these guidelines in everyday clinical practice should improve patient care.

Regenerative potential of the sural neuroadipofascial flap in the treatment of chronic ulcers of the lower third of the leg.

OBJECTIVE: Surgical reconstruction of soft tissue defects in the distal third of the lower limbs has always been challenging for surgeons. The adipofascial flaps are made up of vascularized adipose tissue, which plastically conforms to the site to be reconstructed with its rich presence of stem cells. In this study, we resumed our case history of reverse neuroadipofascial sural flap, and we evaluated the stability of the scar to verify if this type of reconstruction can ensure long-term results and its regenerative power. PATIENTS AND METHODS: In this retrospective cohort study, we analyzed 32 patients who had undergone lower limb reconstruction with the sural neuroadipovenous flap. RESULTS: A total of 32 patients were included in the study. The average age was 62.2 years. Chronic skin ulcer was the cause of the defects in 13 (40.6%) patients, chronic wound after trauma in 7 (21.9%) patients, wheel bedsores in 4 (12.5%) patients, osteomyelitis in 5 (15.6%) patients, exposed internal hardware in 2 (6.3%) patients, dog bite in 1 (3.1%). The site defect comprised 11 heels (34.4%), 4 external malleoli (12.5%), three medial malleoli (9.4%), 12 lower third of the leg (37.5%), and two dorsa of the foot (6.3%). In all cases, defects were covered with reverse sural island flap. The dimension of the flap ranged from 5 to 9 cm in length and from 3 to 7 in width. Six patients showed early or later postoperative complications. CONCLUSIONS: The neuroadipofascial sural flap is versatile, fast, and easy-to-perform to cover a chronic defect in the distal part of the lower limb, including both the malleoli and the heel, due to its long vascular pedicle. Consistent with the studies carried out in other districts, the present study confirms the remarkable regenerative power of the vascularized adipose tissue at the level of complex wounds of the lower third of the leg.

Human collecting lymphatic glycocalyx identification by electron microscopy and immunohistochemistry.

Blood flow is translated into biochemical inflammatory or anti-inflammatory signals based onshear stress type, by means of sensitive endothelial receptors. Recognition of the phenomenon is of paramount importance for enhanced insights into the pathophysiological processes of vascular remodeling. The endothelial glycocalyx is a pericellular matrix, identified in both arteries and veins, acting collectively as a sensor responsive to blood flow changes. Venous and lymphatic physiology is interconnected; however, to our knowledge, a lymphatic glycocalyx structure has never been identified in humans. The objective of this investigation is to identify glycocalyx structures from ex vivo lymphatic human samples. Lower limb vein and lymphatic vessels were harvested. The samples were analyzed by transmission electron microscopy. The specimens were also examined by immunohistochemistry. Transmission electron microscopy identified a glycocalyx structure in human venous and lymphatic samples. Immunohistochemistry for podoplanin, glypican-1, mucin-2, agrin and brevican characterized lymphatic and venous glycocalyx-like structures. To our knowledge, the present work reports the first identification of a glycocalyx-like structure in human lymphatic tissue. The vasculoprotective action of the glycocalyx could become an investigational target in the lymphatic system as well, with clinical implications for the many patients affected by lymphatic disorders.

Domestic trauma with penile and scrotum skin degloving and testicular avulsion.

Traumatic lesions of male external genitalia are certainly less frequent than the other body sites and in the majority of cases they are caused by work accidents in the metalworking environment or by gunshot wounds. We present a rare case of traumatic degloving lesion of the male external genitalia with avulsion of the left testis caused by an accidental fall from the ladder. Reconstructive surgery was carried out in a single procedure, obtaining an excellent esthetic and functional result.

Wide-awake anesthesia in Dupuytren's contracture treated with collagenase.

The injection of collagenase followed by cord manipulation is one of the most popular treatments for Dupuytren's contracture. This is traditionally performed under local anesthesia or regional nerve block potentially with sedation. Neither the treatment with collagenase, nor the wide-awake anesthesia are novel techniques for hand surgeons. Nevertheless, we report the first experience of cord manipulation using the wide-awake approach. In this prospective study, we compared the pain perception of patients who underwent wide-awake anesthesia versus traditional local anesthesia. We recorded the pain sensation on a visual analog scale (VAS) (0 to 10) during anesthetic injection, during cord manipulation and before discharge. Wide-awake anesthesia significantly reduced pain levels during anesthetic injection (p=0.003) and cord manipulation (p=0.0009). Pain levels did not differ significantly right before discharge in the two groups (p=0.54). Wide-awake anesthesia can be successfully applied to cord manipulation after collagenase injection in Dupuytren's contracture. This way, it is possible to improve the patient's subjective perspective of the procedure.

Multi-dorsal metacarpal artery perforator adipofascial turnover flap for index to little finger reconstruction: Anatomical study and clinical application.

Reconstruction of the dorsum of the hand and fingers is one of the main challenges in hand surgery. Regional flaps from the forearm, free flaps, or pocket procedures are options when multiple digits are injured with tendon damage and bone exposure. These procedures can be technically demanding and are often plagued by a texture mismatch. We conducted an anatomical study of 20 fresh frozen hands. The second, third and fourth intermetacarpal spaces were analyzed with the aim of defining the vascular foundation of dorsal hand adipofascial-turnover flaps based on dorsal metacarpal artery (DMA) perforators, analyzing their potential for reconstruction procedures on the dorsum of the hand. In three cases, the 4th intermetacarpal space lacked the DMA. A mean of 3.5 arterial communications were found between the DMA and palmar arterial system. Each hand had 11 ± 2 dorsal skin perforators, which were equally distributed among different intermetacarpal spaces. At least one perforator was present in each one-third of the space. The most distal perforators were the largest in all spaces but missing in two hands. A clinical case of multiple index finger to little finger reconstruction with this new multi-dorsal metacarpal artery perforator (mDMAP) adipofascial turnover flap is presented. Our anatomical study confirmed previous descriptions of the anatomy of the dorsum of the hand. It supports the safety of the mDMAP adipofascial turnover flap based on all distal arterial perforator for the simultaneous reconstruction of index to little finger injuries. Similarly, adipofascial turnover flaps can be raised from more proximal perforators arising from DMAs if more than one intermetacarpal space is included.

Clinical experience with Surgimend in breast reconstruction: an overview.

In the field of breast reconstruction, products and techniques are continuing to evolve to ensure good clinical and quality outcomes. This article reviews the published literature regarding the use of fetal bovine-derived acellular dermal matrix (SurgiMend, SurgiMend PRS and SurgiMend PRS meshed), focusing on safety, clinical outcomes and surgical techniques.

Microsurgery "without borders": new limits for reconstruction of post-burn sequelae in the humanitarian setting.

Post-burn contractures account for up to 50% of the workload of a plastic surgery team volunteering in developing nations. Best possible outcome most likely requires extensive surgery. However, extensive approaches such as microsurgery are generally discouraged in these settings. We report two successful cases of severe hand contractures reconstructed with free flaps on a surgical mission in Kenya. Microsurgery can be safely performed in the humanitarian setting by an integration of: personal skills; technical means; education of local personnel; follow-up services; and an effective network for communication.

Les rétractions après brûlures constituent 50% de l'occupation d'une équipe humanitaire de chirurgie plastique dans les pays en voie de développement. Les meilleurs résultats possibles nécessitent une chirurgie lourde. Cependant certaines de ces approches comme la microchirurgie ne sont généralement pas encouragées dans ce cadre. Nous rapportons deux cas successifs de rétractions majeures de la main, réparées par lambeaux libres dans une mission chirurgicale au Kenya. La microchirurgie peut donc être réalisée en toute sécurité dans le cadre humanitaire, à condition de bénéficier d'une expérience personnelle, de moyens techniques appropriés, de l'éducation du personnel local, des services de suite et enfin d'un réseau effectif de communication.

The instructional value of international surgical volunteerism from a resident's perspective.

The aim of this article is to document the experience of the author who volunteered as a resident for 6 months at a districtlevel hospital in central Kenya. Peculiarities emerging from the report are: specificity of the experience to plastic reconstructive surgery; highly complex reconstructive procedures performed under direct supervision of a qualified mentor; exposure to diverse approaches through collaboration with different volunteer plastic surgeons; enhancement of long-term surveillance; and opportunity to expand surgical knowledge outside one's field of specialty. The humanitarian setting allows maximal exposure and learning and can play a significant role in the resident's education.

Le but de cet article est de rapporter l'expérience de l'auteur, qui a effectué un stage bénévole de résident pendant six mois dans un hôpital régional au centre du Kenya. Les particularités qui ressortent de ce rapport sont: le caractère spécifique de l'expérience en chirurgie plastique et reconstructrice; la complexité des techniques de chirurgie réparatrice réalisées sous la surveillance d'un mentor qualifié; la confrontation avec diverses attitudes chirurgicales à travers la collaboration de différents chirurgiens plastiques bénévoles; l'amélioration de la surveillance à long terme; l'opportunité d'élargir ses connaissances chirurgicales au-delà de son champ habituel. Les conditions de médecine humanitaire permettent un maximum de vision et d'apprentissage, et peuvent jouer un rôle significatif dans la formation du résident.

Management of complex pediatric burn scars in a humanitarian collaboration.

Burn scars still represent a challenge to the reconstructive surgeon. Their management requires a specific expertise and set up involving the possibility of long term rehabilitation and follow up. Cases encountered in humanitarian missions present additional issues. Often the local environment is not suitable for an appropriate treatment plan, requiring the case to be transferred to a foreign country for surgical care as part of an integrated international and multidisciplinary management. We present the case of a three year-old patient injured in a bomb explosion during the Arab Spring and suffering from severe scar contracture limiting thoracic and upper limb movement. After initial consultation at distance, transfer to our country was organized and an intensive surgical and rehabilitative program was carried out over three months. After five months, the patient returned to his home country where a supportive network had been set up for continued rehabilitation, ensuring follow up for over a year and ultimate success.

Les cicatrices de brûlures représentent toujours un défi pour le chirurgien de reconstruction. Leur gestion nécessite une expertise spécifique et la possibilité de réhabilitation à long terme, y compris le suivi. Les cas rencontrés dans les missions humanitaires présentent des problèmes supplémentaires. Souvent l'environnement local n'est pas adapté pour un plan de traitement approprié, et donc il faut transféré le patient dans un pays étranger pour des soins chirurgicaux dans le cadre d'une gestion internationale et multidisciplinaire intégrée. Nous présentons le cas d'un patient de trois ans blessé à cause de l'explosion d'une bombe pendant le printemps arabe. Ce patient souffrait de contractures graves qui limitaient le mouvement du membre thoracique et supérieure. Après une consultation initiale à distance, il a été transferé à notre pays où il a subi un programme de chirurgie et de réadaptation intensive qui a duré trois mois. Après cinq mois, le patient est retourné à son pays d'origine où un réseau de soutien a été mis en place pour continuer la réhabilitation, assurer un suivi de plus d'un an et le succès final.

Polyurethane foam-covered breast implants: a justified choice?

OBJECTIVE: Even if the safety of the polyurethane prosthesis has been the subject of many studies and professional and public controversies. Nowadays, polyurethane covered implants are very popular in plastic surgery for the treatment of capsular contracture. MATERIALS AND METHODS: We have identified 41 papers (1 is a communication of the FDA) by using search browsers such as Pubmed, Medline, and eMedicine. Eleven manuscripts have been used for an introduction, and the remaining thirty have been subdivided into three tables whose results have been summarized in three main chapters: (1) capsular formation and contracture, (2) complications, (3) biodegradation and cancer risk. RESULTS: (1) The polyurethanic capsule is a well defined foreign body reaction characterized by synovial metaplasia, a thin layer of disarranged collagen fibers and a high vascularization. These features make possible a "young" capsule and a low occurrence of capsular contracture even over a long period (10 years); (2) the polyurethane implants may be difficult to remove but there is no evidence that they cause an increase in the other complications; (3) there is no evidence of polyurethane related cancer in long-term studies (after 5 years). CONCLUSIONS: Polyurethane foam covered breast implants remain a valid choice for the treatment of capsular contracture even if it would be very useful to verify the ease of removal of the prosthesis and to continue investigations on biodegradation products.

Multiple symmetric lipomatosis: a rare disease and its possible links to brown adipose tissue.

AIM: Aim of this study is an updated review of our case series (72 patients) as well as available literature on the Multiple Symmetric Lipomatosis (MSL), a rare disease primarily involving adipose tissue, characterized by the presence of not encapsulated fat masses, symmetrically disposed at characteristic body sites (neck, trunk, proximal parts of upper and lower limbs). DATA SYNTHESIS: The disease is more frequent in males, associated to an elevated chronic alcohol consumption, mainly in form of red wine. Familiarity has been reported and MSL is considered an autosomic dominant inherited disease. MSL is associated to severe clinical complications, represented by occupation of the mediastinum by lipomatous tissue with a mediastinal syndrome and by the presence of a somatic and autonomic neuropathies. Hyper-alphalipoproteinemia with an increased adipose tissue lipoprotein-lipase activity, a defect of adrenergic stimulated lipolysis and a reduction of mitochondrial enzymes have been described. The localization of lipomatous masses suggests that MSL lipomas could originate from brown adipose tissue (BAT). Moreover, studies on cultured pre-adipocytes demonstrate that these cells synthetize the mitochondrial inner membrane protein UCP-1, the selective marker of BAT. Surgical removal of lipomatous tissue is to date the only validated therapeutic approach. CONCLUSIONS: MSL is supposed to be the result of a disorder of the proliferation and differentiation of human BAT cells.

Masson's disease in hand surgery: a clinicopathologic study of four cases.

Intravascular papillary endothelial hyperplasia (IPEH), also known as Masson's tumour, is an uncommon benign vascular lesion characterized by small multiple, endothelial-lined, papillary structures with hyaline stalks. It appears to be a reactive condition involving excessive proliferation of endothelial cells in normal blood vessels or in vascular malformations, perhaps in response to blood vessel injury or thrombosis. The lesions are small, superficial, reddish-blue nodules, usually in the head, neck or hand. Distinction from pyogenic granuloma and angiosarcoma usually requires pathological examination. Complete surgical excision is the treatment of choice. Four cases affecting the finger are presented together with histological features.

Breast prostheses and connective tissue disease (CTD): myth or reality?

Since their first appearance, breast prostheses have been criticized as being both responsible for and giving rise to systemic disease. The literature contains many reports on the subject, and theories were controversial from the 1980s to the 2000s. The aim of this review was to gather together the most important studies on breast prostheses and systemic disease, with particular attention to connective tissue disease (CTD), in order to verify any relationship between silicone breast implants and the occurrence of pathologies.

Polymyositis, dermatomyositis and malignancy: a further intriguing link.

The association between malignancy and autoimmune myositis has been largely described and confirmed by numerous epidemiological studies. The temporal relationship between the two pathologic conditions can vary: malignancy may occur before, at the same time or following the diagnosis of myositis. Beside these observations, the molecular mechanisms underlying this association are still unknown, even though it has been demonstrated a possible antigenic similarity between regenerating myoblasts and some cancer cell populations. To better identify peculiar histopathologic features common to cancer and myositis, we screened muscle biopsies from patients affected with polymyositis, dermatomyositis, myositis in association to cancer, and from patients affected with newly diagnosed cancer, but without myositis. Similarly to the histopatologic features that were observed in the muscle from myositis patients, especially in those with cancer associated myositis, in patients affected with malignancy at the clinical onset of disease we observed early sign of myopathy, characterized by internally nucleated and regenerating myofibers, most of them expressing the neural cell adhesion molecule. The hypothesis that in a particular subset of individuals genetically predisposed to autoimmunity, an initial subclinical tumor-induced myopathy may result in an autoimmune myositis, represents a further intriguing link behind the association of these two conditions.

Upper limb bone mineral density and body composition measured by peripheral quantitative computed tomography in right-handed adults: the role of the dominance effect.

BACKGROUND: To investigate the impact on bone and muscle of pathological conditions involving only one of the upper limbs, it is important to know the physiological differences due to the dominance effect. AIM: To evaluate any physiological differences between dominant and non-dominant upper limbs in terms of bone mineral density (BMD), muscle mass, and muscle density at different levels. SUBJECTS AND METHODS: The study considered 60 right-handed healthy adults, 30 men and 30 women. Cortical BMD, muscle area, and muscle density were investigated by pQCT-XCT-3000 Stratec at the proximal radius, trabecular and total BMD at the distal radius, and trabecular and cortical BMD at the second phalanx of the third finger. Hand grip strength was also measured. RESULTS: No significant differences in BMD were found between the dominant and non-dominant upper limbs at any of the sites considered, in men or women. Muscle density was also similar on the two sides, whereas muscle area at the proximal radius was significantly lower on the non-dominant side in both men [4177.5+/-475.1 vs 4009.3+/-552.7 mm2; Delta%: 4.1%; 95% confidence interval (CI) 1.7%-6.5%] and women (2903.9+/-470.9 vs 2720.3+/-411.7 mm2; Delta%: 6.1%; 95%CI 4.3%-7.9%). Hand grip strength proved greater on the right side in both men (48.5+/-8.8 vs 45.2+/-8.7 kg; Delta% 7.1; p<0.001) and women (29.1+/-4.3 vs 27.0+/-5.1 kg; Delta% 7.1; p<0.001). CONCLUSION: The dominance effect does not seem to influence trabecular or cortical BMD at any of the sites in the upper limb. Muscle density is not modified by dominance, while muscle area is reduced on the non-dominant side and this should be borne in mind when the effect of pathological conditions on the body composition of a single forearm is investigated.

[Postmastectomy breast reconstruction--outcome on 33 consecutive cases]. / Reconstructia mamara postmastectomie rezultate pe 33 cazuri consecutive.

UNLABELLED: Nowadays postmastectomy breast reconstruction for breast cancer, seems to receive greater acceptance than in the past due to three important reasons: the improvement of the methods and techniques of plastic surgery; the new improved materials used as breast prosthesis; the better informed patients. The aim of this study is to review the outcomes of breast reconstruction performed for patients with mastectomy for breast cancer. MATERIAL AND METHOD: The medical records of 33 consecutive patients who underwent breast reconstruction, during a one year period, at a large municipal hospital were reviewed retrospectively. The main parameters studied were type of reconstruction, morbidity rate and type and number of reoperations. RESULTS: Among 33 patients , a number of 30 patient (90.9%) had theirs breasts reconstructed using a prostesis material and for 3 patients (9.1%) a flap type reconstruction was used. Immediate breast reconstruction was the preferred method of reconstruction. No major complications were noted. Minor complications were present in 4 patients (12.5%): infection (1 case), haematoma (1 case), skin necrosis (1 case), device extrusion due to local infection (1 case). CONCLUSIONS: Immediate breast reconstruction using expander and implant technique offers very good outcomes with low morbidity rate, excellent cosmetic results and consists in small, reliable and perfect reproductible operations.