Electrochemotherapy for advanced cutaneous angiosarcoma: A European register-based cohort study from the International Network for Sharing Practices of electrochemotherapy (InspECT).

BACKGROUND: Cutaneous angiosarcoma (cAS) is a highly aggressive malignancy that challenges the radicality of surgical treatment. Electrochemotherapy (ECT), a skin-directed treatment based on cytotoxic chemotherapy combined with local electric pulses, may be an intraoperative adjunct and a new opportunity in the therapeutic strategy. This cohort study reports the experience with ECT as an option. METHODS: Data on patients with locally-advanced/metastatic cAS who underwent ECT between October 2013 and October 2018 at eight European centres were prospectively submitted to the InspECT (International network for sharing practices of ECT) register. Patients received therapy according to the European Standard Operating Procedures of ECT (ESOPE). Treatment feasibility was assessed based on tumour coverage with electrodes and recorded tissue current; treatment toxicity and tumour response were graded according to CTCAE v5.0 and RECIST v1.1 criteria, respectively; patient-reported outcomes (PRO) were evaluated using a visual analogue score (VAS) for pain, acceptance of retreatment and the EQ-5D questionnaire. RESULTS: We enrolled 20 patients with advanced cAS in the scalp/face (n = 7), breast/trunk (n = 10) or limbs (n = 3). Target tumours (n = 51) had a median size of 2.3 cm (range, 1-20). We administered 24 ECT courses using 1-4 cm treatment safety margin around tumours. In five patients, ECT was combined/sequenced with surgery. Median tissue current was 3 A (range, 1.5-10), tumour margins coverage rate was 75% (15/20 patients). The objective response rate (ORR) was 80% (complete, 40%). Grade-3 toxicity included skin ulceration (15%) and pain (10%), with no significant change of PRO scores. Bleeding control was achieved in 13/14 patients with ulcerated tumours. With a median overall survival of 12.5 months, the local progression-free survival (LPFS) was 10.9 months. CONCLUSION: ECT produces sustained response rate with minimal side effects and should be considered an option for advanced cAS. Palliative benefits include patient tolerability, local haemostasis and durable local control. Definition of optimal timing, treatment safety margins and combination with surgery need further investigation.

Linguine technique for excision of lentigo maligna and poorly defined non-melanotic skin cancer - A case series.

Accurately identifying the clinical margins of lesions such as lentigo maligna, lentigo maligna melanoma and other non-melanotic skin cancers can often be a clinical challenge. Irregular, poorly-defined peripheral margins accompanied by the presence of subclinical disease only detectable histologically can mean rates of incomplete excision are increased. We seek to highlight the use of the linguine technique for excision of lesions with poorly-defined peripheral margins. We describe in detail the step-by-step process for undertaking the technique, highlighting its advantages and disadvantages with a review of the related literature. We present three cases where the senior author has employed the linguine technique for the excision of lentigo maligna, lentigo maligna melanoma and extramammary Paget's disease.

The distally pedicled gracilis flap for salvage of complex knee wounds.

INTRODUCTION: Soft tissue defects around the knee joint resulting from trauma or because of wound breakdown after total knee arthroplasty present a challenge in a group of patients that often suffer from other co-morbidities. A pedicled gastrocnemius muscle flap remains a workhorse for this kind of wound. However, where the defect lies in the supero-lateral aspect of the proximal knee area, an alternative solution is required. The distally based pedicled gracilis flap has been described as an option for these cases where free-tissue transfer may not be an option and the pedicled gastrocnemius is not sufficient or has already been used. The purpose of this review is to evaluate the usefulness of this flap in the nine cases in which we have utilized it in our unit. METHODS: Nine patients underwent reconstruction of complex proximal knee wound defects with a distally based pedicled gracilis muscle flap. The mean age was 62 years (range 23-83). Five patients had wound breakdown following total-knee arthroplasty (TKR) and four patients had wound complications after road traffic accidents (RTA). Three of the nine flaps were delayed. RESULTS: Eight of the nine patients had successful salvage of the knee with the use of the distally based gracilis flap. Although four of the flaps suffered partial loss, this did not compromise the joint salvage. The patients were moderately satisfied with the reconstruction and achieved a mean range of movement of 75° (±12°). CONCLUSION: The distally based pedicled gracilis flap can be a salvage solution for complex soft tissue defects with exposed knee joint, patella or proximal part of knee or exposed knee prosthesis in cases where a pedicled gastrocnemius muscle is inadequate or the patient is not suitable for a free flap. Evidence Level IV.