Hybrid cooperative complexes to decrease VAS score and enhance sexual function in women with vulvar lichen sclerosus.

OBJECTIVE: Lichen sclerosus is a chronic, inflammatory, progressive skin disease predominantly affecting anogenital areas. Vulvar lichen sclerosus (VLS) is one of the most common conditions treated in vulvar clinics; most patients report distressing symptoms of itching, burning, stinging, and pain (particularly during or after sexual intercourse). A preliminary, prospective, single-center study was performed to investigate the efficacy of hyaluronan hybrid cooperative complex (HCC) comprising high and low molecular weight hyaluronic acid to treat menopausal women with VLS. PATIENTS AND METHODS: Patients (N = 30) received two HCC injections at 32 mg/ml (one month apart). At baseline and one and six months after treatment, patients completed validated psychometric questionnaires to assess their self-reported pain, itching, and dryness using the Visual Analogue Scale (VAS) and sexual function by the Female Sexual Function Index (FSFI). RESULTS: After treatment with HCC, no side effects or complications were reported. VAS scores showed a trend towards reduced pain and itching intensity, and there was a statistically significant reduction in median VAS score for dryness at follow-up vs. baseline (p=0.038). For sexual function, there was a statistically significant improvement in lubrication (p=0.001) and orgasm (p=0.001) FSFI domains. CONCLUSIONS: Overall, this preliminary study demonstrated the promising efficacy of HCC in menopausal women with VLS without side effects.

Platelet-rich plasma for genital lichen sclerosus: analysis and results of 94 patients. Are there gender-related differences in symptoms and therapeutic response to PRP?

BACKGROUND: Lichen sclerosus is a chronic relapsing inflammatory dermatosis with a predilection for anogenital skin in 85%-98% of cases and is more prevalent in women (3%) than in men (> 0.07%). OBJECTIVES: The purpose of this study was to investigate gender differences in clinical presentation and therapeutic response to treatment with platelet-rich plasma (PRP), an emerging innovative strategy for LS. METHODS: Forty-three male and 51 female patients affected by LS were evaluated. Each patient was subjected to PRP treatment (1 infiltration every 15 days, for 3 times). RESULTS: The PRP procedure was well tolerated by all patients and an overall significant decrease in symptoms was reported 6 months after PRP infiltration. Reduction in pain and burning sensation was significant in both gender but more accentuated in women than in men, whereas reduction of itching was similar. On the contrary, dyspareunia evidenced sex-related difference since a significant diminution was observed only in male. CONCLUSIONS: This study demonstrates that PRP based therapy may exert a relevant role in LS patient management due to its effect on Quality of Life (QoL) and sexual function in both gender. In addition, the study underlined gender-related differences in severity of symptoms and disease age onset.

Usefulness of video thermography in the evaluation of platelet-rich plasma effectiveness in vulvar lichen sclerosus: preliminary study.

BACKGROUND: Lichen sclerosus (LS) is a chronic-relapsing and potentially serious skin disease that has a preference for genital skin. Currently, there is no standardized method for assessing the effects of therapies. OBJECTIVE: The objective of this preliminary study is to use video thermography (VTG) in the evaluation of vulvar lichen sclerosus (VLS) before and after platelet-rich plasma (PRP) therapy. METHODS: A sample of six female patients was enrolled. Patients were subjected to PRP treatment. Patients selected for the study had been assessed at baseline (T0) and after 7 and 30 d from PRP treatment (T1 and T2, respectively). Clinical and VTG evaluation was executed in every visit. RESULTS: The VTG examination showed at least one hypothermic area (HA) in all our patients. The average temperature measured in the vulvar and perineal region taken as a reference for each patient was found to be between 33.7 °C and 36.3 °C, with a fair difference between the patients. HAs showed thermal differences which varied between 2.2 °C and 1.2 °C. CONCLUSIONS: It is demonstrated here that PRP offers satisfactory effectiveness in treating VLS and that video thermograpy could represent a useful paraclinic method in the identification and follow-up of LS.

[Merkel cell carcinoma and sentinel lymph node dissection: nine cases report]. / Carcinoma a cellule di Merkel e linfonodo sentinella: osservazioni su nove casi clinici.

Merkel cell carcinoma (MCC) is an aggressive cutaneous-neuroendocrine neoplasia with poor prognosis and high propensity for locoregional and distant metastasis. Lack of knowledge about its biological behavior, pathogenesis, and prognostic factors, complicates the prospective evaluation. Sentinel node dissection, concomitant with radical excision of the lesion, has increased in the last few years. The suitability of this technique is linked to the MCC high tendency to spread "in primis" at locoregional nodes such as other malignancies such as cutaneous melanoma. Aim of the study is the prospective evaluation of the sentinel node dissection and of the adjuvant therapies in 9 patients MCC affected. All patients, underwent evaluation and staging of the neoplasia. Diagnosis was made by excisional biopsy and histological examination. Sentinel node dissection was performed in patients without clinical locoregional metastases (8 cases). Patients with sentinel node positive for metastasis underwent radical lymphadenectomy (3 cases). One patient affected by clinically locoregional metastases had, at once, radical lymphadenectomy. Radiotherapy and/or chemotherapy as adjuvant therapy were implemented (4 cases).

[A case of vulvar melanoma: surgical strategy and five years follow-up]. / Un caso di melanoma vulvare: strategia chirurgica e follow-up a 5 anni.

We report a case of a woman with vulvar melanoma, arisen from a plane melanocytic lesion, extended from clitoris to the left minor labium. After diagnostic biopsy, a preoperative lymphoscintigraphy with 99m-Tc nanocolloid was performed. Surgery consisted in a radical vulvectomy, radio-controlled lymphadenectomy and vulvar reconstruction by two bilateral subgluteus soft-tissue flaps, anastomosing the urethral and vaginal stumps. Five years follow-up was negative for neoplastic recurrence.

Vulvar primitive melanoma and sentinel lymph node: case report.

The case of a 54-year-old woman who developed vulvar melanoma arising from a melanocytic lesion, extending from the clitoris to the left labium minor, without clinical involvement of the groin node station bilaterally is presented. The patient first underwent an incisional diagnostic biopsy that revealed a melanoma 4 mm in thickness; subsequently preoperative lymphoscintigraphy with 99m Tc Nanocoll was executed. Surgery consisted of a radio-controlled lymphadenectomy and radical vulvectomy. Two bilateral subgluteus soft-tissue flaps were made to reconstruct the surgical defect, anastomosing the urethral and vaginal stump. At 36 months follow-up the patient was negative for neoplastic recurrence.

[Merkel cell carcinoma]. / Carcinoma a cellule di Merkel.

Merkel cell carcinoma is a rare form of skin cancer of likely neuroendocrine origin wich affects mainly white population in sun-exposed areas. It is an aggressive tumor and survival is dependent on stage at the time of diagnosis. The staging evaluation include CT imaging and recently PET scan. Surgical excision with or without lymph node dissection, followed by postoperative radiotherapy in stage II disease, is the standard treatment of non metastatic disease. The role of adjuvant chemotherapy is still controversial. In patients with metastatic disease, chemotherapy regimens active in small cell lung cancer are generally used. The combination of cyclophosphamide, doxorubicin and vincristine (CAV) has an overall response rate of 75%, whereas the response rate of etoposide in combination with cisplatin or carboplatin is 60%. Experience with other therapeutic agents, such as tumor necrosis factor, interferon and octreotide is scanty. Recently, encouraging preliminary results with targeted agents have been reported. Our experience in 14 patients, four of whom treated with chemotherapy for advanced disease, is in agreement with literature

Titanium bone-integrated implants in extraoral facial prosthetic rehabilitation: surgical planning and long-term follow-up.

The authors report on their clinical experience in the reconstruction of complex facial deformities using titanium osseo-integrated implants for the retention of soft silicone prostheses. They also evaluate the importance of this surgical technique as a viable alternative to traditional reconstructive procedures using autologous grafts, both in patients with severe osteomuscular defects and corrective surgery of unsuccessful reconstruction operations. The patients who underwent implantation operations were studied by CT 3D and 99m Tc SPECT (Single Photon Emission Computerized Tomography) procedures to evaluate osseo-integration at 3 weeks, 3, 6, 12, 24 months. The study demonstrates that the radiation emission peaks three weeks after surgery with the maximum bone remodeling activity, and after the functional loading of the implants, 3 months after surgery. High uptake past the eight month after surgery has never been detected and must be considered abnormal. SPECT offers the possibility of obtaining a three dimensional reconstruction of the photon emission of selected structures. The use of these nuclear medicine methods in addition to traditional-type radiological procedures introduce new possibilities, although still in the clinical experimentation phase, for the long-term follow-up of the inserted implants in craniofacial rehabilitation.

Lymphatic mapping and sentinel node identification in squamous cell carcinoma and melanoma of the head and neck.

AIM: The aim of our study was to evaluate the role of scintigraphy in lymphatic mapping and in the identification of the sentinel lymph node (SLN) in patients with head and neck cancer. METHODS: Between September 1999 and February 2001 we enrolled 22 consecutive patients with cancer in the head and neck region: five squamous cell carcinomas, one Merkel cell tumor of the cheek, and 16 malignant melanomas. Lymphoscintigraphy was performed three hours before surgery after injection of 30-50 MBq of 99mTc -Nanocoll in 0.3 mL; the dose was fractionated by injecting the radiotracer at two points around the lesion. Static acquisition (anterior and/or lateral views, 512 x 512 matrix, 5 mins pre-set time) was started immediately after the injections so as to visualize the pathways of lymphatic drainage. The skin projection of the SLN was marked with ink. Intraoperative SLN detection was performed with perilesional injection of patent blue. RESULTS: SLNs were found with lymphoscintigraphy in all patients. Thirty-three SLNs were identified: one occipital node, three nodes at the base of the tongue, 10 superficial lateral nodes (external jugular), five submandibular nodes, five submental nodes, three mastoid nodes and six supraclavicular nodes. Biopsy was performed in 21/22 patients. In 20/22 patients the first lymph nodes were visualized in the proximal cranial regions (retroauricular, jugular and submandibular) at five minutes post injection. The SLN positivity rate was 13.6% (three patients). All patients with tumor-positive SLNs were submitted to radical dissection. Poor concordance in the detection of sentinel nodes was observed with patent blue. CONCLUSIONS: The flow of nanocolloid in the lymph vessels of the head is rapid. In our experience immediate scintigraphic imaging was essential to visualize the pathways of lymphatic drainage and the first SLN. Radioguided SLN biopsy is therefore recommended within three hours. Injection of patent blue is inadvisable because of the poor concordance with lymphoscintigraphy and the risk of permanent tattooing of the face.

[Diabetic foot. Physiopathology, clinical aspects, and recent therapeutic approaches]. / Il piede diabetico. Fisiopatologia, clinica e recenti orientamenti terapeutici.

Diabetic foot is a complication of diabetes mellitus occurring in 15% of patients that is of specific surgical interest. Over the past few years, preventive measures and the use of new therapeutic resources has reduced the number of patients undergoing demolitive surgery. The authors present a concise but at the same time sufficiently detailed picture of modern knowledge of the physiopathology, clinical aspects and current therapeutic guidelines for diabetic foot. In particular, they analyse the validity of various forms of complementary treatment to surgery, including techniques to stimulate tissue repair processes, hyperbaric oxygen therapy and laser therapy, and they underline the importance of using a multidisciplinary approach to this pathology. To this end, they review all the articles on the subject reported on Medline from 1992 to June 1998, presenting and commenting on the most significant results.

[Sentinel node biopsy for malignant melanoma. Technical details and clinical results on 390 patients]. / La biopsia del linfonodo sentinella nel melanoma maligno. Dettagli tecnici e risultati in 390 pazienti.

BACKGROUND: The purpose of this paper is to present personal experience with sentinel node biopsy for the treatment of malignant melanoma. Technical details influencing the efficacy of the procedure are presented and the clinical, therapeutic and prognostic advantages of this technique discussed. METHODS: A total of 390 consecutive patients with primary skin melanoma (T2-3,N0,M0) underwent sentinel node biopsy between March 1996 and May 2001. All patients underwent previous excisional biopsy of the primary lesion and clinical and radiographic examination to exclude lymphatic or systemic macroscopic spreading of the disease. Preoperative lymphoscintigraphy (99mTc nanocoll) was routinely performed in the last 315 patients. Intraoperative detection of the sentinel nodes was performed by perilesional, intradermical, injection of blue dye associated with a g probe (Neoprobe(R) 2000) in the last 315 patients. Sentinel nodes, serially sectioned, were all Haematoxylin-Eosin and immunohistochemically stained. All patients positive for micro-metastasis underwent radical lymphadenectomy. Comparative analysis between the incidence of metastasis in sentinel and non-sentinel nodes, according to the clinical stage of the disease, was done. RESULTS: The overall detection rate of sentinel nodes was 97.4%. Relevant differences were found according to the site of dissection and the use of a g probe. The g-probe makes the procedure more effective, less invasive and less expensive. Timing and accuracy of the preoperative lymphoscintigraphy is a basic step of the procedure. The overall incidence of positive sentinel nodes was 14.7% with differences correlated with thickness of primary lesion (0.75-1.5 mm: 5,8%; 1.5-3 mm:18%; 3-4 mm: 24.6%). Metastasis in other non-sentinel nodes was found only with primary tumour thickness exceeding 2 mm. CONCLUSIONS: Sentinel node biopsy is a procedure requiring a multidisciplinary approach (surgery, nuclear medicine and pathology). A specific learning phase (>30 patients) is recommended to obtain reliable results.

[Osteo-hypertrophic angiodysplasia with oromaxillofacial localization. A report of a clinical case and a review of the literature]. / Angiodisplasia osteo-ipertrofizzante a localizzazione oro-maxillo-facciale. Presentazione di un caso clinico e revisione della letteratura.

The authors report a case of oro-facial port-wine stain angiomatosis with cutaneous and mucosal lesions localized in the first and the second branch surface distribution areas of the left trigeminal nerve in association with left upper lip, cheek and hemimaxillary true hypertrophy leading to a severe dento-skeletal malocclusion with open-bite and facial asymmetry. The authors through a revision of the literature locate nosologically this case among the rare congenital angiodysplastic syndromes affecting the maxillo-facial district as the Sturge-Weber and the Klippel-Trenaunay syndromes. They debate also about etiopathogenetic, clinical, differential diagnosis and therapeutic aspects concerning the management of patients affected by this kind of malformation.

[Radial forearm free cutaneous flap. Evaluation of the level of damage to the donor site]. / Lembo libero fascio-cutaneo di radiale. Valutazione degli esiti a livello del sito donatore.

BACKGROUND: After more than a decade of experiences, the radial forearm fasciocutaneous free flap has proven to be a well standardized surgical technique, widely used for its easy application and versatility. The review of the literature shows that most of the contraindications to the use of this flap concern mainly the donor site morbidity. Aim of this work is to evaluate the complications of this surgical technique, to study the functional impairment and the scars secondary to the harvesting of the flap, in order to point out which techniques can contribute to their reduction. METHODS: Seventeen patients submitted consecutively to oral cavity reconstruction using a radial forearm flap, whose donor site has been reconstructed with a full-thickness skin graft have been studied. The postoperative complications have been examined, the functional and aesthetic alteration at the donor site analyzed, with a medium follow-up of 17.5 months. RESULTS: The study of this series has pointed out not relevant early and middle term postoperative complications, no significant hand or finger motility and sensorial deficiencies associated with a percentage of full aesthetic and functional satisfaction of patients for this treatment higher than 80%. CONCLUSIONS: On the basis of personal clinical experience, even if on a small series of cases, the conclusion is drawn that the functional and aesthetic outcomes depend significantly on the surgical techniques used to harvest the flap and to cover the donor site.

External ultrasonic treatment of capsular contractures in breast implants.

The authors report their experience on the nonsurgical treatment of capsular contractures due to breast implant augmentation mammaplasty. External ultrasonic repeated applications have been applied to 24 patients after closed capsulotomy procedures in order to reduce the recurrency rate. The new ultrasonic device used was based on a 2-MHz generator with a timing adjustable power emission connected to eight transducers designed for breast anatomy. The authors report significant improvement of the closed capsulotomy technique demonstrating a persistent stability of the achieved results in 82% of the treated contractures, even in severe cases (Baker's IV), after a minimum follow-up period of 12 months. Methods of application, technical features of the ultrasonic device, experimental charts, and results obtained on 34 breast implant capsular contractures are reported and discussed.

SPECT in the long-term evaluation of osteointegration in intraoral and extraoral implantology.

Scintigraphic methods used in intraoral and extraoral implantology allow the evaluation of bone metabolism in the peri-implant zones, providing anatomic images and functional dynamics information on the osteointegration process. Twenty-five patients who underwent implantation operations for the application of intra- and extraoral prostheses were studied using technetium 99 m single photon emission computed tomographic (SPECT) procedures to evaluate osteointegration dynamics at 3 weeks, and 3, 6, 12, and 24 months. The study demonstrates that radiation emission peaks 3 weeks after surgery with the maximal bone remodeling activity and 6 months after surgery after the functional loading of the implants only in intraoral fixtures. High uptake past the eighth month after surgery has never been detected and must be considered abnormal. SPECT offers the possibility of obtaining a three-dimensional reconstruction of the photon emission of selected structures. The use of these nuclear medicine methods in addition to traditional-type radiological procedures introduces new possibilities, although still in the clinical experimentation phase, for early diagnosis and inserted implant prognosis.