Comparación entre los melanomas de cabeza y cuello con los de tronco y extremidades / Comparison between head and neck melanomas with trunk and extremity melanomas

Antecedentes: los melanomas en cabeza y cuello (MCC) han sido asociados con factores pronósticos diferentes de aquellos en otras localizaciones. Objetivo: comparar características demográficas, clínicas y resultados del tratamiento quirúrgico de pacientes con MCC y pacientes con melanomas en tronco y extremidades (MTE). Material y métodos: se llevó a cabo una revisión retrospectiva de las historias clínicas de pacientes operados por melanoma entre enero de 2012 y diciembre de 2017. Quince pacientes (22,3%) tuvieron MCC y 52 (77,7%) MTE. Resultados: ambos grupos tuvieron edad similar (63,8 ± 21,1 versus 58,5 ± 16), pero los MCC mostraron una tendencia con predominio masculino (80% versus 61,3%). Los MCC tuvieron menor espesor tumoral que los MTE (2,07 versus 5,5 mm) y mayor porcentaje de melanoma in situ, 5 (33,3%) versus 8 (15,3%), pero requirieron vaciamientos ganglionares más a menudo (33% versus 25%) así como reconstrucción del defecto primario con colgajos locales y miocutáneos. Durante el seguimiento, en el grupo de MCC, dos pacientes desarrollaron recidivas locales que fueron extirpadas, y otros tres desarrollaron metástasis a distancia en pulmón, intestino delgado y abdomen y fallecieron por la enfermedad; en el grupo de MTE un paciente tuvo recidiva local y cinco fallecieron de metástasis sistémicas. El tamaño de la muestra no permitió aplicar pruebas de significación entre las diferencias encontradas. Conclusión: los MCC se presentan en un amplio rango de edad y estadios, y tuvieron algunas diferencias clínicas con el MTE. Los defectos producidos por la extirpación de la lesión primaria requieren procedimientos reconstructivos más complejos la mayoría de las veces y se aconseja un abordaje multidisciplinario.

Background: Head and neck melanomas (HNMs) have been associated with prognostic factors different from those on other locations. Objective: The goal of the present study was to compare the demographic and clinical characteristics and the outcomes of surgical treatment between patients with HNM and those with trunk and extremity melanoma (TEM). Material and methods: The clinical records of patients undergoing surgery for melanoma between October 2014 and April 2018 were retrospectively reviewed. Fifteen patients (22.3%) had HNM and 52 (77.7) presented TEM. Results: There were no differences in age between both groups (63.8 ± 21.1 versus 58.5 ± 16), but there was a trend toward higher percentage of men in the HNM group (80% versus 61.3%). Patients with HNM had lower tumor thickness than those with TEM (2.07 versus 5.5 mm), higher incidence of melanoma in situ [5 (33.3%) versus 8 (15.3%)]; lymph node resection was more common (33% versus 25%) as well as reconstruction of the primary defect with local and musculocutaneous flaps. During follow-up, two patients in the HNM group developed local recurrences that were excised and three presented distant metastases in the lung, small bowel and abdomen and finally died due to the disease. In the TEM group, one patient had local recurrence and five died due to systemic metastases. The sample size was not sufficient to assess statistically significant differences. Conclusion: Head and neck melanomas occur in a wide age range and stages and has some clinical differences with TEM. The defects produced after the excision of the primary lesion often require more complex procedures and should be managed with a multidisciplinary approach.

Necrolytic acral erythema in a Chinese patient with hepatitis C and hepatitis B virus coinfection

Abstract: Necrolytic acral erythema is a distinct erythema that has been described as an extrahepatic manifestation of hepatitis C virus infection. Most reported cases have been in Africa, especially Egypt. We report the first case (to the best of our knowledge) of necrolytic acral erythema in a Chinese patient with HCV and HBV coinfection. We aim to increase awareness for recognizing this condition in the Chinese population.

Eosinophilic fasciitis

Abstract Eosinophilic fasciitis is a rare sclerodermiform syndrome of unknown etiology. It is characterized by the thickening of the muscular fascia and subcutaneous tissue, with a variable infiltration of eosinophils. Peripheral eosinophilia, poly or monoclonal hypergammaglobulinemia and increased erythrocyte sedimentation rate can be seen. Clinical features begin acutely, with local edema and a painful and symmetrical stiffening of the limbs, progressing rapidly to fibrosis, which can limit joint movements. Some cases have a history of strenuous physical exercise or trauma. The diagnosis is confirmed by a deep skin biopsy. Glucocorticoids in high doses is the treatment of choice. We report a typical eosinophilic fasciitis case with peripheral eosinophilia and dramatic response to pulse therapy with methylprednisolone.

Differences in Clinical Manifestations and Outcomes between Adult and Child Patients with Henoch-Schonlein Purpura

We aimed to investigate differences in clinical manifestations and outcomes between adult and child patients with Henoch-Schonlein purpura (HSP), and to analyze the factors associated with poor prognosis for HSP nephritis. This retrospective 10-yr study enrolled 160 patients with HSP who visited Severance Hospital. Purpura was mostly detected in lower extremities, but purpura in upper extremities was more frequently observed in adults than children (41.7% vs 19.3%). Children had a greater frequency of arthralgia (55.4% vs 27.1%), while adults had a greater frequency of diarrhea (20% vs 1.6%). Anemia, elevated C-reactive protein, and level of IgA were more frequently observed in adults (25% vs 7.1%, 65.6% vs 38.4%, 26.3% vs 3.5%). Renal involvement in adults was more severe than in children (79.2% vs 30.4%). Chronic renal failure showed a significant difference in outcomes of HSP between adults (10.4%) and children (1.8%) after a follow up period of an average of 27 months. Furthermore, renal insufficiency at diagnosis was significantly related to the progression to chronic renal failure. Our results showed several differences in the clinical features of HSP between adults and children. Adults with HSP had a higher frequency of renal insufficiency and worse renal outcomes than children. Renal insufficiency at diagnosis might be of predictive value for the progression to chronic renal failure in HSP patients.

Sildenafil citrate protects skeletal muscle of ischemia-reperfusion injury: immunohistochemical study in rat model

PURPOSE: To investigate the effect of sildenafil citrate (SC) on skeletal muscle ischemia-reperfusion (IR) injury in rats. METHODS: Adult male Wistar rats were randomized into three groups: vehicle-treated control (CTG), sildenafil citrate-treated (SCG), and sham group (SG). CTG and SCG had femoral artery occluded for 6 hours. Saline or 1 mg/kg of SC was given 5.5 hours after occlusion. SG had a similar procedure without artery occlusion. Soleus muscle samples were acquired 4 or 24h after the reperfusion. Immunohistochemistry caspase-3 analysis was used to estimate apoptosis using the apoptotic ratio (computed as positive/negative cells). Wilcoxon rank-sum or Kruskal-Wallis tests were used to assess differences among groups. RESULTS: Eighteen animals were included in the 4h reperfusion groups and 21 animals in the 24h reperfusion groups. The mean apoptotic ratio was 0.18±0.1 for the total cohort; 0.14±0.06 for the 4h reperfusion groups and 0.19±0.08 for the 24h groups (p<0.05). The SCG had lower caspase-3 ratio compared to the control groups at the 24h reperfusion time point (p<0.05). CONCLUSION: Sildenafil citrate administration after the onset of the ischemic injury reduces IR-induced cellular damage in skeletal muscle in this rat hindlimb ischemia model.

Clinical Characteristics of 75 Patients with Leukemia Cutis

Leukemia cutis (LC) is defined as a neoplastic leukocytic infiltration of the skin. Few clinical studies are available on recent trends of LC in Korea. The purpose of this study was to analyze the clinical features and prognosis of LC in Korea and to compare findings with previous studies. We performed a retrospective study of 75 patients with LC and evaluated the patients' age and sex, clinical features and skin lesion distribution according to the type of leukemia, interval between the diagnosis of leukemia and the development of LC, and prognosis. The male to female ratio was 2:1, and the mean age at diagnosis was 37.6 yr. The most common cutaneous lesions were nodules. The most commonly affected site was the extremities in acute myelocytic leukemia and chronic myelocytic leukemia except for acute lymphocytic leukemia. Compared with previous studies, there was an increasing tendency in the proportion of males and nodular lesions, and LC most often occurred in the extremities. The prognosis of LC was still poor within 1 yr, which was similar to the results of previous studies. These results suggest that there is a difference in the clinical characteristics and predilection sites according to type of leukemia.

[Residual shortening of limb after Legg-Calve-Perthes disease with different treatment modalities]

The residual shortening of limb is the major cause of gait disturbances in Legg-Calre-Perthes [LCP] disease. This study was a probing of limb length discrepancy after puberty by perfect method of teteroentgenogram in these patients. Residual shortening was measured by above method following completion of skeletal maturity in 46 patients and then the data were analyzed by computerized method. The patients were divided into three equal groups that they were treated by varus femoral osteotomy [FVO], abduction orthosis [AO] and untreated, respectively. The residual shortening was significantly more in AO group than FVO group and it was surprisingly a little more than the untreated group. The length of femur was identical in three groups [12.5, 11.1 and 10.4 millimeters, respectively]. The length of ipsilateral tibia was significantly different [2.8 mm shortening for AO group, 1.6 mm lengthening for FVO group and 1 mm lengthening for untreated group]. Overgrowth of ipsilateral tibia seems to be the leading cause of less limb discrepancy in FVO group and disuse atrophy seems to be the major reason for significant discrepancy in AO group which was somehow worse than untreated patients

Populosis atrófica maligna (enfermedad de Degos): a propósito de un caso / Atrophy malignant papulosis (Degos'disease): case report

Presentamos una paciente de sexo femenino, de 53 años de edad, con manifestaciones cutáneas de enfermedad de Degos, sin compromiso sistémico asociado. Se realiza una revisión actualizada de la bibliografía médica mundial, con una descripción clínica, histopatológica, diagnóstica y terapéutica de la enfermedad.

Severe primary antiphospholipid syndrome.

Antiphospholipid syndrome (APS) is characterised by recurrent venous or arterial thrombosis and/or fetal losses. In APS, the homeostatic regulation of blood coagulation is altered, however, the mechanism of thrombosis is not yet defined and it has varied manifestations. Deep vein thrombosis with or without pulmonary embolism is the most common manifestation followed by arterial occlusion of cerebral, coronary and other arteries including subclavian, retinal, renal and pedal arteries. We report a case of a 42 years old female, with severe primary APS, who presented with symmetrical peripheral gangrene, an uncommon presentation and was treated successfully.

O uso de curativos a vácuo como tratamento intermediário no trauma complexo de extremidade: experiência clínica e padronização da técnica / The use of vacuum dressing in intermediate treatment on complex traumac of extremitys: clinic experience and tecnic standardisation

Ferimentos com extensos danos aos tecidos e exposição de estruturas nobres, tradicionalmente, têmsido tratados com múltiplos procedimentos. O curativo a vácuo aplicado sobre uma lesão estáassociado à melhora da perfusão local, controle da infecção, diminuição do edema e proliferação do tecidode granulação. O curativo a vácuo é realizado utilizando-se técnicaasséptica, no centro cirúrgico, de maneira padronizada com materiais facilmente acessíveis e de baixo custo. Omesmo é trocado a cada 48h, sob anestesia e o tratamento definitivo, é realizado quando as condiçõeslocais da lesão forem favoráveis.Em todos os pacientes incluídos no protocolo deste trabalho obtiveram boa evolução, com resolução dainfecção, desenvolvimento de tecido de granulação, melhora da circulação local, possibilitando a execução do tratamento definitivo (retalhos ou enxertos). Dois dos pacientes que foram encaminhados com indicação de amputação do membro tiveram a função do membropreservada. O sucesso no tratamento dos pacientes submetidos ao curativo a vácuo demonstra a eficácia do método. Os materiais utilizados na confecção do mesmo possibilitaram uma grande economia uma vez que podemser adquiridos facilmente no comércio local e apresentam baixo custo. Tem-se como rotina no serviço onde seaplicou o protocolo, a utilização deste método em pacientes com lesões graves do membro inferior e superior.

Wounds with extensive damages to tissues and exposition of noble structures, traditionally, have beentreated with multiple procedures. The vacuum applied on an injury is associated with the improvement of the local perfusion, control of infection, reduction of edema and proliferation of the granulation tissue. The dressing is carried through using aseptictechnique, in the surgical center, in standardized way with easily accessible materials and of low cost. Each 48h itis changed under general anesthesia and the definitive treatment is carried through when the local conditions ofthe injury will be favorable. All patients in the protocol have been presentedwith good evolution, resolution of the infection, development of granulation tissue, improve of the local circulation, making possible the execution of the definitive treatment (free flaps or skin grafs). Two of the patients who had been proposed amputation of the member, had had the functionpreserved. The success in the treatment of the patients submitted to the vacuum demonstrates the effectivenessof this method. The materials used can be acquired easily in the local commerce and are cost effective. It is routinein the service of plastic surgery and reconstructive microsurgery at the Cristo Redentor Hospital, to use thismethod in patients with serious injuries of the inferior and superior member.

Synovial sarcoma of the extremities: prognostic factors for 20 nonmetastatic cases and a new histologic grading system with prognostic significance

PURPOSE: To evaluate 20 cases of nonmetastatic synovial sarcoma of the extremities regarding prognostic factors, and to propose a histologic grading system with prognostic significance. METHODS: The cases of 20 patients (14 females and 6 males) with nonmetastatic synovial sarcomas of the extremities treated between 1985 and 1998, were retrospectively evaluated regarding prognostic factors. A histologic grading system with prognostic significance is proposed. RESULTS: The mean follow-up period was 48.4 months (range, 16-116 months). There was local recurrence in 3 cases (15 percent), microscopic surgical margin being the only prognostic factor identified. Seven patients (35 percent) died of the disease in a mean postoperative period of 31.7 months (range, 16-53 months), all with pulmonary or brain metastasis. The survival rate was 65 percent in 48.4 months of follow-up. CONCLUSION: The unfavorable prognostic factors identified regarding survival were high histologic grade, tumors proximal to the knee or elbow, and spontaneous tumor necrosis over 25 percent. Local recurrence did not have influence on survival in this study. The presence of mast cells appears to have a positive influence on survival, although statistical significance was not reached (P = 0.07). The oncologic and functional result was good in 6 cases (30 percent), regular in 7 (35 percent), and poor in 7 cases (35 percent).

OBJETIVO: Avaliar casos de sarcoma sinovial não-metastático das extremidades no que se refere a fatores prognósticos, e propor um sistema histológico de pontuação com significado prognóstico. MATERIAL E MÉTODO: Vinte casos (14 do sexo feminino e 6 do sexo masculino) de sarcomas sinoviais não-metastáticos das extremidades tratados entre 1985 e 1998 no departamento de Ortopedia foram avaliados retrospectivamente no que se refere a fatores prognósticos e está sendo proposto um sistema de pontuação histológico com significado prognóstico. RESULTADOS: A média dos períodos de acompanhamento foi 48,4 meses (mínimo 16 meses, máximo 116). Houve recorrência localizada em 3 casos (15 por cento), sendo a margem cirúrgica microscópica o único fator prognóstico identificado. Sete pacientes (35 por cento) morreram da doença, todos em período pós-operatório médio de 31,7 meses (mínimo 16 meses, máximo 53), todos com metástase pulmonar ou cerebral. A sobrevida foi de 65 por cento em 48,4 meses de acompanhamento. CONCLUSÃO: Os fatores prognósticos desfavoráveis identificados referentes à sobrevida foram: grau histológico alto, tumores proximais de joelho ou cotovelo e necrose espontânea de tumor acima de 25 por cento. Neste estudo, a recorrência localizada não influiu na sobrevida. Parece que a presença de mastócitos influi positivamente na sobrevida, porém não obtivemos significado estatístico (p=0,07). O resultado oncológico e funcional foi bom em seis casos (30 por cento), regular em sete (35 por cento) e insatisfatório em sete (35 por cento).

Linfedema: aspectos clínicos, diagnósticos y terapéuticos / Lymphedema: clinical, diagnostic and therapeutic aspects

El linfedema se produce por retención de las proteínas de alto peso molecular en el intersticio. Su principal causa en las extremidades superiores son las secuelas de la cirugía y/o de la radioterapia utilizadas en el tratamiento del cáncer de mama. En las extremidades inferiores, en las que es mucho más frecuente, el linfedema es de tipo primario o secundario a procesos bacterianos recurrentes. Es una patología cuya frecuencia va en aumento sea por iatrogenia, por síndrome post-flebítico o por mejor conocimiento y preocupación por pesquisarlo más precozmente. Si bien es una patología que no tiene tratamiento curativo radical existen numerosos recursos que aplicados a tiempo y bien manejados son capaces de detener su evolución y evitar sus complicaciones.

Hypomelanosis of ito.

Four-year-old boy presented with hypopigmented skin lesions since birth and seizure of recent onset. He had psychomotor retardation and hemi hypertrophy of left half of body. Computerised tomography scan findings were suggestive of hemimegalencephaly. On clinical grounds, a diagnosis of Hypomelanosis of Ito was made.

Vasculitis with digital gangrene in a patient with HIV infection.

A case of polyarteritis nodosa (PAN) like systemic necrotizing vasculitis in an HIV infected individual, who presented with digital ischaemia is reported. The pathogenesis of PAN in HIV infected patients is not well understood and whether HIV or other agents are directly involved in the vascular injury remains to be established.