Clinical, Histopathological and Immunohistochemical Aspects of Digital Papillary Adenocarcinoma: A Case Report and Literature Review.

Digital papillary adenocarcinoma (DPA) is a rare malignant eccrine tumor. A 62-year-old female presented with a subcutaneous nodular 1.5cm-mass in the thumb. Macroscopically, a poorly circumscribed mass containing cystic and solid components was observed. Microscopically, epithelial neoplasm consisting of tubular-cystic structures with back-to-back arrangements was observed. The lining epithelium was composed of cuboidal/columnar cells with mild atypia, with micropapillary extensions. Immunohistochemistry revealed double-layered neoplastic epithelium containing two different types of cells: basaloid/myoepithelial and luminal. We recommend two out of vimentin, HMWCK, and D2-40 for myoepithelial/basaloid cells, also CK7 and EMA for luminal/columnar cells. As the tumor had infiltrated the surgical margins, the patient underwent axillary sentinel lymph node (SLN) dissection and re-excision with Mohs micrographic surgery (MMS). Two additional MMS stages were required due to suspicious surgical margin positivity in the frozen sections. The operation was continued despite the risk of loss of function. Upon examination of the permanent sections, we observed no tumors in the suspected positive foci. Additionally, no tumor was found in the surgical margins. No metastasis was detected in the sentinel lymph node. We have reached 300 reported cases of DPA in the literature. We discussed the histopathological and intraoperative diagnostic pitfalls of DPA with a literature review and our experience.

The effects of stem cells and platelet-rich fibrin on colonic anastomosis: An experimental study.

AIM - Anastomotic leakage is among the most common complications following gastrointestinal surgery. MATERIAL AND METHODS - This study aimed to determine the effects of stem cells and platelet-rich fibrin (PRF) on anastomotic healing. The study included 60 rats that were randomly divided into 3 groups, each with 2 subgroups. The study included the control group (no treatment post anastomosis), the PRF group (PRF administered following anastomosis), and the PRF + stem cell group (PRF + stem cells administered following anastomosis). Anastomosis was performed at the descending colon in all groups. Anastomosis bursting pressure was determined, and histopathological and angiographic examination were performed on postoperative D 7. RESULTS - Intraabdominal adhesion was significantly more common in the control group. Anastomosis bursting pressure was significantly higher and angiogenesis was significantly more common in the PRF + stem cell group (P < 0.005). Based on histopathologic examination, vascular proliferation and inflammation were significantly more common in the PRF + stem cell group than in the control group (P < 0.005). CONCLUSION : In cases of risky gastrointestinal system anastomosis, PRF + stem cells might reduce the incidence of anastomotic healing. KEY WORDS: Anastomosis, Platelet-rich fibrin, Stem cell, Wound healing.

The effect of hydrochlorothiazide on the recurrence of nonmelanoma skin cancer: a 7-year retrospective study comprising 300 patients.

BACKGROUND: Hydrochlorothiazide (HCTZ) possesses well-described photosensitizing properties, and a causal association with nonmelanoma skin cancer (NMSC) was recently shown. However, previous studies have not shown whether HCTZ use is associated with the risk of recurrence of basal cell carcinoma (BCC) or squamous cell carcinoma (SCC). This study aims to investigate the association between HCTZ use and recurrence in patients with NMSC. METHODS: We identified cases with NMSC from our hospital archives during the period between 2013 and 2019. Patients were divided into groups according to the pathological diagnosis, HCTZ use, and recurrence. Multivariable analysis was performed to determine factors associated with recurrence in BCC and SCC. RESULTS: Recurrences of BCC were significantly higher in HCTZ users with ORs of 4.839221 (95% confidence interval [CI], 1.22-19.12).In HCTZ users, NMSC cases were associated with increased age (p < 0.001 for both BCC and SCC). BCC recurrences were statistically significant with age, longer follow-up, and positive margins after excision in HCTZ users (p = 0.048, 0.020, and, 0.003, respectively). SCC recurrences were not significantly associated with HCTZ use. DISCUSSION: HCTZ use is significantly associated with BCC recurrences. Especially in the elderly population, cases with a positive margin should be followed closely.

Positive Effect of Platelet-Rich Plasma on Neoureterocystostomy in Rats: An Experimental Study.

OBJECTIVES: Some of the most common problems after kidney transplant are urologic complications, including ureterocystoanastomosis leakage and stenosis with the development of severe renal graft complications. Isolated plasma contains active substances that cause the activation of various growth factors for the processes of tissue repair or regeneration, has an anti- inflammatory effect, activates angiogenesis, and reduces the risk of infectious complications. Platelet-rich plasma is actively used to stimulate bone regeneration, heal wounds and ulcers on the skin, enhance reconstruction of the larynx and trachea, and ameliorate urethral damage, among other uses. This study was developed to evaluate the positive effect of platelet-rich plasma on the healing process of an anastomotic wound in a model of ureterocystoanas-tomosis in rats. MATERIAL AND METHODS: We randomized 14 Wistar albino male rats into 2 groups: group 1 included 7 rats that received platelet-rich plasma after ureterocystostomy; group 2 was the control group and included 7 rats that underwent ureterocystostomy without platelet-rich plasma. On postoperative day 7, all animals were euthanized, and the anastomosis area was resected for determination of the tissue hydroxyproline levels and histopathology examination. RESULTS: Tissue hydroxyproline levels were 767 ± 62.9 µg/g in group 1 and 256 ± 28.0 µg/g in group 2. Tissue hydroxyproline levels were significantly higher in group 1 compared with group 2 (P < .05). There were no significant differences in epithelial damage, acute inflammation, or fibrosis between the tissue samples of both groups. CONCLUSIONS: The results of this study show that the use of platelet-rich plasma during ureterocystostomy produces a positive effect. Our further research will be devoted to the use of autologous platelet-rich plasma in ureterocystostomy in big models.

New-onset cutaneous nodule arising from hypertrichotic brownish patch in a 6-year-old girl.

A 6-year-old girl presented with an enlarging asymptomatic nodule within a hyperpigmented hypertrichotic patch on her left thigh. Histopathological examination revealed tumour cells with round to fusiform nuclei in a fine fibrillary collagenous stroma, along with increased cellularity. Most of the tumour cells were positive for S-100 and negative for HMB-45 and Melan-A.

Effect of Adipose-Derived Stem Cells on Colonic Anastomosis in Rats Immunosuppressed With Everolimus: An Experimental Study.

OBJECTIVES: Immunosuppressed patients sometimes require colorectal surgery. We investigated whether adipose tissue-derived stem cells contributed to anastomosis healing in rats immunosuppressed with the mTOR inhibitor everolimus. MATERIALS AND METHODS: Sixty male Sprague-Dawley rats were randomly divided into 4 groups of 14 each, with all groups undergoing descending colon anastomosis; the 4 remaining rats were used for stem cell retrieval. Group 1 (control) underwent surgery only, group 2 received stem cell injection, group 3 received everolimus only, and group 4 received everolimus plus stem cell injection. After treatment, each group was randomly divided into 2 equal subgroups according to the day of euthanasia (posttreatment day 4 or day 7). We measured anastomosis bursting pressure and tissue hydroxyproline level and performed histopathological evaluation. RESULTS: At both posttreatment days 4 and 7, median weight loss in group 3 was higher than in group 1, group 3 had higher severity of intraabdominal adhesion than group 4, and group 2 had mean hydroxyproline level higher than the other groups. At posttreatment day 4, mean bursting pressure was significantly different in group 1 versus groups 2 and 4 (P = .002) and group 2 versus groups 3 and 4 (P < .001). No significant differences were shown in pathological analysis except for vascular proliferation on day 7 (P = .003). CONCLUSIONS: Injection of adipose tissue-derived stem cells in the anastomosis site prevented anastomosis leakage by contributing to healing. Injection of adipose tissue-derived stem cells in the anastomosis region, especially in the early period after solid-organ transplant in recipients and after gastrointestinal surgery in immunosuppressed patients, may help reduce mortality and morbidity.

Successful Replantation of Tamai Zone I Amputation with Delayed Vein Repair.

Digital vein repair is one of the most challenging phases of distal phalanx replantation. Digital veins at very distal levels have a small vessel caliber and collapsed lumens, which makes them hard to identify and handle. Digital veins may not be visible immediately after arterial anastomosis. In this scenario, the patient can be taken to the operative room several hours after revascularization to visualize dilated and expanded veins for late digital vein repair. Late digital vein repair is a reliable and alternative method to artery only replantation. In this report, a successful replantation with late digital vein repair in Tamai Zone I is presented.

The Effects of Adipose Derived Stromal Vascular Fraction and Platelet-Rich Plasma on Bone Healing of a Rat Model With Chronic Kidney Disease.

BACKGROUND: Chronic kidney disease (CKD) impairs osteoblast/osteoclast balance and damages bone structure with diminished mineralization and results in bone restoration disorders. In this study, we investigate the effects of adipose-derived stromal vascular fraction and platelet-rich plasma (PRP) on bone healing model in rats with CKD. METHODS: Sprague-Dawley rats were separated into 4 groups. All groups except group I (healthy control) had CKD surgery using 5/6 nephrectomy model. All groups had intramedullary pin fixation after receiving bone fracture using drilling tools. Group II rats were used as control group for CKD. Group III rats received PRP treatment on fracture site. Group IV rats received PRP and stromal vascular fraction treatment on fracture site.Weight loss and blood samples were followed at the time of kidney surgery, third, sixth, and 12th weeks. Bone healing and callus formations were compared, biomechanically, radiologically, histopathologically, and immunohistochemically. Osteoblastic transformation of stem cells was assessed with DiI staining. RESULTS: Negative effects of CKD on bone healing were reduced by increasing mechanical, histological, radiological, and biochemical properties of the bone with stromal vascular fraction and PRP treatments. Although thickness of callus tissue delayed bone healing process, it also enhanced biomechanical features and bone tissue organization. CONCLUSIONS: Platelet-rich plasma and adipose-derived stromal vascular fraction treatments were effective for bone healing in animal model, which can be promising for clinical trials.

Nonmelanoma Skin Cancers in Solid-Organ Transplant Recipients: A Single Center Experience.

OBJECTIVES: Skin cancers are one of the most common malignancies in solid-organ transplant recipients. Increased age and immunosuppressive drug use are risk factors for posttransplant skin malignancies. We evaluated nonmelanocytic skin cancer incidence and development time in transplant patients. MATERIALS AND METHODS: We reviewed 1833 patients who received kidney, liver, and heart grafts between 1996 and 2016 at Baskent University. We excluded melanocytic skin cancers, premalignant lesions, and benign skin tumors. RESULTS: Of 1833 patients, 1253 were male (68.4%) and 580 were female (31.6%), composed of 1133 kidney (61.8%), 512 liver (27.9%), and 120 heart recipients (6.5%). Of these, 22 patients (18 kidney/3 liver/1 heart) developed 23 different types of skin cancer. Prevalence of skin cancer was 1.20%. Mean age at presentation was 55.8 years (range, 37-71 y). Average time from transplant to skin malignancy was 6.1 years (range, 1-13 y), with the most common being basal cell carcinoma (43%, 10 cases), followed by squamous cell carcinoma (39%, 9 cases) and Kaposi sarcoma (13%, 3 cases). Tumor sites included head and neck (15 case), trunk (2 cases), lower extremity (2 cases), and upper extremity (2 cases). Neither local recurrence nor distant metastasis was shown. CONCLUSIONS: Skin cancer risk is increased in solid-organ transplant recipients versus the general population. Although squamous cell carcinoma is the most common tumor in this patient population, followed by basal cell carcinoma, we found this reversed in our patients. The low prevalence of skin malignancy (1.20%) may be associated with close clinical follow-up to detect premalignant skin lesions and the lowdose immunosuppressive drug regimen. We believe that local recurrence and distant metastasis were absent because we use a wide surgical margin of excision and provide strict follow-up. Routine dermatologic follow-up visits of transplant recipients are recommended to detect and treat early skin cancer and premalignant lesions and thus lower morbidity and mortality.

Aesthetic Surgery in Transplant Patients: A Single Center Experience.

OBJECTIVES: Transplant patients, like the nontransplant population, can have surgical interventions for body shape disorders. Studies on aesthetic surgeries in transplant patients are scarce. Our aim was to share our experiences with various aesthetic procedures in solid-organ transplant recipients. MATERIALS AND METHODS: Six (5 female, 1 male) transplant patients who received surgical corrections of the aging face, ptosis and lipodystrophy of the breast, and abdomen at the Baskent University Plastic Reconstructive and Aesthetic Surgery Department between 2010 and 2017 were included. Five patients had renal transplants, and 1 patient had liver transplant. Minimal aesthetic procedures, including botulinum toxin, dermal filler injections, and scar revisions, were excluded. All patients were consulted to transplant team preoperatively and hospitalized in the transplant inpatient clinic. RESULTS: Mean age was 46 years. Aesthetic surgeries included breast reduction (2 patients), high suprasuperficial musculoaponeurotic system face lift (1 patient), blepharoplasty (2 patients), and dermofat grafting (1 patient). Mean hospitalization duration was 2.5 days. Four patients had no minor or major complications. One patient had skin flap necrosis, which healed with secondary intention. Another patient had ectropion after lower lid blepharoplasty, which was corrected with another procedure. CONCLUSIONS: Transplant patients are a special group of patients who receive long-term immunosuppressive treatment and medications like high-dose steroids. These treatments can lead to dermal atrophy and cause pseudo-skin laxity. Removal of excess skin and fat tissue should be considered. Efforts should be made to avoid complications such as skin necrosis and unpredictable wound healing problems when resecting the excess tissue. Preoperative consultation with transplant surgeons and keeping operative times short are other important factors. Body dysmorphologies that interfere with normal life activities and demand for younger appearance are the main reasons of aesthetic procedures. Transplant patients can be operated safely with preoperative planning, consultation with transplant surgeons, and close follow-up.

The effect of intradermal administration of inactive platelet-rich plasma on flap viability in rats.

PURPOSE:: To evaluate the effect of inactive form of platelet rich plasma (PRP) on the flap viability. METHODS:: Thirty six rats were used. Rats were divided into six groups then 9x3 cm random pattern skin flaps were elevated from dorsum of all rats. For precluding vascularization from the base, a silicone layer was placed under the flap in groups 2(only flap+silicone), 4(saline+silicone) and 6(PRP+silicone). In groups 1(only flap), 2(only flap+silicone) nothing was done except flap surgery. In groups 3(saline) and 4(saline+silicone), saline was applied intradermally , in groups 5(PRP) and 6(PRP+silicone), inactive form of PRP which obtained from different 16 rats was applied intradermally, into certain points of flaps immediately after surgery. After 7 days flap necrosis ratio was measured in all groups. RESULTS:: Mean necrosis rate in group 5(PRP) (16.05%) was statistically significantly lower than group 1(only flap) (31,93%) and group 3(saline) (30,43%) (p<0.001). Mean necrosis rate in group 6(PRP+silicone) (36.37%) was statistically significantly lower than group 2(only flap+silicone) (47.93%) and group 4(saline+silicone) (45.65%) (p<0.001). CONCLUSION:: Intradermal inactive platelet rich plasma administration decreases flap necrosis so for skin application.

Omega (Ω) Advancement Flap: A Circular Flap Design for the Aesthetic Closure of Circular Skin Defect.

BACKGROUND: Most skin defects that require reconstruction with a local skin flap have a circular- or oval-shaped pattern. The majority of the skin flaps are planned in an angled shape. Therefore, it may be necessary to modify the shape of the defect or the distal flap border to minimize tissue distortion. We have designed a circular-shaped advancement flap to be compatible with the circular defect. METHODS: Eighteen cases of reconstruction of skin defects in the face, chest wall, hand and buttock area were performed using the omega advancement flap between 2010 and 2014. In this technique, a circular-shaped flap that has an equal diameter with the defect is planned adjacent to the defect. To facilitate the advancement of the flap and to avoid standing cones, deepithelialized equilateral triangular flaps are designed on both sides of the main circular flap. The circular flap is easily moved to the defect by pulling of the triangular flaps with minimal tension. RESULTS: All flaps survived without complication such as infection, hematoma or flap necrosis. No secondary surgery was required to correct contour deformities such as standing cones and trap-door deformities. The results were satisfactory aesthetically and functionally. CONCLUSIONS: The omega advancement flap is an easy and reliable procedure for reconstruction of circular skin defects located on various anatomical regions. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The management of non-melanocytic skin malignancies of the scalp and calvarium.

BACKGROUND: The management of advanced cutaneous malignancies has been controversial. Thirteen patients with nonmelanoma skin neoplasias that had invaded the bone of the calvarium and scalp were treated in our centre. OBJECTIVE: The purpose of this study was to evaluate our experience in treating these malignancies with scalp resection and full or partial thickness cranium reconstruction. PATIENTS AND METHODS: From June 2008 to March 2012, thirteen patients with locally advanced tumours of the scalp invading the calvarium were treated with wide local excision of the scalp combined with an underlying craniectomy and dural resection if needed. RESULTS: Using histopathological diagnosis eleven patients were diagnosed with basal cell carcinoma and two patients with squamous cell carcinoma. A full thickness cranium resection was performed in seven patients and partial in six patients. CONCLUSION: These large cancers occasionally invade adjacent structures, as well as bone, presenting a challenging surgical problem. In general, giant rotational or island scalp flaps and free tissue transfers are needed to close the area. Finding clean margins are an important part of treating patients with bone involvement and can usually be attained using outer tabula curettage thus preventing unnecessary morbidity.

Tonsillar leiomyosarcoma.

UNLABELLED: Leiomyosarcomas of the head and neck is an extremely rare entity that because of its infrequency has been associated with both delayed diagnosis and misdiagnosis. Sinonasal tract is the most common site in this region. The overall prognosis is poor. It is necessary for appropriate immunohistochemical investigation for accurate diagnosis. Tonsillar leiomyosarcoma presented only 1 case in the English-language literature (PubMed, Ovid, and Proquest databases). We report a second case of leiomyosarcoma arising in the tonsil in a 38-year-old woman. LEVEL OF EVIDENCE: Level IV therapeutic study.

Differentiated and undifferentiated adipose-derived stem cells improve function in rats with peripheral nerve gaps.

The effect of differentiated and undifferentiated adipose-derived stem cells on the repair of peripheral nerve gaps was studied. Adipose-derived stem cells were maintained in differentiation medium for 2 weeks. The expression of Schwann cell proteins S-100, nerve growth factor receptor (NGFR) p75 and integrin ß4 was examined by immunofluorescence staining and real time-polymerase chain reaction (real time-PCR) at the end of the differentiation period. A 10-mm gap on the left sciatic nerves of 20 Fischer rats was created and bridged with silicone tube (group I), silicone tube filled with collagen gel (group II), nerve graft (group III), silicone tube filled with adipose-derived stem cells (group IV) and silicone tube filled with differentiated adipose-derived stem cells (group V). In vitro, the positivity of differentiated adipose-derived stem cells for S-100, NGFR p75 and integrin ß4 by immunofluorescence staining was 31%, 27% and 12%, respectively. Fold changes by real time-PCR in comparison with undifferentiated cells were 48.4, 168.7 and 284.85, respectively. In vivo, a walking track analysis did not yield any statistically significant differences after 3 months postoperatively; however, after 6 months, group IV (sciatic function index (SFI) = -49.1 ± 13.1) and V (SFI = -52.6 ± 5.7) showed significant improvement compared to other groups (I: -73.3 ± 5.07, II: -79.6 ± 12.01, III: -74.8 ± 12.89) (p < 0.05). Nerve conduction velocity after 6 months was higher in groups IV (4.44 ± 0.3 mm ms(-1)), V (4.25 ± 0.3 mm ms(-1)) and III (4 ± 0.3 mm ms(-1)) than in groups I (2.5 ± 2.25 mm ms(-1)) and II (2.35 ± 1.58 mm ms(-1)) (p > 0.05). Myelin fibre density and myelinated fibre/unmyelinated fibre ratio were significantly higher in the midnerve and the distal nerve in groups IV and V (p < 0.05). These results reveal the therapeutic potential of adipose-derived stem cells in nerve reconstruction.

The utilization of teres major muscle in facial paralysis reanimation: an anatomic study.

PURPOSE: This study explores vascular and morphologic anatomy of the teres major muscle, which can be an alternative to donor muscles used in functional muscle transfer in long-standing facial paralysis reanimation. METHODS: A total of 14 teres major muscles from 7 embalmed cadavers were dissected and examined. Diameters and lengths of major and minor arteries supplying the muscle, venous pedicle diameter, neural pedicle diameter and length, their entrances into the muscle, the extendibility of neurovascular pedicles, when necessary, and the morphology of muscle were evaluated. RESULTS: Mean results obtained for teres major muscle in the study were as follows: the longest distance between the starting point and the area where the tendon started was 17.1 +/- 0.34 cm (range, 14.5-18.8 cm), the distance between the widest points was 5.8 +/- 0.5 cm (range, 5.1-6.2 cm), the thickest area was 3.4 +/- 0.9 cm (range, 2.8-3.9 cm), and surface area was 58.2 +/- 1.02 cm2 (range, 48.1-62.7 cm2). The major pedicle of the muscle, which is type 2 according to Mahtnes-Nahai classification, has a length of 3.0 +/- 0.6 cm (range, 2.4-3.6 cm) and a diameter of 2.7 +/- 0.21 mm (range, 1.85-3.4 mm). The nerve that provides motor innervation to the muscle is 5.9 cm (range, 4.1-9.9 cm) in length and 1.7 mm (range, 1.2-2.5 mm) in diameter. CONCLUSION: As a result of this preliminary study, we think that morphologic and neurovascular structures of this muscle is suitable for use in long-standing facial paralysis reanimation.

Vascular anatomy of the metatarsal bones and the interosseous muscles of the foot.

Utilization of the metatarsal bones and interosseous muscles in foot reconstruction should be based on the vascular anatomy of the metatarsal bones and interosseous muscles. We studied the vascular anatomy of the metatarsal bones and the interosseous muscles to design a split metacarpal musculoosseous flap and dorsal interosseous muscle flap. Twenty-two feet from eleven cadavers that had been embalmed in formalin were studied. Dissection was done using a dissection microscope (x3.5), delineating meticulously the arcuate artery, dorsal metatarsal arteries and the small branches arising from the metatarsal arteries. The dorsal metatarsal arteries do not course at the midline of the interosseous muscles. The first dorsal metatarsal artery proceeds close to the first metatarsal bone in the first metatarsal space. While proceeding to the distal, it shoots out a branch that individually feeds the lateral head of the first dorsal metatarsal muscle and medial face of the second metatarsus, thereby feeding muscle and bone. Except for this branch, the first dorsal metatarsal gives off segmental and periosteal branches that individually feed the medial heads of the first dorsal metatarsal muscle and first metatarsal bone. The second, third and fourth metatarsal arteries proceed close to the third, fourth and fifth metatarsal bones in the metatarsal spaces. In these courses, the arteries give out segmental branches to both faces of the interosseous muscles and periosteal branches to the medial face of metatarsal bones. For defects or disease of the ankle bones, the metatarsal bones can be split at the medial border distally, and a split metatarsal musculoosseous flap, based proximally on the dorsal metatarsal artery, can be done. Distal intermetatarsal anastomoses between the dorsal and plantar vascular networks enables a split metatarsal musculoosseous flap based distally, including the dorsal metatarsal artery for bony defects of the proximal phalanx.