A Regional Survey on Merkel Cell Carcinoma: A Plea for Uniform Patient Journey Modeling and Diagnostic-Therapeutic Pathway.

Merkel cell carcinoma (MCC) is a rare and aggressive cutaneous neuroendocrine cancer that usually affects the elderly and immunosuppressed in sun-exposed areas. Due to its rarity, it is frequently unrecognized, and its management is not standardized across medical centers, despite the more recent availability of immunotherapy, with avelumab as first-line treatment improving the prognosis even in advanced stages of disease. We conducted a purpose-designed survey of a selected sample of physicians working in the Lazio region, in Italy, to assess their awareness and knowledge of MCC as well as their perspective on assisted diagnostic and therapeutic pathways. The Lazio region, and in particular Rome, is one of the most important academic and non- academic center in Italy dedicated to the diagnosis and treatment of skin cancer. A total of 368 doctors (including 100 general practitioners, 72 oncologists, 87 dermatologists, 59 surgeons, and 50 anatomopathologists) agreed to be part of this survey. Surgeons, oncologists, and dermatologists thought themselves significantly more updated on MCC than primary care physicians, but more than half of the interviewees are interested in CCM training courses and training with clearer and more standardized care pathways. Significant differences have been reported from survey participants in terms of multidisciplinary team set up for MCC management. The identification of specialized centers and the improvement of communication pathways among different specialties, as well as between patients and physicians, could be very beneficial in improving patients' journey modeling and starting a uniform diagnostic and therapeutic pathway for MCC patients in the new era of immunotherapies.

[The integrated care pathway for non melanoma skin cancer: the Istituto Dermopatico dell'Immacolata - IRCCS experience in Rome.] / Il percorso diagnostico-terapeutico e assistenziale nella gestione del paziente affetto da tumore cutaneo non melanocitario: l'esperienza dell'IDI - IRCCS di Roma.

The incidence of non-melanoma skin cancers (NMSC) is increasing worldwide and these skin cancers have become an important health issue. An integrated care pathway (ICP) is a multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition. The aim of this paper is to define the ICP for patients affected by NMSC referring to the Istituto Dermopatico dell'Immacolata - IRCCS of Rome and Villa Paola, Italy. This ICP is multidisciplinary and included various specialists like dermatologist, oncologist, general surgeon, plastic surgeon, anatomopathologist, molecular biologist and epidemiologist. This ICP is based on the most recent acquisitions in the literature, referring in particular to the national (EADO and SIDEMAST) and international guidelines (EDF and NCCN). We firstly valued the current practice for patients affected by NMSC referring to our Institute to define the multidisciplinary process map. This process delineated the activities and the responsibilities performed during delivery of care to the patients and the potential problem areas or opportunities for improvements. Subsequently, we defined the final ICP process. This ICP of NMSC represents an innovative strategy to provide high quality healthcare. This allows to ensure all the necessary procedures for the patient, optimizing the "continuum" of care and the use of health services, and improving the organization of the Institute regarding an important health issue.

Intralesional ultrasound-guided combined treatment with triamcinolone plus lincomycin in hidradenitis suppurativa: A pilot study.

Hidradenitis suppurativa (HS) is a chronic, inflammatory, disease of the hair follicle. Intralesional corticosteroid treatment in HS patients has been reported, and while several data described this route of administration as an efficient delivery system, its efficacy is still debated. The aim of this study was to explore the clinical efficacy and the effect on quality of life (QoL) of an innovative intralesional treatment in HS patients. This was an interventional prospective study. The treatment consisted of two intralesional ultrasound-guided injections of triamcinolone plus lincomycin, at baseline and after 2 weeks. Lesions and QoL were evaluated at baseline and at 4 weeks following intralesional therapy. All clinical variables of 36 HS patients significantly improved after 4 weeks. Mean values of the visual analog scale (VAS) pain decreased from 4.6 to 1.5, P = .027. The Bodily Pain (BP) scale of the Short-Form Health Survey (SF-36) significantly improved from 36.2 at baseline to 53.9 at 4-week follow-up (P < .001). On a scale from 0 to 10, over 90% of the patients gave a satisfaction score of 8 or more. This combination of corticosteroids and antibiotics delivered intralesionally seems to be effective, as it improved both patient- and physician-reported outcomes.

Reanimação estática do lábio inferior na paralisia facial como complicação de preenchimento / Static lower lip reanimation as a filler complication of facial paralysis

Procedimentos de rejuvenescimento facial substitutos da cirurgia tradicional tornaram-se cada vez mais populares para promover uma aparência jovial com procedimentos minimamente invasivos, como toxina botulínica injetável, preenchimento de tecidos moles e peelings químicos. No entanto, complicações podem ocorrer mesmo na presença de um injetor habilidoso e experiente. Apresentamos o caso de uma paciente submetida a reanimação labial estática usando retalho dermoadiposo para lesão do nervo facial direito após remoção de nódulos como complicação de preenchimento. A "abordagem modificada de bull horn" foi realizada para elevação do lábio superior em torno das asas nasais e columela e ao longo do sulco nasolabial direito. O retalho foi desepitelizado e obtido. Usando a ponta aberta de uma pequena cânula de lipoaspiração, a porção distal do retalho foi encapsulada e fixada diretamente em C-loop e foram utilizados pontos U, transfixando o retalho para o periósteo do arco zigomático. Nos três anos de seguimento não foram observadas complicações significativas e a paciente não relatou nenhuma limitação funcional ou insatisfação com o aspecto das cicatrizes no sulco nasolabial e ao redor das asas nasais e da columela.

Facial rejuvenation procedures to circumvent traditional surgery have become increasingly popular to promote a youthful appearance with minimally invasive procedures such as injectable botulinum toxin, soft-tissue fillers, and chemical peels. Nevertheless, complications can occur even with an astute and experienced injector. Here we present the case of a patient who underwent static lip reanimation using a dermoadiposal flap for right facial nerve damage following nodule removal as a filler complication. A "modified bulls horn approach" to the upper lip lift was performed around the nasal wings and columella and along the right nasolabial fold. The flap was de-epithelized and harvested. Using the open tip of a small liposuction cannula, the distal portion of the flap was tunneled and fixed directly in a C-loop fashion using U stitches, transfixing the flap to the periosteum of the zygomatic arch. At 3 years follow-up, no significant complications were observed, and the patient reported no functional limitations or dissatisfaction with the scars in the nasolabial fold or around the nasal wings and columella.

The Broad-Spectrum Impact of Hidradenitis Suppurativa on Quality of Life: A Comparison with Psoriasis.

BACKGROUND/AIM: Hidradenitis suppurativa (HS) is a chronic skin disease with a heavy impact on patients' quality of life (QoL). The aim of this study was to evaluate in detail the QoL impact of HS comparing it with other skin conditions, and in particular with psoriasis. METHODS: Patients with a diagnosis of HS were recruited. QoL was measured using the Skindex-17 questionnaire. RESULTS: Data were available for 69 HS patients. HS had the worst QoL among several skin conditions. Compared to psoriasis the mean symptom score was 69.4 versus 53.7, and the mean psychosocial score was 56.1 versus 32.7. Overall, the scores of patients with HS were higher than those of psoriasis patients on 16 of the 17 items of the Skindex-17. CONCLUSIONS: When compared to many different skin conditions, and in particular to psoriasis, HS was the most impairing condition, even at low levels of clinical severity.

Naturally Adipose Stromal Cell-Enriched Fat Graft: Comparative Polychromatic Flow Cytometry Study of Fat Harvested by Barbed or Blunt Multihole Cannula.

Background: Fat grafts enriched with cells of the stromal vascular fraction (SVF), especially adipose-derived stromal cells (ASCs), exhibit significantly improved retention over non enriched, plain fat. Different types of liposuction cannulae may yield lipoaspirates with different subpopulations of cells. Moreover, preparation of adipose tissue for transplantation typically involves centrifugation, which creates a density gradient of fat. Objectives: The authors sought to determine whether liposuction with a barbed or smooth cannula altered the enrichment of the SVF, and specifically ASCs, in low-density (LD) and high-density (HD) fractions of centrifuged adipose tissue. Methods: Fat was harvested from 2 abdominal sites of 5 healthy women with a barbed or smooth multihole blunt-end cannula. After centrifugation, LD and HD fat fractions were digested with collagenase and analyzed by polychromatic flow cytometry to identify and enumerate distinct populations of cells. Results: Overall cell yield and the number of immune cells were consistently higher in HD fractions than in LD fractions, regardless of the cannula employed. More living cells, and specifically more ASCs, populated the HD fractions of lipoaspirates obtained with a barbed cannula than with a smooth cannula. Conclusions: In this study, lipoaspiration with a barbed cannula and isolation of the HD layer of centrifuged adipose tissue yielded maximal amounts of SVF cells, including ASCs.

The effect of time to sentinel lymph node biopsy on cutaneous melanoma survival.

BACKGROUND: Whether timing of sentinel lymph node biopsy (SLNB) in cutaneous melanoma improves survival is not yet clear. The aim of this study was to investigate if the timing of SLNB influences long-term melanoma mortality. METHODS: A 10-year retrospective cohort study was conducted on 748 cutaneous melanoma patients who underwent excision of the SLN. Hazard ratios and 95% confidence intervals were estimated from Cox proportional hazards models. RESULTS: After adjusting for sex, age, Breslow thickness, mitotic rate, ulceration, and histologic type, patients who underwent early SLNB (≤30 days) and resulted positive on final pathology had a 3 times decreased risk of melanoma mortality (hazard ratio = .29; 95%confidence interval = .11 to .77) in comparison to patients who underwent delayed SLNB (≥31 days) and resulted positive on final pathology. CONCLUSIONS: Our findings suggest that early SLNB (≤30 days) improves melanoma survival.

Tumor-infiltrating lymphocytes predict cutaneous melanoma survival.

Understanding differences in survival across distinct subgroups of melanoma patients may help with the choice of types of therapy. Tumor-infiltrating lymphocytes (TILs) are considered a manifestation of the host immune response to tumor, but the role of TILs in melanoma mortality is controversial. The aim of this study was to investigate independent prognostic factors for melanoma mortality. We carried out a 10-year cohort study on 4133 melanoma patients from the same geographic area (Lazio) with primary cutaneous melanoma diagnosed between January 1998 and December 2008. The probability of survival was estimated using Kaplan-Meier methods and prognostic factors were evaluated by multivariate analysis (Cox proportional hazards model). The 10-year survival rate for melanoma decreased with increasing Breslow thickness (Pfor trend<0.0001) and with age (Pfor trend<0.0001) whereas survival increased with increasing levels of TILs (Pfor trend=0.0001). The 10-year survival rate for melanoma divided into TILs intensity as scanty, moderate, and marked was 88.0, 92.2, and 97.0%, respectively. In the multivariate Cox model, the presence of high levels of TILs in primary invasive melanomas was associated with a lower risk of melanoma death (hazard ratio 0.32; 95% confidence interval 0.13-0.82) after controlling for sex, age, Breslow thickness, histological type, mitotic rate, and ulceration. After including lymph node status in the multivariate analysis, the protective effect of marked TILs on melanoma mortality remained (hazard ratio 0.37; 95% confidence interval 0.15-0.94). The results of this study suggest that the immune microenvironment affects melanoma survival.

Delay in diagnosis and treatment of squamous cell carcinoma of the skin.

Advanced squamous cell carcinomas (SCC) of the skin can cause significant tissue destruction and may metastasize. Understanding the determinants of patient delay could help prevent advanced presentation. The purpose of the present study was to examine patient- and healthcare-related factors associated with delay before the detection and treatment of SCC. A sample of 308 patients with SCC treated at a dermatological referral centre in Italy were interviewed. Clinical data were obtained from the medical records. The highest quartile patients reported > 9 months delay between noticing the lesion and the first medical visit (defined as long patient delay). Multivariate analysis showed that SCC arising on pre-existing chronic lesions were associated with long patient delay (odds ratio = 3.17; 95% confidence interval 1.1-9.3). Controlling for confounders, the first physician's advice to remove the lesion immediately was associated with a shorter treatment delay (p < 0.001). In conclusion, our work emphasizes the importance of seeing a doctor about any change in a pre-existing lesion, particularly in light of the fact that SCC on chronic lesions are at greater risk of metastasis and recurrence.

Primary amyloidosis of the eyelid: a case report.

The Authors describe a case of primary localized amyloidosis of the eyelids, focusing on diagnosis and possible treatment. The involment of several structures of the eyelid such as muscles, conjunctiva and puncta lacrimalia, as well as peculiar features of these proteinaceous deposits, suggest different combined procedures and precise timing in choosing the appropriated therapy.

Factors associated with large cutaneous squamous cell carcinomas.

BACKGROUND: Large cutaneous squamous cell carcinoma (SCC) is associated with a higher risk of disfigurement, local recurrence, and metastasis; however, little is known about factors associated with tumor size at diagnosis. OBJECTIVES: We sought to evaluate factors associated with SCC size, including diagnostic/treatment delay and patient and tumor characteristics. METHODS: We studied a stratified sample of 308 patients with SCC recently treated at a dermatologic referral center in Italy. Medical records were reviewed and telephone interviews conducted. Multiple logistic regression was used to examine factors associated with SCC size. RESULTS: With univariate analyses, among both invasive and in situ cases, SCC greater than 2 cm was significantly associated with male gender, tumors arising in chronic lesions, and tumors located on not easily visible sites. Long delay before surgical removal was significantly associated with large SCC size only for invasive SCC (P < .001). Among patients with invasive SCC, when controlling for age and gender, multivariate analysis showed a significantly higher likelihood of SCC greater than 2 cm with a total delay longer than 18 months before surgical removal (odds ratio=4.18; 95% confidence interval 2.45-7.13) and for tumors arising in chronic lesions (odds ratio=6.42; 95% confidence interval 3.13-13.2). LIMITATIONS: The study was cross-sectional and based on a single center. CONCLUSIONS: Long total delay in removal significantly increased the likelihood of invasive SCC greater than 2 cm. Our findings highlight the importance of early detection and treatment to prevent large invasive SCCs, which are associated with a higher risk of disfigurement, recurrence, and metastasis. Particular attention should be paid to chronic skin lesions and not easily visible body sites during physician- and patient-performed examinations.

Skin cancer knowledge and preventive behaviors among patients with a recent history of cutaneous squamous cell carcinoma.

AIMS: To evaluate skin cancer knowledge and preventive behaviors of patients recently treated for cutaneous squamous cell carcinoma (SCC) and to examine the factors associated with the adoption of preventive behaviors. METHODS: Telephone survey on 315 SCC patients treated at a large dermatological hospital in Italy, evaluating skin cancer knowledge, sun protection and skin examination practices as well as medical recommendations received after SCC removal. RESULTS: Skin cancer knowledge was fair/low for 48.9% of the participants. Doctors were the main source of skin cancer information for 24.4% of the patients. Of the patients assessed >or=12 months after SCC removal, 32.7% reported a total skin examination after removal. Of the participants, 41.6% never/rarely used sunscreens. In a multivariate analysis, the likelihood of having complete skin examinations was associated with a doctor's advice to have an examination (odds ratio, OR = 2.29; 95% confidence interval, CI = 1.2-4.4), a higher knowledge level (OR = 2.05; 95% CI = 1.1-3.8) and past skin examinations (OR = 3.62; 95% CI = 1.9-7.0). Doctor's recommendations increased the likelihood of adopting preventive behaviors. CONCLUSIONS: We found substantial knowledge gaps and limited adoption of skin cancer prevention, highlighting the need for interventions promoting knowledge and preventive behaviors, particularly among higher-risk patients.

[Sentinel node radiolocalisation and predictive value in lip squamous cell carcinoma].

PURPOSE: Is to evaluate the role of the sentinel node (SN) radiolocalisation and its prognostic value in state T2N0M0 squamous cell carcinomas (SCC) of the lip. MATERIALS AND METHODS: Between November 1999 and June 2002 we enrolled 11 consecutive patients (8m,3f) affected with lower lip SCC (7 pts.), labio-commissure (3 pts.) and upper lip (1 pt). Lymphoscintigraphy was performed three hours before surgery. After topical anaesthesia (Lidocaine spray 10%), 30-50MBq of Nanocoll-Tc99m diluted in a 0.3 ml physiological solution was injected intradermally, divided into two peri-lesional points. Planar static acquisition began immediately after the injection in order to visual lymph drainage pathways (lateral and/or anterior view, 512x512 matrix, 5 min. pre set time, LEGP collimator). All patients underwent only selective lymph adenectomy of the SN. RESULTS: SN were visible in all patients within 5 minutes after the injection. In all patients the SNs were observed in the submandibular area (I neck level) in three patients a second SN was localized in latero cervical area (II neck level). All patients were staged SN negative. The average disease free interval for patients who underwent a selective lymph adenectomy of the SN was 20 months with continuing follow-up. CONCLUSIONS: We must stress the importance of performing an immediate exploratory dynamic or static scintigraphy within the first minutes of the radio tracer injection, in order to acquire a precise SN localisation and an accurate mapping of the tumour lymphatic pathways. SN radio localisation is especially beneficial in T2N0 stage patients where immediate lymphadenectomy is not necessary. It also saves time and cuts costs, which are specific goals in the current climate of health service management. Although our results are encouraging, a larger data base from multi centre trials with a five year follow-up would confirm the validity of our approach.