Successful Craniotomy for Advanced Basal Cell Carcinomas with Cranial Bone Invasion and Dura Mater Infiltration - Unique Presentation in a Bulgarian Patient.

BACKGROUND: Basal cell carcinomas (BCC) located in the sun-exposed regions are a serious therapeutic challenge. Therefore early diagnosis and adequate therapy should be of a high priority for every dermatologic surgeon. CASE PRESENTATION: We are presenting a patient with multiple BCCs, located on the area of the scalp, who had been treated several years ago with electrocautery and curettage after histopathological verification. However, the last few years the tumours have advanced, infiltrating firstly the tabula external and a year later the tabula interna of the cranium. A computed -tomography (CT) imaging and radiography of the skull were performed to reveal the definite tumour localisation, needed for planning an one - step surgical intervention. Both of the instrumental examinations confirmed the existence of osteolytic tumour lesions. Craniotomy with precise removal of the BCCs infiltrating the cranial bone in all of its thickness was performed. Partial resection of dura mater was also performed also because intraoperative findings established the involvement of the dura. Histopathological verification revealed bone and dural invasion with clean resection margins. The bone defect was recovered with hydroxyapatite cement. Reconstruction as the shape of the skull was carefully modified and adapted to its initial size and form. Layered closure of the skin and soft tissues were performed after the complete removal of the BCCs. The postoperative period had no serious complications. CONCLUSION: Precisely managed therapy of BCC is curative in most of the cases as it ensures good prognosis for the patient.

Subungual Exostosis in a Young Soccer Player.

BACKGROUND: Subungual exostosis is a relatively uncommon, benign osteocartilaginous tumor of the distal phalanx of the toes or fingers in young adults, considered as a rare variant of osteochondroma. Differential diagnoses include subungual verruca (viral wart), pyogenic granuloma, osteochondroma, amelanotic subungual melanoma and glomus tumour. Misdiagnosis and total onychodystrophy frequently occur as a result of late treatment or inadequate treatment strategy. Dermoscopy could be a useful technique, involved in the diagnostic process, although X-ray examination and histopathology are mandatory for the diagnosis. CASE REPORT: We report a rare case of subungual exostosis of the great toe associated with repeated trauma of the nail bed. The lack of radiographic and histopathological examination could lead to misdiagnosis and inadequate treatment. Although completely benign, subungual exostosis should be considered in differential diagnosis of nail bed tumors in young adults, in order to avoid associated complications and unneeded aggressive surgical interventions. CONCLUSION: Complete excision of the lesion and delicate separation from the underlying nail bed structures results in total resolve of the problem, by providing the lowest risk of recurrences.

Small Dysplastic Congenital Melanocytic Nevi in Childhood as Possible Melanoma Imitators.

Small pigmented lesions in children can represent a significant diagnostic challenge. If the diagnostic features and therapeutic approach are relatively well established in large and giant nevi, there is still much controversy regarding small and intermediate-sized congenital pigmented lesions that can lead to significant diagnostic challenges, both clinically and dermoscopically, and consequently to difficulty in defining the optimal approach in such cases. Although dermoscopy can be useful in the diagnosis of pigmented lesions, the diversity of clinical and dermoscopic features of pigmented nevi in children usually hinder the differentiation between them and melanoma. Histological findings after resection often show surprising results that do not correspond either to the clinical nor the dermoscopic features. With the present case, we want to emphasise the variable natural behaviour of melanocytic lesions in children, which sometimes leads to unnecessary surgical excisions, which should be avoided in pediatric patients.

Interdigital melanoma simultaneously affecting two neighboring interdigital spaces : First description in the medical literature.

BACKGROUND: Interdigital melanoma, as a subtype of acral lentiginous melanoma, is relatively uncommon in the Caucasian population. It frequently goes unrecognized for a prolonged period of time prior to diagnosis, due to its asymptomatic nature and variable clinical appearance. METHODS: We report the case of a 67-year-old Caucasian woman who presented with interdigital malignant melanoma affecting two neighboring interdigital spaces. It had evolved over a period of more than 15 years and had been initially misdiagnosed as tinea pedis due to the macerated appearance of the lesion and a positive mycologic examination. RESULTS: We highlight the striking involvement of two adjacent interdigital spaces and the neighboring area of the sole of the foot by the tumor. The melanoma was staged as IIIC, with pathologic grading T4bN2bM CONCLUSIONS: The involvement of two adjacent interdigital spaces is unusual and, to our knowledge, has not been previously highlighted in the medical literature. It may be explained, in part, by the longstanding nature of the lesion in our patient.

Subungual Squamous Cell Carcinoma Associated with Long Standing Onychomycosis: Aggressive Surgical Approach with a Favourable Outcome.

BACKGROUND: Tumours of the nail bed are rare. Squamous cell carcinoma is the most frequent among them. Chronic infection, chemical or physical trauma/microtrauma, genetic disorders such as congenital ectodermal dysplasia, radiation, tar, arsenic or exposure to minerals, sun exposure, immunosuppression, and previous HPV infection have all been discussed as etiologic factors. The diagnosis is often delayed because of the variety of clinical manifestations, often resembling benign or common infectious processes. Rapidly growing ulcerative lesions should also be considered as potential malignancy. Furthermore, a lack of antifungal or antibacterial treatment response is the most indicative symptom, always requiring subungual biopsy. Early diagnosis is of great importance for therapeutic effectiveness. CASE PRESENTATION: We present a case of subungual squamous cell carcinoma, associated with long-lasting onychomycosis in a 76-year-old female patient, treated with amputation of the distal phalanx and the distal part of the proximal phalanx. CONCLUSION: Although there are no available data in the literature to confirm or reject the contribution of the chronic nail infection to the malignant process, we emphasise the importance of this co-existence regarding the possible disguising of the malignant process. An early biopsy of a chronic persistent nail lesion may be preventive and beneficial regarding avoiding more aggressive treatments and achieving a favourable prognosis.