A Tale of Two Tumors: A Collision Tumor of Atypical Fibroxanthoma and Basal Cell Carcinoma.

ABSTRACT: A collision tumor is an infrequent phenomenon characterized by the presence of 2 histologically distinct tumor types (either benign or malignant) occurring within the same specific anatomical site. We describe a rare case of co-occurrence of basal cell carcinoma and atypical fibroxanthoma presenting as a single lesion on the scalp in a 76-year-old man. The lesion was clinically suspicious for basal cell carcinoma and biopsied. Histologic examination showed 2 distinct tumors, one with basaloid cells and the other one with pleomorphic spindle cells colliding and growing together. Immunohistochemical stains were crucial in establishing the diagnosis. This presentation is exceedingly rare and requires additional evaluation for diagnosis.

[High-grade Fetal Adenocarcinoma of the Lung with Scalp Metastasis: A Case Report].

Fetal adenocarcinoma of the lung (FLAC) is a rare tumor. Due to its different clinicopathological features, biological behavior and clinical outcome, FLAC is classified into low-grade FLAC (L-FLAC) and high-grade FLAC (H-FLAC). Most patients with H-FLAC are middle-aged heavy smokers. Here, we describe an extremely rare case of a young male patient who denies smoking and initially presents with a mass on the top of the head and is eventually diagnosed with H-FLAC. The aim of this article is to improve the understanding and awareness of FLAC, and increase the attention to the disease, so as to prevent the underdiagnosis and misdiagnosis of the disease, strengthen early identification and accurate diagnosis, and promote subsequent effective treatment and improve prognosis.
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Craniectomy with soft tissue reconstruction for locally advanced non-melanoma skin cancer of scalp with calvarial invasion: The Nottingham experience.

INTRODUCTION: Locally advanced non-melanoma skin cancer (NMSC) involving the periosteum or calvarium poses a clinical challenge for patients who are unfit for immunotherapy due to medical comorbidities and/or frailty. This case series aims to investigate outcomes for patients undergoing craniectomy and soft tissue reconstruction. METHOD: Patients who underwent craniectomy and soft tissue reconstruction for invasive NMSC with calvarium or periosteal invasion between 2016 and 2022 were included. Data, including demographics, operative details, and clinical outcomes, were gathered from Nottingham University Hospitals' digital health record and the histopathology electronic database. RESULT: Eight patients (average age: 78.4 years, 3 females 5 males) with significant comorbidities and varying degrees of periosteal or bone invasion fulfilled the inclusion criteria. Diagnoses included four squamous cell carcinomas, two basal cell carcinomas, and two pleomorphic dermal sarcomas. Five patients had a history of prior incomplete deep margin excision. The median sizes for soft tissue defect, tumor and bone defect size were 51.83 cm2, 34.63 cm2 and 42.25 cm2, respectively. Intraoperative complications included one dural tear. Four patients underwent local flap reconstruction and with split-thickness skin grafting, four patients underwent free flap reconstruction. Adjuvant radiotherapy was administered to three patients. Complications comprised partial graft loss in two and complete graft loss in one. There was partial flap loss in one case. One patient required subsequent parotidectomy due to regional progression before achieving disease control. All patients achieved lasting locoregional disease control (average follow-up 29.7 months). CONCLUSION: Craniectomy with soft tissue reconstruction proves to be a safe and effective treatment option in advanced NMSC of the scalp in patients unsuitable for immunotherapy due to frailty or medical co-morbidity.

Cutis verticis gyrata associated with congenital heart disease.

Cutis verticis gyrata (CVG) is a very rare benign disorder characterised by convoluted folds and deep furrows of the scalp that mimic cerebral sulci and gyri. Associations with other pathologies as neuropsychiatric and/or ophthalmologic disorders, secondary cases to inflammatory or neoplastic processes, as well as cases associated to genetic disorders as Turner's syndrome have been reported, but there is no literature describing an association with a congenital structural heart defect and no other underlying condition. We report a case of primary CVG in a 3-week-old female infant associated with an echocardiographic diagnosis of cor triatriatum. Other systemic examination findings and investigations were unremarkable, and the patient has normal neurodevelopment at 1 year old. Aside from the neuropsychiatric and ophthalmologic pathologies commonly associated with primary non-essential CVG, it should be noted that isolated congenital cardiac lesions are also possible, so as to increase our index of suspicion in patients with the disorder.

Evaluation of Surface Structure and Morphological Phenomena of Caucasian Virgin Hair with Atomic Force Microscopy.

Background and Objectives: Atomic force microscopy (AFM) as a type of scanning microscopy (SPM), which has a resolution of fractions of a nanometer on the atomic scale, is widely used in materials science. To date, research using AFM in medicine has focused on neurodegenerative diseases, osteoporosis, cancer tumors, cell receptors, proteins and the DNA mismatch repair (MMR) system. Only a few small studies of hair imaging have been conducted, mostly in biotechnology or cosmetology. Thanks to the possibilities offered by AFM imaging, dermatologists can non-invasively assess the condition of hair and its possible disorders. Our goal was to capture images and microscopically analyze morphological changes in the surface of healthy hair. Materials and Methods: In this study, three to five hairs were collected from each person. Each hair was examined at nine locations (0.5; 1.0; 1.5; 2.0; 3.5; 4.5; 5.5; 6.5 and 7.0 cm from the root). At least 4 images (4-10 images) were taken at each of the 9 locations. A total of 496 photos were taken and analyzed. Metric measurements of hair scales, such as apparent length, width and scale step height, were taken. Results: This publication presents the changes occurring in hair during the natural delamination process. In addition, morphoological changes visualized on the surface of healthy hair (pitting, oval indentations, rod-shaped macro-fibrillar elements, globules, scratches, wavy edge) are presented. A quantitative analysis of the structures found was carried out. Conclusions: The findings of this study can be used in further research and work related to the subject of human hair. They can serve as a reference for research on scalp and hair diseases, as well as hair care.

Transcriptome analysis of frontal fibrosis alopecia revealed involvement of immune cells and ferroptosis.

BACKGROUND: Frontal fibrosis alopecia (FFA) is a primary cicatricial alopecia and has received increasing attention in recent years. However, the pathogenesis of FFA has not been fully elucidated. METHODS AND RESULTS: Herein, we collected the transcriptome data of scalp lesions of seven patients with FFA and seven healthy controls. The differential expression analysis and weighted gene co-expression network analysis were conducted and we identified 458 differentially expressed genes (DEGs) in two key modules. Later, we performed functional enrichment analysis and functional modules identification, revealing the participation of immune response and fatty acid metabolism. Based on the results, we processed further studies. On the one hand, we analyzed the infiltrating immune cells of FFA through CIBERSORT algorithm, indicating the activation of M1 macrophage and CD8+ T cell. On the other hand, considering lipid metabolism of FFA and oxidative stress of hair follicle cells in alopecia, we explored the potential ferroptosis of FFA. By intersection of DEGs and ferroptosis-related genes from FerrDb database, 19 genes were identified and their expression was validated in an external dataset containing 36 FFA cases and 12 controls. Then, we used LASSO algorithms to construct a four-gene diagnostic model, which achieved an AUC of 0.924 in validation dataset. Additionally, the immune cells were found to be related to ferroptosis in FFA. CONCLUSION: Taken together, this study contributed to reveal the molecular mechanisms of FFA and is expected to inspire future research on treatment.

Dermoscopy of Lentiginous Melanomas and Equivocal Benign Pigmented Macules of the Scalp: A Case-Control Multicentric Study.

INTRODUCTION: Although the dermoscopic features of facial lentiginous melanomas (LM), including lentigo maligna and lentigo maligna melanoma, have been extensively studied, the literature about those located on the scalp is scarce. This study aims to describe the dermoscopic features of scalp LM and assess the diagnostic accuracy of dermoscopy to discriminate them from equivocal benign pigmented macules. METHODS: Consecutive cases of scalp LM and histopathology-proven benign but clinically equivocal pigmented macules (actinic keratoses, solar lentigos, seborrhoeic keratoses, and lichen planus-like keratoses) from four referral centres were included. Dermoscopic features were analysed by two blinded experts. The diagnostic performance of a predictive model was assessed. RESULTS: 56 LM and 44 controls were included. Multiple features previously described for facial and extrafacial LM were frequently identified in both groups. Expert's sensitivity to diagnose scalp LM was 76.8% (63.6-87.0) and 78.6% (65.6-88.4), with specificity of 54.5% (38.9-69.6) and 56.8% (41.0-71.7), and fair agreement (kappa coefficient 0.248). The strongest independent predictors of malignancy were (OR, 95% CI) chaos of colour (15.43, 1.48-160.3), pigmented reticular lines (14.96, 1.68-132.9), increased density of vascular network (3.45, 1.09-10.92), and perifollicular grey circles (2.89, 0.96-8.67). The predictive model achieved 85.7% (73.8-93.6) sensitivity, 61.4% (45.5-75.6) specificity, and 81.5 (73.0-90.0) area under curve to discriminate benign and malignant lesions. A diagnostic flowchart was proposed, which should improve the diagnostic performance of dermoscopy. CONCLUSION: Both facial and extrafacial dermoscopic patterns can be identified in scalp LM, with considerable overlap with benign pigmented macules, leading to low specificity and interobserver agreement on dermoscopy.

From cryogenic to on-scalp magnetoencephalography for the evaluation of paediatric epilepsy.

Magnetoencephalography (MEG) is a neurophysiological technique based on the detection of brain magnetic fields. Whole-head MEG systems typically house a few hundred sensors requiring cryogenic cooling in a rigid one-size-fits-all (commonly adult-sized) helmet to keep a thermal insulation space. This leads to an increased brain-to-sensor distance in children, because of their smaller head circumference, and decreased signal-to-noise ratio. MEG allows detection and localization of interictal and ictal epileptiform discharges, and pathological high frequency oscillations, as a part of the presurgical assessment of children with refractory focal epilepsy, where electroencephalography is not contributive. MEG can also map the eloquent cortex before surgical resection. MEG also provides insights into the physiopathology of both generalized and focal epilepsy. On-scalp recordings based on cryogenic-free sensors have demonstrated their use in the field of childhood focal epilepsy and should become a reference technique for diagnosing epilepsy in the paediatric population. WHAT THIS PAPER ADDS: Magnetoencephalography (MEG) contributes to the diagnosis and understanding of paediatric epilepsy. On-scalp MEG recordings demonstrate some advantages over cryogenic MEG.

High-Grade Spindle Cell Sarcoma of the Scalp With an MGA::NUTM1 Gene Fusion in a Pediatric Patient.

ABSTRACT: NUT carcinoma (NC) is a rare and aggressive neoplasm associated with a poor prognosis. NC is characterized by a NUTM1- rearrangement on chromosome 15q14, commonly fused with the BRD4 or BRD3 gene . A rare subset of NC defined by fusion of NUTM1 with the MGA gene has been identified, showing mesenchymal differentiation on histology. Few cases of spindle cell sarcomas harboring MGA::NUTM1 gene fusions have been reported in the literature. We describe a case of spindle cell sarcoma harboring an MGA::NUTM1 fusion in a 6-year-old male patient. In contrast to typical cases of spindle cell carcinomas or NC, NUTM1 fusion-positive sarcomas are associated with a better prognosis. This report highlights the importance of diagnostic workup of undifferentiated neoplasms, as identification of the MGA::NUTM1 fusion in spindle cell sarcoma could be used in treatment algorithms and lead to better outcomes, to the benefit of patients.

Recipient site scalp necrosis: A rare postoperative complication of hair transplantation.

BACKGROUND: Recipient area scalp necrosis is considered a potential complication of hair transplantation, but has rarely been reported. A small number of patients have developed scalp necrosis after hair transplantation with the widely used Follicular unit excision (FUE) technique. There are no guidelines to prevent and manage this complication. The aim of this study was to provide an insight into the pathogenesis, prevention, and management of scalp necrosis following hair transplantation. METHODS: From 2012 to 2021, among more than 10 000 patients who underwent hair transplantation, only three developed scalp necrosis in our clinical experience, besides, one patient transferred to our hospital because of scalp necrosis after undergoing hair transplantation. According to the disease etiology and patients' symptom, a combination of wound management and antimicrobial therapy was employed. This study was approved by the institutional ethics committee of Nanfang Hospital. RESULTS: Of the four patients, three received timely treatment and had a good prognosis. Necrosis became confined and healed within 2-3 weeks. Grafts in the lesion area partially survived. In case 4, due to improper treatment at the early stage, the lesion developed extensively and deeply, which not only delayed wound healing, but also resulted in complete loss of grafts. CONCLUSION: Preoperative prophylaxis, timely diagnosis, and immediate treatment of scalp necrosis can prevent serious complications and reduce morbidity after hair transplantation.

Pleomorphic dermal sarcoma of the scalp - A single-centre experience.

BACKGROUND: Pleomorphic dermal sarcoma (PDS) of the scalp is a rare tumour which is usually slow growing, but occasionally displays rapid growth and has a low rate of local recurrence. Surgical resection is the mainstay of treatment, with or without radiotherapy. The aim of this study is to describe the surgical approach and the additional benefit of radiotherapy to the treatment of these patients. METHODS: Retrospective, single-centre analysis of patients with PDS of the scalp that underwent surgical resection between 2007 and 2021 (n = 24). Treatment variables including depth of resection (superficial or deep to the galea aponeurotica) and adjuvant radiotherapy were investigated. RESULTS: Twenty-four patients were included in this study. Median age was 80 (range, 52-95), with a median ASA score of 3 (2-3). Sixteen (66.6 %) patients underwent surgical resection including the galea, while the rest (n = 8) did not or was not known. Radiotherapy was given in 7 (29 %) patients in which only 3 (12.5 %) were in the galeal resection group. Reasons for radiotherapy administration were concomitant SCC found at the same area of resection and close margins. In a median follow-up of was 26.2 months (range, 13.6-102.5) there was only one recurrence event. CONCLUSIONS: PDS of the scalp can be safely managed with a surgical resection if clear surgical margins are achieved without radiotherapy with good oncological outcomes.

Clinical outcomes of scalp or face angiosarcoma treatment with intensity-modulated radiotherapy: a multicenter study.

Combined modality therapy, including radiotherapy (RT), is a common treatment for scalp or face angiosarcoma. Although intensity-modulated radiotherapy (IMRT) can deliver homogeneous doses to the scalp or face, clinical data are limited. This multicenter study aimed to evaluate scalp or face angiosarcoma treated with definitive or post-operative IMRT. We retrospectively analyzed data from patients who received IMRT for scalp or face angiosarcoma at three institutions between January 2015 and March 2020. Local control (LC) rate, overall survival (OS), progression-free survival (PFS), recurrence patterns and toxicity were evaluated. Fifteen patients underwent IMRT during the study period. Definitive RT was performed on 10 patients and post-operative RT was performed on 5 patients. The 1-year LC rate was 85.7% (95% confidence interval [CI], 53.9-96.2%). The 1-year OS and PFS rates were 66.7% (95% CI, 37.5-84.6%) and 53.3% (95% CI, 26.3%-74.4%), respectively. Univariate analysis revealed that a clinical target volume over 500 cm3 was associated with poor LC. Distant metastasis was the most common recurrence pattern. All patients experienced Grade 2 or 3 radiation dermatitis, and five patients experienced grade ≥ 3 skin ulceration. One patient who underwent maintenance therapy with pazopanib developed Grade 5 skin ulceration. Fisher's exact test showed that post-operative RT was significantly associated with an increased risk of skin ulceration of grade ≥ 3. These results demonstrate that IMRT is a feasible and effective treatment for scalp or face angiosarcoma, although skin ulceration of grade ≥ 3 is a common adverse event in patients who receive post-operative RT.

Pressure alopecias: A review.

Pressure-induced alopecias (PAs) are an infrequent group of scarring and nonscarring alopecias that occur after ischemic obstruction of capillaries that leads to circumscribed areas of hair loss. Initially described after prolonged surgeries or immobilization, type 1 PA occurs after sustained external pressure to the skin, mainly the scalp prominences. Alopecia induced by cosmetic procedures, referred in this review as type 2 PA, is reported with increased frequency in literature and predominantly emerges from pressure exerted by the volume of injectables. It is important to differentiate type 2 PA from vascular occlusion-induced alopecia because they represent distinct entities. Clinically, PA may present with erythema, swelling, and tenderness; however, alopecia might be the sole manifestation. Crusts and ulceration are associated with a worse outcome and a higher risk of scarring alopecia. Prompt diagnosis is paramount to prevent complications. Trichoscopy, although considered nonspecific, may provide relevant clues for an accurate diagnosis. Hair regrows in most cases, but prognosis depends on ischemia severity and timely treatment with reperfusion therapies or mobilization. Treatment of hair loss is usually not necessary because the disease in most cases is self-limited and reversible. The role of topical minoxidil and corticosteroids remains unknown.

Linear Scalp Incision in Brain Tumor Surgery: Intraoperative and Postoperative Considerations.

BACKGROUND: Although the linear scalp incision is commonly used in neurosurgical practice, a systematic study elucidating its pros and cons in a specific surgical setting is lacking. Herein, we analyzed our experience with linear scalp incision in brain tumor surgery and the impact on intraoperative variables and postoperative complications. METHODS: Patients undergoing brain tumor surgery (January 2014-December 2021) at 2 neurosurgical departments were included and divided into 2 groups: linear or flap scalp incision. Patients' demographics characteristics, surgical variables, and wound-related complications were analyzed. RESULTS: More than a total of 1036 craniotomies, linear incision (mean length 6cm) was adopted in 282 procedures (27.2%). Mean maximum diameter of the craniotomy was 5.25 cm, with no statistical difference between the 2 groups. In emergency surgery (36 cases), the linear and flap incisions were used indifferently. Linear incision was predominant in supratentorial and suboccipital lesions. Flap incision was significantly more frequent among meningiomas (P < 0.01). Neuronavigation, operative microscope, and subgaleal drain were more frequently used in the flap scalp incision group (P = 0.01). Overall complication rate was comparable to flap scalp opening (P = 0.40). CONCLUSIONS: The use of the linear incision was broadly applied for the removal of supratentorial and suboccipital tumors granting adequate surgical exposure with a low rate of postoperative complications. Tumors skull base localization resulted the only factor hindering the use of the linear incision. The choice of 1 incision over another didn't show to have any impact on intraoperative and postoperative variables, and it remains mainly based on surgeon expertise/preference.