An uncommon presentation of a cutaneous angiosarcoma.

Cutaneous angiosarcoma (cAS) is a rare and aggressive malignant vascular tumor, which mostly occurs in the head and neck region. The outcome of cAS is poor and timely diagnosis is paramount, but often delayed because of the slow onset and the variance in presentation. This paper reports on a case of an 88-year old woman who presented with a persisting "hematoma" in the left retro-auricular region. Although considered at initial differential diagnosis, no signs of malignancy were identified in histopathology and imaging in the diagnostic work-up. At first, short-term follow-up showed no progression of the lesion. But 3 months after the first presentation additional biopsies were taken, because of rapid expansion of the lesion. The initial histopathological findings were most consistent with a benign vascular lesion, with signs of hemorrhage and reactive inflammation. However, the additional immunohistochemical analysis showed the presence of MYC oncoprotein, which confirmed the clinical suspicion of angiosarcoma. Because size and location of the lesion rendered complete resection unattainable, radiotherapy was commenced, but no significant volume reduction could be achieved. Therefore, palliative irradiation was initiated. The patient passed away 1 month later. Clinical diagnosis is often difficult and little is known about imaging of cAS. Histology and immunohistochemistry can be misleading, as cAS are easily mistaken for other lesions. Most studies report that multimodality treatment with surgery and radiotherapy is preferable, but this can be challenging in the head & neck region.

Surgical management of the neck in patients with metastatic melanoma in parotid lymph nodes.

BACKGROUND: The role and extent of neck dissection in patients with parotid metastatic cutaneous head and neck melanoma remain unclear. The aims of this study were to determine the incidence and patterns of cervical node involvement in patients with parotid metastatic melanoma, and to determine if a limited lymphadenectomy of the clinically negative neck is appropriate. METHODS: Patients who underwent parotidectomy and neck dissection for clinically apparent parotid metastatic melanoma, irrespective of neck status, were identified from two prospectively maintained databases. RESULTS: A total of 276 patients fulfilled the study criteria. Median follow-up was 23 months. A total of 185 necks were clinically negative, 82 were clinically positive. A total of 36 elective neck-dissection specimens harbored occult metastases; these were found in levels I (16.7%), II (58.3%), III (36.1%), IV (13.9%), and V (30.6%). Regional recurrence occurred in 32 patients with a clinically negative neck, the majority being in-transit metastases (n = 15). Only one case of recurrence could have potentially been avoided by a comprehensive lymphadenectomy. CONCLUSIONS: In patients with clinically apparent parotid melanoma metastases, elective comprehensive neck dissection reduces failure rates in cervical nodes, and provides more accurate staging and prognostic information. However, our findings support the emerging trend for more limited elective neck dissection. Levels I and IV can probably be safely omitted.

Reconstruction of defects of the trachea.

The trachea has a complex anatomy to fulfill its tasks. Its unique fibro-cartilaginous structure maintains an open conduit during respiration, and provides vertical elasticity for deglutition, mobility of the neck and speech. Blood vessels pierce the intercartilaginous ligaments to perfuse the ciliated epithelium, which ensures effective mucociliary clearance. Removal of a tracheal segment affected by benign or malignant disease requires airtight restoration of the continuity of the tube. When direct approximation of both tracheal ends is no longer feasible, a reconstruction is needed. This may occur in recurrent short-segment defects in a scarred environment, or in defects comprising more than half the length of the trachea. The resulting gap must be filled with vascularized tissue that restores the mucosal lining and supports the semi-rigid, semi-flexible framework of the trachea. For long-segment or circular defects, restoration of this unique biomechanical profile becomes even more important. Due to the inherent difficulty of creating such a tube, a tracheostomy or palliative stenting are often preferred over permanent reconstruction. To significantly improve and sustain quality of life of these patients, surgeons proposed innovative strategies for complex tracheal repair. In this review, we provide an overview of current clinical applications of tracheal repair using autologous and allogenic tissues. We look at recent advances in the field of tissue engineering, and the areas for improvement of these first human applications. Lastly, we highlight the focus of our research, in an effort to contribute to the development of optimized tracheal reconstructive techniques.

Tracheal tissue-engineering: in-vivo biocompatibility of mechanically-stripped allogenic rabbit trachea with autologous epithelial covering.

BACKGROUND: Successful trachea transplantation comprises the use of biocompatible constructs with little immune-reactivity, submucosal revascularization and creation of an epithelial covering. Allogenic chondrocytes might be protected from an overt immune-response due to physical isolation. Our aim was to evaluate in-vivo biocompatibility of allotracheae, stripped of their highly-immunogenic inner lining. Secondly, we established whether these constructs might serve as suitable scaffolds for autologous epithelial grafting. METHODS: Mucosa and submucosa of 12 rabbit donor tracheae were mechanically peeled off. Cartilage was covered with Integra™ regeneration-template. Constructs were implanted within the recipient's lateral thoracic artery flap. Integra of 6 revascularized allotracheae was grafted with autologous buccal mucosa. Macroscopical, histological analysis and immunohistochemistry were performed. RESULTS: Revascularization and buccal grafting was incomplete in the first 2 circular constructs. To enhance blood-vessel outgrowth, the following 10 transplants were opened longitudinally before implantation. Integra revascularized well. Grafted tracheae showed satisfactory mucosa-adherence, albeit with invasion of migrating epithelium within the Integra-scaffold. CONCLUSIONS: Mechanically-stripped allotracheae exhibited beneficial biocompatibility up to two months. This approach might open doors in the treatment of long-segment tracheal pathologies of which immunosuppression is contra-indicated. Thickness of this layered construct limited practical feasibility of orthotopic transfer, though with further refinements, a clinically-useful transplant could be created.

Immediate debridement of road rash injuries with Versajet® hydrosurgery: traumatic tattoo prevention?

UNLABELLED: Traumatic tattoos can result from accidental deposition of foreign particles in the dermis. These pigmented particles become permanently lodged in the dermis after re-epithelialization of the wound and can give rise to irregular black or blue discoloration of the skin. Different methods for tattoo removal exist. The best strategy is to prevent traumatic tattooing by immediate removal of the foreign bodies before the healing process has begun. We present a fine-tuned debridement method to selectively debride the wound and preserve as much viable tissue as possible. LEVEL OF EVIDENCE V: 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 .

Artiss® and burn treatment: a retrospective analysis contributing to current clinical practice.

BACKGROUND: Tangential excision and autologous skin graft coverage is a foundational principle in burn surgery. Fibrin sealant (Artiss®) was developed recently as alternative to staples for graft fixation. The aim of this study was to assess whether graft-fixation with Artiss shows profit in terms of postoperative pain management compared to graft fixation with staples. METHODS: A retrospective single-center, single-surgeon frequency-matched cohort study was completed on 83 patients with thermal injury burns covering 1%-25% of total body surface area, requiring early excision and immediate coverage with split-thickness skin grafts. Grafts were fixated with Artiss only or staples only. Primary outcome parameters include complication rates (graft loss, need for regrafting and wound contamination), the requirement of pain medication for postoperative pain and the need for narcosis for postoperative procedures. RESULTS: Graft-fixation with Artiss resulted in a decrease in administration of analgesics (P=0.005) and anesthetics (P=0.007) postoperatively. No statistically significant difference was found in complication rates (P=0.999) between both groups. CONCLUSION: Fibrin sealant proved to be a safe and effective alternative to staples for graft fixation. It showed profit in short-term burn outcomes, reducing the need for analgesics and anesthetics postoperatively.

Requirements for Successful Trachea Transplantation: A Study in the Rabbit Model.

BACKGROUND: Although creating a tracheal tube de novo might appear straightforward, the first clinical applications have shown that reconstruction of long-segment tracheal defects remains challenging. In this study, the authors aimed to refine the baseline requirements of successful trachea transplantation by means of three proof-of-concept models in the rabbit. METHODS: In each model, one characteristic of a perfect tracheal transplant was eliminated. The first model was developed to map out the immunologic response of vascularized allogenic trachea, transplanted without immunosuppression (n = 6). The second model studied (1) the need for wrapping the transplant with a highly vascularized flap and (2) the source of angiogenesis after autologous trachea transplantation (n = 18). In the third model, the authors examined the importance of an inner epithelial covering (n = 12). All models were compared to a control group of heterotopically transplanted vascularized autologous tracheae (n = 6). RESULTS: Embedded in an avascular matrix, allogenic chondrocytes were protected from an overt immune response. Orthotopic transplantation without additional external vascular wrap was successful in a well-vascularized environment. Nonetheless, an external vascular source was essential to maintain viability of the construct. Epithelial covering was necessary to prevent secondary healing. Epithelial migration from the anastomoses or graft was not sufficient to cover long-segment defects. CONCLUSIONS: These experiments provided ample evidence of the importance of baseline requirements when designing a tracheal transplant study. This study confirmed that different tracheal cell types possess different immunologic sensitivities. External revascularization, preferably in a two-stage procedure, and fast reepithelialization were both paramount to successful transplantation.

Epithelial grafting of a decellularized whole-tracheal segment: an in vivo experimental model.

OBJECTIVES: Prerequisites for successful trachea transplantation include the use of a biocompatible construct, submucosal vascularization and an epithelial covering. Implantation of non-epithelialized tracheal scaffolds may lead to stenosis. However, epithelial grafting or seeding can only be attempted onto a well-vascularized submucosal bed. Our aim was to investigate a method to prevent stenosis during prelamination of non-epithelialized, gently decellularized rabbit tracheae and to evaluate whether grafting of revascularized constructs with buccal mucosa is feasible. METHODS: Allotracheae underwent two 48-h cycles of detergent-enzymatic decellularization using sodium deoxycholate and DNAse. In the first series, 12 circular scaffolds were implanted bilaterally in lateral thoracic artery flaps (n = 6 rabbits). Right-sided transplants were covered internally with Integra™. In the second series, 10 decellularized tracheae covered with Integra were prelaminated in flaps (n = 10 rabbits). Twenty-one days after implantation, revascularized tracheae were grafted with buccal mucosa. A macroscopic, histological analysis and immunohistochemistry were performed on explants. RESULTS: In the first series, tracheae without Integra covering developed significantly greater intraluminal (P = 0.032) and subepithelial narrowing (P = 0.0345) compared with tracheae with Integra covering. All tracheae exhibited insufficient submucosal revascularization. In the second series, submucosal revascularization was incomplete in the first 2 constructs, which were implanted circularly. These tracheae only showed marginal buccal graft ingrowth. To accelerate revascularization, the subsequent 8 transplants were opened longitudinally before implantation. Compared to circularly implanted tracheae, submucosal revascularization of these transplants was superior (P = 0.0008). Graft adherence was complete in 6 opened constructs. Mild lymphocytic infiltration within the buccal graft was detected in 5 specimens. CONCLUSIONS: We observed satisfactory host integration of opened tracheae that were temporarily covered with Integra during revascularization and subsequently grafted with buccal mucosa. Integra successfully prevented stenosis during revascularization. This model may provide an example of an immunosuppressive-free approach in the treatment of long-segment tracheal lesions. With the aid of further refinements such as a respiratory epithelial lining, an orthotopically transplantable construct could be created.

A comparison of tracheal scaffold strategies for pediatric transplantation in a rabbit model.

OBJECTIVES/HYPOTHESIS: Despite surgical advances, childhood tracheal stenosis is associated with high morbidity and mortality. Various tracheal scaffold strategies have been developed as the basis for bioengineered substitutes, but there is no consensus on which may be superior in vivo. We hypothesized that there would be no difference in morbidity and mortality between three competing scaffold strategies in rabbits. STUDY DESIGN: Pilot preclinical study. METHODS: Tracheal scaffolds were prepared by three methods that have been applied clinically and reported: preserved cadaveric ("Herberhold") allografts, detergent-enzymatically decellularized allografts, and synthetic scaffolds (nanocomposite polymer [polyhedral oligomeric silsesquioxane poly(carbonate-urea) urethane (POSS-PCU)]). Scaffolds were implanted into cervical trachea of New Zealand White rabbits (n = 4 per group) without cell seeding. Control animals (n = 4) received autotransplanted tracheal segments using the same technique. Animals underwent bronchoscopic monitoring of the grafts for 30 days. Macroscopic evaluation of tissue integration, graft stenosis, and collapsibility and histological examinations were performed on explants at termination. RESULTS: All surgical controls survived to termination without airway compromise. Mild to moderate anastomotic stenosis from granulation tissue was detected, but there was evidence suggestive of vascular reconnection with minimal fibrous encapsulation. In contrast, three of the four animals in the Herberhold and POSS-PCU groups, and all animals receiving decellularized allografts, required early termination due to respiratory distress. Herberhold grafts showed intense inflammatory reactions, anastomotic stenoses, and mucus plugging. Synthetic graft integration and vascularization were poor, whereas decellularized grafts demonstrated malacia and collapse but had features suggestive of vascular connection or revascularization. CONCLUSIONS: There are mirror-image benefits and drawbacks to nonrecellularized, decellularized, and synthetic grafts, such that none emerged as the preferred option. Results from prevascularized and/or cell-seeded grafts (as applied clinically) may elucidate clearer advantages of one scaffold type over another. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:E449-E457, 2017.