The Usefulness of Ultrasonography for Supporting the Differentiation, Diagnosis, and Treatment of Atypical Fibroxanthoma and Pleomorphic Dermal Sarcoma.

Atypical fibroxanthoma (AFX) and pleomorphic dermal sarcoma (PDS) are rare histomorphological variants of a disease spectrum. After ruling out other tumor entities by immunohistochemistry, PDS can be differentiated from AFX by infiltration into the subcutis, while AFX remains confined to the dermis. The therapeutic approach is more aggressive in PDS as it can potentially metastasize. We assessed the usefulness of preoperative sonography in differentiating between the two tumor entities by identifying a potential subcutaneous infiltration. In our patients (n = 13), preoperative sonography identified and differentiated AFX and PDS with 100% accuracy and even changed the initial histological suspicion of AFX to PDS in 3 cases (23%), which was confirmed after tumor resection. Preoperative sonography of these tumors could strengthen the clinical diagnosis, avoid a delay in therapy initiation and improve patient counseling. While for AFX, micrographic-controlled surgery suffices, for PDS, resection with 2 cm safety margins and lymph node sonography to rule out lymphonodal involvement is necessary. Hence, ultrasonography can improve clinical practice by providing helpful information for dermatosurgeons, which cannot be obtained during clinical examination.

Pre-operative high-frequency ultrasound: a reliable management tool in auricular and nasal non-melanoma skin cancer.

BACKGROUND AND OBJECTIVES: The knowledge of depth infiltration in non-melanoma skin cancer (NMSC) using pre-operative ultrasound could enable clinicians to choose the most adequate therapeutic approach, avoiding unnecessary surgeries and expensive imaging methods, delaying diagnosis and treatment. Our single-center retrospective study determined the usefulness of high-frequency ultrasound (HFUS) for depth infiltration assessment in auricular and nasal NMSC and assessed the subsequent change in therapeutic approach. PATIENTS AND METHODS: In 60 NMSC cases, we assessed the accuracy of HFUS in cartilaginous/bone infiltration detection as well as the correlation of sonographic and histological parameters. RESULTS: In 16.6% of cases, a deep cartilaginous/bone involvement or locoregional disease was identified pre-operatively, resulting in a changed therapeutical scheme of radio-immunological treatment rather than surgery. In two cases, pre-operative HFUS identified local cartilage infiltration, reducing the number of surgical procedures. Forty-eight remaining lesions with no depth infiltration were excised; a correlation of > 99% between the histologic and sonographic tumor depth (p<0.001) was found. CONCLUSIONS: Pre-surgical HFUS influences the therapeutic management in NMSC by detecting subclinical involvement of deeper structures, avoiding more extensive diagnostics, reducing costs, and improving healthcare quality. High-frequency ultrasound should be implemented in dermatosurgery before tumor excision for optimized therapy and improved patient counseling.

Helically Chiral π-Expanded Azocines Through Regioselective Beckmann Rearrangement and Their Charged States.

We report a synthetic approach to π-expanded [6]helicenes incorporating tropone and azocine units in combination with a 5-membered ring, which exhibit intriguing structural, electronic, and chiroptical properties. The regioselective Beckmann rearrangement allows the isolation of helical scaffolds containing 8-membered lactam, azocine, and amine units. As shown by X-ray crystallographic analysis, the incorporation of tropone or azocine units leads to highly distorted [6]helicene moieties, with distinct packing motifs in the solid state. The compounds exhibit promising optoelectronic properties with considerable photoluminescence quantum yields and tunable emission wavelengths depending on the relative position of the nitrogen center within the polycyclic framework. Separation of the enantiomers by chiral high-performance liquid chromatography (HPLC) allowed characterization of their chiroptical properties by circular dichroism (CD) and circularly polarized luminescence (CPL) spectroscopy. The azocine compounds feature manifold redox chemistry, allowing for the characterization of the corresponding radical anions and cations as well as the dications and dianions, with near-infrared (NIR) absorption bands extending beyond 3000 nm. Detailed theoretical studies provided insights into the aromaticity evolution upon reduction and oxidation, suggesting that the steric strain prevents the azocine unit from undergoing aromatization, while the indene moiety dominates the observed redox chemistry.

Ultrasonographic Assessment of Depth Infiltration in Melanoma and Non-melanoma Skin Cancer.

The preoperative assessment of infiltration depth in melanoma and non-melanoma skin cancer by means of high-frequency ultrasound (≥18 MhZ) is essential for optimizing the therapeutic approach in our patients. Often, histologically confirmed skin tumors are directly referred to surgical departments for resection, and sonography is increasingly helping us identify those subjects who are no longer candidates for extensive surgical interventions. In cases of deep tumor infiltration, with potential surgical failure e.g. impairment of the quality of life and significant esthetic and functional complications, preoperative sonography can guide the surgeon to withstand from an operation and decide instead in favor of less mutilating radiooncological or medical treatment options. Furthermore, in melanoma patients, the preoperative knowledge of the tumor depth is essential for the determination of the therapeutic approach, the correct safety margins and the need of a sentinelnode biopsy. We herein encourage the use of preoperative sonography in dermatologic surgery whenever possible as it represents an easy, painless, "in vivo" method, which provides clinicians with significant clinical information that can influence the therapy and improve patient compliance.

Retrospective Analysis of Complication Rates Associated With Auricular Reconstruction After Skin Cancer Surgery.

BACKGROUND: There is limited data regarding postoperative complications after microtia surgery or tympanoplasty; however, complication rates after pinna reconstruction following tumor resection and comorbidities associated with suboptimal outcomes have not been investigated so far. OBJECTIVE: To examine the incidence of postoperative complications after auricular reconstruction surgery following tumor resection and determine the association between postoperative complications and defect size, patients' comorbidities, and reconstruction type. METHODS AND MATERIALS: In a retrospective case series (n = 146, January 2014 to October 2018), we examined the surgical outcome and amount of postoperative complications following auricular surgery as well as the association with different comorbidities. SPSS 16.0 was used for statistical analyses. RESULTS: The following early postoperative complications were identified: pain (29.5%), hematoma (4.1%), flap congestion (4.8%), infection (3.4%), and flap/graft necrosis (2.7%). Late complications including cartilage step-offs, helical rim sulcus alteration, granulomas, or ear deformities occurred only in 3.6% of subjects. Reconstructions of large defects (>1 cm2) were associated with a higher incidence of early postoperative complications compared to small defects (<1 cm2) (P < .001). Neither the presence of smoking or diabetes nor immunosuppression was significantly linked to an increased incidence of early complications. Immunosuppression, however, was associated with a higher incidence of postoperative infection (P < .001). CONCLUSION: The incidence of early and late postoperative complications after skin tumor resection and external ear reconstruction is low. The occurrence of postoperative infection was not linked with smoking or the presence of diabetes, but strongly associated with a state of immunosuppression, which is why a perioperative antibiotic prophylaxis in immune-compromised patients may be considered.

Topical silver and gold nanoparticles complexed with Cornus mas suppress inflammation in human psoriasis plaques by inhibiting NF-κB activity.

New biomaterials based on nanoparticles (NPs) carrying polyphenols-rich extracts (Cornus mas) recently showed promising anti-inflammatory activity in psoriasis. We aimed to understand how topically delivered silver and gold nanoparticles complexed with Cornus mas (Ag-NPs-CM, Au-NPs-CM) modulate inflammation in psoriasis at cellular and molecular level. The impact on psoriatic inflammation was assessed in vitro on pro-inflammatory macrophages, by clinical score, high-frequency ultrasonography and immunohistology of psoriasis plaques treated with Ag-NPs-CM, Au-NPs-CM or control. Incubation of pro-inflammatory macrophages with nanoparticles significantly decreased the release of NO, IL-12 and TNF-α. Immunofluorescence confirmed that nanoparticles significantly reduced CD68-positive macrophages and their IL-12 and TNF-α production in human psoriasis plaques. NPs-CM appear to repress NF-κB activation in macrophages, inhibiting the production of pro-inflammatory factors with causal role in psoriasis. Ag and Au NPs-CM represent a novel nanoparticle-based "green" technology which may provide an efficient tool for modern psoriasis therapy, circumventing immunosuppression-related side effects of biologicals.

Chirurgische Versorgung von Hautkrebs und Trauma im mittleren Drittel der Ohrmuschel.

Die Hauptursachen erworbener Ohrmuscheldefekte sind chirurgische Behandlung von Hauttumoren und Traumata. Wegen der komplexen Anatomie des Außenohrs ist die chirurgische Rekonstruktion von Defekten in dieser Region für Operateure herausfordernd, insbesondere wenn die mittlere Helix und Anthelix von größeren Weichteil- und Knorpelverlusten betroffen sind. Wir stellen hier die wichtigsten Techniken zur Rekonstruktion großer Defekte der mittleren Helix und Anthelix sowie die Vor- und Nachteile jedes chirurgischen Verfahrens vor. Bei älteren, multimorbiden Patienten werden meist einstufige Verfahren mit primärem Verschluss/Keilexzision angewandt; es können aber auch mehrere komplexe chondrokutane, retroaurikuläre, temporoparietale Vollhautlappen-Verfahren durchgeführt werden, um ein normal aussehendes Ohr zu rekonstruieren. Die aurikuläre Rekonstruktion großer Defekte der mittleren Helix-Anthelix Region erfordert gute Kenntnisse der Ohrmuschel-Anatomie und der verschiedenen chirurgischen Verfahren zur Korrektur solcher Defekte.

Surgical management of skin cancer and trauma involving the middle third of the auricle.

The main causes of acquired auricular defects are surgical treatment of skin tumors and trauma. Due to the complex anatomy of the external ear, surgical reconstruction of defects in this area is challenging for surgeons, especially in case of midhelix-antihelix involvement with significant loss of soft tissue and cartilage. Our purpose is to illustrate the main reconstructive techniques of large midhelix and antihelix defects, as well as the advantages or disadvantages associated with each surgical procedure. Primary closure/wedge technique is mainly used in elderly, multimorbid subjects where single-stage procedures are desirable, but several complex chondrocutaneous, retroauricular, temporoparietal full-thickness flap procedures can also be used to recreate an ear with normal appearance. Auricular reconstruction of large midhelix-antihelix defects requires a good knowledge of auricular anatomy and the various surgical procedures available for such defects.

Dermatochirurgie bei Kindern: Gegenwärtiger Stand zu Indikation, Anästhesie, Analgesie und potentiellen perioperativen Komplikationen.

HINTERGRUND: Anders als Erwachsene benötigen Kinder bei dermatochirurgischen Eingriffen besondere Aufmerksamkeit; die Anwendung verschiedener Analgetika, Anästhetika oder Sedativa erfordert eine gründliche Kenntnis von Pharmakokinetik und -dynamik der Medikamente. Außerdem können Medikamente zur Sedierung/Allgemeinanästhesie bei operierten Kindern zu Anästhesie- oder Analgesie-bedingten Komplikationen einschließlich Störungen der geistigen Entwicklung führen. ZIEL: Auf Basis unserer klinischen Erfahrung und einer Literaturübersicht stellen wir die gängigsten in der pädiatrischen Dermatochirurgie verwendeten Analgetika, Anästhetika und Sedativa dar und diskutieren Risiken und Komplikationen nach dermatochirurgischen Eingriffen. ERGEBNISSE: Topische Anästhetika können bei Kindern für oberflächliche dermatologische Eingriffe oder vor einer Infiltrationsanästhesie eingesetzt werden. Die Berechnung der empfohlenen Maximaldosen auf Basis des Körpergewichts ist erforderlich, um eine Überdosierung von Lokalanästhetika zu vermeiden. Die Allgemeinanästhesie gilt bei der Dermatochirurgie als sicher und hat eine geringe Nebenwirkungsrate. Allerdings ist bei Kindern im ersten Lebensjahr aufgrund potentieller langfristiger neurologischer Nebenwirkungen Vorsicht angebracht. NSAR und Opioide spielen bei der Analgesie von Kindern eine bedeutende Rolle. SCHLUSSFOLGERUNGEN: Dieser Artikel gibt eine Übersicht über die derzeit verfügbaren Daten zu Analgesie, Anästhesie und Komplikationen, die im Rahmen der pädiatrischen Dermatochirurgie auftreten können. Diese Daten können dabei helfen, die Sicherheit und Qualität der Versorgung zu optimieren und die Beratung der Eltern zu verbessern.

Dermatologic surgery in children: an update on indication, anesthesia, analgesia and potential perioperative complications.

BACKGROUND: Children undergoing dermatosurgical procedures require, unlike adults, particular attention; the administration of various analgesics, anesthetics or sedatives requires a thorough knowledge of drug pharmacokinetics and pharmacodynamics. Furthermore, there are concerns that drugs used for sedation/general anesthesia may result in anesthetic/analgesic complications in children undergoing surgery, with a risk of impaired mental development. OBJECTIVES: Based on our clinical experience and a literature review, we illustrate the most commonly used analgesic, anesthetic and sedative drugs in pediatric dermatosurgery, and identify risk factors and complications following dermatosurgical procedures. RESULTS: Topical anesthetics can be used in children for superficial dermatologic procedures or prior to infiltration anesthesia. Maximum recommended doses based on body weight should be calculated in order to avoid overdosage of local anesthetics. General anesthesia in dermatosurgery is considered safe and has a low rate of side effects. However, caution is advised in children under the age of one due to potential long-term neurological side-effects. NSAIDs and opioids play a significant role in analgesia for children. CONCLUSIONS: This article reviews currently available data on analgesia, anesthesia and complications that may arise in pediatric dermatosurgery. These data may be useful in optimizing the safety and quality of care and in improving parent counseling.

UVA-1 exposure in vivo leads to an IL-6 surge within the skin.

UVA-1 is a known promotor of skin ageing. Cytokines like IL-1α, Il-1ß or TNF-α, VEGF and IL-6 orchestrate UV effects, and IL-6 is furthermore an effector of UVA-induced photoageing. We investigated how fractionated UVA-1 doses influence the cytokine milieu and especially the IL-6 levels in the skin in vivo. In a study with 35 participants, we exposed previously unirradiated human skin to three UVA-1 irradiation regimes. Cytokine levels in interstitial skin fluid were measured up to 48 hours postexposure and compared to unirradiated control skin fluid. Our results show that IL-6 levels increased significantly after UVA-1 exposure at selected time points. The other candidates IL-1α, Il-1ß or TNF-α and VEGF show no significant response after UVA-1 exposure in vivo. UVA-1 thus raises selectively IL-6 levels in vivo, a fact that underlines its role in photoageing and has potential implications for its modulatory effect on photoageing pathology.

Self-detection frequency and recognition patterns in medium to high-risk cutaneous melanoma patients.

BACKGROUND AND OBJECTIVES: The question of how frequently patients with medium to high-risk melanomas become aware of their tumors and which self-detection patterns exist remains unanswered. PATIENTS AND METHODS: We conducted a retrospective survey of melanoma patients who had undergone sentinel node biopsy between 2004 and 2008. One hundred twenty-seven out of a total of 133 patients completed the questionnaire. RESULTS: Twenty-five percent of patients had not noticed their tumors at all. The remaining 75 % showed three different self-detection patterns, with 25 % of individuals seeking medical advice within 0-12 weeks and another 25 % within 3-6 months. The remaining 25 % had waited for more than six months prior to tumor excision. Age, gender, and melanoma location were comparable in all self-detection subgroups. The most frequent subtypes were: SSM (59), NMM (31), ALM (9), UCM (9) and LMM (4). Rare subtypes occurred in 15 individuals. Patients with lesions previously noticed for 3-6 months revealed the highest average tumor thickness and the significantly highest number of pT4 tumors. Sixty percent of NMM patients had a disease history < 6 months. Rare subtypes such as amelanotic, spindle cell, or spitzoid melanoma were self-detected in only 50 % of cases. CONCLUSIONS: Even advanced melanoma lesions remained undetected in 25 % of patients; rare melanoma subtypes, in 50 % of cases. Thus, self-examination frequency, increased awareness of rare melanoma subtypes, and rapid referral to a specialist ought to be at the center of future awareness campaigns.

Häufigkeit und Muster der Tumorerkennung nach Selbstuntersuchung bei Mittel- bis Hochrisiko-Melanompatienten.

HINTERGRUND UND ZIELSETZUNG: Die Frage, wie oft Melanompatienten mit Mittel- bis Hochrisikomelanomen den Tumor bemerken und welche Eigenerkennungsmuster existieren ist bislang nicht beantwortet. PATIENTEN UND METHODEN: Wir haben eine retrospektive Studie an Melanompatienten durchgeführt, die sich zwischen 2004 und 2008 einer Sentinellymphknotenbiopsie unterzogen haben,. Der Fragebogen wurde von 127 der insgesamt 133 Patienten ausgefüllt. ERGEBNISSE: 25 % bemerkten den Tumor überhaupt nicht. Die restlichen 75 % zeigten verschiedene Eigenerkennungsmuster: 25 % holten nach 0-12 Wochen Rat ein, weitere 25 % innerhalb von 3-6 Monaten, und bei den restlichen 25 % wurde der Tumor mehr als sechs Monate lang beobachtet, bevor er entfernt wurde. Alter, Geschlecht und Lokalisation des Melanoms waren bei allen Eigenerkennungsgruppen vergleichbar. Die häufigsten Subtypen waren: SSM (59), NMM (31), ALM (9), UCM (9) und LMM (4). Seltene Subtypen (15) waren ebenfalls vorhanden. Patienten mit 3-6 Monate alten Läsionen zeigten die höchste durchschnittliche Tumordicke und die bei weitem höchste Anzahl von pT4-Tumoren. 60 % der Patienten mit NMM hatten eine Krankengeschichte von <6 Monaten. Seltene Subtypen wie amelanotische, Spindelzell- und spitzoide Melanome wurden in nur 50 % der Fälle selbstständig erkannt. SCHLUSSFOLGERUNGEN: Selbst fortgeschrittene Melanome blieben von den Patienten in 25 %, seltene Melanom-Subtypen in 50 % der Fälle unerkannt. Daher sollte der Eigenerkennungshäufigkeit, dem erhöhten Bewusstsein für seltene Melanome und der schnellen Überweisung an einen Spezialisten in zukünftigen Aufklärungskampagnen besondere Aufmerksamkeit zukommen.

Chirurgische Behandlung von Melanomen in der Schwangerschaft: eine praktische Anleitung.

Als ein Tumor, der primär eine chirurgische Behandlung erfordert, ist ein neu diagnostiziertes oder vorbestehendes Melanom in der Schwangerschaft eine klinische Rarität. In solchen Fällen steht der Chirurg vor der Herausforderung, ein geeignetes therapeutisches Vorgehen festlegen zu müssen. Auf der Grundlage unserer klinischen Erfahrung und einer Übersicht über die Literatur geben wir in der vorliegenden Arbeit eine Anleitung für das praktische Vorgehen bei dieser seltenen klinischen Konstellation. Unserer Erfahrung nach müssen schwangere Melanom-Patientinnen im Hinblick auf ihre therapeutischen Optionen ausführlich beraten werden. Naturgemäß setzen sie ihr ungeborenes Kind an die erste Stelle und zögern, der erforderlichen Operation zuzustimmen, obwohl bei ihnen eine möglicherweise lebensbedrohliche Erkrankung diagnostiziert worden ist. Daher ist es entscheidend, diese Patientinnen klar darüber zu informieren, dass, wie die vorliegenden medizinischen Erfahrungen zeigen, eine Schwangerschaft per se kein Grund ist, eine notwendige Melanom-Operation aufzuschieben. Jedoch müssen bei einigen Parametern wie den präoperativen Bildgebungsverfahren, der Positionierung auf dem Operationstisch, der Überwachung, Anästhesie und der perioperativen Medikation bestimmte Anpassungen vorgenommen werden, um der speziellen Situation Rechnung zu tragen.

Surgical treatment of melanoma in pregnancy: a practical guideline.

A tumor primarily requiring surgical treatment, newly diagnosed or preexisting melanoma during pregnancy is a clinical rarity. In such cases, the surgeon faces the challenge of having to decide on the appropriate therapeutic course of action. Based on our clinical experience and a review of the literature, we herein provide a guideline on how to practically deal with this rare clinical conundrum. In our experience, pregnant melanoma patients require thorough counseling with respect to their therapeutic options. They naturally tend to put their unborn child first, and are hesitant to consent to necessary surgery despite a potentially life-threatening diagnosis. It is therefore crucial to clearly inform these patients that - based on existing medical experience - pregnancy by itself is no reason to hold off on any type of necessary melanoma surgery. However, various parameters such as preoperative imaging procedures, positioning on the operating table, monitoring, anesthesia, and perioperative medication require certain adjustments in order to comply with this special situation.