Surgical Prevention of Arm Lymphedema in Breast Cancer Treatment

Disruption of the axillary nodes and closure of arm lymphatics can explain the significantly high risk of early and late lymphatic complications after axillary dissection, especially the most serious complication that is arm lymphedema which occurs in about 25% (ranging from 13 to 52%) of patients. Sentinel lymph node (SLN) biopsy has reduced the severity of swelling to nearly 6% (from 2 to 7%) and, in case of positive SLN, complete axillary dissection (AD) is still required. That is why ARM method was developed aiming at identifying and preserve lymphatics draining the arm. It consists in injecting intradermally and subcutaneously a small quantity (1-2 ml) of blue dye at the medial surface of the arm which helps in locating the draining arm lymphatic pathways. ARM technique allowed to find variable clinical anatomical conditions from what was already generally known, that is the most common location of arm lymphatics below and around the axillary vein. In about one-third of the cases, blue lymphatics can be found till 3-4 cm below the vein, site where SLN can easily be located, justifying the occurrence of lymphedema after only SLN biopsy. ARM procedure showed that blue nodes were almost always placed at the lateral part of the axilla, under the vein and above the second intercostals brachial nerve. Leaving in place lymph nodes related to arm lymphatic drainage would decrease the risk of arm lymphedema, but not retrieving all nodes, the main risk is to leave metastatic disease in the axilla. Conversely, arm lymphatic pathways when they enter the axilla, cannot be site of breast tumoral disease and their preservation would certainly bring about a significant decrease of lymphedema occurrence rate

Oral Squamous Cell Carcinoma Mimicking Medication-Related Osteonecrosis of the Jaws (MRONJ): A Case Series

Background: Medication-related osteonecrosis of the jaw (MRONJ) is a potential adverse drug reaction of antiresorptive and/or antiangiogenic treatment. MRONJ is mostly diagnosed by anamnestic data, clinical examination and radiological findings, with signs and symptoms often unspecific. On the other hand, oral squamous cell carcinoma (OSCC) is characteristic for its pleomorphic appearance (e.g., ulcer, mucous dehiscence, non-healing post-extractive socket). We report three cases where OSCC mimicked MRONJ lesions. (2) Patients: Three patients undergoing amino-bisphosphonate treatment for osteoporosis presented with areas of intraorally exposed jawbone and unspecific radiological signs compatible with MRONJ. Due to the clinical suspicious of malignant lesion, incisional biopsy for histological examination was also performed. (3) Results: Histological examination of the tissue specimen revealed the presence of OSCC. All patients underwent cancer treatment. (4) Conclusions: Several signs and symptoms of OSCC may simulate, in patients with a history of anti-resorptive, MRONJ; for these reasons, it is important to perform histologic analysis when clinicians are facing a suspicious malignant lesion

Role of the Cadaver Lab in Lymphatic Microsurgery Education:Validation of a New Training Model

Microsurgical transplantation of vascularized lymph nodes (VLNT) or lymphatic vessels (VLVT) alongside derivative lymphaticovenous procedures are promising approaches for treatment of lymphedema. However, clinically relevant training models for mastering these techniques are still lacking. Here we describe a new training model in human cadaver and validate its use as training tool for microsurgical lymphatic reconstruction

A decade of insertable cardiac monitors with remote monitoring in pediatric patients

Background: Remote monitoring-enabled insertable cardiac monitors (ICMs) are useful tools for arrhythmias and symptom management. This study sought to evaluate the outcome of ICM implantation in a large, heterogeneous cohort of pediatric and young adult patients. Methods: Single centre, retrospective analysis of patients who underwent ICM implantation in 2010–2019. Patients were analysed according to age, symptoms, arrhythmias and underlying heart disease. Results: A total of 200 consecutive patients (58% male), aged 11.5 ± 5.8 years at ICM implantation, were included. Follow-up was 31 ± 18 months. Electrophysiologic study (EPS) was initially performed in 123 patients and was negative in 85%. Patients had no heart disease (57.5%), congenital heart defects (21%), channelopathies (14.5%), cardiomyopathies/heart tumors (8%). The commonest symptoms were syncope/presyncope (45.5%) and palpitations (12.5%). A definite diagnosis was made in 63% of patients (positive diagnosis in 25%, negative in 38%) after 8 (2–19) months of monitoring. EPS results and the presence/absence of an arrhythmia before ICM implantation had no impact on the diagnostic yield. Symptomatic patients as well as patients without structural heart disease showed higher diagnostic yield. Patients with a positive diagnosis underwent pacemaker/implantable cardioverter-defibrillator implantation (13%), pharmacological treatment (10.5%), or catheter ablation (1.5%). Conclusions: In a large cohort of 200 children and young adults, ICMs with remote monitoring showed a high diagnostic yield (63%), especially in symptomatic patients and in patients without structural heart disease

Oral lichen planus in children: An Italian case series

Oral lichen planus usually occurs in adults; there are no clear data regarding the incidence and the clinical features of oral lichen planus in children. This paper reports clinical findings, treatments, and outcomes of 13 Italian patients with oral lichen planus in childhood diagnosed between 2001 and 2021. The most common finding was keratotic lesions with reticular or papular/plaque-like patterns, confined to the tongue in seven patients. Although oral lichen planus in childhood is rare and the malignant transformation index is unknown, specialists must be aware of its characteristics and oral mucosal lesions must be correctly diagnosed and managed

MRONJ in breast cancer patients under bone modifying agents for cancer treatment-induced bone loss (CTIBL): a multi-hospital-based case series

BackgroundCancer treatment-induced bone loss (CTIBL) is the most common adverse event experienced by patients affected by breast cancer (BC) patients, without bone metastases. Bone modifying agents (BMAs) therapy is prescribed for the prevention of CTIBL, but it exposes patients to the risk of MRONJ.MethodsThis multicentre hospital-based retrospective study included consecutive non-metastatic BC patients affected by MRONJ related to exposure to low-dose BMAs for CTIBL prevention. Patients' data were retrospectively collected from the clinical charts of seven recruiting Italian centres.ResultsMRONJ lesions were found in fifteen females (mean age 67.5 years), mainly in the mandible (73.3%). The mean duration of BMAs therapy at MRONJ presentation was 34.9 months. The more frequent BMAs was denosumab (53.3%). Ten patients (66.7%) showed the following local risk factors associated to MRONJ development: periodontal disease (PD) in three cases (20%) and the remaining six (40%) have undergone PD-related tooth extractions. One patient presented an implant presence-triggered MRONJ (6.7%). In five patients (33.3%) no local risk factors were observed.ConclusionsThis is the first case series that investigated BC patients under BMAs for CTIBL prevention suffering from MRONJ. These patients seem to have similar probabilities of developing MRONJ as osteo-metabolic ones. Breast cancer patients under BMAs for CTIBL prevention need a regular prevention program for MRONJ, since they may develop bone metastases and be treated with higher doses of BMAs, potentially leading to a high-risk of MRONJ

Pedicled Anterolateral Thigh Flap for Abdominal Wall Reconstruction

Large full thickness abdominal wall defects following malignancies can be a reconstructive challenge. The purpose of this study was to analyze long-term outcomes and complications following abdominal wall reconstruction using composite antero-lateral thigh (ALT) flaps.\nThe study retrospectively investigated 16 consecutive patients who underwent abdominal wall reconstruction with autologous flap between May 2003 and March 2018. Volumetric flap analysis was used to assess flap atrophy over time, evaluating the role of denervation and reinnervation. The long-term outcome was assessed to compare the two groups (free vs. pedicled ALT flap reconstructions).\nAll flaps successfully covered the defects. We found a significant increase in flap resorption in free flaps when compared to pedicled ones. Abdominal bulging was seen in 3 out of 16 (19%) patients after more than 12 months follow-up, in close correlation with mesh absence.\nFree flaps were shown to be equally effective as their pedicled counterparts, without significant increase in complication rate.\nBACKGROUND/AIM\nPATIENTS AND METHODS\nRESULTS\nCONCLUSIO

Real-life effects of dupilumab in patients with severe type 2 asthma, according to atopic trait and presence of chronic rhinosinusitis with nasal polyps

BackgroundThe efficacy of dupilumab as biological treatment of severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) depends on its ability to inhibit the pathophysiologic mechanisms involved in type 2 inflammation.ObjectiveTo assess in a large sample of subjects with severe asthma, the therapeutic impact of dupilumab in real-life, with regard to positive or negative skin prick test (SPT) and CRSwNP presence or absence.MethodsClinical, functional, and laboratory parameters were measured at baseline and 24 weeks after the first dupilumab administration. Moreover, a comparative evaluation was carried out in relation to the presence or absence of SPT positivity and CRSwNP.ResultsAmong the 127 recruited patients with severe asthma, 90 had positive SPT, while 78 reported CRSwNP. Compared with the 6 months preceding the first dupilumab injection, asthma exacerbations decreased from 4.0 (2.0-5.0) to 0.0 (0.0-0.0) (p < 0.0001), as well as the daily prednisone intake fell from 12.50 mg (0.00-25.00) to 0.00 mg (0.00-0.00) (p < 0.0001). In the same period, asthma control test (ACT) score increased from 14 (10-18) to 22 (20-24) (p < 0.0001), and sino-nasal outcome test (SNOT-22) score dropped from 55.84 ± 20.32 to 19.76 ± 12.76 (p < 0.0001). Moreover, we observed relevant increases in forced expiratory volume in one second (FEV1) from the baseline value of 2.13 L (1.62-2.81) to 2.39 L (1.89-3.06) (p < 0.0001). Fractional exhaled nitric oxide (FeNO) values decreased from 27.0 ppb (18.0-37.5) to 13.0 ppb (5.0-20.0) (p < 0.0001). These improvements were quite similar in subgroups of patients characterized by SPT negativity or positivity, and CRSwNP absence or presence. No statistically significant correlations were detected between serum IgE levels, baseline blood eosinophils or FeNO levels and dupilumab-induced changes, with the exception of FEV1 increase, which was shown to be positively correlated with FeNO values (r = 0.3147; p < 0.01).ConclusionOur results consolidate the strategic position of dupilumab in its role as an excellent therapeutic option currently available within the context of modern biological treatments of severe asthma and CRSwNP, frequently driven by type 2 airway inflammation