Ανατομικές παραλλαγές της αγγείωσης της δερματικής νησίδας του μυοδερματικού κρημνού του προσθίου οδοντωτού μυός. Η κλινική τους σημασία για τον σχεδιασμό και την παρασκευή του κρημνού

Ο πρόσθιος οδοντωτός είναι ένας λεπτός και πλατύς μυς στο πλάγιο θωρακικό τοίχωμα που καλύπτει τις ανώτερες 8 με 9 πλευρές. O μυϊκός κρημνός του SAM σχηματίζεται από τις κατώτερες 4 με 5 μυϊκές δεσμίδες-οδοντώματά του και λαμβάνει αιμάτωση από κλάδο της θωρακοραχιαίας αρτηρίας. Η αιμάτωση της δερματικής νησίδας στους μυοδερματικούς κρημνούς κατά κανόνα εξασφαλίζεται από μυϊκές διατιτρώσες αρτηρίες. Το παραπάνω δε φαινόταν να ισχύει για τον SAM του οποίου το υπερκείμενο δέρμα τροφοδοτείται κυρίως από μεσοπλεύριες διατιτρώσες αρτηρίες και για το λόγο αυτό ο μυοδερματικός κρημνός του SAM δεν έτυχε ευρείας αποδοχής. Μετά από ενδελεχή ανασκόπηση της βιβλιογραφίας, ανευρέθησαν ανατομικές μελέτες της αιμάτωσης της δερματικής νησίδας του SAM που αφορούν στο διάστημα από το 1982 έως το 2019. Από την ανάλυση των δεδομένων τους διαπιστώθηκαν τα παρακάτω. Η κύρια παροχή αιμάτωσης στη δερματική νησίδα του μυοδερματικού κρημνού του SAM εξασφαλίζεται από ενδομυϊκές αναστομώσεις τύπου choke vessels μεταξύ των μεσοπλεύριων διατιτρωσών αρτηριών και του αγγειακού άξονα του SAM. Για το λόγο αυτό και θεωρείται δόκιμη η προετοιμασία του κρημνού με την τεχνική delay. Στην αιμάτωση της δερματικής νησίδας συμβάλλουν επίσης αληθείς ενδομυϊκές αγγειακές αναστομώσεις μεταξύ των μεσοπλεύριων διατιτρωσών αρτηριών και του αγγειακού άξονα του SAM, όπως και δερματικές διατιτρώσες απευθείας από τον αγγειακό άξονα του SAM αλλά σε μικρότερο ποσοστό περιστατικών (περί το 25%) Ένας μυοδερματικός κρημνός του SAM είναι εφικτός και μπορεί να χρησιμοποιηθεί για την επανόρθωση ελλειμμάτων σε πολλές περιοχές του σώματος προσφέροντας συγκριτικά πλεονεκτήματα έναντι άλλων μυοδερματικών κρημνών.Although appealing from a reconstructive standpoint, the incorporation of the overlying skin in a serratus anterior muscle flap has not yet seen widespread use, due to considerations with its blood supply. In the present study, a systematic review of the literature has been performed, evaluating studies that investigated the vascular anatomy and variations of serratus anterior myocutaneous flap. The anatomy of the cutaneous blood supply, the size of the cutaneous territory, the design of the skin paddle and the reconstructive goals were analyzed. The results showed that the main blood supply originates from the intramuscular anastomoses between intercostal artery perforators and the serratus artery branch in the form of choke vessels. Complementary perfusion from true intramuscular vessel anastomoses or from direct serratus artery cutaneous perforators could contribute to the skin blood supply but only in 25% of the cases. The design of the flap is elliptical with its long axis over the harvested muscle slips and maximum width is approximately 6-8 cm. Α myocutaneous serratus anterior flap could be applied in a variety of reconstructive fields, most commonly for head and neck defects. A delay procedure would considerably enhance the perfusion of the cutaneous component and improve the overall viability of the flap

Ramucirumab plus docetaxel versus placebo plus docetaxel in patients with locally advanced or metastatic urothelial carcinoma after platinum-based therapy (RANGE): a randomised, double-blind, phase 3 trial

Few treatments with a distinct mechanism of action are available for patients with platinum-refractory advanced or metastatic urothelial carcinoma. We assessed the efficacy and safety of treatment with docetaxel plus either ramucirumab-a human IgG1 VEGFR-2 antagonist-or placebo in this patient population

Cutaneous metastasis of transitional cell bladder carcinoma: A rare presentation and literature review

Cutaneous metastasis from transitional cell bladder carcinoma is a rare clinical entity associated with poor prognosis. We present a case of cutaneous metastasis arising from a transitional cell bladder carcinoma in a male patient who had undergone a radical cystectomy and bilateral ureterostomy 17 months previously. The cutaneous metastasis became evident 3 months before the manifestations of generalized recurrent disease. An awareness of this rare clinical entity and high index of suspicion is needed to rule out metastatic spread in patients with a previous history of transitional cell bladder carcinoma presenting with cutaneous nodules. Definitive diagnosis requires a histological confirmation, but prognosis is generally poor

Ramucirumab plus docetaxel versus placebo plus docetaxel in patients with locally advanced or metastatic urothelial carcinoma after platinum-based therapy (RANGE): overall survival and updated results of a randomised, double-blind, phase 3 trial

Background: Ramucirumab—an IgG1 vascular endothelial growth factor receptor 2 antagonist—plus docetaxel was previously reported to improve progression-free survival in platinum-refractory, advanced urothelial carcinoma. Here, we report the secondary endpoint of overall survival results for the RANGE trial. Methods: We did a randomised, double-blind, phase 3 trial in patients with advanced or metastatic urothelial carcinoma who progressed during or after platinum-based chemotherapy. Patients were enrolled from 124 investigative sites (hospitals, clinics, and academic centres) in 23 countries. Previous treatment with one immune checkpoint inhibitor was permitted. Patients were randomly assigned (1:1) using an interactive web response system to receive intravenous ramucirumab 10 mg/kg or placebo 10 mg/kg volume equivalent followed by intravenous docetaxel 75 mg/m2 (60 mg/m2 in Korea, Taiwan, and Japan) on day 1 of a 21-day cycle. Treatment continued until disease progression, unacceptable toxicity, or other discontinuation criteria were met. Randomisation was stratified by geographical region, Eastern Cooperative Oncology Group performance status at baseline, and visceral metastasis. Progression-free survival (the primary endpoint) and overall survival (a key secondary endpoint) were assessed in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT02426125; patient enrolment is complete and the last patient on treatment is being followed up for safety issues. Findings: Between July 20, 2015, and April 4, 2017, 530 patients were randomly allocated to ramucirumab plus docetaxel (n=263) or placebo plus docetaxel (n=267) and comprised the intention-to-treat population. At database lock (March 21, 2018) for the final overall survival analysis, median follow-up was 7·4 months (IQR 3·5–13·9). In our sensitivity analysis of investigator-assessed progression-free survival at the overall survival database lock, median progression-free survival remained significantly improved with ramucirumab compared with placebo (4·1 months [95% CI 3·3–4·8] vs 2·8 months [2·6–2·9]; HR 0·696 [95% CI 0·573–0·845]; p=0·0002). Median overall survival was 9·4 months (95% CI 7·9–11·4) in the ramucirumab group versus 7·9 months (7·0–9·3) in the placebo group (stratified HR 0·887 [95% CI 0·724–1·086]; p=0·25). Grade 3 or worse treatment-related treatment-emergent adverse events in 5% or more of patients and with an incidence more than 2% higher with ramucirumab than with placebo were febrile neutropenia (24 [9%] of 258 patients in the ramucirumab group vs 16 [6%] of 265 patients in the placebo group) and neutropenia (17 [7%] of 258 vs six [2%] of 265). Serious adverse events were similar between groups (112 [43%] of 258 patients in the ramucirumab group vs 107 [40%] of 265 patients in the placebo group). Adverse events related to study treatment and leading to death occurred in eight (3%) patients in the ramucirumab group versus five (2%) patients in the placebo group. Interpretation: Additional follow-up supports that ramucirumab plus docetaxel significantly improves progression-free survival, without a significant improvement in overall survival, for patients with platinum-refractory advanced urothelial carcinoma. Clinically meaningful benefit might be restricted in an unselected population. Funding: Eli Lilly and Company