Lymphangiosis Carcinomatosa in a Patient with Giant Cutaneous SCC: Cervicopectoral Advancement Flap in Combination with Tunnel Transposition Flap from the Back as Promising Treatment Approach?

BACKGROUND: One of the features characterising cutaneous SCC as high-risk is lymphovascular infiltration. The diffuse lymphangitic spread of carcinogenic cells is defined as the so-called lymphangitis carcinomatosa. In some cases, it is the only and first sign to alert the presence of an underlying malignancy. Therefore, biopsy in patients with clinical data on lymphangiosis carcinomatosa is of paramount importance. CASE REPORT: We present a 77-year-old man with a progressively growing tumour formation in the area of the right shoulder, clinically suspected for SCC. During the dermatological examination, it was found that the lesion was surrounded by an infiltrated, perilesional relief shaft, which was histologically verified as lymphangitis carcinomatosa. The tumour formation was removed by radical excision and formation of a large skin-subcutaneous defect. To correct the surgical defect, a cervico-pectoral flap was performed, followed by tunnel transposition of the scapular graft through the deltoid muscle. The preoperative, ultrasound-marked artery was the arteria circumflexa scapulae dextra, which was used as the foot of the scapular graft and at the same time ensuring its blood supply. After the performed surgical flaps there remains a small uncovered surgical defect, which was left for subsequent secondary healing or full thickness mesh graft. The subsequent histological examination of the removed tumour formation detected the presence of squamous cell carcinoma. CONCLUSION: Patients with the simultaneous presence of two different pathological cutaneous changes, located in the immediate proximity often require a multidisciplinary and complex treatment approach. For tumour formations close to the area of the neck, the cervical-pectoral flap provides optimal cosmetic recovery of the surgical defect. The tunnel transposition is an individualised, unconventional and difficult to implement the approach, which however showed a good therapeutic result. On the other hand, the preoperative histological examination of reddish peritumoral localised tentacles leads to 1) diagnosis of lymphangiosis carcinomatosa as well as 2) the subsequent precise determination of the limits of surgical excision, which is a large number of cases saves the need for secondary re-excision in these patients

Locally Advanced Basal Cell Carcinoma with Intraocular Invasion

We present a 103 - year - old patient, with duration of complaints of about ten years. The initial complaint had been presented as a small nodule, located on the eyebrow, which subsequently ulcerated and encompassed larger regions of the upper and lower eyelids. For the past three years, the patient also had complaints of a worsening of his vision, without seeking for medical help. Within the dermatological examination, an intraocular and periocular localised tumour was established, characterised by a raised peripheral edge and central ulceration. More careful examination revealed that the bulb was fully consumed. The patient refused further diagnosis and treatment. Advanced basal cell carcinomas with intraocular invasion are rare in general. If the patient refuses surgery, radiotherapy and systemic therapy with modern medications such as Vismodegib or Sonidegib are available as treatment options

Medium Sized Congenital Melanocytic Nevus with Suspected Progression to Melanoma during Pregnancy: What’s the Best for the Patient?

BACKGROUND: Congenital melanocytic nevi (CMN) are pigmented skin lesions usually present at birth. Rare varieties can develop and become clinically very large. Although they are benign nevomelanocytic neoplasms, all CMN may be precursors of the melanoma, regardless of their size. Individual risk of malignant transformation of melanocyte is determined by simultaneous action of exogenous and endogenous factors. The major exogenous risk factor is ultraviolet radiation. Leading roles among the endogenous factors are attributed to skin phenotype, gene mutation, sex hormones and their significance.CASE REPORT: We present a case of a 27 – year - old pregnant female patient with a congenital melanocytic nevus, which increased significantly in size, during her pregnancy. Estrogen levels increase during pregnancy and clinical evidence has suggested that melanocytes are estrogen - responsive. Nevi in a pregnant patient would exhibit increased expression of estrogen receptor β (ERβ) and thus enhanced the potential to respond to altered estrogen levels.CONCLUSION: All pigmented skin lesions should be carefully observed during pregnancy by a dermatologist due to the increased risk of malignant transformation, associated with the endocrine dependence. All lesions with visible changes should be removed surgically with appropriative anaesthesia

Peri - and Intraocular Mutilating Advanced Squamous Cell Carcinoma: ʺMonsters Inside Your Bodyʺ?

Periocular malignancies represent between 5% and 10% of all types of skin cancers. The incidence of eyelid (but also the periocular located) malignancies seems to differ in distribution across the continents.  The incidence of eyelid tumours (but also the periocular located tumours) in a predominantly white population determined that BCC is the most common malignant periocular eyelid tumour in whites. This finding has been replicated consistently throughout the literature, with BCC representing 85–95% of all eyelid malignancies, SCC representing 3.4 - 12.6%, Seb Ca representing 0.6 - 10.2%, and both melanoma and Merkel cell carcinoma representing less than 1%. Most periocular skin cancers are associated with ultraviolet radiation (UVR) exposure. Ultraviolet radiation causes local immune suppression, which, coupled with DNA abnormalities in tumour suppressor genes and oncogenes, leads to the development of skin cancers.  We are presenting a 62 - year - old patient with a small nodule about 2 cm away from the lower lid of his left eye. A tumour was surgically treated. Several years later there was a tumour relapse, treated with radiotherapy and subsequent chemotherapy with Endoxan and Cisplatin. After the second relapse, he was treated surgically in general anaesthesia by orbital exenteration, removal of the orbital floor and resection of zygomatic bone and the maxillary sinus. A couple of months later, he developed a tumour relapse in the scars and the area of a primary tumour with tumour progression. A possible therapy with Cetuximab or radiation therapy was discussed as a possible treatment option

Para - And Intraurethral Penile Tumor - Like Condylomatosis

Condyloma acuminata represents an epidermal manifestation, associated with the epidermotropic human papillomavirus (HPV). They have been reported as the most common sexually transmitted disease, with prevalence exceeding 50%, increased up to 4 times, within the last two decades, as the most common side of affection are the penis, vulva, vagina, cervix, perineum, and perianal area, with increased prevalence in young, sexually active individuals.  Increased attention should be focused on lesions, caused by types, with moderate (33, 35, 39, 40, 43, 45, 51-56, 58) or high risk potential (types 16, 18) for malignant transformation, leading to further development of cancers of anus, vagina, vulva and penis, as well as cancers of the head and neck . A provident of coexistence of many of these types in the same patient could be seen in approximately 10-15% of patients, as the lack of adequate information on the oncogenic potential of many other types complicated the treatment and the further outcome. Although the variety of treatment options, genital condylomata acuminata still show high recurrent rate to destructive topical regiments, because of the activation of the viruses at some point, which emphasise the importance of virus- eradication, instead only of the topical destruction of the lesions.  Despite decreasing the recurrent rate, the most important goal of immunisation is the reduction of the incidence of HPV-associated squamous cell carcinomas using either the quadrivalent (Silgard/Gardasil) or the bivalent (Cervarix) HPV (human papillomavirus) vaccine. We present a patient with periurethral condylomata acuminate, who refused performing of a biopsy for determining the virus type, as we want to emphasize the importance of the virus - treatment in all cases of genital warts, instead only of topical destruction of the lesions, not only because of the recurrence incidence rate, but also because of the well - known oncogenic potential of some HPV - types, as well as the unknown potential of various underestimated types, in contrast

High-Risk BCC Of the Lower Eyelid in Patient with Presternal Located Cutaneous Melanoma and BCC Of the Shoulder: Melolabial Advancement Flap Combined with Undermining Surgical Approach As Promising Complex One Step Treatment Option!

BACKGROUND: It is assumed that the occurrence of keratinocyte and melanocytic tumours is multifactorial driven. Certain risk factors such as solar radiation, p53 protein and Melanocortin-1 receptor (MC1R) prove to be common to their development, which at the same time shows that their simultaneous manifestation in the same patients, for example, is quite possible. Such a manifestation could be observed as collision tumours within the same solitary lesion or as a simultaneous occurrence within two completely different lesions that are clearly distinguished from one another. CASE REPORT: An 85-year-old patient is presented with three primary cutaneous tumours located in region presternal, infraorbital sinistra and scapularis extra. The lesions were removed during a single surgical session. For the high-risk basal cell carcinoma (BCC) in the lower eyelid, the so-called melolabial advancement flap was applied, and for the tumours located in the other two areas, the undermining surgical approach was applied. The subsequent histological analysis found that the case referred to two keratinocyte tumours (BCC) and one melanocyte tumour (cutaneous melanoma). CONCLUSIONS: The patient presented is interesting with regard to 1) the simultaneous presentation of three primaries with different localization (so far not described in the world literature, namely 2 basal cell carcinomas and one melanoma in the same patient concurrently), 2) one of the basal cell tumours belongs to the group of high-risk (according to the localization) and meanwhile advanced BCC (according to the infiltration degree of the underlying tissue-infiltration of the musculature) and 3) their simultaneous successful surgical treatment in a single surgical session under local anaesthesia

Seborrheic Pemphigus, Antigen Mimicry and the Subsequent-Wrong Diagnostic and Therapeutic Approach?

It is well-established that drugs could be leading cause of occurrence of numerous diseases, including pemphigus, being either inducer or triggering factor of the autoimmunity. Despite medications, it should be kept in mind that chronic or acute infections are also capable of being a trigger in various types of cutaneous eruptions, including pemphigus. The rapidly obtained and uncompleted history for accompanied medication leads to general mistakes in the subsequent treatment approach, as the first step in such cases is discontinuation of the drug-inductor. The absence of this information guaranties the fail of the treatment. On the other hand, the lack of performed screening for chronic or acute hepatitis and tuberculosis is not the only mistake, regarding the high dosage of immunosuppressors that have been planned as regiment and the possible fatal effect on the infection’s spread or exacerbation, but also because of the possible triggering ability of chronic or acute infection, which may play also a key role in the generation of antigen- or molecular- mimicry, as a potential source of antibodies reactive with various tissue antigens. It turns out that although the diagnosis of pemphigus in regular cases is usually not a challenge, the treatment occasionally could be, just because of a simple pitfall in anamnesis and screening, as in the presented case. Herein, we present a case of a patient with seborrheic pemphigus, which is strongly demonstrative for these statements, as we want to emphasise the importance of the first and the most powerful clinician’s weapons – the patient’s history and thorough examination

Neurofibromatosis Type 1 with Massive Ventricular Polyposis: First Report in the Medical Literature

BACKGROUND: Neurofibromatosis type 1 (NF1) is a multisystemic disorder with genetic background, characterised by specific cutaneous findings, skeletal dysplasias, and growth of both benign and malignant nervous system tumours. NF1 is caused by mutations in the NF1 gene, situated in chromosome 17q11.2, with an autosomal dominant pattern of inheritance and clinical manifestation of neurofibromas, malignant peripheral nerve sheath tumour, optic and non-optic nerve gliomas, congenital heart disease, cardiovascular and cerebrovascular disease and orthopaedic disorders. The incidence of gastrointestinal manifestations of NF 1 is relatively low, compared to neurological disorders, presenting approximately in 5 to 25% of the patient, but later in life.CASE REPORT: We present a patient with NF1, ventricular polyposis and attentional disorders with cognitive phenotype, while both of her daughters also present with cutaneous manifestations of NF1.CONCLUSION: To the best of our knowledge, this is the first reported case of NF1 with ventricular polyposis as a gastrointestinal manifestation in the mother and NF1 with no signs of inner organ involvement in both of her daughters

Disseminated Porokeratosis with Idiopathic Thrombocytopenia - Case Report and Literature Review of Porokeratosis and Related Disorders

BACKGROUND: Porokeratosis is characterised by one or more atrophic patches surrounded by a distinctive peripheral keratotic ridge, typically found on sun-exposed areas, with several clinical variants and typical histological findings. Despite ultraviolet radiation, varies antibody - related autoimmune disease treated with systemic steroids and other immunosuppressive conditions such as chronic liver disease, HIV and organ transplantations have been implicated in its etiopathology.CASE REPORT: We present a case of porokeratosis, associated with idiopathic thrombocytopenia in 74 - year old, otherwise healthy male patient, as we discuss the previously reported associated disorders.CONCLUSION: Regarding all of the polymorphism of clinical presentation, associated disorders and treatment responses, we could conclude that disseminated porokeratosis is still an unknown well disorder, which will continue to surprise the physicians in future. The screening and follow up of the patients is mandatory in all cases because as we see, porokeratosis has multiple unexpected faces, which require circumstantial clinical and paraclinical behaviour

Innovative One Step Melanoma Surgical Approach (OSMS): Not a Myth-It’s a Reality! Case Related Analysis of a Patient with a Perfect Clinical Outcome Reported from the Bulgarian Society for Dermatologic Surgery (BULSDS)!

BACKGROUND: With the newly described one step melanoma surgical approach, some patient groups could be successfully treated within one surgical session. Depending on the tumour thickness (measured preoperatively) at a later stage (also depending on the ultrasound findings of the locoregional lymph nodes) the respective surgical intervention is planned with the respective field of surgical safety (one-stage melanoma surgery with or without removal of lymph nodes). The innovations could make to some extent some of the already existing algorithms more difficult (due to the introduction of a high-frequency ultrasound to determine the tumor thickness preoperatively as an absolute prerequisite for dermosurgical centres), but it would also lead with absolute certainty to better or least optimal results regarding the prognosis, the side effects and the financial factor also.CASE REPORT: We present a patient from the Department of Dermatology, Venereology and Dermatologic Surgery at the Medical Institute-Ministry of Interior (MVR-Sofia), treated with the one-step melanoma surgery method with perfect final results. The preoperative tumour thickness determined via ultrasound and the postoperatively measured histological tumour thickness was identical: between 0.98 and 1 mm, which allowed removal of the melanoma lesion with a field of surgical security of 1 cm in all directions and did not require additional removal of a draining lymph node or excisions.CONCLUSION: Thanks to this new approach, some patients could avoid one surgical intervention, which could be interpreted as a significant advantage or probably also survival benefit. This methodology and its successful application were first officialised by the representatives of the Bulgarian Society for Dermatologic Surgery- (BULSDS), and the purpose of this action, in general, is to fully improve clinical management of patients suffering from cutaneous melanoma in terms of compactness by 1) reducing the number of unnecessary surgeries or the number of surgical interventions in general; 2) reducing side effects occurring in surgeries and 3) introducing a serious optimization in terms of financial resources needed or used in the second hospitalization of patients. The question remains open whether the accepted or the current recommendations for surgical treatment of melanoma will be transformed or adapted for the matching patient groups