A New Approach in the Management of Triangular Fossa Auricular Defects: The Posterior Auricular Artery Perforator Antihelix-Conchal Flap (PAAP Flap).

Background: The reconstruction of extensive scapha or triangular fossa defects to the ear still represents a challenge considering the lack of local simple surgical procedures. Objective: To present a new perforator flap which is a modification of the Elsahy and Ladocsi chondrocutaneous rotation flaps. Patients and Methods: Ten patients, in whom the oncological resection to the triangular fossa did not include cartilage, but skin and perichondrium. Defects no larger than 3 cm in diameter were treated. The dissection of the flap was carried out from lateral to medial on the anterior subperichondral plane. The flap was thus raised without the cartilage component but with the anterior perichondrium branched with the perforating vessels. Results: All flaps survived and treated patients presented good aesthetic results. Conclusions: We think that this procedure represents a valuable option to be considered in reconstructing well selected composite defects to upper ear

Molecular Targeted Approaches for Advanced BRAF V600, N-RAS, c-KIT, and GNAQ Melanomas

The introduction of a newly developed target therapy for metastatic melanomas poses the challenge to have a good molecular stratification of those patients who may benefit from this therapeutic option. Practically, BRAF mutation status (V600E) is commonly screened although other non-V600E mutations (i.e., K-R-M-D) could be found in some patients who respond to therapy equally to the patients harboring V600E mutations. Furthermore, other mutations, namely, N-RAS, KIT, and GNAQ, should be sequenced according to distinct melanoma specific subtypes and clinical aspects. In our report, a practical flow chart is described along with our experience in this field

Are the neck malignant melanomas different from the ones affecting the head? Clinicopathologic, dermoscopic and prognostic findings

Background: Malignant melanomas of the head and neck are usually considered as a unique entity in comparison to other body sites. However, no characterization of neck melanoma has been performed so far, despite the clear anatomic and histological differences. Aim: We investigated clinical, demographic, histological and dermoscopic differences between face, scalp and neck melanoma. Materials and methods: A retrospective analysis of medical and histologic records from 116 melanomas of the head and neck area collected between January 2003 and January 2008 was performed. Body site, gender, age, number of lesions, age at first melanoma diagnosis, size, Clark level, association with nevi, presence or absence of mitoses and/or ulceration, presence of synchronous and/or metachronous melanoma were recorded. Moreover, digital dermoscopy images of 92 melanomas of the head and neck area were analyzed for main dermoscopic patterns and lesion diameter. Results: Significant differences in Breslow thickness, ex-naevo origin and tumor size among neck and face-scalp melanomas were observed. Neck MM patients were younger than those with MM of face and scalp. In contrast to scalp and face, no patient died from neck melanoma. Dermoscopic patterns were similar to those of trunk-limbs MM, and no lesion showed a lentigo maligna pattern which was observed in most lesions of the face. Conclusion: Melanomas of the neck must be distinguished from face and scalp melanomas because of younger age, different dermoscopic patterns and ex-naevo origin and better prognosis. These data should be taken into account both from an epidemiological and clinical point of view

Shoulder function after breast reconstruction with the latissimus dorsi flap: A prospective cohort study - Combining DASH score and objective evaluation.

Abstract Objectives The latissimus dorsi (LD) flap is well-known in breast reconstruction especially in previously-irradiated patients, in order to have a low capsular contraction rate whenever an implant is associated. The aim of this study is to closely evaluate the effect of LD flap harvesting on shoulder function as well as specific movements related to the LD, both objectively and subjectively. Materials and methods We retrospectively collected data on 86 patients who underwent pedicled LD muscle flap for breast reconstruction at the European Institute of Oncology between September 1995 until March 2011. Results The majority of patients showed a joint recovery superior to 80% in all joint movements examined. Disabilities of the Arm, Shoulder and Hand questionnaire revealed minimal disability similar to normal range and furthermore it appears to decrease in all sports and in particular in those who practice with LD involvement. Conclusion Focusing this data, a growing, "disability-free" percentage changes depending on whether or not the patients have practiced sport could be appreciate

Giant elephantiasis neuromatosa in the setting of neurofibromatosis type 1: A case report

Elephantiasis neuromatosa (EN) can arise from a plexiform neurofibroma of the superficial and deep nerves developing from a hyperproliferation of the perineural connective tissue infiltrating adjacent fat and muscles. To date, the clinical association between EN and neurofibromatosis type 1 (NF1) has been poorly defined, particularly with regard to the role of lymphatic alterations and the consequent lymphedema. The present study reports the clinical and biomolecular features of EN in a NF1 patient with the clear clinical diagnostic criteria of multiple caf\ue8-au-lait macules, neurofibromas, EN, a positive family history and a novel NF1 germline c.1541_1542del mutation. Lymphoscintigraphy (LS) highlighted marked dermal backflow in the affected limb, hypertrophy of the ipsilateral inguinal and external iliac lymph nodes, and a bilateral lower limb lymph flow delay. These data support the hypothesis that an extensive hyperproliferative process involving perineural connective, limb soft tissues, bones and the lymphatic system can be responsible for EN in NF1 patients, on the basis of adipocyte metaplasia triggered by lymphostasis and lymphedema, and bone overgrowth and gigantism caused by chronic hyperemia. LS and magnetic resonance imaging can be efficacious tools in the diagnosis and clinical characterization of the early onset of the disease

Sphenoid asymmetry associated to other skeletal anomalies in a clear cut case of PTCH1 mutated Gorlin-Goltz syndrome: a novel finding?

Gorlin-Goltz syndrome is an autosomal dominantly inherited disorder linked to PTCH1 mutation, recognized by a collection of clinical and radiologic signs (macrocephaly, frontal bossing, multiple intracranial calcifications including falx cerebri and atlanto-occipital ligament). We describe here a the case of a family with clear cut criteria for Gorlin-Goltz syndrome presenting the association of cranio-facial and skeletal anomalies together with a peculiar sphenoid variant. Two patients, father and son, were examined because of multiple basal cell carcinomas and keratocystic odontogenic tumours. Other suggestive findings were multiple positive family history, typical skeletal anomalies and a novel PTCH1 germline mutation (c.1041delAA). Craniofacial and other skeletal anomalies displayed at 3D and helical CT scan were: macrocephaly, skull base asymmetry (positional plagiocephaly), mandibular prognathism, mandibular condylar deformation with hyperplasia of the coronoid process, bifidity of multiple ribs and giant multilocular odontogenic jaw cysts. Extensive multilamellar calcifications were found in falx cerebri, tentorium, falx cerebelli and in the apical segment of the atlanto-occipital ligament. Thoracic anomalies included bifid left 3rd, 4th, 5th and 6th rib, dismorphic body of the 3rd thoracic vertebra, dorsolumbar scoliosis, sacrum acutum. Interestingly, 3D-CT scan showed asymmetry of both sphenoid wings with thickening of the left wing sphenoid wing together with irregularity of the architecture of trabecular bone with alternating osteolytic and sclerotic areas. Abnormalities of the sphenoid bone are not very common, and consist of differently aggressive entities: some of them are typical of the pediatric age in few hereditary and congenital disorders. The application of new criteria (i.e. peculiar calcifications of ligaments and sphenoid asymmetry) to a wider case series can lead to the early diagnosis of Gorlin syndrome, especially in pediatric patients, when the full phenotype is not yet expressed. The inclusion of bifid ribs as a novel major criteria and the recognition of peculiar cranial anomalies such as sphenoid asymmetry, well detected at volume CT reconstruction, might be useful for the recognition and characterization of misdiagnosed cases

Erratum to: Oncoplastic Breast-Conserving Surgery for Tumors Larger than 2 Centimeters: Is it Oncologically Safe? A Matched-Cohort Analysis

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NF1 truncating mutations associated to aggressive clinical phenotype with elephantiasis neuromatosa and solid malignancies

Background/aim: Von Recklinghausen disease is a syndrome characterized by a wide phenotypic variability giving rise to both, cutaneous and visceral benign and malignant neoplasms. The first include cutaneous neurofibromas, subcutaneous and plexiform neurofibromas. The latter can undergo malignant transformation and/or determine elephantiasis neuromatosa. Visceral tumors may include malignant peripheral nerve sheet tumors, gastrointestinal stromal tumors, cerebral gliomas and abdominal neurofibromas. In the present study, the authors discuss the clinical and biomolecular characterization of a cohort of 20 families with a diagnosis of type 1 neurofibromatosis. Patients and methods: Clinically, the cohort includes three probands with elephantiasis neuromatosa and a peculiarly high incidence of breast and gastrointestinal cancer. Results: Among the 14 NF1 mutations documented, 10 encoding for a truncated protein have been associated to particularly aggressive clinical phenotypes including elephantiasis neuromatosa, malignant peripheral nerve sheet tumors, breast cancer, gastrointestinal stromal tumors. Conclusion: This effect on protein synthesis, rather than the type of NF1 mutation, is the key to the explanation of the genotype-phenotype correlations in the context of neurofibromatosis type 1

Adipose stromal/stem cells assist fat transplantation reducing necrosis and increasing graft performance.

Autologous fat transfer (AFT) is a procedure for adipose tissue (AT) repair after trauma, burns, post-tumor resections and lipodystrophies still negatively impacted by the lack of graft persistence. The reasons behind this poor outcome are unclear and seem to involve damages in either harvested/transplanted mature adipocytes or on their mesenchymal progenitors, namely adipose stromal/stem cells (ASC), and due to post-transplant AT apoptosis and involution. A rabbit subcutaneous AT regeneration model was here developed to first evaluate graft quality at different times after implant focusing on related parameters, such as necrosis and vasculogenesis. Standard AFT was compared with a strategy where purified autologous ASC, combined with hyaluronic acid (HA), assisted AFT. Five million of autologous ex vivo isolated CD29+, CD90+, CD49e+ ASC, loaded into HA, enriched 1 ml of AT generating an early significant protective effect in reducing AFT necrosis and increasing vasculogenesis with a preservation of transplanted AT architecture. This beneficial impact of ASC assisted AFT was then confirmed at three months with a robust lipopreservation and no signs of cellular transformation. By a novel ASC assisted AFT approach we ensure a reduction in early cell death favoring an enduring graft performance possibly for a more stable benefit in patients

Understanding Tumor-Stroma Interplays for Targeted Therapies by Armed Mesenchymal Stromal Progenitors: The Mesenkillers.

Tumor represents a complex structure containing malignant cells strictly coupled with a large variety of surroundingcells constituting the tumor stroma (TS). In recent years, the importance of TS for cancer initiation, development,local invasion and metastases became increasingly clear allowing the identification of TS as one of the possibleways to indirectly target tumors. Inside the heterogeneous stromal cell population, tumor associated fibroblasts(TAF) play a crucial role providing both functional and supportive environments. During both tumor and stroma development,several findings suggest that TAF could be recruited from different sources such as locally derived host fibroblasts,via epithelial/endothelial mesenchymal transitions or from circulating pools of fibroblasts deriving form mesenchymalprogenitors, namely mesenchymal stem/stromal cells (MSC). These insights prompted scientists to identifymultimodal approaches to target TS by biomolecules, monoclonal antibodies and, more recently, via cell basedstrategies. These latter appear extremely promising, although associated with still debated and unclear findings. Thisreview discusses on crosstalk between cancers and their stroma, dissecting specific tumor types, such as sarcoma,pancreatic and breast carcinoma where stroma plays distinct paradigmatic roles. The recognition of these distinctstromal functions may help in planning effective and safer approaches aimed either to eradicate or to substitute TSby novel compounds and/or MSC having specific killing activitie