A Misdiagnosed Desmoplastic Neurotropic Melanoma of the Scalp: A Challenging Case for the Pathologist and Surgeon

Desmoplastic neurotropic melanoma (DNM) is a rare melanoma subtype that shows tropism for the nerves, perineural invasion correlates to higher rate of local recurrence, poorer prognosis and worse morbidity. Given the paucity of typical melanoma features, both clinical and pathological, this confusing skin cancer may act as a pretender, thus leading clinician to misdiagnosis and subsequent inappropriate conservative treatment. Sarcomatoid- like cells rearrangement and absence of pigmentation can lead towards sarcoma diagnosis, so specific skills are required to pathologist to properly recognize this melanoma subtype. In this case report, we present an example of how challenging can be the diagnosis, and how it can affect clinical outcom

Gender-specific Anatomical Distribution of Internal Pudendal Artery Perforator: A Radiographic Study for Perineal Reconstruction

Background: Cancer, trauma, infection, or radiation can cause perineal defects. Fasciocutaneous flaps based on perforator vessels (PV) from the internal pudendal artery (IPA) provide an ideal reconstructive option for moderate defects. We hypothesized that, due to gender differences in the pelvic-perineal region, the anatomical distribution of PV differs between genders. Methods: Computed tomography angiographies from male and female patients without pelvic-perineal pathologies were retrospectively analyzed to study the vascular anatomy of the IPA. The number, size, type, and distribution of PV were recorded and compared between genders. Four anatomical regions were defined to describe the distribution of PV on each perineal side: anterior (A), anterior-central (AC), central-posterior (CP), and posterior (P). Results: A total of 63 computed tomography angiographies were analyzed (men, 31; women, 32). Each IPA provides 2 +/- 1 PV and 5 +/- 2 terminal (cutaneous) branches: in both genders, 85% of PV are septocutaneous (15% musculocutaneous). In women, 70.5% of PV are located in AC, 28.2% in CP, 1.2% in A, and 0% in P: average diameter of the PV is 2.4 +/- 0.3 mm. In men, 53.7% of PV are located in CP, 43.1% in AC, 3.3% in A, and 0% in P: average diameter of the PV is 2.8 +/- 0.5 mm. Gender-specific differences in anatomical distribution of PV are significant (P \u3c 0.001). Conclusions: Number, size, and type of terminal branches of PV of the IPA are consistent between genders, but their distribution is different, with women having an anterior predominance. Knowledge of gender-specific anatomy can guide preoperative planning and intraoperative dissection in flap-based perineal reconstruction

The profunda artery perforators: Anatomical study and radiological findings using computed tomography angiography in patients undergoing PAP flap breast reconstruction

Background: The popularity of the profunda femoris artery perforator (PAP) flap is increasing; however, knowledge concerning the standardization of radiological findings and their clinical implications is limited. We evaluated the radiological architecture of posterior thigh perforators using Computed Tomography Angiography (CTA) to identify landmarks to facilitate flap dissection. Methods: A retrospective study was conducted on 35 patients who underwent unilateral breast reconstruction with a PAP flap. The preoperative CTA scans were analyzed, and the perforator characteristics were evaluated. The perforators were mapped using a Cartesian coordinate system. Data were normalized by anatomical landmarks and overlapped. Perioperative and postoperative results were analyzed. Radiological and intraoperative were compared. Results: Two CTA scans were excluded; 66 thighs were examined. The mean perforator number was 3.2. The mean diameter of chosen perforators was 2.7 mm (DS ± 0.6 mm) at the origin, 2.2 mm (DS ± 0.4 mm) at the adductor space midpoint, and 1.7 mm (DS ± 0.3 mm) at the deep fascia. The mean adipose tissue thickness was 3.35 cm (DS ± 0.94) at the deep fascia and 3.59 cm (DS ± 1.19) at the adductor space midpoint. Intraoperatively, the perforator was located 3.22 cm (DS ± 0.87) from the posterior border of the gracilis muscle and 8.98 cm (DS ± 1.44) from the inferior gluteal crease. A radiological area located 9.33 cm (DS ± 4.81) from the y-axis and 7.48 cm (DS ± 1.88) from the x-axis was identified. Conclusions: CTA using the volume-rendering technique is a valuable method to study in vivo the radiological anatomy of the posterior thigh perforators

Los negocios turísticos en playas del caribe

The beach is a destination of the most important attractions of tourist destinations where there are several businesses that are the basis of economic activity offered by the development in the community where they are located. The article compares the model of the life cycle of tourist destinations with the inventory of tourist businesses on the beaches of Cancun, San Juan and Punta Cana, with the purpose of knowing the commercial activity that is offered to visitors in the zones of study. It was reflected on the differences and similarities between the tourist beaches of the three international destinations in different stages, the reflection that allows to project a future scenario of economic development and the establishment of business strategies in the segment of sun and beach.La playa constituye uno de los atractivos más importantes de los destinos turísticos mundiales donde se encuentran diversos negocios que son la base de la actividad económica ofreciendo desarrollo en la comunidad donde se encuentren. El artículo compara elmodelo del ciclo de vida de los destinos turísticos con el inventario de los negocios turísticos en las playas de Cancún, San Juan y Punta Cana, con la finalidad de conocer la actividad comercial que se ofrece a los visitantes en las zonas de estudio. Se reflexiona respecto a las diferencias y similitudes entre playas turísticas de 3 destinos internacionales en diferentes etapas, reflexión que permite proyectar un escenario futuro de desarrollo económico y el establecimiento de estrategias de negocios en el segmento de sol y play

One-Stage Soft Tissue Reconstruction Following Sarcoma Excision: A Personalized Multidisciplinary Approach Called \u201cOrthoplasty\u201d

Background and Objectives. Wide surgical resection is a relevant factor for local control in sarcomas. Plastic surgery is mandatory in demanding reconstructions. We analyzed patients treated by a multidisciplinary team to evaluate indications and surgical approaches, complications and therapeutic/functional outcomes. Methods. We analyzed 161 patients (86 males (53%), mean age 56 years) from 2006 to 2017. Patients were treated for their primary tumor (120, 75.5%) or after unplanned excision/recurrence (41, 25.5%). Sites included lower limbs (36.6%), upper limbs (19.2%), head/neck (21.1%), trunk (14.9%) and pelvis (8.1%). Orthoplasty has been considered for flaps (54), skin grafts (42), wide excisions (40) and other procedures (25). Results. At a mean follow-up of 5.3 years (range 2\u201310.5), patients continuously showed no evidence of disease (NED) in 130 cases (80.7%), were alive with disease (AWD) in 10 cases (6.2%) and were dead with disease (DWD) in 21 cases (13.0%). Overall, 62 patients (38.5%) developed a complication (56 minor (90.3%) and 6 major (9.7%)). Flap loss occurred in 5/48 patients (10.4%). The mean Musculoskeletal Tumor Society (MSTS) and Toronto Extremity Salvage Score (TESS) was 74.8 +/- 14 and 79.1 +/- 13, respectively. Conclusions. Orthoplasty is a combined approach eective in management of sarcoma patients, maximizing adequate surgical resection, limb salvaging and functional recovery. One-stage reconstructions are technically feasible and are not associated with increased risk of complications

ETIOLOGIA DO INSUCESSO ENDODÔNTICO: REVISÃO DE LITERATURA

<p>Diante dos desafios enfrentados por endodontistas, muitas são as causas relacionadas ao fracasso da terapia, a qualidade da execução dos passos operatórios conduz o sucesso do tratamento, uma das possíveis etiologias de falhas dos tratamentos, está relacionado à resistência de microrganismos quanto ao processo de desinfecção, resultando em Infecções Persistentes. Nesse contexto, o profissional deve intervir para reparar os danos causados pelo insucesso, sendo por meio do retratamento endodôntico ou cirurgia paraendodôntica. Este estudo teve como objetivo explorar a etiologia do insucesso endodôntico, bem como os principais microrganismos relacionados à Periodontite Apical. Foram realizadas buscas bibliográficas eletrônicas utilizando base de dados como Google Acadêmico e Periódico Capes. Para tanto, foram utilizados os seguintes descritores de assunto da língua portuguesa: "insucesso endodôntico", "Lesão Endodôntica Refratária", "Reintervenção Endodôntica". Os resultados mostraram que demonstra causas isoladas e associadas frente ao insucesso endodôntico, ademais evidencia que uma das principais manifestações do fracasso da terapia é a Lesão Periapical. Diante da pesquisa observou-se que existem diversos fatores que podem resultar em falhas no tratamento endodôntico, sendo que a maioria está relacionado ao preparo químico-mecânico, obturação final e selamento coronário. Para esses casos de fracasso da terapia é importante considerar uma nova intervenção antes de condenar o dente à uma extração.  </p&gt

Risk of translocated soft-tissue sarcoma recurrence using perforator propeller flap: Case report and literature review

Tumor seeding after intra-abdominal and head and neck cancer surgery is a well-known entity. The risk of disseminating cancerous cells during surgery is also described for soft-tissue sarcoma of the extremities. Nonetheless, after reconstructive surgery using flaps, the risk of recurrence at the donor site is extremely rare. Up to this date, the literature describes only three cases, but none of them reported a translocated recurrence after a reconstruction with a propeller flap. Here, we report a case of high-grade pleomorphic sarcoma of the knee, which recurred at the proximal edge of a propeller flap 28\u2009months after the first excision surgery. The reasons for such local recurrences are not clear and previous works have advocated different theories: direct contamination by tumor cells, physical manipulation of the tumor and creation of surgical wounds with tumor supportive properties. Although these particular cases of recurrence are exceedingly rare, certain precautionary meticulous surgical techniques and a thorough preoperative planning are pivotal to avoid the contamination of \u201cclean\u201d areas during the first excision surgery

Deep inferior epigastric perforator flap preoperative planning: A comparative analysis between dynamic infrared thermography, computerized tomography angiography, and hand-held Doppler

Introduction Hand-held Doppler (HHD) sonography and computerized tomography angiography (CTA) are the common assessment tools for deep inferior epigastric perforator (DIEP) flap preoperative planning. CTA is considered the gold standard method for preoperative perforator mapping but necessitates contrast medium and X-ray exposure. Dynamic infrared thermography (DIRT) does not have these drawbacks and allows the detection of hot and cold spots on a given body area. Our study aimed to compare DIRT, HHD, and CTA in perforator mapping for breast reconstruction using DIEP flap. Patients and Methods From March to September 2020, 12 consecutive patients scheduled for DIEP flap breast reconstruction were preoperatively investigated with HHD, CTA, and DIRT. The patients' mean age was 53 and the mean BMI was 29.23 kg/m(2). All the reconstructions were due to breast cancer. The results of preoperative perforator mapping on the lower abdomen were compared among the three techniques. All the evidence was compared to the intraoperative findings, during flap harvesting, to establish if the techniques were able to correctly locate the perforator. Results We detected 178 perforators intraoperatively, 178 with CTA, 178 with DIRT, and 125 with HHD. The latter revealed a lower number of perforator vessels for each patient (10.42 +/- 3.58), compared with CTA (14.83 +/- 3.04) and DIRT (14.83 +/- 4.76). DIRT resulted superior to HHD (p .05) was found between DIRT and CTA. We calculated a mean sensitivity of 93.87% for CTA, 69.02% for HHD, and 92.06% for DIRT. Conclusion DIRT is a useful tool in the preoperative planning of DIEP flaps, as it provides information about the location of perforators and the hemodynamic properties of angiosomes. It is easy to use, and it does not involve ionizing radiation. DIRT could represent an innovative and promising implementation of CTA and HHD techniques for preoperative perforator mapping in DIEP breast reconstruction