Optimization of Prepectoral Breast Reconstruction

Introduction: Acellular dermal matrix (ADM) were introduced in the early 2000s and more recently permitted new protocols for breast reconstruction allowing a short operative time with improved outcomes until the new muscle-sparing breast reconstruction proposed in 2014 using the Braxon® ADM. The aim of this research is to propose a technique to improve the aesthetic outcome using Braxon ADM with prepectoral implants. Materials and Methods: The enrolled patients were submitted to a nipple skin-sparing mastectomy leaving 1 additional centimeter of subcutis on the proximal part of the upper pole of the breast (see Surgical Technique). Aesthetic outcomes were compared to those obtained with traditional breast reconstruction with prosthesis and the Braxon ADM placed in the prepectoral space. Mean values of aesthetic outcomes were analyzed using the Student t test, and the κ test was used to analyze interobserver variability. Results: The overall aesthetic score was improved of 29.6% of the patients; in particular the most improved score was that for contour (+98.01%). Statistical significance was found for contour, upper pole definition, and total score average (p < 0.05).The κ test showed interobserver variability with a good level of agreement on contour (κ = 0.832). Conclusions: The proposed technique has allowed attainment of good results in terms of aesthetic outcomes. In a small sample we did not register any particular complications but we verified a better satisfaction on the evaluation of the aesthetic result (level of evidence: 3)

Indocyanine green sentinel node in Merkel cell carcinoma of the cheek

Merkel cell carcinoma (MCC) is a rare malignant tumor with a neuroendocrine phenotype. The authors report a case of MCC of the left cheek region in an 85-year-old Caucasian woman who also received sentinel node biopsy using both Technectium-99m-labeled (99mTc) lymphoscintigraphy and indocyanine green lymphography

Comparison of indocyanine green fluorescence lymphangiography and magnetic resonance lymphangiography to investigate lymphedema of the extremities

Questo lavoro confronta le due principali metodiche di imaging attualmente utilizzate per studiare il sistema linfatico periferico nei pazienti affetti da linfedema, la RM (Magnetic Resonance Lymphangiography, MRL) e lo studio a fluorescenza con verde di indocianina (Indocyanine Green Lymphangiography, ICGL), per pianificare il trattamento chirurgico di anastomosi linfatico- venosa o eventuali altri trattamenti. Sono stati inclusi 32 pazienti, dei quali 26 donne, con una età media di 38 anni (range 18-73), arruolati da gennaio 2014 a dicembre 2018; 20 di 32 avevano un linfedema agli arti inferiori e 6 casi di linfedema erano primari; tutti i pazienti avevano una malattia al II stadio. Entrambi gli esami sono stati eseguiti a tutti i pazienti in tempi differenti (intervallo di tempo massimo 1 mese), iniettando il mezzo di contrasto a livello intradermico (Diagnogreen 0.5%; Daiichi Pharmatical, Tokyo, Japan per ICGL e Gd-BOPTA, Multihance, 0.5 M injectable solution, Bracco Imaging, Milan, Italy per MRL), negli spazi interdigitali delle mani o dei piedi con un ago da 24 G. Per ogni paziente sono stati conteggiati, in entrambe le metodiche, i vasi linfatici visualizzati a livello del polso per gli arti superiori e a livello della caviglia per gli arti inferiori, sia negli arti sani che nei malati. Tutti i pazienti hanno completato gli esami senza significative complicazioni. In ogni esame RM il contrasto era in parte drenato anche dal sistema venoso mentre il verde di indocianina era selettivo per il sistema linfatico. Una differenza statisticamente significativa tra le due metodiche è stata trovata tra il numero di vasi linfatici a livello della caviglia/polso sia negli arti malati che nei sani (34 con ICGL vs 70 con MRL e 82 con ICGL vs 26 con MRL), considerando arti malati e sani rispettivamente. In entrambe le metodiche i vasi linfatici negli arti linfedematosi apparivano per lo più tortuosi, mentre i sani presentavano una morfologia lineare ed erano difficilmente visualizzati in RM a causa del rapido flusso linfatico e del loro lume, pressochè virtuale. Lo stravaso intradermico del mezzo di contrasto (dermal backflow) è stato identificato in 14 pazienti, in 6 dei quali lo studio a fluorescenza non ha potuto identificare nessun vaso linfatico, mentre in RM almeno un vaso linfatico è stato visualizzato. Da questi risultati emerge che entrambe le metodiche indagate forniscono informazioni anatomiche e funzionali sul sistema linfatico periferico degli arti, permettendo di scegliere e localizzare accuratamente in fase prechirurgica quei vasi con una pompa linfatica residua. Lo studio a fluorescenza con verde di indocianina è rapido, ben tollerabile dal paziente e può essere impiegato anche in sala operatoria. La RM fornisce una visione panoramica dell’arto, la visulizzazione dei vasi linfatici non è ostacolata dalla presenza stravaso intradermico del mezzo di contrasto grazie alla superiore risoluzione spaziale, e permette di valutare allo stesso tempo il drenaggio venoso; d’altra parte è un esame costoso e meno tollerabile dal paziente per i lunghi tempi d’acquisizione.PURPOSE: The aim of this study is to compare two dynamic imaging modalities employed to study peripheral lymphatic system, Magnetic Resonance Lymphangiography (MRL) and Indocyanine Green Lymphangiography (ICGL), evaluating their role for planning lymphaticovenular anastomosis (LVA) or other surgical-nonsurgical treatments in patients with lymphedema of the extremities. MATERIALS AND METHODS: We conducted a retrospective study of 32 patients (26 women) with a mean age of 38 years (range 18-73) enrolled from January 2014 to December 2018; 20 out of 32 were affected by lower limb lymphedema with 6 cases of primary lymphedema; all of them had stage II disease. All the patient underwent ICGL and MRL within a month of one another, by injecting different contrast medium into interdigital web spaces. In each patient we rated the number of lymphatic vessels visualized, considering the wrist for the upper limb and the ankle for the lower limb. Student's t-test was applied. RESULTS: All patients completed both the diagnostic examinations without any significant complications. A statistically significant difference (p < 0.05) was found between the number of lymphatic vessels identified on the wrist/ankle (34 on ICGL vs 70 on MRL and 82 on ICGL vs 26 on MRL, considering affected and healthy limbs respectively). In particular, dermal backflow in advanced lymphedema seems to hinder lymphatic vessels detection on ICGL. Conversely, on healthy limbs, MRL hardly identifies lymphatics, because of their fast lymphatic flow and almost virtual lumen. CONCLUSIONS: Both MRL and ICGL are dynamic diagnostic modalities that permit an effective evaluation of lymphatic vessels anatomical and functional status in extremities lymphedema these diagnostic procedures may be considered complementary because they show different aspects of lymphatic system. KEY WORDS: Indocyanine green, MR lymphangiography

3D-conformal hypofractionated radiotherapy for prostate cancer with daily transabdominal ultrasonography prostate localization: toxicity and outcome of a pilot study

Aims and background. To evaluate the feasibility, toxicity and patient outcome of hypofractionated 3-dimensional conformal radiotherapy for low- and intermediate-risk prostate cancer, using daily an ultrasound targeting system (BAT\u2122). Methods. Between May 2005 and October 2006, 25 patients (cT1-T2, GS 647,mean initial PSA = 7.06 ng/ml) received a dose of 72 Gy in 30 fractions. Only the prostate was included in the clinical target volume. Immediately before each radiotherapy session, BAT\u2122 ultrasound alignment was performed. Acute and late toxicity was evaluated according to the Radiation Therapy Oncology Group criteria; the Phoenix definition (PSA = nadir + 2 ng/ml) was applied to define biochemical failure. BAT\u2122 localization data were provided for 300 out of 750 procedures. Results. No interruptions in 3-dimensional conformal radiotherapy due to toxicity were registered. There was no acute rectal toxicity in 52% of patients; 28% had G1, 16% had G2, and 1 patient had a G3 event. No acute urinary toxicity was observed in 28% of the patients. G1 toxicity occurred in 40%, G2 in 28%, and G3 in 1 patient; no G4 event was observed. With an average follow-up of 45 months, one biochemical relapse was observed; late toxicity showed an excellent profile: 78% of the patients had no rectal toxicity, 16% had G1, and 1 patient had G2 toxicity. Most of the patients (68%) had no late urinary complications, whereas 32% had G1 toxicity. Localization data showed systematic and random errors in relation to some procedure biases. Conclusions. Promising tumor control and toxicity profile were observed with this mildly hypofractionated BAT-based 3-dimensional conformal radiotherapy. Free full text available at www.tumorionline.it

Our Experience Managing Difficult Accidental Chainsaw Trauma

Background: Chainsaw and circular-saw injuries represent a rare condition within the maxillofacial region. The purpose of this clinical report is to describe the injuries and the clinical and surgical management of these rare traumas.Methods: In this clinical report, 11 patients presenting themselves to the emergency room in the hospital "Policlinico Le Scotte," Siena, from March 2016 to September 2017 with severe chainsaw and circular-saw injuries, were included. All of the patients underwent general anesthesia and surgical treatment. This study describes 3 of the 11 patients with saw injuries.Results: No complications occurred during surgeries and a good primary closure of the wound margins were achieved in all patients. However, after surgery, the authors experienced some complications in 2 patients: the 1st one displayed chewing problems due to extensive local edema; the 2nd one developed a total loss of vision in his left eye, even though there was no damage inflected to the eye ball during the trauma or surgery.Conclusion: All the patients were followed during the 1st year after surgery. The authors evaluated the patients at 3 months, 6 months, and after 1 year, and none of them developed complications or alterations related to the trauma. However, 1 patient is still experiencing loss of vision and he is under constant specialized follow-up

Neuropsychological screening in the acute phase of cerebrovascular diseases

Introduction: Cognitive impairment is a common and disabling consequence of stroke. Its prevalence, the best way to screen for it in the acute setting, and its relation with premorbid status have not been thoroughly clarified. Materials and methods: Ischemic and hemorrhagic stroke patients admitted to our stroke unit underwent a baseline assessment that included a clinical and neuroimaging assessment, two cognitive tests (clock-drawing test, CDT; Montreal Cognitive Assessment-Basic, MoCA-B) and measures of premorbid function (including the Clinical Dementia Rating Scale). A follow-up examination was repeated 3-4 months after the acute event. Results: Two hundred and twenty-three patients (52.5% women, mean age \ub1 SD 75.8 years \ub1 12.3) were evaluated. Prestroke cognitive impairment was present in 91 patients (40.8%). At follow-up, the prevalence of cognitive impairment was 49%, while its incidence among patients who did not have any prestroke cognitive impairment was 38.8%. Of the originally admitted 223 patients (71 were lost to follow-up), only 60 (26.9%) were still cognitively intact at follow-up. On regression analysis, age and baseline CDT were associated with worsening of cognitive status at follow-up. In patients without cognitive impairment at baseline, a cutoff of 23 for MoCA-B and of 8.7 for CDT scores predicted the diagnosis of post-stroke cognitive impairment with sufficient accuracy. Discussion and conclusion: Prestroke and post-stroke cognitive impairment affect a large proportion of patients with stroke. Our findings suggest that a neuropsychological screening during the acute phase might be predictive of the development of post-stroke cognitive impairment

Orthognathic surgery: a randomized study comparing Piezosurgery and Saw techniques

INTRODUCTION: The purpose of this study was to evaluate specific parameters: intra-operative time, facial swelling, degree of pain (VAS scale), recovery time and neurosensory disturbance in patients who underwent orthognathic surgery either using piezo or saw devices. MATERIAL AND METHODS: We designed a retrospective study, which included 100 patients who underwent bilateral sagittal split osteotomy (BSSO) surgery combined with maxillary Le Fort I. They were separated into 2 groups of 50 patients each. The surgeries were performed between September 2015 and April 2017 by the same surgeon. RESULTS: Intra-op time is unchanged but patients operated with the Piezo devices requested fewer painkilling medication and were dismissed on the second day after the surgery. Neurosensory recovery was statistically significant in the Piezo group. CONCLUSION: Far less post-op swelling and the reduction in the use of painkillers lead to a speedier recovery in patients who underwent orthognathic surgery using Piezosurgery. These patients also recovered more sensitivity in the lower lip area. KEY WORDS: Orthognatic surgery, Piezosurgery, Saw