Manejo de defeitos complexos do couro cabeludo após excisão de tumores malignos / Management of complex scalp defects after excision of malignant tumors

Introdução: A reconstrução do couro cabeludo após a ressecção oncológica continua sendo um desafio para o cirurgião, especialmente considerando a incidência crescente de câncer de pele entre pacientes idosos. A matriz dérmica (MD) é um grupo heterogêneo de materiais de cobertura de feridas que auxiliam no fechamento da ferida e substituem algumas das funções da pele, temporária ou permanentemente. Pacientes com maior risco cirúrgico podem se beneficiar do uso de MD, que ajuda a gerar uma nova derme, oferecendo grandes melhorias na cobertura de defeitos complexos e extensos. Métodos: É um trabalho retrospectivo com análise de prontuário e relato de dois casos de pacientes do A.C.Camargo Cancer Center-SP, Brasil. Resultados: Relatamos dois casos de defeitos complexos e extensos de couro cabeludo em um centro único usando MD associada a enxerto cutâneo e terapia de pressão negativa (TPN) na cirurgia reconstrutiva após ressecção de neoplasia maligna da pele com resultados funcionais e estético satisfatório. Conclusões: As lesões extensas do couro cabeludo são um desafio na prática clínica e um tratamento multidisciplinar é fundamental. Os resultados obtidos indicam que a MD associada com a enxertia de pele parcial e com a TPN tem enorme potencial para aumentar as opções terapêuticas disponíveis para o cirurgião e possivelmente beneficiando os pacientes, especialmente aqueles que não têm condições clínicas para uma cirurgia extensa de cobertura com retalho microcirúrgico.

Introduction: Scalp reconstruction after cancer resection remains a challenge for surgeons, especially considering the increasing incidence of skin cancer among elderly patients. Dermal matrix (DM) is a heterogeneous group of wound covering materials that aid in wound closure and replace some of the skins functions, either temporarily or permanently. Patients at higher surgical risk can benefit from the use of DM, which help to generate a new dermis, offering great improvements in coverage of complex and extensive defects Methods: It is a retrospective study with analysis of medical records and report of two cases of patients at the A.C.Camargo Cancer Center-SP, Brazil. Results: We report two cases of complex and extensive scalp defects at a single center using DM associated with skin grafting and negative pressure therapy (NPT) in reconstructive surgery after resection of malignant skin neoplasm with satisfactory functional and esthetic results. Conclusions: Extensive lesions of the scalp are a challenge in clinical practice and a multidisciplinary treatment is essential. The results obtained indicate that DM associated with partial skin grafting and NPT have enormous potential to increase the therapeutic options available to the surgeon and possibly benefit patients, especially those who do not have the clinical conditions for extensive coverage surgery with microsurgical flap.

Intraoperative assessment of surgical margins using ‟en face" frozen sections in the management of cutaneous carcinomas

Abstract Background: Basal cell and squamous cell carcinomas (BCC and SCC) are the most common types of cancer worldwide. Intraoperative assessment of surgical margins by frozen section has been widely used to ensure disease-free margins. The intraoperative ‟en face" freezing technique evaluates all peripheral and deep margins. Objective: To report the results of the ‟en face" freezing technique in relation to tumor recurrence and agreement with paraffin-embedded tissue examination. Methods: Retrospective analysis of patients undergoing surgical excision of BCC and SCC at the A. C. Camargo Cancer Center, Brazil. Results: This study included 542 skin carcinomas, which were excised from 397 patients. A total of 201 male patients (50.6%), and 196 female patients (49.4%) were assessed, whose mean age was 64 years. The tumors were mostly located on the head and neck region (87.8%). BCC corresponded to 79.7% of the cases. The mean follow-up was 38 months. Tumor relapse occurred in 0.86% of the primary tumors and 3.7% of recurrent tumors. The result of the intraoperative ‟en face" frozen section evaluation was in agreement with the final result of the anatomopathological examination (paraffin test) in 98% of the lesions. Study limitations: Not having a minimum follow-up time of 5 years for all patients. Conclusion: The ‟en face" freezing technique shows low tumor relapse, being reliable and safe to guarantee negative surgical margins of the tumor.

Postoperative complications following simultaneous therapeutic and contralateral prophylactic nipple-sparing mastectomy: a retrospective study

Introduction: Nipple-Sparing Mastectomy (NSM) is increasingly indicated for therapeutic and prophylactic purposes due to better cosmetic results with nipple maintenance. Postoperative complications have not been compared among patients who have undergone simultaneous therapeutic and contralateral prophylactic NSM. The aim of the present study was to evaluate the incidence and risk factors for postoperative complications in bilateral/unilateral NSMs, and therapeutic and/or prophylactic NSMs. Methods: Retrospective study of patients who underwent NSM between 2007 and 2017 at A.C. Camargo Cancer Center. Results: Among 290 patients, 367 NSMs were performed, 64 simultaneous therapeutic and contralateral prophylactic NSM. The latter were associated with more postoperative complications (OR=3.42; p=0.002), mainly skin flap necrosis (OR=3.79; p=0.004), hematoma (OR=7.1; p=0.002), wound infection (OR=3.45; p=0.012), and nipple-areola complex (NAC) loss (OR=9.63; p=0.003). Of the 367 NSMs, 213 were unilateral NSMs, which were associated with lower rates of postoperative complications (OR=0.44; p=0.003), especially skin flap necrosis (OR=0.32; p=0.001), hematoma (OR=0.29; p=0.008), wound infection (OR=0.22; p=0.0001), and reoperation (OR=0.38; p=0.008). Obesity was related to more postoperative complications (OR=2.55; p=0.01), mainly hematoma (OR=3.54; p=0.016), reoperation (OR=2.68; p=0.023), and NAC loss (OR=3.54; p=0.016). Patients' age (p=0.169), their smoking status (p=0.138), breast ptosis (0.189), previous chest radiotherapy (p 1), or previous breast surgery (p=0.338) were not related to higher chances of postoperative complications. Conclusions: Results suggest that performing therapeutic and contralateral prophylactic NSM as separated procedures may represent a good strategy for minimizing postoperative complications.

How does the mitotic index impact patients with T1 melanoma? Comparison between the 7th and 8th edition of the American Joint Committee on Cancer melanoma staging system

Abstract Background: The mitotic index is no longer used to classify T1 melanoma patients into T1a and T1b, so it should not be used to indicate sentinel node biopsy in these patients. Objectives: To evaluate patients with T1 melanoma who underwent sentinel lymph node biopsy and to compare those who were classified as T1a with those classified T1b, according to the 7th and 8th Edition of the melanoma staging system, regarding a positive biopsy result. The authors also aimed to assess whether there is any difference in the results in both staging systems. Material and methods: This was a retrospective analysis of 1213 patients who underwent sentinel lymph node biopsy for melanoma, from 2000 to 2015, in a single institution. Results: Of 399 patients with thin melanomas, 27 (6.7%) presented positive sentinel lymph nodes; there was no difference in positivity for sentinel node biopsy when comparing T1a vs. T1b in both staging systems. Furthermore, the clinical results were also similar between the two groups. However, in the complete cohort analysis, the mitotic index was associated with positivity for sentinel lymph node biopsy (p < 0.0001), positivity for non-sentinel lymph node (p < 0.0001), recurrence-free survival (p < 0.0001), and specific melanoma survival (p = 0.023). Study limitation: Unicentric study. Conclusion: The mitotic index was shown to be a very important prognostic factor in the present study, but it was not observed in patients classified as T1. The mitotic index should no longer be used as the only reason to refer sentinel lymph node biopsy in patients with thin melanoma.

Diphencyprone as a therapeutic option in cutaneous metastasis of melanoma. A single-institution experience

Abstract: Diphencyprone has been reported as a local immunotherapy for cutaneous melanoma metastases. We aim to report cases of melanoma patients treated with diphencyprone in a single Brazilian institution and highlight their outcomes. Since 2012, we have treated 16 melanoma patients with cutaneous metastases with topical diphencyprone. To date, we have had 37.5% of complete response, 25% of partial responses, and 31.25% patients without any response. Treatment was well tolerated and local toxicity was easily controlled. We believe topical diphencyprone is a feasible treatment that can be another option for treating melanoma patients, especially in cases of in-transit or extensive disease.

Criação de um nomograma preditivo de comprometimento de linfonodos não sentinela, em pacientes com melanoma cutâneo após linfonodo sentinela positivo / Creating a predictive nomogram for non-sentinel node positivity in melanoma patients after a positive sentinel node biopsy

Ainda que a técnica da biópsia do linfonodo sentinela (BLS) esteja consagrada como ferramenta de estadiamento em pacientes com melanoma cutâneo, a conduta frente à positividade do linfonodo é alvo de discussão. Evidências recentes mostram que não há benefício oncológico em completar a linfadenectomia nesses pacientes. Entretanto, reconhecer pacientes com comprometimento de linfonodos não sentinela (LNNS) tem valor prognóstico e pode auxiliar na seleção de pacientes que se beneficiariam de tratamentos adjuvantes. Objetivos: O objetivo primário é criar um nomograma preditivo de comprometimento de LNNS na linfadenectomia, baseado em características clínicas do paciente e anatomopatológicas do tumor primário e do linfonodo sentinela, nos pacientes portadores de melanoma cutâneo. O objetivo secundário é avaliar, dentro dessas mesmas características, como elas influenciam em sobrevida livre de recidiva (SLR) e sobrevida melanoma específica (SME), nos pacientes com BLS positiva e também nos pacientes com BLS negativa. Material e métodos: Análise retrospectiva dos pacientes com diagnóstico de melanoma cutâneo submetidos à BLS no Núcleo de Câncer de Pele do A.C.Camargo Cancer Center, São Paulo / SP ­ Brasil, entre os anos de 2000 a 2015. Variáveis significativas dentro dos modelos de regressão logística múltipla e regressão de Cox múltipla foram utilizadas para a criação dos nomogramas. Resultados: No período estudado foram realizadas 1223 BLS, das quais 10 foram excluídas das análises. A BLS foi positiva em 246 casos (20,3%), permitindo criar um nomograma preditor de positividade baseado na topografia da lesão primária, espessura de Breslow, índice mitótico, regressão e invasão linfática, com acurácia de 74,5%. Dentre esses pacientes, 242 foram submetidos a linfadenectomia e 37 (15,3%) apresentaram LNNS acometidos. O nomograma preditor dessa situação utilizou como variáveis índice mitótico, número de linfonodos sentinela positivos e diâmetro do maior foco metastático no linfonodo positivo, e apresentou acurácia de 86,3%. Entre os pacientes com BLS negativa, espessura de Breslow, satelitose microscópica e ulceração foram os fatores associados com risco de recidiva, criando assim um terceiro nomograma. Conclusão: Foi possível criar um nomograma preditivo de probabilidade de comprometimento de LNNS em pacientes portadores de melanoma cutâneo com BLS positiva. Também foi possível avaliar fatores de pior prognóstico, no que tange SLR e SME nos pacientes com BLS negativa

Although Sentinel Node Biopsy (SNB) is a well-established staging tool in melanoma patients, the management of these patients after a positive node is controversial. Recent data shows no oncological benefits in completion node dissection. However, identification of patients with positive non-sentinel nodes (NSN) presents a prognostic value and can help on selecting patients that may benefit from adjuvant therapies. Objectives: Primary endpoint is the creation of a predictive nomogram for NSN positivity based on clinical and pathological features and both on primary tumor and sentinel node characteristics in melanoma patients. Secondary endpoint is to evaluate the influence of these features in recurrence free survival (RFS) and Melanoma specific survival (MSS) not only in melanoma patients with a positive SNB but also in those with a negative SNB. Material and Methods: Retrospective analysis of melanoma patients who underwent SNB in the Skin Cancer Department of A.C.Camargo Cancer Center ­ São Paulo / SP ­ Brazil, between 2000 and 2015. Significant variables in the multiple logistic regression models, as well as in Cox regression models were used for the nomograms. Results: There were 1223 SNB in the period, and 10 of them were excluded from the analysis. SNB was positive in 246 cases (20.3%), which led to the creation of a predictive nomogram for positivity based on topography of primary lesion, Breslow thickness, mitotic index, regression and lymphatic invasion, with 74.5% of accuracy. Among these patients, 242 underwent completion node dissection and 37 (15.3%) had positive NSN. For this situation, mitotic index, number of positive sentinel nodes and diameter of the largest metastatic deposit in the positive node were used as variables for the predictive nomogram, with an 86.3% accuracy. Among patients with a negative SNB, Breslow thickness, ulceration and microscopic satellitosis were related to higher recurrence risk, and a third nomogram was done. Conclusion: It was possible to create a predictive nomogram for NSN positivity in melanoma patients after a positive SNB. It was also possible to evaluate worse prognostic factors regarding RFS and MSS in melanoma patients after a negative SNB

Isolated limb perfusion with hyperthermia and chemotherapy: predictive factors for regional toxicity

OBJECTIVE: Isolated limb perfusion combined with melphalan is an accepted treatment for obtaining locoregional control in advanced melanoma of the extremities and other malignant neoplasias restricted to the limb. This study aims to examine the factors associated with toxicity caused by the regional method. We considered the technical aspects of severe complications associated with the procedure in an attempt to diminish the patient morbidity that occurs during the learning curve. METHODS: We conducted a retrospective analysis of the records of patients who underwent perfusion at the AC Camargo Hospital in São Paulo, Brazil between January 2000 and January 2009. The Wieberdink scale was applied to classify local toxicity and its relation to clinical and laboratory variables. RESULTS: Fifty-eight perfusions were performed in 55 patients. Most patients (86.2%) presented a toxicity level between I and III. Grade V toxicity was seen in five cases (8.6%), four of which occurred in the first 2 years. Creatine phosphokinase, an important predictive factor for toxicity, had an average value of 231.8 for toxicity grades I-III and 1286.2 for toxicity grades IV-V (p = 0.001). There was a relationship between the melphalan dose and toxicity, which was 77 mg (25 to 130 mg) for toxicity grades I-II and 93.5 mg (45 to 120 mg) for toxicity grades IV-V (p = 0.0204). CONCLUSION: It is possible to prevent the toxicity associated with melphalan by adjusting the dose according to the patient's body weight (especially for women and obese patients) and the creatine phosphokinase values in the postoperative period.