Three Case Reports of Adult-onset Still Disease Associated with Breast Implantation.

Autoimmune syndrome induced by adjuvants (ASIA) is an uncommon clinical condition reported by Shoenfeld et al. Although this syndrome is not scientifically validated, numerous reports on it have been published, and the manifestations are postulated to be diverse, including generalized symptoms such as chronic fatigue, myalgia, arthralgia, or dry mouth, induced by exogenous substances, specifically adjuvants, which can encompass vaccines, organisms, and silicone. Concurrently, adult-onset Still disease (AOSD) is also an infrequent ailment, characterized by spiking fever, arthritis, skin rash, lymphadenopathy, and serositis. Although the precise pathogenesis remains incompletely understood, some case reports suggest that ASIA may be at the root of AOSD development with the same instigator. In this context, we present three cases of patients diagnosed with AOSD, which possibly could be considered an association with ASIA, years after undergoing breast reconstruction with silicone breast implants. In one case, the patient solely received medical treatment due to her refusal to have the implant removed, resulting in multiple flares and severe complications related to glucocorticoid therapy. Conversely, in the other two cases, a combination of immunosuppressive therapy and silicone breast implant explantation led to the complete resolution of clinical symptoms. To the best of our knowledge, there are only 10 documented case reports of AOSD associated with silicone breast implants insertion. We believe this report serves as a complementary addition to prior research and offers further insights into the ongoing debate about whether explantation should be carried out early in the clinical course or not.

Squamous Cell Carcinoma of the Scalp Arising in a Site of Synthetic Hair Grafts.

Synthetic hair implantation was developed in the 1970s and initially gained popularity until major cutaneous complications, such as facial swelling, severe dermatitis, recurrent cellulitis, and cicatricial alopecia, became an issue. In particular, the procedure has been suggested to have a possible causal relationship with squamous cell carcinoma (SCC). This article describes the third reported case in the English literature of SCC arising in a site of synthetic hair grafts. The patient was an 80-year-old man with a prominent verrucous tumor in the parietal region; he had undergone synthetic hair implantation for the past 28 years. The pathological diagnosis of SCC was made by dermal punch biopsy, and computed tomography images revealed cranial osteolytic changes, with possible direct dural tumor invasion. Extensive resection of the tumor and reconstruction were performed following downsizing radiotherapy. The protruding tumor was excised with the adjacent portion of the parietal bone. Several synthetic hair grafts were found stuck in the cranium. The defect area was reconstructed with a synthetic bone material and a free latissimus dorsi muscle flap with skin graft. The pathological examination revealed well-differentiated SCC surrounded by numerous synthetic hair grafts inducing inflammatory cell infiltration and severe cicatrizing fibrous changes. The postoperative course was uneventful, and no recurrence or metastasis was observed at 9 months postoperatively.

Scarless Total Breast Reconstruction with a Fat-augmented Latissimus Dorsi Flap.

Total breast reconstruction with a fat-augmented latissimus dorsi flap (F-LDF) is a breakthrough approach that surmounts the shortcomings of the latissimus dorsi flap (LDF), such as volume insufficiency. Unlike the abdominal flap, the LDF can be harvested as a sole muscle flap without a skin paddle. This makes it possible to perform breast reconstruction with no donor-site scar when breast skin replacement is not required (eg, nipple-sparing mastectomy, two-stage reconstruction using a tissue expander). Here we describe a new approach for total breast reconstruction, namely scarless F-LDF reconstruction. First, the dorsal and ventral planes of the LDF are widely dissected through an inferolateral incision with monopolar electrocautery. The origin of the muscle is then separated using an energy-based device inserted through a stab incision, and immediate fat grafting is performed concurrently to the LDF and pectoralis major muscle. This new method was used in five cases, with a mean specimen weight of 285 g (range, 181-420), mean flap weight of 174 g (125-230), mean total fat graft volume of 214 ml (126-335), and mean duration of reconstruction surgery of 213 minutes (161-260). In all cases, sufficient volume was obtained postoperatively with satisfactory esthetic results. In addition to avoiding a donor-site scar, this method could reduce postoperative pain and donor-site seroma. The scarless F-LDF can be used for total breast reconstruction in certain populations, especially in cases requiring no skin replacement and for small- to medium-sized breasts.

Successful reconstruction of an intrathoracic tracheal defect using a muscle flap and conchal cartilage graft.

BACKGROUND: Malignant invasion of the respiratory tract is a common complication in advanced cases of esophageal carcinoma. Resection and reconstruction can be extremely challenging, particularly when the invasion is intrathoracic. A circumferential tracheal resection with direct tracheal closure or mediastinal tracheostomy is often performed, but the outcome is not always favorable, with high morbidity rates, loss of vocal function, and reduced quality of life. METHODS: We present our experience in performing an intrathoracic tracheal reconstruction in which a conchal cartilage graft was used in combination with a pectoralis major muscle transposition. RESULTS: This was successfully done following the noncircumferential resection of the intrathoracic trachea due to mural invasion by a metastatic lymph node of esophageal carcinoma. CONCLUSIONS: We believe this report will contribute to the growing body of clinical expertise on procedures for intrathoracic tracheal reconstruction.

Effectiveness of Skin Graft in the Chest for Postburn Cervical Contractures.

Skin grafts (SGs) offer a simple and reliable means of correcting postburn cervical contractures. However, their use has a high risk of contracture recurrence, as proper postoperative care is often difficult to perform. Splinting and pressure therapy are challenging in the neck, which has complex multidirectional mobility and contains critical structures. In contrast, the upper chest area, which also contributes to neck extension, has a relatively plane surface and rigid subcutaneous tissue, and is likely to be a more reliable site for pressure application. Here we report a case with good restoration of neck extension after using a split-thickness SG (STSG) only in the upper chest. A 22-year-old man with third-degree burns survived with the use of multiple SGs. Nine years later, he lacked a healthy donor site for a full-thickness SG or flap surgery. Although a split-thickness SG on the neck was performed for restricted cervical extension, severe contracture of the skin graft developed due to failure to continue postoperative pressure therapy. As a last resort, further surgery with a split-thickness SG was performed in the upper chest after releasing the contracture. With continued, successful postoperative pressure therapy, contracture of the skin graft was minimized. According to our survey of healthy volunteers, chest skin mobilization contributes to about 30% of cervical extension. This suggests that SG use in the chest is a reasonable option to reliability and effectively address restricted neck motility due to postburn contracture when a healthy donor site for a full-thickness SG or flap surgery is unavailable.

Successful Salvage of Pedicled Latissimus Dorsi Flap after Venous Thrombosis by Selective Thrombolytic Therapy.

While the use of free flaps has become routine and is associated with a low complication rate, pedicled flaps remain a solid reconstructive option in various clinical situations. Pedicled flaps provide a reliable vascular supply and involve a simple surgical procedure. Although the procedure is advantageous from the standpoint of a low rate of flap ischemia, thrombosis, and total flap loss, these complications are still occasionally observed due to intraoperative pedicle injury, postoperative torsion, or compression. Here we report on a case of severe venous thrombosis in a pedicled latissimus dorsi (LD) flap used for breast reconstruction. The patient was a 52-year-old woman who underwent mastectomy and immediate breast reconstruction with a LD flap for left breast cancer. Postoperatively, the color of the skin paddle became dark blue over time. Emergent surgical exploration revealed kinking and narrowing of the thoracodorsal vessels and extensive venous thrombi. The kinked pedicles were repaired and selective thrombolytic therapy was performed. A thrombolytic agent was administered through the serratus anterior branch of the thoracodorsal artery in retrograde fashion while the thoracodorsal vessels were clamped just cephalad to the bifurcation. This allowed for draining of the thrombolytic agent and thrombi through the serratus anterior branch of the thoracodorsal vein without flowing into the systemic circulation. To the best of our knowledge, this is the first report of selective thrombolysis using a pedicle branch to treat venous thrombosis in a pedicled flap. If major vascular branches are available in a pedicled flap, selective thrombolytic therapy may be possible without disconnecting the pedicle, as in the present case.

The Prognostic Impact of Determining Resection Margin Status for Multiple Colorectal Metastases According to the Margin of the Largest Lesion.

BACKGROUND: Although the prognostic role of surgical margin status after resection of colorectal liver metastasis (CRLM) has been previously examined, controversy still surrounds the importance of surgical margin status in patients with multiple tumors. METHODS: Patients who underwent curative-intent surgery for CRLM from 2000 to 2015 and who presented with multiple tumors were identified. Patients with R1 resection status determined by the closest resection margin of the non-largest tumor were classified as R1-Type 1; patients with R1 status determined by the resection margin of the largest tumor were defined as R1-Type 2. Data regarding surgical margin status, size of tumors, and overall survival (OS) were collected and assessed. RESULTS: A total of 251 patients met inclusion criteria; 156 patients (62.2%) had a negative margin (R0), 50 had an R1-type 1 (19.9%), and 45 had an R1-type 2 (17.9%) margin. Median and 5-year OS in the entire cohort was 56.4 months and 48.0%, respectively. When all R1 (Type 1 + Type 2) patients were compared with R0 patients, an R1 was not associated with worse prognosis (P = 0.05). In contrast, when R1-type 2 patients were compared with R0 patients, an R1 was strongly associated with worse OS (P = 0.009). On multivariate analysis, although the prognostic impact of all R1 was not associated with OS (hazard ratio [HR] 1.56; P = 0.08), R1-Type 2 margin status independently predicted a poor outcome (HR 1.93; P = 0.03). CONCLUSIONS: The impact of margin status varied according to the size of the tumor assessed. While R1 margin status defined according to the non-largest tumor was not associated with OS, R1 margin status relative to the largest index lesion was associated with prognosis.

Targeting Notch Signaling and Autophagy Increases Cytotoxicity in Glioblastoma Neurospheres.

Glioblastomas are highly aggressive tumors that contain treatment resistant stem-like cells. Therapies targeting developmental pathways such as Notch eliminate many neoplastic glioma cells, including those with stem cell features, but their efficacy can be limited by various mechanisms. One potential avenue for chemotherapeutic resistance is the induction of autophagy, but little is known how it might modulate the response to Notch inhibitors. We used the γ-secretase inhibitor MRK003 to block Notch pathway activity in glioblastoma neurospheres and assessed its effects on autophagy. A dramatic, several fold increase of LC3B-II/LC3B-I autophagy marker was noted on western blots, along with the emergence of punctate LC3B immunostaining in cultured cells. By combining the late stage autophagy inhibitor chloroquine (CQ) with MRK003, a significant induction in apoptosis and reduction in growth was noted as compared to Notch inhibition alone. A similar beneficial effect on inhibition of cloogenicity in soft agar was seen using the combination treatment. These results demonstrated that pharmacological Notch blockade can induce protective autophagy in glioma neurospheres, resulting in chemoresistance, which can be abrogated by combination treatment with autophagy inhibitors.

Mutant KRAS and GNAS DNA Concentrations in Secretin-Stimulated Pancreatic Fluid Collected from the Pancreatic Duct and the Duodenal Lumen.

OBJECTIVES: The analysis of secretin-stimulated pancreatic fluid is being evaluated as an approach to improve the early detection of pancreatic cancer and pancreatic precursor neoplasms. The method of pancreatic fluid sampling may have a significant impact on tumor marker measurements. The aim of this study was to compare concentrations of mutant DNA in pancreatic fluid from patients who had samples collected from both the pancreatic duct and duodenal lumen. METHODS: Thirty-six participants enrolled in the Cancer of the Pancreas Screening studies at Johns Hopkins Hospital who had secretin-stimulated pancreatic fluid collected from the duodenum during endoscopic ultrasound (EUS) and from the pancreatic duct during subsequent endoscopic retrograde cholangiopancreatography. Mutant KRAS and GNAS DNA concentrations were measured in pancreatic fluid samples using digital high-resolution melt-curve analysis and pyrosequencing and were related total DNA concentrations in these samples. RESULTS: Thirty-four patients had subtle parenchymal abnormalities by EUS; seven had small pancreatic cysts; none had pancreatic cancer. KRAS mutations were detected in 29 of 36 (80.6%) pancreatic duct fluid samples. Of these 29 patients, 23 had mutations detected in their duodenal fluid (79.3%). Patients with detectable pancreatic fluid but not duodenal fluid KRAS mutations had lower average pancreatic duct fluid KRAS mutation concentrations (P=0.01). Patients with KRAS or GNAS mutations detected in pancreatic fluid but not duodenal fluid had higher total DNA concentrations in their duodenal compared with pancreatic fluid (P=0.03). KRAS and GNAS mutation concentrations were higher in pancreatic duct fluid samples than in matching duodenal fluid samples (for KRAS: 2.62 vs. 0.39%, P<0.0001). CONCLUSIONS: KRAS and GNAS mutation concentrations are significantly lower in secretin-stimulated pancreatic fluid samples collected from the duodenum compared with samples collected from the pancreatic duct. Efforts to improve the purity of pancreatic fluid collections from the duodenum could improve the detection of mutations arising from the pancreas.