The Expression of Forkhead Box P3 T Regulatory Lymphocytes as a Prognostic Factor in Malignant Melanomas.

Since transcription factor Forkhead Box P3 (FoxP3) was identified as a specific regulatory T cell (Treg) marker, researchers have scrutinized its value as a potential novel therapeutic target or a prognostic factor in various types of cancer with inconsistent results. The present analysis was performed to assess the influence of Treg FoxP3 expression on the prognosis of primary melanoma and to evaluate the correlations with various clinicopathological prognostic factors. We analyzed all eligible patients with stage pT3 primary malignant melanomas treated in a tertiary cancer center. Immunohistochemical staining for Treg FoxP3 expression was performed on retrospectively identified paraffin blocks and subsequently correlated with the outcomes of the patients. A total of 81% of the patients presented a positive Treg FoxP3 expression, being correlated with a higher risk of lymph node metastasis, tumor relapse, and death. Moreover, positive expression was statistically associated with a shorter OS. The tumor relapse rate was estimated at 36.7%. A positive expression of Treg FoxP3 and lymph node metastasis were associated with a higher risk of death based on multivariate analysis. Treg FoxP3 expression may be used as an independent prognostic factor in patients with malignant melanoma to evaluate tumor progression and survival.

Experimental investigation of tension-reducing effectiveness of keystone perforator island flap.

Background and aim: Nowadays, the reconstruction of large and complex defects with keystone perforator island flaps (KPIF) has gained popularity in plastic and reconstructive surgery. The keystone perforator island flap was described as a curvilinear shaped trapezoidal design flap, with two V-Y advancement flaps end-to-side. It is a multiperforator advancement flap, based on multiple fasciocutaneous or musculocutaneous perforators, described by Behan in 2003. These flaps have a simple harvest technique, an easy-to-implement design, and they are time and cost-saving. Their blood supply lends a versatile and robust character, with less complications. Nonetheless, their biomechanical properties and effectiveness are unclear, the wound-closure tension-reducing effect is not well documented in existing literature. The present study aims to investigate the wound closure tension-reducing effect of type I, type IIA, type Sidney Melanoma Unit I (SMU) and type SMU II KPIFs. The main purpose of this study was to clarify the tension-reducing effect of the KPIF technique, which can contribute to the understanding of the biomechanical benefits of the KPIF. Methods: This is an experimental, in vivo study, based on twelve white race porcine models (PIC-FII-377), as their anatomy and wound healing process is very similar to that of humans. In this study, 42 wounds that could not be closed by primary wound closure, known as 'unclosable' elliptical defects, were created in six different anatomical regions. The criteria used for not achieving primary wound closure were the breaking of 0 nylon suture or the edges of the wound. Each defect was closed with different types of keystone perforator island flap: type I, type IIA, type Sydney Melanoma Unit I and type Sydney Melanoma Unit II. Keystone perforator island flaps were used in 42 cases. Intraoperative tissue tension was measured by an AXIS FB50, 50 N force gauge tensiometer. In all cases a wide elliptical excision was performed for the primary defect. Before reconstruction, tissue tension was measured across the widest point of the elliptical primary defect. Skin incision was performed for the first flap, without division of deep fascia. After preparing first flap, tension was measured at the widest point of the wound. Furthermore, deep fascia for the second flap was divided, tissue tension across the widest point of the primary defect was measured. Finally, tension was measurement across the widest point of the donor-site after closure of the defect-side flap and V-Y closure of either end of keystone perforator island flap. Results: In this study were included 12 porcine model (PIC-FII-377). A number of 42 keystone perforator island flaps were performed in this study, in six different anatomical regions, ranging between 3.3 x 12 cm and 16 x 30 cm. All elliptical defects were unclosable, with varying sizes ranging between 2 x 4 cm and 8 x 20 cm. The mean tension that was required to close all wounds with primary closure initially was 24.51 N 10.73 N. After using a type I KPIF a tension decrease of -7.04 N ± 4.93 N was seen, in the case of type IIA KPIF the tension decreased to -12.43 N± 5.63 N. Furthermore, after reconstruction with type SMU I KPIF the tension decreased to -7.38N ± 5.21N. After using a type SMU II KPIF a tension decrease of -10.52 N± 5.74 N was seen. Conclusions: The main purpose of this study was to clarify the tension-reducing effect of the KPIF technique, which can contribute to the understanding of the biomechanical benefits of the KPIF. The outcomes of the present study suggest that type I, type IIA, type SMU I, and SMU II of keystone perforator island flaps have a significant tension-reducing effects, especially the technique that involves the division of the deep fascia. The results of this experimental research thoroughly explain the benefits of these flaps. The effectiveness of the flap and doubts on biomechanical properties have not been answered so far. It will encourage more plastic surgeons to use the flap, especially given its proven benefits.

The Predictive Capabilities of Artificial Intelligence-Based OCT Analysis for Age-Related Macular Degeneration Progression-A Systematic Review.

The era of artificial intelligence (AI) has revolutionized our daily lives and AI has become a powerful force that is gradually transforming the field of medicine. Ophthalmology sits at the forefront of this transformation thanks to the effortless acquisition of an abundance of imaging modalities. There has been tremendous work in the field of AI for retinal diseases, with age-related macular degeneration being at the top of the most studied conditions. The purpose of the current systematic review was to identify and evaluate, in terms of strengths and limitations, the articles that apply AI to optical coherence tomography (OCT) images in order to predict the future evolution of age-related macular degeneration (AMD) during its natural history and after treatment in terms of OCT morphological structure and visual function. After a thorough search through seven databases up to 1 January 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 1800 records were identified. After screening, 48 articles were selected for full-text retrieval and 19 articles were finally included. From these 19 articles, 4 articles concentrated on predicting the anti-VEGF requirement in neovascular AMD (nAMD), 4 articles focused on predicting anti-VEGF efficacy in nAMD patients, 3 articles predicted the conversion from early or intermediate AMD (iAMD) to nAMD, 1 article predicted the conversion from iAMD to geographic atrophy (GA), 1 article predicted the conversion from iAMD to both nAMD and GA, 3 articles predicted the future growth of GA and 3 articles predicted the future outcome for visual acuity (VA) after anti-VEGF treatment in nAMD patients. Since using AI methods to predict future changes in AMD is only in its initial phase, a systematic review provides the opportunity of setting the context of previous work in this area and can present a starting point for future research.

Hidradenitis suppurativa. A case report.

Hidradenitis suppurativa is a disease with underestimated incidence, consequences and treatment difficulty. Regarded as a minor illness, for the patient it is disabling physically and socially, and for the doctor it is a challenge in choosing the appropriate treatment. We present the case of a 28-year-old man who presented with an advanced and persistent form of hidradenitis treated in a general surgery department. Solving the case combined conservative and surgical treatment (wide excisions, plasties with fasciocutaneous superior gluteal artery perforator flap, thoracodorsal artery perforator flap, free anterolateral thigh flap). This case illustrates the problems raised by a seemingly trivial disease. KEY WORDS: Fasciocutaneous Superior Gluteal Artery Perforator Flap, Follicular Occlusion, Free Anterolateral Thigh Flap, Hidradenitis Suppurativa, Skin Ulcer, Skin Fold, Thoracodorsal Artery Perforator Flap.

Treatment and Prevention of Periprosthetic Capsular Contracture in Breast Surgery With Prosthesis Using Leukotriene Receptor Antagonists: A Meta-Analysis.

BACKGROUND: Capsular contracture (CC) is the most common long-term complication of breast surgery with prosthesis. Leukotriene receptor antagonists (LRAs) have been tested as a potential treatment; however, mixed results have been observed. OBJECTIVES: The aim of this study was to undertake a meta-analysis to clarify the treatment and prophylactic capabilities of LRAs in the management of CC. METHODS: A systematic literature search of the most popular English-language databases was performed to identify relevant primary publications. We included all studies that used the Baker scale to evaluate the treatment and preventive capabilities of LRAs. RESULTS: Six eligible studies were included based on predefined inclusion and exclusion criteria, totalling 2276 breasts, of which 775 did not receive LRAs and 1501 did. Final pooled results showed that LRAs could help manage CC with a risk difference (RD) of -0.38 with a corresponding 95% CI of -0.69 to -0.08, showing statistical significance at a Z value of 2.48, P = 0.01. Subgroup analysis based on the type of drug showed that only montelukast yielded statistical significance (RD = -0.27, 95% CI = -0.51 to -0.03, Z = 2.20, P = 0.03). Zafirlukast did not seem to influence CC. Further subgroup analysis based on treatment timing showed that prophylaxis was ineffective and only treatment for ongoing CC yielded statistically significant improvements. CONCLUSIONS: The current meta-analysis proved that LRAs could be used in the management of CC. Only treatment for ongoing CC showed statistically significant improvements. Montelukast seemed to be more efficient with a safer profile for adverse effects, whereas zafirlukast yielded no statistically significant results.

Immediate Breast Reconstruction in Large Ptotic Breasts Using the Inferior Based Dermal Flap. Indications and Technique.

Introduction: Achieving good aesthetic outcomes during immediate reconstruction in women with large ptotic breast presents a unique challenge for the reconstructive surgeon. We present our paradigm regarding immediate reconstruction in patients with large ptotic breasts, using the inferiorly based dermal flap. Materials and Methods: Ten patients with large ptotic breasts underwent mastectomy and immediate implant reconstruction at the "Prof. Dr. I. Chiricuta" Institute of Oncology. The mastectomy was carried out using a Wise pattern skin resection with preservation of a dermal flap at the lower pole of the breast. The flap was sutured to the pectoralis major muscle and completed the subpectoral pocket created for the implant. Results: The reconstruction was done bilaterally in three cases with a total number of 13 reconstructed breasts. Of these 11 required dermal flaps. All reconstructions were completed successfully and there were no implant losses. Four breasts (36%) developed superficial necrosis of the tip of the mastectomy flaps at the T junction. Conclusion: The dermal flap technique is safe, versatile and reliable. It is used in a wide array of reconstructive scenarios as it provides the surgeon with an excellent alternative to more costly and unreliable methods.

The value of tumor infiltrating lymphocytes as prognostic factor for lymph node status and survival amongst patients with cutaneous malignant melanoma.

PURPOSE: Tumor infiltrating lymphocytes (TILs) in cutaneous malignant melanoma are classified as brisk, non-brisk or absent. Numerous studies suggest the presence of TILs, especially brisk, are associated with a lower rate of lymph node metastasis and with an improved overall survival (OS). Our purpose was to assess the value of TILs as a prognostic factor for the lymph node metastasis and survival in completely resected pT3 stage malignant melanoma patients. METHODS: We included a number of 114 patients with pathological pT3 cutaneous malignant melanoma, treated exclusively in our institution, between 2000-2015. Correlations of clinical and pathological factors with lymph node status and OS were analyzed. RESULTS: A brisk infiltrate was present in 60% of the patients, whereas 40% presented a non-brisk infiltrate or absent TILs. In univariate analysis, the presence of ulceration was correlated with a non-brisk infiltrate, whereas in multivariate analysis, lymph node invasion and a non-brisk infiltrate were associated with a higher risk of death. CONCLUSIONS: TILs density grade represents an independent prognostic factor for the OS. Therefore, we conclude that an accurate prognosis may be provided by TILs status in patients with pT3 malignant melanoma.

Using dynamic infrared thermography to optimize color Doppler ultrasound mapping of cutaneous perforators.

AIMS: The high technical demands associated with perforator flaps demand a precise preoperative identification and evaluation of perforator vessels. Color Doppler Ultrasonography (CDU) and Dynamic Infrared Thermography (DIRT) are currently used for preoperative perforator mapping. Each individual technique has advantages and disadvantages. The purpose of this paper is to analyze the value of combining the two methods in order to optimize the process of preoperative perforator mapping. MATERIAL AND METHODS: CDU and DIRT were used for preoperative perforator mapping in 10 pigs. The results were compared to intraoperative findings. Total number of perforators, localization, and identification of the dominant perforator was analyzed for each method. The examination time was recorded for each procedure. RESULTS: Both methods had a high sensitivity in determining the number and localization of perforators when compared to those identified during surgery. DIRT produced a higher number of false positive results. CDU accurately identified the emergence of the perforators in the fascia in all cases. Both methods correctly identified the dominant perforator. The sensitivity, positive predictive value, and accuracy of CDU were 93.56%, 97%, and 91.30% respectively and for DIRT 95.05%, 80.67%, and 77.41% respectively. The average examination was 39.76 minutes for CDU and 10.24 minutes for DIRT. The average time taken into account for the analysis of a single perforator in order to confirm DIRT findings was 1.83 minutes. CONCLUSIONS: Preoperative perforator mapping has become a compulsory step in nearly all reconstructive procedures. In our study, both CDU and DIRT correctly identified the dominant perforator in all cases. By combining the two examinations overall mapping time can be reduced significantly. A reduced examination time translates into increased patient compliance and a lower procedure cost. The combined mapping technique facilitates the selection of the ideal perforator in all cases. Correctly identifying the dominant perforator preoperatively reduces operative time, lowers complication rates and ensures an overall better result.

Dynamic perfusion assessment during perforator flap surgery: an up-to-date.

Flap monitoring technology has progressed alongside flap design. The highly variable vascular anatomy and the complexity associated with modern perforator flaps demands dynamic, real-time, intraoperative information about the vessel location, perfusion patterns and flap physiology. Although most surgeons still assess flap perfusion and viability based solely on clinical experience, studies have shown that results may be highly variable and often misleading. Poor judgment of intraoperative perfusion leads to major complications. Employing dynamic perfusion imaging during flap reconstruction has led to a reduced complication rate, lower morbidity, shorter hospital stay, and an overall better result. With the emergence of multiple systems capable of intraoperative flap evaluation, the purpose of this article is to review the two systems that have been widely accepted and are currently used by plastic surgeons: Indocyanine green angiography (ICGA) and dynamic infrared thermography (DIRT).

Staging laparoscopy in gastric cancer. Accuracy and impact on therapy.

BACKGROUND: Surgical therapy remains the most effective treatment modality in gastric cancer. The importance of multimodal treatment for advanced gastric cancer has contributed to the development of more accurate preoperative staging strategies. We examined the diagnostic accuracy of staging laparoscopy (SL) for abdominal metastases and the predictive value of SL for tumor resectability. MATERIAL AND METHOD: This is a prospective, cohort, observational study of 98 patients with primary gastric adenocarcinoma admitted at a tertiary referral hospital over a three year period. Extended SL, laparoscopic ultrasonography and peritoneal cytology were performed in 45 patients with gastric cancer without distant metastases on pre-therapeutic imaging staging. Of the 45 patients, 17 (37.8%) had distant metastases on SL and were offered palliative therapy and/or supportive care. Open laparotomy and gastrectomy was performed in the patients without distant metastases or with uncertain resectability on SL. RESULTS: An unnecessary laparotomy was avoided in 17 (37.8%) patients. The overall SL sensitivity for distant metastases was 89%, specificity 100% and diagnostic accuracy 95.5%. The sensitivity for lymph node metastases was 54.5%, the specificity 100% and the diagnostic accuracy 64.3%. The SL positive predictive value for resectability was 96% and the negative predictive value was 50%. The morbidity of SL was 2.2% and the mortality 0. CONCLUSION: Staging laparoscopy is a safe and effective staging modality in patients with gastric carcinoma. It avoids unnecessary laparotomies in a significant number of patients and should be mandatory if neoadjuvant treatment is planned.