Pilomatrix Carcinoma of the scalp. A case report and review of the literature.

INTRODUCTION: Pilomatrix Carcinoma (PC) is a rare and malignant dermo-hypodermic tumor. Only 11 cases were reported in patients younger than 18 years old and only 13 cases were reported on the scalp. CASE REPORT: We report the case of a 15-year-old woman who underwent cyst excision on the vertex. Anatomopathology shed light trichilemmal cyst. Five months later, she presented a first local recurrence. The tumor was removed with wide margin. Anatomopathology shed light PC. No adjuvant therapy was performed. The patient presented a second recurrence 3 months later with a parietal bone and superior sagittal sinus invasion and a lung metastasis. She underwent a craniotomy and radiochemotherapy. A third local recurrence was detected 4 months later. Three more lines of chemotherapy were performed without success. DISCUSSION: PC is a locally aggressive tumour, with a high rate of local recurrences and metastases. PC arises de novo or through malignant transformation of a pilomatrixoma. PC were observed frequently in the white male over 50 years old. The histological diagnosis is difficult to prove. Treatment consists of a wide surgical excision. Peritumoral margins are not codified. Because of most cases are on the face and neck, Mohs Micrographic Surgery seems to be a good modality to limit margins. Radiation therapy is an adjuvant treatment. Chemotherapy can be used in metastasis case. CONCLUSION: PC is a rare malignant tumor with high rate of disease relapse. Histological diagnosis is difficult and treatment is not standardized. Surgical procedure with wide margins is recommended to avoid the large recurrence when the staging shows no metastasis.

Initial staging for squamous cell carcinoma of the mouth, larynx and pharynx (except nasopharynx). Part 3: general assessment. 2012 SFORL recommendations.

OBJECTIVES: The French Society of Otorhinolaryngology (SFORL) set up a work group to draw up guidelines for initial staging of head and neck squamous cell carcinoma. Locoregional and remote extension assessment are dealt with in two separate reports. The present part 3 deals with the assessment of frequent associated symptoms and pathologies, requiring early treatment and the collection of data on a certain number of clinical and paraclinical parameters for therapeutic decision-making in the multidisciplinary team meeting. MATERIALS AND METHODS: A multidisciplinary critical analysis of the literature was conducted. General assessment here covers screening, assessment and initial management of the following: usual risk factors (smoking, alcohol, HPV), the most frequent medical comorbidities, nutritional status, social and psychological status, dental status, pain and possible anemia. As oncologic management frequently associates surgery, radiation therapy and chemotherapy, the underlying examinations should be early, as part of initial staging. The levels of evidence for the examinations were estimated so as to grade guidelines, failing which expert consensuses were established. RESULTS: The high rates of pain, malnutrition and anemia call for systematic screening and early management, especially as rapidly effective treatments exist. Assessing comorbidity and social and psychological status enables general health status to be assessed, along with possible contraindications to the usual treatments. Tracheal intubation problems may require intubation under flexible endoscopy or jet-ventilation by inter-cricothyroid catheterization from the diagnostic endoscopy stage. Assessment and adapted dental care should be conducted if radiation therapy is likely or certain. CONCLUSION: Early management of symptoms and comorbidity and anticipation of subsequent treatment are intended to shorten initial staging time and to collate the data needed for therapeutic decision-making. This assessment should be performed at the same time as the locoregional and remote extension assessment, and is obviously to be adapted according to tumoral extension stage and the possible treatment options.

Intradermal tacrolimus prevent scar hypertrophy in a rabbit ear model: a clinical, histological and spectroscopical analysis.

BACKGROUND: Keloids and hypertrophic scars (HSc) affect 4.5-16% of the population. Thus far, the different approaches of keloid treatment are not very efficient, with a 50% relapse rate and many ongoing researches are looking for simple, safe and more efficient therapeutic methods. Tacrolimus is an immunomodulator that could be useful in treating keloid. OBJECTIVES: The objective of this study is to evaluate the effectiveness of Tacrolimus in inhibiting HSc formation on rabbits' ears model and to check optical skin spectroscopy in tissue characterization. METHODS: Our study was carried out on 20 New-Zealand female white rabbits. HSc were obtained by wounding rabbits' ear. These wounds were treated with intradermal injections of tacrolimus (0.2-0.5 mg/cm(2)) or a vehicule. The assessment of treatment efficacy was performed by clinical examinations, histological assay and skin spectrometry. RESULTS: Tacrolimus did not induce general or local side-effects. The scar elevation index in treated subjects was half less than that of the untreated ones. Furthermore, dermal thickness and inflammatory cellular density were both significantly smaller for treated scars than for the control ones. In vivo optical skin spectroscopy can characterize hypertrophic and normal skin with high sensibility and specificity. CONCLUSION: Intradermal injection of tacrolimus at 0.5 mg/cm(2) is an efficient way to prevent HSc in our experiment model and its tolerance is correct. Optical spectroscopy could be a good non-invasive tool to evaluate HSc treatment. These promising results might be proposed for patients suffering from keloid.

[Bizarre parosteal osteochondromatous proliferation or Nora's lesion]. / Prolifération ostéocartilagineuse parostéale bizarre ou lésion de Nora.

Bizarre parosteal osteochondromatous proliferation (BPOP) is a very rare benign lesion on face bones. The first line treatment is surgical exeresis. The frequency of recurrence after exeresis may suggest a malignancy.

Keloids treated with postoperative Iridium 192* brachytherapy: a retrospective study.

BACKGROUND: Post-excisional brachytherapy with Iridium 192 is a treatment of keloids scars (KS). Its indications and its parameters are not subject to any consensus. OBJECTIVE: We wanted to assess the effectiveness and satisfaction of patients treated in our centre. PATIENTS AND METHODS: This was a retrospective study conducted from November 2006 to November 2007. Patients with clinically and histologically proven KS treated between 1990 and 2005, were convened in consultation between September and October 2007. Clinical data and parameters of the brachytherapy have been collected. RESULTS: Eighty-seven patients (138 KS) were treated. Eighty-two KS (46 patients) met the criteria for inclusion. Thirty-two patients (55 KS) have been seen in consultation. The average time between the onset of KS and treatment was 63.5 months. The brachytherapy has begun after a maximum of 7 hours posterior to surgery for all KS. The average dose was 17.9 Gy calculated at 5 mm. We observed 23.6% of recurrence after treatment. Seventy-nine per cent of itching and 87.5% of pain have totally disappeared. The phototypes 5 and 6 had an increased risk of recurrence. DISCUSSION: This is the most important series of KS treated with Post-excisional brachytherapy presented so far. The technique is efficient in preventing keloid recurrence and in treating the functional signs, but at the expense of an unaesthetic result, of which patient must be warned about. A follow-up of at least two years after treatment is recommended.

[A simple tissue expansion device for scalp defect]. / Dispositif simplifié d'extension tissulaire pour la fermeture d'une perte de substance du cuir chevelu.

INTRODUCTION: The closure of scalp defects requires various procedures, but unfortunately with a high rate of sequels. OBSERVATION: The authors report their experience regarding a large pilomatrixoma of the scalp. The closure of an 8 by 10 cm defect resulting from excision was achieved using a simple tissular extension device during 20 days. The scar aspect was very satisfactory. The device is derived from Cohn's model. It is made of simple and widely used material (vascular lacks, staples). DISCUSSION: This simplicity and efficiency of tissular extension devices has been proved. Nevertheless, their use may be restricted. This limitation often results from a high cost and difficulty in applying the adequate tension to the wound edges. Excessive tension may lead to cutaneous necrosis. The use of a simple device derived from Cohn's model seems interesting considering its efficiency, reliability, and low cost.

[Uni-axial tissular extension for covering skin defects of the limbs. A 31 cases review]. / Extension tissulaire uni-axiale dans la couverture des pertes de substance des membres. A propos de 31 cas.

INTRODUCTION: The skin property to adapt to external constraints is widely used in plastic surgery. Tissue expansion is the most known and codified application. Tissue extension appears to be an attractive alternative. The authors propose the usage of a simplified procedure to deal with skin loss in the superior or inferior members. MATERIAL AND METHOD: Thirty-one patients underwent uni-axial traction between February 2000 and October 2003. RESULTS: Closure of skin loss on the upper member has been obtained in 6 days and in 8 days on the inferior member. DISCUSSION: Efficiency, reliability and no subsequent aftermaths are strong arguments in favor of the development of a simplified extension procedure. CONCLUSION: The tissue extension procedure, although scarcely used is an attractive procedure for the coverage of skin losses.

[Analysis of the implications of the adipose tissue in facial morphology, from a review of the literature and dissections of 10 half-faces]. / Analyse des implications du tissu graisseux dans la morphologie faciale, à partir d'une revue de la littérature et de dissections de dix hémifaces.

The morphological implications of the fatty tissue of the face are unequal. We study these with a review of the literature and an anatomical study with dissections of 10 half-faces. The sub-cutaneous fat, over the superficialis fascia, have got the most important implications on the morphology. These depend of the localisations on the face and the age and the weight of each subject. We can observe modifications of the positions of this fatty layer on old subjects, but also a diminution of its volume. The sub-fascial fatty tissue, above the SMAS is represented by few fat pads and seems ,to bee less concerned by modifications of its volumes.

[Facial fat: descriptive and functional anatomy, from a review of literature and dissections of 10 split-faces]. / La graisse de la face : anatomie descriptive et fonctionnelle à partir d'une revue de la littérature et de dissections de dix hémifaces.

The aim of this study is to describe the anatomy of the fat in the face, based on a review of the literature and dissections of 10 half-faces. The facial fat can be divided in two layers. The first-one is superficial, between the skin and the superficialis fascia. Its function is essentially protective and its morphological implications are major, especially according to the facial aging. The other layer is deep, under the superficialis fascia. Its principal function is mechanical and its morphological implications are less important. This layer is made of several fat pads in continuity, excepted the buccal fat pad which is separated from the others by its own capsula. The other fat pads are the intra orbialis fat pad, the sub orbicularis oculi fat pad (SOOF), the retro orbicularis oculi fat pad (ROOF), the galeal fat pad and the temporal fat pad.

[Hypertrophic diseases of facial fatty tissue]. / Pathologies hypertrophiques des tissus graisseux de la face.

Based on our own experience and a review of the literature, we des-cribe hypertrophic diseases concerning the fatty tissue of the face. Pathological patterns are numerous and polymporphous. Fatty localizations involving the face may be associated or not with specific histological presentation.

[Contribution of the pathology examination in the operating theatre in patients with skin cancer: retrospective analysis of 388 patients]. / Intérêt de l'examen histologique extemporané dans les carcinomes cutanés: étude rétrospective de 388 patients.

INTRODUCTION: Pathological examination in the operating theatre in patients undergoing resection of a skin cancer is one of the most adapted therapeutic approaches. We present our experience with 388 patients, comparing the rate of recurrence with or without operating-theatre pathological examination. MATERIAL AND METHOD: The study population included 388 patients, mean age 69.5 years (28-98 years) who underwent resection of 544 skin tumors (520 primary and 36 recurrent), 76.6% unique tumors. The pathological examination of the surgical specimen was performed immediately after removal. This method was systematic procedure for spinocellular carcinomas, was not performed for basocellular carcinomas measuring less than 1 cm when well circumscribed and not peri-orifice, and when reconstruction was not planned. RESULTS: The pathological examination was not performed in the operative theatre for 76 tumors; for 470 examinations performed in the operative theatre, at least one surgical margin was positive in 93 (19.8%). Anatomic regions concerned most were the tip of the nose and the eyelids. Recurrent tumors (5.0% of resections) accounted for 27% of the positive pathological results. Thirty-one patients had to have revision surgery, four after a false negative on the pathological examination performed in the operative theatre, four patients for a healing problem and 23 because of tumor recurrence (4%). DISCUSSION: Pathological examination in the operative theatre can help decrease the rate of recurrence in comparison with classical surgery using empiric margins. This method is reliable if performed by an experienced pathologist so that reconstruction can be undertaken before the definitive pathological results are obtained, improving patient comfort. These therapeutic options have a cost however in terms of equipment and personnel. Indications should be well chosen and balanced against the advantages of a two-phase classical procedure.

[Goal cell carcinoma: really a low malignancy tumor?]. / Les carcinomes cutanés basocellulaires méritent-ils leur réputation de tumeurs à faible malignité?

Although basal cell carcinoma often presents as a fairly "benign" lesion early in its course, it remains the most frequent malignancy worldwide. Prevention, while possible, is not always optimal. We show that advanced basal cell carcinoma can be mutilating or even life threatening depending on location, type of lesion, or pre-existing co-morbidity. The consequences of this disease can be lessened if initial treatment does not underestimate its potential severity.

Microsurgical lip replantation: evaluation of functional and aesthetic results of three cases.

Lip amputations are rare, and microsurgical replantation must be systematically tried to restore form and function in one step. The authors present a series of three cases. Revascularization of the amputated segment was obtained by arterial anastomosis with the corresponding labial coronary artery. No venous anastomosis was carried out, because no vein could be identified. Venous drainage was obtained by inducing bleeding and by postoperative application of leeches for 6 days. Anticoagulant therapy and antibiotherapy were used for 10 days. With this approach, two lip amputations were completely saved, and a third amputation only suffered partial necrosis. Aesthetic and functional results were evaluated as being good, with reestablishment of labial continence and recovery of protective sensitivity.

[Principles of treatment of total unilateral cleft lip and palate. Suggested protocol]. / Principes de prise en charge des fentes labio-maxillo-palatines unilatérales totales. Propositions de protocole.

Complete uni-lateral cleft palates resulting from failed union between internal and external nasal buds cause an imbalance of both superficial and deep nasal structures. After summarizing the principles that should guide the care of these anomalies, the authors present their therapeutic procedure, in which orthopaedic and surgical treatments are intimately associated. They conclude their presentation by emphasizing the difficulty of predicting the definitive result because of the extreme diversity of the sequellae that always accompany the treatment of cleft palates.

[Orthopedic treatment of labio-maxillo-palatal clefts: our approach]. / Traitement orthopédique des fentes labio-maxillo-palatines: notre attitude.

Many authors use a preliminary orthopedic procedure before cleft lip and palate surgical closure in order to prevent possible bone distortion following the rupture of the muscle belts resulting from the cleft. Actually, this is generally not only an orthopedic treatment but rather a surgical orthopedic step which includes lip adhesion before the surgical closure of the clefts. Following the procedures proposed by Georgiade and Latham, we have used since 1996 a treatment based on traction applied with an elastic chain on splints attached by transmaxillary pins for certain types of clefts, namely unilateral complete clefts with endognathy of the small fragment, unilateral complete clefts larger than 7 mm, bilateral wide complete clefts with premaxilla protrusion, and bilateral wide complete clefts with collapsus and premaxillary protrusion. Technical procedures vary with the type of cleft. Standard procedures with or without jacks are used for the other types of complete clefts. These orthopedic procedures with elastic traction are performed between the 3rd and 6th week, before lip adhesion of the upper part of the lip (combined with release of skin and subcutaneous tissues from the underlying alar cartilage). A palatine plate with or without a jack, fitted most of the time with a spring for nostril support, is then inserted until surgical closure.

Postoperative brachytherapy alone for T1-2 N0 squamous cell carcinomas of the oral tongue and floor of mouth with close or positive margins.

PURPOSE: To evaluate the efficacy of postoperative brachytherapy alone (brachy) for Stage T1-2 squamous cell carcinomas (SCC) of the floor of mouth (FM) and the oral tongue (OT) with close or positive margins. METHODS AND MATERIALS: Between 1979 and 1993, 36 patients with T1-2 N0 (24 T1, 12 T2) OT (19), and FOM (17) SCC with close or positive margins following surgery underwent postoperative brachy. Mean patient age was 56 years (range 37-81) and sex ratio was 3.5:1 male:female. Mean surgery to brachy interval was 36 days (range 16-68). The technique used was interstitial Iridium-192 ((192)Ir) brachytherapy with plastic tubes and manual afterloading. Mean total dose was 60 Gy (range 50-67.4) at a mean dose rate of 0.64 Gy/h (range 0.32-0.94). Mean patient follow-up was 80 months. RESULTS: The 5-year actuarial overall and cause-specific survivals of the entire group were 75% and 85%, respectively. The local control was 88.5% at 2 years, with a plateau apparent after 23 months. Of the 4 local relapses, 2 were salvaged with surgery and external beam radiotherapy (EBR). No tumor or treatment factors, including tumor size, margin status, disease site, or radiation dose, were correlated with local control. The 2 head and neck second primaries underwent curative treatment on nonirradiated tissue. One patient developed a grade 3 sequelae (bone and soft tissue necrosis). Grade 2-3 chronic sequelae were seen in 7 of 17 and 3 of 19 FOM and OT tumors, respectively (p = 0.09). CONCLUSION: Postoperative brachy is a promising approach in T1-2 N0 OT and FOM SCC with close or positive margins. This approach is associated with high rate of locoregional control and low risk of chronic sequelae, obviates major surgery, avoids potential sequelae of EBR (xerostomia, dysgueusia, fibrosis), and avoids treatment of second head and neck primary on nonirradiated tissues.

[The value of sialo-MRI in the study of salivary gland duct pathology]. / Intérêt de la sialo-IRM dans l'exploration des pathologies canalaires des glandes salivaires.

Usual imaging diagnostic for salivary glands is sialography. Sialography is not stripped of disadvantages and failures. The MRI-sialography is an examination which is carried out without any injection of contrast's product (without catheterization or intravenous injection). It is thus noninvasive and painless. The complete study of salivary gland and its ducts is always possible and could not be blocked by local or loco-regional conditions. It allows exploration of several salivary glands in the same time. We think that the MRI-sialography must find its place in the diagnosis arsenal for salivary pathology in spite of its current handicaps represented by its cost and the difficulty of access to the apparatuses.