An unusual tumor in a rare localization: intravascular leiomyosarcoma of the cephalic vein. Case report.

Vascular leiomyosarcoma is a very rare soft tissue neoplasma, with a poor prognosis. We report a vascular leiomyosarcoma arising from an unusual site: the media-vascular wall of the cephalic vein. A 71-year-old man with a subcutaneous node on the volar side of right forearm, came to our attention with signs of vascular obstruction and venous stases, without functional or sensory loss of the right upper extremity. We successfully performed a surgical excision of the cancer with a wide margin resection. During surgery no ascellar lympnodes metastes were found. 4 months after surgery the wound had fully healed, and he suffered no effects by surgery, but he became lost to long-term follow-up and refused adjuvant radiotherapy or chemiotherapy. This case report shows that, in presence of venous stases or thrombosis signs of the upper extremity, leiomyosarcoma of the cephalic vein must be considered in the differential diagnosis among lung cancer, lymphoma or mesenchymal tumours.

The three dermoglandular flap support in reduction mammaplasty.

BACKGROUND: Bilateral breast reduction is an established procedure performed to relieve the physical pain and psychological discomfort associated with heavy, pendulous breasts. Numerous techniques have been developed over the years with several refinements to obtain safe nipple-areola complex transposition and harmonious breast shape. Based on the experience of the senior author (M.P.), the three dermoglandular flap technique is proposed to achieve a safe and aesthetically pleasing breast reduction through the surgical concept of dermal support. METHODS: The authors analyzed the benefits of the three dermoglandular flap technique performed in a selected group of smoking patients with a potentially high risk of postoperative complications and high probability of breast ptosis recurrence (each patient had breast volume >1000 cc, breast nipple ptosis grade 3 on Regnault's scale, and body mass index >27). Blood supply to the nipple-areola complex was based on an inferior-central pedicle. RESULTS: Between 1995 and 2007, 47 smokers underwent bilateral breast reduction using the three dermoglandular flap technique. Their ages ranged from 37 to 63 years (mean, 49 years), and their average body mass index was 31.2 kg/m (range, 27 to 38). The overall complications rate was 14.9 percent. No wound breakdowns and no complete or partial necrosis of the nipple-areola complex was observed. Follow-up ranged from 18 to 48 months (mean, 32 months). CONCLUSIONS: : Three dermoglandular flap reduction mammaplasty produced good cone shape, soft texture, and fullness in the central and inferior pole with satisfactory breast projection and was stable over time. It offers a safe and practical approach in the treatment of challenging breast hypertrophy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A new protocol for the treatment of the chronic venous ulcers of the lower limb.

Venous leg ulcer is a pathological condition afflicting prevalently elderly patients, which has been found to have a major impact on individuals' health and social aspects of quality of life. Actually, the best practice treatment is recommended to include wound dressing and multilayer compression therapy. In this study, we have tested the effectiveness and safety of Vulnamin(®), a novel dressing in the form of a metal cellulose gel containing the amino acids glycine, L: -lysine, L: -proline, L: -leucine, and hyaluronic acid, and elastic compressive bandages in the treatment of chronic venous ulcers of the lower limbs. The study has been conducted in two groups of patients, one treated with Vulnamin(®) plus Ca-alginate (ulcer duration = 25.4 ± 6.2 weeks; mean baseline ulcer area = 13.9 ± 4.5 cm(2)) and a control group treated with Ca-alginate alone (ulcer duration = 23.4 ± 4.2 weeks; mean baseline ulcer area = 15.1 ± 4.7 cm(2)). Results have shown that after 70 days of treatment patients significantly ameliorate their pathological condition if they are treated with Vulnamin(®), as compared with patients treated with Ca-alginate alone. In fact, at the end of the treatment, complete healing closure was 61% in the group treated with Vulnamin(®) and, respectively, 27% in the control group. Moreover, ulcer areas showed a significant reduction in patients treated with Vulnamin(®) (mean ulcer area = 3.04 ± 0.8 cm(2)), as compared with controls (mean ulcer area = 10.96 ± 3.8 cm(2)). Overall, the results of this study indicate that Vulnamin(®) together with elastocompression is safe and more effective than standard dressing together with elastocompression in inducing a faster healing in chronic venous ulcers of the lower limb.

The management of neuropathic ulcers of the foot in diabetes by shock wave therapy.

BACKGROUND: Diabetes is becoming one of the most common chronic diseases, and ulcers are its most serious complication. Beginning with neuropathy, the subsequent foot wounds frequently lead to lower extremity amputation, even in the absence of critical limb ischemia. In recent years, some researchers have studied external shock wave therapy (ESWT) as a new approach to soft tissue wound healing. The rationale of this study was to evaluate if ESWT is effective in the management of neuropathic diabetic foot ulcers. METHODS: We designed a randomized, prospective, controlled study in which we recruited 30 patients affected by neuropathic diabetic foot ulcers and then divided them into two groups based on different management strategies. One group was treated with standard care and shock wave therapy. The other group was treated with only standard care. The healing of the ulcers was evaluated over 20 weeks by the rate of re-epithelization. RESULTS: After 20 weeks of treatment, 53.33% of the ESWT-treated patients had complete wound closure compared with 33.33% of the control patients, and the healing times were 60.8 and 82.2 days, respectively (p < 0.001). Significant differences in the index of the re-epithelization were observed between the two groups, with values of 2.97 mm2/die in the ESWT-group and 1.30 mm2/die in the control group (p < 0.001). CONCLUSION: Therefore, ESWT may be a useful adjunct in the management of diabetic foot ulceration.

Improved survival of rat ischemic cutaneous and musculocutaneous flaps after VEGF gene transfer.

When harvesting microsurgical flaps, the main goals are to obtain as much tissue as possible based on a single vascular pedicle and a reliable vascularization of the entire flap. These aims being in contrast to each other, microsurgeons have been looking for an effective way to enhance skin and muscle perfusion in order to avoid partial flap loss in reconstructive surgery. In this study we demonstrate the efficacy of VEGF 165 delivered by an Adeno-Associated Virus (AAV) vector in two widely recognized rat flap models. In the rectus abdominis myocutaneous flap, intramuscular injection of AAV-VEGF reduced flap necrosis by 50%, while cutaneous delivery of the same amount of vector put down the epigastric flap's ischemia by >40%. Histological evidence of neoangiogenesis (enhanced presence of CD31-positive capillaries and alpha-Smooth Muscle Actin-positive arteriolae) confirmed the therapeutic effect of AAV-VEGF on flap perfusion.

Collision tumor of malignant skin cancers: a case of melanoma in basal cell carcinoma.

The coexistence of two malignant skin tumors intermingling in the same histologic specimen is rare. We report a case of melanoma in a basal cell carcinoma collision tumor. The presence of two intermingled neoplasms was confirmed by immunohistochemistry, which showed strong positivity for S-100 and HMB-45. A review of the literature and a case analysis allow for some pathogenetic and prognostic considerations.

Improved survival of ischemic cutaneous and musculocutaneous flaps after vascular endothelial growth factor gene transfer using adeno-associated virus vectors.

A major challenge in reconstructive surgery is flap ischemia, which might benefit from induction of therapeutic angiogenesis. Here we demonstrate the effect of an adeno-associated virus (AAV) vector delivering vascular endothelial growth factor (VEGF)165 in two widely recognized in vivo flap models. For the epigastric flap model, animals were injected subcutaneously with 1.5 x 10(11) particles of AAV-VEGF at day 0, 7, or 14 before flap dissection. In the transverse rectus abdominis musculocutaneous flap model, AAV-VEGF was injected intramuscularly. The delivery of AAV-VEGF significantly improved flap survival in both models, reducing necrosis in all treatment groups compared to controls. The most notable results were obtained by administering the vector 14 days before flap dissection. In the transverse rectus abdominis musculocutaneous flap model, AAV-VEGF reduced the necrotic area by >50% at 1 week after surgery, with a highly significant improvement in the healing process throughout the following 2 weeks. The therapeutic effect of AAV-VEGF on flap survival was confirmed by histological evidence of neoangiogenesis in the formation of large numbers of CD31-positive capillaries and alpha-smooth muscle actin-positive arteriolae, particularly evident at the border between viable and necrotic tissue. These results underscore the efficacy of VEGF-induced neovascularization for the prevention of tissue ischemia and the improvement of flap survival in reconstructive surgery.