Metástasis en glándula parótida por tumoraciones cutáneas melanoma y no melanoma de cabeza y cuello. Pronóstico y tratamiento / Parotid metastatic from cutaneous melanoma y no melanoma of head and neck. Prognostic and treatment

Introducción y objetivo: El melanoma y las tumoraciones cutáneas no melanomas (TCNM) situadas en cabeza y cuello pueden extenderse a la glándula parótida (GP), bien por continuidad o por diseminación a través del sistema linfático. Cuando esto ocurre, el tratamiento a seguir es preferentemente quirúrgico, siempre y cuando la evolución tumoral, el estado general del paciente y la no diseminación del tumor a otras zonas del organismo lo permitan. Nuestro objetivo es analizar el tratamiento seguido, el número de recidivas y la mortalidad en nuestra serie de las citadas tumoraciones, con invasión de la GP. Material y método: Presentamos una serie de 26 pacientes (24 varones y 2 mujeres) con afectación tumoral parotídea consecuencia de metástasis de melanoma o de TCNM. A todos se les realizó tratamiento quirúrgico, parotidectomía del lóbulo superficial en 5 casos y parotidectomía total en 21. La disección cervical radical modificada tipo III se efectuó en 19 pacientes. Posteriormente siguieron tratamiento radio y/o quimio o inmunoterápico. Resultados: Desarrollamos el estudio desde 2012 a 2018, con un seguimiento de los pacientes de 0 a 114 meses, encontrando un grado de recidiva del 15.38% y una mortalidad del 34.6%. La complicación más frecuente como consecuencia de la cirugía ablativa realizada fue la parálisis facial en los 3 casos en que no se preservó el nervio facial y la neuropraxia del nervio facial, principalmente de sus ramas bucal y marginal, que cedió con el tiempo. Conclusiones: El tratamiento de las tumoraciones metastásicas de la GP consecuencia de este tipo de tumoraciones cutáneas, es preferentemente quirúrgico con exéresis de la glándula y respetando el nervio facial siempre que la invasión tumoral no lo afecte. La radioterapia postoperatoria será también útil como complemento del tratamiento. Los resultados con el tratamiento combinado son actualmente poco esperanzadores, pero se espera una mejoría de las expectativas principalmente por los tratamientos inmunoterápicos en el caso de los melanomas y radioterápicos en las invasiones por carcinomas espinocelulares. Seguramente todo ello permitirá que el tratamiento quirúrgico sea menos radical y con secuelas escasas

Background and objective: When developed on head and neck, both melanoma and non-melanoma skin cancer (NMSC) can be spread to the parotid gland (PG) because of its permanence or due to the lymphatic spreading. In this case, the most appropriate option is the surgical procedure, provided that the progression of the tumor, the general condition of the patient and the non-dissemination of the tumor allow it. Our aim is to analyze the treatment followed and the number of recurrences, as well as mortality of our series in which the tumors cited invades the GP. Methods: The study includes a selection of 26 patients (22 male and 2 female) with a parotid gland tumor diagnosis as a consequence of a melanoma/ NMSC metastasis. All of them had undergone surgical procedure, 5 with a superficial lobe parotidectomy, and the remaining 19 with a total parotidectomy. Modified radical neck dissection Type III was applied to 19 patients. After that, they continued receiving radiotherapy and/or chemo o inmunotherapy. Results: This study was conducted between 2012 and 2018, with a patient’s follow-up from 0 to 114 months. Patients had a recurrence rate of 15.38% a mortality of 34.6%. The most frequent complications as a result of the surgical ablation were the facial paralysis in all 3 cases where the facial nerve was not preserved, and the neurapraxia in the facial nerve, specifically the marginal mandibular branches and the buccal branches, which decreased over time. Conclusions: The preferred treatment of metastasis of PG tumors as a consequence of this kind of skin cancer is the surgical procedure with gland exeresis and keeping the facial nerve, as long as the tumor invasion does not affect it. Postoperative radiotherapy will also be an essentially useful resource as a treatment complement. For the moment, the results of the combinated therapy are not encouraging. However, thanks to the immunotherapies applied in melanoma cases and to the radiotherapy applied in squamous cell carcinoma invasions, best prospects are expected. Probably, this will result in less radical surgical procedures with few sequelae

Solanidine and tomatidine trigger scar pruritus.

Scar pruritus is frequently encountered in clinical practice (particularly in burn patients) owing to its poorly known pathogenesis and difficult treatment. In previous work, we demonstrated the usefulness of a diet excluding edible solanaceae (viz., potatoes, tomatoes, peppers and aubergines) in patients with antihistamine-resistant scar pruritus. We hypothesized that alkaloids in solanaceae (particularly their secondary metabolites or aglycones) might be the actual pruritogens. In order to test this hypothesis, we conducted a single-blind prospective study on patients responding favourably to a solanaceae-free diet whose scar pruritus could be ascribed to one of the four foods. The study involved applying the aglycones solanidine and tomatidine to each scar and checking whether, and which, had a pruritogenic effect. A total of 18 patients (90%) responded by developing pruritus; also, the triggering aglycone coincided with that prevailing in the pruritogenic food. We concluded that solanaceae aglycones are directly involved in the pathogenesis of scar pruritus.

Areola size and jugulum nipple distance after bilateral mastectomy and breast reconstruction.

OBJECTIVE: The combination of a single pedicle local flap with tattooing for complete nipple areola complex (NAC) reconstruction is currently the most supported method. Although many technical descriptions of NAC reconstruction exist in the medical literature, there are no data that define the ideal areola size (diameter of the areola) after bilateral mastectomy and breast reconstruction considering the previous areola size. METHODS: This was a 3-year (2009-2012) observational, analytical, and longitudinal prospective study with 103 patients who had undergone NAC tattooing as the last process of bilateral breast reconstruction after surgery for breast cancer. Statistical differences in the areola size and the jugulum-nipple distance before mastectomy and after reconstruction were analyzed by paired Student t tests with a 95% confidence interval. RESULTS: The jugulum-nipple distance before mastectomy was 4.23 cm larger than after bilateral reconstruction (mean jugulum-nipple distance: 23.89 cm vs 19.66 cm), and for that reason shorter (more cephalad). The areola size before mastectomy was 1.59 cm larger than the one chosen by the patient for reconstruction (mean diameter of the areola: 5.25 cm vs 3.65 cm). CONCLUSIONS: We conclude that, after bilateral mastectomy and reconstruction, the jugulum-nipple distance is smaller and women prefer smaller areola sizes.

Serum albumin levels in burn people are associated to the total body surface burned and the length of hospital stay but not to the initiation of the oral/enteral nutrition.

OBJECTIVE: Serum albumin levels have been used to evaluate the severity of the burns and the nutrition protein status in burn people, specifically in the response of the burn patient to the nutrition. Although it hasn't been proven if all these associations are fully funded. The aim of this retrospective study was to determine the relationship of serum albumin levels at 3-7 days after the burn injury, with the total body surface area burned (TBSA), the length of hospital stay (LHS) and the initiation of the oral/enteral nutrition (IOEN). SUBJECT AND METHODS: It was carried out with the health records of patients that accomplished the inclusion criteria and were admitted to the burn units at the University Hospital of Reina Sofia (Córdoba, Spain) and UAB Hospital at Birmingham (Alabama, USA) over a 10 years period, between January 2000 and December 2009. We studied the statistical association of serum albumin levels with the TBSA, LHS and IOEN by ANOVA one way test. The confidence interval chosen for statistical differences was 95%. Duncan's test was used to determine the number of statistically significantly groups. RESULTS: Were expressed as mean±standard deviation. We found serum albumin levels association with TBSA and LHS, with greater to lesser serum albumin levels found associated to lesser to greater TBSA and LHS. We didn't find statistical association with IOEN. CONCLUSION: We conclude that serum albumin levels aren't a nutritional marker in burn people although they could be used as a simple clinical tool to identify the severity of the burn wounds represented by the total body surface area burned and the lenght of hospital stay.

The potential association of later initiation of oral/enteral nutrition on euthyroid sick syndrome in burn patients.

Objective. The aim of this study was to determine if early initiation of oral/enteral nutrition in burn patients minimizes the drop in fT3 levels, reduces the potential for euthyroid sick syndrome (ESS), and shortens the length of hospital stay (LHS). Subjects and Methods. We retrospectively evaluated the statistical association of serum fT3, fT4, and TSH at the first (2nd-5th day) and second sample collection (9th-12th day) after the burn injury in 152 burn patients. Three groups were established depending on time of initiation of the oral/enteral nutrition: <24 h before the injury (Group 1), 24-48 h after the injury (Group 2), and >48 h after the injury (Group 3). Results. They were expressed as mean ± standard deviation. We found that LHS and the fT3 levels were statistically different in the 3 groups. The LHS (in days) was, respectively, in each group, 16.77 ± 4.56, 21.98 ± 4.86, and 26.06 ± 5.47. Despite the quantifiable drop in fT3, ESS was present only at the first sample collection (2.61 ± 0.92 days) in Group 3, but there was no group with ESS at the second sample collection (9.89 ± 1.01 days). Our data suggest that early initiation of nutritional supplementation decreases the length of hospitalization and is associated with decreasing fT3 serum concentration depression. Conclusion. Early initiation of oral/enteral nutrition counteracts ESS and improves the LHS in burn patients.

[Skin graft, smoking and diabetes mellitus type 2]. / Injertos cutáneos, hábito de fumar y diabetes mellitus tipo 2.

Smoking and hyperglycemia decrease the success of skin graft survival in specific circumstances. It is well known that smoking and diabetes mellitus (DM) type 2 increase the oxidative and impair the endothelial function. The objective of this retrospective study was to determine if smoking and DM type 2 are factors associated with lower skin graft survival, in different etiologies of the injury associated to the skin loss. It was a bicentric, retrospective, cross sectional case control study, carried out on 2457 medical patients who met the inclusion criteria. It was carried out over a 10 years period between January 2000-December 2009, at Reina Sofía University Hospital (Córdoba, Spain) and UAB Hospital at Birmingham (Alabama, USA). The percentage of successful graft for each group and its control were analyzed by Chi-square test. The confidence interval chosen for statistical differences was 95%. Smoking and DM type 2 decreased the percentage of skin graft survival when compared with their control groups. DM type 2 was associated with greater negative success on skin graft survival than smoking when compared with their control groups. There was a statistically significant drop in skin graft of 18% in smoking group (range: 68-86%) and 25% in DM type 2 group (53-78%). The OR showed a clear association between the risk factors studied and the lower skin graft success, being stronger for DM type 2. In conclusion, DM type 2 and smoking are factors associated to lower skin graft take.

Injertos cutáneos, hábito de fumar y diabetes mellitus tipo 2 / Skin graft, smoking and diabetes mellitus type 2

El tabaco y la hiperglucemia reducen significativamente el éxito de los injertos cutáneos. El estrés oxidativo y la disfunción endotelial son factores que se asocian tanto al tabaquismo como a la diabetes mellitus (DM) tipo 2. El objetivo de este estudio fue constatar si existe una asociación entre estos factores de riesgo y el descenso en el porcentaje de éxito de los injertos en pérdidas cutáneas de diversa etiología. Estudio bicéntrico, retrospectivo, de casos y controles, llevado a cabo de enero 2000 a diciembre 2009, en los centros hospitalarios de Reina Sofía (Córdoba, España) y Birmingham (Alabama, EE.UU.), con 2457 pacientes que cumplían los criterios de inclusión. El éxito del injerto p ara cada grupo fue analizado mediante chi-cuadrado. El intervalo de confianza fue del 95%. El hábito de fumar y la DM tipo 2 disminuyeron el porcentaje de éxito de los injertos comparados con sus grupos controles, siendo el efecto de la DM tipo 2 mayor que el del tabaco. Se observó un descenso altamente significativo del porcentaje de injertos prendidos, del 18% en el grupo de fumadores (de 86% a 68%), y del 25% en el grupo de los diabéticos (de 78% a 53%). El cálculo de OR demostró asociación entre los factores de riesgo estudiados y el menor éxito de los injertos cutáneos, siendo mayor para la DM tipo 2. En conclusión: la DM tipo 2 y el hábito de fumar son factores que influyen negativamente en el éxito de los injertos cutáneos.

Smoking and hyperglycemia decrease the success of skin graft survival in specific circumstances. It is well known that smoking and diabetes mellitus (DM) type 2 increase the oxidative and impair the endothelial function. The objective of this retrospective study was to determine if smoking and DM type 2 are factors associated with lower skin graft survival, in different etiologies of the injury associated to the skin loss. It was a bicentric, retrospective, cross sectional case control study, carried out on 2457 medical patients who met the inclusion criteria. It was carried out over a 10 years period between January 2000-December 2009, at Reina Sofía University Hospital (Córdoba, Spain) and UAB Hospital at Birmingham (Alabama, USA). The percentage of successful graft for each group and its control were analyzed by Chi-square test. The confidence interval chosen for statistical differences was 95%. Smoking and DM type 2 decreased the percentage of skin graft survival when compared with their control groups. DM type 2 was associated with greater negative success on skin graft survival than smoking when compared with their control groups.. There was a statistically significant drop in skin graft of 18% in smoking group (range: 68-86%) and 25% in DM type 2 group (53-78%). The OR showed a clear association between the risk factors studied and the lower skin graft success, being stronger for DM type 2. In conclusion, DM type 2 and smoking are factors associated to lower skin graft take.

Injertos cutáneos, hábito de fumar y diabetes mellitus tipo 2 / Skin graft, smoking and diabetes mellitus type 2

El tabaco y la hiperglucemia reducen significativamente el éxito de los injertos cutáneos. El estrés oxidativo y la disfunción endotelial son factores que se asocian tanto al tabaquismo como a la diabetes mellitus (DM) tipo 2. El objetivo de este estudio fue constatar si existe una asociación entre estos factores de riesgo y el descenso en el porcentaje de éxito de los injertos en pérdidas cutáneas de diversa etiología. Estudio bicéntrico, retrospectivo, de casos y controles, llevado a cabo de enero 2000 a diciembre 2009, en los centros hospitalarios de Reina Sofía (Córdoba, España) y Birmingham (Alabama, EE.UU.), con 2457 pacientes que cumplían los criterios de inclusión. El éxito del injerto p ara cada grupo fue analizado mediante chi-cuadrado. El intervalo de confianza fue del 95%. El hábito de fumar y la DM tipo 2 disminuyeron el porcentaje de éxito de los injertos comparados con sus grupos controles, siendo el efecto de la DM tipo 2 mayor que el del tabaco. Se observó un descenso altamente significativo del porcentaje de injertos prendidos, del 18% en el grupo de fumadores (de 86% a 68%), y del 25% en el grupo de los diabéticos (de 78% a 53%). El cálculo de OR demostró asociación entre los factores de riesgo estudiados y el menor éxito de los injertos cutáneos, siendo mayor para la DM tipo 2. En conclusión: la DM tipo 2 y el hábito de fumar son factores que influyen negativamente en el éxito de los injertos cutáneos.(AU)

Smoking and hyperglycemia decrease the success of skin graft survival in specific circumstances. It is well known that smoking and diabetes mellitus (DM) type 2 increase the oxidative and impair the endothelial function. The objective of this retrospective study was to determine if smoking and DM type 2 are factors associated with lower skin graft survival, in different etiologies of the injury associated to the skin loss. It was a bicentric, retrospective, cross sectional case control study, carried out on 2457 medical patients who met the inclusion criteria. It was carried out over a 10 years period between January 2000-December 2009, at Reina Sofía University Hospital (Córdoba, Spain) and UAB Hospital at Birmingham (Alabama, USA). The percentage of successful graft for each group and its control were analyzed by Chi-square test. The confidence interval chosen for statistical differences was 95%. Smoking and DM type 2 decreased the percentage of skin graft survival when compared with their control groups. DM type 2 was associated with greater negative success on skin graft survival than smoking when compared with their control groups.. There was a statistically significant drop in skin graft of 18% in smoking group (range: 68-86%) and 25% in DM type 2 group (53-78%). The OR showed a clear association between the risk factors studied and the lower skin graft success, being stronger for DM type 2. In conclusion, DM type 2 and smoking are factors associated to lower skin graft take.(AU)

Giant earlobe epidermoid cyst.

Epidermoid cysts represent the most common cutaneous cysts. They are usually small and benign; however, sometimes they can grow to giant epidermoid cists, and occasionally malignancies develop. Giant epidermoid cysts at the earlobe have never been described but in other locations. We describe a case of a giant epidermoid cyst at the earlobe, a location where such a large cyst has never been reported before. The mass was completely resected and the wound of the pedunculated base was sutured with four stitches of nylon 5/0. Histopathology confirmed the presumptive diagnosis of an epidermoid cyst. Six months after the resection, the patient did not have any relapse of the epidermoid cyst. The earlobe is a potential location for giant epidermoid cysts. Although the clinical diagnosis could be enough, due to the possibility of malignancy and to ensure appropriate diagnosis, we consider that all cysts should be sent to the anatomic pathology laboratory for histological evaluation.

Smoking and diabetes mellitus type 2 reduce skin graft take; the use of fibrin glue might restore graft take to optimal levels.

Efficacy has been demonstrated in some uses of fibrin glue associated with graft loss. Smoking and hyperglycemia significantly decrease the success of skin graft survival in specific injuries. This retrospective study aimed to verify the association with decreased skin graft survival and whether fibrin glue is useful in reversing the influence of these factors. This bicentric, retrospective, cross sectional case control study was carried out on 1881 medical patients. Patients who met inclusion criteria were admitted to the Plastic Surgery Service of Reina Sofia University Hospital (Spain) and the Trauma/Burn intensive Care Unit of UAB Hospital at Birmingham (USA) between January 2000 and December 2009. The successful graft take for each group and its control were analyzed by a Chi-square test; the confidence interval was 95%. Smoking and DM type 2 decrease skin graft survival when compared with their control groups. There was a statistically significant improvement in skin graft take when fibrin glue was used. The percentage improvement in the control groups was approximately 10%, whereas in the study groups it was 2-3 times higher. We conclude that graft loss is associated with smoking and DM type 2, but fibrin glue might restore graft adherence to almost normal levels.

Chondromucosal nasal flap with the transposition flap of von langenbeck as a good election for the total lower eyelid defect reconstruction in an old patient with an elevated vision loss in the contralateral eye.

OBJECTIVE: The management of lower eyelid reconstruction has a variety of treatment strategies with varying success depending on the patient. We tried to apply the most suitable reconstruction techniques for this particular case. METHODS: We report a case of a 99-year-old woman, with a vision loss of 70% in the left eye and 40% in the right eye, who underwent basal cell carcinoma resection of the lower right eyelid 3 months before. The margins of resection and the deepest layers were affected. After the histopathology report, we decided to plan a more aggressive treatment with a total resection of the lower right eyelid. We had a case with 3 added difficulties: the old age of the patient, the vision loss in the contralateral eye, and the size of the resection. RESULTS: On the basis of our experience and the bibliography reviewed, we decided to use the chondromucosal nasal flap for the posterior lamella reconstruction and the transposition flap of von Langenbeck for the anterior lamella. We found it was a good election for this patient since we achieved good functional, anatomical, and aesthetical results with a one-step operation. CONCLUSIONS: The chondromucosal nasal flap with the transposition flap of von Langenbeck was a good election for a total lower eyelid defect reconstruction in an old patient with a high vision loss in the contralateral eye.

Keloids: A viral hypothesis.

The triggering cause of keloid formation on a healing wound remains an enigma. In fact, the hypotheses put forward so far to explain this phenomenon seem inconsistent with some clinical features of the disease. The recently established bonds between infectious agents and some pathologies of unknown origin such as peptic ulcer disease, Kaposi's sarcoma or cervical cancer among others led us to consider a potential infectious origin for keloids. This paper presents an infection-based hypothesis (specifically, a viral hypothesis) intended to account for most of their clinical features. Essentially, we hypothesize that healthy individuals carrying a virus, whether known or unknown, associated to some adjuvant, and having some genetic susceptibility, may develop keloids during the scar maturation process in the following manner: the virus would make the bone marrow or lymphatic system its reservoir, residing there in a silent state, and reach the wound via two different mechanisms. The primary mechanism might use an internal circuit through which the viral genome would be transported from its myeloid reservoir to the wound via bone marrow or circulating fibrocytes chemotactically attracted to the damaged skin region. The secondary mechanism might involve an external circuit by which infecting virions via saliva would be shed in the wound directly (preferentially in the sternal or deltoid region) or indirectly (other satellite regions) via the hands or some fomites. A combination of both mechanisms might also be possible. Once in the wound, the virus would switch from a silent state to a latent state by effect of some chemical stimulus probably generated during the tissue repair process; in the new state, the transcription of some of the powerful viral proteins might cause thorough derailment of the normal repair process. As a result, keloid growth might depend both on individual susceptibility and on the viral load deposited into the wound; the greater the susceptibility and viral load were, the more markedly the keloid would develop and the more aggressive it would be.