Deep Soft Tissue Research Articles

LOW-GRADE MYOFIBROBLASTIC SARCOMA OF THE ORAL CAVITY

Low-grade myofibroblastic sarcoma (LGMS) represents a distinct atypical myofibroblastic tumor of deep soft tissues, with a head and neck predilection. It has a variety of appearances, from fasciitis-like or fibromatosis-like to fibrosarcoma-like. Here, a series of four cases from two different institutions is shown, represented by 2 men and 2 women presenting a nodular lesion, with equal distribution in maxilla and mandibula. Microscopically, all cases showed neoplasms formed by oval to spindle cells in a fibrous stroma with myxoid and dense areas, some atypical mitoses, and prominent nucleoli. These findings suggested a mesenchymal tumor. An immunohistochemical panel was performed, which showed positivity for smooth muscle actin (3 of 4 cases), HHF35 (2 of 4 cases), β-catenin (3 of 3 cases), calponin (2 of 4 cases), and Ki-67 (range 5-40%). H-Caldesmon was negative for all cases, demonstrating myofibroblastic and smooth muscle differentiation. The diagnosis of LGMS was confirmed in all cases. Low-grade myofibroblastic sarcoma (LGMS) represents a distinct atypical myofibroblastic tumor of deep soft tissues, with a head and neck predilection. It has a variety of appearances, from fasciitis-like or fibromatosis-like to fibrosarcoma-like. Here, a series of four cases from two different institutions is shown, represented by 2 men and 2 women presenting a nodular lesion, with equal distribution in maxilla and mandibula. Microscopically, all cases showed neoplasms formed by oval to spindle cells in a fibrous stroma with myxoid and dense areas, some atypical mitoses, and prominent nucleoli. These findings suggested a mesenchymal tumor. An immunohistochemical panel was performed, which showed positivity for smooth muscle actin (3 of 4 cases), HHF35 (2 of 4 cases), β-catenin (3 of 3 cases), calponin (2 of 4 cases), and Ki-67 (range 5-40%). H-Caldesmon was negative for all cases, demonstrating myofibroblastic and smooth muscle differentiation. The diagnosis of LGMS was confirmed in all cases.

Needle tract seeding of a sclerosing epithelioid fibrosarcoma in a biopsy tract: a case report

BackgroundA sclerosing epithelioid fibrosarcoma (SEF) is an uncommon tumor of the deep soft tissue. An SEF has been described as a low-grade tumor with high local recurrence and metastatic rates. Generally, in bone and soft tissue tumors, a resection of the biopsy route is recommended; however, there is limited evidence with respect to the dissemination of the tumor tissue during a needle biopsy.Case presentationA mass in the right pelvic cavity, with no symptoms, was observed in a 45-year-old woman during a gynecological examination. Computed tomography (CT) revealed a multilocular mass with calcification in the pelvic cavity. The magnetic resonance imaging (MRI) showed an iso-signal intensity on T1 weighted images and hypo- and iso-signal intensity on T2 weighted images. The CT-guided core needle biopsy was performed using a dorsal approach, and the biopsy diagnosis was a low-grade spindle cell tumor. The tumor was excised using an anterior approach. The tumor tissue comprised spindle cells and epithelioid cells with irregular nuclei, and the immunohistological analysis was positive for vimentin and epithelial membrane antigen, which was consistent with a diagnosis of sclerosing epithelioid fibrosarcoma. Five years after the surgery, the MRI showed a tumor recurrence in the subcutaneous tissue of the right buttock, which was consistent with the needle biopsy tract. The patient underwent a tumor excision, and the resected tumor was similar to the primary tumor.ConclusionsThe recurrent tumor was excised with a surgical margin, and the tumor specimen had the histological features of a sclerosing epithelioid fibrosarcoma. It was difficult to investigate the association of the core needle biopsy with the tumor recurrence because the approach of the biopsy tract is usually same as that used in a tumor excision. However, the present case indicated the tumor may recur in the biopsy tract of a soft tissue sarcoma. Surgeons should be aware of the possibility of disseminating tumor tissues in a needle biopsy.

FGFR1 gene fusions in a subset of pediatric mesenchymal tumors: Expanding the genetic spectrum of tumors sharing histologic overlap with infantile fibrosarcoma and "NTRK-rearranged" spindle cell neoplasms.

As the classification of kinase-driven spindle cell tumors continues to evolve, we describe the first series of pediatric mesenchymal tumors harboring FGFR1 gene fusions that share histologic overlap with infantile fibrosarcoma and "NTRK-rearranged" spindle cell neoplasms. Herein, we present three cases of FGFR1-rearranged pediatric mesenchymal tumors, including one case with FGFR1::PARD6B gene fusion and two cases with FGFR1::EBF2 gene fusion. The tumors involved infants ranging from 3 to 9 months in age with a male-to-female ratio of 2:1. All tumors involved the deep soft tissue of the gluteal, pelvic, or perirectal region. Histologically, the tumors comprised a cellular spindle cell neoplasm with primitive stellate cells, focal myxoid stroma, focal epithelioid features, no necrosis, and occasional mitotic figures (2-6 per 10 high-power field). By immunohistochemistry, the neoplastic cells focally expressed CD34 but lacked expression of S100 protein, SMA, desmin, myogenin, MyoD1, pan-TRK, and ALK. These three cases, including a case with long-term clinical follow-up, demonstrate that FGFR1 fusions occur in a subset of newly described pediatric kinase-driven mesenchymal tumors with locally aggressive behavior. Importantly, knowledge of these genetic alterations in this spectrum of pediatric tumors is key for diagnostic and targeted therapeutic purposes.

Ruptured ulcerated and inflammed gout tophi with deep soft tissue infection of left foot – when rheumatology meets surgery: a case report treated with local ozone therapy

Abstract
 Tophaceouse gout is a rare condition and chronic complication of gout due to storage of derivates of uric acid – crystals of monosodium urate, accompanied by lipids, mucopolisaharides matrix and proteins. Rheumatology meets the surgery in cases of rupture, ulceration and inflammation of tophi with complication with severe soft tissue infection, sepsis, large swelling, destruction of affected joints and periphery neuropathy chronic pain. Spontaneous or traumatic perforation and ulceration of tophi are rare conditions, that’s why there no any rheumatology or surgical guideline for management of that condition. We present a case report of male patient with posttraumatic perforated gout tophus and soft tissue secondary infection of left foot. He was treated with standard surgical debridement and local ozone therapy with stabilized ozonides over wound surface. That article presents a pioneer experience in the treatment of complicated tophaceouse gout with topical administration of ozonated olive oil with vitamin E and shows the effect of that treatment in progress.

The free chimeric medial sural artery perforator flap for individualised and three-dimensional reconstruction of complex soft-tissue defects in extremities.

Trauma or lesion resection often causes complex wounds with deep soft tissue defects in extremities. Simply covering with a skin flap will leave a deep dead space resulting in infection, non-healing wounds, and poor long-term outcomes. Thus, effectively reconstructing complex wounds with dead space leaves a clinical challenge. This manuscript presents our experience using chimeric medial sural artery perforator (cMSAP) flap, to reconstruct complex soft tissue defects of the extremities, thereby exploring broader analysis and indications for future reference. Between March 2016 and May 11, 2022, patients (8 males and 3 females) with a mean age of 41 years (range from 26 to 55 years) underwent reconstructive surgery with the cMSAP flap. The cMSAP flap consists of an MSAP skin paddle and a medial sural muscle paddle. The size of the MSAP skin paddle ranged between 9 × 5cm and 20 × 6cm, and the size of the medial sural muscle paddle ranged between 2 × 2cm and 14 × 4cm. Primary closure of the donor site was achieved in all cases. Of the 11 patients, the cMSAP flap survived in 10 cases. The vascular compromise occurred in one special case and was treated with surgical procedures. The mean follow-up duration was 16.5months (range of 5-25 months). Most patients present satisfactory cosmetic and functional results. The free cMSAP flap is a good option for reconstructing complex soft tissue defects with deep dead space in extremities. The skin flap can cover the skin defect, and the muscle flap can fill the dead space against infection. In addition, three types of cMSAP flaps can be used in a broader range of complex wounds. This procedure can achieve an individualised and three-dimensional reconstruction of the defects and minimise the donor site morbidities.

The biomechanical efficacy of a hybrid support surface in protecting supine patients from sacral pressure ulcers.

Support surfaces are the most important pressure ulcer/injury prevention technology available to clinicians for protecting their at-risk patients. A hybrid support surface marries the benefits of reactive and active support surfaces, by using high-quality foam material inside inflatable air cells. When used in its "static mode", it is a constant low air pressure mattress which delivers pressure redistribution in response to patient bodyweight and movements, by maximising the immersion and envelopment performance of the support surface. When used in its powered "dynamic mode", this system further delivers alternating pressure care via the connected foam and air cells. Modes of action of hybrid support surfaces were never studied quantitatively before, excluding through the limited scope of interface pressure mapping. In this work, we developed a novel computational modelling framework and simulations to visualise and quantify the state of soft tissue loading at the buttocks of a supine patient positioned on a hybrid support surface, in both the static and dynamic modes. We found that the dynamic mode effectively shifts deep concentrated soft tissue loading from under the sacral bone (towards the sacral promontory) to the tip of the sacrum (coccyx) and vice versa, and thereby, generates a deep tissue offloading effect.

TAF15::NR4A3 gene fusion identifies a morphologically distinct subset of extraskeletal myxoid chondrosarcoma mimicking myoepithelial tumors.

Extraskeletal myxoid chondrosarcoma (EMC) is a rare sarcoma of uncertain differentiation predominantly arising in deep soft tissue. Its conventional morphologic appearance manifests as a relatively well-circumscribed, multilobular tumor composed of uniform short spindle-to-ovoid primitive mesenchymal cells with deeply eosinophilic cytoplasm arranged in anastomosing cords within abundant myxoid matrix. The genetic hallmark of EMC has long been considered to be pathognomonic gene rearrangements involving NR4A3, which when fused to TAF15, often have high-grade morphology with increased cellularity, moderate to severe cytologic atypia, and rhabdoid cytomorphology. Herein, we describe two cases of EMC with TAF15::NR4A3 fusion that appear morphologically distinct from both conventional and high-grade EMC. Both cases had an unusual biphasic appearance and showed diffuse positivity for p63, mimicking myoepithelial tumors. DNA methylation profiling demonstrated that both cases clearly cluster with EMC, indicating that they most likely represent morphologically distinct variants of EMC. The clinical significance and prognostic impact of this morphologic variance remains to be determined. Molecular testing, including DNA methylation profiling, can help to confirm the diagnosis and avoid confusion with mimics; it adds another layer of data to support expanding the morphologic spectrum of EMC.

Atypical invasive secondary meningioma with extensive intracranial invasion: A case report

Invasive and metastatic version of meningioma as an atypical type of the tumor has been rarely described in the literatures. Recurrent secondary meningioma invaded to pre-orbital soft and hard tissues can be found in extremely rare cases. We described a case of atypical invasive meningioma invaded to deep orbital soft tissue due to recurrence of the primary tumor previously treated by surgical removing and chemoradiotherapy. In this case, invasion to orbit, paranasal sinuses and masticator, infratemporal and buccal spaces leading to destruction of adjacent bony structures and mass engulfing the right globe resulting in considerable proptosis was the prominent feature.

S1-guideline cutaneous and subcutaneous leiomyosarcoma.

Superficial leiomyosarcomas (LMS) are rare skin cancers (2-3% of cutaneous sarcomas) that originate from dermally located hair follicle muscles, dartos or areolar muscles (cutaneous/dermal LMS), or from vascular muscle cells of the subcutaneous adipose tissue (subcutaneous LMS). These superficial LMS are distinct from LMS of the deep soft tissues. Leiomyosarcomas are typically localized at the lower extremities, trunk or capillitium, and present as painful, erythematous to brownish nodules. Diagnosis is made by histopathology. The treatment of choice for primary LMS is complete (R0) microscopically controlled excision, with safety margins of 1cm in dermal LMS, and 2cm in subcutaneous LMS, if possible. Non-resectable or metastatic LMS require individual treatment decisions. After R0 resection with 1cm safety margins, the local recurrence rate of dermal LMS is very low, and metastasis is very rare. Subcutaneous LMS, very large, or incompletely excised LMS recur and metastasize more frequently. For this reason, clinical follow-up examinations are recommended every six months for cutaneous LMS, and every three months for subcutaneous LMS within the first two years (in subcutaneous LMS including locoregional lymph node sonography). Imaging such as CT/MRI is indicated only in primary tumors with special features, recurrences, or already metastasized tumors.

VIM::KMT2A-rearranged sarcomas: A report of two new cases confirming an entity with distinct histologic features.

The recently described KMT2A-rearranged sarcomas are rare emerging entities where the KMT2A gene fuses with YAP1 and, less commonly, VIM, resulting in two distinct morphologies. Unlike the sclerosing epithelioid fibrosarcoma-like features that characterize tumors with KMT2A::YAP1 fusions, VIM::KMT2A-rearranged sarcomas are more uniformly cellular and lack the extensively sclerotic background seen in the former. Most tumors behave aggressively with metastases on presentation. Here, we describe the clinicopathologic and molecular findings in two additional cases of VIM::KMT2A rearranged sarcomas that arose in the deep soft tissues of adult males. Both tumors were composed of hypercellular fascicles of uniform spindle cells with pale eosinophilic cytoplasm and ovoid nuclei. The stroma had scant delicate collagen with occasional thin-walled ectatic blood vessels and perivascular hyalinization. Immunohistochemical studies showed an unspecific staining pattern with diffuse positivity for CD99 and BCL2 and variable staining for S100 protein. RNA-sequencing detected the presence of VIM::KMT2A gene fusion involving VIM exon 4 and KMT2A exon 2 in both cases. Sarcomas with VIM::KMT2A gene fusions seem to have sufficient morphologic features to warrant distinction from KMT2A-rearranged sarcomas with YAP1 partner. Without the benefit of molecular testing, these tumors pose a diagnostic challenge due to their lack of specific immunohistochemical profile and great morphologic overlap with other monomorphic spindle cell neoplasms.

Undifferentiated and Dedifferentiated Metastatic Melanomas Masquerading as Soft Tissue Sarcomas: Mutational Signature Analysis and Immunotherapy Response

The distinction between undifferentiated melanoma (UM) or dedifferentiated melanoma (DM) from undifferentiated or unclassifiable sarcoma can be difficult and requires the careful correlation of clinical, pathologic, and genomic findings. In this study, we examined the utility of mutational signatures to identify patients with UM/DM with particular attention as to whether this distinction matters for treatment because the survival of patients with metastatic melanoma has dramatically improved with immunologic therapy, whereas durable responses are less frequent in sarcomas. We identified 19 cases of UM/DM that were initially reported as unclassified or undifferentiated malignant neoplasm or sarcoma and submitted for targeted next-generation sequencing analysis. These cases were confirmed as UM/DM by harboring melanoma driver mutations, UV signature, and high tumor mutation burden. One case of DM showed melanoma in situ. Meanwhile, 18 cases represented metastatic UM/DM. Eleven patients had a prior history of melanoma. Thirteen of 19 (68%) of the tumors were immunohistochemically completely negative for 4 melanocytic markers (S100, SOX10, HMB45, and MELAN-A). All cases harbored a dominant UV signature. Frequent driver mutations involved BRAF (26%), NRAS (32%), and NF1 (42%). In contrast, the control cohort of undifferentiated pleomorphic sarcomas (UPS) of deep soft tissue exhibited a dominant aging signature in 46.6% (7/15) without evidence of UV signature. The median tumor mutation burden for DM/UM vs UPS was 31.5 vs 7.0 mutations/Mb (P < .001). A favorable response to immune checkpoint inhibitor therapy was observed in 66.6% (12/18) of patients with UM/DM. Eight patients exhibited a complete response and were alive with no evidence of disease at the last follow-up (median 45.5 months). Our findings support the usefulness of the UV signature in discriminating DM/UM vs UPS. Furthermore, we present evidence suggesting that patients with DM/UM and UV signatures can benefit from immune checkpoint inhibitor therapy.

Application of Three Different Types of Pedicled Latissimus Dorsi Flaps in Repairing Nearby Deep Soft Tissue Defects: Cosmetic Result and Shoulder Functionality Evaluation in One Center.

The latissimus dorsi (LD) flap has generally been considered a workhorse flap in clinics. However, the impairment of shoulder function and the dramatic appearance in the donor site are the major problems associated with traditional latissimus dorsi myocutaneous flap (LDMF). Here, we analyzed the reliability of three types of LD flaps in repairing deep soft tissue defects in the upper limbs, shoulder, back, and chest wall. From December 2016 to December 2020, 21 patients from our center underwent reconstruction of deep soft tissue defects using different types of LD flaps. The distribution of the thoracodorsal artery and the location of its branches were confirmed by imaging examination. Based on the defects, traditional LDMF, thoracodorsal artery perforator flap with capillary perforators (TAPcp), or low-skin-paddle pedicled LDMF was selected and specifically designed for each patient. The appearance satisfaction and shoulder functional of daily life recovery were evaluated. A total of 12 traditional LDMF, 4 TAPcp, and 5 low-skin-paddle pedicled LDMFs were used. All flaps survived well. The donor site was sutured directly with satisfactory appearance (n = 7) or repaired using skin grafts (n = 14). Compared to traditional LDMF, TAPcp and low-skin-paddle pedicled LDMF have faster shoulder function of daily life recovery. Based on the characteristics of defects, personalized design of different types of LD flaps is a reliable option to repair different defects.

How Is the Spectrum of Sarcoma Surgery Assessed?

To meet the challenges of the precision medicine era, quality assessment of shared sarcoma care becomes pivotal. The MDT approach is the most important parameter for a successful outcome. Of all MDT disciplines, surgery is the key step to rendering sarcoma patients disease free; therefore, defining its spectrum is critical. To the best of the authors' knowledge, a comprehensive interoperable digital platform to assess the scope of sarcoma surgery in its full complexity is lacking. An interoperable digital platform on sarcoma surgery has been created to assess the clinical exposure, tumor characteristics, and surgical settings and techniques applied for both resections and reconstructions of sarcomas. The surgical exposure of an individual surgeon over time served as a pilot. Over the study period of 10 years, there were 723 sarcoma board/MDT meetings discussing 3130 patients. A total of 1094 patients underwent 1250 surgical interventions on mesenchymal tumors by one single sarcoma surgeon. These included 615 deep soft tissue tumors (197 benign, 102 intermediate, 281 malignant, 27 simulator, 7 metastasis, 1 blood); 116 superficial soft tissue tumors (45 benign, 12 intermediate, 40 malignant, 18 simulator, 1 blood); and 519 bone tumors (129 benign, 112 intermediate, 182 malignant, 18 simulator, 46 metastasis, 14 blood, and 18 sequelae of first treatment). Detailed types of resections and reconstructions were analyzed. An interoperable digital data platform on sarcoma surgery with transparent real-time descriptive analytics is feasible and enables large-scale definition of the spectrum of sarcoma surgery to meet the challenges of sarcoma precision care in the future.

Pleomorphic rhabdomyosarcoma: diagnostic considerations and case report

Pleomorphic rhabdomyosarcoma is a rare entity almost exclusively in older adults and portends aggressive disease with early metastasis. Pleomorphic rhabdomyosarcoma predominantly arises in the soft tissue of lower extremities and presents as a rapidly enlarging, deep soft tissue swelling. Although the aetiology is unknown, these sarcomas have complex karyotypes without a consistent molecular abnormality. Histologically, these tumours contain sheets of pleomorphic sheets of multinucleated polygonal, rhabdoid or spindled cells with an eosinophilic cytoplasm.

Expanding the Molecular Diversity of CIC-Rearranged Sarcomas With Novel and Very Rare Partners

Capicua transcriptional repressor (CIC)-rearranged sarcoma represents a distinct pathologic entity and constitutes the second most prevalent category of undifferentiated round cell sarcomas (URCSs) after Ewing sarcoma. The 2 most common translocations are t(4;19) and t(10;19), resulting in CIC fusions with either DUX4 and DUX4L paralog, respectively; however, other rare variant fusions have also been reported. In this study, we expand the molecular spectrum of CIC-gene partners, reporting on 5 cases of URCSs showing CIC fusions with AXL, CITED1, SYK, and LEUTX by targeted RNA or DNA sequencing. There were 4 female patients and 1 male patient with a wide age range (12-70 years; median, 36 years). Four cases occurred in the deep soft tissues (lower extremity, 3; neck, 1) and 1 case in the central nervous system (midbrain/thalamus). All cases showed similar histologic findings within the spectrum of URCSs. Immunohistochemistry, showed variable positivity for ETV4 in 4 of the 4 cases and positive results for ERG in 3 of the 4 cases and for WT1 in 1 of the 4 cases. CD31 showed positivity in 2 of the 3 cases, including one coexpressing ERG. Unsupervised clustering of methylation profiles by T-distributed stochastic neighborhood embedding performed in 4 cases showed that all clustered tightly together and along the CIC sarcoma methylation class. RNA-sequencing data showed consistent upregulation of ETV1 and ETV4 mRNA in all cases examined, at similar levels to CIC::DUX4 URCSs. Our study expands the molecular diversity of CIC-rearranged URCSs to include novel and rare partners, providing morphologic, immunohistochemical, gene expression, and methylation evidence supporting their classification within the family of tumors harboring the more common DUX4/DUX4L partner genes.

Image-Guided Radar Reflector Localization for Small Soft-Tissue Lesions in the Musculoskeletal System.

Preoperative localization of nonpalpable breast lesions using a radar reflector surgical guidance system has become commonplace, but the clinical utility of this emerging technology in the musculoskeletal system has not yet been well established. The system components include a console, a handpiece, an implanted radiofrequency reflector that works as a lesion marker, and an infrared light-emitting probe to guide the surgeon. The reflector can be deployed to localize small nonpalpable nodules within the subcutaneous fat as well as lesions within the deeper soft tissues. It can also be used for lymph nodes and foreign bodies. Localization can be performed both before and after treatment. The objective of this article is to describe the potential applications and our technique and initial experience for radar reflector localization within the musculoskeletal system.

Perioperative imaging for high-stage cutaneous squamous cell carcinoma helps guide management in nearly a third of cases: A single-institution retrospective cohort

To the Editor: Current cutaneous squamous cell carcinoma (CSCC) National Comprehensive Cancer Network (NCCN) guidelines recommend imaging when there is suspicion of extensive disease defined as bone, perineural, and deep soft tissue disease.1 However, the decision on whether or not to image and what type of imaging to obtain is not systematic.2 Published data on radiologic imaging in CSCC is limited. Two prior retrospective cohorts from our institution on imaging of high-risk tumors found imaging to change management in 17% to 33% of cases,3,4 and one study found that tumors that underwent imaging at the time of diagnosis were twice as likely to receive adjuvant therapy and experienced improved outcomes compared to tumors that did not receive imaging.

Malignant undifferentiated epithelioid neoplasms with MAML2 rearrangements: A clinicopathologic study of seven cases demonstrating a heterogenous entity.

Among mesenchymal tumors, MAML2 gene rearrangements have been described in a subset of composite hemangioendothelioma and myxoinflammatory fibroblastic sarcoma (MIFS). However, we have recently encountered MAML2-related fusions in a group of seven undifferentiated malignant epithelioid neoplasms that do not fit well to any established pathologic entities. The patients included five males and two female, aged 41-71 years old (median 65 years). The tumors involved the deep soft tissue of extremities (hip, knee, arm, hand), abdominal wall, and the retroperitoneum. Microscopically, the tumors consisted of solid sheets of atypical epithelioid to histiocytoid cells with abundant cytoplasm. Prominent mitotic activity and necrosis were present in 4 cases. In 3 cases, the cells displayed hyperchromatic nuclei or conspicuous macronucleoli, and were admixed with background histiocytoid cells and a lymphoplasmacytic infiltrate. By immunohistochemistry (IHC), the neoplastic cells had a nonspecific phenotype. On targeted RNA sequencing, MAML2 was the 3' partner and fused to YAP1 (4 cases), ARHGAP42 (2 cases), and ENDOD1 (1 case). Two cases with YAP1::MAML2 harbored concurrent RAF kinase fusions (RBMS3::RAF1 and AGK::BRAF, respectively). In 2 cases with targeted DNA sequencing, mutations in TP53, RB1 and PTEN were detected in 1 case, and PDGFRB mutations, CCNE1 amplifications and CDKN2A/2B deletion were detected in another case, which showed strong and diffuse PDGFRB expression by IHC. Of the 4 cases with detailed clinical history (median follow-up period 8months), three developed distant metastatic disease (one of which died of disease); one case remained free of disease 3 years following surgical excision. In conclusion, we describe a heterogeneous series of MAML2-rearranged undifferentiated malignant epithelioid neoplasms, a subset of which may overlap with a recently described MIFS variant with YAP1::MAML2 fusions, further expanding the clinicopathologic spectrum of mesenchymal neoplasms with recurrent MAML2 gene rearrangements.

Can L-PRF be helpful for delayed deep wound healing after a tracheotomy or lymph node dissection in a pN0 status?: A case report

Leukocyte platelet-rich fibrin (L-PRF) is used for its ability to deliver high concentrations of autologous growth factors to host tissues, to promote tissue repair. This report describes the case of a 48-year-old woman with tongue cancer treated surgically (pT3pN0), who experienced a delay of five weeks in the process of deep wound healing after a tracheotomy and cervical lymph node dissection that was treated with L-PRF. The patient had no risk factors for delayed wound healing, except for active preoperative smoking. Several attempts were made to stimulate bleeding and edge-to-edge closure, without conclusive results. However, five days after L-PRF placement, the subcutaneous tissues were adhering to the deep planes in both wounds. Fifteen days after L-PRF treatment, a complete wound healing was observed which allowed initiation of postoperative radiotherapy. This case report questions the potential of L-PRF for patients with a pN0 status, not only in superficial wounds, but also in deep wound healing. However, the use of L-PRF for patients with a pN1 status is not recommended, given the possible presence of tumour cells in the tissues, and the activation of these tumour cells by the growth factors present in L-PRF. This report supports the idea that L-PRF can contribute to deep soft tissue healing for patients with a pN0 status due to its positive clinical healing effects.

Determination of the adequate vascular perfusion time of cross-leg free latissimus dorsi myocutaneous flaps in reconstruction of complex lower extremity defects.

Lower limb defects may be present due to various causes including infections, vascular diseases, tumor resections, and crush or avulsion injuries. Management of lower leg defects is acomplex problem, especially when they are large with deep soft tissue loss. These wounds are difficult to be covered with local skin flaps, distant skin flaps or even conventional free flaps because of the compromised recipient vessels. In such cases, the vascular pedicle of the free flap could be anastomosed to the recipient vessels of the contralateral healthy leg temporarily and then divided after adequate neo-vascularization of the flap from the wound bed. The ideal time to divide such pedicles should be investigated and accurately assessed to have the maximum success rate possible for these challenging conditions and procedures. Sixteen patients who did not have asuitable adjacent recipient vessel for free flap reconstruction had been operated with cross leg free latissimus dorsi flap between February 2017 and June 2021. The mean soft tissue defect dimension was 12 ×11 cm (the smallest 6 × 7 cm; the largest 20 × 14cm). Gustilo type 3B tibial fractures were present in 12 patients, while no fractures were present in the other 4 patients. Preoperatively, arterial angiography was performed on all patients. After the fourth week post-operatively, non-crushing clamp was applied around the pedicle for 15minutes. The clamping time was increased by 15 minutes on each consequent day (average 14 days). On the last 2 days, the pedicle was clamped for 2 hours, and bleeding was assessed by aneedle prick test. Clamping time was assessed in each case to reach ascientific calculation of the adequate vascular perfusion time needed for full flap nourishment. All flaps survived completely except two cases of distal flaps necrosis. Cross-leg free latissimus dorsi can provide asolution for large soft-tissue defects in lower extremities especially with absence of any suitable recipient vessels or when the use of vein grafts would not be feasible. However, ideal time before dividing the cross vascular pedicle should be identified to have the maximum success rate possible.