Initial Excision Research Articles

Oxidative Modification of Guanine in a Potential Z-DNA-Forming Sequence of a Gene Promoter Impacts Gene Expression.

One response to oxidation of guanine (G) to 8-oxo-7,8-dihydroguanine (OG) in a gene promoter is regulation of mRNA expression suggesting an epigenetic-like role for OG. A proposed mechanism involves G oxidation within a potential G-quadruplex-forming sequence (PQS) in the promoter, enabling a structural shift from B-DNA to a G-quadruplex fold (G4). When OG was located in the coding vs template strand, base excision repair led to an on/off transcriptional switch. Herein, a G-rich, potential Z-DNA-forming sequence (PZS) comprised of a d(GC) n repeat was explored to determine whether oxidation in this motif was also a transcriptional switch. Bioinformatic analysis found 1650 PZSs of length >10 nts in the human genome that were overrepresented in promoters and 5'-UTRs. Studies in human cells transfected with a luciferase reporter plasmid in which OG was synthesized in a PZS context in the promoter found that a coding strand OG increased expression and a template strand OG decreased expression. The initial base excision repair product of OG, an abasic site (AP), was also found to yield similar expression changes as OG. Biophysical studies on model Z-DNA strands found OG favored a shift in the equilibrium to Z-DNA from B-DNA, while an AP disrupted Z-DNA to favor a hairpin, placing AP in the loop where it is a poor substrate for the endonuclease APE1. Overall, the impact of OG and AP in a PZS on gene expression was similar to that in a PQS but reduced in magnitude.

Benign Phyllodes Tumor of the Breast Recurring as a Rapidly Growing Recurrent Malignant Phyllodes Tumor: A Case Report

: Phyllodes tumor is a fibroepithelial lesion that accounts for 0.3 % to 1.0 % of all breast neoplasms, and it is commonly observed as a fast-growing breast mass. Recurrences are frequent regardless of the histology, both in benign and malignant phyllodes tumors, and when it recurs, the prognosis is known as very poor. The average time to local recurrence reported is around two years from the initial excision. In this report, we describe a case of a benign phyllodes tumor of the breast recurring as a rapidly growing recurrent malignant phyllodes tumor in a 45-year-old woman, along with the imaging findings. There are many reports about recurrent phyllodes tumor in the medical field. However, the fascinating point about this case is the very short time interval of recurrences (shortest within one week) at the same location. To our knowledge, no case has been reported with such short interval time.

Otologic presentation of multiple myeloma with isolated temporal bone involvement: Diagnostic and therapeutic implications

Plasma cell disorder spectrum ranges from the benign plasma cell granuloma to malignant multiple myeloma characterized by the monoclonal proliferation of plasma cells. Multiple myeloma with temporal bone involvement is a rare entity and may present with nonspecific otological symptoms similar to chronic ear disease leading to a diagnostic challenge. Suspicion of multiple myeloma involving temporal bone primarily is difficult, and most of the cases are diagnosed after initial surgical excision. The differential diagnosis includes temporal bone carcinoma and glomus tumor due to similar radiological features. The final diagnosis is, however, made by the histopathological and immunohistochemical analysis. The mainstay of treatment of multiple myeloma is chemotherapy; however, surgical excision of the lesion is warranted in cases of pressure symptoms and intracranial involvement. We present a case who presented with ear canal mass, facial palsy, and cerebellar symptoms and was diagnosed to be a case of multiple myeloma with temporal bone involvement and was treated successfully. He is on regular follow-up for 1 year and remains in complete remission.

Comparative transcriptome reveals circadian and hormonal control of adventitious rooting in mulberry hardwood cuttings

Adventitious rooting derived from the parenchyma cells of vascular cambium is a highly efficient rooting type for cutting propagation of woody species. To unravel the molecular mechanisms underlying this distinct rooting process in mulberry stem hardwood cuttings, RNA-seq approach was adopted to perform wide transcriptional expression profiles of three stages characterized by initial excision (stage 1), root primordia induction (stage 2) and emergence of adventitious roots (stage 3). Compared to the former two stages, stage 3 had the most expressed genes (19,987) to establish functionally mature adventitious roots. In contrast, differentially expressed genes (DEGs) identified in stage 1 vs stage 2 comparison group were over threefold higher than stage 2 vs stage 3 comparison group (8930 vs 2739), suggesting a drastic transcriptional activation of genes involved in root primordia induction. GO and KEGG enrichment analysis of the DEGs showed that circadian rhythm-plant pathway was significantly enriched in response to environmental and endogenous changes in stage 2, whereas plant hormones including auxin, ethylene and cytokinin coordinately participated in the formation of adventitious roots in a stage-specific manner via an extensive and delicate regulation of their biosynthesis and signal transduction. Among which, several sets of genes relevant to circadian clock and hormone biosynthesis and signaling are speculated to potentially associated with the induction and differentiation of parenchyma cell initiated adventitious rooting. These findings will enrich our understandings to the mechanisms of adventitious rooting in mulberry, and provide theoretical support for the development of rooting techniques for other woody crops.

Influence of unplanned excisions on the outcomes of patients with stage III extremity soft-tissue sarcoma.

Soft-tissue sarcomas (STSs) are a heterogeneous group of malignant tumors that can be difficult to treat. This is particularly true after incomplete or unplanned excisions and especially for patients with American Joint Committee on Cancer stage III tumors, who are at high risk for relapse. Numerous studies have shown that an inadequate sarcoma excision is associated with a worse prognosis. However, other reports have suggested an improved prognosis for patients with an initial unplanned excision and subsequent re-excision in comparison with patients who undergo planned primary surgery. The purpose of this study was to determine the impact of an unplanned excision on treatment and subsequent oncologic and functional outcomes for patients with stage III extremity STS. From the prospectively collected database at a tertiary-referral sarcoma center, all patients with stage III STS of the extremities treated between 1989 and 2010 were identified. Patient records were reviewed to identify patient demographics, tumor details, treatments, complications, and functional and oncologic outcomes. Five hundred patients with stage III STSs of the extremities were identified, and 94 of these patients (18.8%) were referred after inadequate excisions had been performed elsewhere. All 94 patients with unplanned excisions underwent re-excision in an attempt to achieve clear margins, and 83% of these patients had residual tumor in the re-excision specimen. In the re-excision group, the rates of plastic reconstruction (eg, skin grafts and rotational or free flaps) and amputation were significantly higher in comparison with the rates for patients who underwent a primary planned resection (P = .023 and P = .03, respectively). The rates of local recurrence, metastasis-free survival, and overall survival were not significantly different between the 2 groups, nor were the functional outcomes. Unplanned excision of stage III STS leads to an unfavorable clinical course and necessitates more extensive surgery. As a result of aggressive re-excision and multidisciplinary treatment, a negative effect on oncologic outcomes cannot be confirmed.

Staged excision of primary periocular basal cell carcinoma: absence of residual tumour in re-excised specimens: a 10-year series

AimsThe aim is to study staged periocular basal cell carcinoma (BCC) excision in a tertiary oculoplastic referral centre in Sheffield, UK. In particular, we examined patients with close or positive...

Time to Initial Debridement and wound Excision (TIDE) in severe open tibial fractures and related clinical outcome: A multi-centre study

BackgroundRecent national (NICE) guidelines in England recommend that initial debridement and wound excision of open tibial fractures take place within 12 h of the time of injury, a change from the previous target of 24 h. This study aims to assess the effect of timing of the initial debridement and wound excision on major infective complications, the impact of the new guidance, and the feasibility of adhering to the 12 h target within the infrastructure currently existing in four major trauma centres in England. MethodsA retrospective review was performed of Gustilo-Anderson grade 3B open tibial fractures presenting acutely to four Major Trauma Centres (MTCs) in England with co-located plastic surgery services over a ten-month period. The incidence of deep infective complications was compared between patients who underwent initial surgery according to the new NICE guidance and those who did not. Patients warranting emergency surgery for severely contaminated injury, concomitant life-threatening injury and neurovascular compromise were excluded. Multi-variable logistic regression analysis was performed to assess the effect of timing of surgical debridement on development of deep infective complications. Results112 patients with 116 fractures were included. Six fractures (5.2%) developed deep infective complications. 38% (n = 44) underwent primary debridement within 12 h and 90% within 24 h. There was no significant difference in the incidence of major infective complications if debrided in less than or greater than 12 h (4.5% vs 5.6%, p = 1.00). Logistic regression found no significant relationship between timing of wound excision and development of deep infection. There was no significant decrease in mean time to debridement following introduction of new national guidance (13.6 vs 16.1 h) in these four MTCs. ConclusionOverall, the rate of deep infection in high energy open tibial fractures managed within the four major trauma centes is low. Achieving surgical debridement within 12 h is challenging within the current infrastructure, and it is unclear whether adhering to this target will significantly affect the incidence of severe infective complications. Debridement within 24 h appears achievable. If a 12-h target is to be met, it is vital to ensure dedicated orthoplastic capacity is adequately resourced.

Paraneoplastic immune-mediated neutropenia in a dog following thymoma excision with later development of metastatic thymic carcinoma treated with toceranib phosphate

A thymoma was an incidental finding in a seven-year-old, female neutered, crossbred dog referred for an acute hepatopathy. Excision of the thymoma was performed via median sternotomy, and 11 weeks...

High Rate of Major Morbidity after Surgical Excision for Pilonidal Disease.

Recurrent pilonidal disease has been reported to occur in up to 30% of patients after their initial infection. Surgical resection is often performed to prevent recurrence of disease, however, morbidity after surgical excision from incision complications and disease recurrence is common. The aim of this study was to quantify major morbidity after initial pilonidal excision. Patients with pilonidal disease who had initial excision procedures between 2011-2013 at hospitals reporting data to the Pediatric Health Information System (PHIS) were included. Predictors of the composite outcome of major surgical site complication or surgical re-excision within one year were evaluated using multivariable logistic regression models. Kaplan-Meier analysis was used to examine time to surgical re-excision. Of the 1,932 patients included, 4.7% (n = 138) had a major surgical site complication, 8.0% (n = 154) had a surgical re-excision, and 8.7% experienced either event within one year of their initial excision. The majority of re-excisions for recurrent disease occurred during the first two years after the initial excision. Risk factors associated independently with a greater risk of the composite outcome included older age (odds ratio [OR] 1.04 [95% confidence interval {CI} 1.00-1.07), p = 0.03), male gender (OR 1.49 [95% CI 1.09-2.08), p = 0.01), and the presence of a complex chronic gastrointestinal condition (OR 4.33 [95% CI 1.96-9.59], p < 0.001). Surgical excision of pilonidal disease is often complicated by site complications and nearly 1 of 10 patients develop recurrent disease requiring re-excision within two years after their initial excision. Future research into alternative therapies to treat pilonidal disease is warranted.

Sentinel lymph node metastasis in primary cutaneous basosquamous carcinoma. A cross-sectional study.

Basosquamous carcinoma (BSC) is a rare, biologically aggressive tumor. This cross-sectional study aims to define risk factors for subclinical nodal metastasis in primary BSC, and identify the patients who would benefit from routine sentinel node biopsy (SLNB) as part of the initial management. A total of 142 patients, with histologically proven BSC without palpable lymph nodes, underwent SLNB after the initial excision. Clinicopathological features and demographics were analyzed between the patients with detected micrometastasis (SLNM) and those with negative SLN. In 7.7% patients, subcapsular and <0.1 mm SLNM were found. The frequency of SLNM was 0.9%, 11.8%, and 80.0% in patients with maximum lesion diameter ≤ 2 cm, 2.1-3.0 cm and >3.0 cm, respectively (P < 0.001) and was strongly associated with perineural (P < 0.001; OR = 26.46, 95% CI = 5.62-124.52) and lymphatic invasion (P < 0.001; OR = 17.35, 95% CI = 4.44-67.91). Within 18-84 months, no recurrence or metastasis were observed in SLNM positive patients. False negative SLNB rate of 15.4% was recorded. Cutaneous BSC is associated with early nodal metastatic potential. Tumor size >2 cm, lymphatic and perineural invasion are significant determinants for SLN micrometastasis. In the absence of palpable lymphadenopathy, wide resection and SLNB with long-term follow-up are highly recommended in these patients.

Les brûlures profondes par agents basiques : évaluation d’une stratégie chirurgicale en deux temps

Chemical burns are rare but often lead to deep cutaneous lesions. Alkali agents have a deep and long lasting penetrating power, causing burns that evolve over several days. The local treatment for these patients is excision of the wound and split thickness skin graft. Early excision and immediate skin grafting of alkali burns are more likely to be complicated by graft failure and delayed wound healing. We propose a two-step method that delays skin grafting until two-three days after burn wound excision. Our population included 25 controls and 16 cases. Men were predominant with a mean age of 41.9years. In 78% of cases, burns were located on the lower limbs. The mean delay between the burn and excision was 16.5days. In cases, the skin graft was performed at a mean of 11.3days after the initial excision. We did not unveil any significant difference between both groups for the total skin surface affected, topography of the burns and the causal agent. Wound healing was significantly shorter in cases vs controls (37.5 days vs 50.3days; P<0.025). Furthermore, we observed a decreased number of graft failures in cases vs controls (13.3% vs 46.7%; P=0.059). Our study shows the relevance of a two-step surgical strategy in patients with alkali chemical burns. Early excision followed by interval skin grafting is associated with quicker wound healing and decreased rate of graft failure.

206 Time from Burn Injury to Initial Excision and its Association with Surgical Blood Loss

206 Time from Burn Injury to Initial Excision and its Association with Surgical Blood Loss

Study of the Lyase Activity of Human DNA Polymerase β Using Analogues of the Intermediate Schiff Base Complex.

DNA polymerase β (Pol β) participates in mammalian base excision repair. The enzyme has a two-domain architecture, reflecting its dual functionality. The polymerase activity, which replaces damaged nucleosides removed during an initial excision process, is within the C-terminal 31 kDa domain, while the N-terminal 8 kDa domain participates in a lyase function, working to remove a 5'-deoxyribose phosphate (5'-dRP) moiety from the damaged DNA substrate. The currently accepted mechanism of the lyase reaction involves a transient covalent enzyme-DNA intermediate in the form of a Schiff base connecting Lys72 of the enzyme with the 5'-dRP moiety. The Schiff base intermediate is resolved via a β-elimination reaction, initiated by abstraction of a C2'-H atom from the 5'-dRP moiety. Presently, we describe the preparation of three Pol β enzymes modified at position 72 with aminooxy or hydrazinyl analogues of lysine. These enzymes form transient covalent bonds with the 5'-dRP moiety of the damaged DNA, in the form of an oxime or hydrazone, respectively. Both types of enzyme DNA intermediates are ultimately resolved by the lyase activities of each of the modified enzymes. Unsurprisingly, the formation and resolution of these E-S complexes proceed with diminished kinetics, and with an altered pH profile. The performed experiments provide additional support for Schiff base formation as an obligatory intermediate on the pathway to DNA repair, as well as for the proposed participation of Lys72 in effecting opening of the 5'-dRP ring via protonation of the ring oxygen atom, and for complex resolution via a β-elimination reaction.

Abstract P4-15-04: A longitudinal cohort study to identify risk factors for the development of invasive cancer in unresected DCIS

Abstract Background: The variable natural history of ductal carcinoma in situ (DCIS) remains poorly understood. Randomized trials of active surveillance versus guideline concordant care are currently underway: the Comparison of Operative to Monitoring and Endocrine Therapy (COMET) trial in the US, LOw Risk dcIS (LORIS) trial in the UK and Low Risk Dcis (LORD) in Europe. Given this context, we examined the outcomes of a contemporary group of women with DCIS who did not undergo initial surgical resection. Methods: A longitudinal cohort of women diagnosed with DCIS on needle biopsy who did not undergo initial surgical excision for ≥1 year were identified through the Cancer Registry with case note and death certificate review for subsequent outcomes. Results: Eighty-nine eligible women with DCIS alone diagnosed on needle biopsy (most with 14-gauge core needle biopsy) between 1998 and 2010 were identified. The mean age at diagnosis was 72 years (range 44-94 years) with mean follow-up (diagnosis to death, invasive disease or last review) of 62 months (range 12-180 months). Twenty-nine women (33%) developed histologically proven invasive breast cancer, 28 at the site of the initial DCIS biopsy, after a mean interval of 54 months (range 12-144 months): 14/29 (48%) women originally had high grade DCIS, 10/31 (32%) intermediate grade and 3/17 (18%) low grade DCIS (initial grade not known in 12). Time to detect a diagnosis of invasive breast cancer was associated with initial grade of DCIS (p=0.0016, log-rank test): after mean intervals of 41 months (high grade), 69 months (intermediate grade) and 78 months (low grade) respectively. Younger age was associated with development of invasive disease (p&amp;lt;0.003, Mann-Whitney U-Test). High grade (grade 3) invasive breast cancer exclusively occurred in women with a prior diagnosis of high grade DCIS. Invasion was more frequent in lesions with calcification as the predominant feature than those without (23/50 v. 5/25; p&amp;lt;0.05, Fisher exact test). Forty-four women were prescribed endocrine therapy, use of which was associated with a lower rate of invasive breast cancer (p&amp;lt;0.05). Ultimately 18 women underwent surgery, 17 for invasive cancer. The mean interval from DCIS diagnosis to death was 76 months for those who developed invasive cancer; 48/89 women died, 12 had a certified cause of death as breast cancer. Conclusion: High grade DCIS, mammographic microcalcification and lack of endocrine therapy were associated with progression to invasion. The findings suggest surgical excision of high grade DCIS should continue but provides support that women with DCIS features which include low grade should be considered for the COMET, LORIS or LORD active surveillance trials. Citation Format: Maxwell AJ, Clements K, Hilton B, Dodwell DJ, Evans A, Olive K, Pinder SE, Thomas J, Matthew WG, Thompson AM. A longitudinal cohort study to identify risk factors for the development of invasive cancer in unresected DCIS [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-15-04.

Is Surgical Excision Necessary in Breast Papillomas 10 mm or Smaller at Core Biopsy

Background: The objective of this study was to propose managements for breast papillomas of 10 mm or smaller initially diagnosed at core biopsy. Method: We reviewed the data of patients in our center from 2004 to 2013. 116 lesions of 10 mm or smaller as measured by ultrasound (US) were diagnosed as papillomas at core needle biopsy (CNB) or vacuum-assisted biopsy (VAB). 74 of the papillomas diagnosed by CNB were surgically excised, the others were followed by imaging surveillance. Result: 13 of 116 lesions were found to be malignant, with an upgrade rate of 11.2%. Analyzing the difference between malignant and nonmalignant lesions, patients with malignant lesions were older than those with nonmalignant lesions (56.6 vs. 46.6 years, p = 0.002). Papillomas with atypia had a significantly higher upgrade rate than without, both in the surgical results (p = 0.030) and overall (p = 0.0392). None of 16 papillomas larger than 5 mm upgraded to malignancy. Breast papillomas diagnosed by CNB had a significantly higher upgrade rate (16.5%) than those diagnosed by VAB (0%) (p = 0.021). Conclusion: Our finding suggests that breast papillomas of 6-10 mm at initial CNB need additional surgical excision, but imaging surveillance may be suitable for papillomas no larger than 5 mm and papillomas detected by VAB.

Role of Brachial Artery Ligation in Management of Prosthetic Arteriovenous Graft Infections

Arteriovenous graft (AVG) infections can present as major life-threatening hemorrhage or sepsis in a chronic kidney disease patient. Frequently, all these patients present in critical condition which need prompt and expeditious management. Various procedures are described for management of infected grafts and its bleeding complications. However, these procedures are associated with postop-operative bleeding and persistent infection. The aim was to study brachial artery ligation (BAL) near the elbow joint in the management of an infected AVG. It was a retrospective study where data collection was done for 51 patients who underwent BAL in infected AVGs from January 2007 to December2016. During the study period, AVG infections were treated in 62 patients. Fifty-one BALs were done in 62 limbs treated. All were arm grafts (brachial artery to axillary vein) using expanded polytetrafluoroethylene grafts. In 49 patients, BAL was done as a primary procedure. In 2 patients, BAL was done after they presented with uncontrolled infection after initial subtotal excision with oversewing of graft stump at arterial anastomosis. There were 36 men and 15 women, with a mean age of 49years (range, 23-82). The primary etiologies for renal failure were hypertension (56.2%), diabetes (34.3%), and others (9.5%). Follow-up was 100% at 1 month and 82.3% (42 patients) at 3months, and none showed any signs of ischemia or sepsis. All had biphasic signals in radial and ulnar arteries with normal peripheral capillary oxygen saturation readings in fingers. None of the patients underwent additional interventions. BAL in AVG infections is a safe alternative considering the critical general condition of chronic kidney disease patient. It reduces the operative time significantly and avoids complex revascularization and anastomotic dehiscence without any ischemic or bleeding complications. BAL near the elbow joint in patients with good back-bleeding can be used as a primary approach in an infected AVG. However, close monitoring of patient in postoperative period is essential.

Low-stage pediatric neuroblastoma: A 20-year single institution review

BackgroundNeuroblastoma is a common childhood cancer with poor prognosis. This is a retrospective review of the outcomes in children with low-stage neuroblastoma in Taiwan. MethodsWe reviewed the charts of all children with International Neuroblastoma Staging System (INSS) stages 1 and 2 diagnosed at the Mackay Memorial Hospital between November 1994–December 2013. The patients' demographic data, age of diagnosis, treatment, and survival rates were analyzed. ResultsA total of 75 children with all stages of neuroblastoma were identified, of which 23 children in the low stage were enrolled. There were 12 (16.0%) patients in stage 1, and 11 (14.6%) patients in stage 2. The mean age of diagnosis for stage 1 and stage 2 was 5.4 months and 10.2 months, respectively. A total of 18 (78.3%) patients received initial complete surgical excision, and 5 patients received initial biopsy. The site of the tumor was the adrenal gland in 19 (82.6%) patients. Total or near-total resection was possible in 18 (78.3%) patients; all children with stage 1 were treated by complete surgical resection. Seven patients (63.6%) in stage 2 received chemotherapy. Children in both stages 1 and 2 had the same 5-year overall survival of 100%. The event-free survival rate for patients in stage 1 and stage 2 was 91.7% and 81.8%, respectively. ConclusionThis retrospective study confirmed that children with stage 1 and 2 neuroblastoma had good outcomes. Specifically, children with stage 1 disease are best treated by surgery alone, but selected patients in stage 2 need additional chemotherapy.

Is initial excision of cutaneous melanoma by General Practitioners (GPs) dangerous? Comparing patient outcomes following excision of melanoma by GPs or in hospital using national datasets and meta-analysis

BackgroundMelanomas are initially excised in primary care, and rates vary internationally. Until now, there has been no strong evidence one way or the other that excising melanomas in primary care is safe or unsafe. European guidelines make no recommendations, and the United Kingdom (UK) melanoma guidelines require all suspicious skin lesions to be initially treated in secondary care based on an expert consensus, which lacks supporting evidence, that primary care excision represents substandard care. Despite this, studies have found that up to 20% of melanomas in the UK are excised by general practitioners (GPs). Patients receiving primary care melanoma excision may fear that their care is substandard and their long-term survival threatened, neither of which may be justified. MethodsScottish cancer registry data from 9367 people diagnosed with melanoma in Scotland between 2005 and 2013 were linked to pathology records, hospital data and death records. A Cox proportional hazards regression analysis, adjusting for key confounders, explored the association between morbidity and mortality and setting of primary melanoma excision (primary versus secondary care). A pooled estimate of the relative hazard of death of having a melanoma excised in primary versus secondary care including 7116 patients from a similar Irish study was also performed. ResultsThe adjusted hazard ratio (95% CI) of death from melanoma for those having primary care excision was 0.82 (0.61–1.10). Those receiving primary care excision had a median (IQR) of 8 (3–14) out-patient attendances compared to 10 (4–17) for the secondary care group with an adjusted relative risk (RR) (95% CI) of 0.98 (0.96–1.01). Both groups had a median of 1 (0–2) hospital admissions with an adjusted rate ratio of 1.05 (0.98–1.13). In the meta-analysis, with primary care as the reference, the pooled adjusted hazard ratio (HR, 95% CI) was 1.26 (1.07–1.50) indicating a significantly higher all-cause mortality among those with excision in secondary care. ConclusionsThe results of the Scottish and pooled analyses suggest that those receiving an initial excision for melanoma in primary care do not have poorer survival or increased morbidity compared to those being initially treated in secondary care. A randomised controlled trial to inform a greater role for GPs in the initial excision of melanoma is justified in the light of these results.

Flap repair of complex pilonidal sinus: a single institution experience

Healing of pilonidal cysts after initial excision remains a vexing problem for surgeons. While simple sinus can be managed with success, recurrence of the cyst after primary excision or sizeable sinus often requires a more complex repair; however, the morbidity and ultimate success of these procedures are unknown. A retrospective review from 2009 to 2014 of all consecutive patients undergoing surgical intervention for pilonidal cyst disease from a single institution was performed. Management of pilonidal disease after excision with flap coverage was examined. Patient demographics, co-morbidities, procedural data, and post-operative outcomes were analyzed. Twenty-one flap patients were identified. These included 15 V-Y fasciocutaneous repairs, 5 rotational flaps, and 1 Romberg flap closure. Mean BMI was 32, mean defect size was 8 cm, and the patients have had an average of 1.05 attempts prior to the excision and flap repair. The flap group demonstrated 14% recurrence rate, 33% reoperation rate, and 47% dehiscence rate. Mean time to healing was 36.4 days. Flap repairs for complex pilonidal cysts have high rates of recurrence, reoperation, and wound dehiscence. However, flap patients represent a more challenging repair with long operative times, blood loss, and large sinus size. Absence of the perfect approach to managing a complex sinus necessitates a thorough description of the problem and a discussion between the surgeon and the patient about the merits of each approach before a decision is made. Level of Evidence: Level IV, therapeutic study.

Carcinome épidermoïde associé à une dépigmentation volontaire

Women widely use skin-lightening products for cosmetic purposes in sub-Saharan Africa despite numerous reported cutaneous and systemic complications. The occurrence of epidermoid carcinoma has long been reported, but only three cases have been published so far. We report the first case in Mali. A 30-year old woman with no noteworthy medical history was seen at our outpatient center for cervical ulceration that had been present for the last 5 years. She had used cosmetic bleaching cream over a period of around ten years. Physical examination revealed extensive ulceration on the left side of her neck. Blood tests for viral hepatitis and human immunodeficiency virus were negative. The pathological examination of the skin biopsy confirmed the diagnosis of squamous cell carcinoma. After failure of the initial excision with early relapse, multiple surgical ablations were performed 3 months later. The high prevalence of skin-lightening cosmetic use contrasts with the rarity of epidermoid carcinoma in depigmented skin. However, a large chronic ulcer on uncovered parts of the upper body, particularly the neck, should prompt physicians to consider skin cancer. Appropriate preventive measures include the promotion of educational messages for the general population, the use of sun-protection devices, and routine skin biopsy for all women presenting chronic cervical ulceration after long-term use of skin-lightening products.