Multiple Excisions Research Articles

Clinicopathological Factors Associated with Incomplete Excision of Cutaneous Squamous Cell Carcinoma.

Cutaneous squamous cell carcinoma (SCC) is the second most common type of cancer in Swedish men and women. The incidence of SCC is increasing rapidly. Primary treatment is complete surgical excision with sufficient margins to avoid recurrence and metastasis. The aim of this retrospective study was to identify the clinicopathological factors associated with incomplete excision of SCCs. Clinicopathological data and surgical outcome was obtained for 691 SCCs excised during a 2-year period (2014 to 2015) in Gothenburg, Sweden. Overall, 81 SCCs (11.7%) were incompletely excised. Incomplete excisions were associated with physician specialty and experience, tumour localization in the head and neck region, larger tumour diameter, and lower grade of tumour differentiation. However, multiple regression analysis revealed that large tumour size and excisions carried out by general practitioners were the only factors that significantly negatively affected rates of incomplete excision. These results should be taken into consideration when excising SCCs, in order to avoid multiple excisions.

The role of muscle forces in elite athletes before and after ACL surgery while performing a drop landing task

To report the characteristics of patients with restrictive diplopia following pterygium excision and a successful treatment approach for the strabismus.Retrospective interventional case series.This study was set in a single academic institution and included 15 patients with restrictive diplopia after pterygium excision. Patients with any other reason for strabismus were excluded. Patients were evaluated for deficits with special attention to diplopic measures. The intervention was a combined procedure by a strabismologist and oculoplastic surgeon to correct the diplopia. The primary outcome measurements were subjective and objective improvement of diplopia.Fifteen patients (mean age = 49 years) who developed diplopia after pterygium excision were included. Mean time to diplopia was 6 months. All patients had limited abduction in the previously operated eye causing esotropia in the abductive field (mean deviation = 18 prism diopters). After intervention, all patients were no longer diplopic in primary gaze. In the abductive field, 11 (73%) patients had residual small angle esotropia (mean = 7 prism diopters) in ipsilateral extreme end-gaze only. Only 2 patients required additional surgical intervention for scar tissue removal. No patients underwent medial rectus recession.Restrictive diplopia is a potential complication after pterygium excision, particularly for patients with a history of recurrent pterygia requiring multiple excisions and previous amniotic membrane graft placement with fibrin glue. However, diplopia after pterygium excision in primary position is surgically correctable with scar tissue removal and ocular surface reconstruction, without needing medial rectus recession. Given the high volume of pterygium excision, awareness of postoperative restrictive strabismus and the potential for correction is critical.

Eccrine porocarcinoma of the scalp: diagnosis and importance of early surgical intervention

Eccrine porocarcinoma is a rare and potentially fatal malignant adnexal tumor that can arise de novo or develop from its benign precursor, poroma. Diagnosis is difficult due to its rarity and resemblance to many other (benign) skin tumors. We present the case of a 71-year-old woman presenting with a long-standing case of eccrine porocarcinoma on the scalp. After multiple incomplete excisions over the last 15 years, no metastases were found. Major reconstructive surgery was necessary after complete excision of the lesion. Complete removal of the eccrine porocarcinoma was achieved in 2 stages. The defect was closed with a large rotation flap of the scalp. No adjuvant radio- or chemotherapy was given. Twenty-one months later, the patient presented with a rapidly growing lymph node recurrence, which was treated by lymph node dissection followed by chemoradiation. This case demonstrates the consequences of suboptimal surgical treatments and follow-up of eccrine porocarcinoma and its benign precursor, poroma. Early recognition, proper pathological diagnosis, and adequate surgical treatment are highly recommended in order to obtain a good prognostic outcome. Level of evidence: Level V, Risk/Prognostic study.

Identification and Correction of Restrictive Strabismus After Pterygium Excision Surgery

To report the characteristics of patients with restrictive diplopia following pterygium excision and a successful treatment approach for the strabismus. Retrospective interventional case series. This study was set in a single academic institution and included 15 patients with restrictive diplopia after pterygium excision. Patients with any other reason for strabismus were excluded. Patients were evaluated for deficits with special attention to diplopic measures. The intervention was a combined procedure by a strabismologist and oculoplastic surgeon to correct the diplopia. The primary outcome measurements were subjective and objective improvement of diplopia. Fifteen patients (mean age= 49 years) who developed diplopia after pterygium excision were included. Mean time to diplopia was 6months. All patients had limited abduction in the previously operated eye causing esotropia in the abductive field (mean deviation= 18 prism diopters). After intervention, all patients were no longer diplopic in primary gaze. In the abductive field, 11 (73%) patients had residual small angle esotropia (mean= 7 prism diopters) in ipsilateral extreme end-gaze only. Only 2 patients required additional surgical intervention for scar tissue removal. No patients underwent medial rectus recession. Restrictive diplopia is a potential complication after pterygium excision, particularly for patients with a history of recurrent pterygia requiring multiple excisions and previous amniotic membrane graftplacement with fibrin glue. However, diplopia after pterygium excision in primary position is surgically correctable with scar tissue removal and ocular surface reconstruction, without needing medial rectus recession. Given the high volume of pterygium excision, awareness of postoperative restrictive strabismus and the potential for correction is critical.

SAVI SCOUT® localization of breast lesions as a practical alternative to wires: Outcomes and suggestions for trouble-shooting

ObjectiveThe purpose of our study was to determine the frequency of successful SAVI SCOUT® localizations, to identify the factors contributing to unsuccessful procedures, and to provide a problem-solving algorithm to address those factors. Subjects and methodsThis retrospective study was performed following IRB approval. We included all consecutive patients with SCOUT® reflector placement performed at a single tertiary-care cancer center. Each case was reviewed and the following data were recorded: patient age, breast density, localization target, imaging modality used for guidance, post procedure mammogram reflector to skin and reflector to target distances, presence of the reflector in the specimen radiograph, excisional biopsy pathology and any procedure complications. ResultsIn 129 women, 152 SAVI SCOUT® reflectors were placed. Most patients had only 1 reflector placed, but 19 (15%) women had multiple reflectors placed for the purposes of bracketing, multiple excisions in 1 breast, bilateral excisions, or any combination thereof. The most common target was a mass (65%) and the most common modality for guidance was ultrasound (73%). SAVI SCOUT® localization was successful in 97%of reflectors, including 89% of reflectors targeting axillary lymph nodes. The most common failure encountered was the inability to obtain a signal in the radiology suite, due to (1) excessive target depth for the radiology suite handpiece and console, (2) obscuration by a hematoma, or (3) faulty reflector. No post-operative complications occurred. ConclusionThe SAVI SCOUT® surgical guidance system is an accurate and reliable method for localization of non-palpable breast lesions, bracketing, and axillary lymph nodes.

Expression of CD3, PD-L1 and CTLA-4 in mammary and extra-mammary Paget disease.

Mammary and extra-mammary Paget disease is a rare form of intra-epithelial glandular neoplasm which is characteristically recurrent and necessitates multiple excisions that have an important impact on morbidity. Local immuno-modulating treatments have been applied with promising results, but the local immune markers of Paget disease have not been studied. To investigate the local immune micro-environment of Paget disease. Sixty-four specimens from 41 patients, including cases with multiple recurrences and underlying primary neoplasm, have been studied for their expression of CD3, PD-L1 and CTLA-4. Nineteen cases were mammary; 22 were extra-mammary and involved the vulva, the anus, the inguinal region and the lower extremity. PD-L1 was not expressed by any neoplastic lesion or the associated lymphocytes. CTLA-4 expression was found in nine cases. Higher stromal CD3 expression and moderate levels of intra-epithelial CD3 expression were present in most cases. Biopsies, subsequent excision specimens and recurrences showed the same immunohistochemical profile of CD3 and PD-L1, although there were different levels of CTLA-4 ina few cases. The underlying lesions in mammary Paget disease showed the same immunohistochemical profile as the intra-epithelial neoplastic cells. The expression of the markers did not correlate with age, sex, localization or recurrence. Paget disease is characterized by an intense lymphocytic response, devoid of the immune-suppressive impact of the PD-L1 pathway, but with occasional CTLA-4 expression.

Trifecta Outcomes in Multifocal Tumors: A Comparison Between Robotic and Open Partial Nephrectomy.

To report a comparative analysis of outcomes in patients who underwent multiple excisions for unilateral synchronous multifocal renal tumors using both open and robotic approaches. We retrospectively reviewed 110 patients who underwent robotic and open partial nephrectomy and had multiple tumor excisions in an ipsilateral kidney. "Trifecta" was defined as negative surgical margins, no urologic complications, and a glomerular filtration rate (GFR) preservation of ≥90% at last follow-up. Inverse probability of treatment weighting (IPTW) was applied to equilibrate treatment groups, minimize selection bias, and optimize inference on the basis of each patient's clinicodemographic characteristics. Sixty-eight robotic and 42 open patient approaches had sufficient data for IPTW. After weighting, there were no statistical differences in baseline characteristics between the two groups. On adjusted analyses, robotic partial nephrectomy achieved equivalent rates of trifecta to open surgery (16.3% vs 16.5%, p = 0.99), which persisted on subgroup analyses of patients with two (20.1% vs 23.7%, p = 0.82) or more than two tumors (6.8% vs 7.4%, p = 0.95). There were no differences between robotic and open cohorts for negative margin rates, absence of complications, or GFR ≥90%. The robotic cohort had a shorter mean length of stay (3.4 vs 4.9 days, p < 0.001). Surgical resection remains the mainstay for patients with unilateral, synchronous, and multifocal renal tumors. Our analysis found that both open and robotic approaches to partial nephrectomy are equally likely to achieve the "trifecta" outcome in an equilibrated high-risk group of patients. The robotic approach for these complex patients may be safe and feasible for a carefully selected group of patients.

Severe xanthomatosis in heterozygous familial hypercholesterolemia

Familial hypercholesterolemia is a genetic lipoprotein disorder characterized by elevated plasma low-density lipoprotein cholesterol level, (tendinous xanthomas, xanthelasmas, and premature arcus corneus) and early onset atherosclerotic cardiovascular disease. Familial hypercholesterolemia is caused by mutations in the low-density lipoprotein receptor, apolipoprotein B or proprotein convertase subtilisin/kexin type 9 genes. Rare mutations in low-density lipoprotein receptor adapter protein 1, APOE p.Leu167del or lysosomal acid lipase genes can mimic FH. The prevalence of heterozygous familial hypercholesterolemia is estimated to be 1/250 worldwide, although some populations with founder effects show a higher prevalence. The rare homozygous form has an estimated prevalence of 0.000004 or 1/250,000 and is characterized by markedly elevated low-density lipoprotein cholesterol, skin manifestations (planar xanthomas, tendinous xanthomas) in childhood and extremely premature atherosclerotic cardiovascular disease. While tendinous xanthomas are considered pathognomonic for familial hypercholesterolemia, they can also be found in rare diseases, including sitosterolemia. Here, we report a case of severe tendinous xanthomatosis with heterozygous familial hypercholesterolemia due to the low-density lipoprotein receptor del >15 kb mutation. The phenotypic expression of the disease is out of proportion with the genetic diagnosis or biochemical measurements. We report the case of 51-year-old woman of French-Canadian origin diagnosed with heterozygous familial hypercholesterolemia since age 12. She presented with hypercholesterolemia with total cholesterol 7.6 mmol/L, with an imputed low-density lipoprotein cholesterol level of 6.5 mmol/L. She had extensive tendinous xanthomas of the Achilles tendons, knees, elbows and metacarpophalangeal joints. Because of cosmetic disfigurement, she had multiple excisions of Achilles, knee and elbow xanthomas, albeit with rapid recurrence. Our patient has a significant family history of lung cancer and other autoimmune diseases associated with familial hypercholesterolemia and xanthoma. Lipid-lowering therapy was started, at age 12; which included initially cholestyramine, then changed to statin and ezetimibe. Eventually, evolocumab was added. Despite trying different lipid-lowering therapy, there has been no noticeable decrease in the size of the xanthomas. Our patient has severe xanthomatosis out of proportion with the genetic diagnosis or biochemical measurements. Her xanthomatosis did not improve by pharmacological therapy consisting of statins and evolocumab despite a 50% reduction in low-density lipoprotein cholesterol. It is likely that the patient presented here has a second genetic disorder that leads to extensive xanthomatosis.

Microcystic adnexal carcinoma—diagnostic criteria and therapeutic methods: case report and review of the literature

Microcystic adnexal carcinoma (MAC) is a rare, infiltrating, locally aggressive cutaneous neoplasm of combined follicular and eccrine/apocrine histogenesis, usually presenting on the upper lip or face. Differentiation from other adnexal tumours is very important because the clinical management of these tumours is radically different, and misdiagnosis may lead to incorrect treatment. A case of recurrent MAC in the upper lip, treated with multiple excisions and postoperative radiation therapy (PORT), is presented herein. There have been no signs or symptoms of recurrence since the subsequent reconstructive surgery and PORT. Based on reports in the literature it appears that although immunohistochemistry can be helpful in distinguishing between MAC and other adnexal tumours, careful histopathological examination is essential for an accurate diagnosis. Perineural and intramuscular invasion strongly suggest the diagnosis of MAC. Its predilection for the facial area often limits the width of surgical excision. In such cases, PORT may be considered.

Management of extraoral sinus via nonsurgical root canal treatment

Cutaneous sinus tracts of dental origin have been well-documented in the medical literature. However, these lesions continue to be a diagnostic dilemma. A review of several reported cases reveals that patients have had multiple surgical excisions, radiotherapy, multiple biopsies, and multiple antibiotic regimens, all of which have failed, with a recurrence of the cutaneous sinus tract, as the primary etiology was dental that was never correctly diagnosed or addressed. This case report demonstrates the healing of an extraoral draining sinus by means of conventional nonsurgical root canal treatment.

Meningitis Secondary to Pseudomonal Endophthalmitis in a Burn Patient: A Case Report and Review of the Literature

Background: To report the case of a burn patient with meningitis secondary to pseudomonal endophthalmitis that led to death. Case Presentation: An 18-year-old female who sustained flame burns in a house fire was admitted to our burn center. She sustained burns that accounted for 68% of her total body surface area, including her face. The patient underwent multiple excision and grafting procedures. On the thirteenth post-burn day, wound cultures revealed a resistant Pseudomonas sensitive only to aminogyclosides and colistin. On the twentieth post-burn day the patient developed edema, erythema, and proptosis of the right eye. Ophthalmology was consulted and endophthalmitis was diagnosed. A lateral right canthotomy was performed. Treatment modalities including intra-vitreous antibiotic injection were discussed but not performed. Computed tomography (CT) of the head at that time showed concern for retrobulbar inflammation. There was a progressive decrease in her mental status. An additional brain CT scan showed diffuse cerebral abnormalities and edema. Clinical examination at that time demonstrated decreased cerebral activity consistent with brain death and repeat neurologic examination confirmed brain death. Conclusion: Meningitis constitutes a rare complication of endophthalmitis and its prompt diagnosis and treatment via administration of systemic antibiotics via intravenous or intrathecal routes, with intra-vitreal antibiotics could lead to a more favorable outcome.

Pseudoangiomatous stromal hyperplasia \u2013 a benign and rare tumor of the breast in an adolescent: a case report

BackgroundPseudoangiomatous stromal hyperplasia is an uncommon mesenchymal breast neoplasm.Case presentationHere we present a case of an 11-year old hispanic girl affected by bilateral mammary nodular pseudoangiomatous stromal hyperplasia, an uncommon breast disease, with a review of the literature related to diagnostic workup, differential diagnosis, and management. A rapidly growing mass in the breast may be stressful for both parents and child as the suspicion of malignancy arises. Multiple wide excisions of both breasts were performed.ConclusionsThe purpose of this case report is to draw attention to the fact that most emerging lesions of the breast in girls during puberty are benign diseases.

Use of fat transfer to treat a chronic, non-healing, post-radiation ulcer: a case study

Problematic wound healing and ulceration in radiation-damaged tissue is a surgical challenge. Clinical studies have shown that grafting fat tissue in an irradiated area can improve the quality of the skin and has regenerative effects. This case study describes how fat transfer led to the healing of a chronic ulcer resistant to other forms of treatment. A 67-year-old lady with a chronic, non-healing ulcer in her leg had a squamous cell carcinoma excised, followed by radiotherapy. Despite multiple excisions, the ulcer continued to cause symptoms. Following an initial procedure in which fat was infiltrated around and under the ulcer, the patient underwent a wide local excision and split-thickness skin grafting. Histology demonstrated a post-radiation dermatitis ulcer with no evidence of malignancy. After a period of management with dressings showing a reduction in ulcer size, more fat was infiltrated around the lesion. Two months later, the ulcer had fully healed and has not recurred. The use of adipose-derived stem cells to heal wounds in irradiated tissue has been the focus of research for some time. This case highlights the potential of adipose tissue to improve damaged skin. Its use could negate the need for complex surgical procedures.

Qualité de vie des patients opérés d’une dermo-hypodermite ou fasciite nécrosante, une étude sur 10 ans

Bacterial necrotizing dermis-hypodermitis and necrotizing fasciitis (BNDH-NF) are serious life-threatening soft-tissue infections. The object is to evaluate the quality of life (QOL) of patients who have been operated in our plastic surgery departement. This is a retrospective study of cases who have been treated at Nancy University Hospital between 2005and 2014. We analyzed the perioperative data (demographic, clinical, bacteriological), the surgical data (excision, reconstruction) and the follow up data (consequences, mortality). The quality of life was assessed by the Short-Form 36score, and the patients' satisfaction was assessed by a four-level scale. We analyzed 23patients with an average age of 60years (28-84years). The main comorbidities were diabetes (43%) and obesity (39%). The average number of surgical excision was about 1.9 (1-5) and the average excised body surface area was about 5% (1-16%). The short-term mortality was about 17%. The mortality rate has been statistically correlated with the surgically excised body surface area (short-term 95days: P=0.02; and long-term: P=0.003). The statistical analysis has shown a strong relative linear relationship between number of surgical excision and the physical score of QOL (P<0.001), between number of surgical excision and mental score of QOL (P=0.032), and between age and physical score of QOL (P≤0.021). The statistical analysis has also shown a strong relative linear relationship between E.coli infections and physical score of QOL (P=0.01). The percentage of patients' satisfaction in our study was evaluated at 86%. We have found that multiple surgical excisions, an advanced age of patients and E.coli infections have been associated with poor QOL. The mortality rate increased in relation with the importance of excised body surface. In spite of the gravity of these infections, our patients were satisfied of their treatment.

The Usefulness of Intraoperative Circumferential Frozen-Section Analysis of Lumpectomy Margins in Breast-Conserving Surgery.

PurposeIntraoperative frozen-section analysis of the lumpect-omy margin during breast-conserving surgery (BCS) is an excellent method in obtaining a clear resection margin. This study aimed to investigate the usefulness of intraoperative circumferential frozen-section analysis (IOCFS) of lumpectomy margin during BCS for breast cancer, and to find factors that increase the conversion into mastectomy.MethodsFrom 2007 to 2011, 509 patients with breast cancer underwent IOCFS during BCS. The outer surfaces of the shaved lumpectomy margins were evaluated. A negative margin was defined as no ink on the tumor. All margins were evaluated using the permanent section analysis.ResultsAmong the 509 patients, 437 (85.9%) underwent BCS and 72 (14.1%) finally underwent mastectomy. Of the 483 pathologically confirmed patients, 338 (70.0%) were true-negative, 24 (5.0%) false-negative, 120 (24.8%) true-positive, and 1 (0.2%) false-positive. Twenty-four patients (4.7%) among total 509 patients had undetermined margins as either atypical ductal hyperplasia or ductal carcinoma in situ in the first IOCFS. The IOCFS has an accuracy of 94.8% with 83% sensitivity, 99.7% specificity, 93.4% negative predictive value, and 99.2% positive predictive value. Sixty-three cases (12.4%) were converted to mastectomy, the first intraoperatively. Of the 446 (87.6%) patients who successfully underwent BCS, 64 patients received additional excisions and 32 were reoperated to achieve clear margin (reoperation rate, 6.3%). Twenty-three of the reoperated patients underwent re-excisions using the second intraoperative frozen section analysis, and achieved BCS. Nine cases were additionally converted to mastectomy. No significant differences in age, stage, and biological factors were found between the BCS and mastectomy cases. Factors such as invasive lobular carcinoma, multiple tumors, large tumor, and multiple excisions increased the conversion to mastectomy.ConclusionThe IOCFS analysis during BCS is useful in evaluating lumpectomy margins and preventing reoperation.

Multiple Tumor Excisions in Ipsilateral Kidney Increase Complications After Partial Nephrectomy.

The surgical morbidity of ipsilateral synchronous multifocality (ISM) is poorly characterized. We assessed the impact of ISM on complications after robotic partial nephrectomy (RPN). We abstracted data on RPN cases performed between 2006 and 2015 at our institution. Multifocal disease was characterized by >1 renal mass on preoperative imaging or >1 mass excision during RPN. The primary outcome was the rate of overall postoperative complications. The association between multifocality and complications was evaluated using univariate and multivariable analyses. Of 1121 cases, 59 (5.3%) had >1 ipsilateral renal mass and 50 (4.5%) required >1 excision. The overall complication rate was 20.3% (230/1121). The radiographic number of ipsilateral renal masses was not significantly associated with complications (20.2% for 1 mass vs. 25.4% for >1 mass, p = 0.338). However, the actual number of ipsilateral mass excisions performed during RPN was significantly associated with complications (20.2% for ≤2 excisions vs. 42.9% for >2 excisions, p = 0.037). Major complications were higher (14.3% vs. 5.3%) for >2 versus ≤2 excision(s), but this difference was not significant (p = 0.174). The most common complications associated with multiple excisions were transfusion, urine leak, arrhythmia, venous thromboembolism, and ileus. On multivariable analysis, number of excisions independently predicted complications (OR 3.1, 95% CI 1.03-9.33, p = 0.041). Other independent predictors of complications included age, race, Charlson score, body mass index, RENAL score, and surgeon experience. ISM requiring ≥2 excisions is associated with increased morbidity after RPN. Pending external validation, this information may facilitate clinical decision-making and preoperative patient counseling.

EPN-02FINAL RESULTS OF THE 2ND AIEOP PROTOCOL FOR INTRACRANIAL EPENDYMOMA (EPD)

EPN-02. FINAL RESULTS OF THE 2ND AIEOP PROTOCOL FOR INTRACRANIAL EPENDYMOMA (EPD) Maura Massimino1, Rosalba Miceli1, Felice Giangaspero2,3, Luna Boschetti1, Paolo Ferroli4, Paola Peretta5, Emilia Pecori1, Laura Valentini4, Veronica Biassoni1, Maria Luisa Garre6, Elisabetta Schiavello1, Iacopo Sardi7, Armando Cama6, Silvia Scoccianti8, Maurizio Mascarin9, Lorenzo Genitori7, Daniele Bertin5, Anna Mussano10, Elisabetta Viscardi11, Piergiorgio Modena12, GiuseppinaCalareso1, Salvina Barra13, Giovanni Scarzello14, LuciaQuaglietta15, Giuseppe Cinalli15, Angela Mastronuzzi16, Carlo Giussani17, Carlo Marras16, Rita Balter18, Patrizia Bertolini19, Ermanno Giombelli19, Francesca Buttarelli2, Manila Antonelli2, and Lorenza Gandola1; Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; Universita Sapienza Roma, Roma, Italy; Neuromed Pozzilli, Pozzilli, Italy; Fond IRCCS Istituto Neurologico Carlo Besta, Milano, Italy; Ospedale Infantile Regina Margherita, Torino, Italy; Istituto Giannina Gaslini, Genova, Italy; Ospedale Pediatrico Meyer, Firenze, Italy; OspedaleCareggi,Firenze, Italy;CRO,Aviano, Italy;OspedaleS.Anna, Torino, Italy; Clinica di Oncoematologia Pediatrica, Padova, Italy; Genetica, Osp S. Anna, Como, Italy; Istituto dei Tumori, Genova, Italy; Istituto Oncologico del Veneto, Padova, Italy; Ospedale Pausillipon, Napoli, Italy; Ospedale Bambino Gesu, Roma, Italy; Ospedale S. Gerardo, Monza, Italy; Ospedale Borgo Roma, Verona, Italy; Ospedale, Parma, Italy This study stratified patients after surgical resection (complete 1⁄4 NED vs incomplete 1⁄4 ED) and centrally reviewed histology(gr.2 vs gr. 3). Gr2 tumors/NEDpts were focally irradiated with a 3D-conformal technique 1.8Gy/d up to 59.4 Gy, gr3/NED received also 4 VEC(Cyclo,VP16,VCR) after irradiation. EDpts received 1-4 VEC, second-look surgery whenever possible,59.4 Gy followed by 8 Gy boost into 2 fractions on still measurable residue. Children aged 1-3 yrs received the same treatment but for those gr2/NED who could receive only 6 VEC. Between January 2002/December 2014, 160 consecutive children, median age 4.9 years, entered the protocol; follow-up was a median 67 months. M/F was 100/60, infratentorial origin in 110(2 plus metastasis). After surgery, NEDpts were 110,grade 3 was assessed in 84. 100 resections were performed in 46/160 children with another 12 rendered NED after first excision,10 after 1-4 VEC,2 after radiation. Boost was applied to 24/40 still ED patients after surgery/ies and VEC obtaining PFS/OS of 58.1%/68.7% in this severe prognosis subgroup. For the whole series,5-year PFS/OS were 65.4%/81.1% with no toxic deaths. In univariable analysis, female gender, supratentorial origin, NED status before RT, grade 2, shunt absence were favourable for OS, in multivariable NED status and grade 2 were. For PFS, female gender, NED status before RT, grade 2 were significant in univariable, only grade in multivariable. In a multicentric collaboration this trial accrued the highest patient number so far published with comparable results to best monoinstitutional series. Radiation boost was feasible and efficacious in improving local control. Complete surgery, also through multiple excisions, still confirmed its prognostic strength as well as grade. Further biological parameter definition on this series will be the object of next coming studies. Neuro-Oncology 18:iii30–iii39, 2016. doi:10.1093/neuonc/now070.2 #The Author(s) 2016. Published by Oxford University Press on behalf of the Society for Neuro-Oncology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Report on immediate irradiation of a rapidly growing sarcoma of the scalp prior to wound closure.

Cutaneous sarcomas are primarily treated with extensive surgery, and occasionally require adjuvant radiation therapy following complete wound healing. Thus, sarcoma surgery leads to large and deep wounds, and the initiation of adjuvant radiation therapy depends on the time required for defect closure. We present the case of a male patient with pleomorphic sarcoma of the temporal skin, which was treated with multiple wide and deep excisions, instant application of an Integra(®) bilayer, and immediate radiation therapy prior to wound closure. The objective was to investigate the usefulness of a dermal substitute (Integra(®) ) in accelerating the effect of adjuvant radiation therapy on scalp defects after tumor surgery. A ring-shaped skin area - at risk for recurrence - around the Integra(®) bilayer was irradiated with a total of 59.4Gy. No necrosis, infection, or major radiotoxicity was observed, and a subsequent split skin graft following radiation therapy remained fully vital until complete healing. In conclusion, a combined procedure consisting of sequential tumor surgery and subsequent application of a dermal substitute in conjunction with immediate initiation of adjuvant radiation therapy is, in principle, possible, and may permit innovative therapeutic options in dermatooncology and dermatosurgery.

Treatment of a Recurrent Neuroma Within Nerve Allograft With Autologous Nerve Reconstruction.

The purpose of this case report is to describe the findings of a neuroma within an allograft, highlight the unique opportunity to evaluate the allograft (following human engraftment) ex vivo histologically, to reinforce an effective treatment strategy, and review outcomes in peripheral nerve surgery regarding gap defect distance. A 55-year-old, right hand dominant man suffered a workplace injury 37 years ago resulting in lacerations and crush injury of the palm and lacerations of the left index finger requiring multiple neuroma excisions and eventual ray amputation. In an attempt to address stump neuroma pain and restore sensation of the radial digital nerve of the middle finger, which was lost after the ray amputation, a neuroma was resected and reconstructed with a 45-mm bioabsorbable allograft (AxoGen, Inc, Alachua, Florida). After the inciting injury in 1977, the patient initially presented to our clinic in 2013 with return of pain at the palm and numbness along the distribution of the common digital nerve and radial nerve of the middle finger prompting surgical exploration. A recurrent common digital nerve neuroma was identified at the proximal aspect of the allograft measuring 20 mm and was resected along with the remaining allograft. A 50-mm reversed superficial peroneal interpositional nerve graft was used for reconstruction resulting in progressive resolution of pain. On 6-month follow-up, the patient regained indiscriminate sensation with moving 2-point discrimination at the pulp of the middle finger with improved grasp function. In the setting of recalcitrant neuromas and intractable pain following multiple neuroma excisions, allografts may be suboptimal in reconstruction of larger gap defects. Autologous reconstruction with porcine submucosa extracellular matrix, as in this case, can avoid tethering, local ischemia, and nerve traction to optimize outcomes.

The diagnostic conundrum of Florid Reactive Periostitis: A case report and review of the literature

We report on a case of digital benign fibroblastic proliferative lesion that aggressively recurred after multiple excisions and showed histologic progression from a Fibrosseous Pseudotumor (FOPT) to Florid Reactive Periostitis (FRP). We recommend caution on incisional biopsies that do not excise the lesion fully based on the clinical course, radiographic, and histologic findings. Our case demonstrates the protean nature of this entity and the difficulty in obtaining an accurate diagnosis based on the clinical course and radiographic and histologic findings.