Small Superficial Lesions Research Articles

Primary classic Kaposi sarcoma of the thigh

Classic-sporadic Kaposi’s sarcoma is a clinical variant of the broad spectrum of Kaposi’s sarcoma, and represents an angioproliferative rare disorder whose development is caused by human herpesvirus 8 (HHV-8) infection; also known as Kaposi’s sarcoma-associated herpesvirus (KSHV). The tumour appears to have an indolent course and good prognosis. Herein, we present the rare case of a 90-year-old Greek woman who presented with a 5-month history of a painful indurated area in the lower inner half of her left thigh, covered with multiple red, brown and bluish plaques and nodules. Symptoms were not specific of the disease. Excisional biopsy of a lesion confirmed Kaposi’s sarcoma. Due to extensive disease, the patient was offered radiotherapy as apposite treatment. Three months later, the lesion displayed a remarkable remission. Treatment for classic Kaposi’s sarcoma is not standard; it should be tailored to each individual case. Radiotherapy seems to offer the best treatment option for locally advanced symptomatic disease, while surgery may be of benefit to solitary or small superficial lesions. Despite the rarity of this tumour, surgeons, oncologists, and dermatologists need to be very suspicious when faced with such unusual lesions on the extremities.

Primary penile kaposi’s sarcoma in a HIV negative patient - case report

Kaposi's sarcoma (KS) to the external genitalia is extremely rare in HIV seronegative individuals. We present a 68-year-old man with multiple lesions on the penile glans, near the external meatus and coronal sulcus, that infiltrated in the distal penile shaft with a history of 12 months. Clinical examination revealed small skin superficial lesions with red violaceous aspects, two on the right flank, 1.5-2cm diameter, and one on the external retromaleolar right foot 2 cm in diameter. Histological examination of penile lesions revealed the presence of a dermal nodular proliferation of spindle cells into intersecting fascicles, with moderate cytologic atypia and hyaline globules, slit-like vascular spaces containing erythrocytes, with negative margins. Immunohistochemical profile was HHV-8, VIM, CD34, CD31, FVIII positive and Ki67 20%. At 6 months, after partial penile amputation, the patient observed small superficial red violaceous macular lesions, 0.5 cm, on the restant penile shaft. After resection the histological examination showed again KS. At 14 months follow-up, no signs of progression or local recurrence were registered. Despite the fact that primary penile KS is extremely rare, it should be always considered by clinician in the differential diagnosis of non-specific lesions in this area, even in HIV negative patients.

A Clinical Study of Transoral Pharyngectomies to Treat Superficial Hypopharyngeal Cancers

For years, it has been a major interest for surgeons and oncologists to develop a novel technique to detect hypopharyngeal cancers at an early stage and to treat the lesions in a less invasive manner. The advent of the narrow band imaging system combined endoscopy and various endoscopic approaches shed light on the new era of the minimum invasive management of superficial cancers in hypopharyngeal regions. Three endoscopic approaches, endoscopic mucosal resection, endoscopic submucosal dissection and endoscopic laryngopharyngeal surgery, were chronologically introduced at our institute. In this study, we focused on the clinical outcomes, advantages and limitations of each procedure. A total of 30 patients (42 procedures) received transoral pharyngectomies between June 2006 and May 2012. Tracheotomy was performed in 9 of 42 (21%) patients. Three patients developed local recurrence and were subsequently controlled by additional transoral pharyngectomies. The 2- and 5-year local control rates were 92.8 and 83.5%. The 2- and 5-year overall survival rates were 82.1%. Endoscopic mucosal resection, endoscopic submucosal dissection and endoscopic laryngopharyngeal surgery-transoral pharyngectomies are useful procedures for treating superficial hypopharyngeal cancers. Endoscopic mucosal resection manifested the least invasiveness and may be beneficial for resecting small superficial lesions, endoscopic submucosal dissection may be advantageous for patients with difficult laryngopharyngeal exposure and endoscopic laryngopharyngeal surgery has shown the optimal effectiveness and minimal complications and can be applied to most of the hypopharyngeal sub-sites. All three procedures require a high level of technical skill and close collaboration between otolaryngologists and gastroenterologists.

Hemangioma Curative Effect of PDL, Alexandrite, Er:YAG and CO2 Lasers

Hemangioma is a mesenchymal benign tumor formed by blood vessels. Anomalies affect up to 10% of children and they are more common in females than in males. The aim of this study was to evaluate hemangioma treatment using four different types of lasers, namely, alexandrite, Er:YAG, CO(2), and pulsed dye laser (PDL). The argon laser was the first to be used for dermatological patients, namely, with port wine stains (PWS) in the late 1960s and early 1970s. A variety of different lasers and light sources were useful in the treatment of vascular lesions, e.g., KTP, Nd:YAG, CO(2), PDL, and Er:YAG. A group of 869 consecutive patients with hemangioma was retrospectively reviewed. The patients including in our study were divided into four groups according to the type of laser used: Alexandrite laser (n=85, 58 women and 20 men), CO(2) laser (n=78, 58 women and 20 men), Er:YAG laser (n=105, 87 women and 18 men), and PDL laser (n=601, 453 women and 148 men). All patients were treated in one session without anesthesia application. The ablative systems vaporized the tissues until the hemangioma was removed. The non-ablative systems used one shot, which destroyed the hemangioma blood vessels. For the treatment efficacy analysis, the following factors were evaluated: therapeutic effect (yes vs. no), loss of pigment (yes vs. no), and appearance of scar (yes vs. no). From results it was evident that the therapeutic effect of all the lasers except alexandrite was very high; almost 100%. In the CO(2) and the Er:YAG laser groups a high percentage of side effects was also observed. Exposure to these lasers caused loss of pigment and scar formation in many cases. The best therapeutic effect, with only minor side effects, has been achieved with the PDL laser. It was confirmed that PDL (595 nm, 1.5 ms, 7 mm, 9 - 11 J/cm(2)) had optimal effect without scars. Er:YAG or CO(2) laser radiation with specific characteristics was also useful for small superficial lesions.

Clinical, Biological, and Skin Histopathologic Effects of Ionic Macrocyclic and Nonionic Linear Gadolinium Chelates in a Rat Model of Nephrogenic Systemic Fibrosis

the purpose of this study was to compare the clinical, pathologic, and biochemical effects of repeated administrations of ionic macrocyclic or nonionic linear gadolinium chelates (GC) in rats with impaired renal function. rats submitted to subtotal nephrectomy were allocated to single injections of 2.5 mmol/kg of gadodiamide (nonionic linear chelate), nonformulated gadodiamide (ie, without the free ligand caldiamide), gadoterate (ionic macrocyclic chelate), or saline for 5 consecutive days. Blinded semi-quantitative histopathologic and immunohistochemical examinations of the skin were performed, as well as clinical, hematological, and biochemical follow-up. Rats were killed at day 11. Long-term (up to day 32) follow-up of rats was also performed in an auxiliary study. epidermal lesions (ulcerations and scabs) were found in 4 of the 10 rats treated with nonformulated gadodiamide. Two rats survived the study period. Inflammatory signs were observed in this group. No clinical, hematological, or biochemical signs were observed in the saline and gadoterate- or gadodiamide-treated groups. Plasma fibroblast growth factor-23 levels were significantly higher in the gadodiamide group than in the gadoterate group (day 11). Decreased plasma transferrin-bound iron levels were measured in the nonformulated gadodiamide group. Histologic lesions were in the range: nonformulated gadodiamide (superficial epidermal lesions, inflammation, necrosis, and increased cellularity in papillary dermis) > gadodiamide (small superficial epidermal lesions and signs of degradation of collagen fibers in the dermis) > gadoterate (very few pathologic lesions, similar to control rats). repeated administration of the nonionic linear GC gadodiamide to renally impaired rats is associated with more severe histologic lesions and higher FGF-23 plasma levels than the macrocyclic GC gadoterate.

European laryngological society propose four types endoscopic supraglottic laryngectomy

The limited excision addresses small superficial lesions affecting free edge of the epiglottis, the aryepiglottic fold or the superior edge of the arytenoid. The median supraglottic laryngectomy excluding the pre-epiglottic space addresses small superficial T1 lesions of the endolaryngeal epiglottis. The incision line extends to the pre-epiglottic space but does not aim at removing the pre-epiglottic space entirely. The pharyngo-epiglottic folds, aryepiglottic folds, and ventricular folds are preserved. The median supraglottic laryngectomy including the pre-epiglottic space addresses T1 and T2 lesions of the endolaryngeal epiglottis. The entire pre-epiglottic space is removed as far as possible. Depending on extent of the lesion, the resection can include one or two ventricular bands and the aryepiglottic folds. The lateral supraglottic laryngectomy addresses lesions affecting the three folds or T1 and T2 lesions of the aryepiglottic fold. The procedure removes free edge of the epiglottis ipsilateral to the lesion, the area of the three folds and the aryepiglottic fold. The resection can include the inner wall and anterior angle of the pyriform sinus, the entire ventricular fold and the arytenoid (provided it is mobile).

CT Laparoscopy for Detecting Small Superficial Metastatic Lesions of the Liver Surface: Initial Experience

The purpose of this study was to determine the efficacy of CT laparoscopy in the detection of superficial metastasis of the liver surface. From April 1, 2007, to July 1, 2007, a total of 34 consecutively registered patients (19 men, 15 women; median age, 55 years) with various intraabdominal malignant tumors underwent preoperative CT and composed the study population. All patients underwent superparamagnetic iron oxide-enhanced MRI and portal phase contrast-enhanced 64-MDCT, including CT laparoscopy. CT laparoscopy is a form of volume-rendering 3D imaging of the liver that depicts the liver surface in detail. Among 23 patients who underwent surgery for management of a primary tumor, four patients had seven superficial metastatic lesions of the liver surface. None of these lesions had been detected with preoperative axial CT or superparamagnetic iron oxide-enhanced MRI. In contrast, CT laparoscopy revealed four of seven lesions in four patients. On a lesion-by-lesion basis, the sensitivity was 57%, the positive predictive value was 100%, and the accuracy was 57%. Our initial experience proves that CT laparoscopy is a promising method for detecting small superficial metastatic lesions of the liver surface. The findings can influence decisions regarding tumor resectability.

Novel Techniques and Instrumentation for EMR, ESD, and Full-Thickness Endoscopic Luminal Resection

Endoscopic intervention is evolving into an established therapeutic alternative for small superficial lesions, and an eventual application for en bloc resection of large lesions, deeper layers, and a reliable access to lesions outside of the gastrointestinal wall. Although further developmental and clinical evaluation is necessary, we believe endoscopic resection by the submucosal route and by full-thickness approaches will replace standard surgical procedures in the next several years.

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More than 90% of skin cancers develop in exposed areas such as the head, neck and extremities. Most non-melanomatous skin cancers begin as small superficial lesions. These lend themselves to successful treatment using variety of modalities. The principal objective of treatment is the complete regression of the lesion, while minimizing functional and cosmetic impairment. The aim of this study is to investigate the use of HDR surface applicators as an alternative radiotherapy modality for the treatment of skin lesions. Only patients with histologically proven epithelial skin cancer, in various sites (face, scalp and lower extremities) were included. Treatment was delivered by HDR Brachytherapy (Ir-192), with standardized Leipzig surface applicators. The appropriate applicator was fitted in thermoplastic casts, dimension chosen so that the lesion fell within 80% of the nominal field diameter; thus the maximum lesion size is about 2.5 cm in diameter. India ink was used to verify the planning target volume (PTV), (lesion plus 0.5 cm margin) coverage. A total dose of 40 Gy (5 Gy twice weekly for four weeks) was prescribed to the surface. TLD chips measurement were used twice during the course of treatment. Acute skin toxicity was evaluated twice weekly during radiation using the modified RTOG morbidity criteria. Local response was monitored at periodic intervals after treatment completion. Between January 2003 to January 2006, 20 patients with a total of 21 lesions were treated. Eleven male and nine females, with a median age of 69 years. Out of twenty one lesions treated, twelve were squamous cell carcinoma and eight were basal cell cancers. Ten lesions involved the nose, six in face and scalp, ear pinna in two and three in the lower extremities. Eleven patients were treated for pathological positive margins, close margin in two and seven with gross disease. After a median follow-up of 18 months, nineteen lesions underwent complete remission with excellent cosmesis and partial remission in two. Grade 1 acute skin toxicity was detected in sixteen patients and grade 2 in four. HDR Brachytherapy (Ir-192), with standardized surface applicators (Leipzig applicators) offer an alternative in treatment of small superficial skin carcinomas. Patients’ setup and reproducibility were accurate and treatment time was short which added great convenience for the patients.

The Shoelace Method in Congenital Aplasia of the Scalp and Skull

Aplasia cutis congenita (ACC) is an uncommon skin disorder characterised by the absence of some or all layers of the skin. It may involve any part of the body, but is most common in the scalp. Some scalp lesions are associated with a defect of the underlying skull or even dura. Small superficial lesions heal spontaneously. Options available for larger defects and those involving the skull include conservative management, skin grafts, composite grafts, local scalp or pericranial flaps, and free microvascular transplants. This case report presents a delayed primary closure of a scalp and skull defect with the shoelace method and a temporary skin graft. The method is simple, gives an excellent cosmetic result, and can be used in moderately sized defects, where a direct suture is not possible.

確実な脳動静脈奇形全摘のための手術戦略

There is high risk of intraoperative hemorrhage in AVM surgery due to abnormal vessels and changing hemodynamic pattern of brain. Inadequate coagulation of vessels, arterialization of veins and loss of tissue planes are major pitfalls. Preoperative embolization and temporary clipping of feeding arteries contribute to safe surgical techniques. There were 281 patients who underwent treatment for AVM in our institution: 242 were operated (99 of them with intracerebral hemorrhage) and 39 cases were treated with embolization and/or gamma knife. Radiological evaluation was carried out by CT, dynamic and 3D-CT, MRI, fMRI, MRA, and surface anatomy scanning. Strategic image analysis and preoperative embolization were employed where feeders were behind the nidus or vein and where another craniotomy was found necessary to secure feeding arteries. Endovascular nidus obliteration is successful only in 10% of patients. Surgical results showed risk of intraoperative bleeding in Grade 4 and 5 cases (1.5%). Recovery showed GR (205), MD (13), SD (7), PVS (2), and death (15) on 242 cases, based on Glasgow Outcome Score. Preoperative staged nidus embolization helps prevent bleeding in large AVM; small superficial lesions have the best results with surgery. Temporary clips for feeders, good plane between nidus and brain, definition of eloquent cortex, adequate coagulation of draining veins and total nidus excision are important steps in surgical strategy.

Comparaison de deux stratégies thérapeutiques dans les endométrioses sévères, chez des femmes jeunes consultant pour stérilité ou douleurs. Résultats en cas de douleurs pelviennes chroniques

Aim of the study – Compare two medical strategies associated to surgery in women requiring for chronic pelvic pain due to stage III-IV endometriosis. Material and methods – Two different patient groups, A (N 27) and B (N 41), requiring for chronic pelvic pain, associated with AFS stage III-IV endometriosis, operated on from 1992 to 1997, were compared. The medium age was 35 and 34 years, respectively. Pelvic pain, classified in three stages, was similar in both groups but they were more AFS stage IV in group A,67 % than in group B, 46 % ( p < 0.01). Both groups had similar operative procedure: laparoscopic resection of deep endometriotic nodules or endometriomas, plus destruction of small superficial lesions using CO 2 laser (A) or bipolar coagulation (B). Associated medical strategy was different: group A: operative laparoscopy without preoperative treatment and in 25 % a second laparoscopy taking place after two-three months of LHRH analogues ; no postoperative treatment; group B, operative laparoscopy taking place after ovarian blockage with three-six weeks of Diane® (Androcur® + ethinyl estradiol), then two-three months of analogue postoperative treatment immediately followed by long term progestoid treatment in order to prevent recurrences in women without pregnancy desire. Results – After one year, 6/27 (22 %) of A and 3/ 41 (7 %) of B had no follow-up. Of the followed patients, a complete improvement was observed in 18/21 (86 %) A, 33/38 (87 %) B, moderate pelvic pain continued in 2/21 (10 %) A, 4/38 (11 %) B, and the treatment was in failure in 1/21 (5 %) A, 1/38 (3 %) B, without significant difference. After two years, 67 % of A and 76 % of B had a follow-up and the corresponding rates of complete improvement are 72 % (A), 87 % (B), incomplete improvement: 22 % (A), 10 % (B) and failure: 6 % (A), 3 % (B). The difference is lightly significant ( p < 0.05) and remains so if patients without follow-up are considered as failures. There was no persistence nor recurrence of endometriosis nor endometrioma two years after the surgery was completed. Conclusion – Since there were more stage IV endometriosis in group A than in B, the different medical strategies and particularly the long term postoperative treatment used in B seem have little influence on results. However, these data was obtained in women of medium age > 30, with a relatively short follow-up. It should be of interest to compare in a prospective multicentric study the long term follow-up of two cohorts of young women operated on for stage III-IV endometriosis, receiving or not a long term medical treatment after surgery in order to prevent recurrences.

Stereotactic craniotomy for lesions in eloquent areas

CT compatible stereotactic systems are being increasingly used in the management of intracranial mass lesions. This study deals with the use of BRW stereotactic system for excisional biopsy of small (<30 mm), superficial, solitary cerebral lesions located in eloquent areas. Out of a total of 113 cases of stereotactic craniotomy carried out in the department since 1987, 78 fitted the above criteria. Out of these 78 patients, 70 lesions (90%) were less than 20 mm in size. Local anaesthesia was used in 10 cases (13%) whereas the rest had general anaesthesia. Cortical incision using standard techniques were used in 51 patients (65%), whereas in 27 patients (35%) excisional biopsy was done using trans-sulcal microsurgical techniques. Twenty-one (41%) patients had some degree of neurological deficit in the immediate postoperative period when a cortical incision was used compared to 4 patients (15%) when a trans-sulcal microsurgical excisional biopsy was done ( P < 0.05). However, significant neurological deficits were present in 10 cases (12.8%) and all but two had had cortical incisions. When assessed one month after surgery significant residual deficit was present in only 2 patients (2.5%) who had had cortical incisions. There was no postoperative infection or mortality in this series. CT guided stereotactic craniotomy coupled with trans-sulcal microsurgical techniques can be safely used for the excisional biopsy of small superficial lesions located in eloquent areas of the brain.

Relationship between clinical signs and early lesions of contagious caprine pleuropneumonia caused by Mycoplasma strain F38

Diagnosis of contagious caprine pleuropneumonia (CCPP) caused by Mycoplasma strain F38 employs post-mortem examination and isolation. Sacrificed goats are preferred for diagnosis in hot tropical countries. Lesions observed in sacrificed animals are often not fully developed to the extent of causing death. Early lesions were studied in sequentially sacrificed goats and a comparison made between the lesions and clinical signs. Goats sacrificed on days 0, 3 and 8 after contact between healthy and diseased goats were free from lesions and clinical signs. Goats sacrificed on days 11, 15 and 22 after contact showed small superficial lung lesions characterized by hyperaemia and edema, and mild clinical signs characterized by an occasional cough. Fever first occurred 27 days after contact. Goats sacrificed after fever showed lung consolidation characterized by firmness. The area of consolidation increased in diameter from day 1 up to day 5 of fever. Complement fixation test (CFT) titres were low up to the time of death. The relationship between clinical signs and early lesions can be used as a guide in diagnostic work.

CT-guided stereotactic surgery in the management of intracranial tuberculomas

CT-guided stereotactic techniques were used in the management of 21 patients (22 procedures) with intracranial tuberculomas. In 17 patients CT-guided stereotactic surgery was performed to obtain a diagnosis; 10 patients with small superficial lesions or masses in eloquent areas had an excision biopsy following CT-guided stereotactic craniotomies (Group A); seven patients underwent a closed stereotactic biopsy (Group B). Four patients (five procedures) with previously proven tuberculous disease had stereotactic aspiration of a cystic tuberculous mass (Group C). All patients in Group A had a definite histological diagnosis of a tuberculoma. Of the seven in Group B, a definitive diagnosis was obtained in two; in four patients the biopsy showed evidence of chronic inflammation; and in one the procedure was abandoned due to venous hemorrhage. All patients in Group C had amelioration of their symptoms following aspiration of the contents of the cystic mass. There was transient operative morbidity in two patients. There was no procedure-related permanent disability or mortality. CT-guided stereotactic biopsy being minimally invasive, is ideally suited for the management of deep-seated intracranial tuberculomas as they can be treated medically once a diagnosis is secured. A diagnosis of chronic inflammation obtained on CT-guided stereotactic biopsy, in correlation with the clinical and radiological findings, often provides confirmatory evidence of a tuberculoma in a patient with an intracranial mass. It also rules out a neoplasm and avoids empiric therapy of brain masses. Stereotactic localization techniques also help avoid possible morbidity associated with the excision of superficial small tuberculomas from eloquent areas.

A simple and accurate aiming-device for the surgical approach of small superficial brain lesions.

The operative approach of small superficial brain lesions through a mini-craniotomy is occasionally complicated because of inaccurate localising of the process. A simple aiming-device which can be used easily as a routine addition to normal CT scanning procedures in selected cases, is described. The method has a high degree of accuracy, is patient-friendly and offers the possibility to perform surgery with minimal disturbance to the patient, thus allowing early mobilisation, and with a reduced operating-time.

Head and neck MR imaging in the pediatric patient.

Magnetic resonance (MR) imaging studies of the head and neck (excluding the brain) were obtained in 49 children believed to have lesions of the head and neck. Seven children had normal images; in the remaining 42, lesions were divided into four categories: midline lesions, lesions of symmetric paired structures, facial lesions, and nasopharyngeal and oropharyngeal lesions. All entities were well delineated by MR imaging. The imaging planes and sequences chosen depended on the suspected abnormality. Midline lesions were best imaged in the sagittal plane, lesions of paired structures and the face in the axial or coronal planes, and nasopharyngeal and oropharyngeal lesions in the axial or sagittal planes. Intracranial extension of head and neck neoplasms was best evaluated in the coronal plane. Surface coils provided better resolution and were thus more useful in evaluating small superficial lesions; head or body coils were more useful in defining the extent of large lesions. T2-weighted images provided better differentiation between normal and tumor tissue in patients with head and neck neoplasms.

Small superficial cerebrovascular lesions: Clinical and computed tomographic correlations

The clinical and diagnostic studies in 40 patients with small superficial cerebrovascular lesions which were detected by CT is reviewed. Nine patients presented with seizures. Fourteen patients had pure motor hemiparesis. Eight of 17 patients had angiographic evidence of extracranial internal carotid stenosis (greater than 80%). CT showed an isodense gyral enhancing lesion in 21, hypodense lesion with enhancement in 11 and a hypodense nonenhancing lesion in 8. The prognosis for clinical recovery was best in those patients with an idodense enhancing lesion.

Cumulative experience with Solcoderm in the treatment of basal cell epithelioma.

Over 300 patients with basal cell epithelioma have been treated with Solcoderm during the past 4 years. The treatment is simple and effective for small superficial lesions and particularly useful in patients with periocular or multiple lesions.

Projections of cerebellar Purkinje cells in the dogfish, Scyliorhinus

In the dogfish Scyliorhinus degenerating axons and terminals arising from Purkinje cells and resulting from small superficial lesions made in the cerebellar corpus were found to be predominantly restricted to the ipsilateral cerebellar nucleus; none was observed in the tegmentum. Horseradish peroxidase placed within the cerebellar nucleus was transported retrogradely to the Purkinje cells. It appears that in these fishes, as in mammals, cerebellar output is relayed through cerebellar nuclei.