Breast cancer patient-reported outcomes on level 1 and level 2 oncoplastic procedures using BREAST-Q®

PURPOSE

In breast cancer management not only mortality and surgical morbidity measurements are important but also patient satisfaction indexes. The authors evaluated the satisfaction and health-related quality of life (HRQOL) using the breast-conserving therapy (BCT) and breast reduction (BR) modules of BREAST-Q^®.

METHODS

This is a cross-sectional study that analyzed breast cancer patients consecutively submitted to breast surgery between January 2011 and April 2018 using two modules of BREAST-Q^®. 968 patients were contacted and 232 answers were gathered: 171 patients submitted to oncoplastic level 1 surgery answered the BCT module and 61 submitted to oncoplastic level 2 surgery answered the BR module. Clinical data were retrieved from patients' medical records.

RESULTS

Among the 232 questionnaires received, the median scores for psychosocial well-being, sexual well-being and (postoperative) satisfaction with breasts for BCT and BR modules were, respectively, 77.0 and 73.5 (p = 0.17); 62.0 and 53.0 (p = 0.14); 72.0 and 66.0 (p = 0.66). The median of adverse effects of radiation in the BCT module was 87.0. The median satisfaction with outcome in the BR module was 86.0. Both groups of patients revealed high scores of satisfaction with care. For the BCT patients, satisfaction with breasts strongly correlated with sexual well-being and was moderately correlated with psychosocial and physical well-being. For the BR patients, the satisfaction with outcome strongly correlated with satisfaction with medical team and moderately correlated with the remaining scales.

CONCLUSION

Both oncoplastic surgery levels yielded similar satisfaction outcomes when assessed using BCT and BR modules of BREAST-Q^®.

Initial experience with targeted axillary dissection after neoadjuvant therapy in breast cancer patients

Background

Targeted axillary dissection (TAD) combines sentinel node biopsy (SNB) with the removal of the previously marked metastatic node. TAD is a promising concept for axillary restaging in node-positive breast cancer patients with pathological complete response (pCR) to neoadjuvant therapy (NAT). We aimed to evaluate TAD feasibility in this context.

Methods

A prospective observational study was conducted in biopsy-confirmed cN1 patients. The removal of the clipped node (CN) was guided by intraoperative ultrasound. SNB used indocyanine green and patent blue V dye. If the CN or sentinel lymph nodes (SLN) had any metastatic foci, or the TAD procedure was unsuccessful, the patient underwent axillary lymph node dissection (ALND).

Results

Thirty-seven patients were included. TAD and SNB identification rates were 97.3%. Every retrieved CN was also a SLN. At the individual level, SNB identification rate was 89.2% with indocyanine green and 85.5% with patent blue V dye. The CN identification rate was 81.1%, being higher when the CN was localized on the intraoperative ultrasound (84.4% vs 60.0%). Nodal pCR was achieved by 54.1% of our patients and was more frequent in HER2-positive and triple-negative tumors (p = 0.039). Nineteen patients were spared from ALND.

Conclusion

TAD with intraoperative ultrasound-guided excision of the CN and SNB with indocyanine green and patent blue V dye is a feasible concept to identify patients without axillary residual disease after NAT, that can be spared from ALND, although the need for marking the biopsied node should be further investigated.

Psychological Morbidity in Endometriosis: A Couple's Study

Endometriosis is a chronic gynecological disease that impacts more than 176 million women worldwide, having a strong impact on psychological morbidity. This study aimed to evaluate the contribution of psychological morbidity, in women with endometriosis, taking into consideration the duration of the couple’s relationship and the duration of the disease and also examined whether women’s sexual satisfaction had an impact on their psychological morbidity (actor effect) and on their sexual partners’ psychological morbidity (partner effect) and vice versa. Participants were 105 women and their partners, who answered the Hospital Anxiety and Depression Scale (HADS); Couple Satisfaction Index (CSI-4) and the Global Measure of Sexual Satisfaction (GMSEX). The results revealed a direct effect between the perception of symptom severity, marital satisfaction, and women’s psychological morbidity. Sexual activity and the presence of infertility had an indirect effect on the relationship between sexual satisfaction, diagnosis duration, and psychological morbidity, respectively. Finally, women’s sexual satisfaction had a direct effect on their own and their partner’s marital satisfaction that predicted less psychological morbidity, in both. Thus, a multidisciplinary intervention focused on the couple’s sexual and marital relationship is needed to promote psychological well-being in this population.

Demonstration of Isthmocele Surgical Repair

STUDY OBJECTIVE

To describe the surgical treatment of a uterine isthmocele.

DESIGN

Demonstration of the laparoscopic technique with narrated video footage.

SETTING

Cesarean section rate has been increasing despite the World Health Organization's recommendation of a maximum 15%, with some countries reaching rates as high as 50%. The choice of delivery method is a complex topic based on physical and psychologic health, social and cultural context, and quality of maternity care. With the increasing number of cesarean sections, a new entity was recognized, the isthmocele [1]. A uterine isthmocele is a dilatation of the uterine cesarean scar and functions as a reservoir collecting blood during menstruation. Isthmocele prevalence ranges from 19% to 84%[2]. The most frequent complaint relates to intermittent postmenstrual bleeding (30%). Isthmocele can be a cause of infertility and pelvic pain [3]. Interstitial pregnancy is a known complication with a mortality rate up to 2.5%. The diagnosis can be made by transvaginal ultrasound and/or magnetic resonance imaging but also by hysteroscopy or hysterosalpingography. Treatment can be done by controlling the symptoms with oral combined contraceptive (decreasing metrorrhagia) or with surgical correction improving symptoms and/or fertility [4-7]. Isthmocele correction seems to improve secondary infertility in patients in whom a fertility workup did not find other cause [8,9]. Surgical approach can be done by vaginal route with hysteroscopy; abdominal route with laparoscopy, robotic or laparotomy; or through a combine procedure with both routes. Hysterectomy is the definitive treatment, but for those who want to preserve fertility, isthmocele correction can be offered. For laparoscopic surgery, several ways have been described to detect the isthmocele such as Foley catheter, hysteroscopy, methylene blue, and Hegar probe. When we do laparoscopy, we prefer concomitant use of hysteroscopy. There is a trending opinion that patients with a smaller isthmocele could be treated hysteroscopically (2.5 mm according to Jeremy et al [10] and 3.0 mm described by Marotta et al [11]). The goal of hysteroscopy correction is to remove the inflammatory infiltration in the endocervix, cutting the superior and inferior edges of the defect enabling normal blood evacuation of the uterus. By contrast, those with a larger isthmocele (with <2.5-3.0-mm residual myometrium) and a risk of perforation during hysteroscopy could be better treated by laparoscopy. This is especially important in patients interested in pregnancy because of the risk of uterine perforation [12]. There is still no strong evidence that hysteroscopic correction leads to an increased number of uterine ruptures compared with laparoscopy, but myometrium thickness seems to be greater after laparoscopic correction. Myometrium thickness is an independent risk factor for uterine rupture [13], and therefore, laparoscopic correction is preferred over hysteroscopic in women with a pregnancy desire. Finally, after surgical correction of an isthmocele, we recommend a 6-month interval before attempting pregnancy.

INTERVENTIONS

Laparoscopic treatment is important in women who are symptomatic, have thin endometrium, and desire a pregnancy. Key strategies are (1) dissection of the vesicouterine pouch laterally to avoid entering the bladder wall; (2) transillumination with hysteroscopy; (3) cut with cold scissors avoiding thermal damage of remaining myometrium; and (4) suture with figure 8 in multiple layers. No evidence of using a specific suture is available.

CONCLUSION

Surgical treatment of a uterine isthmocele is a good option in women who are symptomatic and infertile. Laparoscopic treatment guided by hysteroscopy is a good option if residual myometrium is <3 mm.

Successful Treatment of Endometriosis-Related Hemorrhagic Ascites: A Report of Three Cases

Endometriosis-related ascites is rare and is frequently confused with an ovarian malignancy. Since it affects women in reproductive age, its diagnosis and therapy are even more challenging. These patients usually present with abdominal distension, pelvic pain, and weight loss, but a careful questioning usually reveals the typical endometriosis symptoms-such as dysmenorrhea and dyspareunia. We present three cases of endometriosis-related ascites, one of them with pleural effusion. All cases were associated with extensive disease and required laborious laparoscopic surgery, medical therapy with gonadotropin releasing hormone analogs, and long-term follow-up. One of the patients delivered twins following an in vitro fertilization (IVF) cycle without recurrence of ascites. We aim to raise awareness toward the importance of considering endometriosis in a patient with ascites of unknown origin.

Cutaneous Morbidity Among Inflammatory Bowel Disease Patients: A Cohort Study

BACKGROUND AND AIMS

Patients with inflammatory bowel diseases are prone to cutaneous manifestations. The aim of this study was to investigate their prevalence, type and association to demographic and clinical factors.

METHODS

This was a cross-sectional study. Information relative to patients of a central Portuguese hospital with a definitive diagnosis of an inflammatory bowel disease, who were prospectively recruited, was collected.

RESULTS

The final cohort included 342 patients, 62% of whom had Crohn's disease and 38% had ulcerative colitis. Cutaneous extraintestinal manifestations were present in 44.4% of all patients; this prevalence was lower [14.9%] when excluding cutaneous manifestations secondary to nutrition deficiency or drugs. These skin lesions were classified as granulomatous [0.3%], reactive [4.4%], immunologically associated [10.5%] and secondary to nutritional deficiencies [6.4%] or to bowel-related therapy [29.5%]. Excluding those secondary to nutrition or drugs, cutaneous manifestations were significantly associated with females (odds ratio [OR] 3.210 [1.625-6.340], p = 0.001) and younger patients (OR 0.954 [0.924-0.985], p = 0.004). Additionally, their occurrence was related to patients up to 16 years (OR 13.875 [1.332-144.484], p = 0.028) among the Crohn's disease sub-cohort, whereas in the ulcerative colitis sub-cohort they were more likely to occur in patients with extensive colitis (OR 5.317 [1.552-18.214], p = 0.008).

CONCLUSIONS

Nearly half of the patients analysed had at least one cutaneous extraintestinal manifestation. The fact that certain lesions tend to be more common among patients with defined characteristics should alert the physicians and allow an early diagnosis and, when pertinent, a reference to dermatology.

MRI for adenomyosis: a pictorial review

Adenomyosis is defined as the presence of ectopic endometrial glands and stroma within the myometrium. It is a disease of the inner myometrium and results from infiltration of the basal endometrium into the underlying myometrium. Transvaginal ultrasonography (TVUS) and magnetic resonance imaging (MRI) are the main radiologic tools for this condition. A thickness of the junctional zone of at least 12 mm is the most frequent MRI criterion in establishing the presence of adenomyosis. Adenomyosis can appear as a diffuse or focal form. Adenomyosis is often associated with hormone-dependent lesions such as leiomyoma, deep pelvic endometriosis and endometrial hyperplasia/polyps. Herein, we illustrate the MRI findings of adenomyosis and associated conditions, focusing on their imaging pitfalls.

TEACHING POINTS

• Adenomyosis is defined as the presence of ectopic endometrium within the myometrium. • MRI is an accurate tool for the diagnosis of adenomyosis and associated conditions. • Adenomyosis can be diffuse or focal. • The most established MRI finding is thickening of junctional zone exceeding 12 mm. • High-signal intensity myometrial foci on T2- or T1-weighted images are also characteristic.

Treatment for Uterine Isthmocele, A Pouchlike Defect at the Site of a Cesarean Section Scar

An isthmocele appears as a fluid pouchlike defect in the anterior uterine wall at the site of a prior cesarean section and ranges in prevalence from 19% to 84%, a direct relation to the increase in cesarean sections performed worldwide. Many definitions have been suggested for the dehiscence resulting from cesarean sections, and we propose standardization with a single term for all cases-isthmocele. Patients are not always symptomatic, but symptoms typically include intermittent abnormal bleeding, pain, and infertility. Pregnancy complications that result from an isthmocele include ectopic pregnancy, low implantation, and uterine rupture. Magnetic resonance imaging and transvaginal ultrasound are the gold standard imaging techniques for diagnosis. Surgical treatment of an isthmocele is still a controversial issue but should be offered to symptomatic women or the asymptomatic patient who desires future pregnancy. When surgery is the treatment choice, laparoscopy guided by hysteroscopy, hysteroscopy alone, or vaginal repair are the best options depending on the isthmocele's characteristics and surgeon expertise.

Satisfaction with a therapeutic sleeve for arm lymphedema secondary to breast cancer treatment: Controlled crossover trial

Highlights

Secondary lymphedema is a late iatrogenic side effect of breast cancer treatment.Despite multimodal decongestive therapy in their daily life breast cancer survivors with lymphedema have few alternatives but to use a compressive sleeve.Concerned with the well-known low compliance to the daily use of traditional sleeves, we conducted a comparative study to evaluate the subjective assessment of an innovative class 1 compression sleeve.We concluded that the PRADEX^® sleeve, not being worse in its compressive efficacy, is much better with regard to patient comfort.

Abstract

Secondary arm lymphedema is a feared late iatrogenic side effect of breast cancer survivors with a negative impact on patient's self-image and quality of life. Its reported incidence is extremely variable, from 6% to 80%, as well as the effectiveness of the multimodal decongestive lymphedema therapy.In their daily life breast cancer survivors with lymphedema have few alternatives but to use a compressive sleeve. Concerned with the well-known low compliance to the daily use of traditional sleeves, we conducted a comparative study in a subgroup of our patients with lymphedema secondary to breast cancer treatment for the subjective assessment of PRADEX^®, an innovative class 1 compression sleeve. Secondarily, we aimed to assess the non-inferiority of PRADEX^® regarding subjective and objective measures of the severity of lymphedema.We studied 46 women with grade 1 secondary arm lymphedema, who used their usual sleeve and PRADEX^® daily for 2 weeks each, in a crossover design.The new therapeutic sleeve was classified as having a better design and a better usability and comfort (more comfortable, thinner, fresher, softer, more flexible, comfortable, resistant to dirt and easier to dress and to wear). Women's subjective opinion about the severity of lymphedema favored their usual sleeve in detriment of PRADEX^®, but this subjective feeling was contradicted by objective measurements of different perimeters of the arm at the beginning and at the end of the study.We concluded that the PRADEX^® sleeve, not being worse in its compressive therapeutic efficacy, is much better with regard to patient comfort.

Abdominal Wall Endometriosis Excision with Mesh Closure - Report of Two Cases

Abdominal wall endometriosis (AWE) is a rare condition included in the differential diagnosis of an abdominal wall mass and/or pelvic pain in women of reproductive age. It usually occurs after pelvic surgery, most commonly caesarean section. Given the variable clinical presentation, diagnosis can be challenging if a high index of suspicion for AWE does not exist. Consequently, the correct diagnosis is often missed in the preoperative assessment. The presence of endometriosis in other locations can aid in the diagnosis, but other endometriotic lesions do not always exist. Image studies, particularly ultrasound and magnetic resonance imaging, can also be of help in the differential diagnosis. Even though new management techniques such as ultrasound-guided percutaneous cryoablation seem to be promising, surgical excision is still the mainstay of treatment. When the aponeurosis is involved, lesion excision might need to be followed by wall closure with the use of a mesh to lessen tissue tension. We present two typical cases of AWE after caesarean section, one of them recurrent, in patients with concurrent endometriosis of other locations. Total lesion excision followed by polypropylene mesh closure has been performed, with very good post-operative outcomes. We aim to raise awareness towards this diagnosis and to highlight the importance of complete lesion excision and adequate closure of the abdominal wall.

Laparoscopic Psoas Hitch Double Ureteral Re-implantation in the Duplex Urinary System for Treatment of Ureterovaginal Fistula

INTRODUCTION

Although laparoscopy is widely established for ablative urologic procedures, pelvic reconstructive procedures are still mostly performed by open-surgery. As urologists continue to introduce advanced laparoscopic skills to reconstructive urologic procedures, we present our experience with a laparoscopic psoas hitch double ureteral re-implantation in a patient with an ureterovaginal fistula and an ipsilateral duplex urinary system.

MATERIALS AND METHODS

A 42-year-old patient presented with continuous involuntary urine loss from the vagina after an abdominal hysterectomy. A double modified Lich-Gregoir ureteral re-implantation with a psoas hitch was performed, using a 4-port laparoscopic approach.

RESULTS

There were no post-operative complications and the cystography at post-operative day 14 revealed good positioning of the psoas hitch, with no leak or reflux. At three-months follow-up, the patient is completely dry and asymptomatic.

CONCLUSION

Laparoscopic ureteroneocystostomy with psoas hitch for the treatment of lesions of the distal ureter is a possible, safe, and effective way to resolve a complex urologic situation with minimally invasive surgery. Laparoscopy is becoming the standard approach to urologic pelvic reconstructive procedures, even in the most complex cases.

Laparoscopic Neurolysis of Deep Endometriosis Infiltrating Left Femoral Nerve: Case Report

Pelvic endometriosis may infiltrate somatic nerves causing severe neuropathic symptoms with a high impact on quality of life. It is a medical condition poorly known, and few published data about involvement of femoral nerve are available. We report an isolated unilateral endometriosis lesion of the left lumbar region infiltrating the femoral nerve in a 38-year-old woman. She described severe dysmenorrhea, dyspareunia, dischezia, and chronic pelvic pain with irradiation to the anterior part of the left thigh. After investigation, it was identified as a 5-centimeter endometriotic nodule involving the femoral nerve and the psoas muscle. The patient was treated by two laparoscopic surgeries with neurolysis of the involved somatic nerve by a multidisciplinary team, with improvement of the symptoms. Laparoscopic neurolysis is the first approach advocated in these cases, leading to relief of neurological symptoms resulting from nerve infiltration by endometriosis.

Oral Lichen Planus in IBD Patients: A Paradoxical Adverse Effect of Anti-TNF-α Therapy

INTRODUCTION AND AIMS

The efficacy of tumor necrosis factor alpha (TNF-α) inhibitors in the treatment of Inflammatory Bowel Disease (IBD) is well established. Many cutaneous and mucosal lesions have been described under anti-TNF-α therapy, some of them being considered as paradoxical. In this series we aimed to review the cases of oral lichen planus (OLP) in IBD patients under treatment with anti-TNF-α agents.

METHODS

Histologic findings from oral lesions of IBD patients treated with anti-TNF were revised.

RESULTS

Three female patients with IBD developed oral lichen planus (OLP) after starting anti-TNF-α therapy. Other etiologies were excluded.

CONCLUSIONS

In light of the increasing use of TNF-α inhibitors the occurrence of OLP is a potentially emerging side effect, thus we recommend a careful monitoring for oral manifestations in IBD patients treated with anti-TNF-α agents.

Validation of the Portuguese Version of EHP-30 (The Endometriosis Health Profile-30)

INTRODUCTION

Endometriosis Health Profile Questionnaire-30 is currently the most used questionnaire for quality of life measurement in women with endometriosis. The aim of this study is to evaluate the psychometric properties and to validate the Portuguese Endometriosis Health Profile Questionnaire-30 version.

MATERIAL AND METHODS

A sequential sample of 152 patients with endometriosis, followed in a Portugal reference center, were asked to complete a questionnaire on social and demographic features, the Portuguese version of the Endometriosis Health Profile Questionnaire-30 and of the Short Form Health Survey 36 Item â version 2. Appropriate statistical analysis was performed using descriptive statistics, factor analysis, internal consistency, item-total correlation and convergent validity.

RESULTS

Factorial analysis confirmed the validity of the five-dimension structure of the Endometriosis Health Profile Questionnaire-30 core questionnaire, which explained 83.2% of the total variance. All item-total correlations presented acceptable results and high internal consistency, with Cronbach's alpha ranging between 0.876 and 0.981 for the core questionnaire and between 0.863 and 0.951 for the modular questionnaire. Significant negative associations between similar scales of Endometriosis Health Profile Questionnaire-30 and Short Form Health Survey 36 Item â version 2 were demonstrated. Data completeness achieved was high for all dimensions. The emotional well-being scale in the core questionnaire and the infertility scale in the modular section had the highest median scores, and therefore the most negative impact on the quality of life of participating women.

DISCUSSION

The test-retest reliability and responsiveness of the questionnaire should be evaluated in future studies.

CONCLUSION

The present study demonstrates that the Portuguese version of the Endometriosis Health Profile Questionnaire-30 is a valid, reliable and acceptable tool for evaluating the health-related quality of life of Portuguese women with endometriosis.

Infliximab in psoriasis and psoriatic arthritis

Psoriasis is a chronic inflammatory disorder of the skin and joints. Although rarely life threatening, psoriasis can significantly impair quality of life (QOL) and cause considerable physical and psychological distress. Between 6 and 42% of patients with psoriasis develop psoriatic arthritis, which is characterized by stiffness, pain, swelling and tenderness of the joints. Nail psoriasis is highly prevalent in both plaque-type psoriasis and psoriatic arthritis and is found in approximately 50% of patients with psoriasis and in 80% of patients with psoriatic arthritis. Infliximab, a chimeric human-murine monoclonal antibody directed against tumour necrosis factor α, is approved in the USA and EU for the treatment of plaque psoriasis and psoriatic arthritis at a recommended dosage of 5 mg/kg administered by intravenous infusion at 0,2 and 6 weeks, then every 8 weeks thereafter. The EXPRESS and EXPRESS II trials demonstrated that infliximab is efficacious as induction and maintenance therapy in the treatment of moderate to severe plaque psoriasis and also improved health-related QOL. Infliximab is also efficacious in the treatment of psoriatic arthritis, as shown in the IMPACT and IMPACT II studies. Infliximab is generally well tolerated, with a similar adverse event profile in both psoriasis and psoriatic arthritis. The use of infliximab in three case reports is presented. The patients are similar to those normally seen by clinicians, and include a male patient with plaque psoriasis and a history of severe psoriatic arthritis who was corticosteroid dependent and in whom other systemic treatments were not effective or were not able to be used. This patient showed a rapid response to infliximab with no skin lesions or arthritis after 7 weeks' treatment. Infliximab was also safe and effective in the treatment of a female patient with plaque and nail psoriasis and a history of psoriatic arthritis. Importantly, this case report supports the efficacy of infliximab in psoriatic nail disease in the context of severe skin and joint involvement. Case 3 describes a young male patient with moderate plaque-type psoriasis associated with severe nail involvement and early signs of psoriatic arthritis. Treatment with infliximab improved nail psoriasis and appears to be an effective biological treatment for nail psoriasis. Importantly, ultrasound was able to diagnose joint involvement, as seen from the proliferative synovitis in the distal interphalangeal joint and mild enthesitis, despite there being no clinical evidence of psoriatic arthritis. This case report highlights the importance of early screening. If such abnormalities are detected early on in the course of psoriasis, clinicians may be able to predict which patients are more likely to develop psoriatic arthritis, and therefore offer effective and long-term treatment that may reduce the disability and impairment of daily activities that can be associated with psoriatic arthritis.

Laparoscopic re-anastomosis of a uterine avulsion following cold-knife conization

This report presents an exceptional case of uterine avulsion following a cold-knife conization, an unprecedented surgical complication of a common gynecological procedure. Furthermore, it describes the outcomes of the conservative laparoscopic reconstruction that was performed. A 30-year-old nulliparous was referred to our department with secondary amenorrhea and cyclic pelvic pain following a cold-knife conization performed 9 months previous in another institution. The patient underwent a diagnostic laparoscopy, which confirmed that the cervix had been completely resected and that the uterine and vaginal cavities were no longer in contact. We performed an end-to-end utero-vaginal anastomosis followed by a prophylactic cerclage. No intraoperative or postoperative complications were observed. One month after surgery the patient was asymptomatic with normal withdrawal bleeding and remained asymptomatic during her 12-month follow-up consult. To our knowledge, this is the first time that this serious complication with a potential for irreversible damage to reproductive function is reported as a complication of cervical conization. Although our conservative surgical correction repaired the anatomy and reestablished menstruation outflow, further follow-up is necessary to confirm the extent to which reproductive function was restored.

[Total laparoscopic hysterectomy: retrospective analysis of 262 cases]

INTRODUCTION

Hysterectomy is one of the most common gynecological procedures and may be performed either by vaginal approach, laparotomy or laparoscopy. Although total laparoscopic hysterectomy has multiple advantages, conflicting major complication rates have been previously reported.

OBJECTIVES

To describe our experience performing TLH and to evaluate complication rates.

MATERIAL AND METHODS

A retrospective observational study of all total laparoscopic hysterectomy performed in our department, by the same surgical team, between April 2009 and March 2013 (n = 262), was conducted. Medical records were reviewed for patient characteristics, operating time, uterine weight, post-operative hemoglobin variation, length of hospital stay, and intra and postoperative complications.

RESULTS

Patient average age was 48.9 ± 9.0 years and 49.2% had previous abdominopelvic surgery. The average body mass index was 26.5 ± 4.5 kg/m(2) and 42% of women were either overweight or obese. The mean operating time during the total study period was 77.7 ± 27.5 minutes, but it decreased significantly as the surgical team's training increased. Average uterine weight was 241.0 ± 168.4 g and average hospital stay was 1.49 ± 0.9 days. The mean postoperative hemoglobin variation was -1.5 ± 0.8 g/dL. The major and minor complication rates were 1.5% (n = 4) and 11.5% (n = 30), respectively. One procedure was converted to laparotomy and two women had a vaginal vault dehiscence. No important urinary tract or bowel injuries occurred.

CONCLUSIONS

This study demonstrates that, in experienced hands, total laparoscopic hysterectomy is safe and with low complications rates.

Anti-TNF-alpha induced psoriasiform eruptions with severe scalp involvement and alopecia: report of five cases and review of the literature

We describe 5 cases of anti-tumor necrosis factor-alpha (anti-TNF-α) induced psoriasiform eruptions with severe scalp involvement inducing inflammatory alopecia and review the literature on this subject. All our 5 patients were provided topical therapy, with good results in only 1 case. The remaining 4 were provided systemic therapy (methotrexate ± cyclosporine): 3 concomitantly suspended the anti-TNF-α treatment (2 are currently clear/almost clear but 1 has so far only observed mild improvement) and 1 switched anti-TNF-α (recurrent flare-ups of the disease continue). So far, no patient has developed scarring alopecia. To our knowledge, a total of 15 cases of anti-TNF-α induced psoriatic alopecia have been described. Anti-TNF-α was discontinued in 9 of the 15 patients and systemic therapy was provided to 9 of the 15 patients. Nonetheless, 2 patients developed scarring alopecia. We conclude that in anti-TNF-α induced psoriasiform eruptions some patients may respond to topical treatment, however in cases of severe scalp involvement anti-TNF-α suspension and systemic treatment should be considered in order to avoid scarring alopecia.

Pili annulati--what about racial distribution?

Pili annulati is a rare hair shaft abnormality and, as far as we know, there are no published data on pili annulati's racial distribution. To our knowledge, this is the first case reported in an African-American patient.

[Scrotal ulcers revealing pulmonary and genitourinary tuberculosis]

A 76-year-old male patient with an angioimmunoblastic T-cell lymphoma under treatment with fludarabine was referred because of scrotal ulcers, evolving for several months. Respiratory, gastrointestinal, and urinary symptoms were denied. Histopathological examination showed the presence of a chronic inflammatory process with epithelioid granulomas. Ziehl-Neelsen stain was positive for acid-fast bacilli. PCR analysis allowed the identification of a mycobacteria strain belonging to the Mycobaterium tuberculosis complex. Skin biopsy was repeated and culture revealed M. tuberculosis sensitive to traditional tuberculostatic drugs. This bacteria was also isolated in bronchial and urinary specimens. Although no abnormal findings were detected on chest radiography or abdominal ultrasonography, scrotal ultrasound showed areas of nodular thickening in the lower part of the epididymis. The diagnosis of cutaneous, lung, and genitourinary tuberculosis was made and the patient was treated with multidrug therapy (rifampicin 600 mg/day, isoniazid 250 mg/day, pyrazinamide 1500 mg/day, and ethambutol 1200 mg/day for the first 2 months, followed by rifampicin and isoniazid with the same dosages for the subsequent 7 months). Complete resolution of skin lesions was observed after two months of treatment. Diagnosis and treatment modalities are discussed. This case emphasizes the importance of considering tuberculosis in the differential diagnosis of genital ulcer.

Incontinentia Pigmenti with vesicular stage in utero

Incontinentia pigmenti (IP) is a genodermatosis with a characteristic evolution of skin lesions. Most patients present with vesicles at birth or within the first weeks of life. We report a case of a female infant with genetically confirmed sporadic IP who presented with verrucous and hyperpigmented lesions with no previous vesicular stage.