Atypical Wassel type VI thumb duplication treated with on-top plasty

Congenital thumb duplication is estimated to occur between 0.08 and 7.6 times per 1,000 live births; however its cause is still undetermined. In this report, we present a case of Wassel type VI thumb polydactyly. clinical examination revealed an optimal functional position and an aesthetically pleasing shape of the ulnar thumb as well as a superior nail and pulp. However, preoperative X-ray indicated a well formed carpometacarpal joint of the radial thumb compared to an underdeveloped CMC joint of the ulnar thumb. Through surgical procedure we combined the best parts of both thumbs with on-top plasty to achieve the most optimal outcome. In conclusion, it is important to determine an adequate treatment strategy for a patient based on both clinical and radiological assessments.

Subepidermal Basal Cell carcinoma Following Laser Treatment of Congenital Capillary Malformation: A Case Report

While basal cell carcinoma is the most common type of skin cancer in humans, its subepidermal presentation is extremely rare. The risk factors for basal cell carcinoma development are well-known, but it remains unclear in which setting the tumor restricts itself to the dermal compartment. We present the fifth known case of subepidermal basal cell carcinoma. However, this particular presentation is unique due to arising beneath a capillary malformation. The patient had previously undergone multiple laser treatments which yielded no success. Initially, the vascular malformation was removed and sent for histopathological diagnosis. After the discovery of basal cell carcinoma, wide surgical resection was performed. The patient had no recurrence up to the last follow-up at 18 months postoperatively. This case demonstrates a new presentation of a very rare condition, but also highlights the importance of histopathological examination and the need for future research on any possible association between laser therapy and carcinogenesis.

Combination of cable ties and barbed sutures for fasciotomy closure - two case reports

While fasciotomy is the only urgent treatment option for compartment syndrome, the resulting open wound leaves room for complications. Closure of the wound can be done by different techniques, including split-thickness skin grafts, negative pressure therapy, an absorbable barbed suture system and a cable ties system. The aim of this paper is to demonstrate how a combined application of these methods can reduce their respective individual disadvantages. Our combined method was tried in two patients, one with an open tibial fracture and the other who underwent ulnar nerve reparation. Both patients started exhibiting signs of compartment syndrome within 3 hrs after surgery. Firstly, absorbable barbed suture systems were positioned with the running intradermal technique. Following this the cable ties were inserted and the limb in question was placed in an elevated position. Complete closure of the patient's wounds was achieved within 2 weeks without complications. This result is a testament to the added benefit of a combination of these methods in comparison with the results they produce individually.

TREATMENT OF PEDIATRIC FEMORAL FRACTURES IN THE CITY OF ZAGREB

Femur fractures in children can be treated with a number of operative and conservative methods. Numerous factors determine which method is optimal for a specific fracture. The aim of this research was to analyze distribution of femur fractures in children living in the urban communities of Zagreb and Zagreb County by localization, type and frequency of treatment methods used according to age and fracture mechanism. The research included 103 children aged up to 18 years, treated for femur fractures at the Zagreb University Hospital Centre and Zagreb Children’s Hospital. Data were collected from these institutions and a retrospective study covered the 2010-2015 period. The cause of fracture and diagnosis were coded with the help of the International Statistical Classification of Diseases and Related Health Problems. Operative treatment was applied in 55% of cases, which is contrary to previous researches. The highest incidence of femur fractures was recorded in the 0- to 4-year age groups, accounting for 49.1% of all fractures. These fractures mostly occurred due to falls and were more often treated with non-operative methods. All other age groups were mostly treated with operative methods. Coxofemoral immobilization and traction were used as non-operative methods, whereas flexible intramedullary nailing was the most frequently used operative method. The treatment depended on age, complexity of the fracture, fracture type, fragment displacement, and associated injuries. The cause was also an important factor on choosing the treatment method. Non-operative treatment was mostly used for fractures caused by falls (64.71% of cases due to falls) and operative treatment was mostly used for fractures caused by traffic accidents (79.4% of cases due to traffic accidents). It is a wide-known opinion that the best treatment for femur fractures in children is non-operative treatment. However, recent studies have shown that the use of operative methods in femur fracture treatment is growing. Our cohort of children treated during a five-year period (2010-2015) also underwent operative treatment more often than non-operative one. Two non-operative and eight operative methods were used. With such a large number of methods, it is clear that there is no unique method for all fractures. However, it is clear that the trend of using operative treatment is connected to the perennial trend of considerable sociodemographic and socioeconomic changes in urban settings such as Zagreb. Lifestyle changes directly affect the prevalence of femur fractures among children, as well as approach to treatment choice. General opinion is that most of fractures that occur at an early age can be treated with non-operative methods. Our research on femur fractures in children confirmed this rule. The youngest age group that had the highest incidence of fractures (49.1% of all fractures) was treated with non-operative methods in 75% of cases. Operative methods prevailed in other age groups. Similar results have been published by other authors. In conclusion, nearly half of all femur fractures (49.1%) occurred at a young age (0-4 years). Diaphysis fractures were most common. Most of the fractures that occurred during the 2010-2015 period were treated with operative methods, mostly in children aged 5-9 years. Out of eight different operative methods, elastic stable intramedullary osteosynthesis was most frequently used (60%). Coxofemoral immobilization and traction were used as non-operative methods.

Tattoo Pigment within Regional Lymph Nodes Mimicking Cutaneous Melanoma Metastasis

Dear Editor, The diagnosis of malignant melanoma accounts for 1-2% of all cancer diagnoses, around 4% of all malignant skin diseases, and 80% of all skin cancer deaths (1). The prognosis depends on several factors including tumor size, Clark level, Breslow thickness, location, ulceration, and presence of metastases. Detection of lymph node metastasis is initially accomplished by clinical examination and by operative evaluation for occult metastasis using sentinel lymph node biopsy (SLNB) when indicated (2). Lymph nodes (LN) with melanoma metastasis may appear normal in early stages, but eventually they become dark, firm, and enlarged (3). In 2017, a 32-year-old female patient was referred to our ward by a dermatologist following a biopsy excision of a nevus under her right breast that tested positive for a cutaneous melanoma grade T2aNx with a Breslow thickness of 1.9 mm, with no sign of ulceration and no history of previous illnesses or chronic diseases. Based on the American Joint Committee on Cancer (AJCC) guidelines, wide excision with a sentinel lymph node (SLN) biopsy was indicated (4). The patient was injected with 0.4 mL CiTc 99m Nanocoll in all four quadrants around the primary scar. A 2 cm wide elliptical excision was performed circumferentially around the scar and to the depth of the muscular fascia of the thorax. With the aid of a gamma probe, a single radioisotope positive lymph node was located in the ipsilateral axilla, but 5 dark pigmented lymph nodes situated behind the SLN were visualized during manual dissection and thought to be consistent with metastatic disease (Figure 1). Due to this new finding, an excisional biopsy of all pigmented nodes was performed. Histology of the excised skin did not demonstrate any further cancerous cells. The size of the SLN was 15 mm, and immunohistochemistry for Melan A was negative for metastatic melanoma. Histological analysis of the darkly pigmented nodes was negative for metastatic melanoma as the pigment was demonstrated to originate from the dermal tattoo on the patient's back that had been removed by dermabrasion 3 years before melanoma development (Figure 2, Figure 3). Dermal tattooing results in initial sloughing of the overlying epidermis, variable dermal inflammation, and gradual assimilation of pigment into macrophages. Much of the pigment is rapidly carried into regional draining LN, which was shown in 2010 on a SKH-1a mouse model, and causes lymphadenopathy which is thought to be a result of local inflammation (6). Importantly, even after removal of the offending cutaneous tattoo the tattoo pigment can persist in draining or distant nodes visible to the naked eye (7). In such cases, LN can mimic metastatic malignant melanoma and may prompt the surgeon to proceed with radical lymph node dissection which may not be necessary. Despite clear guidelines for melanoma treatment in the general population, there are several questions that need to be addressed: firstly, how should a physician approach a patient with unknown history of tattoo removal, a diagnosis of melanoma, and intraoperative darkly pigmented lymph nodes? Secondly, due to the lack of scientific data and treatment protocol, if the SLN is normally colored while other regional nodes are darkly pigmented, what should the treatment plan entail?

Successful separation of xypho-omphalopagus conjoined twins with extrauterine twin-twin transfusion syndrome: a case report

Conjoined twining is a rare medical phenomenon, with an overall prevalence of 1.47 per 100 000 births. This report describes a successful separation of xypho-omphalopagus conjoined twins complicated by unbalanced blood shunting through the porto-systemic anastomoses within the shared liver parenchyma. Significant extrauterine twin-twin transfusion syndrome caused by unbalanced shunting is an extremely rare, and probably under-recognized, hemodynamic complication in conjoined twins necessitating urgent separation. Progressive deterioration with a poor outcome can be prevented if the condition is recognized in a timely manner.

Reconstruction of a Thumb Defect Following Subungual Melanoma Resection Using Foucher's Flap

Dear Editor, The main challenge in the treatment of subungual melanoma in situ is obtaining adequate oncological resection while preserving the aesthetics and functionality of the affected digit (1). Traditionally, subungual melanoma in situ was treated with amputation of the distal phalanx of the digit, but management has recently become more conservative, attempting to preserve the full length of the digit (1). Although many recent studies support more conservative treatment by demonstrating successful results of the digit salvaging approach for both in situ and invasive subungual melanoma (1-3), there is still no agreed consensus in terms of the optimal surgical approach for this condition (1). It is the deep resection margin that is not uniformly accepted in the recent literature reports. Some authors recommend resection to the level of the periosteum (3,4), some include the periosteum (1), and some even perform a shave resection of the dorsal cortex of the distal phalanx (1). The reconstructive procedures also vary between authors, ranging from simple full thickness grafts (1,3,4) to toe free flaps (5). Reconstruction with a full thickness skin graft sometimes leads to complications, such as inclusion cysts and persistent hypersensitivity (1,3). These complications occur due to positioning the skin graft directly on the bone. A 31-year old women with a subungual melanoma in situ on her left thumb, diagnosed after several nail matrix biopsies, underwent a 5 mm margin resection of the entire nail complex with the distal part of the fingertip, including the distal phalanx periosteum. After intraoperatively confirming adequate tumor free margins, the residual defect measured 2×3 cm with exposed distal phalanx and without the distal fingertip (Figure 1). We reconstructed the defect using a pedicled innervated fasciocutaneous Foucher's flap (6) from the dorsum of the index proximal phalanx (Figure 2). Based on the first dorsal metacarpal artery and innervated by a branch of the superficial radial nerve, it provided stable soft tissue cover to the exposed bone, as well as fingertip sensation (Figure 3). The donor site was covered with a full-thickness skin graft taken from the volar side of the elbow. Postoperative course was uneventful with primary healing of all the wounds. Definite pathohistological analysis confirmed the diagnosis of in situ melanoma with adequate tumor resection margins. At three months follow-up, all the wounds were fully healed, there were no signs of local or regional recurrences, the hand was fully functional, and the patient was very satisfied with the appearance of the thumb (Figure 4, a and b). The patient achieved full sensory cortical reorientation. Although the finger sparing resection procedures for the treatment of subungual melanoma have not been clearly defined, we believe that the inclusion of the periosteum in the resection enhances the likelihood of obtaining tumor-free margins, especially the base, which is the most critical area due to the thinness of the nail matrix. Inclusion of the periosteum also ensures the complete removal of previous matrix biopsy scars. This extent of the resection necessitates reconstruction with an adipofascial or fasciocutaneous flap, preferably innervated if the fingertip is included in the resection. The defect in our patient was a full-thickness soft tissue defect extending to the level of the cortical bone, which included the distal fingertip due to the presence of pigmentation on the fingertip. Therefore, the ideal reconstructive option had to provide adequate soft tissue cover and be innervated to provide sensation to the fingertip. Foucher's flap is a reliable option for the cover of the thumb fingertip, and although traditionally used to resurface the thumb pulp, it provides excellent innervated cover for the thumb dorsum in cases like this, with minimal donor morbidity.

Quality of Life and Depression Among Female Patients Undergoing Surgical Treatment for Breast Cancer: A Prospective Study

BACKGROUND

Breast carcinoma is the most common malignant disease in women in the majority of developed countries. The development of depression as well as the quality of life (QoL) in these patients depends not only on the result of oncologic treatment, but on the cosmetic outcome as well. The primary aim of this prospective study was to investigate the changes in QoL and depressive symptoms among patients undergoing surgical treatment for breast cancer.

SUBJECTS AND METHODS

We conducted a prospective study that included 100 female patients (mean age 60.26 years) who underwent surgical and oncological treatment for breast carcinoma at the University Hospital Center Zagreb, Croatia. The patients were photographed before and after treatment and were required to fill out a standardized quality of life questionairres QLQ - C30 and QLQ - BR23, Beck Depression Inventory (BDI) and a questionnaire on breast asymmetry.

RESULTS

Our results show that patients had significantly higher QoL levels compared with their pre-surgical results. Statistical trend of a lower degree of depression was also observed. A worse cosmetic outcome (i.e., postoperative assymetry) was associated with a lower QoL, but there was no association with depression. Depression was significantly related to the level of pain and lower financial status.

CONCLUSION

QoL improved after surgical treatment of breast cancer and was dependant on postoperative asymmetry, whereas the findings for depressive symptoms remained less clear. Future research should investigate more factors that may contribute to the QoL and degree of depression in this patient population.

Reduced E-cadherin expression is a predictor of lower overall survival and metastatic disease in invasive ductal breast cancer

BACKGROUND

E-cadherin, a transmembrane adhesion molecule, is implicated in the development of many solid tumors as well as in the acquisition of metastatic potential of epithelial tumors. Its clinical use has yet to be established.

PATIENTS AND METHODS

The prognostic value of E-cadherin expression in 134 invasive ductal breast carcinoma patients over a 10-year follow-up period was investigated. Additionally, the correlation between E-cadherin expression and other traditional prognostic factors was investigated.

RESULTS

A statistically significant influence on overall survival was found for estrogen receptor, tumor size, histological and nuclear grade, HER2, lymph node involvement, vascular invasion, proliferative index, and E-cadherin. E-cadherin expression had a significant impact on overall survival and development of metastases in the group of patients not receiving chemotherapy, while it had no such effect in the group of patients who received chemotherapy.

CONCLUSION

We conclude that determination of E-cadherin expression can be used as an adjunct in selecting patients who may benefit from adjuvant chemotherapy in the presence of otherwise favorable prognostic factors.

A case of duplicated right renal artery and triplicated left renal artery

A rare anomaly of the vessels supplying the kidney of a 65 year-old male cadaver was found during a routine dissection. The right kidney received two renal arteries from the aorta that were similar in diameter, both entering through the hilus. The left kidney had three arteries originating from the aorta, one at its usual hilar position and two entering the renal cortex at its upper and lower poles. The upper pole of the left kidney also gave rise to an additional tributary of the renal vein.

Gastric lesion development in normal and pylorus ligated rats after cervical vagotomy

The main purpose of this study was to further investigate the effects of vagotomy on gastric lesion development. In contrast to the usual subdiaphragmal vagotomy, a different vagotomy at the level of the trigonum caroticum was used both alone and in combination with pylorus ligation (done immediately after vagal transection). The animals were killed 15 min, 30 min, 1 h and 6 h following vagotomy. No damaging effects of sham-vagotomy, or obvious negative effects of cervical vagotomy were noted. Prominent lesions appeared after 1 h in rats subjected to cervical vagotomy and significantly increased lesions in the early period of pylorus ligation were noted. No further aggravation in pylorus ligated rats (even an apparent amelioration at 1-h interval) and no lesions in rats with cervical vagotomy in the latter period could be explained in terms of a lack of reactivity due to exhaustion preceding fatal outcome. Consistent with this, the rats subjected to cervical vagotomy died shortly after the 6-h period.