YAP1::MAML2 fusions in poromatosis: A report of two patients

Poromatosis is a rare condition characterized by the development of multiple poromas, mainly reported in patients with a history of malignancy. Recently, frequent YAP1::MAML2 and YAP1::NUTM1 fusions have been described in poromas and porocarcinomas. To date, the molecular features of poromatosis have been investigated in one patient only, wherein the poromas harbored YAP1::MAML2 fusions. Herein, we present two additional cases of poromatosis with YAP1::MAML2 fusions. Case 1: An 81-year-old woman presented with nine papules on the scalp, trunk, and extremities persisting for a year. She had a history of breast cancer, with no information on the treatment. Seven papules were excised. Case 2: A 65-year-old woman presented with 21 lesions on her trunk and lower extremities persisting for 2 years. She had been diagnosed with breast cancer 11 years prior and had undergone partial mastectomy, radiotherapy, chemotherapy, and endocrine therapy. Four lesions were excised. All 11 lesions in both patients were histopathologically similar: anastomosing cords and strands extending from the epidermis, and poroid and cuticular cell proliferation with interspersed small ducts. The tumors showed diffuse nuclear expression of YAP1 N-terminus and loss of YAP1 C-terminus expression. No lesions showed NUT immunopositivity. Sanger sequencing identified YAP1::MAML2 fusions in the poromas of both patients.

A Case of Dissecting Cellulitis which Was Initially Suspected to Be a Trichilemmal Cyst

We treat infected cysts on a daily basis, but it is difficult to diagnose similar lesions produced by inflammatory conditions that are not primarily caused by bacteria. Dissecting cellulitis of the scalp (DCS) is a chronic inflammatory disease that results in disfiguring, painful, and purulent lesions. It often takes a long time to diagnose. The pathophysiology of DCS remains unclear. Various treatments for DCS have been proposed, depending on the severity of the disease. However, none of these treatments are clearly superior to the others. If DCS spreads to the entire occipital region, aggressive surgical treatment may be beneficial in terms of the patient's quality of life. However, surgical interventions, such as drainage, are not effective at preventing the progression of the disease. Herein, we report the case of a young female patient who developed a cyst in the occipital region. We initially suspected that the lesion was a normal infected trichilemmal cyst. However, DCS was subsequently suspected because the lesion exhibited an unusual course after drainage and debridement. We consider that we made a diagnosis relatively early, but if we had sufficient knowledge about DCS we could have made a diagnosis even earlier by performing debridement sooner. Minocycline was administered for 5 months, which caused the lesion to disappear. After 2 years, no recurrence had been observed.

Aesthetic reconstruction of a defect in the skin of the upper lip using a hatchet flap

Reconstruction of the upper lip requires symmetrical reconstruction of the free border according to the aesthetic principle. We have reconstructed this area with a hatchet flap, so that the scars match the subunit line as far as possible by rotation and advancement of the flap. We operated on six patients. The lower pedicled flap was used in 4 cases and the upper pedicled flap in 2, who also needed reconstruction of the vermillion. In one patient the scar did not match the nasolabial fold. For the upper pedicled cases, scars made on the vermillion were not conspicuous. However, trap door deformity occurred in half, which was a disadvantage. We think that our flap is useful, because it leaves a minimal scar in an inconspicuous area.

Mortality and recurrence rate after pressure ulcer operation for elderly long-term bedridden patients

We operated on 16 sacral pressure ulcers in elderly and long-term residential patients who were immobile as a result of cerebral vascular disease. The mean age of patients was 76 years. Eight ulcers were treated with local fascial flaps and 8 by simple closure. The follow-up period was from 1 to 4 years. Recurrence and mortality rates were examined retrospectively. In the 16 patients, recurrence occurred in 37.5%, and 43.8% died without recurrence. The recurrence rate was 37.5% for local fascial flaps and 37.5% for simple closure. Overall mortality was 68.8% in the follow-up period. Because postoperative death was common, we should not only focus on reducing local pressure but also pay attention to any underlying disease. Because of this high mortality rate, the least invasive procedure possible should be used. Because the recurrence rate of simple closure was the same as for local fascial flaps, simple closure should be considered as a reconstructive method.

Clinical comparison of the scanning CO2 laser and conventional surgery in the treatment of ingrown nail deformities

AIM

To compare statistically the clinical effects and postoperative course of the scanning CO(2) laser and conventional surgical method to evaluate the clinical effectiveness of the former for the treatment of ingrown nail deformities.

METHODS

We performed vaporization of the nail matrix using the scanning CO(2) laser in 25 cases with ingrown nail deformities.

RESULTS

In 21 cases, the recurrence of ingrown nail deformity was not observed during follow-up. All cases were free of postoperative infection. Use of the scanning CO(2) laser reduced postoperative pain, and all patients were able to return to their daily activities by day 3 post-surgery without any problems.

CONCLUSIONS

Statistically, the operating time and the duration of postoperative pain were reduced significantly by the scanning CO(2) laser. Furthermore, patients treated with CO(2) laser were able to return to daily life significantly sooner.

Distortion and movement of the expander during skin expansion

Distortion and movement of tissue expanders can cause expansion of the wrong area, such as the naevus or the scar that is to be resected. In 71 rectangular expanders, we examined the incidence of distortion (over 15 degrees) and movement (over 3 cm). We divided the expanders into three anatomical site groups: scalp, body, and extremities, and compared the complication rate between two study groups (distortion or movement, or not). In total, the incidence of distortion was 15/71 (21%) and that of movement 5/71 (7%). Distortion occurred mainly in the extremities (11/33,33%). The implanted expanders tended to move more often in the body part (3/15, 20%). In the extremities, the bigger the angle between the axis of the implanted expander and that of the extremity, the bigger the angle of distortion. Although the incidence of complications between the two groups was not significant, except for alteration in design of the flap, we recommend that these points should be considered when preoperative plans are being made for appropriate patients.

Rare case of a rudimentary medial metatarsal non-ossified structure

A 9-year-old boy presented with a rudimentary medical metatarsal non-ossified structure. We considered his condition to be classified as hypoplastic medial member type in the metatarsal type of medial ray polydactyly. When it was considered as polydactyly, it had the longest delay of ossification among reported cases.

Preshaped hydroxyapatite tricalcium-phosphate implant using three-dimensional computed tomography in the reconstruction of bone deformities of craniomaxillofacial region

We prepared solid life-sized models and templates of implants based on three-dimensional computed tomography data in six cases with a bone deformity of the craniomaxillofacial region. After simulation surgery using these models and templates, the preshaped hydroxyapatite-tricalcium phosphate (HAP-TCP) implants were prepared to fill in the facial bone defects, and implantation was performed. Consequently, implants fitted the individual bone defects, and satisfactory facial contouring was obtained in five cases. In one case with severe cutaneous scarring in the grafted site, it was necessary to reduce the volume of the preshaped HAP-TCP implant during surgery. In conclusion, the three-dimensional, solid, life-sized model and template are useful for preoperative detailed simulation, and the use of preshaped HAP-TCP implants based on the template probably contributes to successful reconstruction of complex facial bone deformities and to the reduction of surgical invasion, resulting in achievement of better results.

Experience with surgical treatment of hidradenitis suppurativa

The authors report their experience with 23 sites of hidradenitis suppurativa, including cases with musculocutaneous flap repair, and discuss the surgical methods applied. Twenty-three sites in 19 patients with chronic inflammatory skin lesions were reviewed. The lesions were divided into two groups: The limited group was comprised of mild lesions, which appear isolated and have limited abscesses without sinus tract formations. The severe group was compromised of severe lesions, which included diffuse, multiple abscesses with severe sinus tract formation and fibrosis. Nine sites were limited and 14 sites were severe. After resecting the lesion, the defect was covered with a split-thickness skin graft (four sites were limited, nine sites severe), a musculocutaneous flap (five sites severe), primary closure (four sites limited), and a local skin flap (one site limited). In six sites in 6 severe-group patients, local recurrence occurred. The local recurrence rate differed significantly between the limited and the severe groups. The reason for this may be because the lesions in the limited group could be resected completely, whereas the lesions in the severe group were diffuse and total resection was sometimes difficult for various reasons. The method of surgical repair did not affect the local recurrence rate. In recurrent cases, four sites treated with skin grafting required further surgical treatment, and two sites treated with musculocutaneous flaps were controlled with oral antibiotics. In conclusion, sufficient resection of the lesion is the most important issue in treating follicular occlusion triad disease. In lesions that can be resected completely, the surgical procedure to cover the lesions should be selected to suit the size and site of the defect. However, in cases that cannot be resected completely, a musculocutaneous flap is recommended instead of a skin graft for enhanced postoperative management of the recurring wound, and its contribution to aesthetic and functional improvement.

The difference in E-cadherin expression between nonvascularized and vascularized nerve grafts: study in the rat sciatic nerve model

BACKGROUND

We investigated the expression of E-cadherin during nerve regeneration after nonvascularized and vascularized nerve grafts.

MATERIALS AND METHODS

We used the rat sciatic nerve model. E-cadherin expression was detected by Western blot analysis and immunofluorescent staining with anti E-cadherin monoclonal antibody. The level of E-cadherin expression was calculated as the amount relative to that of E-cadherin expression of normal control nerve. Furthermore, repair of the neural tissue structure was examined by toluidine blue staining.

RESULTS

In both cases, the level of E-cadherin expression decreased at first, and then gradually increased. The maximum level was 1.61 +/- 0.066-fold in the nonvascularized nerve graft and 2.254 +/- 0.071-fold in the vascularized nerve graft. From the 1st to the 16th postoperative weeks, the level of E-cadherin expression in the vascularized nerve graft was significantly higher than that in the nonvascularized nerve graft. In the immunofluorescent staining, E-cadherin expression was almost negative or decreased immediately after the operation, but the degree of expression was gradually increased in Schwann cells. The degree of E-cadherin expression in the vascularized nerve graft was greater than that in the nonvascularized nerve graft. In toluidine blue staining, the velocity of tissue repair was more rapid in the vascularized nerve graft than in the nonvascularized graft.

CONCLUSION

These results demonstrate that the E-cadherin expression of grafted nerve was increased during the nerve regeneration, and the expression was mainly observed in Schwann cells. Because the level of E-cadherin expression was significantly higher in the vascularized nerve graft than in the nonvascularized nerve graft, the level of E-cadherin expression may affect the rapidity of nerve regeneration.

Detection of E-cadherin expression after nerve repair in a rat sciatic nerve model

The authors investigated E-cadherin expression during nerve regeneration after nerve suture using the rat sciatic nerve model. Five rats were used during each postoperative period. E-cadherin expression was detected by Western blot analysis and immunofluorescent staining with an anti-E-cadherin monoclonal antibody. The level of E-cadherin expression was calculated as the amount relative to that found in normal control nerve. The level of E-cadherin expression was decreased at first, and then gradually increased. The maximum level of E-cadherin was 1.92 +/- 0.07 fold in the sutured nerve. The level of E-cadherin expression in the sutured nerve was significantly greater (p < 0.0001) than that of the normal control nerve from postoperative day 3 to 21, and that of sutured nerve returned to the control level by postoperative day 28. The immunofluorescent staining results indicated that E-cadherin expression was almost negative or decreased immediately after the operation, but the degree of expression increased gradually in Schwann's cells. The degree of E-cadherin expression was significantly greater than that of normal control nerves from postoperative day 7 to 14, and returned to the control level by postoperative day 21. These results demonstrate that E-cadherin expression increases during nerve regeneration, and the expression was observed mainly in Schwann's cells. The degree of E-cadherin expression may affect the rate of nerve regeneration.

Lip reconstruction of comparatively large defect including the commissure using remaining lip tissue: a modification of reconstructed method

We present two reconstructed cases after malignant skin tumor of comparatively large defects of lip including the commissure using remaining lip tissue alone. After resecting a tumor including wedge-shaped full-thickness lip tissue, a full thickness oblique incision is made at the site 5 mm distant from the contralateral commissure. The rhomboid-shaped lower lip flap is created, transposed to the defect, and sutured with the defect margin, including the upper lip, to reconstruct the commissure. The cross lip flap is created at the contralateral side of the lower lip, 5 mm from the commissure, and the defect is closed with the crosslip flap. Although our method is applicable only to selected cases, we believe that it is useful in terms of maintaining symmetry of the lip and function of the commissure in the reconstruction of comparatively large defects including the commissure.

Application of artificial dermis graft to correct a depression after tissue resection

The authors present 7 cases of artificial dermis implantation to correct a depression after tissue resection. Four of the seven cases resulted from resection of a malignant tumor (N = 3) and from a benign subcutaneous tumor (N = 1). The other 3 cases were the result of temporal muscle harvest to reconstruct facial palsy. In 1 patient a mild degree of bone deformity also existed. The pieces of artificial dermis employed varied from 35 x 40 to 40 x 80 mm in size. In 5 patients two sheets were implanted, and in 2 patients three sheets were implanted. In 2 patients the dermis sheets were covered by a pedicled temporal fascial flap with a free split-thickness skin graft because whole skin was resected as a result of a malignant skin tumor. There was no postoperative infection or allergic reaction in any of the patients. In all cases there was no postoperative contracture, and the implanted area was soft. An adequate or acceptable thickness of subcutaneous tissue was obtained. Artificial dermis may be a useful option as implantation material to correct a depression after tissue resection, especially for wide and comparatively shallow depressions.

Alteration of the cellular response to interleukin-1 beta by SV40 large T antigen in rheumatoid synovial fibroblasts

The large T antigen of SV40 (LT) has been widely used to immortalize primary cells for various studies. In this study, synovial fibroblasts of a patient from rheumatoid arthritis (RA) were transformed with LT gene to analyze the effect of SV40-mediated transformation on the production of cytokines, such as IL-6, IL-8, and GM-CSF, that are under the control of interleukin-1 beta (IL-1 beta), a physiological inducer of nuclear factor kappa B (NF-kappa B). It was noted that the basal levels of GM-CSF and IL-8 were upregulated, whereas that of IL-6 was downregulated. Moreover, the extents of induction of these cytokines in response to IL-1 beta were markedly downregulated in synovial fibroblasts transformed by LT as compared from parental cells. Although IL-1 beta could translocate NF-kappa B to the nucleus in all cells, some of the transformed cells exhibited nuclear translocation of NF-kappa B even before the stimulation with IL-1 beta, suggesting that transformation of LT resulted in the constitutive activation of NF-kappa B, either directly or indirectly. In order to examine whether LT downregulate the kappa B-dependent gene expression, we performed the transient luciferase gene expression assay. We found that cotransfection of LT did not downregulate the kappa B-dependent gene expression that was stimulated with L-1 beta. These observations suggest that the apparent inhibitory effect of LT on the IL-1-induced expression of cytokines may not be through its direct action on the NF-kappa B transactivation.

Involvement of vascular endothelial growth factor in Kaposi's sarcoma associated with acquired immunodeficiency syndrome

To examine the role of vascular endothelial growth factor (VEGF) in the development of edema associated with Kaposi's sarcoma (KS) in acquired immunodeficiency syndrome (AIDS), we exploited animal model systems to detect the activity that induces vascular hyper-permeability (VHP) using cultured AIDS-KS spindle cells. Cultured AIDS-KS spindle cells and conditioned medium (AIDS-KS-CM) that had been semi-purified through a heparin affinity column were tested for the ability to induce VHP in animals. The AIDS-KS spindle cells and AIDS-KS-CM induced VHP that was histamine-independent. The VHP-inducing activity was detected in the 0.5 M NaCl fraction from the heparin affinity column and was blocked by anti-VEGF neutralizing antibody. In addition, the production of VEGF was demonstrated in fresh AIDS-KS tissue as well as in cultured AIDS-KS cells, while control cells were negative for VEGF production. From these observations, we concluded that AIDS-KS cells produce a factor(s) that promotes VHP, and this factor could be VEGF.

[Mechanism of poor responsiveness to therapy of bacterial infection in patients with connective tissue diseases]

Infectious complications are important factors for poor prognosis of connective tissue diseases (CTD). 33% of the fatal cases with CTD were caused by infectious complications in our study. It was characteristic of infectious complications with CTD, that pneumonia was recognized in all CTD, especially, commoner in PSS, PM and OL, and frequently caused a fatal outcome. Gram negative bacillus, for instance E. coli and K. pneumoniae were frequently detected as pathogens. On the other hand, methicillin resistant Staphylococcus aureus (MRSA) was increased recently, and tuberculosis, especially atypical tuberculosis, such as, miliary and cutaneous forms were also recognized. The risk factors in the development of bacterial infections is considered to be intricately correlated with cellular and humoral immunodeficiency due to CTD or steroid hormones.

[A case of Legionnaires' disease due to aspiration of hot spring water and isolation of Legionella pneumophila from hot spring water]

We report a case of fulminant pneumonia that was due to aspiration of contaminated hot spring water and was not affected by beta-lactam antibiotics. We suspected that the patient had Legionnaires' disease and treated the clinical symptoms with erythromycin. Legionellaceae could not be isolated from sputum or lung biopsy material, but an elevated titer to Legionella pneumophila serogroup 4 was found by indirect immunofluorescence test. We diagnosed the patent as having Legionnaires' disease with improved clinical symptoms. Furthermore, we went to the hot spring that he visited and tried to isolate Legionellaceae. Hot spring water was collected from the bathroom and water, hot water, and shower water from the guest-room. After using a low-pH method, samples were cultured on BCYE alpha medium. Serogroups are classified by agglutination method with immune rabbit serum. As a result, we successfully isolated Legionella pneumophila serogroup 4 from hot spring water (42 degrees C) from the bath. No bacteria could be isolated from the other samples. Therefore, we believe that this case of Legionnaires' disease was caused by aspiration of contaminated hot spring water. The infection route of Legionnaires' disease is unclear. There are no previous reports of isolation of Legionellaceae from Japanese hot springs. This case would provide important information when considering the infection route of Legionnaires' disease in Japan.