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Dermatologic Surgery : Official... Dec 2019Wide local excision (WLE) with 2 to 5 cm margins has been conventionally used for the treatment of superficial leiomyosarcoma (LMS). Because margin control is the...
BACKGROUND
Wide local excision (WLE) with 2 to 5 cm margins has been conventionally used for the treatment of superficial leiomyosarcoma (LMS). Because margin control is the strongest predictor of clinical recurrence, many dermatologic surgeons have recently recommended Mohs micrographic surgery (MMS) over wide local excision (WLE) as the primary treatment modality.
OBJECTIVE
To determine the aggregate rate of local recurrence after treatment of superficial LMS with MMS among the few reports in the literature.
METHODS
A systematic literature search using the PubMed/MEDLINE database and the Cochrane Library was performed from inception to June 2017. One case report from our institution was included.
RESULTS
A meta-analysis of 14 reports of 48 cases of superficial LMS treated with MMS showed a mean recurrence rate of 2.08% to 6.25% with a mean follow-up period of 1570.9 days, compared to reported recurrence rates of 30% to 50% for WLE. Among these cases there were no reports of distant metastases.
CONCLUSION
Treatment of superficial leiomyosarcoma with MMS shows markedly lower rates of recurrence compared to reported rates of recurrence after WLE. Further prospective trials with larger sample sizes are needed to compare both modalities.
Topics: Aged; Dermis; Humans; Incidence; Leiomyosarcoma; Male; Mohs Surgery; Neoplasm Recurrence, Local; Skin Neoplasms; Treatment Outcome
PubMed: 31397774
DOI: 10.1097/DSS.0000000000001992 -
Journal of Plastic, Reconstructive &... Jul 2019The use of implants for breast reconstruction began over four decades ago, with implants initially placed in the prepectoral space. Concerns arose regarding the high...
The use of implants for breast reconstruction began over four decades ago, with implants initially placed in the prepectoral space. Concerns arose regarding the high incidence of capsular contracture and complication rates. With the introduction of acellular dermal matrix (ADM), plastic surgeons are again considering the advantages of prepectoral implant placement. A systematic review was conducted to examine complication profiles in prepectoral breast reconstruction alone versus prepectoral with ADM or mesh. A systematic review of the PubMed database was performed from inception to March 2017 to identify literature on postmastectomy patients undergoing prepectoral breast reconstruction with and without ADM or mesh. Study characteristics, complication rates, and outcomes were extracted for analysis. Study quality was assessed using the Newcastle-Ottawa Scale, and complication profiles were analyzed using the random-effects model. Twenty-seven studies met criteria for inclusion out of 550 identified for review. For 1881 total breasts, the complication rate with ADM was 23.4%, while the rate without an additional implant material was 27.5%. The difference in the capsular contracture rate with and without ADM was 2.3% and 12.4%, respectively. The use of ADM in prepectoral breast reconstruction correlated with lower capsular contracture and overall complications rates; however, rates of implant loss, infection, and mastectomy flap necrosis were higher with the use of ADM. Results were variable across studies, and in general, the quality of evidence reported was low. Because the methodology for outcome assessment was inconsistent, there is a need for further investigation with comparative studies and standardized outcome reporting.
Topics: Acellular Dermis; Breast Implantation; Female; Humans; Postoperative Complications; Risk Factors; Surgical Mesh
PubMed: 31076195
DOI: 10.1016/j.bjps.2019.04.005 -
Journal of the American Academy of... May 2019There is lack of uniformity in reflectance confocal microscopy (RCM) terminology for nonmelanocytic lesions (NMLs).
BACKGROUND
There is lack of uniformity in reflectance confocal microscopy (RCM) terminology for nonmelanocytic lesions (NMLs).
OBJECTIVE
To review published RCM terms for NMLs and identify likely synonymous terms.
METHODS
We conducted a systematic review of original research articles published up to August 19, 2017, adhering to Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. Two investigators gathered all published RCM terms used to describe basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and seborrheic keratosis/solar lentigo/lichen planus-like keratosis (SK/SL/LPLK). Synonymous terms were grouped on the basis of similarity in definition and histopathologic correlates.
RESULTS
The inclusion criteria was met by 31 studies. Average frequency of use per term was 1.6 (range 1-8). By grouping synonymous terms, the number of terms could be reduced from 58 to 18 for BCC, 58 to 36 for SCC, 23 to 12 for SK/SL/LPLK, and from 139 to 66 terms (52.5% reduction) in total. The frequency of term usage stratified by anatomic layer (suprabasal epidermis vs epidermal basal layer, dermoepidermal junction, and superficial dermis) was 27 (25.7%) versus 78 (74.2%) for BCC; 60 (64.5%) versus 33 (34.5%) for SCC, and 15 (45.4%) versus 18 (54.5%) for SK/SL/LPLK, respectively.
LIMITATIONS
Articles that were not peer reviewed were excluded.
CONCLUSION
Systematic review of published RCM terms provides the basis for future NMLs terminology consensus.
Topics: Carcinoma, Basal Cell; Carcinoma, Squamous Cell; Humans; Keratosis, Seborrheic; Lentigo; Microscopy, Confocal; Skin Neoplasms; Terminology as Topic
PubMed: 30529706
DOI: 10.1016/j.jaad.2018.12.007 -
The Cochrane Database of Systematic... Dec 2018Early accurate detection of all skin cancer types is important to guide appropriate management, to reduce morbidity and to improve survival. Basal cell carcinoma (BCC)... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Early accurate detection of all skin cancer types is important to guide appropriate management, to reduce morbidity and to improve survival. Basal cell carcinoma (BCC) is almost always a localised skin cancer with potential to infiltrate and damage surrounding tissue, whereas a minority of cutaneous squamous cell carcinomas (cSCCs) and invasive melanomas are higher-risk skin cancers with the potential to metastasise and cause death. Dermoscopy has become an important tool to assist specialist clinicians in the diagnosis of melanoma, and is increasingly used in primary-care settings. Dermoscopy is a precision-built handheld illuminated magnifier that allows more detailed examination of the skin down to the level of the superficial dermis. Establishing the value of dermoscopy over and above visual inspection for the diagnosis of BCC or cSCC in primary- and secondary-care settings is critical to understanding its potential contribution to appropriate skin cancer triage, including referral of higher-risk cancers to secondary care, the identification of low-risk skin cancers that might be treated in primary care and to provide reassurance to those with benign skin lesions who can be safely discharged.
OBJECTIVES
To determine the diagnostic accuracy of visual inspection and dermoscopy, alone or in combination, for the detection of (a) BCC and (b) cSCC, in adults. We separated studies according to whether the diagnosis was recorded face-to-face (in person) or based on remote (image-based) assessment.
SEARCH METHODS
We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL; CPCI; Zetoc; Science Citation Index; US National Institutes of Health Ongoing Trials Register; NIHR Clinical Research Network Portfolio Database; and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles.
SELECTION CRITERIA
Studies of any design that evaluated visual inspection or dermoscopy or both in adults with lesions suspicious for skin cancer, compared with a reference standard of either histological confirmation or clinical follow-up.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where information related to the target condition or diagnostic thresholds were missing. We estimated accuracy using hierarchical summary ROC methods. We undertook analysis of studies allowing direct comparison between tests. To facilitate interpretation of results, we computed values of sensitivity at the point on the SROC curve with 80% fixed specificity and values of specificity with 80% fixed sensitivity. We investigated the impact of in-person test interpretation; use of a purposely-developed algorithm to assist diagnosis; and observer expertise.
MAIN RESULTS
We included 24 publications reporting on 24 study cohorts, providing 27 visual inspection datasets (8805 lesions; 2579 malignancies) and 33 dermoscopy datasets (6855 lesions; 1444 malignancies). The risk of bias was mainly low for the index test (for dermoscopy evaluations) and reference standard domains, particularly for in-person evaluations, and high or unclear for participant selection, application of the index test for visual inspection and for participant flow and timing. We scored concerns about the applicability of study findings as of 'high' or 'unclear' concern for almost all studies across all domains assessed. Selective participant recruitment, lack of reproducibility of diagnostic thresholds and lack of detail on observer expertise were particularly problematic.The detection of BCC was reported in 28 datasets; 15 on an in-person basis and 13 image-based. Analysis of studies by prior testing of participants and according to observer expertise was not possible due to lack of data. Studies were primarily conducted in participants referred for specialist assessment of lesions with available histological classification. We found no clear differences in accuracy between dermoscopy studies undertaken in person and those which evaluated images. The lack of effect observed may be due to other sources of heterogeneity, including variations in the types of skin lesion studied, in dermatoscopes used, or in the use of algorithms and varying thresholds for deciding on a positive test result.Meta-analysis found in-person evaluations of dermoscopy (7 evaluations; 4683 lesions and 363 BCCs) to be more accurate than visual inspection alone for the detection of BCC (8 evaluations; 7017 lesions and 1586 BCCs), with a relative diagnostic odds ratio (RDOR) of 8.2 (95% confidence interval (CI) 3.5 to 19.3; P < 0.001). This corresponds to predicted differences in sensitivity of 14% (93% versus 79%) at a fixed specificity of 80% and predicted differences in specificity of 22% (99% versus 77%) at a fixed sensitivity of 80%. We observed very similar results for the image-based evaluations.When applied to a hypothetical population of 1000 lesions, of which 170 are BCC (based on median BCC prevalence across studies), an increased sensitivity of 14% from dermoscopy would lead to 24 fewer BCCs missed, assuming 166 false positive results from both tests. A 22% increase in specificity from dermoscopy with sensitivity fixed at 80% would result in 183 fewer unnecessary excisions, assuming 34 BCCs missed for both tests. There was not enough evidence to assess the use of algorithms or structured checklists for either visual inspection or dermoscopy.Insufficient data were available to draw conclusions on the accuracy of either test for the detection of cSCCs.
AUTHORS' CONCLUSIONS
Dermoscopy may be a valuable tool for the diagnosis of BCC as an adjunct to visual inspection of a suspicious skin lesion following a thorough history-taking including assessment of risk factors for keratinocyte cancer. The evidence primarily comes from secondary-care (referred) populations and populations with pigmented lesions or mixed lesion types. There is no clear evidence supporting the use of currently-available formal algorithms to assist dermoscopy diagnosis.
Topics: Adult; Aged; Algorithms; Carcinoma, Basal Cell; Carcinoma, Squamous Cell; Dermoscopy; Humans; Keratinocytes; Middle Aged; Photography; Physical Examination; Sensitivity and Specificity; Skin Neoplasms
PubMed: 30521688
DOI: 10.1002/14651858.CD011901.pub2 -
The Cochrane Database of Systematic... Oct 2018Gingival recession is defined as the oral exposure of the root surface due to a displacement of the gingival margin apical to the cemento-enamel junction and it is... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Gingival recession is defined as the oral exposure of the root surface due to a displacement of the gingival margin apical to the cemento-enamel junction and it is regularly linked to the deterioration of dental aesthetics. Successful treatment of recession-type defects is based on the use of predictable root coverage periodontal plastic surgery (RCPPS) procedures. This review is an update of the original version that was published in 2009.
OBJECTIVES
To evaluate the efficacy of different root coverage procedures in the treatment of single and multiple recession-type defects.
SEARCH METHODS
Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 12) in the Cochrane Library (searched 15 January 2018), MEDLINE Ovid (1946 to 15 January 2018), and Embase Ovid (1980 to 15 January 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 January 2018). No restrictions were placed on the language or date of publication when searching the electronic databases.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) only of at least 6 months' duration evaluating recession areas (Miller's Class I or II ≥ 3 mm) and treated by means of RCPPS procedures.
DATA COLLECTION AND ANALYSIS
Screening of eligible studies, data extraction and risk of bias assessment were conducted independently and in duplicate. Authors were contacted for any missing information. We expressed results as random-effects models using mean differences (MD) for continuous outcomes and odds ratios (OR) for dichotomous outcomes with 95% confidence intervals (CI). We used GRADE methods to assess the quality of the body of evidence of our main comparisons.
MAIN RESULTS
We included 48 RCTs in the review. Of these, we assessed one as at low risk of bias, 12 as at high risk of bias and 35 as at unclear risk of bias. The results indicated a greater reduction in gingival recession for subepithelial connective tissue grafts (SCTG) + coronally advanced flap (CAF) compared to guided tissue regeneration with resorbable membranes (GTR rm) + CAF (MD -0.37 mm; 95% CI -0.60 to -0.13, P = 0.002; 3 studies; 98 participants; low-quality evidence). There was insufficient evidence of a difference in gingival recession reduction between acellular dermal matrix grafts (ADMG) + CAF and SCTG + CAF or between enamel matrix protein (EMP) + CAF and SCTG + CAF. Regarding clinical attachment level changes, GTR rm + CAF promoted additional gains compared to SCTG + CAF (MD 0.35; 95% CI 0.06 to 0.63, P = 0.02; 3 studies; 98 participants; low-quality evidence) but there was insufficient evidence of a difference between ADMG + CAF and SCTG + CAF or between EMP + CAF and SCTG + CAF. Greater gains in the keratinized tissue were found for SCTG + CAF when compared to EMP + CAF (MD -1.06 mm; 95% CI -1.36 to -0.76, P < 0.00001; 2 studies; 62 participants; low-quality evidence), and SCTG + CAF when compared to GTR rm + CAF (MD -1.77 mm; 95% CI -2.66 to -0.89, P < 0.0001; 3 studies; 98 participants; very low-quality evidence). There was insufficient evidence of a difference in keratinized tissue gain between ADMG + CAF and SCTG + CAF. Few data exist on aesthetic condition change related to patients' opinion and patients' preference for a specific procedure.
AUTHORS' CONCLUSIONS
Subepithelial connective tissue grafts, coronally advanced flap alone or associated with other biomaterial and guided tissue regeneration may be used as root coverage procedures for treating localised or multiple recession-type defects. The available evidence base indicates that in cases where both root coverage and gain in the width of keratinized tissue are expected, the use of subepithelial connective tissue grafts shows a slight improvement in outcome. There is also some weak evidence suggesting that acellular dermal matrix grafts appear as the soft tissue substitute that may provide the most similar outcomes to those achieved by subepithelial connective tissue grafts. RCTs are necessary to identify possible factors associated with the prognosis of each RCPPS procedure. The potential impact of bias on these outcomes is unclear.
Topics: Acellular Dermis; Dental Enamel Proteins; Gingival Recession; Gingivoplasty; Guided Tissue Regeneration, Periodontal; Humans; Randomized Controlled Trials as Topic; Surgical Flaps
PubMed: 30277568
DOI: 10.1002/14651858.CD007161.pub3 -
BMC Cancer Aug 2018Pulmonary is an uncommon site of extramedullary involvement in multiple myeloma (MM). Diffuse parenchymal amyloidosis as pulmonary manifestation of MM is even rarer. We...
BACKGROUND
Pulmonary is an uncommon site of extramedullary involvement in multiple myeloma (MM). Diffuse parenchymal amyloidosis as pulmonary manifestation of MM is even rarer. We report a rare case of diffuse parenchymal pulmonary amyloidosis associated with MM diagnosed by video-assisted thoracoscopic lung biopsy (VATLB).
CASE PRESENTATION
A 58-year-old woman complained of cough and shortness of breath. HRCT disclosed diffuse ground-glass opacifications with interlobular septal thickening in bilateral lungs. A lung-biopsy sample obtained by VATLB revealed Congo Red-positive amorphous eosinophilic deposits in the alveolar septa. Surgical biopsy of abdominal wall skin and subcutaneous fat was also performed, which showed the apple-green birefringence with polarized light on Congo red stain was demonstrated in dermis. The serum immunoelectrophoresis showed monoclonal lambda light chains. A bone marrow biopsy specimen comprised 11.5% plasma cells. She was therefore diagnosed with diffuse parenchymal pulmonary amyloidosis accompanied by MM. The patient was referred to the hematology department for further chemotherapy.
CONCLUSIONS
It is important to recognize diffuse parenchymal pulmonary amyloidosis to avoid misdiagnosis.
Topics: Amyloidosis; Female; Humans; Lung Diseases, Interstitial; Middle Aged; Multiple Myeloma
PubMed: 30089469
DOI: 10.1186/s12885-018-4565-5 -
Journal of the European Academy of... Jan 2019Favre-Racouchot disease (FRD) is a relatively common dermatosis induced by chronic sun exposure. FRD is clinically and histologically characterized by the presence of...
Favre-Racouchot disease (FRD) is a relatively common dermatosis induced by chronic sun exposure. FRD is clinically and histologically characterized by the presence of both comedones and cysts in the context of an elastotic degeneration of the dermis. Those lesions are mainly located in the face, especially in the malar and periorbital areas. Smoking and radiotherapy seem to play a role in the pathogenesis together with UV exposure. The disease affects predominantly the aged population and seems to be a problem of mainly aesthetic concern. No official guidelines are available for the treatment of FRD; most common therapeutic strategies are represented by topical retinoids and laser treatments. The goal of our review was to identify the principal clinical and epidemiological characteristics of FRD and to analyse all the therapeutic strategies available. We also focused our attention on the follow-up of this particular dermatosis. Our aim was therefore to suggest alternative possible strategies for both the treatment and the follow-up of these patients. Our data support the efficacy of carbon dioxide laser and topical retinoids in the setting of FRD, but we also suggest considering alternative treatments, such as plasma exeresis. We also recommend planning both a short-term and a long-term follow-up visit, as the majority of relapses is observed after 10-12 months.
Topics: Administration, Cutaneous; Cysts; Facial Dermatoses; Humans; Lasers, Gas; Retinoids
PubMed: 30022555
DOI: 10.1111/jdv.15184 -
International Journal of Biological... Oct 2018Psoriasis is defined as a long-lasting multifactorial inflammatory autoimmune skin condition precisely characterized by delimited, erythematic papules with adherent... (Meta-Analysis)
Meta-Analysis Review
Psoriasis is defined as a long-lasting multifactorial inflammatory autoimmune skin condition precisely characterized by delimited, erythematic papules with adherent shiny scales. The conditions are led by hyperproliferative responses of epidermis due to hyperactivation and immature keratinocytes production. The psoriatic skin consists of the thickened epidermal layer, in concurrence with inflammatory exudates in the dermis mainly of dendritic cells, neutrophils, T cells, and macrophages, contributing to the distinct manifestation of psoriatic lesions. It consents to multifaceted and discrete pathology due to the genetic and immunological alteration resulting from abnormal expression of various regulatory and structural proteins. These proteins are associated with various cellular and sub-cellular activities. Therefore, the presence of protein in a pathological cellular environment in the psoriatic lesions as well as in serum could be a great avenue for the insight of pathomechanism, anticipation and diagnosis of psoriasis. Research of protein biomarker in psoriasis is yet a developing realm to be explored by both fundamental and clinical researchers. This review is an attempt to assimilate the current discoveries and revelations of different proteins as a biomarker and their importance in pathogenesis, diagnosis, treatment, and anticipation of both the inflammatory and other dermatological aspects of psoriasis.
Topics: Autoimmunity; Biomarkers; Cytokine TWEAK; Humans; Keratinocytes; Proteome; Proteomics; Psoriasis; Signal Transduction
PubMed: 30017989
DOI: 10.1016/j.ijbiomac.2018.07.021 -
Otolaryngology--head and Neck Surgery :... Oct 2018Objective To assist otolaryngologists in counseling patients with hoarseness who would benefit from injection laryngoplasty on whether or not to perform the procedure in... (Comparative Study)
Comparative Study Meta-Analysis
Objective To assist otolaryngologists in counseling patients with hoarseness who would benefit from injection laryngoplasty on whether or not to perform the procedure in the office vs the operating room. Data Sources Cochrane library, CINAHL, PubMed, and EMBASE. Review Methods Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting standards of English-language articles that compared voice outcomes for in-office and in the operating room injection laryngoplasty. Two independent investigators assessed study eligibility, rated the quality using Methodological Index for Non-Randomized Studies (MINORS), and abstracted data for comparative analysis. Results Of 689 initial studies, 4 observational, comparative studies met inclusion criteria, with follow-up of 2 weeks to 12 months postinjection. Laryngoplasty was most commonly performed for vocal fold immobility with varied injectable materials (micronized dermis, hyaluronic acid, and calcium hydroxyapatite). Follow-up ranged from 2 weeks to 12 months. Voice outcomes improved in all studies, with comparable improvement for patients injected in the office vs the operating room ( P = .42 to P = .88). Meta-analysis of 3 studies showed no difference in Voice Handicap Index-10 voice outcomes by treatment setting (standardized mean difference -0.11, P = .441), with the 95% confidence interval (-0.405 to 0.176), making it unlikely that anything larger than a small or trivial difference was missed. Conclusion Our systematic review makes it unlikely that meaningful clinical differences exist in postprocedure voice outcomes for injection laryngoplasty in the office vs the operating room.
Topics: Anesthesia, General; Anesthesia, Local; Female; Humans; Injections, Intralesional; Laryngoplasty; Male; Office Visits; Operating Rooms; Treatment Outcome; Vocal Cords; Voice Disorders; Voice Quality
PubMed: 29989849
DOI: 10.1177/0194599818780207 -
Arthritis Care & Research Apr 2019To identify and synthesize the best available evidence on the use of ultrasound to assess skin involvement in systemic sclerosis (SSc).
OBJECTIVE
To identify and synthesize the best available evidence on the use of ultrasound to assess skin involvement in systemic sclerosis (SSc).
METHODS
We conducted a systemic review of the literature on PubMed Medline and Embase, using the vocabulary terms ("systemic sclerosis OR scleroderma") AND ("ultrasonography" OR "elasticity imaging techniques") AND ("skin" OR "dermis"). Two independent reviewers selected articles, collected data from studies, and carried out a manual search of the references from the studies included. This search was further enhanced by a review of bibliographic references extrapolated from these studies. The quality of the evidence was assessed by the Effective Public Health Practice Project system.
RESULTS
A total of 30 studies were identified, enrolling 1,171 SSc patients, predominantly middle-aged (mean age 55.5 years) females (88.8%). The ultrasound skin measurements that were reported included thickness in 28 studies and/or echogenicity (7 studies), and/or stiffness (6 studies), and/or vascularity (1 study). The main comparator was the global and site-specific modified Rodnan skin thickness score. Reported interrater and intrarater reproducibility appeared to be excellent, but this reproducibility was assessed by a small number of studies. Moreover, there were no published evaluations of construct or criterion validity of skin ultrasound assessment. The responsiveness to change of ultrasound elastography has not been assessed.
CONCLUSION
Published reports have strong limitations and are highly heterogeneous, hindering the evidence to support the use of skin ultrasound assessment in clinical practice. Further studies, with modern devices and appropriate methodology, are needed to establish the real value of skin ultrasound assessment in the early diagnosis and monitoring of SSc patients.
Topics: Humans; Scleroderma, Systemic; Ultrasonography
PubMed: 29781576
DOI: 10.1002/acr.23597