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The increase life expectancy led to an expected increase in skin cancer incidence in older patients. Their treatment can require a complex decision-making process. Limited data are available on characteristics, management and outcome of skin tumours in nonagenarian and centenarian patients. The aim of our study was to describe epidemiology, clinical-pathological features and treatment strategies of skin cancers in a cohort of patients aged ≧95 years. A total of 116 patients ≧95 years of age presented for the evaluation of 225 skin lesions (mean of 1.94 lesions per patient). The mean age was 97.4 years, 57.8% were women. Most patients had an ECOG score of 3 (49.3%) or 4 (32%). Lesions were mainly located on the head and neck area (74.2%), upper (7.1%) and lower (6,2%) limbs. The majority of patients presented with non-melanoma skin cancers (183/225; 81.3%), 25/225 (11.1%) had actinic keratosis, 5 (2.2%) melanoma and 2 (0.9%) atypical fibroxanthoma. Forty-eight lesions (21.3%) were treated with surgery, 58 (25.8%) with radiotherapy. The management of 73 lesion (32.4%) was discussed at the multidisciplinary tumour board meeting. One patient died for the progression of a squamous cell carcinoma; 74 patients died for causes unrelated to skin tumours, 36 are still alive after a mean follow-up of 27.27 months. This cohort study confirms that age is not per se a contraindication for treatment of skin cancers in elderly patients. Our results support the importance of a patient-centred care approach that should take into consideration patient's preferences, comorbidities, compliance and possible adverse events.

Breast oncoplastic techniques followed by radiotherapy represent nowadays the standard of care for breast cancer treatment. For tumours located at the upper outer quadrant in patients with large and ptotic breasts, the use of level II breast reduction mammoplasty, allows large quadrantectomies without compromising the breast natural shape and reducing the breast volume to be irradiated. When the skin overlying the tumour in the upper outer quadrant is involved, the removal of the skin during mammoplasty could lead to an extreme reduction of the breast, resulting in a bad outcome. Different strategies have been adopted to avoid a poor cosmetic result including a Z plastic or latissimus dorsi (LD) mini flap. At our institution we developed a new technique utilizing an inferior bifurcated pedicle mammoplasty with the preservation of a skin island for a patient with a residual tumour following chemotherapy involving the skin in the upper outer quadrant of the right breast. The patient did show no complications, with no delay for adjuvant radiotherapy treatment. Our method is a novel technique to treat malignancies in this location for patients with large and ptotic breasts when skin removal is indicated and it may represent an effective strategy to prevent excessive gland reduction, thus avoiding poor cosmetic result.

The aim of this study was to investigate the role of PRAME in reducing the risk of an underestimation of tumour margins, in a consecutive series of acral melanomas recurring on skin grafts.

Skin-reducing mastectomy (SRM) with subpectoral implant positioning represents a consolidated, oncologically safe and cosmetically effective method for the immediate reconstruction of large and ptotic breasts. Acellular dermal matrix (ADM) has been proposed as a substitute for the pectoralis major muscle in this surgical approach; this technique led to a progressive evolution toward prepectoral reconstructions even in skin-reducing mastectomies. Obese patients with macromastia who are typical candidates for SRM with ADM are at increased risk of complications associated with ADMs. Therefore, we avoided ADMs and developed a novel autologous technique for immediate breast reconstruction in large and ptotic breasts eligible for SRM. Specifically, an autologous dermal graft is harvested from contralateral healthy breast reduction to cover the upper pole of the prepectoral implant.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Acellular dermal matrices have been introduced to optimize direct-to-implant breast reconstruction. We selected a bovine pericardium noncross-linked matrix. The study consists in the retrospective analysis of 123 patients (141 breasts) who underwent conservative mastectomy and immediate implant-based breast reconstruction with bovine pericardium matrix Veritas® from March 2012 to October 2017. The overall rates of early and late complications, after a median follow-up of 51.84 months, were, respectively, 37.6% and 24.1%. The most noticeable early complications were flap ischemia [n = 39 (27.7%)], hematoma [n = 5 (3.6%)], marginal skin flap necrosis [n = 5 (3.6%)] and dehiscence of the surgical wound [n = 2 (1.4%)]. The most common late complications were rippling [n = 18 (12.7%)] and seroma [n = 4 (2.8%)]. The rate of clinically relevant capsular contracture was low: 12.1% (n = 17) presented grade II and only 2.1%% (n = 3) grade III. Implant substitution became necessary for five patients (3.6%). Early complications occurred more frequently in patients undergoing therapeutic mastectomy (p = 0.031). Patients undergoing preoperative radiotherapy more frequently developed late complications (p = 0.012). A clinically relevant capsular contracture (grade II–III) was found in higher average patients age (p = 0.0019). The left side developed less frequently late complications except for rippling (p = 0.002). Rippling occurred more frequently in patients who sustained a nipple skin-sparing mastectomy (p = 0.035). Our results further support the safety of Veritas® in immediate implant-based breast reconstruction. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Merkel cell carcinoma (MCC) is an aggressive tumor with an uncertain histogenesis typically arising on sun-damaged skin of the elderly. It has rarely been described in association with other tumors such as epithelial, melanocytic, and mesenchymal, but not vascular neoplasias. However, an exuberant vascular reaction is considered a common phenomenon in neuroendocrine neoplasms, where it can even obscure the proliferating cells and mimic a primary vascular neoplasia. A 47-year-old man was referred for the evaluation of a long-lasting reddish skin tumor located on the right buttock. After 2 punch biopsies, the patient underwent surgical excision of the lesion. Histological examination showed a dermal florid, benign vascular proliferation overlying some large deep coalescent nodules made up of monomorphous round cells with scant cytoplasm and a high mitotic activity. After the appropriate immunohistochemical stainings, a final diagnosis of hemangioma overlying a previously unrecognized MCC was rendered. Whether the angiomatous proliferation should be considered an exuberant reaction to the tumor, induced by an angiogenetic drive, or a true hemangioma is somewhat controversial. The main point is that such a neoplastiform angiomatous proliferation may represent a potential diagnostic pitfall, especially in limited specimens, and that an accurate clinicopathologic correlation is always needed. In our case, even if additional punch biopsies had been performed, the vascular proliferation would dominate the histological picture and an accurate diagnostic conclusion would probably not be reached due to the deep location of the MCC.

Melanoma in childhood is rare, and appears more commonly either in association with a preexisting (congenital) nevus, or with spitzoid features than de novo. Thus, problematic melanocytic lesions in children are essentially represented by congenital nevi and Spitz nevi that can be regarded as melanoma precursors and melanoma simulators, respectively. As a consequence, clinical and dermoscopic features of melanoma in children differ from those in an adult population. Herein we describe common clinical and dermoscopic features of problematic lesions in children, focusing on congenital and Spitz/Reed nevi, and including other problematic lesions, such as atypical, blue, acral, and scalp nevi.

Capsular naevi (CNs) in lymph nodes (LNs) are relatively common, occurring in 3-22% of patients who undergo LN surgery for melanoma. Naevus count is one of the principal risk factors for melanoma, as well as a prognostic factor in melanoma patients. However, little is known about the occurrence of CN in melanoma patients on the basis of their naevus count. A case-control study was performed, to look at the naevus count differences between CN-positive and CN-negative melanoma patients. Cases (CN positive) were matched for age, sex and Breslow thickness with controls (CN negative). Total naevus count was recorded at diagnosis and compared between the two groups. This study was conducted in a tertiary referral academic centre for skin cancer. Twenty-two positive CN patients were matched with 22 negative CN patients. The mean Breslow thickness was 2.66 mm (range: 0.6-9). Positive CN patients were significantly associated with an increasing naevus count on their skin (P=0.02). Patients with more than 100 naevi reported an odds ratio of 7.78 on having a CN compared with patients with fewer than 50 naevi on their skin (P=0.02). An increased melanocytic migration to LNs might be the reason for the association between CNs and a high number of melanocitic naevi on the skin. This could shed some light on the physiology of melanocytes and could be an easy way to predict patients at greater risk of having CNs.

There are three possible explanations for the improved melanoma recognition when a clinician uses dermoscopy: first, the presence of early dermoscopy signs that become visible in melanoma much before the appearance of the classical clinical features; second, an increased attitude of clinicians to check more closely clinically banal-looking lesions; and third, an improved attitude of clinicians to monitor their patients. In this review, the light and the dark sides of melanoma screening are briefly discussed, including the need to find better strategies to decrease the number of unnecessary excision of benign lesions on one hand, and to finally decrease melanoma mortality rates on the other.

Summary Bilateral prophylactic mastectomy without reconstruction is not accepted by the majority of patients. Successful reconstruction is therefore a mandatory condition for prophylactic mastectomy. Of the many options for autologous breast reconstruction, the deep inferior epigastric perforator (DIEP) flap best meets requirements for bilateral reconstruction in selected patients. The goal of this study is to verify the feasibility of the procedure in our conditions and to find out how it is accepted by patients. We present 55 consecutive patients who were scheduled for bilateral DIEP flap reconstruction during a 4-year period. We reviewed medical charts, performed clinical assessments and processed anonymous questionnaires. There were 77 immediate and 33 delayed breast reconstructions. There was 100% flap survival and no microanastomoses revisions. In 11 patients (10%) the surgeon preferred to convert the DIEP into a mini transverse rectus abdominis muscle (miniTRAM) flap in order to provide adequate blood supply. Complications: revision for haematoma under the flap in four patients (7.2%), excessive blood loss in four patients (7.2%) and partial mastectomy skin flap necrosis in 10 immediate breast reconstructions (12.9%). Patients' evaluation of the aesthetic result was good or excellent in 96.2% of cases. In 33.9% of patients the postoperative quality of life was considered unchanged and 50.9% of them it even improved. The DIEP flap is recommended for bilateral breast reconstruction. Occasional conversion into a miniTRAM flap can increase the total flap survival rate. Bilateral prophylactic mastectomy and DIEP flap reconstruction are very well accepted by patients.

Ex vivo fluorescence confocal microscopy (FCM) is a novel imaging technique that can be applied on freshly excised tumors for rapid bedside pathology for Mohs surgery and in general pathology. The first clinical application of FCM was on skin cancers such as basal cell carcinoma, for which it has demonstrated high sensitivity and specificity for margin assessment. Later, FCM was applied on freshly excised specimens in general pathology and in particular on breast cancer samples. Preliminary studies highlighted the potential applicability of this fascinating new tool to characterize the tumor and obtain a rapid detection of residual tumor in surgical margins.

Management of breast abscess in lactating women remains controversial. During pregnancy, women may develop different kinds of benign breast lesions that could require a surgical incision performed under general anesthesia with consequent breastfeeding interruption. The purpose of this study was to prospectively evaluate the management of large breast abscesses with ultrasound-assisted drainage aiming at breastfeeding preservation.34 lactating women with a diagnosis of unilateral breast abscess have been treated with an ultrasound (US)-assisted drainage of the abscess. A pigtail catheter was inserted into the fluid collection using the Seldinger technique under US guide and connected to a three stop way to allow drainage and irrigation of the cavity until its resolution.All procedures have been found safe and well tolerated. No recurrence was observed and breastfeeding was never interrupted.The described technique allows to avoid surgery and to preserve breastfeeding in well-selected patients with a safe, well-tolerated and cost-effective procedure.

Overexpansion techniques are useful in overcoming a shortage of donor site for expansion: the aim of the authors was to verify whether this technique should be chosen instead of serial expansions for creation of wider and more malleable flaps for reconstruction. From 1993 to May 2005 we have overexpanded 59 patients with burn scars. The patients always underwent reconstruction at least 2 years after complete healing. Almost any body region capable of expansion has been overexpanded. The technique is illustrated here in the reconstruction of scalp, neck, trunk and thigh. Tissue expander original volume ranged from 450 to 800 cc: the silicon implant shape was both round and rectangular. Mean overinflation was 3.6 times beyond the stated vendor's maximum volume. The principle ratios were performed in the trunk (4.375) and in the lower extremities (4.125). The largest volume instilled in a single tissue expander was 3500 cc. Overall expansion length was on average 172.6 days (range: 101–248). All patients were compliant with inflation once a week. The reconstructions were planned as the expansion of a transposition or an advancement flap. All patients had completion of their reconstruction with satisfactory resolution of their problem: complications occurred in three of all hyperinflated prostheses. Tissue overexpansion, if carefully planned and conducted, allows the completion of reconstruction in one-stage. Instead of serial expansions, it enhances patient compliance and reduces cost.

Background. A useful reconstructive tool, as a delayed method, for marginal defects of the ear of more than 2.5 cm wide with no deficit of the cartilaginous frame and low scapha involvement, consists of tubed flaps raised from neighboring areas. The patients treated with this technique sustained a dog bite in three cases, a human bite in one case, a motorcycle accident in one case, and finally, a burn trauma in two cases. Objective. Three different cases of acquired marginal defects, namely ascending superior helix, descending helix, and cauda elicis with lobule involvement, are shown. Methods. In the helix reconstruction, the tube width has not to be more than 15 mm, and the tube length has to be 1 cm longer than the defect. There was no conditioning of the flaps. No pedicle bridge was interposed along the major tube. The interval between two divisions was on average approximately 5 weeks. Results. Seven patients were treated with this technique: In all cases, we had no infections or skin necrosis. To avoid a shrinkage of the tube, a correct ratio between flap dimensions and helical defect has to be estimated. Conclusion. Although it is considered an old technique and it is a multistage reconstructive sequence, this procedure could be the first preference in cases of marginal defects more than 2.5 cm wide. This is because it restores naturally the anatomy of the helix.

A new method for lower lip reconstruction is proposed. It is based on a double cutaneous and mucous V-Y advancement flap and is suggested for the surgical treatment of lip cancer confined between the skin and the vermilion with a horizontal spread. Sixteen patients were treated from 1996 to 2001 with this technique and the results were satisfactory both from the functional and the aesthetic standpoints.

The dermoscopic findings of basal cell carcinoma (BCC) were first described more than a decade ago and the list of BCC-related criteria has been several times updated and enriched. Today, the dermatoscope is considered the key tool for the diagnosis of BCC, since it allows its early detection and enables its discrimination from other pigmented and nonpigmented skin tumors. The dermoscopic pattern of BCC results from several combinations of well-known BCC criteria, depending on several factors, including histopathologic subtype, location, gender, age and pigmentary trait. In addition, recent evidence highlighted that dermoscopy is also useful in the management of BCC, since it provides information on the tumor subtype, the presence of pigmentation or ulceration and the response to nonablative treatments.

Background: Autologous fat grafting is a widely accepted approach for breast reconstruction after mastectomy but its oncological safety has not been established. This study aimed to compare recurrence in patients who underwent fat-grafting procedures after autologous breast reconstruction and those who did not. Patients and methods: We retrospectively reviewed 207 consecutive patients, who underwent mastectomy and reconstruction using free flap surgery. We divide them in two groups: a study group of patients who underwent fat grafting procedure and a control group of patients who did not. Outcome regarding local and regional recurrence was compared between the two groups. Particularly, we studied recurrences from primary surgery to baseline (first lipofilling) and from baseline to most recent follow-up. Results: Median follow-up was 60 months from surgery to baseline and 29 months from baseline to most recent follow-up. The overall observational period after mastectomy in the control group was 120 months. Local recurrence was observed in 6 patients from the study group, respectively 3 in the first observational period and 3 after the fat grafting procedure. The control group, as the study one, presented a total of 6 recurrences (p ¼ 0.555; Hazard Ratio free flap and lipo vs only free flap: ¼ 0.66; 95% CI 0.16e2.66). Conclusions: We found no significant differences in recurrence between patients who underwent fat grafting and those who did not. These encouraging findings support previous results but larger series of patients are required to confirm long-term oncological safety in these procedures.

Introduction : Ductal Carcinoma In Situ (DCIS) is a heterogeneous, pre-malignant disease accounting for 15–20% of all new breast cancers. If appropriately managed, DCIS has a small chance of impacting on patient life expectancy. Despite the possibility of a further recurrence or of a development in an invasive form, we are unable to select treatment of choice especially in the elderly. In particularly we risk an overtreatment of women at low risk of progression to invasive breast cancer. The aim of this study was to retrospectively evaluate the outcome of elderly patients affected by DCIS not undergoing Radiation Therapy (RT) after Breast Conserving Surgery (BCS). Material and methods : We reviewed our prospectively-maintained database from 1998 to 2013, selecting all women over 65 years old diagnosed with DCIS who did not receive RT for personal choice. We considered two groups, according to the risk of local recurrence (Low Risk (Group 1) vs. High Risk (Group 2)). Results : We identified 44 cases of DCIS treated with surgery alone or with surgery followed by adjuvant tamoxifen. 24 patients presented low risk of local recurrence (Group 1) and 20 had characteristics associated to high risk of local recurrence (Group 2). At a median follow-up of 66.3 months, no local recurrences have been described in group 1. No patients presented distant metastases, while 4 patients died for other causes. At a median follow-up of 72 months we observed 5 local recurrences in the second group ( p Conclusion : Our results suggest that radiation therapy can be safely avoided in a selected group of elderly patients affected by DCIS.

Confocal microscopy is a non-invasive method of optical imaging that may provide microscopic images of untreated tissue that correspond almost perfectly to hematoxylin- and eosin-stained slides. Nowadays, following two confocal imaging systems are available: (1) reflectance confocal microscopy, based on the natural differences in refractive indices of subcellular structures within the tissues; (2) fluorescence confocal microscopy, based on the use of fluorochromes, such as acridine orange, to increase the contrast epithelium-stroma. In clinical practice to date, confocal microscopy has been used with the goal of obviating the need for excision biopsies, thereby reducing the need for pathological examination. The aim of our study was to test fluorescence confocal microscopy on different types of surgical specimens, specifically breast, lymph node, thyroid, and colon. The confocal images were correlated to the corresponding histological sections in order to provide a morphologic parallel and to highlight current limitations and possible applications of this technology for surgical pathology practice. As a result, neoplastic tissues were easily distinguishable from normal structures and reactive processes such as fibrosis; the use of fluorescence enhanced contrast and image quality in confocal microscopy without compromising final histologic evaluation. Finally, the fluorescence confocal microscopy images of the adipose tissue were as accurate as those of conventional histology and were devoid of the frozen-section-related artefacts that can compromise intraoperative evaluation. Despite some limitations mainly related to black/white images, which require training in imaging interpretation, this study confirms that fluorescence confocal microscopy may represent an alternative to frozen sections in the assessment of margin status in selected settings or when the conservation of the specimen is crucial. This is the first study to employ fluorescent confocal microscopy on surgical specimens other than the skin and to evaluate the diagnostic capability of this technology from pathologists' viewpoint.

Actinic keratoses (AKs) represent the earliest stage in the development of squamous cell carcinoma (SCC) and represent important biomarkers for individuals at risk for development of invasive SCC. Based on clinical morphology, AK can be subdivided into three different grades, which correspond to specific dermatoscopic, reflectance confocal microscopic, and histopathologic substrates. Given the risk for potential progression toward invasive SCC, AK should be treated at the earliest stage. A wide range of minimal destructive or topical therapies is available for the treatment of AK. The choice of treatment depends on the number, size, clinical grading, duration, and location of lesions, patient's compliance, general health conditions, and cosmetic outcome. Treatment can be divided into lesion-directed and field-directed therapies. Lesion-directed treatment focuses on the treatment of single lesions, whereas field-directed treatment aims to eliminate both clinically visible and subclinical lesions within the field of actinic damage (concept of field cancerization). Noninvasive techniques such as dermoscopy and reflectance confocal microscopy can be helpful in identifying AK potentially progressing toward SCC, as well as in the selection of the adequate treatment and monitoring of the treatment outcome.

Sentinel lymph node biopsy has been proposed as a diagnostic method for estimation of the malignant potential of atypical Spitz tumours. However, although cell deposits are commonly detected in the sentinel lymph nodes of patients with atypical Spitz tumours, their prognosis is substantially better than that of patients with melanoma and positive sentinel lymph node biopsies. We did a systematic review of published reports to assess the role of sentinel lymph node biopsy as a prognostic method in the management of atypical Spitz tumours. The results of our analysis did not show any prognostic benefit of sentinel lymph node biopsy; having a positive sentinel lymph node does not seem to predict a poorer outcome for patients with atypical Spitz tumours. These findings indicate that, especially in the paediatric population, it might be prudent initially to use complete excision with clear margins and careful clinical follow-up in patients with atypical Spitz tumours.

Mohs micrographic surgery can be employed in recurrent basal cell carcinoma, although it is a time-consuming technique. Recently, ex vivo fluorescence confocal microscopy (FCM) has been employed to obtain a fast assessment of tumor margins at the bedside. In our case we successfully employed ex vivo FCM to assess the tumor margins and we treated the persistent tumor with intensity-modulated radiation therapy. Our case demonstrates that a multidisciplinary approach is very efficient in managing complex and recurrent tumors and highlights the benefits of FCM as a new technique that can be used in the surgical theater to speed up the entire procedure.

Out of 262 hands with total finger amputations treated by replantation of finger/fingers from January 2001 until January 2006, there were only 6 cases of type III ring avulsion injuries, all of which were replanted. Radical resection of the damaged part of the artery with primary vein grafting was used in each case; only 1 artery and 2 veins were anastomosed for each finger. The survival rate was 100%. Mean total active motion was 195 degrees (ranging from 175 degrees to 220 degrees ). Mean 2-point discrimination was 8.6 mm static (ranging from 4 to 11 mm) and 6.2 mm moving (ranging from 3 to 9 mm), and mean grip strength was 37.4 kg. We believe that liberal resection of the "zone of contusion" of vessels and primary vein grafting for arterial repair can improve the overall survival rate of replantation in type III ring avulsion injuries, and replantation can be attempted in majority of the cases; good hand function can be expected.

The international literature describes many different techniques for correcting prominent ears. Some of these techniques use weakening of the anterior surface in an “open or close” way. Others use suturing of the unfold antihelix. Still others suture the concha with mastoid, and some combine several of these procedures. There is thus no most widely accepted single method. Since 1993, the senior author has used the described technique on a group of 40 patients (35 bilateral and 5 monolateral cases). Before 1993, the senior author always used an “open” technique, but the anterior cartilage was weakened by the partial parallel incision procedure. In the current study, the surgical approach for cases with a normal or moderately deep concha consisted of open anterior otoplasty with cartilage abrasion by an electric burr alone. If the concha was severely hypertrophied, concha–mastoid suturing was combined with otoabrasion, as previously described. The follow-up period was a minimum of 16 months and a maximum of 8 years. Complications were rare and rapidly resolved. The outcome was successful whether the burr alone or a combined method was used. The authors believe that anterior abrasion of ear cartilage is a useful, simple technique that is not too time consuming by which an immediate postoperative aesthetic improvement is reached. It also is more precise and safe than the partial parallel incision procedure.