Volumetric Modulated Arc Therapy Capabilities for Treating Lower-Extremity Skin Affected by Several Merkel Cell Carcinoma Nodules: When Technological Advances Effectively Achieve the Palliative Therapeutic Goal while Minimising the Risk of Potential Toxicities

The peculiar and rare clinical condition below clearly requires a customized care approach in the context of personalized medicine. An 80-year-old female patient who was subjected in 2018 to surgical removal of a cutaneous Merkel cell carcinoma (MCC) nodule located on the posterior surface of the left thigh and to three subsequent palliative radiotherapy treatments developed a fourth relapse in October 2020, with fifteen nodular metastases located in the left thigh and leg. Since the overall macroscopic disease was still exclusively regionally located and microscopic spread was likely extended also to clinically negative skin of the thigh and leg, we performed an irradiation of the whole left lower extremity. For this purpose the total target (65.5 cm) was divided into three sub-volumes. Dose prescription was 30 Gy in 15 daily fractions. A sequential boost of 10 Gy in 5 daily fractions was planned for macroscopic nodules. Plans were calculated by means of volumetric modulated arc therapy (VMAT) with the field overlap technique. Thanks to this, we obtained a homogeneous dose distribution in the field junction region; avoidance structures were delineated in the central part of the thigh and leg with the aim of achieving an optimal superficial dose painting and to reduce bone exposure to radiation. This case study demonstrates that VMAT allows for a good dose coverage for circumferential cutaneous targets while sparing deeper organs at risk. A reproducible image-guided set-up is fundamental for an accurate and safe dose delivery. However, local treatments such as radiotherapy for very advanced MCC of the lower extremities might have limited impact due to the high probability of systemic progression, as illustrated in this case. Radiation is confirmed as being effective in preventing MCC nodule progression toward skin wounding.

A Rare Case of Squamous Cell Carcinoma Presented with Multiple Discharging Sinus Over the Posterior Aspect of Left Thigh

Squamous cell carcinoma is the second most common cutaneous malignancy. The most important etiological factor is chronic exposure to the ultraviolet rays and hence exposed areas of the body are the most common site of squamous cell carcinoma. It is very uncommon for SCC to occur at unexposed areas of the body, and it is usually associated with long standing ulcers, sinus or immunosuppression. Here we are reporting a rare of Squamous Cell carcinoma which developed from multiple discharging sinus over the posterior aspect of left thigh in a 67 year old male.

BCG Induced Cold Abscess as a Complication of Inadvertent Vaccine Injection, a Case Series

We report a four-month-old girl with a right thigh swelling, an eight-month-old girl with a left thigh swelling, and a five-month-old boy with a left thigh swelling with the final diagnosis of BCG-induced cold abscess as a result of erroneous injection of BCG vaccine into the infants’ thigh muscle.

An extrahepatic hydatid cyst with the fat-fluid level

A hydatic cyst is a zoonosis caused by the larva of a tapeworm Echinococcus granulosus. The liver is the most commonly affected organ. Soft tissue localization has been reported in 2.3% of cases. Herein, we present a patient with a fat-containing hydatid cyst located in the left thigh. There are only a few reports in the literature on the presence of the fat-fluid level within a hydatid cyst. Previous studies have suggested that fat-containing hydatid cysts occur due to their cysto-biliary communication in the liver. In our case, we describe a fat-containing hydatid cyst in the extrahepatic location and discuss the pathophysiologic mechanism of fat inside it.

Cutaneous Larva Migrans in Urban Area: A Case Report

Cutaneous larva migrans (CLM) is a zoonotic skin disorder caused by the infestation of animal hookworm larvae, the most common being Ancylostoma braziliense. The larvae penetrate the skin surface and subsequently migrate to the epidermis, leaving a typical manifestation of linear or serpiginous erythematous burrow-like tracks, known as creeping eruption. This report presented a case of a young man with complaints of the serpiginous erupted lesion over the upper left thigh, following a recent history of beach travel. On dermatological examination, an erythematous serpiginous lesion and papules were found, portraying the clinical presentation of CLM. The administration of albendazole 400 mg was started, and the symptoms were completely resolved. Keywords: larva migrans, skin disease, creeping eruption, nematodes, albendazole.

A curious case of toddler with hernia and much more

Transverse testicular ectopia (TTE) with fused vas deferens is an extremely rare clinical entity. Herein, we presented a case of a 2 years old patient with left inguino-scrotal swelling associated with pain lasting for 3 days. Clinical examination revealed an empty right hemi-scrotum, a left-sided giant inguino-scrotal swelling. Laboratory tests were normal. Ultrasound imaging (US) of the scrotum demonstrated the presence of both testes in the same left hemi-scrotum with inguinal hernia and enterocele as content. Surgical intervention in suspicion of obstruction was carried out through inguinal incision. There was a congenital inguinal hernia with appendix (type 1-Amyand’s hernia) and cecum as content with two well developed testes on the same side with separate epididymis and vas deferens. Both the testes were united by a mesorchium. Hence, reduction of contents with herniotomy and both the testes were anchored to inner aspect of left thigh one above the other. We reviewed the literature for rare diagnosis of TTE.