Resection of tumors in irradiated fields with subsequent immediate reconstruction

With increased use of primary radiation therapy for treatment of cancer and adjuvant radiation therapy after surgical removal of a bulk tumor, recurrence in these fields has posed significant new and increasingly technical and biologic problems. We report our experience with ten such cases in which difficult wounds were reconstructed immediately after major regional resections of advanced or recurrent tumors in fields of previous irradiation. All of these patients could undergo extirpation of their recurrent tumors in irradiated fields because of improved techniques in reconstructive flap surgery allowing large amounts of well-vascularized tissue to be transferred, sometimes over a significant distance. Follow-up of these patients has ranged from three to 18 months (median, nine months). Primary healing, decreased deformity, reduced morbidity, and prolonged disease-free intervals have been achieved with the combination of extirpative and reconstructive techniques.

[Ultraradical surgery of the shoulder and thoracic wall--indications and prognosis]

Super-radical surgery upon shoulder-girdle and chest wall often means mutilation and is therefore a heavy burden for the patient. Nevertheless it can have very rewarding results, if the indications are correct. They include treatment of soft tissue tumours, under certain conditions of metastases within the thoracic wall and very rarely of trauma. Experiences with 9 patients, treated between 1983 and 1985, are reported. Indications for these operations and their prognosis are discussed.

Microscopically proven cure of actinic cheilitis by CO2 laser

Actinic cheilitis is a premalignant condition of the lip frequently seen in individuals with chronic sun exposure. Various surgical and ablative therapies have been employed, but microscopic outcome has not been well documented. In this study CO2 laser ablation was performed on 16 patients with actinic cheilitis that involved 50% or greater of the lower lip. Pre- and post-treatment biopsies were performed to assess results of therapy. After treatment all 16 patients showed microscopic clearing of atypical cells and disorderly maturation characteristic of actinic cheilitis. One patient had clinical recurrence at 14 months, which was retreated with laser.

Total or near total thyroidectomy versus limited resection for radiation-associated thyroid nodules: a twelve-year follow-up of patients in a thyroid screening program

Controversy continues regarding the extent of thyroidectomy appropriate for patients with radiation-associated thyroid nodules. The incidence of cancer in this group of patients is more than 50% when near total or total thyroidectomy is done and all thyroid tissue is serially sectioned and examined. Tumor multicentricity is common. Is total or near total thyroidectomy warranted in all of these patients? A prospective study and follow-up program of 2118 patients with prior low-dose head and neck irradiation who entered into a thyroid screening program allowed us to examine how the extent of thyroidectomy influenced the clinical course of these patients. Near total or total thyroidectomy was performed in 59 patients (36 had cancer), and limited thyroid resection, that is, lobectomy or less, was done in 78 patients (four of whom had cancer). During follow-up, only three patients have developed recurrent cancer; two had near total thyroidectomy and one had total thyroidectomy at first operation. Two patients with limited thyroid resection have had reoperation for new thyroid nodules, both of whom had benign nodules. We conclude that although limited thyroid resection may leave occult malignancies in unresected thyroid tissue, there is no significant difference in outcome between patients with limited resection and those with near total or total thyroidectomy after a 12-year follow-up of the program. Significant differences in cancer recurrence rats may occur with longer follow-up.

Operative strategy for thyroid cancer. Is total thyroidectomy worth the price?

The authors conducted a retrospective analysis with 5- to 30-year follow-up on 109 patients in order to determine the optimum management of nonmedullary thyroid cancer. Results of total thyroidectomy were compared to partial thyroidectomy, among patients well matched for prognostic indicators. No differences in cancer mortality or recurrence rates were evident. However, there were significantly more complications when total thyroidectomy was employed. In view of these results, partial thyroidectomy is recommended as the treatment of choice for nonmedullary thyroid cancer.

Effects of transplantation and resection of a radiation-induced rat insulinoma on glucose homeostasis and the endocrine pancreas

Twenty-one days after s.c. subscapular transplantation of a radiation-induced insulinoma, male NEDH rats exhibited hyperinsulinaemia and hypoglycaemia. These features were associated with islet atrophy, degenerative changes in pancreatic A and B cells, and decreases in the pancreatic contents of insulin, glucagon and somatostatin. The immunoreactive glucagon and somatostatin contents of extrapancreatic tissues of insulinoma-bearing rats were unchanged. Surgical resection of the tumour resulted in an immediate fall of plasma insulin, attaining concentrations similar to those of anaesthetised control rats by 10 min. The estimated half-life of insulin was 3.5 min. Hypoglycaemia persisted until 60 min after resection, followed by hyperglycaemia of 1-2 days duration. Glucose tolerance was impaired 1 day after tumour resection despite the coexistence of raised insulin concentrations. Evidence for abnormal pancreatic B cell function was gained by injection of arginine which failed to evoke a plasma insulin response in the resected rats. Two days after resection, plasma glucose and insulin concentrations were similar to those of control rats. Plasma glucose and insulin responses to glucose and arginine were suggestive of tumour recurrence by 12 days. A single large encapsulated tumour was eventually observed in each rat, with resection giving a 17-56 day prolongation of life.

[Radiation-induced meningioma--a case report]

A case of meningioma following irradiation for a tumor of the third ventricle is reported. A four year old girl was admitted complaining of headache and vomiting. The pneumoventriculography revealed marked hydrocephalus and a mass lesion at the third ventricle. Under the diagnosis of a tumor of the third ventricle, ventriculo-atrial shunt and radiation therapy were performed. Totally, 4170 rad irradiation was directed from left temporal area through a single portal. Though she had no complaints for fourteen years, at the age of eighteen, she was admitted complaining of right hemiparasis and general convulsion. CT scan and left carotid angiogram revealed a left fronto-temporal tumor diagnosed as meningioma. Histological examination showed transitional type meningioma. The post-operative course was uneventful, and discharged without neurological sign except for slight right hemiparesis. A review of available literature revealed about 150 cases of post irradiated meningiomas. However, there were only 18 cases of meningiomas following irradiation for the treatment of brain tumors. These reported cases were also discussed.

[Unwanted sequelae of irradiation in the intestinal tract--pathogenesis, diagnosis, therapy]

The therapy of irradiation sequelae in the intestinal tract is still problematic. Within the period from 1967-1984 285 patients have been treated for late radiation injuries of the intestine. Our experiences are demonstrated and discussed with reference to the literature. Specific topics are: pathogenesis, clinical problems and aspects of conservative and operative treatment.

[Epidermoid cancer of the thoracic esophagus following mediastinal irradiation]

Squamous cell carcinoma of the esophagus induced by radiation therapy is a rare entity. We report 4 cases observed during the past 4 years. Three women and one man aged from 47 to 78 years developed squamous cell carcinoma of the esophagus 8 to 11 years after radiation therapy. The 3 women had been irradiated for breast cancer and the man for Hodgkin's disease with 40 to 57.5 Gy. Three patients were operated on and the immediate postoperative course was uneventful. Culling data from this report and from the literature we reviewed the different steps concerning the diagnosis and the treatment of this complication of radiation therapy. We suggest that diagnostic and therapeutic modalities should follow the same guidelines as in other esophageal cancers.

Malignant phyllodes tumor following irradiation of the breast

This is a case report of malignant phyllodes tumor (cystosarcoma phyllodes) which appeared 15 years following medical irradiation of the breast for presumable carcinoma which had not been histologically or cytologically confirmed prior to treatment. Histology of the phyllodes tumor disclosed remnant of fibroadenoma in one area, and it is believed that the latter gave rise to the malignant phyllodes tumor within the field of irradiation. In view of recent popularity of the limited surgery and postoperative irradiation in treatment of breast carcinoma the possibility of malignant transformation of fibroadenoma left in situ is raised.

Application of microvascular free osteocutaneous flaps in the management of post-radiation recurrent oral cancer

Fifty-nine patients underwent free flap osteocutaneous reconstruction that consisted of flaps of the dorsum of the foot in 26 patients and iliac crest flaps in 33 with a success rate of 92 percent and a mortality rate of 1.6 percent. These flaps, which require the expertise of microvascular surgeons, are time-consuming and complicate operating room and time management, but they represent a remarkable advance in reconstruction that can facilitate cosmetic and functional recovery of the patient. In particular, they promote healing in radiation-recurrent oral cancer and represent a definitive form of management for established radionecrosis of the mandible. The large volume of tissue available with iliac crest osteocutaneous grafts permits the management of patients with extensive cancer involving the skin, mucosa, and bone, but cancer control may still be disappointing and there is a need for improved adjuvant chemotherapy protocols. This technique appears to be a dependable, repeatable, and significant advance in management of the patient with head and neck cancer.

[Long-term experiences in plastic surgery treatment of radiation damage]

Over a period of 22 years the authors reconstructed 49 patients with radiation injuries of varying severity. The retrospective study examined the indications for the radiation therapy, the interval between the treatment and the development of tissue damage, its site and severity. A few typical case reports are presented. Particular aspects emerging from this series, the reconstructive methods used and the results achieved with regard to partial or complete excision of radiation damaged skin are discussed.

Basal-cell carcinoma resulting from radiation therapy for hypertrophic tonsils

Benign dermatologic conditions are no longer treated with therapeutic radiation because of the late complications that can result. One of the most serious complications that may occur is the development of skin cancer of various types. In this report, a patient received radiation for hypertrophic tonsils and later developed basal-cell carcinomas in the irradiated areas.

Radiation and thyroid carcinoma: radiotherapy, head and neck regions, thyroid carcinoma

Radiotherapy for benign conditions of the head and neck area was first linked to thyroid carcinoma in 1950. All the salivary glands, the parathyroids, and the facial skin can also develop neoplastic lesions in this setting. Thyroid carcinoma is most commonly papillary or mixed papillary and follicular. It is very often multifocal and can be detected by hand palpation, nuclear scanning, high resolution sonography, and needle aspiration. Each test has its limitations and appropriate protocols for screening and detection should be adapted to different medical centers. The surgical management is controversial and ranges from simple lobectomy to total thyroidectomy with adjuvant 131I treatment and thyroid suppression. We prefer total thyroidectomy if it can be performed safely. With adequate treatment the survival should be good. Prevention by administration of iodine at the time of exposure to radiation seems feasible and deserves further clinical trial.

Brain sarcoma of meningeal origin after cranial irradiation in childhood acute lymphocytic leukemia. Case report

The authors report their experience with an unusual case of intracerebral sarcoma of meningeal cell origin in an 8 1/2-year-old girl. This tumor occurred 6 1/2 years after cranial irradiation at relatively low dosage (2200 rads) had been delivered to the head in the course of a multimodality treatment for acute lymphocytic leukemia. The tumor recurred approximately 10 months after the first surgical intervention. Macroscopic total excision of the recurrent growth followed by whole-brain irradiation (4500 rads) failed to eradicate it completely and local recurrence prompted reoperation 18 months later. This complication of treatment in long-term childhood leukemia survivors is briefly discussed, as well as the pathology of meningeal sarcomas.

Radiation to the breast. Complications amenable to surgical treatment

Major complications of radiation directed to the breast, axilla, and mediastinum were treated in 54 patients from 1974 to 1983. A classification of these complications facilitates both an understanding of the pattern of injury and the development of a treatment plan.

CLASSIFICATION

I. Breast necrosis; II. Radionecrosis and Chest Wall Ulceration; III. Accelerated Coronary Atherosclerosis with Median Sternotomy Wound Failure After Coronary Revascularization; IV. Brachial Plexus Pain and Paresis; V. Lymphedema and Axillary Cicatrix; VI. Radiation-induced Neoplasia. The treatment has evolved during the 10-year study period to excision of the necrotic wound, including any tumor, and closure with a transposed muscle or musculocutaneous flap of latissimus dorsi (II, III, V) or rectus abdominis (I, II, VI). This strategy reflects a change from primary use of the omentum during the first years of the study. The vascularity, oxygen and antibiotic delivery of these muscle and musculocutaneous flaps promote wound healing, usually with one operation. The transfer of these muscles has not caused significant functional deficits.

Surgery for radiation-induced carcinoma of the hypopharynx

Eighteen radiation-induced tumors of the hypopharynx examined during a 20-year period are described. These tumors represent slightly less than 5 per cent of all tumors of the hypopharynx examined during the same period. Most were due to irradiation for thyrotoxicosis, and the mean latent period was 35 years. Five patients were not treated, and 13 patients were treated, mainly by pharyngolaryngectomy followed by skin flap repair (deltopectoral or pectoralis major). Despite a fairly high complication rate, an adjusted five-year survival of 35 per cent was achieved.

Male breast cancer following repeated fluoroscopy

A man with cancer of the breast following repeated fluoroscopy for pulmonary tuberculosis is described.

[Meningioma following irradiation for vascular nevus. A case report]

A case of meningioma that developed 37 years after irradiation therapy for vascular nevus of the scalp over the right frontoparietal region was reported. A 49-year-old male was admitted to the hospital of Gifu University on October 26, 1979, because of a generalized seizure. He had been born with a vascular nevus affecting the right frontoparietal scalp, for which he began receiving local irradiation at the age of 12. The total dose was not known because the only source of information regarding this treatment was the patient's memory. From the age of 17, the suffered from occasional attacks of dysesthesia in the left side of his body without consciousness disorder. He otherwise remained well for the intervening 37 years. Upon admission, he had a vascular nevus remaining with post irradiation skin changes over the right frontoparietal region. General and neurological examination were not remarkable. Right carotid angiogram and CT scan disclosed the presence of a right frontal tumor. A right frontotemporal craniotomy was performed on December 4, 1979 and a hard tumor was found firmly attached to the dura and bone at the right site. All visible tumor and involved bone were completely removed without difficulty. Histological examination of the surgical specimen showed the characteristic features of a transitional meningioma. There was no evidence of malignancy in the sections examined. Since Mann et al reported a malignant meningioma following irradiation therapy for optic nerve glioma, there have been many reports, over seventy cases of so-called radiation-induced meningioma. However, a meningioma following irradiation therapy for vascular nevus of scalp or face is exceedingly rare.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of needle biopsy in postradiation thyroid disease

Retrospective review was carried out of 124 patients with nodular disease of the thyroid gland and a history of radiation exposure who had undergone needle aspiration biopsy. Latency period from time of radiation varied from 2 to 50 years; but in 92 patients it exceeded 2 decades. Our patient group included those with occupational exposure and a past history of radiation for cancer. Incidence of cancer in the entire group was 49% but, for solitary lesions, this was increased to 56%, while only a 30% incidence of cancer was found in cases of multinodular goiters. Accuracy of needle aspiration biopsy overall was 74%: for the group with cancer--90%, for the group with adenomas--65%, and for the group with "benign" tumors--83%. Further assessment of needle technique indicated a sensitivity of 70%, specificity of 90%, positive predictive value of 90%, and negative predictive value of 83% to 65%. The accuracy could be increased to 84% if all adenomas were considered as possible malignancies. Eighteen percent of our patients had second tumors in the head and neck or breast area. Near-total thyroidectomy was considered to be the preferred procedure without accidental nerve injury and was done in one case of hypoparathyroidism after excision of an extensive tracheal invasive cancer. No evidence of death, recurrence, or metastasis as a result of thyroid cancer has been noted. While needle biopsy is indispensable to intelligent management, the history of radiation to the head and neck area must be preeminent in the selection of patients for surgical treatment. Conservative management appears to be reasonable in those patients with "benign" cytology, a less than 1 cm nodule, multinodularity, a functioning thyroid scan result, but persistence in the face of a lack of response to conservative management does not appear to be warranted.

Multiple primary cancers: with reference to atomic bomb survivors in Hiroshima

We treated 44 patients with multiple primary cancers, at the Second Department of Surgery, Hiroshima University, during the 14 year period from 1968-1981. The total number of malignant tumors was 1,934 during this period, thus the incidence of multiple primary cancers was 2.3 per cent. Nine of the 44 were atomic bomb survivors in Hiroshima and were characterized by the frequent incidence of the second tumor about 30 years after exposure to the atomic bomb. In addition, the second tumor tended to develop later in patients prescribed radiotherapy for the first tumor. As for the site of tumor, there was no tendency of more frequent development of tumors in organs highly sensitive to radiation other than the thyroid.