Early postoperative brachytherapy following free flap reconstruction

Is Brachytherapy Feasible After Head and Neck Cancer Reconstructive Surgery? Preliminary Report

The purpose of the study was to evaluate the influence of interstitial postoperative brachytherapy for the vitality and quality of flaps used for reconstruction of tissue defects after head and neck cancer salvage resection. We aimed at presenting six consecutive patients with recurrent squamous cell carcinoma in head and neck region who underwent salvage surgery and tissue reconstruction with a regional or free flap followed by brachytherapy. Reconstruction was performed with a free radial forearm flap in 2 cases, with a free thigh flap in 2 cases, and with a myocutaneous lateral upper arm flap in the next 2 cases. In all patients, pulsed-dose-rate brachytherapy was used with a median value of 0.7 Gy (range 0.6–0.8 Gy) per pulse and a median total dose of 20 Gy (range 20–40 Gy). In the analyzed group, there were no serious wound and flap complications after brachytherapy. In one case, peripheral skin necrosis was noticed. No revision surgery was needed but only surgical debridement of the necrotic margins. All wounds healed within 14 days after surgery as well as donor sites which healed within 4 weeks. Based upon our data, pulsed-dose-rate brachytherapy seems to be a safe option that can be performed at the site of reconstruction in immediate postoperative period with minimal wound complications and with no impact on flap survival. Further clinical study based on larger patient series is needed to present statistically proven results.

Neither high-dose nor low-dose brachytherapy increases flap morbidity in salvage treatment of recurrent head and neck cancer

Purpose

While brachytherapy is often used concurrently with flap reconstruction following surgical ablation for head and neck cancer, it remains unclear whether it increases morbidity in the particularly high risk subset of patients undergoing salvage treatment for recurrent head and neck cancer (RH&NC).

Material and methods

A retrospective chart review was undertaken that evaluated patients with RH&NC who underwent flap coverage after surgical re-resection and concomitant brachytherapy. The primary endpoint was flap viability, and the secondary endpoints were flap and recipient site complications.

Results

In the 23 subjects included in series, flap viability and skin graft take was 100%. Overall recipient site complication rate was 34.8%, high-dose radiation (HDR) group 50%, and low-dose radiation (LDR) group 29.4%. There was no statistically significant difference between these groups.

Conclusions

In patients who undergo flap reconstruction and immediate postoperative radiotherapy following salvage procedures for RH&NC, flap coverage of defects in combination with brachytherapy remains a safe and effective means of providing stable soft tissue coverage.

Tolerance of Cutaneous or Mucosal Flaps Placed into a Radiation Therapy Field in Dogs

OBJECTIVE

To determine the clinical outcome and factors affecting cutaneous or mucosal flaps in dogs treated with radiation therapy (RT).

STUDY DESIGN

Longitudinal clinical study.

ANIMALS

Twenty-six client-owned dogs.

METHODS

Dogs entered in the study had a flapping procedure and RT as part of their treatment. The sequence of flapping and RT included: (1) planned preoperative RT, (2) postoperative RT, and (3) flapping as a salvage procedure for management of complications or local tumor recurrence after RT. Flap complications were defined as necrosis, local infection, dehiscence, and ulceration. The risk and severity of flap complication were analyzed independently.

RESULTS

Twenty (77%) dogs had a complication; 6 dogs required an additional flapping procedure; and 4 dogs had an unresolved complication. Flapping procedures performed to correct a complication, or failure of RT, had a significantly greater risk for complication; however, postoperative RT decreased the severity of complication. A dose per fraction of 4 Gy compared with 3 Gy was prognostic for increased severity of complications, whereas the head and neck location was prognostic for decreased severity of complication.

CONCLUSIONS

Although morbidity was substantial, cutaneous or mucosal flaps were used successfully in an RT field in 85% of the dogs. Flaps that were part of the planned therapy as opposed to those used to correct a complication or failure of RT had a better clinical outcome.

CLINICAL RELEVANCE

Cutaneous or mucosal flaps can be part of the treatment of dogs with tumor when adjuvant or neoadjuvant RT is to be used.

Reconstruction after soft tissue sarcoma resection in the setting of brachytherapy: a 10-year experience

Management of recurrent soft tissue sarcomas often involves surgical resection and adjuvant brachytherapy. This study reviews our experience in the management of these patients and proposes a logical approach toward reconstruction. All patients who underwent soft tissue sarcoma resection, adjuvant brachytherapy, and soft tissue flap reconstruction (pedicled or free) during the 10-year period from 1991 to 2000 were included in this study. There were 17 patients (14 male, 3 female) with a mean age of 51 years (range, 16-80 years). Soft tissue sarcomas were distributed in the lower extremity (n = 9), upper extremity (n = 5), and trunk (n = 3). Reconstruction was accomplished by regional transposition flaps (n = 10) and free tissue transfer (n = 7). The average defect size was 143 cm. Patients received 5 to 12 (mean, 8) brachytherapy catheters. The brachytherapy dose delivered ranged from 1600 to 4500 cGy (mean, 3773 cGy). Brachytherapy catheters were loaded with radioactive sources between 5 and 7 days postoperatively. All flaps in this series survived. One patient required return to the operating room for revision of a venous thrombosis with flap salvage. Closed suction drainage tubes were left in place until after the brachytherapy catheters were removed to avoid dislodging the catheters. Two patients developed postradiation partial-thickness skin necrosis with delayed secondary wound healing. This study demonstrates that soft tissue reconstruction in the setting of sarcoma resection and brachytherapy catheter placement is safe and efficacious. Postoperative wound healing complications can be minimized through coordination among the ablative surgeon, reconstructive surgeon, and radiation oncologist. Specifically, placement of microvascular anastomoses well away from the radiation target area is indicated whenever possible. Finally, removal of closed suction drainage tubes should be deferred until after the brachytherapy catheters are removed to minimize complications resulting from catheter dislodgement.

Tolerance of tissue transfers to adjuvant radiation therapy in primary soft tissue sarcoma of the extremity

PURPOSE

Treatment of extremity sarcomas occasionally requires tissue transfer in the form of pedicle flaps, free flaps, or skin grafts to repair surgical defects. These tissues are often subject to radiation (RT) and are therefore at risk for wound breakdown requiring reoperation. This study reviews a single center's experience with tissue transfer and postoperative RT. METODS AND MATERIALS: Between 1983 and 2000, 43 adult patients (>16 years old) with primary high-grade soft tissue extremity sarcomas underwent limb-sparing surgery and reconstruction of their surgical defects, followed by adjuvant RT. The reconstructions were as follows: pedicle flaps (n = 14), free flaps (n = 10), skin grafts (n = 4), or a combination (n = 15). Postoperative external beam radiation therapy (EBRT) (median dose: 63 Gy) alone was given to 27 patients (63%). Adjuvant brachytherapy (BRT) was given to 16 patients (37%); BRT alone (median dose: 45 Gy) was given to 12 patients and combined with EBRT for 4 patients (EBRT: 45 Gy; BRT: 20 Gy). Comorbid conditions such as diabetes, hypertension, tobacco use, and obesity (calculated using body mass index >or=30) were present in 30 patients (70%). Tumor characteristics were as follows: 26 were >5 cm in size, 37 were deep, and 30 were in the lower extremity. The median follow-up time, calculated from the date of operation, was 32 months. Five of 43 patients suffered wound complications necessitating reoperation; however, 3 patients developed complications before initiation of RT and were therefore excluded from the analysis. Two of 43 patients (5%) required reoperation for wound complications after RT; 1 of these patients ultimately required amputation for necrosis. The 5-year overall wound reoperation rate was 6% (95% confidence interval: 0-14%). The influence of patient and tumor characteristics, as well as the type of RT, on the wound reoperation rates is as follows: BRT vs. EBRT (17% vs. 0%, p = 0.06); upper vs. lower extremity (0% vs. 8%, p = 0.41); <or=5 cm vs. >5 cm (8% vs. 4%, p = 0.9); comorbidity vs. no comorbidity (3% vs. 13%, p = 0.8); age <or=50 vs. >50 (8% vs. 4%, p = 0.8).

CONCLUSION

Based on this review, most tissue transfers (95%) tolerated subsequent adjuvant radiation therapy well. Although more wound complications necessitating reoperation were seen in patients who received BRT, whether this is because of the inherent susceptibility of flaps and skin grafts to breakdown in the immediate postoperative period vs. the direct result of BRT needs further investigation.

The radiotherapeutic injury--a complex 'wound'

Radiotherapeutic normal tissue injury can be viewed as two simultaneously ongoing and interacting processes. The first has many features in common with the healing of traumatic wounds. The second is a set of transient or permanent alterations of cellular and extracellular components within the irradiated volume. In contrast to physical trauma, fractionated radiation therapy produces a series of repeated insults to tissues that undergo significant changes during the course of radiotherapy. Normal tissue responses are also influenced by rate of dose accumulation and other factors that relate to the radiation therapy schedule. This article reviews the principles of organised normal tissue responses during and after radiation therapy, the effect of radiation therapy on these responses, as well as some of the mechanisms underlying the development of recognisable injury. Important clinical implications relevant to these processes are also discussed.

Trans-osseous passage of head and neck brachytherapy tubes

Brachytherapy following surgical resection of head and neck malignancy is a useful adjunct if full dose external beam radiotherapy has been performed previously. Percutaneous tube placement has been described but accurate placement can be technically difficult in certain areas of the head and neck. A case report is presented of trans-osseous brachytherapy tube placement through the zygoma bone to allow for optimum surgical bed irradiation without kinking of the tubes. It is proposed that the trans-osseous placement is a useful technique when siting of the tubes is difficult.

Head and neck skin involvement by non-cutaneous head and neck cancers: free flap reconstruction

INTRODUCTION

Patients with skin involvement from head and neck cancer have a poor prognosis, with a median survival time of 2 months.

METHOD AND RESULTS

During a 9 year period, 31 patients with skin involvement above the clavicle by non-cutaneous malignant tumours of the head and neck were treated. In 19 males and 12 females with a mean age of 62 years, the parotid gland (32%) and the oral cavity (29%) were the commonest sites of primary disease and 77% of the cases were squamous cell carcinomas. Twenty-six had recurrent disease, 20 had received previous radiotherapy and all underwent surgical resection with free flap reconstruction, the commonest being the radial forearm (78%). Complete histological clearance was achieved in 53% of the cases, and adjuvant post-operative irradiation was given to 60%. With this form of management, palliation was extended to a mean survival of 23 months. Six patients are currently alive and disease free at a mean follow up of 4.5 years.

CONCLUSIONS

Patients with head and neck skin involvement by non-cutaneous head and neck malignancies have a very poor prognosis, but surgical resection combined with free microvascular flap reconstruction and planned post-operative radiotherapy, can offer good long-term palliation.

Early wound complications in advanced head and neck cancer treated with surgery and Ir 192 brachytherapy

OBJECTIVES

Brachytherapy, either as primary or adjuvant therapy, is increasingly used to treat head and neck cancer. Reports of complications from the use of brachytherapy as adjuvant therapy to surgical excision have been limited and primarily follow Iodine 125 (I125) therapy. Early complications include wound breakdown, infection, flap failure, and sepsis, and late complications may include osteoradionecrosis, bone marrow suppression, or carotid injuries. The authors sought to identify the early wound complications that follow adjuvant interstitial brachytherapy with iridium 192 (IrS92).

STUDY DESIGN

A retrospective chart review of all patients receiving adjuvant brachytherapy at a tertiary medical center over a 4-year period.

METHODS

Nine patients receiving Ir192 brachytherapy via afterloading catheters placed during surgical resection for close or microscopically positive margin control were evaluated. It was used during primary therapy in six patients and at salvage surgery in three. Early complications were defined as those occurring within 6 weeks of surgical therapy.

RESULTS

The overall complication rate was 55% (5/9), and included significant wound breakdown in two patients, minor wound dehiscence in three, and wound infection, bacteremia, and local tissue erosion in one patient each. All complications occurred in patients receiving flap reconstruction and one patient required further surgery to manage the complication. Complication rates were not associated with patient age, site, prior radiotherapy, timing of therapy, number of catheters, or dosimetry.

CONCLUSIONS

The relatively high complication rate is acceptable, given the minor nature of most and the potential benefit of radiotherapy. Further study should be undertaken to identify those patients who will achieve maximum therapeutic benefit without prohibitive local complications.

Malignant tumours of the parotid gland: a 12-year review

Malignant parotid tumours are uncommon and present a significant management challenge. Fifty-one such patients (25 male, 26 female, median age 64 years) operated on in the Newcastle Plastic Surgery Unit between 1983 and 1994 were retrospectively evaluated. Preoperative investigations included FNA cytology (n = 20), and for staging CT and/or MRI scans (n = 21). Of the 35 primary tumours 32 were epithelial and three lymphomatous. Metastatic tumours were squamous cell carcinoma (7), melanoma (6), renal cell carcinoma (2) and sebaceous carcinoma (1). FNA cytology correctly diagnosed malignancy with an 88% sensitivity (false negatives = 2). A total or radical parotidectomy was required in 60% of patients, the rest undergoing superficial parotidectomy. In continuity neck dissection was undertaken in 23 (45%) cases. Postparotidectomy reconstruction included 10 free, 3 myocutaneous, and 4 local transposition/rotation flaps. Thirty-seven patients (73%) received postoperative radiotherapy. Seventy-two per cent of patients are alive after a mean follow-up of 42 months. The crude 5- and 10-year survival rates were 68% and 49% respectively while the loco-regional control rate (Kaplan-Meier method) at 10 years was 79%. Fifteen patients (30%) have permanent facial palsy. It is concluded that radical surgery with appropriate reconstruction followed by planned postoperative adjuvant radiotherapy gives effective control of malignant parotid tumours.

Wound complications associated with brachytherapy for primary or salvage treatment of head and neck cancer

Brachytherapy can be employed in the primary or salvage treatment of head and neck cancer. The advantage of brachytherapy is the stereotactic limitation of radiation exposure to noninvolved tissues. Wound complications associated with brachytherapy have been discussed only sporadically in the literature. This retrospective study examines 28 patients, 20 for initial treatment and eight for salvage, with varying site and stage head and neck cancer treated with brachytherapy in addition to external beam radiation therapy and/or surgery. The overall complication rate was 50% (14/28), with infection and minor flap breakdown being the most common problems. Tumor site in the primary treatment group was the only significant factor in wound complications. In the salvage group complications were minor and primarily related to flap coverage of brachytherapy catheters.

Brachytherapy in orbital tumors

PURPOSE

To evaluate whether the use of iridium-192 brachytherapy would reduce the incidence of complications noted with external beam radiation therapy in patients with orbital tumors.

METHODS AND MATERIALS

This study is a retrospective review of a clinical series of 25 patients with various orbital tumors treated with brachytherapy between 1988 and 1995.

RESULTS

Patients were observed for an average of 40 months (range, 16-88 months) during which one patient died of metastatic disease and 24 patients are alive with no evidence of disease. Recurrent disease was observed in four patients. In 3 patients, exenteration was necessary and in 22 patients, the eye was preserved. The visual acuities after therapy ranged from no light perception to 20/20 (average, 20/40).

CONCLUSIONS

Since brachytherapy has been used as an alternative to exenteration, the results of this treatment have been excellent in most patients. However, in advanced disease, external radiation therapy or even mutilating surgery still remains inevitable.

[Reconstruction with free vascularized or island flaps of soft tissue loss in the upper limb after tumor resection. 16 cases]

We have reviewed 16 cases of soft tissue sarcomas of the upper limb treated with wide excision of the tumour and immediate soft tissue reconstruction by means of a microvascular flap. 9 patients were males, 7 females; age ranged from 12 to 74 years. All the patients had been referred to us after previous failed or inadequate excisions. All the tumours were high-grade malignancies in an extracompartmental location (stade IIB according to Enneking). Histopathologic diagnosis was: synovial-sarcoma in 11 cases; fibrosarcoma in 2 cases; malignant fibrous histiocytoma in 1 case, soft tissue osteosarcoma in 1 case, epitheloid sarcoma in 1 case. The site of the tumour was the hand in 2 cases, the wrist in 6 cases, the forearm in 5 cases and the elbow in 3 cases. The free flaps used for soft tissue reconstructions were the latissimus dorsi in 6 cases, the dorsalis pedis in 2 cases, the lateral arm flap in 2 cases, the serratus in 1 case, the gracilis in 1 case. The island flaps were the radial forearm flap in 1 case, the posterior interosseous flap in 1 case, the cubital flap in 1 case. 14 cases required immediate associated reconstructive procedures such as tendon transfers or grafts (5 cases), vascularized or non vascularized bone grafts (4 cases), articular allografts (1 case), ligament reconstruction (1 case), nerve grafts (2 cases). Brachytherapy was associated to microsurgical reconstruction in the last 6 cases of this group. The catheters were charged with the radioisotope 5 days after surgery. No complications were observed.(ABSTRACT TRUNCATED AT 250 WORDS)