Superficial temporal artery injury and delayed post-cranioplasty infection

OBJECTIVE

Complications after cranioplasty after decompressive craniectomy (DC) have been reported to be as high as 40%. The superficial temporal artery (STA) is at substantial risk for injury in standard reverse question-mark incisions that are typically used for unilateral DC. The authors hypothesize that STA injury during craniectomy predisposes patients to post-cranioplasty surgical site infection (SSI) and/or wound complication.

METHODS

A retrospective study of all patients at a single institution who underwent cranioplasty after decompressive craniectomy and who underwent imaging of the head (computed tomography angiogram, magnetic resonance imaging with intravenous contrast, or diagnostic cerebral angiography) for any indication between the two procedures was undertaken. The degree of STA injury was classified and univariate statistics were used to compare groups.

RESULTS

Fifty-four patients met inclusion criteria. Thirty-three patients (61%) had evidence of complete or partial STA injury on pre-cranioplasty imaging. Nine patients (16.7%) developed either an SSI or wound complication after cranioplasty and, among these, four (7.4%) experienced delayed (>2 weeks from cranioplasty) complications. Seven of 9 patients required surgical debridement and cranioplasty explant. There was a stepwise but non-significant increase in post-cranioplasty SSI (STA present: 10%, STA partial injury: 17%, STA complete injury: 24%, P=0.53) and delayed post-cranioplasty SSI (STA present: 0%, STA partial injury: 8%, STA complete injury: 14%, P=0.26).

CONCLUSIONS

There is a notable but statistically non-significant trend toward increased rates of SSI in patients with complete or partial STA injury during craniectomy.

Abstract P5-14-07: Noninfectious Wound Complications after Mastectomy with and without Immediate Breast Reconstruction

Background: Noninfectious wound complications, including tissue necrosis and dehiscence, may complicate healing of the breast surgical incision after mastectomy. Breast cancer patients may be at increased risk of noninfectious wound complications due to adjuvant chemo-and radiotherapy.

Objective: To identify independent risk factors for noninfectious wound complications (necrosis and/or dehiscence), including the impact of neo-and adjuvant chemotherapy, and previous and adjuvant radiotherapy after mastectomy alone or with immediate breast reconstruction. Methods: We performed a prospective cohort study of all mastectomy patients with invasive or in situ breast cancer at a tertiary care academic medical center from 8/2005 — 7/2008. Data were collected from the original surgical admission and all hospital readmissions and surgery and oncology clinic visits within 1 year of surgery. Follow-up data included documented signs and symptoms of wound complications, microbiology cultures, additional surgical procedures, and chemo-and radiation therapy dates. Extended Cox proportional hazards models were used to determine independent risk factors for wound complications, controlling for underlying comorbidities, previous chest irradiation and neoadjuvant chemotherapy, and with adjuvant radiotherapy and chemotherapy included as time-dependent covariates.

Results: 777 women had a mastectomy (408 (52.5%) mastectomy only, 325 (41.8%) mastectomy plus implant, and 44 (5.7%) mastectomy plus autologous tissue reconstruction). 173/777 women (22.3%) received neoadjuvant chemotherapy. 105 women had breast wound complications within 180 days after surgery (13.5%). Repeat surgery (incision and drainage, debridement, and/or implant removal) was required in 40/105 (38.1%) women with wound complication. 13/105 (12.4%) women had subsequent infection after wound complication, while 9/105 (8.6%) had infection diagnosed before the wound complication. Independent risk factors for noninfectious wound complication within 180 days after surgery included autologous tissue reconstruction (hazard ratio (HR) 5.6, 95% CI: 2.9-10.5), implant reconstruction (HR 4.3, 95% CI: 2.8-6.8), smoking (HR 3.3, 95% CI: 2.2-4.9), higher ASA class (HR 1.7 (95% CI: 1.0-2.9), and morbid obesity (BMI > 35, HR 2.6, 95% CI: 1.7-4.0). Preadmission anticoagulant therapy was marginally associated with increased risk of necrosis/dehiscence (HR 1.8, 95% CI: 0.9-3.7). Diabetes (p = .365), neoadjuvant chemotherapy (p = .254), adjuvant chemotherapy (p = .222), previous radiotherapy (p = .195), and adjuvant radiotherapy (p = .106) were not associated with increased risk of necrosis/dehiscence within 180 days of surgery after accounting for other risk factors for wound complication. Discussion: Immediate breast reconstruction, smoking, and morbid obesity were associated with increased risk of tissue necrosis/dehiscence within 180 days after mastectomy. Neo-and adjuvant chemotherapy and adjuvant radiotherapy were not associated with increased risk of noninfectious wound complications after controlling for underlying comorbidities and other risk factors. These results emphasize the important of smoking cessation in women undergoing mastectomy, particularly with immediate breast reconstruction.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-14-07.

Hepatocellular carcinoma invasive to chest wall

An 88-year-old white man developed hepatocellular carcinoma forming a large subcutaneous mass by direct invasion of the posterior chest wall. Forty-seven cases of cutaneous metastases from primary liver cancer have been reported. These cutaneous metastases showed protean morphologic features with the face and scalp being the most common sites of involvement. The metastatic lesions may be the presenting sign of the cancer. Average survival, after development of a skin metastasis, was 5 months. Skin metastases from primary liver cancer are being reported more frequently. This is due, in part, to more prolonged survival of liver cancer patients, which allows development of skin metastases, and also due to increased awareness by the clinician.