Radiation to the breast. Complications amenable to surgical treatment

Radiation-induced thoracic necrosis with a pulmonary cutaneous fistula repaired using a free omental flap: a case report

Background

Chest wall necrosis can manifest as a late effect of radiation therapy for breast cancer. Only two cases of fistulas communicating with the respiratory tract as a result of radiation-induced necrosis of the lungs or bronchi have been reported. To the best of our knowledge, we report the first case of a pulmonary cutaneous fistula arising as a late effect of radiation therapy for breast cancer, which was successfully repaired using a free omental graft.

Case presentation

A 64-year-old woman underwent Halsted surgery and postoperative radiation therapy for breast cancer 25 years earlier. One year before visiting our hospital, she developed a fistula and bleeding in her left clavicular region, which was expanding. On initial examination, a 6-cm-wide skin defect was observed in the left clavicular region and the clavicle appeared sequestrated. Computed tomography revealed part of the first to third left ribs, part of the left clavicle, the subclavian artery, and the brachial plexus to be missing. Several rounds of debridement revealed approximately 10 bronchial stumps on the surface of the collapsed lung, from which exhaled air and sputum were effusing. Surgery was performed to implant a free omental flap with vascular anastomosis and a skin graft in the neck region, and the pulmonary cutaneous fistula was closed. Two years after surgery, emphysema remained inside the omentum, which spontaneously resolved by the 3rd postoperative year.

Conclusions

Various treatment options are conceivable for the repair of pulmonary cutaneous and bronchocutaneous fistulas induced by radiation damage (e.g., free tissue grafts and endoscopic bronchial occlusion); however, these are rarely reported, and the most reliable method thus remains unclear. Positive outcomes in our case indicate that implanting a free omental graft may be effective. Furthermore, spontaneous healing can be expected for the residual emphysema inside the omentum.

Optimal Reconstruction Method for Large Radionecrosis Following Breast Cancer Treatment: Utility of Free Transverse Rectus Abdominis Myocutaneous Flap Using Contralateral Internal Mammary Artery as Recipient

INTRODUCTION

In extensive radionecrosis following radiotherapy for breast cancer (BC) treatment, the defect after excision can be reconstructed with a transverse rectus abdominis myocutaneous (TRAM) flap. In this study, we report outcome of free TRAM flap using contralateral internal mammary artery (IMA) as a recipient in comparison with pedicled TRAM.

METHODS

We reviewed cases of chest wall radionecrosis following BC treatment during the past 8 years. Radionecrosis involving full-thickness soft tissue with defect sizes greater than 10 × 10 cm were included. We compared the outcomes of patients who underwent reconstruction with either pedicled TRAM flaps or free TRAM flaps. We used IMA as a recipient for free TRAM flap, whereas we used contralateral superior epigastric artery-based flap for pedicled TRAM.

RESULTS

A total of 14 BC patients underwent chest wall reconstruction due to radionecrosis: 7 received pedicled TRAM flaps, 5 received free TRAM flaps, and 2 were excluded because of the small defect size. The pedicled and free TRAM groups were similar in patient demographics and defect size. However, distal flap loss rate was significantly higher in the pedicled TRAM group compared with the free TRAM group (P = 0.028). There was no difference in abdominal hernia incidence between the 2 groups (P = 0.100).

CONCLUSIONS

Wide chest wall defects caused by radionecrosis following BC treatment can be successfully reconstructed with a free TRAM flap that uses a contralateral IMA as a recipient. The free TRAM flap demonstrates a lower rate of distal flap loss than the pedicled TRAM flap, hence reduces the risk of severe morbidity.

A difficult case: omental transposition flap reconstruction of a large radionecrotic axillary ulcer in a patient with extensive previous abdominal surgery

Radionecrotic ulcers due to breast cancer treatment is a highly morbid and disabling condition, causing pain, malodour, need for frequent dressings, reduced range of shoulder movements and an unacceptable cosmetic appearance. In patients with radiotherapy to the chest and/or axilla and general poor health the usual reconstructive options may not be suitable due to regional tissue damage and inappropriate long anaesthetic time, respectively. Described procedures include the pedicled latisimus dorsi flap, transverse rectus abdominal flap (TRAM) and omental transposition flap, as well as free tissue transfer (e.g. free TRAM, DIEP). We report a case of a morbidly obese female patient presenting with a large radionecrotic ulcer in her left axilla, following mastectomy, axillary clearance and local radiotherapy to left chest and axilla for breast cancer. She underwent reconstruction using an omental transposition flap, despite previous abdominal surgery.

The Role of the Latissimus Dorsi Flap in Reconstruction of the Irradiated Breast

BACKGROUND

The role of the latissimus dorsi flap with a prosthesis in reconstruction of the previously irradiated breast is examined in this retrospective review of one surgeon's 10-year experience.

METHODS

Twenty-eight patients with available charts were divided into five groups: (1) 11 patients with previous breast conservation therapy and recurrence; (2) eight patients with previous mastectomy and radiation; (3) four patients with an expander that had been irradiated; (4) three patients with prior irradiation and implant reconstruction presenting for revision; and (5) two patients with breast deformity from breast conservation therapy.

RESULTS

Eighteen patients had a latissimus flap placed at the time of the expander and 10 had a latissimus flap at the time of implant placement or exchange. Average follow-up was 28.8 months (range, 1 week to 7 years). All patients had soft breasts at follow-up, with no evidence of capsular contracture. Donor-site complications included five donor-site seromas. The majority of patients (65 percent) underwent a planned two-stage reconstruction, and the majority of the revision operations were for exchanges to smaller implants. The response rate to a patient satisfaction survey was 67 percent. The average cosmetic satisfaction rating was 8.5 of 10 (with 10 being the highest). The average pain rating was 1.7 of 10 (with 10 being the worst). The overall satisfaction rating was 8.8 of 10. Fourteen of 16 patients indicated that they would undergo this procedure again.

CONCLUSIONS

Although purely autologous reconstructions may be the best choice for many irradiated breasts, it has been shown in this study that a cosmetically acceptable reconstruction with manageable risk can be performed using a prosthesis combined with a latissimus dorsi flap.

Attenuation of pain perception after transposition of the greater omentum to the cauda equina region of rats--a preliminary observation

BACKGROUND

This paper addresses a specific experimental design to suggest the possible role of the greater omentum in the modulation of pain in rats.

METHODS

Fifteen male Sprague-Dawley rats weighing between 275 and 325 g were selected. The animals were randomized and then anesthetized with pentobarbital (35 mg/kg) and divided into three groups: (1) sham: laparotomy followed by laminectomy with exposure of the spinal epidural space (n=5); (2) transposition of pedicled omentum (n=5) to the cauda equina epidural space; and (3) transposition of pedicled omentum (n=5) to the cauda equina intradural space. The animals were operated upon and once more randomized by an independent investigator, so that the groups were thought to be similar during post-operative testing. The latency of paw withdrawal to noxious heat stimulation was tested and the values (seconds) plotted for 1, 3, 6, 11, 14 and 30 days after surgery. Randomization codes were open after the animals were euthanized. The analysis of variance (ANOVA) without replication was applied for each of the dataset and comparisons established among the different study groups involved. The omenta were removed and standard immunohistochemistry was performed for gamma-amino-butyric acid (GABA), serotonin, calcitonin-gene related protein (CGRP), vascular intestinal peptide (VIP) and Met-enkephalin.

RESULTS

The response to high heating rates of stimulation favored intradural versus sham and epidural omental transpositions. High and low noxious heat stimulation suggested an increased threshold to noxious stimulation after the 3 and 30 days of omental transposition. In the low heat stimulation series, responses were comparatively higher than in the sham animals.

CONCLUSIONS

The suggested increased threshold of response to noxious stimulation after transposition of the greater omentum onto the spinal cord of rats suggested a novel role of the omentum and a potential future application in the clinical arena.

Chest wall dose in MammoSite™ breast brachytherapy: Radiobiologic estimations of late complication risk based on dose–volume considerations

PURPOSE

To estimate the risk of late effects in women treated with MammoSite brachytherapy (MBT), the balloon catheters of which were placed near the ribs.

METHODS AND MATERIALS

Upon reviewing 93 plans, 16 patients (17%) treated with MBT were considered to have received a high chest wall dose (>or=120% isodose line in contact with a rib). A dose-volume histogram was generated for this rib, and its distance from the MBT balloon measured. Using the linear quadratic equation, the equivalent dose, delivered in 10 fractions, to the dose that causes a 5% and 50% risk of rib late effects at 5 years using 2Gy per fraction, was calculated to be 37 and 44Gy, respectively. The rib volume receiving greater than or equal to these doses (V37 and V44) was correlated to the balloon-to-rib distance. Chest wall signs, symptoms, and radiologic findings for all 16 patients were recorded.

RESULTS

The median balloon-to-rib distance was 4.8mm. The median values of V37 and V44 were 13.5% and 3.3%, respectively. All patients with a V37>or=15% and V44>or=5% had a minimum balloon-to-rib distance of <5mm. Two patients reported treatment-related chest wall tenderness (both had balloons placed <5mm from the chest wall), but neither presented with radiologic complications.

CONCLUSIONS

Sixteen patients considered to receive relatively high chest wall doses had less than one-third of their primary rib volume being exposed to the estimated TD 5/5 and TD 50/5 doses. Therefore, we estimate the risk of late effects in women treated with MBT, the balloon catheters of which placed near the ribs were negligible, and believe that MBT remains a safe and effective treatment for selected patients with early stage breast cancer.

Management of Sternal Wounds With Pectoralis Major Musculocutaneous Advancement Flaps in Patients With a History of Chest Wall Irradiation

Although debridement and pectoralis major musculocutaneous advancement flap closure has proved to be an effective treatment of sternal wounds in the general population, the purpose of this study was to examine the use of these flaps in patients with previously irradiated chest walls. The authors examined 5 patients with a history of breast cancer and chest wall radiation therapy who developed poststernotomy wound complications that were treated with debridement and pectoralis major musculocutaneous advancement flaps. The average patient age was 76 years. Three patients had previously undergone a radical mastectomy and had only 1 pectoralis major muscle remaining. There were no intraoperative deaths. One patient died during the 30-day postoperative period. There were no hematomas, seromas, or dehiscences. One woman developed a postoperative wound infection. Functional and aesthetic results were excellent. This study demonstrates that early, aggressive sternal debridement and closure with pectoralis major musculocutaneous advancement flaps is effective in patients with a history of chest wall irradiation, including those who have had 1 pectoralis major muscle previously resected.

The creation of new rotation arc to the rat latissimus dorsi musculo-cutaneous flap with delay procedures

Background

Latissimus dorsi musculocutaneous flap is one of the most frequently performed reconstructive techniques in surgery. Latissimus dorsi muscle has two arcs of rotation. It is classified as type V muscle. This muscle can be elevated on the thoracodorsal artery to cover large defects in the anterior chest and also, the muscle can be elevated on the segmental vessels to cover midline defects posteriorly. The aim of this study was to create a new arc of rotation on a vertical axis for the muscle and investigate effectiveness of vascular and chemical delays on the latissimus dorsi muscle flap with an inferior pedicle in an experimental rat model. We hypothesized that the latissimus dorsi muscle would be based on inferior pedicle by delay procedures.

Methods

We tested two different types of delay: vascular and combination of vascular and chemical. We also tried to determine how many days of "delay" can elicit beneficial effects of vascular and combination delays in an inferior pedicled latissimus dorsi musculocutaneous flap. To accomplish this, 48 male Sprague-Dawley rats were randomly subjected to vascular or combination delay (vascular and chemical). In addition, one ear of each rat was assigned into a delay procedure and the other ear was used as a control. Results were evaluated macroscopically, and micro-angiography and histological examinations were also performed. As a result, there was a significant difference in viable flap areas between vascular delay alone and control groups (p < 0.05).

Results

The higher rate of flap viability was obtained in seven-day vascular delay alone. However, there was no significant difference in the viability between seven-day vascular delay and five-day vascular delay (p < 0.05), so the earliest time when the flap viability could be obtained was at five days. The rate of flap viability was significantly higher in the vascular delay combined with chemical delay than the control group (p < 0.05).

Conclusion

The combination of vascular and chemical delays increased the rate of viability. Nevertheless, there was no significant difference between vascular delay alone and combination of vascular and chemical delays. Chemical delay did not significantly decrease the delay period. Better histological and microangiographical results were achieved in delay groups compared to control groups. We concluded that the arch of the latissimus dorsi musculocutaneous flap can be changed and the flap can be used for various purposes with the delay procedures.

Lower back coverage with endoscopically harvested pedicled greater omental flap

An alternative surgical treatment is proposed here for radionecrosis of the lower back. A 78-year-old patient was treated successfully for a nonhealing ulcer with a pedicled omental flap. The omentum was harvested endoscopically and brought out of abdominal cavity through a limited incision on lateral left side of abdominal wall. The omentum was then tunneled to the back for coverage the lower back. The combination of an endoscopic harvest of an omental flap performed by a general surgeon and wound debridement and skin grafting of the omentum by a plastic surgeon allows minimal donor-site morbidity and avoids the use of delicate microsurgical technique. Additionally, omentum is an ideal flap for the treatment of radionecrosis.

Controversy in breast reconstruction

We have discussed the major controversies in the reconstruction of the breast. As trends in cancer ablative surgery have shifted toward breast conservation techniques, the reconstructive choices available to the plastic surgeon have evolved. Advances in oncology, adjuvant therapy, and surgical techniques have changed the defects left following ablative surgery. Patient preferences have also changed, with a greater number of patients presenting to the reconstructive surgeon having already decided the timing and type of reconstruction they prefer. We must continually remind ourselves that the best and least controversial option is the one reached through appropriate consultation among patient, oncologist, and surgeons.

TRAM flap breast reconstruction after radiation treatment

OBJECTIVE

Patients with and without radiation treatment before their breast reconstruction were compared to study the relationship of radiation to flap-related complications.

SUMMARY BACKGROUND DATA

The transverse rectus abdominis muscle (TRAM) flap for breast reconstruction involves a a vascular pedicle and recipient bed, both included in the radiated field of patients undergoing adjunctive therapy. Detailed reviews of flap-related complications in this subgroup of patients have been limited.

METHODS

One hundred eight patients with radiation treatment who subsequently underwent a TRAM flap breast reconstruction were compared with 572 patients with no radiation treatment before similar reconstruction. Flap-related complications, radiation dosage, time, fields, relationships between risk factors, and complications were studied.

RESULTS

Overall complication rates were comparable between the two groups. Only fat necrosis (> 10% of total reconstruction) was found to be statistically significant (17.6% vs. 10.1%, p = 0.03228). No difference was found for fat necrosis in unipedicled vs. bipedicled flaps controlled for radiation (17.7% vs. 17.4%). Obesity and radiation therapy were associated with fat necrosis and major infection in a logistic regression. Significant abdominal scarring was also associated with major infection (p = 0.0044).

CONCLUSIONS

In this, the largest reported series, radiation therapy was associated with increased fat necrosis and major infection. The use of the TRAM flap was not found to be prohibitive in radiated patients and should still be the first choice in this subgroup of patients.

Vascularized tissue transfer for closure of irradiated wounds after soft tissue sarcoma resection

During the years 1985 to 1989, 82 patients were included in the soft tissue sarcoma protocol. Preoperative irradiation (50-54 Gy) was performed in all patients before tumor extirpation. Microwave hyperthermia was performed in conjunction with radiation in patients who had gross tumor remaining after initial biopsy. Primary closure with vascularized tissue (flaps) in lieu of conventional wound closure by skin approximation led to less complications (19% versus 51%), fewer secondary procedures for wound closure (10% versus 35%), shorter average hospitalization (15 versus 48 days) and greater limb salvage rate (97% versus 91%). The authors conclude that vascularized tissue (flaps) for primary wound closure in irradiated tissue leads to improved wound healing, and should be considered the procedure of choice for heavily irradiated soft tissue sarcoma defects.

Reconstruction after mastectomy

Advances in materials and techniques, especially those involving transposition of muscle and skin flaps, have made breast reconstruction possible for most women who undergo mastectomy for breast cancer. The availability of this option can alleviate the breast and chest wall deformity that results from virtually all local treatment of breast cancer. It is essential that the reconstruction surgeon be part of the breast cancer management team from the beginning of treatment planning and that this surgeon work closely with the general surgeon, medical oncologist, and radiation therapist as well as the adjunctive treatment team members. The patient's clinical status and the type of local treatment will be significant determinants of the reconstructive options. For women with stage I breast cancer, these decisions may be based largely on the oncologist's local and adjunctive therapy procedures and the woman's desire to proceed or delay. For women with systemic disease, all members of the breast management team may need to agree on the advisability and timing of reconstruction. Central to all of the numerous decisions described in this paper regarding the timing, type, and extent of breast reconstruction is the primary goal of the entire team: the best possible management of the breast cancer itself. The promise of attractive, symmetric, and natural appearing breasts, complete with a symmetric nipple-areolar complex, has eased somewhat the diminishment of self-esteem and the threat to femininity that can accompany the loss of a breast. By lowering fear, the widely recognized availability of breast reconstruction may encourage more women to monitor their breasts and seek diagnosis of changes and may influence selection of the type of local treatment if cancer is detected. Because of the psychological and cultural significance of the breast, the reconstructive surgeon must be particularly sensitive to the psychological and aesthetic expectations of the patient. Even in those patients with metastases and limited life expectancy, breast reconstruction can enhance the quality of life.

Sternal osteomyelitis: treatment with rectus abdominis muscle

Sternal osteomyelitis complicates recovery in a small number of patients following median sternotomy. Techniques for operative treatment have in common the wide debridement of devitalised tissue and administration of culture-specific antibiotics. The resultant wound can be managed by delayed primary closure or transposition of well-vascularised adjacent tissue. Omentum, pectoralis major muscle and rectus abdominis muscle are suitable for transposition either alone or in combination. Our series is composed of ten patients who underwent rectus abdominis muscle transfer for the treatment of sternal osteomyelitis. The rectus abdominis obliterates dead space in the lower third of the wound, a difficult area to reach with the pectoralis major muscle. Five patients had one rectus abdominis muscle alone transposed, avoiding the aesthetic and functional deficits of pectoralis major transposition and the risks of omental transfer. Wound healing occurred in every case with a minimum of postoperative complications.

Breast reconstruction after mastectomy

The goal of breast reconstruction is to reconstruct breasts which meet the patient's expectations both psychologically and aesthetically, while adhering to the principles of sound oncological management. Breast reconstruction is usually started around 3 to 9 mos after mastectomy. The simplest method of reconstruction uses tissue available after mastectomy and a silicone implant. The recent advances with tissue expansion of the skin of the mastectomy site can permit reconstruction without the use of a flap. The latissimus dorsi flap from the back is a useful source of muscle and skin and the transverse rectus abdominus musculocutaneous flap provides tissue from the lower abdomen enabling breast reconstruction without the use of a silicone implant. Fat and skin from the buttocks may be used in a microsurgical transfer technique. Prophylactic mastectomy and immediate breast reconstruction are still controversial, but are options for the woman who is worried about the development of breast cancer. The reconstruction of the nipple and areola is only done after reconstructed breast symmetry is ascertained.

Conservative treatment for breast cancer. Complications requiring reconstructive surgery

Women who select conservative treatment for carcinoma of the breast (tumor excision followed by supervoltage radiation therapy) place a premium on breast preservation and aesthetics. When local control fails and they require a mastectomy, or when the aesthetic appearance is unacceptable, they may request breast reconstruction. The goal of this study is to evaluate a series of 10 patients who required reconstructive breast surgery after complications of conservative treatment. Patient classification: I. Breast or chest wall necrosis (3). II. Breast fibrosis and gross asymmetry (3). III. Local recurrence of breast cancer (5). IV. Positive margins after the initial lumpectomy (1). The mean age was 34 years. Radiation dosage average was 5252 rads with two patients receiving iridium-192 implant boosts. The reconstructive management was complex and usually required a major musculocutaneous flap because of the radiation effects.

Radiation-induced chronic arterial injury

Acute arterial disruption associated with infection, previous irradiation, and the postoperative state is a well-described entity. The recognition of a chronic form of radiation-induced arterial injury presenting years after therapeutic doses of radiation is less well appreciated. This paper summarizes the vital data obtained by reviewing the literature concerning 162 cases of arterial injury associated with prior radiotherapy. The vessels involved include coronary arteries, the aorta, renal arteries, the extra- and intracranial circulation, the ilio-femoral system, and the upper extremity arteries. A review of the histologic findings, the studies regarding pathogenesis, and the morphology of the lesions found in these 162 patients suggests a disease distinct from the atherosclerotic process.