Radiotherapy and wound healing

Does Time to Initiation of Adjuvant Radiotherapy Affect Reconstruction Outcomes after Endoscopic Resection of Skull Base Malignancies?

Introduction and Objective  It is unclear if the length of the time interval to initiation of adjuvant radiation therapy (RT) after endoscopic endonasal surgery affects reconstruction outcomes. In this study we present our experience with adjuvant RT after endoscopic endonasal procedures, to determine if the time to RT after surgery impacts post-RT reconstruction complication rates. Methods  A retrospective cohort study of 164 patients who underwent endoscopic endonasal surgery between 1998 and 2021 was conducted. Using Cox proportional hazard ratios (HRs), we evaluated several variables and the complications that occurred during the 1-year period after starting RT. Results  Seventy-eight (47.5%) and eighty-six patients (52.5%) received RT before and after the sixth postoperative week, respectively. The overall post-RT complication rates were 28%, most of these were severe infections ( n  = 20, 12.2%) and delayed CSF leak ( n  = 4, 2.5%). There was no significant difference in the post-RT complications between the patients who received postoperative RT before or after the sixth operative week (HR: 1.13; 95% confidence interval: 0.63-2.02; p = 0.675 ). Univariate analysis demonstrated negative impact associated with smoking history ( p = 0.015 ), the use of neoadjuvant chemotherapy ( p = 0.0001 ), and the use of photon therapy ( p = 0.012 ); and we found a positive impact with the use of multilayer reconstruction techniques (overall, p = 0.041 ; with fat, p = 0.038 ; and/or fascia graft, p = 0.035 ). After a multivariate analysis only, smoking history was an independent risk factor for post-RT complications ( p = 0.012 ). Conclusion  Delaying RT for more than 6 weeks after endoscopic endonasal surgery does not provide a significant benefit for reconstruction outcomes. However, special attention may be warranted in patients with smoking history who have received neoadjuvant chemotherapy, or in patients who will receive photon-based RT after surgery as these groups were found to have increased complication rates post-RT.

Different Biocompatibility and Radioprotective Activity of Squid Melanin Nanoparticles on Human Stromal Cells

Squid ink melanin nanoparticles (NPs) have recently been demonstrated to have a number of bioactivities; however, their biocompatibility has been poorly investigated. In this study, we aimed to evaluate the effects of this NP on stromal cells, including human fibroblasts (hFBs), human umbilical vein endothelial cells (hUVECs), and human umbilical cord-derived mesenchymal stem cells (UCMSCs), and on the development of zebrafish embryos under normal X-ray irradiation conditions. The NPs showed high biocompatibility with low cytotoxicity, no cell senescence induction, and no effect on cell migration in hFBs or cell differentiation in UCMSCs. Nonetheless, this compound prevented cell movement in UCMSCs and significantly suppressed tube formation in hUVECs at a dose of 25 μg/mL. The NPs successfully penetrated the hUVECs but not the other two stromal cell types. The expression levels of functional genes involved in angiogenesis, apoptosis, antioxidant activity, and radiation sensitivity were altered in NPs subjected to hUVECs but were not affected in hFBs and UCMSCs. Melanin NPs significantly rescued cell viability and gene expression in irradiated hFBs and UCMSCs but not in hUVECs. In vivo treatments of zebrafish embryos showed that melanin NPs were nontoxic whether alone or under X-ray irradiation. These findings suggested that nanosized squid ink melanin had biocompatibility with selective stromal cells and was safe for early development.

Optimizing Morbidity in Unplanned Soft Tissue Sarcoma Excisions: Should We Skip the Reconstructive Ladder?

INTRODUCTION

Soft tissue sarcomas (STSs) are rare and diverse primary malignant tumors that comprise approximately 1% of all malignancies. Misdiagnoses and unplanned excisions of STSs are common due to the tumor's rarity, leading to secondary tumor bed excisions (TBEs). Reconstructive outcomes for TBEs remain poorly understood, prompting this study to address the knowledge gap and inform preoperative discussions.

METHODS

This was a retrospective cohort study of patients who underwent STS excisions at a quaternary cancer center. Patients were categorized into mass excision (ME) and TBE groups. Reconstructive approaches were divided into simple (primary closure, complex repair, skin grafts, local flaps) and advanced (pedicled or free flaps). The groups were compared for postoperative outcomes, including complications, recurrence, and death.

RESULTS

When simple reconstructive techniques were used, TBEs exhibited higher rates of overall and major complications, whereas MEs had higher rates of overall and minor complications. Intergroup analysis revealed that with simple reconstruction, rates of overall and major complications were higher in TBEs than in MEs, and rates of minor complications were higher in MEs than in TBEs. Regression analyses revealed that simple reconstruction of TBEs had 90% and 180% higher odds of major complications and reoperation compared to simple reconstruction of MEs ( P < 0.05).

CONCLUSION

TBEs, despite their smaller size, exhibited a heightened susceptibility to overall and major complications, challenging the notion that simpler techniques suffice in these cases. Our findings encourage the consideration of advanced reconstructive techniques for TBEs that may seem amenable to simple reconstructive techniques.

Prophylactic Antibiotic Use in Reconstruction of Nasal Mohs Defects

OBJECTIVE

To evaluate the effect of prophylactic antibiotics on outcomes and complications following surgical reconstructions of nasal Mohs defects in the outpatient setting.

STUDY DESIGN

Retrospective cohort study.

SETTING

Single tertiary care center, July 2021 to June 2023.

METHODS

All adult patients who underwent reconstruction of nasal Mohs defects in an outpatient office setting were examined. Patient demographics, surgical details, prophylactic postprocedural antibiotic use, and postprocedural complications (infection, flap or graft necrosis, wound dehiscence) were collected. Outcomes and complications were compared between patients who received and did not receive prophylactic antibiotics using χ2, Kruskal-Wallis, and multivariable logistic regression.

RESULTS

A total of 211 patients met inclusion criteria. A majority of reconstructions utilized a local flap (70%), followed by a skin or composite graft (22%), then an interpolated flap (8%). Over half of patients (55%) were prescribed prophylactic antibiotics. Postprocedural complications were documented in 16 patients (7.6%), including infection (3.3%) and flap or graft loss or necrosis (1.4%). The rate of complications did not differ based on receipt of antibiotics. The only factors independently associated with the development of complications were history of chemoradiation and reconstruction with skin or composite grafts.

CONCLUSION

Prophylactic antibiotics after nasal Mohs reconstructions performed in the office setting were not associated with any differences in the rate of postprocedural complications, including surgical site infections.

A Multidisciplinary Update on Treatment Modalities for Metastatic Spinal Tumors with a Surgical Emphasis: A Literature Review and Evaluation of the Role of Artificial Intelligence

Spinal metastases occur in up to 40% of patients with cancer. Of these cases, 10% become symptomatic. The reported incidence of spinal metastases has increased in recent years due to innovations in imaging modalities and oncological treatments. As the incidence of spinal metastases rises, so does the demand for improved treatments and treatment algorithms, which now emphasize greater multidisciplinary collaboration and are increasingly customized per patient. Uniquely, we discuss the potential clinical applications of AI and NGS in the treatment of spinal metastases. Material and Methods: A PubMed search for articles published from 2000 to 2023 regarding spinal metastases and artificial intelligence in healthcare was completed. After screening for relevance, the key findings from each study were summarized in this update. Results: This review summarizes the evidence from studies reporting on treatment modalities for spinal metastases, including minimally invasive surgery (MIS), external beam radiation therapy (EBRT), stereotactic radiosurgery (SRS), CFR-PEEK instrumentation, radiofrequency ablation (RFA), next-generation sequencing (NGS), artificial intelligence, and predictive models.

Antioxidants Hydroxytyrosol and Thioredoxin-Mimetic Peptide CB3 Protect Irradiated Normal Tissue Cells

Reducing side effects in non-cancerous tissue is a key aim of modern radiotherapy. Here, we assessed whether the use of the antioxidants hydroxytyrosol (HT) and thioredoxin-mimetic peptide CB3 (TMP) attenuated radiation-induced normal tissue toxicity in vitro. We used primary human umbilical vein endothelial cells (HUVECs) and human epidermal keratinocytes (HaCaT) as normal tissue models. Cells were treated with HT and TMP 24 h or immediately prior to irradiation. Reactive oxygen species (ROS) were assessed via luminescent- and fluorescence-based assays, migration was investigated using digital holographic microscopy, and clonogenic survival was quantified by colony formation assays. Angiogenesis and wound healing were evaluated via time-dependent microscopy. Secreted cytokines were validated in quantitative polymerase chain reaction (qPCR) studies. Treatment with HT or TMP was well tolerated by cells. The application of either antioxidant before irradiation resulted in reduced ROS formation and a distinct decrease in cytokines compared to similarly irradiated, but otherwise untreated, controls. Antioxidant treatment also increased post-radiogenic migration and angiogenesis while accelerating wound healing. HT or TMP treatment immediately before radiotherapy increased clonogenic survival after radiotherapy, while treatment 24 h before radiotherapy enhanced baseline proliferation. Both antioxidants may decrease radiation-induced normal tissue toxicity and deserve further pre-clinical investigation.

Highly efficient prevention of radiation dermatitis using a PEGylated superoxide dismutase dissolving microneedle patch

PEGylated superoxide dismutase (PEG-SOD) is commonly used as a cytoprotective agent in radiotherapy. However, its effectiveness in preventing radiation dermatitis is limited owing to its poor skin permeability. To address this issue, a PEG-SOD-loaded dissolving microneedle (PSMN) patch was developed to effectively prevent radiation dermatitis. Initially, PSMN patches were fabricated using a template mold method with polyvinylpyrrolidone K90 as the matrix material. PSMNs exhibited a conical shape with adequate mechanical strength to penetrate the stratum corneum. More than 90 % of PEG-SOD was released from the PSMN patches within 30 min. Notably, the PSMN patches showed a significantly higher drug skin permeation than the PEG-SOD solutions, with a 500-fold increase. In silico simulations and experiments on skin pharmacokinetics confirmed that PSMN patches enhanced drug permeation and skin absorption, in contrast to PEG-SOD solutions. More importantly, PSMN patches efficiently mitigated ionizing radiation-induced skin damage, accelerated the healing process of radiation-affected skin tissues, and exhibited highly effective radioprotective activity for DNA in the skin tissue. Therefore, PSMN patches are promising topical remedy for the prevention of radiation dermatitis.

Advances in Surgery for Metastatic Disease of the Spine: An Update for Oncologists

STUDY DESIGN

Narrative review.

OBJECTIVE

Metastatic spine disease is an increasingly common clinical challenge that requires individualised multidisciplinary care from spine surgeons and oncologists. In this article, the authors describe the recent surgical advances in patients presenting with spinal metastases.

METHODS

We present an overview of the presentation, assessment, and management of spinal metastases from the perspective of the spine surgeon, highlighting advances in surgical technology and techniques, to facilitate multidisciplinary care for this complex patient group. Neither institutional review board approval nor patient consent was needed for this review.

RESULTS

Advances in radiotherapy delivery and systemic therapy (including immunotherapy and targeted therapy) have refined operative indications for decompression of neural structures and spinal stabilisation, while advances in surgical technology and technique enable these goals to be achieved with reduced morbidity. Formulating individualised management strategies that optimise outcome, while meeting patient goals and expectations, requires a comprehensive understanding of the factors important to patient management.

CONCLUSION

Spinal metastases require prompt diagnosis and expert management by a multidisciplinary team. Improvements in systemic, radiation, and surgical therapies have broadened operative indications and increased operative candidacy, and future advances are likely to continue this trend.

Risk prediction of complicated course in patients undergoing major head and neck surgery with free flap reconstruction

The British Association of Oral and Maxillofacial Surgeons (BAOMS) Quality and Outcomes in Oral and Maxillofacial Surgery (QOMS) reconstructive audit aims to provide surgical teams with risk adjusted comparative performance data. The goal is to enable surgeons to optimise surgical pathways. Risk adjustment requires that data on appropriate predictive variables are collected. This study looked at variables predicting major complications and flap failure in a single institution with the aim of determining whether the QOMS dataset adequately captures the appropriate data points. A prospective database of head and neck flap procedures and associated postoperative complications has been maintained in the maxillofacial surgery department since August 2009 up to August 2022 (n=1327). A total of 25 putative risk variables were extracted from the health records for each patient. The outcomes of interest were total flap failure and major complications. Independent predictors of flap failure were recipient site (sinonasal/anterior skull base), previous major surgery, previous major surgery and radiotherapy, and flap selection. For major complications ACE-27 comorbidity score, flap type, use of tracheostomy, elevated preoperative plasma C-reactive protein (CRP) and flap selection were independently predictive. Apart from preoperative activated innate immunity all relevant risk stratification variables identified in this study form part of the QOMS dataset. QOMS is therefore likely to adequately risk stratify patients based upon currently collected variables.

Exploring Extravasation in Cancer Patients

Extravasation, the unintended leakage of intravenously administered substances, poses significant challenges in cancer treatment, particularly during chemotherapy and radiotherapy. This comprehensive review explores the pathophysiology, incidence, risk factors, clinical presentation, diagnosis, prevention strategies, management approaches, complications, and long-term effects of extravasation in cancer patients. It also outlines future directions and research opportunities, including identifying gaps in the current knowledge and proposing areas for further investigation in extravasation prevention and management. Emerging technologies and therapies with the potential to improve extravasation prevention and management in both chemotherapy and radiotherapy are highlighted. Such innovations include advanced vein visualization technologies, smart catheters, targeted drug delivery systems, novel topical treatments, and artificial intelligence-based image analysis. By addressing these aspects, this review not only provides healthcare professionals with insights to enhance patient safety and optimize clinical practice but also underscores the importance of ongoing research and innovation in improving outcomes for cancer patients experiencing extravasation events.

Expanded polytetrafluoroethylene mesh in chest-wall reconstruction: A 27-year experience

OBJECTIVE

The study objective was to evaluate the success of expanded polytetrafluoroethylene mesh in chest-wall reconstruction.

METHODS

We retrospectively reviewed patients who underwent expanded polytetrafluoroethylene (Gore-Tex) chest-wall reconstruction. The main outcome was a mesh-related event, defined as a mesh-related reoperation (eg, mesh infection requiring debridement with/without explant, tumor recurrence with explant) or structural dehiscence/mesh loosening with/without a hernia. Demographics and surgical outcomes were reported.

RESULTS

A total of 246 reconstructions met inclusion (1994-2021). Fifty-five reconstructions (22.4%) had mesh-related events within a median of 1.08 years (interquartile range, 0.08-4.53) postoperatively; those without had a stable chest for a median of 3.9 years (interquartile range, 1.59-8.23, P < .001). Forty-one meshes (16.6%) became infected, requiring reoperation. Eighty-eight percent (36/41) were completely explanted; 8.3% (3/36) required additional mesh placement. Predictors of mesh-related events were prior chest-wall radiation (odds ratio, 9.73, CI, 3.47-30.10, P < .001), higher body mass index (odds ratio, 1.08, CI, 1.01-1.16, P = .019), and larger defects (odds ratio, 1.48, CI, 1.02-2.17, P = .042). The risk of mesh-related events with obesity was higher with prior chest-wall radiation.

CONCLUSIONS

Most patients (78%) with an expanded polytetrafluoroethylene mesh had a stable reconstruction after a median of 4 years. Obesity, larger defects, and prior chest-wall radiation were associated with a higher risk of a mesh-related event mostly due to mesh infections. Seventeen percent of reconstructions had reoperation for mesh infection; 88% were completely explanted. Only 8% required replacement mesh, suggesting that experienced surgeons can safely manage them without replacement. Future studies should compare various meshes for high-risk patients to help guide the optimal mesh selection.

Wound healing after surgery for soft tissue sarcomas, and the effect of primary plastic reconstruction - A retrospective cohort study

BACKGROUND

Immediate vascularized reconstruction after sarcoma resection may reduce wound complications common in primary closure, but previous research is conflicting. The present study analysed wound complication rates and compared wound-related outcomes among immediate vascularized reconstruction with primary closure.

MATERIALS AND METHODS

Patient- and tumour characteristics were collected from patients who received primary surgery with curative intent between 2010 and 2020 at the Stockholm Sarcoma Centre. Clinical outcomes were sought in free text in medical records. The primary outcome measures were early (<30 days) wound complications. Secondary outcome measures included late (30-day to 2-year) wound complications, time to wound healing, 30-day postoperative complications according to Clavien Dindo, and health care consumption.

RESULTS

A total of 482 patients were included, of whom 69 had immediate vascularized reconstruction. Comparison of early complications for reconstructive surgery with primary closure revealed a significantly higher complication rate for the first group (59.4 % vs 29.8 %, p < 0.01). The groups had comparable health care consumption the first and second postoperative years. In-depth analyses identified BMI >25, smoking and high-grade lesions as factors with adverse effects on wound healing.

CONCLUSIONS

Sarcoma patients experience high rates of wound complications and consume considerable health care resources. Reconstructed individuals were more susceptible to such complications than were subjects with primary closure.

Management of irradiated post-mastectomy wound dehiscence with synthetic electrospun fiber matrix: a case report

Breast-conserving surgery (BCS) is a well-established standard treatment option alternative to mastectomy for patients with early breast cancer that consists of a lumpectomy followed by adjuvant radiotherapy. However, irradiated tissues are at an increased risk of wound healing complications when post-treatment surgical management is required. The management of an irradiated wound dehiscence can be challenging, as it often requires a multimodal treatment approach that includes more invasive interventions when compared to a traditional surgical wound dehiscence. We present a 64 year old female patient with a remote history of right BCS with radiation therapy for early breast cancer 12 years ago, who recently required a simple mastectomy due to ipsilateral breast cancer recurrence. The post-operative course was complicated by dehiscence of the mastectomy wound. After standard wound care therapies failed, her surgical wound successfully healed after treatment with a synthetic electrospun fiber matrix application. Patients with additional comorbidities often do not qualify for invasive reconstructive options; therefore, effective local management options are warranted. This is the first reported case documenting synthetic electrospun fiber matrix efficacy and safety in healing a dehisced surgical wound within a previously irradiated fibrotic area, without the need for further invasive surgical intervention. Larger scale research, such as a prospective cohort study or randomized control trial, is needed to investigate its novel use in irradiated wounds.

Outcomes of Dermal Regeneration Templates in Irradiated and Nonirradiated Scalp Defects

OBJECTIVES

Dermal regeneration templates (DRTs) are frequently used to treat scalp defects. The aim was to compare the time course of healing for DRTs in scalp defects with and without preoperative radiation.

METHODS

The authors conducted a retrospective cohort study of DRT-based scalp reconstruction at 2 academic medical centers between 2013 and 2022. Information was collected on demographic variables, comorbidities, medication use, history of radiation, and DRT outcomes. The primary outcome was DRT loss, defined as exposed calvarium or DRT detachment based on postoperative follow-up documentation. Kaplan-Meier survival analysis and multivariable Cox proportional-hazard regressions were used to compare DRT loss in irradiated and nonirradiated defects. Multivariable logistic regressions were used to compare 30-day postoperative complications (infection, hematoma, or seroma) in irradiated and nonirradiated defects.

RESULTS

In total, 158 cases were included. Twenty-eight (18%) patients had a preoperative history of radiation to the scalp. The mean follow-up time after DRT placement was 2.6 months (SD: 4.5 mo). The estimated probability of DRT survival at 2 months was 91% (95% CI: 83%-100%) in nonirradiated patients and 65% (95% CI: 48%-88%) in irradiated patients. In the 55 patients with a bony wound base, preoperative head radiation was associated with a higher likelihood of DRT loss (hazard ratio: 11). Half the irradiated defects experienced uncomplicated total wound closure using Integra Wound Matrix Dressing with or without second-stage reconstruction.

CONCLUSIONS

Dermal regeneration template can offer durable coverage in nonirradiated scalp defects. Although DRT loss is more likely in irradiated scalp defects, successful DRT-based reconstruction is possible in select cases.

Systematic Review of Prophylactic Plastic Surgery Closure to Prevent Postoperative Wound Complications Following Spine Surgery

Spinal surgeries are increasingly performed in the United States, but complication rates can be unacceptably high at up to 26%. Consequently, plastic surgeons (PS) are sometimes recruited by spine surgeons (SS) for intraoperative assistance with soft tissue closures. An electronic multidatabase literature search was systematically conducted to determine whether spinal wound closure performed by PS minimizes postoperative wound healing complications when compared to closure by SS (neurosurgical or orthopedic), with the hypothesis that closures by PS minimizes incidence of complications. All published studies involving patients who underwent posterior spinal surgery with closure by PS or SS at index spine surgery were identified. Filtering by exclusion criteria identified 10 studies, 4 of which were comparative in nature and included both closures by PS and SS. Of these 4, none reported significant differences in postoperative outcomes between the groups. Across all studies, PS were involved in cases with higher baseline risk for wound complications and greater comorbidity burden. Closures by PS were significantly more likely to have had prior chemotherapy in 2 of the 4 (50%) studies (P = 0.014, P < 0.001) and radiation in 3 of the 4 (75%) studies (P < 0.001, P < 0.01, P < 0.001). In conclusion, closures by PS are frequently performed in higher risk cases, and use of PS in these closures may normalize the risk of wound complications to that of the normal risk cohort, though the overall level of evidence of the published literature is low.

Predicted factors of surgical site infection in glioblastoma patients: A meta-analysis

Surgical site infection (SSI) is one of the common postoperative complications after craniotomy for glioblastoma patients. Previous studies have investigated the risk factors for SSI in patients with glioblastoma. Whereas big differences in research results exist, and the correlation coefficients of different research results are quite different. A meta-analysis was conducted to examine the risk factors related to surgical site infection in patients with glioblastoma. We searched English databases to collect case-control studies or cohort studies published before 15 October 2023 including PubMed, Web of Science, Embase. The risk of bias of the included studies was assessed via Newcastle-Ottawa Scale. The analysis was performed using RevMan 5.4.1 tool. A total of 4 articles (n = 2222) were selected in this meta-analysis. The following risk factors were presented to be correlated with SSI in glioblastoma: irradiation (OR = 1.88, 95% CI [0.46, 7.60]), more than 3 surgeries (OR = 2.99, 95% CI [1.47, 6.08]). Occurrence of SSI is influenced by a variety of factors. Thus, we should pay close attention to high-risk subjects and take crucial targeted interventions to lower the SSI risk following craniotomy. Owing to the limited quality and quantity of the included studies, more rigorous studies with adequate sample sizes are needed to verify the conclusion.

Post-prostatectomy anastomotic stenosis: systematic review and meta-analysis of endoscopic treatment

OBJECTIVE

To perform a systematic review and meta-analysis of endoscopic procedures for treating vesico-urethral anastomotic stenosis (VUAS) after prostatectomy, as initial VUAS management remains unclear.

METHODS

A search of the MEDLINE database, the Cochrane database, and clinicaltrials.gov was performed (last search February 2023) using the following query: (['bladder neck' OR 'vesicourethral anastomotic' OR 'anastomotic'] AND ['stricture' OR 'stenosis' OR 'contracture'] AND 'prostatectomy'). The primary outcome was the success rate of VUAS treatment, defined by the proportion (%) of patients without VUAS recurrence at the end of follow-up.

RESULTS

The literature search identified 420 studies. After the screening, 78 reports were assessed for eligibility, and 40 studies were included in the review. The pooled characteristics of the 40 studies provided a total of 1452 patients, with a median (interquartile range [IQR]) follow-up of 23.7 (13-32) months and age of 66 (64-68) years. The overall success rate (95% confidence interval [CI]) of all endoscopic procedures for VUAS treatment was 72.8% (64.4%-79.9%). Meta-regression models showed a negative influence of radiotherapy on the overall success rate (P = 0.012). After trim-and-fill (addition of 10 studies), the corrected overall success rate (95% CI) was 62.9% (53.6%-71.4%).

CONCLUSION

This first meta-analysis of endoscopic treatment success rate after VUAS reported an overall success rate of 72.8%, lowered to 62.9% after correcting for significant publication bias. This study also highlighted the need for a more thorough reporting of post-prostatectomy VUAS data to understand the treatment pathway and provide higher-quality evidence-based care.

Malignant wound aetiology, diagnosis and management: a case series and literature review

OBJECTIVE

Malignant wounds develop when neoplastic cells invade the skin either locally or by lymphatic and haematogenous spread. They can present as hard-to-heal wounds and underlying causes include: primary skin cancer; metastasis of extracutaneous primary malignancy; malignant transformation of a hard-to-heal wound; iatrogenic injury; and cutaneous forms of cancers of non-skin origin. High clinical suspicion for a malignant wound should be confirmed with skin biopsy. The aim of this case series is to highlight a combination of both clinically clear cutaneous malignancies and not-so-obvious wounds caused by malignancy.

METHOD

This case series examines patients with malignant wounds of varying aetiology and appearance. For each case, we explain the pathophysiology, atypical features, diagnostic approach and treatment. We also discuss types of wound biopsy and general wound management principles.

RESULTS

Among the 11 cases analysed using descriptive statistics, median wound duration before presentation at our clinic was one year, while median age at presentation was 65 years. Our case series included the following diagnoses: cutaneous metastasis of invasive ductal carcinoma of the breast (n=2); cutaneous metastasis of colorectal adenocarcinoma (n=1); Marjolin's ulcer (n=1), basal cell carcinoma (BCC) (n=2), primary cutaneous squamous cell carcinoma (SCC) (n=1), metastatic malignant melanoma (n=1), cutaneous T-cell lymphoma (n=1), cutaneous angiosarcoma (n=1), Kaposi sarcoma (n=1) and recurrent tonsillar SCC with osteoradionecrosis (n=1); one case had both BCC and SCC.

CONCLUSION

Punch and excisional biopsies were the most frequently used diagnostic techniques. Local wound therapy addressed bleeding, malodour, exudate, pain and infection. However, wound healing is usually achieved once the underlying malignancy is treated. In advanced or metastatic disease, palliative wound care aims to prevent exacerbation of existing wounds and focuses on patient comfort.

Salvage Strategies for Local Recurrences of Squamous Cell Carcinoma of the Nasal Vestibule: A Single-Center Experience of 22 Years

Squamous cell carcinomas of the nasal vestibule are an extremely rare neoplastic disease. Although brachytherapy is gaining popularity for primary treatment, surgery remains the best option in case of recurrences. The aim of this paper is to outline our treatment experience of local recurrence of SCCNVs over the past 22 years. We retrospectively reviewed the clinical data of the patients who underwent surgical treatment for local recurrence of SCCNV: data regarding age, sex, primary tumor treatment, recurrence location and time of appearance, surgical resection, type of reconstruction, postoperative complication, surgical revision, and re-recurrence rate were analyzed. Twenty patients were included in the study. The median period for recurrence appearance was 17 months, and the prevalent location of recurrence was the nasal alae. Prevalent reconstructive procedures were the nasolabial flap and paramedian forehead flap. No postoperative complications were observed, and one case of re-recurrence was detected at 12-months of follow-up. Based on our experience, salvage surgical procedures for SCCNV recurrences must be individualized and carefully planned, taking into account the peculiar pattern of tumor spread and the presence of scar and heavily radiotherapy damaged tissue from previous treatment; delayed reconstruction should be considered for all the cases with skeletal involvement.

Comparable survival in rats with intracranial glioblastoma irradiated with single-fraction conventional radiotherapy or FLASH radiotherapy

Background

Radiotherapy increases survival in patients with glioblastoma. However, the prescribed dose is limited by unwanted side effects on normal tissue. Previous experimental studies have shown that FLASH radiotherapy (FLASH-RT) can reduce these side effects. Still, it is important to establish an equal anti-tumor efficacy comparing FLASH-RT to conventional radiotherapy (CONV-RT).

Methods

Fully immunocompetent Fischer 344 rats with the GFP-positive NS1 intracranial glioblastoma model were irradiated with CONV-RT or FLASH-RT in one fraction of 20 Gy, 25 Gy or 30 Gy. Animals were monitored for survival and acute dermal side effects. The brains were harvested upon euthanasia and tumors were examined post mortem.

Results

Survival was significantly increased in animals irradiated with CONV-RT and FLASH-RT at 20 Gy and 25 Gy compared to control animals. The longest survival was reached in animals irradiated with FLASH-RT and CONV-RT at 25 Gy. Irradiation at 30 Gy did not lead to increased survival, despite smaller tumors. Tumor size correlated inversely with irradiation dose, both in animals treated with CONV-RT and FLASH-RT. Acute dermal side effects were mild, but only a small proportion of the animals were alive for evaluation of those side effects.

Conclusion

The dose response was similar for CONV-RT and FLASH-RT in the present model. Tumor size upon the time of euthanasia correlated inversely with the irradiation dose.

Impact of external beam radiation on total shoulder arthroplasty outcomes: a propensity-matched cohort study

BACKGROUND

External beam radiation therapy has a number of deleterious effects on the body, and a number of post-operative complications have been reported for several surgeries including total knee arthroplasty. However, few studies have investigated the impact of external beam radiation therapy for total shoulder arthroplasty (TSA). Our study aimed to assess the systemic and joint complications associated with TSA in patients with prior radiation exposures, as well as evaluate the surgical outcomes of radiation patients compared to non-radiation TSA patients.

MATERIALS AND METHODS

A retrospective cohort analysis was conducted using the TriNetX Analytics Network. A 1:1 propensity score matching function was utilized to create two cohorts with matched baseline characteristics within the TriNetX network. Comparisons of the primary and secondary outcomes between the two cohorts were made using odds ratios. A p value of < 0.05 was determined to be significant.

RESULTS

A total of 75,510 patients that received TSA were identified with 1505 having a history of radiation therapy (RT) and 73,605 with no radiation therapy (non-RT). After propensity matching, both groups contained 1484 patients. RT patients were at higher risk for developing prosthetic joint infection, acute renal failure, altered mental state, cerebrovascular event, DVT, PE, pneumonia, respiratory failure, and UTI compared to non-RT patients at different time points (p < 0.5).

CONCLUSION

Patients with prior history of external beam radiation undergoing TSA had a higher risk of systemic complications and prosthetic joint infection compared to patients without a prior history. These complications suggest a more complicated post-operative management course for these patients.

Technical consideration for breast reconstruction in patients requiring neoadjuvant or adjuvant radiotherapy: a narrative review

Background and Objective

Surgical considerations for breast reconstruction (BR) in patients requiring neoadjuvant radiotherapy (NART) or adjuvant radiotherapy (ART) cannot be understated. The management of irradiated tissue leads surgeons to face several challenges. Therefore, it is essential to comprehensively understand the proper patient selection and preoperative planning to ensure the best outcomes and minimize the risk of complications. This narrative review aims to provide an update and summary of the most important technical considerations every breast surgeon must contemplate reconstructing the irradiated breast.

Methods

The search strategy was performed on January 10th, 2023. The PubMed, Embase, Cochrane Library, and Web of Science databases were queried to capture all publications regarding surgical considerations in BR of patients undergoing NART and ART.

Key Content and Findings

This review shows that the effects of radiotherapy (RT) on BR are still being studied. RT represents an essential factor for overall patient survival, and its use is increasing. However, the range of RT treatments across different cancer centers complicates the creation of a single treatment protocol. BR improves women's quality of life, so finding the proper integration of BR and RT is essential. When deciding on the reconstructive method, there are several factors to consider, such as the patient's body characteristics, tumor stage, RT protocol, and chemotherapy. To achieve the best surgical results and the most satisfied patient, using less aggressive and safer RT methods in the treatment sequence is recommended.

Conclusions

The timing of the radiation will influence the selection of the best reconstructive methods to be employed in the breast cancer patient. However, there is clear evidence of preference for immediate autologous-based BR in cases due to the low rate of complications in the long term. But patient individualization is the key. Therefore, the benefits and risks of immediate versus delayed and autologous versus implant-based reconstruction must be weighed in every single case.

Modeling of metamaterial based incision patterns for generating high expansions in skin grafts

BACKGROUND

Split-thickness skin grafting is a widely used treatment for burn patients. It requires removing a small portion of healthy skin, making parallel incisions on it, stretching it, and surgically implanting it into the burn site. Although skin graft mesher companies claim to significantly expand the size of the skin graft, in reality, the amount of expansion achieved is much smaller.

METHODS

This study aimed to improve the expansion potential of skin grafts by designing new incision patterns with auxetic properties, using a skin simulant material and additive manufacturing. The mechanical properties and digital image correlation was used to analyze the strain, effective Poisson's ratio, local strains, void area, and meshing ratio of the auxetic skin graft simulants.

FINDINGS

The results showed that the Y-shaped skin graft simulant had the highest effective negative Poisson's ratio, largest areal expansions, lowest maximum induced stresses and strains, and uniform strain distribution properties, making it the best choice for generating high expansions in skin grafts.

INTREPRETATION

The study found that the expansions were highly strain sensitive, with higher auxeticity observed at lower strains. The novel findings with auxetic skin graft simulants are expected to provide valuable insights for developing skin grafts with higher expansion potential in the future.

Intraoperative radiotherapy after resection of brain metastases located in the posterior fossa. Analysis of postoperative morbidity and mortality in a single center cohort

INTRODUCTION

In order to improve surgical outcome and accelerate the adjuvant oncologic therapy, intraoperative Radiotherapy (IORT) has become a treatment option in oncologic surgery for various diseases including glioma and brain metastasis (BM). BMs are often located in the cranial posterior fossa (PF) requiring specific surgical considerations due to its complex anatomy. Up until now, data on IORT for BMs is limited and detailed description in the use of IORT for lesions in the PF is lacking. Our aim is to provide more insight into this emerging treatment strategy.

METHODS

We performed a retrospective analysis of patients receiving surgery for BMs and undergoing IORT at our institution. Each patient was discussed at the interdisciplinary tumor board decision before the intervention. Patient characteristics, functional status (Karnofsky Performance Score, KPS) before and after surgery, disease (recursive partitioning analysis, lesion size) and operative parameters were analyzed. Adverse events (AE) were recorded up until 30 days after the intervention and rated according to the Clavien Dindo Rating scale.

RESULTS

Nine patients (5 female) were included. None underwent prior radiotherapy (RT). Mean age was 66 ± 11 years. Preoperative median KPS was 80%. Mean BM diameter was 3.2 ± 0.9 cm. There was no statistically significant deterioration of the functional status after the intervention. Two patients experienced AEs with both of them needing revision surgery.

CONCLUSION

Surgery for BMs with IORT in the PF seems safe and feasible. Further studies are needed to evaluate the influence of IORT on long-term outcome after BM surgery.

Reconstruction using a free jejunal patch flap in salvage head and neck surgery after radiotherapy

BACKGROUND

Chemoradiotherapy is a standard treatment for functional preservation in patients with advanced head and neck carcinoma. However, chemoradiotherapy increases the risk of postoperative complications.

AIMS/OBJECTIVES

We report the usefulness of reconstruction using a free jejunal patch flap in treating recurrence or residual head and neck carcinoma after radiotherapy. Furthermore, we investigated the factors for the occurrence of postoperative complications in patients who underwent salvage surgery using a free flap transfer.

MATERIAL AND METHODS

This study included 41 patients with head and neck carcinoma who underwent salvage surgery using a free flap transfer, including 11 patients who underwent reconstruction using a free jejunal patch flap. Prognostic analysis was performed for the development of complications.

RESULTS

Ten jejunal patch flaps survived without microvascular problems. One patient underwent revision reconstructive surgery because of flap failure. However, no patient had a pharyngocutaneous fistula. Oral intake could be resumed in all patients at a median 14 days postoperatively. Multivariate logistic regression analysis indicated that the use of cutaneous flaps was significantly associated with the development of complications.

CONCLUSIONS AND SIGNIFICANCE

Free jejunal patch flaps can be considered useful for head and neck reconstruction after radiotherapy for early intake resumption and complication prevention.

Radiotherapy-induced Pathology of the Ear

Acute radiotherapy (RT)-induced external ear soft tissue changes start with erythema and dry desquamation and may progress to moist desquamation and epidermal ulceration. Chronic RT-induced changes include epithelial atrophy and subcutaneous fibrosis. Although RT-induced radiation dermatitis has been well studied, interventions for soft tissue disease involving the external auditory canal (EAC) warrant investigation. Medical management includes topical steroid treatment for EAC radiation dermatitis and topical antibiotic therapy for suppurative otitis externa. Hyperbaric oxygen and pentoxifylline-vitamin E therapy have shown promise for other applications, but their clinical effect on soft tissue EAC disease is currently undefined.

Impact of surgical site infection on unplanned hospital readmissions, initiation of adjuvant treatment following surgery, and disease-free survival on patients with upper aerodigestive tract squamous cell carcinoma

INTRODUCTION

Unplanned hospital readmission (UHR) is an important indicator of the quality of the healthcare system in place. It has various implications for the patients and the healthcare system at large. In this article, we have attempted to understand the various factors influencing UHR and the start of adjuvant treatment following cancer surgery.

PATIENTS & METHODS

In this study adult patients above 18 years of age with upper aerodigestive tract squamous cell carcinoma who underwent surgery at our center between July 2019 to December 2019 were included in the study. Various factors influencing UHR and delay in receiving adjuvant treatment were analyzed.

RESULTS

A total of 245 patients satisfied the inclusion criteria. Surgical site infection (SSI) was the factor that had the maximum influence on the UHR (p < 0.002, OR: 5.6, 95% CI: [1.911-16.4]) and delaying the start of adjuvant treatment (p = 0.008, OR: 3.786, 95% CI: [1.421-10.086]) on multivariate analysis. Surgery lasting for >4 h and patients who had received prior treatment tended to develop SSI postoperatively. The presence of SSI also seemed to have had a negative influence on disease-free survival (DFS) as well.

CONCLUSIONS

SSI is an important postoperative complication having major implications in terms of increased UHR and delays in starting adjuvant treatment which in turn is reflected as a poorer DFS among patients who develop SSI postoperatively.

Reconstruction of the thoracic radiation-induced ulcer with the pedicled internal mammary artery fasciocutaneous flap: Review of the literature and a case report

Objective

The pedicled Internal Mammary Artery Perforator (IMAP) flap is not yet a well-known technique. However, it seems practical for use in thoracic radiation-induced ulcer, especially in recurrence after the failure of convenient reconstructive techniques. This technique is applied to patients with breast hypertrophy. In this article, we present our experience with the indications, surgery details, and advantages of this technique.

Materials and methods

A 63-year-old woman had a right mastectomy 11 years ago. The patient's ulcers recurred after radiotherapy and were treated with a regional and local flap. The opposite breast was ptotic, and the patient was not eligible for microsurgery. The patient underwent reconstruction using the contralateral pedicle IMAP flap.

Results

The IMAP flap was designed with a size of 14 × 22 cm, including the inferior half of the breast and the areolar. The flap could completely cover the chest wall defect, and the contralateral breast was reduced to match. The final results were evaluated after two years of follow-up.

Conclusion

The contralateral breast pedicle IMAP flap is a reliable, versatile, and easy-to-perform technique. This flap is a useful technique for chest wall coverage after radiation-induced ulcers, particularly in elderly patients. The major limitation of this technique is the higher risk of second primary breast cancer as the transfer flap of the contralateral breast.

Relationship between Characteristics of the Wound and Healing Duration among Patients Treated during Home-Visits

In humans, wound healing is a vital but complex process governed by chronological yet overlapping stages, such as hemostasis, inflammation, proliferation, and remodeling. Because of the complexities of wound healing, it is prone to pausing at multiple levels. Wound healing can potentially be influenced by factors that affect cellular functions and physiologic responses. This research aimed to investigate the relationship between wound healing duration and demographic properties and characteristics of wounds among patients treated during home visits in Erbil, Iraq. To this end, a longitudinal correlational quantitative design was employed in the current study. A random sample of about 101 chronic wounds was found in 77 patients of both genders selected from all ages during home visits for around four years in Erbil. The professional nurse applied nursing management according to the nursing plan during home visits until the wound recovered. The total duration of wound healing was calculated and documented for each wound. Seventy-seven patients participated in the current study, with their mean±SD age being 58.02±16.29 years, ranging from 19 to 89. The median age was 60. More than half of the sample (54.5%) were ≥60 years, and 62.3% were males. Less than one-third of patients (31.2%) were of normal weight, 93.5% were married, 37.7% were housewives, and 35.1% were illiterate. Regarding the duration of wound healing, in more than one quarter (26.7%), it was delayed (took more than three months for healing). The longest mean healing time (20.06 weeks) was for pressure ulcers (P<0.001), which was significantly higher than all the mean healing times of other types of wounds. The study showed a significant (P=0.011) association between the mean healing time and the anatomic location of wounds, revealing that the highest mean healing time was for wounds located in the trochanteric area (21.10 weeks) or the sacrum (18.25 weeks). A significant association (P=0.002) was also detected between the mean healing time and the edge of the wound, with the highest mean healing time (18.64 weeks) found in wounds with undermined edges. Furthermore, the mean healing time was significantly higher among those with infected wounds (14.59 weeks) than the mean (6.50 weeks) among those with no infection (P<0.001). In conclusion, wound healing progression is an important but complicated process that healthcare providers use for patients during home visits. It is divided into phases, including hemostasis, inflammation, proliferation, and remodeling. The current study revealed that the healing time was affected by the anatomical site of the wound and took longer in pressure ulcers, undermined edge wounds, and infected wounds.

Clinical Outcomes of Total En Bloc Spondylectomy for Previously Irradiated Spinal Metastases: A Retrospective Propensity Score-Matched Comparative Study

This study aimed to investigate the clinical outcomes of total en bloc spondylectomy (TES) for spinal metastases previously treated with radiotherapy (RT). This study enrolled 142 patients who were divided into two groups: those with and those without an RT history. Forty-two patients were selected from each group through propensity score matching, and postoperative complications, local recurrence, and overall survival rates were compared. The incidence of postoperative complications was significantly higher in the group with an RT history than in the group without an RT history (57.1% vs. 35.7%, respectively). The group with an RT history had a higher local recurrence rate than the group without an RT history (1-year rate: 17.5% vs. 0%; 2-year rate: 20.8% vs. 2.9%; 5-year rate: 24.4% vs. 6.9%). The overall postoperative survival tended to be lower in the group with an RT history; however, there was no significant difference between the two groups (2-year survival: 64.3% vs. 66.7%; 5-year survival: 47.3% vs. 57.1%). When planning a TES for irradiated spinal metastases, the risk of postoperative complications and local recurrence should be fully considered.

Surgical Site Infections in Glioblastoma Patients-A Retrospective Analysis

Surgical site infections (SSIs) after craniotomy lead to additional morbidity and mortality for patients, which are related to higher costs for the healthcare system. Furthermore, SSIs are associated with a longer hospital stay for the patient, which is particularly detrimental in glioblastoma patients due to their limited life expectancy. Risk factors for SSIs have already been described for craniotomies in general. However, there is limited data available for glioblastoma patients. As postoperative radiation influences wound healing, very early radiation is suspected to be a risk factor for SSI. Nevertheless, there are no data on the optimal timing of radiotherapy. To define risk factors for these patients, we analyzed our collective. We performed a retrospective analysis of all operations with histological evidence of a glioblastoma between 2012 and 2021. Open biopsy and tumor removal (gross total resection, subtotal resection) were included. Stereotactic biopsies were excluded. Demographic data such as age and gender, as well as duration of surgery, diameter of the trepanation, postoperative radiation with interval, postoperative chemotherapy, highest blood glucose level, previous surgery, ASA score, foreign material introduced, subgaleal suction drainage, ventricle opening and length of hospital stay, were recorded. The need for surgical revision due to infection was registered as an SSI. A total of 177 patients were included, of which 14 patients (7.9%) suffered an SSI. These occurred after a median of 45 days. The group with SSIs tended to include more men (57.1%, p = 0.163) and more pre-operated patients (50%, p = 0.125). In addition, foreign material and subgaleal suction drains had been implanted more frequently and the ventricles had been opened more frequently, without reaching statistical significance. Surprisingly, significantly more patients without SSIs had been irradiated (80.3%, p = 0.03). The results enable a better risk assessment of SSIs in glioblastoma patients. Patients with previous surgery, introduced foreign material, subgaleal suction drain and opening of the ventricle may have a slightly higher for SSIs. However, because none of these factors were significant, we should not call them risk factors. A less radical approach to surgery potentially involving these factors is not justified. The postulated negative role of irradiation was not confirmed, hence a rapid chemoradiation should be induced to achieve the best possible oncologic outcome.

Management of Radiation-induced Tissue Injuries: A Review of Current Treatment Strategies

Although radiation therapy remains an integral component in cancer treatment, the sequela of tissue damage can result in long-term morbidity and mortality for patients. This article aimed to perform a comprehensive review of the current literature for both nonsurgical and surgical management strategies for radiation-induced injuries.

Methods

A literature search was performed on PubMed to review the current described management and treatment options for radiation-induced injuries. Patient demographics, medical diagnoses, complications, strategies of management care, and outcomes were reviewed.

Results

The most commonly described management options and reconstructive techniques of radiation wounds were analyzed and reported.

Conclusions

Consideration of current techniques and outcomes in the management of radiation-induced wounds demonstrates that impaired wound healing remains a major problem. This literature review provides a detailed overview of the most frequently used therapies with recommendations for surgeons.

Reducing Risks for Poor Surgical Wound Healing

This review summarizes common risk factors for poor surgical healing on the face and neck and a generalized approach to treating a delayed healing wound. During the preoperative evaluation patients should be screened for prior irradiation, cigarette or e-cigarette use, chronic steroid use, alcoholism, diabetes, malnutrition, and other chronic medical conditions and medications. Despite the surgeon's best efforts to prevent poor surgical healing, some wounds may display signs of persistent inflammation. The facial plastic surgeon should be astute in recognizing delayed healing and identifying intrinsic and extrinsic risk factors so that timely intervention can be performed.

Additive risk of surgical site infection from more than one risk factor following craniotomy for tumor

PURPOSE

This study seeks to expound upon risk factor etiologies for surgical site infection (SSI) and investigate their combinatorial effects on infection rate following craniotomy for neuro-oncologic pathology.

METHODS

Patients who underwent neuro-oncologic craniotomy between 2006 and 2020 were included. Medical records were reviewed to identify the occurrence of wound infection at ≤ 3 months postoperatively. Potential risk factors for infection included tumor pathology, location, anesthesia type, indication, ventricular entry, foreign body, brachytherapy, lumbar drain, prior operation, prior cranial radiation, prior infection, bevacizumab, and medical comorbidities (hypertension, obesity, diabetes, hyperlipidemia, other cancer, cirrhosis). Logistic regression was implemented to determine risk factors for SSI. Chi-square tests were used to assess whether the number of risk factors (e.g., 0, ≥ 1, ≥2, ≥ 3, ≥4) increases the risk of SSI compared to patients with fewer risk factors. The relative increase with each additional risk factor was also evaluated.

RESULTS

A total of 1209 patients were included. SSI occurred in 42 patients (3.5%) by 90 days after surgery. Significant risk factors on multivariate logistic regression were bevacizumab (OR 40.84; p < 0.001), cirrhosis (OR 14.20, p = 0.03), foreign body placement (OR 4.06; P < 0.0001), prior radiation (OR 2.20; p = 0.03), and prior operation (OR 1.92; p = 0.04). Infection rates in the combinatorial analysis were as follows: ≥1 risk factor = 5.9% (OR 2.74; p = 0.001), ≥ 2 = 6.7% (OR 2.28; p = 0.01), ≥ 3 = 19.0% (OR 6.5; p < 0.0001), ≥ 4 = 100% (OR 30.2; p < 0.0001).

CONCLUSIONS

Risk factors in aggregate incrementally increase the risk of postoperative SSI after craniotomy for tumor.

Optimal Timing of Delayed Microvascular Breast Reconstruction after Radiation Therapy

BACKGROUND

 The purpose of this study was to determine the optimal timing of delayed microvascular breast reconstruction after completion of postmastectomy radiation therapy (PMRT). The authors evaluated whether the timing of reconstruction after PMRT completion affects the development of major postoperative complications. We hypothesize that delayed microvascular breast reconstruction can be safely performed within 12 months of PMRT completion.

METHODS

 A retrospective chart review of microvascular, autologous breast reconstructions at Brigham and Women's Hospital from 2007 to 2019 was performed. Logistic regression analysis and marginal estimation methods were used to estimate the probability of any major complication (flap compromise requiring operative intervention, hematoma formation requiring evacuation, infection requiring readmission, and flap necrosis requiring operative debridement) occurring in 2-month intervals after PMRT. Patients were classified as having undergone reconstruction 0 to 12 months after PMRT (group 1), 12 to 18 months after PMRT (group 2), or 18 to 50 months after PMRT (group 3).

RESULTS

 A total of 303 patients were identified. All patients received postmastectomy radiation (n = 143 group 1, n = 57 group 2, n = 103 group 3). Mean follow-up time was 71.4 ± 38 months. Patients in group 1 were significantly younger and more likely to have undergone neoadjuvant chemotherapy (p < 0.05). Major complications occurred in 10% of patients. There was no significant difference in the development of major complications between the three groups (p = 0.57). Although not statistically significant, the probability of any major complication peaked 2 to 6 months after PMRT completion.

CONCLUSION

 There was no significant difference in major complications among patients who underwent delayed, microvascular breast reconstruction within versus beyond 1 year of PMRT completion. These findings suggest that delayed microvascular breast reconstruction can be safely performed beginning 6 months after PMRT completion.

Relationship between characteristics of glioma treatment and surgical site infections

PURPOSE

Surgical site infections (SSIs) after neurosurgery are common in daily practice. Although numerous reports have described SSIs in neurosurgery, reports specific to gliomas are limited. This study aimed to investigate the relationship between SSIs and glioma treatment characteristics, such as reoperations, radiation therapy, and chemotherapy.

METHODS

We examined 1012 consecutive patients who underwent craniotomy for glioma between November 2013 and March 2022. SSIs were defined as infections requiring reoperation during the observation period, regardless of their location. We retrospectively analyzed SSIs and patient factors.

RESULTS

During the observation period, SSIs occurred in 3.1% (31/1012). In the univariate analysis, three or more surgeries (P = 0.007) and radiation therapy (P = 0.03) were associated with SSIs, whereas intraoperative magnetic resonance imaging (MRI) was not significantly associated (P = 0.35). Three or more surgeries and radiation therapy were significantly correlated with each other (P < .0001); therefore, they were analyzed separately in the multivariate analysis. Three or more surgeries were an independent factor triggering SSIs (P = 0.02); in contrast, radiation therapy was not an independent factor for SSIs (P = 0.07). Several SSIs localized in the skin occurred more than 1 year after surgery.

CONCLUSIONS

Undergoing three or more surgeries for glioma is an independent risk factor for SSIs. Glioma SSIs can occur long after surgery. These results are considered characteristic of gliomas. We recommend careful long-term observation of patients at a high risk of SSIs.

Effect of the hospital-community-family (HCF) nutritional management on patients with esophageal and head and neck cancers undergoing radiotherapy: a randomized control trial

Background

Malnutrition is particularly common in patients undergoing radiotherapy for head and neck cancers (HNC) and esophageal cancers (EC). Proper nutritional management plays an important role in improving the nutritional status and reducing complications in patients undergoing radiotherapy for malignancy. With most nutrition studies limited to the nutritional management of patients during hospitalization or after discharge, there is a lack of research evidence on the nutritional management of patients in combination with out-of-hospital. The aim of this study was to evaluate the effect of the hospital-community-family (HCF) nutritional management model on nutritional status and radiotherapy complications in EC and HNC radiotherapy patients.

Methods

Between October 2019 and October 2021, a total of 116 EC and HNC radiotherapy patients were randomized into control group (conventional nutritional support) and experimental group (HCF-model nutritional management), and assessed weekly for 3 months. The primary endpoint was the patient's Nutrition Risk Screening 2002 (NRS2002) score, Scored Patient-Generated Subjective Global Assessment (PG-SGA), weight change, and Eastern Cooperative Oncology Group (ECOG) score from baseline level to 3 months after the end of treatment. The secondary endpoints were the incidence of albumin, hemoglobin, hematological parameters, and radiotherapy complications.

Results

A total of 95 patients (47 in the control group and 48 in the experimental group) completed the study. At 3 months after treatment, NRS2002 (P=0.028) and PG-SGA (P=0.022) decreased, and albumin was higher (P=0.001) than at the beginning of treatment in HCF group. Weight decreased (P<0.001) and PG-SGA was higher after 3 months of treatment (P=0.012) in the control group. PG-SGA (P<0.001), NRS2002 (P<0.001), and ECOG (P=0.006) in the HCF group at the end of the 3-month treatment period were lower in the conventional group (P<0.05). The incidence of radiation mucositis (P=0.018)and radiation dermatitis (P=0.028) in the HCF nutrition management group was significantly reduced (P<0.05).

Conclusions

HCF-model nutritional management significantly improved the nutritional status and reduced the incidence and severity of radiation mucositis and dermatitis for EC and HNC radiotherapy patients. These findings suggest that HCF-model nutritional management is a promising nutritional management model.

Trial Registration

Chinese Clinical Trial Registry identifier: ChiCTR2300068399.

Radiation therapy attenuates lymphatic vessel repair by reducing VEGFR-3 signalling

Introduction: Surgery and radiotherapy are key cancer treatments and the leading causes of damage to the lymphatics, a vascular network critical to fluid homeostasis and immunity. The clinical manifestation of this damage constitutes a devastating side-effect of cancer treatment, known as lymphoedema. Lymphoedema is a chronic condition evolving from the accumulation of interstitial fluid due to impaired drainage via the lymphatics and is recognised to contribute significant morbidity to patients who survive their cancer. Nevertheless, the molecular mechanisms underlying the damage inflicted on lymphatic vessels, and particularly the lymphatic endothelial cells (LEC) that constitute them, by these treatment modalities, remain poorly understood. Methods: We used a combination of cell based assays, biochemistry and animal models of lymphatic injury to examine the molecular mechanisms behind LEC injury and the subsequent effects on lymphatic vessels, particularly the role of the VEGF-C/VEGF-D/VEGFR-3 lymphangiogenic signalling pathway, in lymphatic injury underpinning the development of lymphoedema. Results: We demonstrate that radiotherapy selectively impairs key LEC functions needed for new lymphatic vessel growth (lymphangiogenesis). This effect is mediated by attenuation of VEGFR-3 signalling and downstream signalling cascades. VEGFR-3 protein levels were downregulated in LEC that were exposed to radiation, and LEC were therefore selectively less responsive to VEGF-C and VEGF-D. These findings were validated in our animal models of radiation and surgical injury. Discussion: Our data provide mechanistic insight into injury sustained by LEC and lymphatics during surgical and radiotherapy cancer treatments and underscore the need for alternative non-VEGF-C/VEGFR-3-based therapies to treat lymphoedema.

Radiation-Induced Aortic Stenosis: An Update on Treatment Modalities

The adverse effects of radiation therapy for cancer are well described and can include a wide array of cardiac complications. Radiation-induced aortic stenosis (AS) is an increasingly recognized entity that poses particular therapeutic challenges. Several retrospective studies comparing the outcomes after transcatheter aortic valve replacement (TAVR) vs those after surgical aortic valve replacement patients with radiation-induced AS have found a trend toward decreased mortality and fewer major complications with TAVR. Surgical aortic valve replacement is associated with increased mortality in patients with radiation-induced AS compared with patients without a history of prior radiation. TAVR has been shown to be a safe and effective alternative in patients with radiation-induced AS, with safety similar to that for patients who have not received prior radiation. However, rare and unexpected complications may occur after TAVR from the deleterious effects of radiation on mediastinal structures. More studies are needed to identify the optimal way of managing patients with radiation-induced AS, and algorithms are needed for planning these complex interventions.

Outcomes of Coronary Artery Bypass Grafting in Patients With Previous Mediastinal Radiation

Studies have shown that patients with radiation therapy-associated coronary artery disease tend to have worse outcomes with percutaneous revascularization. Previous irradiation has been linked with future internal mammary artery graft disease. Studies investigating the outcomes of coronary artery bypass surgery (CABG) among patients with previous radiation are limited. The Nationwide Readmission Database for the years 2016 to 2019 was queried for hospitalizations with CABG and history of mediastinal radiation. Complex samples multivariable logistic and linear regression models were used to determine the association between the history of mediastinal radiation and in-hospital mortality, 90 days all-cause unplanned readmission rates, and acute coronary syndrome readmission rates. A total of 533,702 hospitalizations (2,070 in the irradiation history group and 531,632 in the control group) were included in this analysis. Patients with radiation therapy history were less likely to have traditional coronary artery disease risk factors and more likely to have associated valvular disease. Patients with a history of irradiation had similar in-hospital mortality and 90-day readmission risk at the expense of higher hospitalizations costs (β coefficient: $2,764; p = 0.005). They had a higher likelihood of readmission with acute coronary syndrome within 90 days (adjusted odds ratio 1.67, p = 0.02). In a conclusion, a history of mediastinal irradiation is not associated with increased rates of short-term mortality or increased all-cause readmission risk after CABG. However, it may be associated with increased acute coronary syndrome readmission rates.

Recent Progress and Trends in X-ray-Induced Photodynamic Therapy with Low Radiation Doses

The prominence of photodynamic therapy (PDT) in treating superficial skin cancer inspires innovative solutions for its congenitally deficient shadow penetration of the visible-light excitation. X-ray-induced photodynamic therapy (X-PDT) has been proven to be a successful technique in reforming the conventional PDT for deep-seated tumors by creatively utilizing penetrating X-rays as external excitation sources and has witnessed rapid developments over the past several years. Beyond the proof-of-concept demonstration, recent advances in X-PDT have exhibited a trend of minimizing X-ray radiation doses to quite low values. As such, scintillating materials used to bridge X-rays and photosensitizers play a significant role, as do diverse well-designed irradiation modes and smart strategies for improving the tumor microenvironment. Here in this review, we provide a comprehensive summary of recent achievements in X-PDT and highlight trending efforts using low doses of X-ray radiation. We first describe the concept of X-PDT and its relationships with radiodynamic therapy and radiotherapy and then dissect the mechanism of X-ray absorption and conversion by scintillating materials, reactive oxygen species evaluation for X-PDT, and radiation side effects and clinical concerns on X-ray radiation. Finally, we discuss a detailed overview of recent progress regarding low-dose X-PDT and present perspectives on possible clinical translation. It is expected that the pursuit of low-dose X-PDT will facilitate significant breakthroughs, both fundamentally and clinically, for effective deep-seated cancer treatment in the near future.

Surgical site complications of isolated salvage neck dissection post-radiotherapy and post-chemoradiotherapy - A cohort analysis (1997-2017)

INTRODUCTION

This study aims to quantify surgical site complications (SSC) after isolated salvage neck dissection (ND) compared with primary ND.

PATIENTS AND METHODS

Between 1997 and 2017 in the Netherlands Cancer Institute - Antoni van Leeuwenhoek, a total of 323 isolated NDs were performed in 308 patients: primary ND (n = 144), post-radiotherapy (RT) ND (n = 53) and post-chemoradiotherapy (CRT) ND (n = 126). Patient, tumor and therapy characteristics were recorded. SSCs were scored according to the Clavien-Dindo Classification (CDC).

RESULTS

101 NDs (31%) were complicated by at least one SSC. In total, 189 different SSCs occurred. Translated to CDC, 45 complications were grade 2, 25 grade 3a and 31 grade 3b. No significant difference in occurrence of SSC (CDC >1) was found between all groups. However, post-CRT, selective (SND) and modified radical ND and radical ND (MRND/RND) (p = 0.005), resection of sternocleidomastoid muscle (SCM) (p = 0.039) and duration of super selective ND surgery (p = 0.048) were significantly associated with more SSC. SCM muscle removal was associated with more surgical site infection (p = 0.045) and necrosis (p = 0.036). From week 10 post-RT/CRT, no difference in complication frequency with primary ND was seen.

CONCLUSION

Post-CRT SND, MRND/RND and SCM muscle resection were associated with an increased incidence of SSCs. If oncologically possible, limit the extent of ND and when an MRND is inevitable, preserve the SCM muscle for optimal prevention of SSC. Concerning SSC, optimal timing of salvage ND is minimal 10 weeks after RT/CRT.

Editor's Choice - Eligibility of Common Femoral Artery Atherosclerotic Disease for Endovascular Treatment - the CONFESS Study

OBJECTIVE

Advances in endovascular technologies have allowed the treatment of common femoral artery (CFA) steno-occlusive disease by minimally invasive means; however, the proportion of lesions treated with common femoral artery endarterectomy (CFAE) which would be amenable to endovascular treatment is unknown. This observational study aimed to describe the morphology and composition of CFA lesions treated with CFAE and report the proportion that would be amenable to endovascular treatment with modern technologies.

METHODS

Patients presenting with symptomatic peripheral artery disease who underwent CFAE from January 2014 to December 2018 in two tertiary NHS hospitals were included. Extensive data relating to patient demographics, risk factors, clinical outcomes, as well as anatomical and morphological characteristics of the CFA atherosclerotic lesions, were collected which included detailed plaque analysis using 3D reconstruction of pre-operative computed tomography angiograms. CFA lesions were considered suitable for endovascular treatment if presented with patent iliac inflow, at least one patent outflow vessel (superficial femoral artery [SFA] or profunda femoral artery [PFA]), and stenotic rather than occluded CFA.

RESULTS

A total of 829 CFAs in 737 consecutive patients who underwent CFAE were included (mean age 71 ± 10 years; 526 males, 71%); 451 (62%) presented with chronic limb threatening ischaemia. Overall, 35% of CFAs had a localised lesion (no bifurcation disease) that could possibly be treated endovascularly. In total, 376 (45%) target vessels did not feature severe calcium load, with a patent CFA, PFA, and proximal SFA and therefore would have been amenable to endovascular treatment; while 271 CFAs (33%) featured a significant calcium load which would have potentially required stenting.

CONCLUSION

A significant proportion of patients with atherosclerotic CFA lesions who undergo surgery could potentially be candidates for endovascular treatment. A randomised trial comparing CFAE and new endovascular techniques in this clinical context is required.

Extracts of Rheum palmatum and Aloe vera Show Beneficial Properties for the Synergistic Improvement of Oral Wound Healing

Various local and systemic factors compromise oral wound healing and may lead to wound dehiscence, inflammation, or ulcers. Currently, there is a lack of topical therapeutical options. Thus, this study aimed to investigate the effect of Aloe vera (AV) and Rheum palmatum root (RPR) on oral wound healing capacity in vitro. The effect of AV and RPR on human primary fibroblast viability and migration was studied by measuring metabolic activity and gap closure in a scratch assay. Furthermore, cell cycle distribution and cytoskeletal features were analyzed. Antimicrobial activity against the oral pathogen Porphyromonas gingivalis was evaluated by broth microdilution assay. AV and RPR increased fibroblast migration after single agent treatment. Synergistic effects of the plant extract combination were observed regarding cellular migration which were confirmed by calculation of the phenomenological combination index (pCI), whereas the cell cycle distribution was not influenced. Furthermore, the combination of AV and RPR showed synergistic antibacterial effects as determined by the fractional inhibitory concentration index. This study demonstrated that the combination of AV and RPR can promote the migration of human primary fibroblasts in vitro and exert antimicrobial efficacy against P. gingivalis, suggesting these compounds for the topical treatment of wound healing disorders.

From Chronic Wounds to Scarring: The Growing Health Care Burden of Under- and Over-Healing Wounds

Significance: Wound healing is the largest medical market without an existing small molecule/drug treatment. Both "under-healing" (chronic wounds) and "over-healing" (scarring) cause a substantial biomedical burden and lifelong consequences for patients. These problems cost tens of billions of dollars per year in the United States alone, a number expected to grow as the population ages and the prevalence of common comorbidities (e.g., diabetes) rises. However, no therapies currently exist to produce the "ideal" healing outcome: efficient wound repair through regeneration of normal tissue. Recent Advances: Ongoing research continues to illuminate possible therapeutic avenues for wound healing. By identifying underlying mechanisms of wound repair-for instance, tissue mechanics' role in fibrosis or cell populations that modulate wound healing and scarring-novel molecular targets may be defined. This Advances in Wound Care Forum issue includes reviews of scientific literature and original research from the Hagey Laboratory for Pediatric Regenerative Medicine at Stanford and its alumni, including developing approaches for encouraging wound healing, minimizing fibrosis, and coaxing regeneration. Critical Issues: Wound healing problems reflect an enormous and rapidly expanding clinical burden. The issues of both under- and over-healing wound outcomes will continue to expand as their underlying causes (e.g., diabetes) grow. Targeted treatments are needed to enable wound repair with functional tissue restoration and decreased scarring. Future Directions: Basic scientists will continue to refine understanding of factors driving undesirable wound outcomes. These discoveries are beginning to be translated and, in the coming years, will hopefully form the foundation for antiscarring drugs and other wound therapeutics.

Endoprosthetic Reconstruction in Ewing's Sarcoma Patients: A Systematic Review of Postoperative Complications and Functional Outcomes

Ewing's sarcoma (ES) is a rare primary bone cancer managed by radiotherapy, chemotherapy and surgical resection. The existing literature on limb salvage surgery with endoprostheses combines data for ES patients with osteosarcoma. This review aimed to evaluate surgical and functional outcomes of endoprosthetic reconstruction in exclusively Ewing's patients. We believe that this is the first comprehensive review to evaluate the outcomes of limb salvage surgery with endoprostheses exclusively in Ewing's sarcoma patients. Clinical data and outcomes were collected from PubMed, Embase, Medline and Scopus. The inclusion criteria were studies on limb salvage surgery in ES patients, where individual patient data was available. Seventeen studies with a total of 57 Ewing's patients were included in this review. Fifty-three of the ES patients preserved the limb after limb salvage with endoprostheses. The average five-year implant survivorship was 85.9% based on four studies in this review. Postoperative complications were categorised by Henderson's failure modes. Soft tissue failure was the most common, occurring in 35.1% of patients, followed by deep infection in 15.7% of patients. There was a suggestion of 'good' functional outcomes with limb salvage surgery. The salient limitation of this review is the variability and rarity of the patient population. Homogenous data in a larger population is necessary to provide more insight into outcomes of limb reconstruction in ES.

Plant and Herbal Extracts as Ingredients of Topical Agents in the Prevention and Treatment Radiodermatitis: A Systematic Literature Review

Background: The use of herbal extracts as the source of antioxidant substances capable of neutralizing free radicals and providing protection from ionizing radiation appears to be an alternative therapy for radiodermatitis. As concerns the prevention and treatment of side effects, a lot of recommendations are based on proper experience of radiotherapy centers. We summarize recent research aiming at reducing radiation-induced skin injuries by use of proper skin care, using topical preparations with herbal extracts including onco-cosmetics. Methods: This article is limited to a critical analysis of scientific and professional literature. It concerns preparations in different physicochemical forms, e.g., gels, emulsions, ointments. We stress the connection between the type of applied skin care (type of preparation, its composition, the dose), the properties of the herbal extract and the evaluation of its efficiency in preventing and treating radiation reaction on skin. Conclusions: Herbal extracts can be added to recipes because they are part of a category of cosmeceutical supplements and can be introduced into preparations without prescription. The effectiveness evaluation for herbal extracts in radiotherapy is not an easy task since there are no strict guidelines. Studies should be preceded by the analysis of herbal extracts and recipe in terms of physicochemical, dermatological and performance characteristics.

Evaluation of the Concentration of Selected Elements in Patients with Cancer of the Reproductive Organs with Respect to Treatment Stage-Preliminary Study

(1) Background: The aim of this study was to assess the concentrations of selected elements in female patients with cancer of the reproductive organs, taking into account the stage of treatment. (2) Methods: The study sample consisted of 51 patients with advanced endometrial cancer and ovarian cancer, undergoing chemotherapy. The median age of the studied patients with endometrial cancer was 66.0 years (IQR: from 60.75 to 70.25), and with ovarian cancer―60.0 years (IQR: from 49.0 to 64.0). Each of the qualified women, after consent to participate in the study, had her blood drawn several times (before surgery, the first course of chemotherapy, the third course of chemotherapy, and the sixth course of chemotherapy) in order to determine serum levels of macro- and micronutrients (Na, Mg, Ca, Zn, P, Cu, Fe, Cd, Ni, and Sr). (3) Results: In the study group of patients with cancer of the reproductive tract, the concentrations of iron (<0.001), magnesium (0.038), sodium (0.014), and nickel (0.037) varied significantly over the course of the study. The analysis showed that the interaction between the stage of chemotherapy and the type of cancer had an effect on the concentrations of magnesium and cadmium (p < 0.05). (4) Conclusions: In the studied group of patients with ovarian and endometrial cancer, the applied chemotherapy significantly changed the concentrations of Fe, Na, and Ni, regardless of the type of tumor. Changes in Mg and Cd concentrations resulted from the interaction between the stage of chemotherapy and the type of cancer. The results of serum concentrations of selected elements in women with cancer of the reproductive organs may help understand the physiological changes resulting from the applied chemotherapy.