Posterior thigh flap revisited: clinical use in oncology patients.

PURPOSE: The posterior thigh flap is a reliable flap owing to the dependability of the inferior gluteal artery. Its utility for the reconstruction of sacral, perineal, ischial, pelvic, trochanteric and vulvar defects is well established. We herein describe the use of the flap for a variety of indications, and discuss the results with respect to postoperative complications in oncology patients. METHODS: We reviewed nine oncology patients who were treated with pedicled posterior thigh flaps. We assessed the use of this treatment by recording the site of the defect, the type of flap used, and the presence or absence of previous surgical procedures, radiation therapy and postoperative complications. RESULTS: Defects after resection of soft tissue sarcomas were the most common condition (n = 4), followed by skin cancers (n = 2), gastrointestinal cancers (n = 2) and radiation osteomyelitis (n = 1). Six patients (66 %) developed complications; three (33 %) were major and three (33 %) were minor. There was one case of total necrosis of the flap and two cases of partial necrosis. CONCLUSIONS: In oncology patients, the posterior thigh flap is an excellent choice for the reconstruction of sacral, ischial, pelvic or buttock defects, since it does not cause any donor site morbidity.

Clinical experience using a tensor fascia lata flap in oncology patients.

PURPOSE: The tensor fascia lata (TFL) flap is used to reconstruct various anatomical structures in different regions of the body. We herein describe the use of TFL flaps for a variety of indications, and discuss the results of such procedures with respect to postoperative complications in oncology patients. METHODS: We reviewed 15 oncology patients who were treated with TFL flaps. RESULTS: The lesions were located in the groin in five patients, the lower abdomen in five, and the buttocks, ischium, shoulder, thigh and upper abdomen in one patient each. Abdominal wall reconstruction was performed in nine patients. Three patients underwent resection of femoral vessels and the tumor in the groin, followed by a vascular graft implant. In these patients, the combined flaps were transferred to reconstruct the defects. Nine patients developed complications. No total flap loss occurred in any patient. CONCLUSIONS: Postoperative complications, such as necrosis in the distal part of the flap (33 %) and ventral hernias (11 %) were seen, but these percentages were comparable to those seen in previous reports. Our review shows that the TFL flap is useful to reconstruct the defects in various anatomical sites in oncology patients.

Reconstruction of periorbital defects following malignant tumour excision: a report of 50 cases.

BACKGROUND: Treatment in malignant periorbital tumours requires a radical resection of the tumour, and reconstruction of eyelid defects is difficult task because it should aim at gaining functional and aesthetical improvement. METHODS: We have reviewed 50 cases of malignant periorbital tumour that were treated surgically from 1992 to 2010. We assessed the type of reconstruction performed, and present or absent of any complication. RESULTS: The decision of the appropriate reconstructive procedure was based on the location of the tumour and the size of the defects. For the upper eyelid, switch flap from lower lid was performed in 11 out of 14 patients those defects exceeding 50% of the horizontal length. There were 21 complications (42%); major complications in 11 patients (22%) and minor complications in 10 patients (20%). Major complications have occurred only in upper eyelid or in lower eyelid. All of the major complications appeared in the patients with larger defects exceeding 50%. CONCLUSIONS: The 72% of major complications were associated with reconstruction of larger defects in upper eyelid. It might be extremely difficult to obtain good results in the patients with large upper eyelid defects, although switch flap is applicable to such defects.

Effectiveness of muscle coverage to manage osteomyelitis of very late onset in the irradiated chest wall.

Radiation therapy for breast cancer has improved survival rates; however, a consequence of this is treatment-induced complications in longer-living patients. Decades after chest wall irradiation, very late onset radiation-induced osteomyelitis can develop, caused by osteoradionecrosis. This may lead to the development of small, but very refractory, skin ulcers. Many reports recommend well-vascularized tissue coverage after appropriate debridement for irradiation ulcers; however, when the ulcers are of very late onset, this sometimes causes recurrence of ulceration in non-muscle-covered areas after flap transfer. Thus, for very late onset cases, we propose treatment with an absolute muscle flap to cover both the obviously infected focus and the surrounding irradiated area. A muscle flap consisting of the entire latissimus dorsi, the shape of which is very large in the horizontal direction, satisfies this requirement. Latissimus dorsi muscle coverage for the treatment of very late onset osteomyelitis should be reappraised.

Sentinel node biopsy versus elective lymph node dissection in patients with cutaneous melanoma in a Japanese population.

BACKGROUND: In Japan, elective lymph node dissection (ELND) has been the standard treatment for patients with possible nodal melanoma. Sentinel node biopsy (SNB) has now replaced ELND, not only in Japan but also worldwide. The objective of this study was to compare the interim outcomes of SNB and ELND. METHODS: A retrospective study was conducted among patients with clinically node-negative disease treated at our institute with either SNB (n = 30) or ELND (n = 72). RESULTS: The background was similar in the two groups. Nodal metastases were found in 40.0% of patients in the SNB group, but in only 26.4% in the ELND group (P = 0.173). The median follow-up was 31.5 months for the SNB group and 82 months for the ELND group. The incidence of locoregional recurrence and distant metastasis in the SNB group was 10.0% and 16.7%, respectively, and for the ELND group the incidence was 5.6% and 31.9%, respectively. The 3-year disease-free survival rate was similar in the two groups (P = 0.280), and the 3-year disease-free survival rates for node-positive patients were also similar in the two groups (P = 0.90), as were the 3-year disease-free survival rates for node-negative patients (P = 0.193). CONCLUSION: This interim result in a Japanese melanoma population with clinically node-negative disease demonstrated that SNB identified more nodal micrometastases than ELND. This increase in accurate staging likely resulted from the reliable identification of the lymph node field by lymphoscintigraphy, as well as the more detailed pathologic examination of the nodes removed in SNB. It is quite reasonable to perform SNB instead of ELND in this population.

Malignant blue nevus: case report of a Japanese man with a distant cutaneous metastasis.

We report a 55-year-old Japanese patient with a malignant blue nevus (MBN) on the scalp. The patient had regional lymph nodes metastases at his first visit, and a distant cutaneous metastatic papule appeared on the back 1 year later despite therapeutic intervention. Histology of the primary tumor lacked a junctional component and showed a typically biphasic pattern in the degree of pigmentation similar to a cellular blue nevus (BN). One pattern showed nests of less-pigmented, oval-shaped cells with a fairly uniform appearance, and the other pattern showed an aggregation of spindle-shaped cells containing a large amount of melanin pigment intermingled with heavily pigmented melanophages. Histology of metastatic regional lymph nodes also showed a biphasic proliferative pattern of oval-shaped, pale cells and spindle-shaped, richly pigmented cells. A distant cutaneous metastatic papule on the back showed massive proliferation of atypically large, pale, and oval-shaped melanoma cells with heavily pigmented melanophages just beneath the uninvolved epidermis. These histologic features were different from those of metastatic tumor proliferation from conventional melanoma. It seems probable that MBN might maintain a different biological and histopathologic character from conventional melanoma when it grows in metastatic sites.

Forehead lipoma resection via a small remote incision using a surgical raspatory.

Lipomas are benign tumors and, therefore, a surgical technique that does not leave a visible scar would be an ideal method. A forehead lipoma can be extracted using a small remote incision with endoscopic assistance for aesthetic purposes. However, endoscope-assisted surgery is usually technically demanding, time-consuming, and less cost-effective. In this report, we propose an alternative approach to the surgical resection of a forehead lipoma with a small remote incision. Our method uses a surgical raspatory. Our technique allows the complete removal of the lipoma with no complications using a raspatory passed down a subcutaneous tunnel from an incision placed in an aesthetically advantageous site.

Reconstructive considerations after resection of malignant melanoma in the head and neck.

Little has been written about reconstructive methods after resection of melanomas in the head and neck region. We investigated reconstructive methods retrospectively related to the site and size of the melanomas resected by examining the medical records of 28 patients who had malignant melanomas of the head and neck resected at our hospital from 1984 to 2001. The tumour distribution was 12 in the cheek, 6 in the conjunctiva, 2 in the upper lip, 2 in the lower lip, one each in the lower eyelid, eyebrow, scalp, nose, and auricle. Reconstructive methods were 18 skin grafts, seven local flaps, and three free flaps. Three patients who had skin grafts required secondary reconstruction using free flaps. No local recurrences were observed. Reconstructions with local flaps give better aesthetical and functional results than free flaps and skin grafts. Immediate reconstruction with a flap is safe and it does not affect observation of local recurrences.

Management of superficial leiomyosarcoma: a retrospective study of 10 cases.

BACKGROUND: Superficial leiomyosarcoma is a rare soft-tissue tumor. Management of this tumor, including pathological evaluations and therapies, is not clearly defined in the existing literature. METHODS: Ten patients with superficial leiomyosarcoma treated in our institutes were recalled and scheduled for examination. Assessments were carried out according to clinical characteristics, therapies used, histological grade (based on the grading system of the Fédération Nationale des Centres de Lutte Contre Le Cancer), tumor-node-metastasis stage (using the American Joint Committee on Cancer staging system), recurrences rates, state of metastases, and the current condition of each patient. RESULTS: No local recurrences or distant metastases were seen in eight patients with low-grade and early-stage disease, whereas two patients with high-grade and advanced-stage disease had recurrence and one of these two patients died of the disease. CONCLUSIONS: This study indicates that evaluations using the Fédération Nationale des Centres de Lutte Contre Le Cancer grading system and the American Joint Committee on Cancer tumor staging system were useful. The authors advocate that surgical treatment of low-grade cutaneous leiomyosarcoma by complete excision with a narrow margin is adequate. For low-grade and early-state subcutaneous or soft-tissue leiomyosarcoma, wide excision with a minimum 2-cm lateral margin and one-tissue barrier deep margin is recommended. Management of high-grade leiomyosarcomas is still difficult; adequate wide excision may be the only option.

Use of the "supercharge" technique in esophageal and pharyngeal reconstruction to augment microvascular blood flow.

BACKGROUND: Although gastric tubes are commonly used in thoracic esophageal reconstruction, sometimes circumstances are such that an alternative method must be found. On these occasions, pedicled jejunum transfer and colonic interposition are used. After reconstruction, partial necrosis can occur because of poor blood flow in the oral end of the segment used to restore esophageal continuity. To improve this blood flow, we created a technique-the "supercharge" technique-in which we perform additional microvascular blood flow augmentation. METHODS: The supercharge technique was performed in 82 esophageal reconstructions with microvascular blood flow augmentation. Reconstructive methods included a gastric tube in 5 patients, a gastric tube combined with a free jejunal graft in 2, an elongated gastric tube in 6, a pedicled colonic interposition in 26, and a pedicled jejunum in 43. Recipient vessels were located in the neck or chest regions. RESULTS: After microvascular blood flow augmentation, the color and blood flow of the transferred intestine appeared greatly improved. During the operation, thrombosis was noticed in 3 patients and successfully salvaged by reanastomosis. Partial graft necrosis of the oral end of the segment occurred in only 2 patients; 2 patients had anastomotic leakage. CONCLUSIONS: The risk of leakage and partial necrosis of the transferred gut conduit appear to be reduced by using the supercharge technique to augment microvascular blood flow. This reliable technique contributes to the successful reconstruction of esophageal defects.

Indications for lymph node dissection in the treatment of extramammary Paget's disease.

BACKGROUND: In extramammary Paget's disease, compared with patients with carcinoma in situ (CIS), patients with malignancies underlying dermis and subcutaneous tissues or lymph node metastasis appear to have a much worse prognosis. OBJECTIVE: The purpose was to examine our extramammary Paget's diseases patients in terms of pathological tumor invasion, lymph node metastasis, and prognosis and to refer to indications of lymph node dissection. METHODS: The 34 patients were divided into four groups by pathological tumor invasion: CIS, microinvasion to the papillary dermis (MIPD), invasion to the reticular dermis (IRD), and invasion to subcutaneous tissues (IST). Their age, sex ratio, follow-up periods, history of other cancers, lymph node metastasis, and prognosis were compared among the four groups and referred to indications of lymph node dissection. RESULTS: In the groups of CIS and MIPD, all patients appeared to have no lymph node metastasis and death caused by this disease. In the groups of IRD and IST, 8 of 12 patients showed pathological lymph node metastasis, and all of them died due to metastasis of the tumor. In the cumulative survival rate of the patients according to the level of invasion, 5-year survival rate was 100% in CIS and MIPD groups, 33.3% in the IRD group, and 0% in the IST group. CONCLUSION: In the treatment of extramammary Paget's disease, indications of lymph node dissection are an important issue as well as wide local excision. From this prospective study, we have developed an algorithm for indications of lymph node dissection.

Squamous cell carcinoma in chronic lymphedema: case report and review of the literature.

BACKGROUND: Squamous cell carcinoma (SCC) arising in chronic lymphedema is rare; only nine cases have been reported. OBJECTIVE: To present the evolution of SCC in chronic lymphedema. METHODS: Case report and literature review. RESULTS: The tumor was treated by wide excision and covered by a skin graft. CONCLUSION: In most of the other reported SCC cases in lymphedema, there are additional factors for carcinogenesis. There is no additional carcinogenic factor except for chronic lymphedema in our case. This strongly supports that lymphedema itself is one of the carcinogenic factors for not only angiosarcoma but also SCC.