Transplantation of the Stromal Vascular Fraction (SVF) Mitigates Severe Radiation-Induced Skin Injury.

Severe radiation-induced skin injury is a complication of tumor radiotherapy and nuclear accidents. Cell therapy is a potential treatment for radiation-induced skin injury. The stromal vascular fraction (SVF) is a newer material in stem cell therapy that is made up of stem cells harvested from adipose tissue, which has been shown to promote the healing of refractory wounds of different causes. In this study, SVF was isolated from patients with radiation-induced skin injury. Adipose-derived stem cells (ADSCs) accounted for approximately 10% of the SVF by flow cytometry. Compared with the control group of rats, administration with SVF attenuated the skin injury induced by electron beam radiation. The effect of SVF on the human skin fibroblast microenvironment was determined by proteomic profiling of secreted proteins in SVF-co-cultured human skin fibroblast WS1 cells. Results revealed 293 upregulated and 1,481 downregulated proteins in the supernatant of SVF-co-cultured WS1 cells. WS1 co-culture with SVF induced secretion of multiple proteins including collagen and MMP-1. In the clinic, five patients with radiation-induced skin injury were recruited to receive SVF transfer-based therapy, either alone or combined with flap transplantation. Autogenous SVF was isolated and introduced into a multi-needle precision electronic injection device, which automatically and aseptically distributed the SVF to the exact layer of the wound in an accurate amount. After SVF transfer, wound healing clearly improved and pain was significantly relieved. The patients' skin showed satisfactory texture and shape with no further wound recurrence. Our findings suggest that transplantation of SVF could be an effective countermeasure against severe radiation-induced skin injury.

[Skin engineering for severe burns]. / L'ingénierie cutanée pour le traitement des brûlures graves.

Severe burned patients need definitive and efficient wound coverage. Outcome of massive burns has been improved by using cultured epithelial autografts (CEA). Despite fragility, percentages of success take, cost of treatment and long-term tendency to contracture, this surgical technique has been developed in few burn centres. First improvements were to combine CEA and dermis-like substitute. Cultured skin substitutes provide earlier skin closure and satisfying functional result. These methods have been used successfully in massive burns. Second improvement was to allow skin regeneration by using epidermal stem cells. Stem cells have capacity to differentiate into keratinocytes, to promote wound repair and to regenerate skin appendages. Human mesenchymal stem cells contribute to wound healing and were evaluated in cutaneous radiation syndrome. Skin regeneration and tissue engineering methods remain a complex challenge and offer the possibility of new treatment for injured and burned patients.

Pioneering technique using Acellular Dermal Matrix in the rescue of a radiation ulcer.

BACKGROUND: Radiotherapy as an adjuvant to mastectomy is integral to the treatment of breast cancer, but can result in skin ulceration. Skin ulceration following radiotherapy is traditionally managed by removing the implant and allowing the skin to heal by secondary intention. CASE REPORT: A 42-year-old woman underwent radiotherapy following a breast reconstruction. She developed a 2 x 3cm radiation ulcer. The ulcer was managed by removing the implant and performing capsulectomy. A Beckers 50 expander was placed and reinforced with acellular dermal matrix inferolaterally. At follow-up the patient had a good cosmetic outcome. CONCLUSION: Post-radiation skin ulcers present a challenge to treat with no current standardised management. The use of acellular dermal matrix may present a new technique to promote healing in these testing cases.

Change of paradigm in thoracic radionecrosis management.

Classically, muscular or omental flaps are the gold standard in the management of thoracic defects following radionecrosis debridement. Their vascular supply and antibacterial property was supposed to enhance healing compared with cutaneous flaps. The evolution of reconstructive surgery allowed us to challenge this dogma. Therefore, we present five consecutive cases of thoracic radionecrosis reconstructed with cutaneous perforator flaps. In four patients, we performed a free deep inferior epigastric perforator (DIEP) flap and one patient had a thoracodorsal perforator (TDAP) flap. Median time healing was 22.6 days with satisfactory cutaneous covering and good aesthetic results. There were no flap necrosis, no donor site complications. We believe that perforator flaps are a new alternative, reliable and elegant option that questions the dogma of muscular flaps in the management of thoracic radionecrosis.

First Reported Case of Postirradiation Pseudosclerodermatous Panniculitis After Stereotactic Body Radiation Therapy for the Treatment of Non-Small Cell Lung Cancer.

Postirradiation pseudosclerodermatous panniculitis is a rare complication of radiation therapy that presents as an indurated plaque and/or subcutaneous nodule in an area of previously irradiated tissue. The histopathologic pattern is of mixed lobular and septal panniculitis with necrotic adipocytes and thickened sclerotic septa as well as dense inflammatory infiltrates consisting mainly of histiocytes. The typical time interval is 1 month to several years after treatment with radiation therapy. This is a case of an 86-year-old man with a medical history significant for diffuse large B-cell lymphoma who was given 3 fractions of stereotactic body radiation therapy for treatment of stage IA non-small cell lung adenocarcinoma of the right upper lobe. Two years later, he presented with several small palpable subcutaneous right axillary nodules, which coalesced into a 6-cm firm multilobulated right axillary mass over several weeks. Histopathology showed sclerosing panniculitis with lipomembranous changes and septal fibrosis. This is the first reported case describing postirradiation pseudosclerodermatous panniculitis in a patient with lung cancer treated with stereotactic body radiation therapy. This diagnosis must be differentiated from other subtypes of panniculitis and complications of radiation therapy.

[Reconstruction of Defects after Oncologic Resection and Radiation - Indications for Microsurgical Reconstruction]. / Defektrekonstruktion nach onkologischer Resektion und Bestrahlung - Indikationen zur mikrochirurgischen Rekonstruktion.

The surgical treatment of soft tissue sarcomas in the extremities frequently requires radiation therapy to achieve local tumour control. However, both adjuvant and neoadjuvant radiation are associated with significant morbidity caused by impaired wound healing, ulcers or osteonecrosis with subsequent fractures. This is due to altered local cell mediator levels, fibrosis occurring simultaneously with decreased cell division rates and diminished vascularity. This article describes a number of local conservative treatment options, all of which have limited success rates. In addition, it describes plastic surgical treatment options for radiation-induced local morbidity. Surgical reconstruction includes the full range of plastic reconstructive techniques. However, less complex options such as random pattern flaps or split thickness skin grafts are often associated with complications. Therefore, a large number of cases require free tissue transfer.

[Application of "tennis racket" flap with fascial pedicle on the healthy chest for the radiation ulcer after surgical treatment of breast carcinoma].

OBJECTIVE: To introduce the application of "tennis racket" flap with fascial pedicle on the healthy chest for radiation ulcer after surgical treatment of breast cancer. METHODS: The " tennis racket" flap was designed on the healthy chest along the cartilage with fascia pedicle near the sternum. 9 cases were treated. The flaps size ranged from 5.0 cm x 3.5 cm to 13 cm x 11 cm with pedicle size of 2-8 cm in length and 2.0-3.0 cm in width. RESULTS: All the 9 flaps survived completely with satisfactory appearance. The patients were followed up for 2 months to 3 years without ulcer reoccurrence. CONCLUSIONS: The "tennis racket" flap has a slender fascial pedicle without major blood vessel. It has the advantages of good flexibility for rotation and large flap size for the reconstruction of the radiation ulcer after surgical treatment of breast cancer.

[Pediculated deltoid muscle flap: an alternative for coverage of chronic radionecrotic lesions in the shoulder region]. / Der gestielte Deltoideusmuskellappen: Eine Alternative zur Deckung chronischer Strahlenschäden des Schultergürtels.

Soft tissue lesions in the clavicular region may be the result of trauma, infections or oncological resection and necessitate plastic surgery coverage. A case of an 85-year-old woman is presented with non-union of the mid-portion of the left clavicle with an overlying skin defect and a brachial plexus lesion after radiation therapy for breast cancer. The left arm was functionless so after partial resection of the medial part of the clavicle coverage of the defect was conducted by a proximally pediculated anterior part of the deltoid muscle with a split thickness skin graft.

[Chronic radiodermatitis following coronaroplasty]. / Radiodermite chronique du dos après coronaroplastie.

We report the case of a 72-year-old patient sent by his dermatologist in January 2009 for a back burn. His medical history reported one coronarography and two coronaroplasties between September and October 2005. This enabled us to form the diagnosis of chronic radiodermatitis after coronaroplasty from literature data. The occurrence of chronic radiodermatitis of the back and axilla area after cardiac catheterization has been observed in many countries. It almost always occurred in patients who underwent difficult and long-acting procedures leading to high doses radiation. There is not always acute radiodermatitis. Lesions appear between three and 30 months after exposure or even later. They are well-defined four-sided centimetrics lesions going from simple radiodystrophy to ulceration such as late radionecrosis requiring surgical coverage procedure.

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

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

[Severe thoracic radionecrosis: muscle-sparing latissimus dorsi flap (MSLD)]. / Radionécrose thoracique sévère : couverture par lambeau avec préservation partielle du latissimus dorsi (PPLD).

INTRODUCTION: Cutaneous radionecrosis and osteoradionecrosis are severe complications of the radiotherapy which can arise after a variable free interval. The loss of substance is frequently associated with a peripheral radiodermatitis and stays an infectious front door exposing patients to a sepsis. The reference treatment remains surgical and consists in realizing the debridment of necrosis tissues associated with flap in order to cover the soft tissus defect. The purpose of our study is to estimate efficiency and tolerance of management radionecrosis thoracique by muscle-sparing latissimus dorsi flap (MSLD). MATERIAL AND METHODS: We realized a study on a series of cases of thoracic radionecrosis with costal exposure covered by MSLD. Fat transfer into peripheral radiodermitis was performed at the same time surgical. Efficiency and tolerance surgery were estimated. The duration of the postoperative antibiotic treatment was estimated. The complications (hematoma, infection, cutaneous suffering, necrosis, seroma, radionecrosis relapse) were screened. The follow-up was realized by the same surgeon. RESULTS: Seven patients managed by the same surgeon were included, They had radionecrosis after radiotherapy for processing adjuvanting of mastectomy after breast cancer. The average age was 66 years (from 61 to 76 years). The average time of hospitalisation was of four days. The average follow-up was of six months. The average treatment of the antibiotic treatment was four weeks. We didn't notice any complications and any recurrence of the radionecrosis. We noticed one dorsal collection (30 cm(3)) 15 days after surgical procedure for one patient. The follow-up showed a stable and good quality cutaneous cover in six months postoperative. CONCLUSIONS: MSLD flap is reliable and reproducible to cover moderate thoracic defect. The surgical parage-wash has a fundamental importance to avoid any infectious complication. The management of the thoracic radionecrosis is complex and multidisciplinary. In conclusion, MSLD flap seems to be an elegant surgical alternative insuring a custom-made optimal cover with a reduction of the morbidity of the site donor.

Chronic scalp ulceration as a late complication of fluoroscopically guided cerebral aneurysm embolization.

Fluoroscopy-induced chronic radiation dermatitis resulting from prolonged exposure to ionizing radiation during interventional procedures has been documented in the medical literature. However, this condition often requires a high clinical suspicion in order to establish a correct diagnosis. In this report, the development of deep scalp ulceration with bone exposure following the endovascular coiling of an anterior communicating artery aneurysm 8 years before is described. A skin biopsy specimen demonstrated changes consistent with chronic radiation dermatitis and ruled out malignancy. This case report expands the clinical manifestation spectrum of fluoroscopy-induced chronic radiation skin injury and highlights the importance of recognizing these lesions early to prevent morbidity related to radiation-induced skin damage.

Human fat grafting alleviates radiation skin damage in a murine model.

BACKGROUND: Autogenous fat grafting has been observed to alleviate the sequelae of chronic radiodermatitis. To date, no study has replicated this finding in an animal model. METHODS: The dorsa of adult wild-type FVB mice were shaved and depilated. The dorsal skin was then distracted away from the body and irradiated (45 Gy). Four weeks after irradiation, 1.5-cc fat or sham grafts were placed in the dorsal subcutaneous space. Gross results were analyzed photometrically. The animals were euthanized at 4 and 8 weeks after fat or sham grafting and their dorsal skin was processed for histologic analysis. RESULTS: Hyperpigmentation and ulceration were grossly improved in fat-grafted mice compared with sham-grafted controls. This improvement manifested histologically in a number of ways. For example, epidermal thickness measurements demonstrated decreased thickness in fat-grafted animals at both time points (20.6 ± 1.5 µm versus 55.2 ± 5.6 µm, p = 0.004; 17.6 ± 1.1 µm versus 36.3 ± 6.1 µm, p = 0.039). Picrosirius red staining demonstrated a diminished scar index in fat-treated animals at both time points as well (0.54 ± 0.05 versus 0.74 ± 0.07, p = 0.034; and 0.55 ± 0.06 versus 0.93 ± 0.07, p = 0.001). CONCLUSION: Fat grafting attenuates inflammation in acute radiodermatitis and slows the progression of fibrosis in chronic radiodermatitis.

[Present and future of cell therapy in burns]. / Présent et futur de la thérapie cellulaire des brûlures.

Severe burned patients need definitive and efficient wound coverage. Outcome of massive burns has been improved by using cultured epithelial autografts (CEA). Despite fragility, percentages of success take, cost of treatment and long-term tendency to contracture, this surgical technique has been developed in few burn centres. First improvements were to combine CEA and dermis-like substitute. Cultured skin substitutes provide earlier skin closure and satisfying functional result. These methods have been used successfully in massive burns. Second improvement was to allow skin regeneration by using epidermal stem cells. Stem cells have capacity to differentiate into keratinocytes, to promote wound repair and to regenerate skin appendages. Human mesenchymal stem cells contribute to wound healing and were evaluated in cutaneous radiation syndrome. Skin regeneration and tissue engineering methods remain a complex challenge and offer the possibility of new treatment for injured and burned patients.

Radiation induced cutaneous ulcer on the back in a patient with congenital anomaly of the upper cava system.

Recent years have seen the introduction of a number of additive diagnostic and therapeutic procedures in invasive cardiology. Cardiac catheterization procedures using fluoroscopy reduce patient morbidity and mortality compared to conventional surgical interventions. The associated radiation exposure for the patient is, however, often underestimated, while implantation of cardiac resynchronization therapy (CRT) and/or implantable cardioverter defibrillator (ICD) pacemaker systems sometimes entails even higher radiation exposures due to prolonged fluoroscopic studies. Radiation induced skin injuries including ulceration are mainly dose dependent effects of ionizing radiation and can be acute, subacute or chronic. The time between radiation exposure and manifestation of skin injuries varies greatly, from a few days up to months or even years. We report a 54-year-old male patient who presented to the Department of Dermatology in the year 2006, with erythema in the interscapular area associated with occasional pruritus. His medical report included several diagnostic cardiac catheterization procedures. Several attempts to implant CRT and ICD had failed owing to an undetected congenital anomaly of the upper vena cava system; these attempts had entailed prolonged fluoroscopy. The patient's history, clinical presentation and histopathological findings finally led to the diagnosis of radiation induced cutaneous ulcer.