RESUMO
Chronic complications following anterior cranial fossa tumor extirpation, such as cerebrospinal fluid leak, meningitis, mucocele, pneumocephalus, and abscess, negatively impact patient quality of life. Robust vascularized tissue is generally required to adequately reconstruct and obliterate this complex geometric space. The aim of this study was to describe outcomes and advantages of the omental flap for these defects. Following institutional review board approval, a prospective, reconstructive database was reviewed from 2011 to 2020. Four patients with chronic anterior skull base complications treated with omental flap reconstruction were identified, with chart reviews performed. Median time from the index operation until the complication ultimately required a free omental transfer was 7.3 years. All patients underwent adjuvant radiation with the indications for surgery, including cerebral abscess, recurrent meningitis, osteomyelitis, and pneumocephalus. All free flaps survived without any need for revision. There were no donor site complications. One patient had delayed healing at an adjacent nasal wound that healed secondarily. At a median follow-up of 19.4 months, none of the patients had recurrent infections. The omental free flap has a number of properties, which make it ideally suitable for anterior skull base defects. Its malleable nature combined with the presence of multiple vascular arcades enable flexibility in flap design to contour to the crevices of 3-dimensional skull base defects. Although other free flaps are available to the plastic surgeon, the versatility and reliability of the omentum make it a first-line consideration for anterior skull base reconstruction.
RESUMO
The use of IFN-alpha in clinical oncology has generally been based on the rationale of exploiting its antiproliferative and antiangiogenic activities. However, IFN-alpha also exhibits enhancing effects on T-cell and dendritic cell functions, which may suggest a novel use as a vaccine adjuvant. We have carried out a pilot phase I-II trial to determine the effects of IFN-alpha, administered as an adjuvant of Melan-A/MART-1:26-35(27L) and gp100:209-217(210M) peptides, on immune responses in stage IV melanoma patients. In five of the seven evaluable patients, a consistent enhancement of CD8(+) T cells recognizing modified and native MART-1 and gp100 peptides and MART-1(+)gp100(+) melanoma cells was observed. Moreover, vaccination induced an increase in CD8(+) T-cell binding to HLA tetramers containing the relevant peptides and an increased frequency of CD45RA(+)CCR7(-) (terminally differentiated effectors) and CD45RA(-)CCR7(-) (effector memory) cells. In all patients, treatment augmented significantly the percentage of CD14(+) monocytes and particularly of the CD14(+)CD16(+) cell fraction. An increased expression of CD40 and CD86 costimulatory molecules in monocytes was also observed. Notably, postvaccination monocytes from two of the three patients showing stable disease or long disease-free survival showed an enhanced antigen-presenting cell function and capability to secrete IP10/CXCL10 when tested in mixed leukocyte reaction assays, associated to a boost of antigen and melanoma-specific CD8(+) T cells. Although further clinical studies are needed to show the adjuvant activity of IFN-alpha, the present data represent an important starting point for considering a new clinical use of IFN-alpha and new immunologic end points, potentially predictive of clinical response.