0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Observation |

Differential Radiation Dermatitis in Native Skin and an Autologous Transplanted Myocutaneous Flap FREE

Viswanath R. Belum, MD1; Amanda Hill, RN2; Evan Matros, MD3; Mario E. Lacouture, MD1; Christopher A. Barker, MD2
[+] Author Affiliations
1Dermatology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
2Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
3Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
JAMA Dermatol. 2014;150(12):1365-1367. doi:10.1001/jamadermatol.2014.888.
Text Size: A A A
Published online

In this case, radiation dermatitis (RD) is characterized by a differential response in 2 developmentally equivalent tissues from distinct anatomic locations.

REPORT OF A CASE

A man in his 50s presented with a gradually enlarging erythematous patch on the upper chest overlying an area of surgery performed 12 years before for the removal of a neurotropic basal cell carcinoma (Figure A). Computed tomographic–positron emission tomographic scans revealed an infiltrative mass (10 cm) invading the osseous structures of the anterior chest wall and soft tissues of the neck, which prompted their radical resection. This was followed by reconstruction with an autologous myocutaneous free flap harvested from the anterolateral thigh (Figure B). After an uncomplicated 3-month postoperative course and flap “take,” a cumulative radiation therapy (RT) dose of 66 Gy (33 fractions) was delivered over 6.6 weeks.

Place holder to copy figure label and caption
Figure.
Clinical Images of Differential Radiation Dermatitis in Native Skin and an Autologous Transplanted Myocutaneous Flap

A, Prior to surgery, an infiltrative basal cell carcinoma of the upper chest had invaded the sternum, manubrium, left clavicle, and soft tissues of the anterior mediastinum and neck. B, Clinical image taken after autologous myocutaneous free flap reconstruction, following radical resection of the anterior chest wall and bilateral neck dissection. C, Grade 2, radiation dermatitis manifesting as brisk erythema with dry desquamation over the neck and upper chest; note the marked sparing of the skin within the flap (inset).

Graphic Jump Location

During RT, the patient reported a pruritic, erythematous eruption outside the flap, but within the RT target volume. The eruption conspicuously spared the skin of the free flap. At an RT dose of 56 Gy in 23 fractions (5.6 weeks from start of RT), the patient developed a grade 2 RD outside the flap (Figure C). A grade 1 RD was noted over the flap, consisting of faint erythematous papules. In vivo dosimetry of sites exhibiting the differential pattern (Figure C, inset) excluded inconsistent dosing. Cultures from outside the flap in areas with erythema and pustules grew methicillin-sensitive Staphylococcus aureus. A 5-day course of oral antibiotics and topical corticosteroids improved the symptoms, with complete resolution by 12 weeks without recurrence.

DISCUSSION

The reasons for RD relatively “sparing” skin within the transplanted flap are unknown. In a small series, the response of autologous split- and full-thickness grafts to RT ranged from pronounced radiosensitivity to relative radioresistance; fresh grafts (<3 months old) were prone to developing brisk and more vigorous reactions than normal skin, while older grafts (>1 year old) tended to be relatively radioresistant.13 The tolerance to RT was similar in grafts that were 3 months to 1 year old, and differential reaction patterns were not described. It was noted that recovery from RD may be delayed in fresh grafts or absent in old grafts.

Similar studies involving flaps are sparse. Wang et al4 found that the rate of acute toxic effects in some reconstructed free and pedicle flaps was significantly lower (radioresistance) than in the surrounding normal tissues, and they attributed it to mild tissue hypoxia. Also, in his discussion, Withers5 noted that myocutaneous flaps and free flaps showed less skin damage from postoperative radiation than skin grafts and pedicle flaps, which suggests that the response to radiation is dependent on graft and/or flap vascularity, as shown in rat the models described by Sumi et al.6

The effect of the anatomical origin of transplanted skin has not been considered a factor influencing the development of RD. In our patient, RT was administered 3 months after a microsurgical flap reconstruction. Although this leads to the restoration of vascular and lymphatic flow within days,7 the extent of revascularization and immune surveillance in the skin of flaps is not known. Scar remodeling peaks at around 3 to 6 months. It is not clear whether any of these factors might have affected inflammatory responses (free radical generation) in flap skin due to disruption of collateral processes or poor inflammatory cell trafficking to locoregional nodes. The role of variations in regional skin thickness (thicker in the thigh [54.3 μm] vs the chest [37.6 μm]), prior sun exposure (chest > thigh), severance of neural networks, and bacterial flora needs to be determined.

Our observations suggest that the anatomic-physiologic condition of the irradiated native skin, or its competence, has a clear role in determining the outcome.

ARTICLE INFORMATION

Corresponding Author: Mario E. Lacouture, MD, Dermatology Service, Memorial Sloan-Kettering Cancer Center, Rockefeller Outpatient Pavilion, Ste 228, 160 E 53rd St, New York, NY 10022 (lacoutum@mskcc.org).

Published Online: August 6, 2014. doi:10.1001/jamadermatol.2014.888.

Conflict of Interest Disclosures: Dr Lacouture has served as a speaker, consultant, or advisor with Advancell, AstraZeneca, Aveo, Bayer, BergPharma, Bristol-Myers Squibb, Galderma, Genentech, Genzyme, GlaxoSmithKline, Helsinn, Imclone, Lilly, LindiSkin, Merck, Novocure, Novartis, Onyx, Pfizer, Roche, Sandoz, Sanofi Aventis and Wyeth. Dr Barker serves as a consultant to RP Pharmaceuticals.

Additional Contributions: We are indebted to Ying Zhou, MS, for assistance with in vivo dosimetry.

REFERENCES

Grise  JW, Rubin  P, Ryplansky  A, Cramer  L.  Factors influencing response and recovery of grafted skin to ionizing irradiation; experimental observations. Am J Roentgenol Radium Ther Nucl Med. 1960;83:1087-1096.
PubMed
Rubin  P, Grise  JW.  The differences in response of grafted and normal skin to ionizing irradiation. Am J Roentgenol Radium Ther Nucl Med. 1960;84:645-655.
PubMed
Elkin  M, Salvioni  D, Binstock  M.  The effect of localised radiation on autologous skin transplants. Br J Radiol. 1962;35:235-240.
PubMed   |  Link to Article
Wang  Z, Qiu  W, Mendenhall  WM.  Influence of radiation therapy on reconstructive flaps after radical resection of head and neck cancer. Int J Oral Maxillofac Surg. 2003;32(1):35-38.
PubMed   |  Link to Article
Withers  EH. Discussion: postoperative irradiation after reconstructive surgery: comparative study of radiosensitivity between free-skin grafts and skin flaps.Plast Reconstr Surg. 1984;74(3):392. http://journals.lww.com/plasreconsurg/Citation/1984/09000/Postoperative_Irradiation_after_Reconstructive.10.aspx. Accessed June 25, 2014.
Sumi  Y, Ueda  M, Kaneda  T, Oka  T, Torii  S, Sakuma  S.  Postoperative irradiation after reconstructive surgery: comparative study of radiosensitivity between free-skin grafts and skin flaps. Plast Reconstr Surg. 1984;74(3):385-392.
PubMed   |  Link to Article
Slavin  SA, Upton  J, Kaplan  WD, Van den Abbeele  AD.  An investigation of lymphatic function following free-tissue transfer. Plast Reconstr Surg. 1997;99(3):730-743.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Clinical Images of Differential Radiation Dermatitis in Native Skin and an Autologous Transplanted Myocutaneous Flap

A, Prior to surgery, an infiltrative basal cell carcinoma of the upper chest had invaded the sternum, manubrium, left clavicle, and soft tissues of the anterior mediastinum and neck. B, Clinical image taken after autologous myocutaneous free flap reconstruction, following radical resection of the anterior chest wall and bilateral neck dissection. C, Grade 2, radiation dermatitis manifesting as brisk erythema with dry desquamation over the neck and upper chest; note the marked sparing of the skin within the flap (inset).

Graphic Jump Location

Tables

References

Grise  JW, Rubin  P, Ryplansky  A, Cramer  L.  Factors influencing response and recovery of grafted skin to ionizing irradiation; experimental observations. Am J Roentgenol Radium Ther Nucl Med. 1960;83:1087-1096.
PubMed
Rubin  P, Grise  JW.  The differences in response of grafted and normal skin to ionizing irradiation. Am J Roentgenol Radium Ther Nucl Med. 1960;84:645-655.
PubMed
Elkin  M, Salvioni  D, Binstock  M.  The effect of localised radiation on autologous skin transplants. Br J Radiol. 1962;35:235-240.
PubMed   |  Link to Article
Wang  Z, Qiu  W, Mendenhall  WM.  Influence of radiation therapy on reconstructive flaps after radical resection of head and neck cancer. Int J Oral Maxillofac Surg. 2003;32(1):35-38.
PubMed   |  Link to Article
Withers  EH. Discussion: postoperative irradiation after reconstructive surgery: comparative study of radiosensitivity between free-skin grafts and skin flaps.Plast Reconstr Surg. 1984;74(3):392. http://journals.lww.com/plasreconsurg/Citation/1984/09000/Postoperative_Irradiation_after_Reconstructive.10.aspx. Accessed June 25, 2014.
Sumi  Y, Ueda  M, Kaneda  T, Oka  T, Torii  S, Sakuma  S.  Postoperative irradiation after reconstructive surgery: comparative study of radiosensitivity between free-skin grafts and skin flaps. Plast Reconstr Surg. 1984;74(3):385-392.
PubMed   |  Link to Article
Slavin  SA, Upton  J, Kaplan  WD, Van den Abbeele  AD.  An investigation of lymphatic function following free-tissue transfer. Plast Reconstr Surg. 1997;99(3):730-743.
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

441 Views
0 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Jobs