SJ Goodwin, CN Parnaby, PS Chong.
Department of General Surgery, Southern General Hospital, Glasgow, Scotland.
Correspondence to: Mr Peter S Chong, Department of Surgery, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TP
SMJ 2007 52(2): 56
Oral cancers constitute 4% of all cancers worldwide with an incidence of approximately 4500 new cases annually in the UK.1 Squamous cell carcinomas (SCC) account for greater than 90% of oral and pharyngeal tumours.2
Oral cancers usually present as a persistent ulcer or mass3 and disease is often advanced by the time of specialist review. Consequently, the average 5-year survival remains just 57% despite ongoing oncological advances. Metastasis of oral SCC occurs predominantly via direct, lymphatic and haematogenous spread.2
Management involves a multidisciplinary approach, comprising a combination of resection, radiotherapy and chemotherapy. Extensive ablative surgery is often required, necessitating reconstructive surgery with the aim of restoring a satisfactory degree of function and cosmetic appearance. Reconstruction is frequently achieved by utilising myocutaneous4 or osteomyocutaneous flaps.5 Rare cases of metastasis of primary tumours to donor sites have been reported in oral SCC,6,7,8 breast cancer9,10 and rectal adenocarcinoma.11
We report a case of metastatic spread of oral SCC to an iliac crest free flap donor site.
A 51 year-old lady underwent primary surgery for an advanced right sided T4 retromolar oral SCC. Resection involved hemi-mandibulectomy, radical parotidectomy, tonsillectomy, posterior maxillectomy and right medial masticatory space clearance. Reconstruction was achieved with a right vascularised iliac crest free flap pedicled on the deep circumflex iliac artery, and the defect reconstructed with a right radial forearm free flap. Postoperative wound breakdown necessitated further reconstruction with a pectoralis major flap one month later. Adjuvant radiotherapy was completed 4 months postoperatively.
At 18 months’ follow-up the patient was noted to have an area of swelling and tenderness in the right flank at the upper aspect of the iliac crest flap site thought to represent an incisional hernia or abscess. Aspiration of the swelling produced pus and she was treated with antibiotics. The patient was admitted the following month with persistent sepsis and formal incision and drainage was planned.
Exploration revealed a tumour mass of 11x8x5 cm at the proximal end of the iliac crest donor site wound. The lesion was resected with a margin of normal tissue and histology confirmed a moderately differentiated squamous carcinoma consistent with metastasis from the previously excised oral SCC. Subsequent CT of chest, abdomen and pelvis showed right axillary lymphadenopathy and a mass lesion within the region of the porta hepatis consistent with further lymphadenopathy or intrahepatic metastases. The patient was then referred for palliative chemotherapy.
Donor site metastasis following reconstructive flap surgery is a rare late complication. Secondaries from oral SCC have been reported in pectoralis major 8 and deltopectoral sites.7 There are no reported cases following iliac crest free flap reconstruction.
Systemic dissemination and iatrogenic tumour cell transfer are postulated as mechanisms of tumour spread. An affinity between tumour cells and tissues affected by surgical trauma has been demonstrated in experimental studies.12 Animal studies have also demonstrated a correlation between mitotic activity of human colorectal carcinoma cells and levels of epidermal growth factor.13 Such associations imply that a presence of disseminated tumour cells in combination with growth factors and a hypervascular environment related to wound healing may be applicable to the behaviour of circulating tumour cells in vivo. Surgical wounds are therefore prospective sites for metastasis, with higher risk in tumours such as SCC which are prone to systemic dissemination.
Iatrogenic intra-operative tumour cell seeding has been speculated upon in previous reports. Attention to surgical technique and the changing of gloves and surgical instruments prior to flap harvest have been proposed as prophylactic measures.6,7,8
In this case, the diagnosis was not suspected until the time of resection, with only the more common complications of incisional hernia and wound abscess considered pre-operatively. Including metastatic disease in the differential diagnosis of donor site complications and appropriate imaging prior to considering surgical intervention are recommended. This case highlights the importance of maintaining an index of suspicion for recurrence when faced with flap or donor site complications.
Cancer Research UK. www.cancerresearchuk.org. 2002 figures.
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Vartanian JG, Carvalho AL, Carvalho SM, Mizobe LM, Magrin J, Kowalski LP. Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: experience with 437 cases at a single institution. Head Neck 2004; 26:1018-1023
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Persichetti P, Tenna S, Simone P, Cagli B, Marangi GF, Di Lella F, Vitelli CE, Fortunato L. Donor-site recurrence of rectal adenocarcinoma after reverse latissimus dorsi flap. Plast Reconstr Surg 2004;114 (2):615-8
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