Hyun Suk Suh

Factors predicting radiation pneumonitis in locally advanced non-small cell lung cancer

Purpose Thoracic radiotherapy is a major treatment modality of stage III non-small cell lung cancer. The normal lung tissue is sensitive to radiation and radiation pneumonitis is the most important dose-limiting complication of thoracic radiation therapy. This study was performed to identify the clinical and dosimetric parameters related to the risk of radiation pneumonitis after definitive radiotherapy in stage III non-small cell cancer patients. Materials and Methods The medical records were reviewed for 49 patients who completed definitive radiation therapy for locally advanced non-small cell lung cancer from August 2000 to February 2010. Radiation therapy was delivered with the daily dose of 1.8 Gy to 2.0 Gy and the total radiation dose ranged from 50.0 Gy to 70.2 Gy (median, 61.2 Gy). Elective nodal irradiation was delivered at a dose of 45.0 Gy to 50.0 Gy. Seven patients (14.3%) were treated with radiation therapy alone and forty two patients (85.7%) were treated with chemotherapy either sequentially or concurrently. Results Twenty-five cases (51.0%) out of 49 cases experienced radiation pneumonitis. According to the radiation pneumonitis grade, 10 (20.4%) were grade 1, 9 (18.4%) were grade 2, 4 (8.2%) were grade 3, and 2 (4.1%) were grade 4. In the univariate analyses, no clinical factors including age, sex, performance status, smoking history, underlying lung disease, tumor location, total radiation dose and chemotherapy were associated with grade ≥2 radiation pneumonitis. In the subgroup analysis of the chemotherapy group, concurrent rather than sequential chemotherapy was significantly related to grade ≥2 radiation pneumonitis comparing sequential chemotherapy. In the univariate analysis with dosimetric factors, mean lung dose (MLD), V20, V30, V40, MLDipsi, V20ipsi, V30ipsi, and V40ipsi were associated with grade ≥2 radiation pneumonitis. In addition, multivariate analysis showed that MLD and V30 were independent predicting factors for grade ≥2 radiation pneumonitis. Conclusion Concurrent chemotherapy, MLD and V30 were statistically significant predictors of grade ≥2 radiation pneumonitis in patients with stage III non-small cell lung cancer undergoing definitive radiotherapy. The cutoff values for MLD and V30 were 16 Gy and 18%, respectively.

A New Approach for Reconstruction of Diabetic Foot Wounds Using the Angiosome and Supermicrosurgery Concept.

Background: Major vessels in the diabetic foot are often calcified and inadequate for use as recipient vessels. Thus, a supermicrosurgery technique using small branches or perforators from other collateral vessels with an adequate pulse may be an alternative method. This study evaluated outcome using the supermicrosurgery concept and the risk factors involved. Methods: Ninety-five cases of diabetic foot reconstruction were reviewed; the average patient age was 57 years; average follow-up was 43.5 months. Débridement was performed according to the angiosome concept, and reconstruction was performed with perforator flaps using the supermicrosurgery approach. Correlation between total flap loss and 16 preoperative risk factors (age, sex, diabetes mellitus type, smoking, immunosuppression, flap size, hemoglobin A1c, ankle-brachial index, preoperative transcutaneous partial pressure of oxygen, C-reactive protein, computed tomographic angiography, amputation history, peripheral artery disease, American Society of Anesthesiologists physical status, osteomyelitis, and chronic renal failure) were analyzed. Results: Of 95 cases, nine cases of total loss and 12 of minor complication were noted. Among the risk factors, the odds for failure after peripheral artery disease was 10.99 (p = 0.035), and that associated with a history of amputation was 9.44 (0.0006). Other factors had no correlation with flap loss, including cases with no or one major vessel. Flap survival rate was 90.5 percent, and the overall limb salvage rate was 93.7 percent. Conclusions: Despite the high risk of failure related to peripheral artery disease and history of amputation, the supermicrosurgery approach using a recipient vessel with good pulsation regardless of the source can achieve limb salvage. This approach extends the possibility for reconstruction in patients with severe ischemic diabetic foot. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Safety of silastic sheet for orbital wall reconstruction.

Background Many implants are being used for the reconstruction of orbital wall fractures. The effect of the choice of implant for the reconstruction of an orbital wall fracture on the surgical outcome is under debate. The purpose of this article is to compare the outcomes of orbital wall reconstruction of small orbital wall fractures on the basis of the implants used. Methods The authors conducted a retrospective study using electronic databases. Between March 2001 and December 2012, 461 patients with orbital wall fractures were included in this study. Among them, 431 patients in whom the fracture size was less than 300 mm2 were analyzed. The fracture size was calculated using computed tomography scans of the orbit in the sagittal and coronal images. Cases in which the fracture size was less than 300 mm2 were included in this study. Results One hundred and twenty-nine patients were treated with silastic sheets; 238 patients were treated with titanium meshes; and absorbable meshes were used in the case of 64 patients. Overall, 13 patients required revision, and the revision rate was 3.0%. The revision rate of the silastic sheet group was 5.4%. In the multivariable analysis, the revision rate of the group reconstructed with silastic sheets was highly statistically significant (P=0.043, odds ratio=3.65). However, other factors such as age, sex, fracture type, and fracture size were not significant. Conclusions Reconstruction of orbital wall fractures with silastic sheets may cause more complications than that with other materials such as titanium meshes and absorbable meshes.

Long-term results of forward intensity-modulated radiation therapy for patients with early-stage breast cancer

Purpose To observe long-term clinical outcomes for patients with early-stage breast cancer treated with forward intensity-modulated radiation therapy (IMRT), including local control and clinical toxicities. Materials and Methods We retrospectively analyzed a total of 214 patients with stage I-II breast cancer who were treated with breast conserving surgery followed by adjuvant breast radiation therapy between 2001 and 2008. All patients were treated using forward IMRT. The whole breast was irradiated to a dose of 50 to 50.4 Gy followed by an 8 to 12 Gy electron boost to the surgical bed. Results The median age was 46 years (range, 21 to 82 years) and the medial follow-up time was 7.3 years (range, 2.4 to 11.7 years). Stage T1 was 139 (65%) and T2 was 75 (35%), respectively. Ipsilateral breast recurrence was observed in 3 patients. The 5- and 10-year local control rates were 99.1% and 97.8%, respectively. The cosmetic outcome was evaluated according to the Harvard scale and 89.4% of patients were scored as excellent or good. Conclusion The whole breast radiation therapy as an adjuvant treatment using a forward IMRT technique showed excellent long-term local control as well as favorable outcomes of toxicity and cosmesis.

Study of the Medial Superficial Perforator of the Superficial Circumflex Iliac Artery Perforator Flap Using Computed Tomographic Angiography and Surgical Anatomy in 142 Patients

Background: The two major perforators supplying the superficial circumflex iliac artery perforator flap are the medial (superficial) and lateral (deep) perforators; however, they lack detailed description. The purpose of this study was to clarify the anatomy. Methods: In a prospective analysis of 142 patients, computed tomographic angiograms of 284 superficial circumflex iliac artery perforator regions were evaluated, and 142 superficial circumflex iliac artery perforator flaps were surgically correlated. The origin of the superficial circumflex iliac artery, the origin of the medial perforator, the location where it penetrates the deep fascia, and its pattern of pathway after penetration of the superficial fascia were evaluated. Results: There was 100 percent correlation between computed tomographic angiogram and surgical findings. The superficial circumflex iliac artery originates mostly from the femoral artery in 84.8 percent. The medial perforator originated from the superficial circumflex iliac artery in 94 percent. The medial perforator typically penetrated the deep fascia within an oval of 4.2 × 2 cm located 4.5 cm lateral and 1.5 cm superior from the pelvic tubercle. After passing the superficial fascia, the medial perforator either anchored directly into skin (56 percent) or traveled in an axial pattern (44 percent) beyond the anterior superior iliac spine. Conclusions: Despite the origin of the medial perforator, it was constantly observed penetrating the deep fascia. However, the pathway of the medial perforator can be either anchoring directly into the dermis or extending as an axial pattern artery, implicating a different effect on the survival of the flap. These new findings will allow better understanding for elevating the superficial circumflex iliac artery perforator flap based on the medial perforator.

Posterior interosseous artery perforator-free flap: Treating intermediate-size hand and foot defects

INTRODUCTION Ambiguous defects on the hand and foot, especially on the fingers and toes, are still challenging to treat despite achievements in reconstruction. AIM The purpose of this study was to evaluate the use of the posterior interosseous artery perforator flap for resurfacing intermediate-sized defects and provide adequate coverage over tendons and bones. METHOD Between October 2008 and March 2013, a total of 19 patients with soft-tissue defects on the hand or foot were treated. Flap elevation, anatomy, and clinical progress were evaluated. RESULT All flaps survived and covered the defects, which ranged in area from 12 to 45 cm(2). The freestyle approach was used to harvest the flaps. The average length of the pedicle was 2.5 cm, and the pedicle was harvested without affecting the source vessel. The average diameter of the artery was 0.8 mm, and the average thickness of the flap was 3.5 mm. Anastomosis was performed either end-to-end on the perforator, or end-to-side on deep vessels. No subsequent thinning or surgical flap correction was necessary. Ambulation was allowed at 3 days postsurgery. The donor site was closed primarily to leave an acceptable donor site. DISCUSSION A posterior interosseous artery perforator-free flap is a suitable choice for intermediate-size defects that are too large to cover using a local flap or too small for a first-line perforator flap. Up to 45 cm(2) of adequate coverage can be provided using a thin posterior interosseous artery perforator-free flap that does not require additional debulking. The disadvantages of a short pedicle can be overcome using perforator-to-perforator supermicrosurgery.

Freestyle multiple propeller flap reconstruction (jigsaw puzzle approach) for complicated back defects.

BACKGROUND The reconstruction of the posterior trunk remains to be a challenge as defects can be extensive, with deep dead space, and fixation devices exposed. Our goal was to achieve a tension-free closure for complex defects on the posterior trunk. PATIENTS AND METHODS From August 2006 to May 2013, 18 cases were reconstructed with multiple flaps combining perforator(s) and local skin flaps. The reconstructions were performed using freestyle approach. Starting with propeller flap(s) in single or multilobed design and sequentially in conjunction with adjacent random pattern flaps such as fitting puzzle. All defects achieved tensionless primary closure. The final appearance resembled a jigsaw puzzle-like appearance. RESULTS The average size of defect was 139.6 cm(2) (range, 36-345 cm(2)). A total of 26 perforator flaps were used in addition to 19 random pattern flaps for 18 cases. In all cases, a single perforator was used for each propeller flap. The defect and the donor site all achieved tension-free closure. The reconstruction was 100% successful without flap loss. One case of late infection was noted at 12 months after surgery. CONCLUSION Using multiple lobe designed propeller flaps in conjunction with random pattern flaps in a freestyle approach, resembling putting a jigsaw puzzle together, we can achieve a tension-free closure by distributing the tension to multiple flaps, supplying sufficient volume to obliterate dead space, and have reliable vascularity as the flaps do not need to be oversized. This can be a viable approach to reconstruct extensive defects on the posterior trunk.

Dummy run of quality assurance program in a phase 3 randomized trial investigating the role of internal mammary lymph node irradiation in breast cancer patients: Korean Radiation Oncology Group 08-06 study

PURPOSE The Korean Radiation Oncology Group (KROG) 08-06 study protocol allowed radiation therapy (RT) technique to include or exclude breast cancer patients from receiving radiation therapy to the internal mammary lymph node (IMN). The purpose of this study was to assess dosimetric differences between the 2 groups and potential influence on clinical outcome by a dummy run procedure. METHODS AND MATERIALS All participating institutions were asked to produce RT plans without irradiation (Arm 1) and with irradiation to the IMN (Arm 2) for 1 breast-conservation treatment case (breast-conserving surgery [BCS]) and 1 mastectomy case (modified radical mastectomy [MRM]) whose computed tomography images were provided. We assessed interinstitutional variations in IMN delineation and evaluated the dose-volume histograms of the IMN and normal organs. A reference IMN was delineated by an expert panel group based on the study guidelines. Also, we analyzed the potential influence of actual dose variation observed in this study on patient survival. RESULTS Although physicians intended to exclude the IMN within the RT field, the data showed almost 59.0% of the prescribed dose was delivered to the IMN in Arm 1. However, the mean doses covering the IMN in Arm 1 and Arm 2 were significantly different for both cases (P<.001). Due to the probability of overdose in Arm 1, the estimated gain in 7-year disease-free survival rate would be reduced from 10% to 7.9% for BCS cases and 7.1% for MRM cases. The radiation doses to the ipsilateral lung, heart, and coronary artery were lower in Arm 1 than in Arm 2. CONCLUSIONS Although this dummy run study indicated that a substantial dose was delivered to the IMN, even in the nonirradiation group, the dose differences between the 2 groups were statistically significant. However, this dosimetric profile should be studied further with actual patient samples and be taken into consideration when analyzing clinical outcomes according to IMN irradiation.

Reply: The efficacy of Perforator flaps in the treatment of chronic osteomyelitis

Background: Treatment of chronic osteomyelitis involves aggressive débridement followed by soft-tissue coverage. The dictum of muscle coverage being superior has been challenged by successful reports of coverage with skin flaps. The objective of this article is to evaluate the efficacy of perforator flaps for reconstruction of chronic osteomyelitis defects. Methods: A retrospective review of 120 patients with chronic osteomyelitis who underwent débridement and reconstruction using perforator flaps from April of 2000 to November of 2015 was conducted. Inclusion criteria were cases with chronic osteomyelitis for a minimum of 6 weeks and with a follow-up of at least 2 years after surgery. Correlation between recurrence and the following factors was analyzed: comorbidities, frequency of débridement, duration of chronic osteomyelitis, limb vascular status, and method of dead space obliteration. The outcomes analyzed were flap loss, recurrence rate, primary remission rate, secondary remission rate, and amputation rate. Results: The flap loss rate was 4.2 percent flap, the recurrence rate was 8.3 percent, the primary remission rate was 91.6 percent, the secondary remission rate was 98.3 percent, and the amputation rate was 1 percent. Significant predictors of recurrence were peripheral vascular disease and major vessel compromise, which had 5.1 times higher odds of recurrence (p < 0.05). Conclusions: Used with adequate débridement, bone reconstruction, and obliteration of dead space, a primary remission rate of 91.6 percent and a secondary remission rate of 98.3 percent were achieved using perforator flap. The predictors of chronic osteomyelitis recurrence were peripheral vascular disease and major vascular compromise. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Radiation Pneumonitis in Association with Internal Mammary Node Irradiation in Breast Cancer Patients: An Ancillary Result from the KROG 08-06 Study

Purpose The aim of this study is to present the incidence of radiation pneumonitis (RP) reported within 6 months after treatment for breast cancer with or without internal mammary node irradiation (IMNI). Methods In the Korean Radiation Oncology Group (KROG) 08-06 phase III randomized trial, patients who were node-positive after surgery were randomly assigned to receive radiotherapy either with or without IMNI. A total of 747 patients were enrolled, and three-dimensional treatment planning with computed tomography simulation was performed for all patients. Of the 747 patients, 722 underwent chest X-rays before and within 6 months after radiotherapy. These 722 patients underwent evaluation, and RP was diagnosed on the basis of chest radiography findings and clinical symptoms. The relationship between the incidence of RP and clinical/dosimetric parameters was analyzed. Results RP developed in 35 patients (4.8%), including grade 1 RP in 26 patients (3.6%), grade 2 RP in nine patients (1.2%); there was no incidence of grade 3 or higher RP. Grade 2 RP cases were observed in only the IMNI group. The risk of developing RP was influenced by IMNI treatment; pneumonitis occurred in 6.5% of patients (n=23/356) who underwent IMNI and in 3.3% of patients (n=12/366) who did not (p=0.047). The differences in lung dosimetric parameters (mean lung dose, V10–40) were statistically significant between the two groups. Conclusion IMNI treatment resulted in increased radiation exposure to the lung and a higher rate of RP, but the incidence and severity of RP was minimal and acceptable. This minor impact on morbidity should be balanced with the impact on survival outcome in future analyses.