Flap delineation guidelines in postoperative head and neck radiation therapy for head and neck cancers

Guévelou, Jennifer Le; Bastit, Vianney; Marcy, Pierre Yves; Lasne-Cardon, Audrey; Guzene, Leslie; Gerard, M; Larnaudie, A.; Beddok, Arnaud; Calugaru, Valentin; Johnson, Alison; Géry, B.; Liem, X.; Pointreau, Y.; Bourhis, Jean; Thariat, Juliette; Gortec,

doi:10.1016/j.radonc.2020.08.025

Cited by 13 publications

(11 citation statements)

References 31 publications

(33 reference statements)

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“…7 The anatomy and clinical aspects of anterolateral thigh flap in adults have been extensively studied, and relevant guidelines have been established. 8 However, some scholars are cautious about performing free flap in children because of narrow blood vessels, rapid change of disease, and complicated perioperative management. 9 Therefore, anterolateral thigh flaps are rarely used in pediatric patients.…”

Section: Discussionmentioning

confidence: 99%

Microsurgical Anterolateral Thigh Flap for Reconstruction of Extremity Soft Tissue Defects in Pediatric Patients

Shi¹,

Xu²,

Zhu³

et al. 2022

Ann Plast Surg

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Background: The anterolateral thigh flap is one of the most widely used flaps because it has the advantages of less damage to the donor site, no sacrifice of main blood vessels, and abundant soft tissue. However, the application of anterolateral thigh flap in children is relatively rare because of small blood vessels and rapid physiological changes. The aim of this study was to explore the effectiveness and characteristics of free anterolateral thigh flaps for the reconstruction of extremity soft tissue defects in pediatric patients. Patients and Methods: This study included 26 pediatric patients, with an average age of 6.7 years (range, 2-13 years). There were 5 cases of upper limb defects and 21 cases of lower limb defects, all of which were accompanied by exposed bones or tendons. The causes of defects included traffic injury in 9 cases, mechanical injury in 7 cases, collision injury in 4 cases, spoke injury in 3 cases, cicatricial contracture in 2 cases, and fibroma in 1 case. All defects were reconstructed with free anterolateral thigh flaps. Results: Twenty-six anterolateral thigh flaps were harvested, including 15 fasciocutaneous flaps and 11 musculocutaneous flaps. The mean size of the flap was 73.4 cm 2 (range, 4 Â 3 to 24 Â 8 cm). The donor sites were sutured directly in 19 cases and underwent split-thickness skin grafting in 7 cases. There were 3 cases of vascular crisis, 3 cases of flap edge necrosis, 3 cases of infection, 1 case of pressure ulcer, and 1 case of dehiscence after surgery. Eleven patients had scar hyperplasia in the donor site. A total of 34 reoperations were performed, including 14 flap debulking, 7 debridement, 4 skin graft, 3 vascular crisis re-exploration, and 6 other procedures. Conclusions: Free anterolateral thigh flap was a safe and reliable option for reconstructing soft tissue defects of extremities in pediatric patients. Notably, the incidence of scar hyperplasia in the donor site and the possibility of reoperation in pediatric patients were higher than those in adult patients.

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Section: Discussionmentioning

confidence: 99%

Microsurgical Anterolateral Thigh Flap for Reconstruction of Extremity Soft Tissue Defects in Pediatric Patients

Shi¹,

Xu²,

Zhu³

et al. 2022

Ann Plast Surg

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“…underdosing in the area of the target volume and to avoid the risk of overdosing in the area of healthy tissue at the same time [ 7 ]. Especially in case of free flap soft tissue reconstruction, which is performed frequently in patients with large head and neck tumors, precise delineation of the tumor bed in postoperative medical imaging poses a challenging task due to similar contrast values of native and reconstructed soft tissue [ 8 , 9 ]. In this context, intraoperative incorporation of titanium ligature clips has been demonstrated to facilitate precise definition of the tumor bed in postsurgical imaging, allowing for an increased accuracy of adjuvant radiation treatment [ 9 , 10 ].…”

Section: Introductionmentioning

confidence: 99%

Evaluation of computed tomography settings in the context of visualization and discrimination of low dose injections of a novel liquid soft tissue fiducial marker in head and neck imaging

et al. 2021

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Background Intraoperative incorporation of radiopaque fiducial markers at the tumor resection surface can provide useful assistance in identifying the tumor bed in postoperative imaging for RT planning and radiological follow-up. Besides titanium clips, iodine containing injectable liquid fiducial markers represent an option that has emerged more recently for this purpose. In this study, marking oral soft tissue resection surfaces, applying low dose injections of a novel Conformité Européenne (CE)-marked liquid fiducial marker based on sucrose acetoisobutyrate (SAIB) and iodinated SAIB (x-SAIB) was investigated. Methods Visibility and discriminability of low dose injections of SAIB/x-SAIB (10 µl, 20 µl, 30 µl) were systematically studied at different kV settings used in clinical routine in an ex-vivo porcine mandible model. Transferability of the preclinical results into the clinical setting and applicability of DE-CT were investigated in initial patients. Results Markers created by injection volumes as low as 10 µl were visible in CT imaging at all kV settings applied in clinical routine (70–120 kV). An injection volume of 30 µl allowed differentiation from an injection volume of 10 µl. In a total of 118 injections performed in two head and neck cancer patients, markers were clearly visible in 83% and 86% of injections. DE-CT allowed for differentiation between SAIB/x-SAIB markers and other hyperdense structures. Conclusions Injection of low doses of SAIB/x-SAIB was found to be a feasible approach to mark oral soft tissue resection surfaces, with injection volumes as low as 10 µl found to be visible at all kV settings applied in clinical routine. With the application of SAIB/x-SAIB reported for tumors of different organs already, mostly applying relatively large volumes for IGRT, this study adds information on the applicability of low dose injections to facilitate identification of the tumor bed in postoperative CT and on performance of the marker at different kV settings used in clinical routine.

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“…Flap definition on imaging has hardly been addressed in the literature and is described with 105 grade C evidence at best [2,14,15,25,41]. Still, at final review, flap definition was able to 106 achieve strong agreement for 6 items (Table 2).…”

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confidence: 99%

“…Ten items were controversial: 7 after the second round and 3 after external review (Table 2). 115 Experts disagreed on the degree of difficulty in identifying flap contours or components on a 116 planning CT as well as identification of the junctional area [15]. More importantly, no 117 consensus was reached within the committee as to how the flap should be delineated (Table 118 2).…”

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confidence: 99%

“…The review group disagreed 143 on the need for systematic coregistration of the preoperative imaging with the postoperative 144 CT scan to define the postoperative CTV, and on the inclusion in the CTV of "direct" 145 postoperative modifications (edema, hematoma, lymphocele) due to flap surgery. The review 146 group did not agree on the likelihood of microscopic tumor spread patterns from the 147 junctional area toward deep native tissues or whether tumor spread pattern was dependent 148 on flap components (mucosa / skin, fat, muscle / fascia, bone) [15]. The review group also 149 would not endorse consensus on a 6 mm size to define the junction area [44].…”

mentioning

confidence: 99%

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Recommendations for postoperative radiotherapy in head & neck squamous cell carcinoma in the presence of flaps: A GORTEC internationally-reviewed HNCIG-endorsed consensus

Carsuzaa

Lapeyre

Grégoire

et al. 2021

Radiotherapy and Oncology

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Flap delineation guidelines in postoperative head and neck radiation therapy for head and neck cancers

Cited by 13 publications

References 31 publications

Microsurgical Anterolateral Thigh Flap for Reconstruction of Extremity Soft Tissue Defects in Pediatric Patients

Microsurgical Anterolateral Thigh Flap for Reconstruction of Extremity Soft Tissue Defects in Pediatric Patients

Evaluation of computed tomography settings in the context of visualization and discrimination of low dose injections of a novel liquid soft tissue fiducial marker in head and neck imaging

Recommendations for postoperative radiotherapy in head & neck squamous cell carcinoma in the presence of flaps: A GORTEC internationally-reviewed HNCIG-endorsed consensus

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