Indian J Surg Oncol (December 2015) 6(4):443–445 DOI 10.1007/s13193-015-0441-9
CASE REPORT
Pedicled TRAM Flap in Presence of Desmoid Tumor of the Rectus Sheath; a Case Report Ashraf Khater 1
Received: 18 April 2015 / Accepted: 23 June 2015 / Published online: 4 July 2015 # Indian Association of Surgical Oncology 2015
Abstract Creating TRAM flap in obese patient is a challenging issue with a hazard of flap ischemia and breast envelope loss or sepsis. In this case we show our experience in doing an interval TRAM flap in markedly obese patient (BMI index 39) in the presence of Desmoid tumor of the anterior abdominal wall on top of previous mesh hernioplasty in the contralateral side of the tumor. Interval TRAM was decided with achieving of a complete vascular delay in the same sitting with skin sparing mastectomy. On doing abdominal ultrasonography for perforator mapping a desmoid tumor was encountered in the contralateral side. The decision was to elevate the flap together with excision of the desmoid tumor with the flap to be sutured in situ at the end of operation and after 5 days to transfer the flap to the mastectomy site. There was no major complications apart from mild wound sepsis of the breast pocket that was controlled medically. According to our proposed aesthetical score, our patient expressed the outcome as good (8/10 points). Pedicled TRAM flap creation in markedly obese patients is hazardous and we recommend this new concept of interval TRAM for this situation. Moreover the presence of desmoid tumor in the rectus sheath is not a contraindication to this flap elevation. The presence of abdominal desmoid tumor is not a contraindication for TRAM flap provided that it can be resected with sparing of perforators on one side of the rectus sheath. Keywords TRAM flap . Vascular delay . Desmoid tumor
Background Desmoid tumor is a rare tumor that constitutes about 3 % of all soft tissue tumors. It is a type of aggressive fibromatosis that invades locally with a tendency for recurrence. However it has no metastatic potential [1, 2]. It can occur in the extremities, deep musculoaponeurosis of the anterior abdominal wall, rectus sheath or intraabdominal (intestinal mesenteric Desmoid) especially in association with familial adenomatous polyposis coli (FAP) [3]. Desmoid tumor (DT) can be sporadic or familial (with FAP) [4]. There is a controversy about the etiology of the sporadic cases but the common incidence in females in the child bearing period with rare occurrence after menopause and the noticeable size increase in pregnancy raised the estrogen growth dependence theory and hence tamoxifen was introduced as a therapeutic option [1]. However a recent larger studies that studied the presence of estrogen receptor and HER2 are not supporting the presence of these receptors among most of patients which make surgical resection with safety margin is the corner stone of treatment [5]. Trauma, irradiation, old scars are common association with abdominal desmoid [3]. We presents a 39 years old lady with a 3 years history of inlay mesh repair of the anterior abdominal wall who presented by a left breast cancer. Abdominal wall desmoid was detected on doing abdominal ultrasonography with duplex for perforator evaluation for a planned TRAM flap.
* Ashraf Khater [email protected]; [email protected]
Case Presentation 1
Surgical Oncology Department, Mansoura Oncology Center (OCMU), Faculty of Medicine, Mansoura University, Gomhoria Street, 35511 Mansoura, Egypt
This report presents a 39 years old lady who presented by a breast lump in the upper outer quadrant of the left breast
444
Indian J Surg Oncol (December 2015) 6(4):443–445
Fig. 1 a Patient anterior view with black arrow pointing to the planned perforators and the red arrow pointing to the old abdominal scar. b abdominal ultrasonography showing the desmoid tumor
that was proven to be malignant after an incisional biopsy taken by a general surgeon. This patient gave a history of inlay mesh repair of the lower abdominal wall mainly on the lower right abdomen (Fig. 1). After doing the routine investigations and after patient counseling, TRAM flap was decided. Because of being markedly obese (BMI was 39) and because of the marked abdominal belly redundancy, interval inset was decided within the same hospital stay with a first operation including skin sparing mastectomy together with skin and vascular delay of TRAM flap which is to be sutured again in situ (Fig. 2) and after 5 days in the same hospital admission, the deepithelialized TRAM flap was transmitted into the breast envelope after being sure of its vascularity and absence of breast envelope necrosis. On doing abdominal ultrasonography with duplex study for perforator evaluation, there was a surprising well circumscribed lesion of about 10 cm in maximum diameter that was attached to the anterior abdominal wall of the opposite side of the tumor that was consistent with Desmoid tumor (Fig. 1). The decision was to excise the Desmoid tumor with safety margin in the same situation with TRAM flap elevation with the flap being based on the ipsilateral perforators (left side). Fig. 2 a Elevated TRAM exposing the desmoid tumor (green arrow). b TRAM sutured in situ with closure of the mastectomy wound over a drain
Method In the first exploration, skin sparing mastectomy was done. Then the TRAM flap was dissected away from the right anterior abdominal wall with exposure of the Desmoid tumor which was then resected with safety margin that was confirmed with frozen section. The TRAM flap was elevated in the usual manner with complete skin and vascular delay then it was sutured in situ with closure of the mastectomy skin with a simple tube drain (Fig. 2). After 5 days, the patient was reexplored with definitive TRAM inset after de-epithelialization when being sure of the flap and envelope vascularity and after division of area four. The parietal defect after excision of the Desmoid was closed with a proline mesh.
Results No major complications were encountered apart from mild breast wound sepsis that was controlled medically. For assessment of the aesthetic outcome we used a simplified scoring system based on subjective patient satisfaction about her reconstructed breast that was expressed as excellent (5 points),
Indian J Surg Oncol (December 2015) 6(4):443–445
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ligation of the inferior epigastric system [8]. In this case the presence of abdominal wall desmoid tumor (DT) did not preclude the flap elevation and was not a contraindication of TRAM flap. Wide local excision was possible with flap dependence on the perforators of the other side (it was the ipsilateral side for the tumor).
Conclusion
Fig. 3 Anterior view 3 weeks postoperatively
good (4 points), satisfactory (3 points), poor (2 points) and very poor (1 point) combined with an objective score based on breast shape, symmetry and symmetry of the nipple areola complex that was made from 1 to 5. We collected the data gathered from both systems to be expressed as excellent (9 to 10 points), good (7 to 8 points), satisfactory (5 to 6 points), poor (3 to 4 points) and very poor (1 to 2 points). Our patient expressed the aesthetic outcome as good (8 points) (Fig. 3).
The presence of abdominal Desmoid tumor is not a contraindication for TRAM flap provided that it can be resected with sparing of perforators on one side of the rectus sheath. Acknowledgments The author is thankful for Dr. Aiman Elsaed for his technical support throughout this work. Conflict of Interest interest.
References 1.
Discussion TRAM flap inset in presence of obesity is a challenging situation with hazard of both flap loss either partially or completely [6]. Envelope flap necrosis is another bothersome problem that makes the final cosmetic appearance markedly jeopardized [7]. Our concept of interval TRAM flap inset that can be applied for cases with risk of flap loss such as obese females entails creation of vascular and skin delay together with skin sparing mastectomy in the first operation that ends by suturing of the TRAM in situ with closure of the mastectomy skin with a simple tube drain. After 5 to 7 days within the same hospital admission, the patient is re-explored after being sure that the envelope skin is viable and the TRAM flap is well vascularized with transmission of the de-epithelialized flap to the mastectomy bed after division of area four in the usual way. Of course the vascular delay within the same hospital stay was proven to augment the arterial supply and decrease the problem of the venous congestion that occurs after acute
The author declares that he has no conflict of
2.
3.
4.
5.
6.
7.
8.
Ma JH, Ma ZH, Dong XF, Yin H, Zhao YF (2013) Abdominal wall desmoid tumors: a case report. Oncol Lett 5(6):1976–1978 Economou A, Pitta X, Andreadis E, Papapavlou L, Chrissidis T (2011) Desmoid tumor of the abdominal wall: a case report. J Med Case Rep 5:326 Overhaus M, Decker P, Fischer HP, Textor HJ, Hirner A (2003) Desmoid tumors of the abdominal wall: a case report. World J Surg Oncol 1:11 Colombo C, Foo WC, Whiting D, Young ED, Lusby K, Pollock RE, Lazar AJ, Lev D (2012) FAP-related desmoid tumors: a series of 44 patients evaluated in a cancer referral center. Histol Histopathol 27(5):641–649 Leithner A, Gapp M, Radl R, Pascher A, Krippl P, Leithner K, Windhager R, Beham A (2005) Immunohistochemical analysis of desmoid tumours. J Clin Pathol 58(11):1152–1156 Chang DW, Wang B, Robb GL, Reece GP, Miller MJ, Evans GR, Langstein HN, Kroll SS (2000) Effect of obesity on flap and donorsite complications in free transverse rectus abdominis myocutaneous flap breast reconstruction. Plast Reconstr Surg 105(5):1640–1648 Atisha DM, Comizio RC, Telischak KM, Higgins JH, Collins ED (2010) Interval inset of TRAM flaps in immediate breast reconstruction: a technical refinement. Ann Plast Surg 65(6):524–527 Codner MA, Bostwick J III, Nahai F, Bried JT, Eaves FT (1995) TRAM flap vascular delay for high-risk breast reconstruction. Plast Reconstr Surg 96(7):1615–1622
CASE REPORT
Pedicled TRAM Flap in Presence of Desmoid Tumor of the Rectus Sheath; a Case Report Ashraf Khater 1
Received: 18 April 2015 / Accepted: 23 June 2015 / Published online: 4 July 2015 # Indian Association of Surgical Oncology 2015
Abstract Creating TRAM flap in obese patient is a challenging issue with a hazard of flap ischemia and breast envelope loss or sepsis. In this case we show our experience in doing an interval TRAM flap in markedly obese patient (BMI index 39) in the presence of Desmoid tumor of the anterior abdominal wall on top of previous mesh hernioplasty in the contralateral side of the tumor. Interval TRAM was decided with achieving of a complete vascular delay in the same sitting with skin sparing mastectomy. On doing abdominal ultrasonography for perforator mapping a desmoid tumor was encountered in the contralateral side. The decision was to elevate the flap together with excision of the desmoid tumor with the flap to be sutured in situ at the end of operation and after 5 days to transfer the flap to the mastectomy site. There was no major complications apart from mild wound sepsis of the breast pocket that was controlled medically. According to our proposed aesthetical score, our patient expressed the outcome as good (8/10 points). Pedicled TRAM flap creation in markedly obese patients is hazardous and we recommend this new concept of interval TRAM for this situation. Moreover the presence of desmoid tumor in the rectus sheath is not a contraindication to this flap elevation. The presence of abdominal desmoid tumor is not a contraindication for TRAM flap provided that it can be resected with sparing of perforators on one side of the rectus sheath. Keywords TRAM flap . Vascular delay . Desmoid tumor
Background Desmoid tumor is a rare tumor that constitutes about 3 % of all soft tissue tumors. It is a type of aggressive fibromatosis that invades locally with a tendency for recurrence. However it has no metastatic potential [1, 2]. It can occur in the extremities, deep musculoaponeurosis of the anterior abdominal wall, rectus sheath or intraabdominal (intestinal mesenteric Desmoid) especially in association with familial adenomatous polyposis coli (FAP) [3]. Desmoid tumor (DT) can be sporadic or familial (with FAP) [4]. There is a controversy about the etiology of the sporadic cases but the common incidence in females in the child bearing period with rare occurrence after menopause and the noticeable size increase in pregnancy raised the estrogen growth dependence theory and hence tamoxifen was introduced as a therapeutic option [1]. However a recent larger studies that studied the presence of estrogen receptor and HER2 are not supporting the presence of these receptors among most of patients which make surgical resection with safety margin is the corner stone of treatment [5]. Trauma, irradiation, old scars are common association with abdominal desmoid [3]. We presents a 39 years old lady with a 3 years history of inlay mesh repair of the anterior abdominal wall who presented by a left breast cancer. Abdominal wall desmoid was detected on doing abdominal ultrasonography with duplex for perforator evaluation for a planned TRAM flap.
* Ashraf Khater [email protected]; [email protected]
Case Presentation 1
Surgical Oncology Department, Mansoura Oncology Center (OCMU), Faculty of Medicine, Mansoura University, Gomhoria Street, 35511 Mansoura, Egypt
This report presents a 39 years old lady who presented by a breast lump in the upper outer quadrant of the left breast
444
Indian J Surg Oncol (December 2015) 6(4):443–445
Fig. 1 a Patient anterior view with black arrow pointing to the planned perforators and the red arrow pointing to the old abdominal scar. b abdominal ultrasonography showing the desmoid tumor
that was proven to be malignant after an incisional biopsy taken by a general surgeon. This patient gave a history of inlay mesh repair of the lower abdominal wall mainly on the lower right abdomen (Fig. 1). After doing the routine investigations and after patient counseling, TRAM flap was decided. Because of being markedly obese (BMI was 39) and because of the marked abdominal belly redundancy, interval inset was decided within the same hospital stay with a first operation including skin sparing mastectomy together with skin and vascular delay of TRAM flap which is to be sutured again in situ (Fig. 2) and after 5 days in the same hospital admission, the deepithelialized TRAM flap was transmitted into the breast envelope after being sure of its vascularity and absence of breast envelope necrosis. On doing abdominal ultrasonography with duplex study for perforator evaluation, there was a surprising well circumscribed lesion of about 10 cm in maximum diameter that was attached to the anterior abdominal wall of the opposite side of the tumor that was consistent with Desmoid tumor (Fig. 1). The decision was to excise the Desmoid tumor with safety margin in the same situation with TRAM flap elevation with the flap being based on the ipsilateral perforators (left side). Fig. 2 a Elevated TRAM exposing the desmoid tumor (green arrow). b TRAM sutured in situ with closure of the mastectomy wound over a drain
Method In the first exploration, skin sparing mastectomy was done. Then the TRAM flap was dissected away from the right anterior abdominal wall with exposure of the Desmoid tumor which was then resected with safety margin that was confirmed with frozen section. The TRAM flap was elevated in the usual manner with complete skin and vascular delay then it was sutured in situ with closure of the mastectomy skin with a simple tube drain (Fig. 2). After 5 days, the patient was reexplored with definitive TRAM inset after de-epithelialization when being sure of the flap and envelope vascularity and after division of area four. The parietal defect after excision of the Desmoid was closed with a proline mesh.
Results No major complications were encountered apart from mild breast wound sepsis that was controlled medically. For assessment of the aesthetic outcome we used a simplified scoring system based on subjective patient satisfaction about her reconstructed breast that was expressed as excellent (5 points),
Indian J Surg Oncol (December 2015) 6(4):443–445
445
ligation of the inferior epigastric system [8]. In this case the presence of abdominal wall desmoid tumor (DT) did not preclude the flap elevation and was not a contraindication of TRAM flap. Wide local excision was possible with flap dependence on the perforators of the other side (it was the ipsilateral side for the tumor).
Conclusion
Fig. 3 Anterior view 3 weeks postoperatively
good (4 points), satisfactory (3 points), poor (2 points) and very poor (1 point) combined with an objective score based on breast shape, symmetry and symmetry of the nipple areola complex that was made from 1 to 5. We collected the data gathered from both systems to be expressed as excellent (9 to 10 points), good (7 to 8 points), satisfactory (5 to 6 points), poor (3 to 4 points) and very poor (1 to 2 points). Our patient expressed the aesthetic outcome as good (8 points) (Fig. 3).
The presence of abdominal Desmoid tumor is not a contraindication for TRAM flap provided that it can be resected with sparing of perforators on one side of the rectus sheath. Acknowledgments The author is thankful for Dr. Aiman Elsaed for his technical support throughout this work. Conflict of Interest interest.
References 1.
Discussion TRAM flap inset in presence of obesity is a challenging situation with hazard of both flap loss either partially or completely [6]. Envelope flap necrosis is another bothersome problem that makes the final cosmetic appearance markedly jeopardized [7]. Our concept of interval TRAM flap inset that can be applied for cases with risk of flap loss such as obese females entails creation of vascular and skin delay together with skin sparing mastectomy in the first operation that ends by suturing of the TRAM in situ with closure of the mastectomy skin with a simple tube drain. After 5 to 7 days within the same hospital admission, the patient is re-explored after being sure that the envelope skin is viable and the TRAM flap is well vascularized with transmission of the de-epithelialized flap to the mastectomy bed after division of area four in the usual way. Of course the vascular delay within the same hospital stay was proven to augment the arterial supply and decrease the problem of the venous congestion that occurs after acute
The author declares that he has no conflict of
2.
3.
4.
5.
6.
7.
8.
Ma JH, Ma ZH, Dong XF, Yin H, Zhao YF (2013) Abdominal wall desmoid tumors: a case report. Oncol Lett 5(6):1976–1978 Economou A, Pitta X, Andreadis E, Papapavlou L, Chrissidis T (2011) Desmoid tumor of the abdominal wall: a case report. J Med Case Rep 5:326 Overhaus M, Decker P, Fischer HP, Textor HJ, Hirner A (2003) Desmoid tumors of the abdominal wall: a case report. World J Surg Oncol 1:11 Colombo C, Foo WC, Whiting D, Young ED, Lusby K, Pollock RE, Lazar AJ, Lev D (2012) FAP-related desmoid tumors: a series of 44 patients evaluated in a cancer referral center. Histol Histopathol 27(5):641–649 Leithner A, Gapp M, Radl R, Pascher A, Krippl P, Leithner K, Windhager R, Beham A (2005) Immunohistochemical analysis of desmoid tumours. J Clin Pathol 58(11):1152–1156 Chang DW, Wang B, Robb GL, Reece GP, Miller MJ, Evans GR, Langstein HN, Kroll SS (2000) Effect of obesity on flap and donorsite complications in free transverse rectus abdominis myocutaneous flap breast reconstruction. Plast Reconstr Surg 105(5):1640–1648 Atisha DM, Comizio RC, Telischak KM, Higgins JH, Collins ED (2010) Interval inset of TRAM flaps in immediate breast reconstruction: a technical refinement. Ann Plast Surg 65(6):524–527 Codner MA, Bostwick J III, Nahai F, Bried JT, Eaves FT (1995) TRAM flap vascular delay for high-risk breast reconstruction. Plast Reconstr Surg 96(7):1615–1622
