LETTERS AND INVITED COMMENTARY Surgical Treatment of Angiosarcoma of the Scalp With Superficial Parotidectomy
To the Editor: t has been just 6 years since Lim et al1 performed a radical tumor resection of the scalp, ipsilateral superficial parotidectomy, and reconstruction using a latissimus dorsi free flap. In this article, the authors operated on 8 patients presenting with angiosarcoma solely of the scalp. Their procedure consisted of a radical tumor resection of the scalp with minimal 5-cm safety margins from the most peripheral scattered lesions with a burring of the external table of the cranium, ipsilateral superficial parotidectomy, and ipsilateral upper neck dissection. After a resection of the tumor of the scalp, the defect was covered with the latissimus dorsi free flap. Their outcomes were very encouraging to the readers because complete excisions were obtained and negative surgical margins were achieved in all 8 patients. The 18-month diseasefree survival of the entire operation group was 100% (median follow-up, 24 months). According to a previous article that Lim et al did not cite, Pawlik et al2 operated on and analyzed 29 patients having angiosarcoma of the scalp and stated that negative surgical margins were achieved in only 21.4% of the patients and the median actuarial survival was 28.4 months. They also wrote that radiation therapy was significantly associated with a decreased chance of death (hazard ratio, 0.16; P = 0.006). Because regional lymph node metastasis has appeared even 5 years after the initial treatment,3 I would really like to know the long-term follow-up results of the 8 patients operated on by Lim et al. To date, some authors advocate radical excision with regional lymph node clearance, with or without adjuvant radiotherapy, whereas others recommend primary radiation therapy, with surgery held in reserve.4–6 Morrison et al5 reported that the 5-year actuarial incidence of distant metastases for all patients was 63%. Lydiatt et al6 treated 18 patients, and among them, 12 patients (67%) had died of disease a mean of 25 months after diagnosis. The overall 5-year survival was 33%, but only 20% of the patients were disease-free. Mark et al7 stated a 5-year disease-free survival of 26% (7/27 patients), in which 21 patients had recurrences after
I
Conflicts of interest and sources of funding: none declared. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7506-0686 DOI: 10.1097/SAP.0000000000000486
686
www.annalsplasticsurgery.com
primary treatment, and 90% (19/21 patients) had a component of local failure. I do hope that their method can be the ideal treatment strategy for scalp angiosarcoma, if only Lim et al would respond with long-term favorable results with tables including histological grading because the only factor affecting survival was histological grade (odds ratio, 6.7; 95% confidence interval, 1.6–28.9) in the previous study.8 Kun Hwang, MD, PhD Department of Plastic Surgery Inha University School of Medicine Incheon, Republic of Korea [email protected]
REFERENCES 1. Lim SY, Pyon JK, Mun GH, et al. Surgical treatment of angiosarcoma of the scalp with superficial parotidectomy. Ann Plast Surg. 2010;64:180–182. 2. Pawlik TM, Paulino AF, McGinn CJ, et al. Cutaneous angiosarcoma of the scalp: a multidisciplinary approach. Cancer. 2003;98;1716–1726. 3. Girod A, Breton P, Freidel M, et al. Cutaneous angiosarcoma of the head: three cases. Rev Stomatol Chir Maxillofac. 2002;103:69–73. 4. Holden CA, Spittle MF, Jones EW. Angiosarcoma of the face and scalp, prognosis and treatment. Cancer. 1987;59:1046–1057. 5. Morrison WH, Byers RM, Garden AS, et al. Cutaneous angiosarcoma of the head and neck: a therapeutic dilemma. Cancer. 1995;76:3l9–327. 6. Lydiatt WM, Shaha AR, Shah JP. Angiosarcoma of the head and neck. Am J Surg. 1994;168:451–454. 7. Mark RJ, Tran LM, Sercarz J, et al. Angiosarcoma of the head and neck. The UCLA experience 1955 through 1990. Arch Otolaryngol Head Neck Surg. 1993;119:973–978. 8. Köhler HF, Neves RI, Brechtbühl ER, et al. Cutaneous angiosarcoma of the head and neck: report of 23 cases from a single institution. Otolaryngol Head Neck Surg. 2008;139:519–524.
Two-Stage Repair for Severe Proximal Hypospadias Using Oral Mucosal Grafts: Combination of a Modified Bracka Method and a Modified Byars Flap Method: Should Local Flaps be Used for Urethral Reconstruction in Hypospadias Repair? Dear Editor, e read with interest the article by Mitsukawa et al.1 The authors have presented a novel repair for the correction of severe hypospadias that combines the use of
W
Byars flaps with the Bracka grafting technique. Although their method seems to give good results, we believe several issues need to be addressed. Bracka's 2-staged technique was originally described in 1995 and updated more recently in 2012.2,3 The first stage is to create a new urethral plate. It entails excising the inadequate, short native urethral plate, an incision to deepen the glans cleft (with creation of glans wings), correcting chordee, and grafting the resulting ventral defect with skin taken from the inner layer of the prepuce. Oral mucosa (or even postauricular skin) can be used as an additional or alternative urothelium substitute at the first stage if there is insufficient inner prepuce available to cover the entire defect, or the patient is already circumcised, as in cases of salvage surgery. In the second stage, the newly created urethral plate is tubularized to form a urethra. A key feature of Bracka's technique is the avoidance of local flaps for creation of the new urethral plate. There is increasing recognition from long-term follow-up that preputial flapbased urethras often have insufficient mechanical support (because of absent spongiosum cover), and so tend to undergo hydraulic dilatation with the passage of time. This can result in significant postmicturition dribbling and weak or retained ejaculations. Urethras formed from free grafts have the advantage of better mechanical support, as they are more firmly fixed to their surroundings and therefore at lower risk of long-term mechanical dilatation. It would appear from the authors' descriptions that they are incorporating external preputial skin or possibly even dorsal penile skin to construct the penile part of the new urethral plate. Unlike inner prepuce or oral mucosa, external penile skin seems biologically less suited to constant urine exposure. The Byars repair is now largely obsolete because using bulky, mobile flap tissue for urethral reconstruction makes it difficult to achieve a natural slit meatus with incorporation of ventral glans sponge support—this predisposes to a high incidence of urinary spraying as a long-term issue. The Byars repair inherently creates a poorly defined, bulky glans cleft. This bulkiness makes it difficult or impractical to fully correct the external rotation deformity of the glans wings (a common anatomical feature of hypospadias), and therefore it is often necessary to leave the glans wings splayed apart at the second stage. Indeed, the authors show this in their illustrations and clinical photos. They rely instead on advancing the external skin cover up between the glans wings
Conflicts of interest and sources of funding: none declared. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7506-0686 DOI: 10.1097/SAP.0000000000000569
Annals of Plastic Surgery • Volume 75, Number 6, December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
To the Editor: t has been just 6 years since Lim et al1 performed a radical tumor resection of the scalp, ipsilateral superficial parotidectomy, and reconstruction using a latissimus dorsi free flap. In this article, the authors operated on 8 patients presenting with angiosarcoma solely of the scalp. Their procedure consisted of a radical tumor resection of the scalp with minimal 5-cm safety margins from the most peripheral scattered lesions with a burring of the external table of the cranium, ipsilateral superficial parotidectomy, and ipsilateral upper neck dissection. After a resection of the tumor of the scalp, the defect was covered with the latissimus dorsi free flap. Their outcomes were very encouraging to the readers because complete excisions were obtained and negative surgical margins were achieved in all 8 patients. The 18-month diseasefree survival of the entire operation group was 100% (median follow-up, 24 months). According to a previous article that Lim et al did not cite, Pawlik et al2 operated on and analyzed 29 patients having angiosarcoma of the scalp and stated that negative surgical margins were achieved in only 21.4% of the patients and the median actuarial survival was 28.4 months. They also wrote that radiation therapy was significantly associated with a decreased chance of death (hazard ratio, 0.16; P = 0.006). Because regional lymph node metastasis has appeared even 5 years after the initial treatment,3 I would really like to know the long-term follow-up results of the 8 patients operated on by Lim et al. To date, some authors advocate radical excision with regional lymph node clearance, with or without adjuvant radiotherapy, whereas others recommend primary radiation therapy, with surgery held in reserve.4–6 Morrison et al5 reported that the 5-year actuarial incidence of distant metastases for all patients was 63%. Lydiatt et al6 treated 18 patients, and among them, 12 patients (67%) had died of disease a mean of 25 months after diagnosis. The overall 5-year survival was 33%, but only 20% of the patients were disease-free. Mark et al7 stated a 5-year disease-free survival of 26% (7/27 patients), in which 21 patients had recurrences after
I
Conflicts of interest and sources of funding: none declared. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7506-0686 DOI: 10.1097/SAP.0000000000000486
686
www.annalsplasticsurgery.com
primary treatment, and 90% (19/21 patients) had a component of local failure. I do hope that their method can be the ideal treatment strategy for scalp angiosarcoma, if only Lim et al would respond with long-term favorable results with tables including histological grading because the only factor affecting survival was histological grade (odds ratio, 6.7; 95% confidence interval, 1.6–28.9) in the previous study.8 Kun Hwang, MD, PhD Department of Plastic Surgery Inha University School of Medicine Incheon, Republic of Korea [email protected]
REFERENCES 1. Lim SY, Pyon JK, Mun GH, et al. Surgical treatment of angiosarcoma of the scalp with superficial parotidectomy. Ann Plast Surg. 2010;64:180–182. 2. Pawlik TM, Paulino AF, McGinn CJ, et al. Cutaneous angiosarcoma of the scalp: a multidisciplinary approach. Cancer. 2003;98;1716–1726. 3. Girod A, Breton P, Freidel M, et al. Cutaneous angiosarcoma of the head: three cases. Rev Stomatol Chir Maxillofac. 2002;103:69–73. 4. Holden CA, Spittle MF, Jones EW. Angiosarcoma of the face and scalp, prognosis and treatment. Cancer. 1987;59:1046–1057. 5. Morrison WH, Byers RM, Garden AS, et al. Cutaneous angiosarcoma of the head and neck: a therapeutic dilemma. Cancer. 1995;76:3l9–327. 6. Lydiatt WM, Shaha AR, Shah JP. Angiosarcoma of the head and neck. Am J Surg. 1994;168:451–454. 7. Mark RJ, Tran LM, Sercarz J, et al. Angiosarcoma of the head and neck. The UCLA experience 1955 through 1990. Arch Otolaryngol Head Neck Surg. 1993;119:973–978. 8. Köhler HF, Neves RI, Brechtbühl ER, et al. Cutaneous angiosarcoma of the head and neck: report of 23 cases from a single institution. Otolaryngol Head Neck Surg. 2008;139:519–524.
Two-Stage Repair for Severe Proximal Hypospadias Using Oral Mucosal Grafts: Combination of a Modified Bracka Method and a Modified Byars Flap Method: Should Local Flaps be Used for Urethral Reconstruction in Hypospadias Repair? Dear Editor, e read with interest the article by Mitsukawa et al.1 The authors have presented a novel repair for the correction of severe hypospadias that combines the use of
W
Byars flaps with the Bracka grafting technique. Although their method seems to give good results, we believe several issues need to be addressed. Bracka's 2-staged technique was originally described in 1995 and updated more recently in 2012.2,3 The first stage is to create a new urethral plate. It entails excising the inadequate, short native urethral plate, an incision to deepen the glans cleft (with creation of glans wings), correcting chordee, and grafting the resulting ventral defect with skin taken from the inner layer of the prepuce. Oral mucosa (or even postauricular skin) can be used as an additional or alternative urothelium substitute at the first stage if there is insufficient inner prepuce available to cover the entire defect, or the patient is already circumcised, as in cases of salvage surgery. In the second stage, the newly created urethral plate is tubularized to form a urethra. A key feature of Bracka's technique is the avoidance of local flaps for creation of the new urethral plate. There is increasing recognition from long-term follow-up that preputial flapbased urethras often have insufficient mechanical support (because of absent spongiosum cover), and so tend to undergo hydraulic dilatation with the passage of time. This can result in significant postmicturition dribbling and weak or retained ejaculations. Urethras formed from free grafts have the advantage of better mechanical support, as they are more firmly fixed to their surroundings and therefore at lower risk of long-term mechanical dilatation. It would appear from the authors' descriptions that they are incorporating external preputial skin or possibly even dorsal penile skin to construct the penile part of the new urethral plate. Unlike inner prepuce or oral mucosa, external penile skin seems biologically less suited to constant urine exposure. The Byars repair is now largely obsolete because using bulky, mobile flap tissue for urethral reconstruction makes it difficult to achieve a natural slit meatus with incorporation of ventral glans sponge support—this predisposes to a high incidence of urinary spraying as a long-term issue. The Byars repair inherently creates a poorly defined, bulky glans cleft. This bulkiness makes it difficult or impractical to fully correct the external rotation deformity of the glans wings (a common anatomical feature of hypospadias), and therefore it is often necessary to leave the glans wings splayed apart at the second stage. Indeed, the authors show this in their illustrations and clinical photos. They rely instead on advancing the external skin cover up between the glans wings
Conflicts of interest and sources of funding: none declared. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7506-0686 DOI: 10.1097/SAP.0000000000000569
Annals of Plastic Surgery • Volume 75, Number 6, December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
