Invasive basosquamous cell carcinoma of the head treated with wide excision and reconstruction with fascia lata graft and two muscle flaps. Case report
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Published
Jun 30, 2015
Abstract
Background: Basosquamous carcinoma (BSC) is a variant of basal cell carcinoma subtype that is locally aggressive with high tendency for recurrence and metastasis and a poor prognosis. Up to 95% are located in head and neck area. Treatment for invasive BSC with aggressive growth pattern is wide excision and reconstruction. Complex defects require free tissue transfer to protect underlying structures and to sustain the adjuvant radiotherapy. Case report: A 57 year-old male presented with ulcerated, bleeding tumors in frontal and periauricular area, identified as BSC on biopsy. CT-scan revealed contact to dura mater. Wide excision included frontal bone and dura mater, frontal sinus, lateral orbital wall and exenteration, ear en-bloc with parotid gland. Dura mater was replaced with fascia lata graft, frontal sinus was filled with pedicled temporalis muscle and 20/25 cm soft tissue defect was covered with free Latissimus dorsi muscle anastomosed to superior thyroid artery and internal jugular vein branch, respectively. The muscle was skin grafted 14 days later. Results: Postoperative recovery was complicated: cerebrospinal fluid leak, extradural hematoma, posthemorrhagic anemia, pneumonia, and withdrawal syndrome, remitted under specific treatment. Muscle flap survived entirely with skin graft fully integrated. Positive margins on dura mater and mastoid bone required radiotherapy. Conclusions: Wide excision of head invasive BSC resulted in complex defect reconstructed with fascia lata graft, temporalis muscle and Latissimus dorsi free flap grafted secondarily. Short-term evaluation showed no recurrence and good life-quality; follow-up is needed to evaluate long-term results. Interdisciplinary approach is the key for patients successful treatment.
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Keywords
basosquamous carcinoma, head and neck, wide excision, Latissimus dorsi free flap, interdisciplinary approach
References
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2. De Stefano A, Dispenza F, Petrucci AG, et al. Features of biopsy in diagnosis of metatypical basal cell carcinoma (Basosquamous Carcinoma) of head and neck. Otolaryngol Pol 2012; 66(6):419-423.
3. Garcia C, Poletti E, Crowson N. Basosquamous carcinoma. J An Acad Dermatol 2009; 60(1):137-143.
4. Leibovitch I, Huilgol SC, Selva D, et al. Basosquamous carcinoma: treatment with Mohs micrographic surgery. Cancer 2005; 104(1):170-175.
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7. Rigel DR, June K, Robinson JK, et al. Cancer of the Skin. 2nd Ed. China: Elsevier Saunders; 2011. Chapter 52, Radiation therapy in the treatment of skin cancers; p. 578-581.
8. Newman MI, Hanasono MM, Disaj JJ, et al. Scalp Reconstruction: A 15-Year Experience. Ann Plast Surg 2004; 52(5):501-506.
9. Plichta K, Mackley HB, Radiotherapy for cutaneous malignancies of the head and neck. Operative Techniques in Otolaryngology 2013; 24(1):59-62. doi:10.1016/j.otot.2012.12.004.
10. Hussain SI, Hussainy AS. Baso-Squamous Cell Carcinoma - a Case Report. Pak Med Assoc 2004; 54(1):30-32.
11. Cognetta AB, Howard BM, Heaton HP, et al. Superficial x-ray in the treatment of basal and squamous cell carcinomas: A viable option in select patients. J Am Acad Dermatol 2012; 67(6):1235-1244.
12. van Loo E, Mosterd K, Krekels GAM, et al. Surgical excision versus Mohs micrographic surgery for basal cell carcinoma of the face: A randomised clinical trial with 10 year follow-up. Eur J Cancer 2014; 50(17):3011-3020.
13. Aguayo-Leiva IR, Ríos-Buceta L, Jaén-Olasolo P. Surgical vs. Nonsurgical Treatment of Basal Cell Carcinoma. Actas Dermosifiliogr 2010; 101(8):683–692.
14. Wain RAJ, Tehrani H. The plastic & reconstructive Mohs surgery service. J Plast Reconstr Aesthet Surg 2014; 67(3):331-335.
15. Smeets NW, Krekels GAM, Ostertag JU, et al. Surgical excision vs. Mohs micrographic surgery for basal cell carcinoma of the face: randomised controlled trial. Lancet 2004; 364(9447):1766-1772.
16. Mosterd K, Krekels GA, Nieman FH, et al. Surgical excision versus Mohs micrographic surgery for primary and recurrent basal-cell carcinoma of the face: a prospective randomised controlled trial with 5-years follow-up. Lancet Oncol 2008; 9(12):1149-1156.
17. Rowe DE, Carroll RJ, Day CL. Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol 1989; 15(4):424-431.
18. Parlato C, Granata R, Moraci A, et al. Dural Reconstruction in Meningioma Surgery. In: Monleon D. Meningiomas - Management and Surgery. China: InTech, 2012. Chapter 6, Dural reconstruction in meningioma surgery; p. 103-124.
19. Rengachary SS, Benzel EC. Calvarial and Dural Reconstruction. U.S.A.: AANS, 1998. Chapter 3, Cranioplasty materials; p. 35-45.
20. Baker SR. Local flaps in facial reconstruction. 3rd Ed. China: Elsevier Saunders; 2014. Chapter 24, Reconstruction of the scalp; p.641-667.
21. Janis JE, Leedy JE. Lip, cheek and scalp reconstruction. SRPS 2006; 10(13):1-39.
22. Bayles SW, Hayden RE. Gastro-omental free flap reconstruction of the head and neck. Arch Facial Plast Surg 2008; 10(4):255-259.
23. Kruse-Losler B, Presser D, Meyer U, et al. Reconstruction of large defects on the scalp and forehead as an interdisciplinary challenge: Experience in the management of 39 cases. Eur J Surg Oncol 2006; 32(9):1006-1014.
24. Thorne CH, Chung KC, Gosain GC, et al. Grabb and Smith's Plastic Surgery. 7th Ed. China: Lippincott Williams Walkins, 2014. Chapter 31, Reconstruction of the scalp, calvarium, and forehead; p. 342-351.
25. Wei F, Mardini S. Flaps and Reconstructive Surgery. China: Elsevier Saunders, 2009. Chapter 23, Latissimus dorsi flap; p.287-303.
26. Xua ZF, Suna CF, Duana WY. Clinical anatomical study and evaluation of the use of the free anteromedial thigh perforator flaps in reconstructions of the head and neck. Br J Oral Maxillofac Surg 2013; 51(8):725-730.
27. Bhujel N, Johnston C, Parmar S, et al. An unusual anatomical variant of the vascular anatomy in the anterolateral thigh free flap. Int J Oral Maxillofac Surg 2010; 39(1):94-95.
28. Shawa RJ, Batstone MD, Blackburn TK, et al. The anterolateral thigh flap in head and neck reconstruction: “Pearls and pitfalls”. Br J Oral Maxillofac Surg 2010; 48(1):5–10.
29. Marsh DJ, Chana JS. Reconstruction of very large defects: a novel application of the double skin paddle anterolateral thigh flap design provides for primary donor-site closure. J Plast Reconstr Aesthet Surg 2010; 63(1):120-125.
30. Agostini T, Lazzeri D, Spinelli G. Anterolateral thigh flap: Systematic literature review of specific donor-site complications and their management. J Craniomaxillofac Surg 2013; 41(1):15-21.
31. Hierner R, vaan Loon J, Goffin J, et al. Free latissimus dorsi flap transfer for subtotal scalp and cranium defect reconstruction: report of 7 cases. Microsurgery 2007; 27(5):425-428.
32. Fattah A, Pollock J, Maheshwar A, et al. Big Bad BCCs: Craniofacial resection and reconstruction for atypical basal cell carcinoma. J Plast Reconstr Aesthet Surg 2010; 63(5):433-441.
33. Fattahi T, DiPasquale J. Utility of the pericranial flap in frontal sinus and anterior cranial fossa trauma. Int. J. Oral Maxillofac Surg 2009; 38(12):1263-1267.
34. Uyar Y, Kumral TL, Yıldırım G. Reconstruction of the orbit with a temporalis muscle flap after orbital exenteration. Clin Exp Otorhinolaryngol 2015; 8(1):52-56.
35. Bagheri SC, Bell B, Khan HA. Current Therapy In Oral and Maxillofacial Surgery. China: Elsevier Saunders, 2012. Chapter 64 - The temporalis system of flaps in head and neck reconstruction: temporoparietal fascia and temporalis muscle flaps; p. 527-533.
36. Serra MP, Longhi P, Carminati M, et al. Microsurgical scalp and skull reconstruction using a combined flap composed of serratus anterior myo-osseous flap and latissimus dorsi myocutaneous flap. J Plast Reconstr Aesthet Surg 2007; 60(10):1158-1161.
37. Arai H, Yanai A, Nishida M, et al. Reconstruction of scalp and cranium defect utilizing latissimus dorsi musculocutaneous and serratus anterior muscle free flaps with interpositional anastomosis of T-shaped flap artery. Skull Base Surg 1995; 5(2):117-121.
38. Abolhoda A, Bui TD, Milliken JC, et al. Pedicled latissimus dorsi muscle flap routine use in high-risk thoracic surgery. Tex Heart Inst J 2009; 36(4):298-302.
39. Chao AH, Yu P, Skoracki RJ, et al. Microsurgical reconstruction of composite scalp and calvarial defects in patients with cancer: A 10-year experience. Head Neck 2012; 34(12):1759-1764.
40. Stula D. Cranioplasty: Indications, Techniques, and Results. Wien: Springer-Verleg, 1984. Chapter C, Surgical procedures and techniques of cranial repair; p.57-61.
41. Perisanidis C, Herberger B, Papadogeorgakis N, et al. Complications after free flap surgery: do we need a standardized classification of surgical complications? Br J Oral Maxillofac Surg 2012; 50(2):113-118.
42. McMahon JD, MacIver C, Smith M, et al. Postoperative complications after major head and neck surgery with free flap repair – prevalence, patterns, and determinants: a prospective cohort study. Br J Oral Maxillofac Surg 2013; 51(8):689-695.
43. Bianchi B, Copelli C, Ferrari S, et al. Free flaps: outcomes and complications in head and neck reconstructions. J Craniomaxillofac Surg 2009; 37(8): 438-442.
44. Puram SV, Yarlagadda BB, Sethi R, et al. Transfusion in head and neck free flap patients: practice patterns and a comparative analysis by flap type. Otolaryngol Head Neck Surg 2015; 152(3):449-457.
45. Kehler U, Hirdes C, Weber C, et al. CSF leaks after cranial surgery-a prospective multicenter analysis. Innov Neurosurg 2012; 1(1):49-53.
46. Quinones-Hinojosa A, Schmidek, S. Operative Neurosurgical Techniques: Indications, Methods and Results. 6th Ed. vol. 2. China: Elsevier Saunders, 2012. Chapter 138, Management of cerebrospinal fluid leaks; p.1579-1595.
47. Korinek AM, Baugnon T, Golmard JL, et al. Risk factors for adult nosocomial meningitis after craniotomy: role of antibiotic prophylaxis. Neurosurg 2006; 59(1):126-133.
48. Pichierri A, Ruggeri A, Donnarumma P, et al. Postoperative Extradural Hematomas. J Neurol Surg 2013; 74(1):25-28.
49. Sherry KR, Reid LA, Wilmshurst AD. A five year review of basal cell carcinoma excisions, J Plast Reconstr Aesthet Surg 2010; 63(9):1485-1489.
50. Liu FF, Maki E, Warde P, et al. A management approach to incompletely excised basal cell carcinomas of skin. Int J Radiat Oncol Biol Phys 1991; 20(3):423-428.
51. Ríos-Buceta L. Management of basal cell carcinomas with positive margins. Actas Dermosifiliogr 2007; 98(10):679-687.
52. Birgfeld C, Neligan P. Surgical Approaches to Facial Nerve Deficits. Skull Base 2011; 21(3):177-184.
53. Penel N, Yann Mallet Y, Roussel-Delvallez M, et al. Factors determining length of the postoperative hospital stay after major head and neck cancer surgery. Oral Oncol 2008; 44(6):555-562.
54. Miller MJ, Swartz WM, Miller RH, et al. Cost analysis of microsurgical reconstruction in the head and neck. J Surg Oncol 1991; 46(4):215-277.
2. De Stefano A, Dispenza F, Petrucci AG, et al. Features of biopsy in diagnosis of metatypical basal cell carcinoma (Basosquamous Carcinoma) of head and neck. Otolaryngol Pol 2012; 66(6):419-423.
3. Garcia C, Poletti E, Crowson N. Basosquamous carcinoma. J An Acad Dermatol 2009; 60(1):137-143.
4. Leibovitch I, Huilgol SC, Selva D, et al. Basosquamous carcinoma: treatment with Mohs micrographic surgery. Cancer 2005; 104(1):170-175.
5. Clinical Practice in Oncology – Basal Cell Skin Cancer. NCCN 2015. [http://www.nccn.org/professionals/physician_gls/f_guidelines.asp available at 06.15.2015]
6. Smith V, Walton S. Treatment of Facial Basal Cell Carcinoma: A Review. J Skin Cancer 2011; doi:10.1155/2011/380371.
7. Rigel DR, June K, Robinson JK, et al. Cancer of the Skin. 2nd Ed. China: Elsevier Saunders; 2011. Chapter 52, Radiation therapy in the treatment of skin cancers; p. 578-581.
8. Newman MI, Hanasono MM, Disaj JJ, et al. Scalp Reconstruction: A 15-Year Experience. Ann Plast Surg 2004; 52(5):501-506.
9. Plichta K, Mackley HB, Radiotherapy for cutaneous malignancies of the head and neck. Operative Techniques in Otolaryngology 2013; 24(1):59-62. doi:10.1016/j.otot.2012.12.004.
10. Hussain SI, Hussainy AS. Baso-Squamous Cell Carcinoma - a Case Report. Pak Med Assoc 2004; 54(1):30-32.
11. Cognetta AB, Howard BM, Heaton HP, et al. Superficial x-ray in the treatment of basal and squamous cell carcinomas: A viable option in select patients. J Am Acad Dermatol 2012; 67(6):1235-1244.
12. van Loo E, Mosterd K, Krekels GAM, et al. Surgical excision versus Mohs micrographic surgery for basal cell carcinoma of the face: A randomised clinical trial with 10 year follow-up. Eur J Cancer 2014; 50(17):3011-3020.
13. Aguayo-Leiva IR, Ríos-Buceta L, Jaén-Olasolo P. Surgical vs. Nonsurgical Treatment of Basal Cell Carcinoma. Actas Dermosifiliogr 2010; 101(8):683–692.
14. Wain RAJ, Tehrani H. The plastic & reconstructive Mohs surgery service. J Plast Reconstr Aesthet Surg 2014; 67(3):331-335.
15. Smeets NW, Krekels GAM, Ostertag JU, et al. Surgical excision vs. Mohs micrographic surgery for basal cell carcinoma of the face: randomised controlled trial. Lancet 2004; 364(9447):1766-1772.
16. Mosterd K, Krekels GA, Nieman FH, et al. Surgical excision versus Mohs micrographic surgery for primary and recurrent basal-cell carcinoma of the face: a prospective randomised controlled trial with 5-years follow-up. Lancet Oncol 2008; 9(12):1149-1156.
17. Rowe DE, Carroll RJ, Day CL. Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol 1989; 15(4):424-431.
18. Parlato C, Granata R, Moraci A, et al. Dural Reconstruction in Meningioma Surgery. In: Monleon D. Meningiomas - Management and Surgery. China: InTech, 2012. Chapter 6, Dural reconstruction in meningioma surgery; p. 103-124.
19. Rengachary SS, Benzel EC. Calvarial and Dural Reconstruction. U.S.A.: AANS, 1998. Chapter 3, Cranioplasty materials; p. 35-45.
20. Baker SR. Local flaps in facial reconstruction. 3rd Ed. China: Elsevier Saunders; 2014. Chapter 24, Reconstruction of the scalp; p.641-667.
21. Janis JE, Leedy JE. Lip, cheek and scalp reconstruction. SRPS 2006; 10(13):1-39.
22. Bayles SW, Hayden RE. Gastro-omental free flap reconstruction of the head and neck. Arch Facial Plast Surg 2008; 10(4):255-259.
23. Kruse-Losler B, Presser D, Meyer U, et al. Reconstruction of large defects on the scalp and forehead as an interdisciplinary challenge: Experience in the management of 39 cases. Eur J Surg Oncol 2006; 32(9):1006-1014.
24. Thorne CH, Chung KC, Gosain GC, et al. Grabb and Smith's Plastic Surgery. 7th Ed. China: Lippincott Williams Walkins, 2014. Chapter 31, Reconstruction of the scalp, calvarium, and forehead; p. 342-351.
25. Wei F, Mardini S. Flaps and Reconstructive Surgery. China: Elsevier Saunders, 2009. Chapter 23, Latissimus dorsi flap; p.287-303.
26. Xua ZF, Suna CF, Duana WY. Clinical anatomical study and evaluation of the use of the free anteromedial thigh perforator flaps in reconstructions of the head and neck. Br J Oral Maxillofac Surg 2013; 51(8):725-730.
27. Bhujel N, Johnston C, Parmar S, et al. An unusual anatomical variant of the vascular anatomy in the anterolateral thigh free flap. Int J Oral Maxillofac Surg 2010; 39(1):94-95.
28. Shawa RJ, Batstone MD, Blackburn TK, et al. The anterolateral thigh flap in head and neck reconstruction: “Pearls and pitfalls”. Br J Oral Maxillofac Surg 2010; 48(1):5–10.
29. Marsh DJ, Chana JS. Reconstruction of very large defects: a novel application of the double skin paddle anterolateral thigh flap design provides for primary donor-site closure. J Plast Reconstr Aesthet Surg 2010; 63(1):120-125.
30. Agostini T, Lazzeri D, Spinelli G. Anterolateral thigh flap: Systematic literature review of specific donor-site complications and their management. J Craniomaxillofac Surg 2013; 41(1):15-21.
31. Hierner R, vaan Loon J, Goffin J, et al. Free latissimus dorsi flap transfer for subtotal scalp and cranium defect reconstruction: report of 7 cases. Microsurgery 2007; 27(5):425-428.
32. Fattah A, Pollock J, Maheshwar A, et al. Big Bad BCCs: Craniofacial resection and reconstruction for atypical basal cell carcinoma. J Plast Reconstr Aesthet Surg 2010; 63(5):433-441.
33. Fattahi T, DiPasquale J. Utility of the pericranial flap in frontal sinus and anterior cranial fossa trauma. Int. J. Oral Maxillofac Surg 2009; 38(12):1263-1267.
34. Uyar Y, Kumral TL, Yıldırım G. Reconstruction of the orbit with a temporalis muscle flap after orbital exenteration. Clin Exp Otorhinolaryngol 2015; 8(1):52-56.
35. Bagheri SC, Bell B, Khan HA. Current Therapy In Oral and Maxillofacial Surgery. China: Elsevier Saunders, 2012. Chapter 64 - The temporalis system of flaps in head and neck reconstruction: temporoparietal fascia and temporalis muscle flaps; p. 527-533.
36. Serra MP, Longhi P, Carminati M, et al. Microsurgical scalp and skull reconstruction using a combined flap composed of serratus anterior myo-osseous flap and latissimus dorsi myocutaneous flap. J Plast Reconstr Aesthet Surg 2007; 60(10):1158-1161.
37. Arai H, Yanai A, Nishida M, et al. Reconstruction of scalp and cranium defect utilizing latissimus dorsi musculocutaneous and serratus anterior muscle free flaps with interpositional anastomosis of T-shaped flap artery. Skull Base Surg 1995; 5(2):117-121.
38. Abolhoda A, Bui TD, Milliken JC, et al. Pedicled latissimus dorsi muscle flap routine use in high-risk thoracic surgery. Tex Heart Inst J 2009; 36(4):298-302.
39. Chao AH, Yu P, Skoracki RJ, et al. Microsurgical reconstruction of composite scalp and calvarial defects in patients with cancer: A 10-year experience. Head Neck 2012; 34(12):1759-1764.
40. Stula D. Cranioplasty: Indications, Techniques, and Results. Wien: Springer-Verleg, 1984. Chapter C, Surgical procedures and techniques of cranial repair; p.57-61.
41. Perisanidis C, Herberger B, Papadogeorgakis N, et al. Complications after free flap surgery: do we need a standardized classification of surgical complications? Br J Oral Maxillofac Surg 2012; 50(2):113-118.
42. McMahon JD, MacIver C, Smith M, et al. Postoperative complications after major head and neck surgery with free flap repair – prevalence, patterns, and determinants: a prospective cohort study. Br J Oral Maxillofac Surg 2013; 51(8):689-695.
43. Bianchi B, Copelli C, Ferrari S, et al. Free flaps: outcomes and complications in head and neck reconstructions. J Craniomaxillofac Surg 2009; 37(8): 438-442.
44. Puram SV, Yarlagadda BB, Sethi R, et al. Transfusion in head and neck free flap patients: practice patterns and a comparative analysis by flap type. Otolaryngol Head Neck Surg 2015; 152(3):449-457.
45. Kehler U, Hirdes C, Weber C, et al. CSF leaks after cranial surgery-a prospective multicenter analysis. Innov Neurosurg 2012; 1(1):49-53.
46. Quinones-Hinojosa A, Schmidek, S. Operative Neurosurgical Techniques: Indications, Methods and Results. 6th Ed. vol. 2. China: Elsevier Saunders, 2012. Chapter 138, Management of cerebrospinal fluid leaks; p.1579-1595.
47. Korinek AM, Baugnon T, Golmard JL, et al. Risk factors for adult nosocomial meningitis after craniotomy: role of antibiotic prophylaxis. Neurosurg 2006; 59(1):126-133.
48. Pichierri A, Ruggeri A, Donnarumma P, et al. Postoperative Extradural Hematomas. J Neurol Surg 2013; 74(1):25-28.
49. Sherry KR, Reid LA, Wilmshurst AD. A five year review of basal cell carcinoma excisions, J Plast Reconstr Aesthet Surg 2010; 63(9):1485-1489.
50. Liu FF, Maki E, Warde P, et al. A management approach to incompletely excised basal cell carcinomas of skin. Int J Radiat Oncol Biol Phys 1991; 20(3):423-428.
51. Ríos-Buceta L. Management of basal cell carcinomas with positive margins. Actas Dermosifiliogr 2007; 98(10):679-687.
52. Birgfeld C, Neligan P. Surgical Approaches to Facial Nerve Deficits. Skull Base 2011; 21(3):177-184.
53. Penel N, Yann Mallet Y, Roussel-Delvallez M, et al. Factors determining length of the postoperative hospital stay after major head and neck cancer surgery. Oral Oncol 2008; 44(6):555-562.
54. Miller MJ, Swartz WM, Miller RH, et al. Cost analysis of microsurgical reconstruction in the head and neck. J Surg Oncol 1991; 46(4):215-277.
How to Cite
Chelmuş, A., Dobreanu, C. N., Tripa, A. F., Filipescu, R., Slătineanu, A. D., Rusu, D. M., Ferariu, D., Bugean, G., Lupaşcu, C. D., & Gheţu, N. (2015). Invasive basosquamous cell carcinoma of the head treated with wide excision and reconstruction with fascia lata graft and two muscle flaps. Case report. Archive of Clinical Cases, 2(2), Arch Clin Cases 2015; 2(2):58-70. https://doi.org/10.22551/2015.06.0202.10034
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How to Cite
Chelmuş, A., Dobreanu, C. N., Tripa, A. F., Filipescu, R., Slătineanu, A. D., Rusu, D. M., Ferariu, D., Bugean, G., Lupaşcu, C. D., & Gheţu, N. (2015). Invasive basosquamous cell carcinoma of the head treated with wide excision and reconstruction with fascia lata graft and two muscle flaps. Case report. Archive of Clinical Cases, 2(2), Arch Clin Cases 2015; 2(2):58-70. https://doi.org/10.22551/2015.06.0202.10034