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    • Local recurrence remains challenging adjuvant radiotherapy c

    2018-10-22

    Local recurrence remains challenging; adjuvant radiotherapy can be administered after a wide excision to reduce the risk of local recurrence in patients with close or positive margins. DFSP is radiosensitive and disposed to excellent local control. radiotherapy is recommended as a systemic adjuvant treatment to reduce the risk of local recurrence. Adjuvant radiotherapy has been shown to enable effective control of local recurrence even for positive margins. For patients who are not candidates for surgical resection, radiotherapy is recommended in the National Comprehensive Cancer Network guidelines. The chance of radiation toxicity is low, but the benefit must be weighed against the risk. Although radiotherapy can be used for a positive margin or to reduce local recurrence, the most crucial factor in preventing recurrence is obtaining a negative margin through a wide excision. Castle et al stated that 93% of patients with a history of multiple recurrence and positive margins, combining surgical excision and adjuvant radiotherapy, exhibited a 10-year actuarial local control. We send resected tumor to a pathologist for frozen section to confirm a negative margin before wound coverage and allowed superior local control and reduced the recurrence rate. The fusion gene COL1A1-PDGFβ resulting from translocation t(17:22) is present in > 90% of DFSPs. Inhibitors of this pathway may become a nonsurgical option in the future. The oral tyrosine kinase inhibiter, imatinib, has exhibited a favorable response rate in unresectable and metastatic DFSP studies. Although imatinib should not be used to reduce the surgical margin, the current National Comprehensive Cancer Network guideline recommends it for unresectable diseases, positive surgical margins, recurrent diseases in critical functional and cosmetic areas, and metastatic diseases. There is no standard staging for DFSP. The primary tumor can be considered Stage I, regional gingerol node metastasis as Stage II, and distant metastasis as Stage III. Although DFSP rarely distally metastasizes and the reported 5-year survival is > 99%, most patients with metastatic disease die within 2 years. The most crucial prognostic factor is to obtain a negative surgical margin. Lesions > 10 cm, involving a deeper structure, positive margin, and multiple recurrences share a higher risk of local recurrence and distant metastasis. The overall survival rates for both 5 years and 10 years were 98% with a negative margin excision and adjuvant radiotherapy. According to previous studies, numerous surgeons have used skin graft after tumor resection. Scar contracture, hyperpigmentation, ulceration, and partial graft loss have often occurred after adjuvant radiotherapy. Although skin graft tolerated the adjuvant radiotherapy after complete healing, we still had to wait for 8 weeks after the operation for improved results. Nevertheless, the loss of skin graft is considerably increased after a single dose of ≥ 25 Gy, even after complete healing within 4 weeks. Numerous surgeons do not advocate skin graft for oncologic reconstruction if adjuvant radiotherapy is required. With the refinement of surgical techniques, it is possible to use regional or free flaps to improve the esthetic results and functional outcomes for oncologic reconstruction with a high success rate. Nearby pedicled perforator flaps can reconstruct the defect with anatomically similar tissue to resolve the color mismatch and volume deficiency of the skin graft. Rarely, perforator flaps require a debulking procedure and an excellent esthetic outcome can be achieved. Faster wound healing allows patients to initiate radiotherapy 4 weeks after an operation, compared with 8 weeks after having undergone a skin graft. Perforator flaps provide an adequate volume and superior resistance to radiotherapy-induced contracture, ulceration, and partial loss, and also eliminate secondary surgeries. Although > 80% of the ALT flap donor sites could be primarily closed, we did not achieve primary closure in three patients. Overall, the donor sites with a flap width-to-thigh circumference ratio of < 16% can be primarily closed. Skin graft was used to cover the donor sites in those three patients. Furthermore, skin graft was implanted on the donor site and did not result in any restriction of movement after healing. An ALT flap recently became the prime-example flap for soft-tissue reconstruction and could be the first choice for free-tissue transfer. To improve donor-site esthetics, a remainder island ALT flap from the distal portion, which is based on a retrograde pedicle, can be used to close in a V-Y advancement manner. Up to 16% of the circumference can be primarily closed for improvement of the scar. It can be harvested as myocutaneous or fasciocutaneous flaps according to the defect requirement, has long and reliable pedicles for microanastomosis or even for transfer as a regional flap, has a primary closed donor site with minimal morbidity, and the scar can be easily hidden underneath clothing.