Introduction
Despite extensive screening and a significant increase in the numbers of diagnosed
and treated
precancerous lesions, cervical cancer is the second most common cancer in women. Screening
programs have
resulted in a drop in the number of women newly diagnosed with cervical cancer every
year, and many
tumors are detected in their early stages [1 ]. Vaccinations against different
human papilloma viruses only became generally available a few years ago, and most
women between the age
of 30 and 40 years have therefore not benefitted from the protection afforded by vaccination
[2 ]. Early lymphatic metastasis often occurs in the parametrium and the pelvic
lymph nodes. Hematogenous dissemination tends to occur relatively late and commonly
involves the liver,
lungs and skeleton [3 ]. Cutaneous metastases are found in fewer than 2 % of
patients and are usually associated with a poor prognosis [4 ]. Straightforward
plastic surgery with reconstruction using advancement or rotation flaps obtained from
the area around
the defect are unsuitable in these cases because the recipient site has been treated
with radiotherapy,
which is likely to increase the problem. Microsurgical free-tissue transfer uses healthy,
non-irradiated, well-vascularized tissue. There are very few reports of abdominal
wall recurrence of the
type described here, and their treatment, particularly if local flap plasty results
in further skin and
soft-tissue defects, represents a challenge for an interdisciplinary team of gynecologists
and general
and plastic surgeons. In addition to covering the defect, the aim of surgery is either
to preserve the
prosthetic mesh required for stabilization or to create an alternative means of stabilization.
The
treatment algorithm used in this interdisciplinary approach is described for a patient
with this rare
recurrence.
Case Report – Early History
Case Report – Early History
During regular screening, a 34-year-old patient with two previous uncomplicated pregnancies
and births
was diagnosed with squamous cell cancer of the cervix (pT2b, pN1 [2/29] G3 pL1 pV1
pR1, anterior
cervical wall/left parametrium, stage II b). The patient underwent a Wertheim-Meigs
extended radical
hysterectomy with preservation of the adnexa and pelvic lymphadenectomy. The patient
subsequently
underwent radiation therapy of the pelvis which included the lymphatic drainage area
(dose: 50.4 Gy)
with a booster dose delivered to the parametrium (total dose: 59.4 Gy) and an afterload
dose of 5 Gy
administered intravaginally. The patient received simultaneous chemotherapy with cisplatin,
1× week for
6 weeks.
One and a half years after the primary diagnosis, abdominal wall recurrence in the
vicinity of the
laparotomy scar was diagnosed as an incidental finding during scar and wound revision.
This was treated
by wide resection. Histopathological examination showed a moderately differentiated,
focally
keratinizing squamous cell carcinoma with tumor which had spread to the soft tissue
resection margin
(pR1 G2–3). Oncological treatment at the time was done at another hospital and consisted
of non-R0
resection, followed by combined radiation and chemotherapy with radiation therapy
of the periumbilical
abdominal wall up to the mons pubis (dose: 50.4 Gy), a booster up to a dose of 55.8 Gy
and cisplatin
chemotherapy for 6 weeks. After a recurrence-free interval, metastasis of the abdominal
wall was
detected again 3 years after the primary diagnosis, whereupon the patient again underwent
non-complete
resection at another hospital, resulting 6 months later in yet another abdominal wall
recurrence, upon
which the patient presented to our hospital.
Abdominal Wall Recurrence after Squamous Cell Cancer of the Cervix
Abdominal Wall Recurrence after Squamous Cell Cancer of the Cervix
The case was presented to our interdisciplinary tumor board. Multiple punch biopsies
were done to define
the tumor-free margins of the recurrence ([Fig. 1 a ]). Laparoscopy was
performed to exclude intraabdominal/intraperitoneal tumor seeding. After interdisciplinary
discussion of
the case, the recurrence was completely resected without complications. Resection
consisted of bilateral
resection of the anterior lamina of the rectus sheath. A double Prolene mesh was implanted
to reinforce
the abdominal wall and primary wound closure was done using a local expanded flap
with mobilization of
the abdominal wall like an abdominoplasty with umbilical resection. Postoperatively,
the patient
presented with wound edge necrosis and increasing demarcation. Subsequent to debridement,
a VAC sponge
was placed temporarily to treat the wound ([Fig. 1 b ]). Debridement and
cleaning of the wound resulted in exposure of the Prolene mesh with a soft tissue
defect in the lower
abdomen, extending cranially from the former demarcation line to the pubic symphysis
caudally and
measuring approx. 20 × 30 cm. The mesh was exposed almost across the entire surface
area ([Fig. 1 c ]).
Fig. 1 a to c a Third recurrence in the abdominal wall after squamous cell
carcinoma of the cervix. After punch biopsy and determination of the resection margins.
b After wound healing disorder subsequent to repeated VAC treatment and wound demarcation.
c After treatment of the open wound and the exposed mesh with daily rinsing, prior
to
undergoing more debridement and coverage of the defect.
Defect Coverage with Free Muscle Flap Plasty
Defect Coverage with Free Muscle Flap Plasty
When the patient first presented to our Department of Plastic and Hand Surgery, examination
showed a
defect of the abdominal wall with exposure of the mesh which had been used to reinforce
the abdominal
wall after resection of the anterior lamina of the rectal sheath. An interdisciplinary
team of
gynecologists and general and plastic surgeons studied the findings and proposed abdominal
wall revision
with mesh explantation and reconstruction of the defect with free latissimus dorsi
muscle flap.
Preoperative computed tomography/angiography of the abdominopelvic region showed no
evidence of local
recurrence.
Defect reconstruction began with explantation of the exposed Prolene mesh by the general
surgeon and
included wound margin biopsies for quick section diagnosis ([Fig. 2 a ]).
Rapid histological examination found no evidence of malignancy. Based on the evaluation
of the general
surgeon, the abdominal wall appeared sufficiently stable without requiring implantation
of a new mesh.
Defect coverage and closure was done by free microsurgical myocutaneous latissimus
dorsi flap plasty
with end-to-side arterial anastomosis to the femoral artery and a venous coupler for
anastomosis to the
left great saphenous vein. The muscle flap was covered by a split skin graft obtained
from the thigh and
a VAC sponge was applied. Perfusion of the flap was initially checked every hour,
then every second hour
using a monitoring skin island ([Fig. 2 b ]). Perfusion was normal at all
times.
Fig. 2 a and b a Defect after radical wound debridement with resection of the
anterior lamina of the rectal sheath and removal of the exposed mesh used to reinforce
the abdominal
wall. b Defect coverage with free myocutaneous latissimus dorsi flap and microsurgical
end-to-side arterial anastomosis to the femoral artery and a coupler for venous anastomosis
to the
left great saphenous vein. The muscle flap was covered by meshed split-thickness skin
graft from the
thigh. A skin island to monitor perfusion was temporarily sewn on.
The monitoring island was experienced as troublesome by the patient when flexing her
hip joint and was
removed after one week. The ensuing defect was covered by split-thickness skin graft
from the monitoring
skin island. The postoperative course was unremarkable except for a small wound healing
disorder on the
left side lateral to the flap plasty ([Fig. 3 b ]). It was treated
conservatively and healed without complications. Another small wound healing disorder
developed on the
patientʼs back which also healed quickly after conservative wound treatment ([Figs. 3 a ] and [c ]).
Fig. 3 a to g a Wound healing disorder at the harvesting site of the latissimus
dorsi flap around 4 weeks after surgery. b Earlier local findings around 4 weeks after
surgery after removing the monitoring island with a small wound healing disorder located
laterally
on the left side. c Healed harvesting site of the latissimus dorsi flap 10 months after
surgery. d The patient experiences no constraints in her arm movements on side where the
latissimus dorsi flap was harvested. e Wound healing outcome 10 months after surgery; the
flap is stable and has healed well. f and g Due to pronounced subcutaneous fat tissue,
there is still a distinct contour in the lower abdomen in the transition area to the
flap, but the
healing outcome is stable.
Follow-up
The patient comes for regular follow-up examinations to the Gynecological Department
and the Plastic and
Hand Surgery Department. At 12 months after surgery, the patient remains free of recurrence
and there
has been no evidence of further metastasis or repeat recurrence in the abdominal wall.
The flap and the
transplanted skin-thickness graft are well perfused, and after healing the areas are
fully functional
([Fig. 3 e ] to [g ]). Due to pronounced
subcutaneous fat tissue, there is still a distinct contour in the lower abdomen in
the transition area
to the flap but the healing outcome is stable. At the start, great care was taken
not to place too much
stress on the abdominal wall. The patient avoided lifting any heavy loads weighing
more than 5 kg for a
period of 10 weeks after surgery and wore an abdominal belt. No abdominal wall weakness
or hernia was
noted during the follow-up period of 1 year.
The scar on the patientʼs back healed well and has already faded. The patient has
been careful to carry
out intensive scar care with lipid-replenishing creams and silicone-containing scar
ointments. The
patient experiences no constraints with regard to arm movements on the side where
the flap was harvested
([Fig. 3 d ]). The patient has only reported a slight reduction in
movement when twisting her torso and during maximum flexion, which is perceptible
as pulling and tension
on the muscles, but this has already decreased with physiotherapy and scar massage.
After this extensive
soft tissue reconstruction the patient is able to carry out all daily activities with
almost no
restrictions and is able to care for her children.
Discussion
Metastasis of the abdominal wall after cervical cancer is a rare occurrence in the
follow-up of tumor
patients and represents a challenge for the interdisciplinary team of gynecologists
and general and
plastic surgeons [5 ]. The majority of treatments described in the literature
consist predominantly of radiation and chemotherapy with local excision of metastases
[6 ]. One case report describes a patient with cutaneous lymphangitis
carcinomatosa who received palliative chemotherapy [7 ].
Skin and soft tissue resection is often possible without any difficulty as there is
sufficient skin and
soft tissue in the lower abdomen. However, if the patient has undergone prior several
operations or has
previously had adjuvant therapy, as was the case with our patient who had undergone
radiation therapy
(twice) previously, this may negatively affect local conditions. Moreover, it should
be noted critically
for this patient that, during initial treatment at an external hospital, no R0 resection
was achieved.
This can negatively affect the prognosis for overall and local recurrence and impacts
directly on the
necessity for adjuvant treatment. Patients who have had several cycles of radiation
therapy may go on to
develop substantial wound healing deficits and necrosis which may preclude sufficient
local tissue being
available for coverage and require tissue transplantation from other sites. In the
case described here,
tissue from the surrounding soft tissue area had already been mobilized. The external
aspect clearly
shows the permanent damage done by repeated radiation therapy ([Fig. 1 ]).
Moreover, a mesh had been implanted to reinforce the abdominal wall, and this mesh
required explantation
subsequently due to infection. It was therefore no longer possible to use simple split-thickness
graft
or local pedicled flap plasty for defect coverage. Consequently it was necessary to
use easily
transferrable, free vascularized muscle tissue. The free flap plasty allowed tissue
which had not
suffered previous injury to be transferred to the irradiated area.
Free muscle flap plasties have been used since many decades to treat similar skin
and soft tissue defects
at different sites in the body. All reconstructive surgery of the abdominal wall must
aim to restore
functional stability and provide sufficient soft tissue coverage. Different approaches
have been
described in the literature. The pedicled tensor fasciae latae muscle flap has been
used to recreate
fascia continuity and prevent hernia recurrence in patients with extensive fascia
defects who have
suffered repeated hernia recurrence without an anatomically accessible hernia orifice.
An innervated,
microsurgically revascularized latissimus dorsi muscle flap can be used to achieve
optimal functionality
and for esthetic repair of extensive abdominal wall defects affecting all anatomical
layers [8 ]. After healing and reinnervation, a microsurgically anastomosed latissimus
dorsi flap can even assume some of the functions of the abdominal wall muscles in
patients who have
suffered a total loss of abdominal wall muscles [9 ]. This was not necessary in
our patient in whom abdominal wall muscles could be preserved. Use of a perforator-based
monitoring skin
island in latissimus dorsi flap plasty was first described in 2012 [10 ]. It
was suggested that this could do away with the necessity for a second split-thickness
skin graft when
removing the monitoring skin island. Unfortunately, in our patient, no suitable perforator
was available
and the monitoring skin island had be raised using the classical technique and removed
later in a second
procedure which was followed by repeat split-thickness skin graft. Free latissimus
dorsi muscle flaps
are also used in the abdomen together with biological meshes to treat complicated
hernias. Because of
its complexity, this approach is not used routinely in hernia repair but can be a
salvage option when
treating selected at-risk patients [11 ]. The latissimus dorsi flap was
already used in 1993 together with a Marlex® mesh to close a defect in a patient with
cervical cancer
and extensive abdominal wall metastasis. The inferior epigastric artery and the external
iliac vein were
used as the principle anastomoses [12 ]. As the quality of the vasculature in
regions previously treated with radiation therapy is often poor due to radiation damage,
the principle
anastomoses were chosen from areas outside the irradiated region. Another case report
describes a
patient with an infected abdominal wall defect from a gunshot wound who underwent
reconstruction of the
abdominal wall using a polypropylene mesh and free latissimus dorsi muscle flap coverage
with an
interposition graft and anastomosis to the femoral artery and the great saphenous
vein [13 ]. Because of the good vascularization this approach can also be used to
treat large infected abdominal wall defects. In patients with cervical cancer, muscle
flap plasty is
also used to reconstruct the pelvic floor or vagina and for fistula closure [14 ]. Unilateral or bilateral pedicled myocutaneous vertical rectus abdominis muscle
flaps
have been used to close vesicovaginal fistulas [15 ]. Myocutaneous gracilis
flap plasty has been successfully used to reconstruct vulvovaginal defects and fistulas
[16 ]. The possibility of using free muscle plasty to close skin and soft tissue
defects should be considered as a therapeutic option in patients with advanced cervical
cancer who have
had to undergo extensive surgical resection.
Conclusion
In some rare cases, advanced cervical cancer or its recurrence can involve the abdominal
wall.
Previously, such cases were usually treated with radiation therapy and chemotherapy
as it was thought
that extensive resection was too risky because of the exposed structures this would
involve. But as
microsurgical techniques have continued to evolve and improve, microsurgical free
muscle plasty carried
out in high volume centers represents a safe plastic surgery procedure for defect
closure and could
significantly expand the range of extensive local resections by gynecologists. If
extensive resection is
planned, an interdisciplinary approach involving gynecologists and general and plastic
surgeons is
important during the early stages of planning as this can help achieve optimal results
for the patient
with the best possible quality of life and the best chances for long-term survival.
