RT Related Wound Necrosis

[Haybrant]

I saw a pt with surgeon who was treated with RT in 1998 for unknown primary "poorly diff epithelial malignancy". He had groin dissection, 7 nodes taken 2 w disease and ECE. He had adjuvant RT, 50 to the groin with conedown to 60 Gy to I guess what they considered the high risk region. He says they took a week break due to dermatitis after 15 fractions. Don't really have much more than that. He had lymphedema on the ipsilateral side that developed a few years later, some tightness but tolerable.

He noticed a small blister in the groin in January 2015 that over the course of the next 6 months slow increased in depth. No other symptoms, no infectious like sxs. Surgery saw him and were concerned about RT necrosis and sent him for 40 tx of hyperbaric O2. On HBO the wound got particularly worse and the size expanded from 2 x 2 to 9.5 x 6 cm by the end of treatment. They debrided the tissue but could only go so far, surgeon was concerned about exposure of femoral vessels. Pathology doesn't show any recurrent disease. They have him packing the wound, the surgeon discussed possible need of an amputation before (sounded extreme but the wound is quite large). They'll see plastics next wk.

Is this consistent with RT necrosis almost 20 years out, Is it unusual to see such enlargement while on HBO. Would you avoid HBO again given that it increased in size. I think the wound has stabilized but it is quite impressive.

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[seper]

if it is indeed radionecrosis (doubt it), you should write it up as a case report.

 

[Palex80]

This is quite an interesting case. Has the patient developed any new condition in the past years, that may have increased the chances of something like this happening? Arteriosclerosis or diabetes perhaps?

Plastics sounds like a very good option, one should try anything before considering amputation.

Other than that it's highly interesting, that this guy survived a CUP 20 years out.

 

[Haybrant]

nothing that stands out which is new in the last year; has CAD at baseline so probably isnt a great substrate. I included a picture. Its kind of gross (he wasnt getting good wound care) so I can take it down if the mods think I need to. It was taken horizontally so head it at the right, feet at the left. Anyone think HBO again make sense? Is there something about HBO making it worse that leads people to think something different?

 

[Gfunk6]

nothing that stands out which is new in the last year; has CAD at baseline so probably isnt a great substrate. I included a picture. Its kind of gross (he wasnt getting good wound care) so I can take it down if the mods think I need to. It was taken horizontally so head it at the right, feet at the left. Anyone think HBO again make sense? Is there something about HBO making it worse that leads people to think something different?

Wowzers! That is horrible necrosis!

Honestly, even though everyone likes to use HBO for necrosis I don't think the evidence to do so is great. If you've already given him a good shot at HBO and it has done nothing, I don't see the benefit in repeating it. I agree that a graft is probably the only shot for a decent outcome.

It's a bit academic at this point, but I would try to see if you can track his old plan down. Would be interesting to see if there was a hot-spot somewhere that can account for this reaction.

 

[medgator]

Underlying risk factors? Horrible pvd? Diabetic that smokes like a chimney?

 

[radoncopotamus]

It probably looks so well defined secondary to the debridements, but possibly a syphilis gumma? Might want to check RPR, VRDL since it is such an unusual story.

 

[RadOncDoc21]

Seriously, don't just let those surgeons chalk it up to radiation toxicity! I'm sure the dermatitis and lymphadema is real but skin necrosis almost 20 years out come on... If so my consent form will never be able to fit everything on it!

 

[Palex80]

My God, that is huge! And it looks quite deep indeed. I don't know what that is...
Do you see any other kind of late reaction? If this patient is prone to late reactions and this was planned 20 years ago, I assume an anterior/posterior pair of fields was used up to 50 Gy to cover the external iliac area too? It might be interesting to have a look at the posterior part of his lower limb (+buttocks?). Can you see any skin alterations there? Hyperpigmentation, teleangiectasia?

 

[Mandelin Rain]

If all they are sending to path is the debrided, necrotic tissue, I'd probably ask for a deeper biopsy. Can't really make it worse at this point. I'd probably also do a superficial autoimmune workup with ESR, ANA, RF, CXCL4, etc... They may all be high from the inflammation, but maybe you'll get some answer.

 

[thecarbonionangle]

Very interesting from an internal medicine perspective. Make sure a deep biopsy tissue is sent for all the wound cultures and path (including infectious PCRs). I agree with broad rheum work up and infectious work up (get as many minds in the cut as possible), including a very detailed physical exam looking at the skin, mucosa of the mouth/anus/genitalia, and perhaps even an ophthalmological exam. Is the patient a diabetic/smoker? Some would consider pan-scanning to see if it shows you anything interesting (splenomegaly not detectable by physical exam, lymphadenopathy)

 

[deltamed]

I saw a pt with surgeon who was treated with RT in 1998 for unknown primary "poorly diff epithelial malignancy". He had groin dissection, 7 nodes taken 2 w disease and ECE. He had adjuvant RT, 50 to the groin with conedown to 60 Gy to I guess what they considered the high risk region. He says they took a week break due to dermatitis after 15 fractions. Don't really have much more than that. He had lymphedema on the ipsilateral side that developed a few years later, some tightness but tolerable.

He noticed a small blister in the groin in January 2015 that over the course of the next 6 months slow increased in depth. No other symptoms, no infectious like sxs. Surgery saw him and were concerned about RT necrosis and sent him for 40 tx of hyperbaric O2. On HBO the wound got particularly worse and the size expanded from 2 x 2 to 9.5 x 6 cm by the end of treatment. They debrided the tissue but could only go so far, surgeon was concerned about exposure of femoral vessels. Pathology doesn't show any recurrent disease. They have him packing the wound, the surgeon discussed possible need of an amputation before (sounded extreme but the wound is quite large). They'll see plastics next wk.

Is this consistent with RT necrosis almost 20 years out, Is it unusual to see such enlargement while on HBO. Would you avoid HBO again given that it increased in size. I think the wound has stabilized but it is quite impressive.

What does the pathology report actually say? Was the tissue sent for pan-culture? Would be very suspicious for pyoderma gangrenosum if its sterile, worsening with debridement and the path is neutrophilic- something the pathologist will not even mention unless its brought up clinically. Is patient running a white count?