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Outcomes Following Calvarial Reconstruction in 269 Cancer Patients
Edward Lee, MD1, Albert Chao, MD2, Roman Skoracki, MD3, Peirong Yu, MD3, Franco DeMonte, MD3, Matthew Hanasono, MD3.
1Baylor College of Medicine, Houston, TX, USA, 2Ohio State University, Columbus, OH, USA, 3MD Anderson Cancer Center, Houston, TX, USA.
PURPOSE: To describe our experience with calvarial reconstruction in cancer patients, including the reliability of various cranioplasty materials, based on the rates of short-term and long-term complications.
METHODS: A retrospective review of patients undergoing calvarial reconstruction with or without soft tissue reconstruction at a tertiary care center over a 12-year period was performed.
RESULTS: Two hundred eighty-nine calvarial reconstructions were performed on 269 patients from 1999 to 2011. Materials used for cranioplasty included: titanium mesh (49.8%), methylmethacrylate 16.3%), calcium phosphate cement (17.6%), porous polytheylene (4.8%), polyetheretherketone (PEEK) (4.5%), and autologous bone graft (2.1%), as well as combined titanium mesh with methylmethacrylate (4.8%) and titanium mesh with calcium phosphate cement (13.5%).
The average bony defect measured 38.3 ± 45.3 cm2. Seventy-two cases (24.9%) required concurrent scalp reconstruction measuring an average of 214.6 ± 152.3 cm2. Of these, twelve (16.7%) were reconstructed with local flaps while the remaining sixty (83.3%) required free tissue transfer, which was necessary to replace scalp involved with tumor (n=50), necrotic tissue from infection (n=5) or osteoradionecrosis (n=5).
Following surgery 42 (14.5%) cases developed short-term (≤30 days) complications, of which 29 (10.0%) were at the recipient site. Short-term recipient complications included: infection (2.8%), cerebrospinal fluid leak (2.4%), dehiscence (1.7%), flap loss (1.7%), meningitis (1.4%) and hematoma/seroma (1.4%). Significant risk factors for short-term complications include: radiation therapy (p=0.012), prior surgery (p=0.003), recurrent cancer (p=0.003), and prior infection (p=0.009). There were 2 (3.3%) free flap losses and no local flap losses.
There were 20 (6.9%) long-term (>30 days) complications at the recipient site. Long-term complications included infection (3.8%) and dehiscence (3.1%). Radiation therapy was a significant risk factor for developing a long-term complication (p=0.011). With regard to the selection of various cranioplasty materials, use of calcium phosphate cement with or without titanium mesh was associated with increased long-term complication rate (p<0.001). Twenty-five cases (8.7%) required removal of hardware due to various complications. Infection and dehiscence were significant risk factors for eventual hardware removal (p<0.001 for both).
With the exception of calcium phosphate cement, the type of cranioplasty material used did not affect surgical outcome. However, there was a statistically significant difference in the size of the defect and the cranioplasty material used, with the tendency to use PEEK for larger defects and porous polyethylene and calcium phosphate cement for smaller defects (p<0.001).
CONCLUSION: This study represents the largest series of calvarial reconstruction in cancer patients. Alloplastic cranioplasty is a safe and effective procedure for cancer patients undergoing calvarial reconstruction. Most commonly used materials seem to be equivalent in reliability with the exception of calcium phosphate cement, which should be utilized with caution given the increased complication rate associated with its use. Every effort should be made to prevent wound infection and dehiscence since they are strong risk factors for failure of reconstruction and eventual hardware removal.
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