Radical surgery with appropriate and optimal reconstruction followed by postoperative adjuvant radiotherapy or chemoradiotherapy is the current established standard of care in oral cavity squamous cell carcinoma. Definitive chemoradiotherapy is an alternate option in unresectable case. Out of several options available for head-neck reconstructions, PMMC flap is commonly used as a primary modality as well as a salvage mechanism after failure of a free vascularized flap since last 40 years due to its ease of raising the flap, predictable blood supply, less time consuming, cost effective and reliability2,3. The common complications associated with use of PMMC have been described which include flap necrosis, infection, seroma, fistula2. The rare complications like rib osteomyelitis, metastasis to donor site of PMMC flap has been described but occur very rarely 4,5. In PMMC donor site recurrence the underlying cause and mechanism of seeding of the primary tumor to graft donor site is not clear. Although direct contamination by viable tumor cells present on gloves and surgical instruments while performing definitive operation and harvesting autologous graft at the same sitting is most likely, however, it can also be attributed to altered circulation at the healing donor site. Some theoretical and experimental evidence links localization of tumour cells due to surgically induced trauma. Theories supporting this include increased circulating tumor cells occurring during manipulation of primary tumor, damaged endothelium of the microcirculation causing increased adherence of tumor cells, and blood flow or coagulation mechanism alteration in the traumatized graft harvesting site7.
After a definitive treatment of HNSCC, recurrence and/or distant metastasis happens in approximately 50% of the patients over a period of time8. These patients obviously have extremely poor prognosis (median overall survival of 6–12 months)9. Although the contemporary established treatment methods for recurrent and/or metastatic HNSCC are either local therapy (salvage surgery and/or radiotherapy) or systemic therapy (chemotherapy, biological therapy, immunotherapy), local therapy only yields better durable response in comparison with systemic therapy10.
Our patient developed an unifocal superficial solid-cystic fixed tender biopsy proven recurrence at left upper anterior chestwall near PMMC donor scar site resembling with above literature described PMMC donorsite recurrence. In view of clinicoradiologically unifocal biopsy proven recurrence, controlled loco-regional disease and good general condition, the institutional multidisciplinary tumor board suggested for a curative intent salvage radical radiotherapy with weekly cisplatin based concurrent chemotherapy over a radical re-do surgery as radiologically the tumor was encasing the subclavian vein. On followup after 6 months of treatment, there was clinico-radiologically complete response. Now he is on regular follow up for last 2 years
Table 14,5,11,12,13,14 highlights other similar cases described in literature where oral cavity squamous cell carcinoma recurred over the anterior chest wall at PMMC donor site. The pattern of recurrence can be two types – one is metastases on PMMC vascular pedicle site4,5,12, which can be attributed mainly to lymphovascular spread of tumour cells occurring through the PMMC flap itself, and second is metastases over sites other than vascular pedicle site – either anterior chest wall5,11,13, or PMMC flap muscle14 which can be due to direct transfer of tumour cells as contamination during surgery highlighting importance to change of gloves, thorough wash of surgical site and cleaning of instruments or to use a different set to avoid cross contamination during surgery.