What is the role of reconstructive surgery in the treatment of angiosarcoma of the scalp?

Updated: Jan 03, 2020
  • Author: Jonathan S Zager, MD, FACS; Chief Editor: Gregory Gary Caputy, MD, PhD, FICS  more...
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The primary treatment for scalp sarcoma of all histologic types is wide surgical excision to histologically negative margins whenever possible. As noted above, achieving a negative margin is frequently difficult in angiosarcoma patients because of the extensive microscopic spread common with this disease. Therefore, in trying to achieve a negative margin, a wound is created that almost never can be closed primarily.

In this clinical setting, the reconstructive surgeon is faced with the dilemma of either (1) performing a primary reconstruction and potentially discovering later that further excision, possibly including sacrifice of the entire reconstruction, is necessary, or (2) performing a staged reconstruction after final confirmation of the margin status has been obtained. The authors prefer the latter approach, although it mandates a second surgical procedure for all patients.

The following are available options for reconstructive surgeons to use for initial temporary coverage and for definitive reconstruction:

  • Homograft skin/bovine collagen constructs

  • Autologous skin grafts

  • Rotation flaps

  • Free flaps

Each option is useful in different situations.

Staged reconstruction is the principal treatment of angiosarcoma of the scalp. Because most patients are elderly, the preferred reconstructive algorithm is skin grafts initially, followed by rotation flaps, and, finally, free-tissue transfer. (See image below).

Although treatment of scalp angiosarcomas mandates Although treatment of scalp angiosarcomas mandates excision to negative margins (when possible), plastic reconstruction should be delayed. Homograft is initially used to temporarily reconstruct the scalp. Homograft has the advantage of being a durable skin substitute for 5-7 days. Once the pathology report shows definitive clear margins, the patient is returned to the operating room for a staged reconstruction.

Typically, oncologic principles require that permanent sections confirm free margins. Therefore, the large defects created after resection must have some type of temporizing reconstruction. This aspect of the case is important because preserving the pericranium allows the use of skin grafts, the simplest form of reconstruction. Rarely does tumor removal require resection of the pericranium, thus preventing the use of a skin graft as the first option; previous radiotherapy is the only possible exception to using skin grafts initially.

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