Surgical Reconstruction Toxicity Following Hypofractionated Adjuvant Radiation Therapy for Primary Cutaneous Melanoma

Abstract

Purpose: Adjuvant radiation therapy (RT) to a cutaneous target has been associated with elevated risk of surgical complications such as graft, flap, or skin substitute reconstruction failure. We sought to better quantify the risk of surgical site complications after hypofractionated adjuvant RT delivered in the modern era to patients undergoing surgical reconstruction for their primary site cutaneous melanoma.

Methods and materials: We reviewed clinical data on all patients treated for cutaneous melanoma at our center between 2008 and 2021 with primary tumor resection and reconstruction (graft, flap, or skin substitute), followed by 5 × 6 Gy RT. Details on post-treatment complications were assessed.

Results: A total of 193 patients with melanoma undergoing surgical reconstruction followed by hypofractionated RT were identified. Most patients carried at least 1 risk factor for wound healing complications (70% with cardiovascular disease, 64% overweight, and 23% with diabetes). Most tumors were located in the head and neck (89%). Patients initiated RT a median of 7 weeks (IQR, 5-9 weeks) from surgical reconstruction. Skin grafts were used in 62% of reconstructions, and flaps used in 44%. Electron-based RT was used for the majority of patients (n = 166, 86%). Ten patients (5%) required surgical revision after reconstruction, with half occurring after RT. The primary reconstruction for all 5 patients requiring surgical revision after RT was graft reconstruction of the scalp, with a wide range of times from reconstruction to RT (5-11 weeks) and a wide range of times from RT to surgical revision (2-28 months).

Conclusions: The risk of surgical revision after adjuvant hypofractionated RT to a surgical reconstruction involving a graft, flap, or skin substitute is low. Half of graft failures occurred before adjuvant RT and half after, which suggests that adjuvant RT only marginally increases the risk of postreconstruction complications if adequate time for healing is given.