Surgical Treatment of Late Radiation-Induced Soft Tissue Injuries of the Chest Wall Using Mobilized Vascularized Flaps Based on Muscles in Patients with Breast Cancer

The dissertation is devoted to the surgical treatment of late radiation-induced soft tissue injuries of the chest wall in patients with breast cancer. The study investigates the features of development of local radiation injuries depending on the conditions of radiation therapy, as well as the indications and methods for using mobilized vascularized flaps based on muscles to replace extensive chest wall defects. The immediate and late results of plastic surgical operations, typical complications, and preventive measures are studied. The validation of results was conducted at scientific conferences and implemented in the practice of a leading medical radiological research center.

Relevance of the Research. Currently, the incidence of late radiation injuries worldwide amounts to approximately 5% of all patients who have undergone radiation therapy; however, according to data from certain investigators, the formation of this pathology in our country exceeds 10–15% [6, 10, 15, 25, 101, 145, 147, et al.].

A typical complication of radiation treatment of various oncological diseases is local radiation injury of soft tissues in the irradiation field area (fibrosis, ulcer). Correction of this pathology presents a complex task and requires radical excision of all altered tissues (including bone fragments) followed by adequate replacement of the formed defect, which, as a rule, has a large area and volume and cannot be closed by traditional plastic surgery methods. Widespread and successful use in surgical practice of tissue flaps with axial blood supply (pedicle transfer, free graft) gives grounds for expecting good results also in the treatment of local radiation injuries of soft tissues. Late radiation injuries of soft tissues forming during the posthospital stage of treatment of malignant neoplasms significantly reduce the patient's quality of life. They may become a cause of suffering, deep disability, malignant transformation, and death of the patient. Therefore, a favorable outcome of the primary disease does not yet mean complete recovery. Given that most patients are of working age, the problem of local radiation injuries acquires social significance and requires the search for effective methods of prevention and rehabilitation that would ensure acceptable conditions of life and activity 2–3, 6–8, 9–10, 12, 18–19, 23, 41–42, 68, 72, 78–79, et al.].

In connection with the above, the search for ways to increase the effectiveness of rehabilitation measures in patients with local radiation injuries of soft tissues of the chest wall, the development of indications for corrective plastic surgical operations (using mobilized vascularized flaps with axial circulation based on muscles) and the assessment of the effectiveness of their application remain relevant.

The aim of the work is to increase the effectiveness of surgical treatment of late radiation injuries of soft tissues of the chest wall in patients with breast cancer.

Tasks of the research:

1. To study the features of development and structure of local radiation injuries of soft tissues of the chest wall depending on the conditions of radiation therapy in patients with breast cancer.

2. To develop indications for the use of mobilized muscular and musculocutaneous flaps for replacement of chest wall defects of various localization.

3. To develop optimal methods of surgical treatment of late radiation injuries of soft tissues of the chest wall using vascularized mobilized muscular and musculocutaneous flaps,

4. To study the effectiveness of the application of mobilized flaps based on muscles in the early and late postoperative periods.

5. To assess the nature and causes of postoperative complications. To develop preventive measures.

Scientific novelty. In this work, the representations of the causes, features of development, and clinical course of local radiation injuries of soft tissues have been expanded. The frequency of distant complications forming after combined and radiation treatment of breast cancer has been studied, as well as its dependence on the conditions of irradiation. For the first time, on a sufficient clinical material, the indications and criteria of effectiveness of plastic surgical operations using mobilized muscular and musculocutaneous flaps aimed at replacement of extensive defects of the chest wall by area and volume, which previously were not amenable to radical treatment, have been detailed. An optimal method of preoperative examination and postoperative care for patients who have undergone such interventions has been developed. The immediate and late results of plastic surgical operations have been studied, as well as typical complications that have allowed an objective assessment of the advisability of their use in this category of persons.

Practical significance. As a result of the conducted research, the effectiveness of rehabilitation measures in patients with local radiation injuries of soft tissues of the chest wall has been increased. The developed methods of surgical treatment of local radiation injuries of soft tissues in patients with malignant neoplasms of the breast have made it possible to reduce the number of disabled persons, improve the conditions and qualitative characteristics of life of such persons. The effectiveness of the use of flaps with autonomous blood supply in the treatment of late radiation ulcers developing in the irradiation field area of the chest wall has been assessed.

The main provisions and conclusions of the dissertation may be proposed for practical application in the work of oncological institutions, radiology departments, as well as departments and groups engaged in the rehabilitation of oncological patients and reconstructive-plastic surgery.

Validation of the work and forms of implementation. Based on the dissertation materials, 5 scientific works have been published in the central medical press, in the materials of congresses, symposia, and conferences with international participation. The results of the dissertation research were reported at the III Congress of Oncologists of the CIS, Minsk, 2004; the Russian Radiology Conference, Moscow, 2004; a scientific-practical conference, Tomsk, 2004; the VI Congress of Oncologists of Russia, Rostov-on-Don, 2005.

The developed treatment methods have been implemented in the practice of the State Medical Research Center of the Russian Academy of Medical Sciences (GU-MRNC RAMN).

The validation of the dissertation was conducted on December 16, 2005, at an expanded joint scientific conference of the Department of Faculty Surgery named after S.I. Spasokukotsky (head — academician of the RAMS and RAMN, professor V.S. Savelyev), of the problem research laboratories of intraosseous and contrast methods of radiological research (head — professor V.I. Prokubovsky), of angiology (head — member-correspondent of the RAMS, professor A.I. Kirnenko), of anesthesiology and resuscitology (head — member-correspondent of the RAMS, professor B.R. Gelfand), of endoscopy (head — professor V.I. Revyakin) of the Russian State Medical University, of the staff of the department of radioisotopic research methods (head — Doctor of Medical Sciences A.V. Karalkin), of the department of ultrasonic diagnosis and remote lithotripsy (head — Candidate of Medical Sciences V.M. Kulikov), of surgical departments 1, 2, and 4 of City Clinical Hospital No. 1 named after N.I. Pirogov, Moscow (chief physician — professor Kh.V. Rutkovsky), as well as of the clinical radiology sector of GU-MRNC RAMN (director — academician of RAMN, professor A.F. Tsyb). The dissertation work was carried out in the department of surgical and conservative treatment of radiation injuries in accordance with the plan of scientific research of the State Medical Research Center of the RAMN and is a fragment of the scientific research topic "Improvement of Conservative and Surgical Methods of Treatment of Local Radiation Injuries" (Registration No. 01.9.90 002863).

Structure and volume of the dissertation. The dissertation consists of an introduction, a literature review, 3 chapters of the author's research, a conclusion, conclusions, and practical recommendations. The list of cited literature includes 174 sources, including 93 foreign ones. The work is presented on 146