A Systematic Review and Retrospective Cohort Study of Non-Operative Management of Exposed Calvarium Post Radiotherapy

Purpose: Scalp defects that have previously been irradiated present a unique reconstructive challenge for the surgeon. Traditionally, reconstruction with free tissue transfer has been thought to be necessary when local and regional options are insufficient. However, elderly patients with medical comorbidities are occasionally poor surgical candidates. The aim of this study is to determine complications of non-operative management for exposed calvarium post radiotherapy in elderly patients who are not candidates for free tissue transfer.

Method: A retrospective chart review was performed to identify patients who developed exposed calvarium after undergoing radiotherapy for skin cancer on the scalp. Data from four surgeons at tertiary hospitals from 2008-Aug 2017 was collected. Patient demographics, comorbidities, type of skin cancer, radiation history, wound characteristics, and complications were recorded. Next, a systematic review of PubMed, EMBASE, Cochrane Library and CINAHL was conducted to identify articles in which non-operative management was utilized for exposed calvarium post radiotherapy.

Results: Eleven patients (10 male, 1 female; mean age=84.7 years) who received radiotherapy for biopsy-confirmed skin cancers and subsequently developed exposed calvarium were reviewed. Patients on average had eight medical comorbidities declared in the initial consultation, with most common ones including hypertension, dyslipidemia, gastroesophageal reflux disease, and diabetes. All patients were classified as American Society of Anesthesiologists (ASA) class three or four. Local reconstruction and skin grafts were unsuccessfully attempted in nine patients and all patients were ultimately managed with local wound care. Complications included soft tissue infections (n=8) and osteomyelitis (n=2). Six patients died of unrelated causes and one died of sequelae of metastases. The electronic search yielded 342 articles, of which three met inclusion criteria. A total of twenty-four patients who underwent local wound care for exposed skull post radiotherapy were included. Two studies reported wound infections.

Conclusion: This retrospective cohort and systematic review did not find major complications or deaths occurring secondary to non-operatively managed exposed calvarium post radiotherapy. Non-operative management appears to be an option for elderly patients who choose not to undergo free tissue transfer reconstruction either due to multiple medical comorbidities that put them at high operative risk or because of personal choice. However, to be clear, more data is required to make a strong clinical recommendation.