Local recurrence along surgical incisions is a rare and potentially avoidable complication that can result after oncological surgery. When it does occur, however, it is considered a cutaneous metastasis and generally results in a poor prognosis.1
There are many reports in the literature of incisional recurrence following open surgical excision of intra-abdominal and pelvic malignancies, with the overall incidence rate of 5% or less.11
Some examples include cancers of the cervix (0.8%),12
colon (0.8 to 3.3%),13,14
and rectum (5.3%).15
There has been considerable debate with regards to the route of spread leading to these recurrences. Some believe that implantation of viable tumor cells that are dislodged at the time of surgery is the likely mechanism,16
although others have suggested that the mode of transmission is retrograde spread of tumor secondary to lymphatic obstruction.17
Since the advent of laparoscopic and endoscopic equipment and surgical techniques, there has been a push to maintain the effectiveness of a procedure while minimizing the morbidity of the surgical approach. It would make sense then, especially if one ascribes to the notion of tumor seeding at the time of the primary surgery, that tumor seeding at the portals of entry for the instruments could be a site of possible tumor recurrence. This idea has been supported by reports of tumor recurrence at trocar sites for thoracoscopic4
surgery for tumors and is further enforced by the numerous reports of gastrostomy site seeding from tumors of the upper aerodigestive tract.8,9,10
Oncological surgery of the skull base brings with it additional challenges of limited exposure as well as several nearby vital neurovascular structures that preclude wide oncological margins, at times making en bloc resection impossible. Given that tumor fragmentation may occur intentionally or inadvertently during resection, it would be reasonable to assume that incisional recurrence may be more frequent following craniofacial surgery compared with open approaches in other body locations. This was not observed in our patient population, however. In our group, there were a total of two pathologically confirmed tumor recurrences along the surgical incision line out of a total of 70 patients undergoing up-front surgical management of their tumors. This 3% risk is similar to what is seen following surgery for cervical,12
tumors. With regards to skull base malignancies, clival chordomas of the skull and cervical spine have been found to carry a risk of ~5% for incisional recurrence when managed with combined surgery and radiation.18,19
In the current study, both patients who developed incisional recurrence in our series had squamous cell carcinomas as their primary tumor. This is similar to what has been observed in other parts of the body where adenocarcinoma, squamous cell carcinoma, and undifferentiated carcinoma3,20
were the most frequently described tumors resulting in incisional recurrence. This suggests that, when possible, en bloc resection of these tumors is advisable and should be considered when choosing the surgical approach.
There are times, however, when en bloc resection of an anterior skull base tumor is not possible. In these instances, endoscopic assistance should be considered. When a true transnasal endoscopic approach is utilized to assist the neurosurgeon, the raw surface for potential tumor seeding would be reduced, minimizing the likelihood of developing incisional recurrence.
Our series of patients demonstrates that, despite the limitations of exposure in the anterior skull base, there was a similar risk for developing tumor recurrence along the surgical excision line compared with other body sites.2,3,4,5
Those patients at highest risk were those with squamous cell carcinoma as the pathology of their primary tumors. As a result, when contemplating surgery as part of the management for these types of sinonasal malignancies, surgical approaches that avoid tumor handling and fragmentation while minimizing raw surface edges of the surrounding soft tissue should be employed.
Management of incisional recurrence usually entails salvage surgery with or without reirradiation. If the nidus is affecting only the skin incision without significant depth of penetration, electron beam radiation can be utilized to avoid additional tissue damage to the prior treatment area. In our patient population, salvage surgery was performed with reirradiation, using protons and proton radiosurgery boost for the dural recurrence in an attempt to maximize local control while minimizing radiation damage to the underlying brain parenchyma. Despite these efforts, however, the prognosis in these patients is generally poor, and avoidance is the best strategy.