Large axillary defect after lymph node dissection directly closed by suturing the pectoralis major to the latissimus dorsi.

SUMMARY: In 2009, the Union for International Cancer Control defined lymph node (LN) metastasis ≥6 cm in diameter as stage 4 in squamous cell carcinoma of the skin. Lesions from such LNs become ulcerated and infected and bleed without treatment. A 67-year-old man suffered from skin cancer on his right back and a 7-cm-diameter LN metastasis. After axillary LN dissection, a large skin and soft tissue defect was apparent. To rectify the defect, we simply sutured the pectoralis major muscle to the latissimus dorsi muscle and covered the suture with a split-skin mesh graft. After the surgery, the range of motion of the upper limb on the side where surgery was performed remained in good condition.

Surgery is generally not a curative approach for stage 4 cancer. In 2009, the Union for International Cancer Control defined LN metastasis ≥6 cm in diameter as stage 4 in squamous cell carcinoma of the skin. However, we believe that a surgical approach can be adapted at this cancer stage depending on the case. Lesions from such LNs become ulcerated and infected and bleed without treatment, all of which negatively affect the patient’s quality of life. We treated a case in which a simple LN dissection was performed to prevent an unfavorable situation and in which a large skin and soft tissue defect was apparent.

CASE REPORT

A 67-year-old man with a 15 × 12cm squamous cell carcinoma on his right back and a 7-cm-diameter LN metastasis adhered to the overlying skin with inflammation was treated at our institution (Fig. 1).

Fig 1.

A 7-cm-diameter LN metastasis was present in the right axilla and was adhered to the overlying skin with inflammation.

SURGICAL PROCEDURE

The primary cancer was surgically removed and covered with a split-skin mesh graft. The axillary LN and overlying skin were dissected with a 2-cm lateral margin. We ligated the thoracodorsal artery, but the tumor was not completely removed, and a large skin and soft tissue defect was still apparent after dissection (Fig. 2). Because the primary tumor was present on the same side of the back, we preferred not to use a latissimus dorsi muscle or a thoracodorsal fasciocutaneous flap[1-3] to cover the defect, which were ordinarily used. Instead, we directly sutured the pectoralis major muscle to the latissimus dorsi muscle (Fig. 3) and covered the suture with a split-skin mesh.

Fig 2.

A large skin and soft tissue defect was apparent after the right axillary dissection.

Fig 3.

We directly sutured the pectoralis major muscle to the latissimus dorsi muscle to rectify the defect.

RESULTS

The sutures did not rupture, and the split-skin mesh graft survived well. In particular, the range of motion of the upper limb on the side where the surgery was performed remained in good condition (Fig. 4). The residual tumor grew beneath the muscles that were sutured together, and the tumor did not appear on the skin surface until the patient’s death. Thus, the dissection improved this patient’s quality of life.

Fig 4.

The range of motion of the upper limb on the side where the surgery (his right arm) was performed remained in good condition.

DISCUSSION

Dissection of stage 4 LN metastasis, particularly one adhering to the skin, is always challenging. In particular, the skin and soft tissue defect is large and deep after axillary dissection. Several choices are available to repair an axillary defect after LN dissection.

CONCLUSION

In this study, we present a very simple approach by suturing muscles, which has not been reported until now as far as we know. Our method did not result in any side effects and successfully hid the recurrent tumor beneath the muscles that were sutured together.

ACKNOWLEDGMENTS

We are indebted to Drs. Chihiro Onami and Fumiko Monma for their contribution to the patient’s treatment.

PATIENT CONSENT

The patient provided written consent for the use of his image.