# Wound Healing in a Patient with Psoriasis Vulgaris and Femur Megaprosthesis Implantation

Authors: Markus Nottrott; Jendrik Hardes; Winfried Winkelmann; Georg Gosheger
Journal: Sarcoma
 (2008)

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## Abstract

Extraskeletal mesenchymal chondrosarcoma is extremely rare and, in combination
with psoriasis, it has never been described before. We report a case of wide resection of an
extraskeletal chondrosarcoma of the thigh and reconstruction with a femoral megaprosthesis in a patient
with psoriasis vulgaris. Special emphasis has been laid to postoperative wound healing in psoriatic skin
which did not show any problems.


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## Body

## 1. Introduction

Psoriasis in patients who should undergo surgery is a controversially discussed
problem and today there are no controlled,  prospective studies existing on this
topic [1]. While elective surgery in psoriatic skin is a more common problem, surgery
in psoriatic skin for implantation of a megaprosthesis because of a
chondrosarcoma has never been described before. We report a case of the
resection of an extraskeletal chondrosarcoma of the thigh and reconstruction
with a femoral megaprosthesis in a patient with psoriasis vulgaris. Special
attention is given to postoperative wound healing in psoriatic skin.


## 2. Case Report

A 20-year-old man with a history of Psoriasis
vulgaris was presented to our department for resection of an extraosseous mesenchymal
chondrosarcoma of the left thigh.The patient recognized a half year before admission a tumour in his left
thigh and suffered of pain over some weeks before he contacted a local hospital
where X-rays and an
MRI were suspicious for a malignant tumour. Physical examination showed no skin
disorders at this point of time. Open biopsy showed an extraosseous mesenchymal
chondrosarcoma G3. Tumour size was18×8×14 cm. The tumour was localized
close to the femur in the middle third of the thigh. Tumour staging with CT of
the chest showed no pathology in the thorax but abdominal CT revealed two intraabdominal
lymph node metastases besides the left A. and V. iliaca interna. Skeletal scintigraphy
supported these findings with high uptake in the middle third of the thigh and
the two lymph nodes.Chemotherapy with Ifosfamide and Adriamycine was initiated with a good initial
tumour response regarding tumour size and lymph node reduction. Four months
later, a left inguinal and iliacal lymphadenectomy was performed where six metastases
were removed in another hospital. Chemotherapy was continued afterwards with a
total number of 5 cycles with Adriamycine (60 mg/m2) and Ifosfamide (8 g/m2) up to 5 months after diagnosis. Curative treatment with a wide
tumour resection of all contaminated tissue, including the groin (high amputation),
was planned but preoperative restaging one month later showed bipulmonal and new
inguinal metastases in CT and tumour growth in the thigh. Therefore, curative
treatment seemed to be impossible and it was decided to perform a marginal
resection of the tumour and reconstruction of the defect with a cemented diaphyseal
femurprosthesis implantation allowing immediate weight bearing and mobilization
of the patient.Also at this restaging examination the patient had no skin disorders,
but on admission to the hospital two weeks later he presented with ubiquitary psoriasis
vulgaris efflorescence’s especially on the left thigh. These lesions were characterized
as erythemato-squamouse. Treatment with Clobetasol-17-propionat
(Dermoxin) crème was initiated and the patient responded well to this treatment
(Figure1). Because of tumour progression and in spite of an expected increased
postoperatively infection risk, operation with local wide tumour resection (360 mm) and implantation of a Mutars femur diaphyseal implant was performed one
week after psoriasis treatment started (Figure 2). Intraoperatively,
subcutaneous dissection appeared to be difficult because of the psoriasis efflorescence’s
effect on the subcutaneous
tissue. However, closure of the subcutaneous and cutaneous tissue was without
any problems by using an
M. biceps femoris flap covering the prosthesis. Postoperatively the patient
received Ceftriaxone (Rocephin) 2 g ×1 and Clindamicine (Sobelin) 600 mg ×3 intra
venously for one week. Wound healing did not show any problems. No wound
infection was seen but a slight necrosis of the skin in central areas of the
wound without any clinically relevance and without any relationship to the
psoriasis efflorescence’s (Figure 3) was observed. Psoriasis treatment was
changed from Clobetasol-17-propionate crème to Calcipotriol Betamethasone (Psorcutan)
crème and clinically a slight remission of the efflorescence’s could be
observed (Figure 4). Two weeks postoperatively, the patient was mobilized and
dismissed from the hospital. Histological examination of the tumour showed an
extraskeletal mesenchymal chondrosarcoma G3 with a small-blue-round cell
component. Resection margins were wide and the response grade was V according
to Salzer-Kuntschik [2]. Palliative chemotherapy with Topotecan/Cyclophosphamide was initiated. Treatment with Psorcutan crème of the psoriasis
efflorescence’s was continued.Figure 1
Preoperative clinical picture showing psoriasis vulgaris efflorescence’s on the
left thigh.Figure 2
Left thigh after wide tumour resection and implantation of a Mutars femur
diaphysis implant.Figure 3
Left thigh 1 week postoperatively with a slight necrosis of the skin in central
areas of the wound.Figure 4
Left
thigh 2 weeks postoperatively after removal of the clips.


## 3. Discussion

Extrasceletal mesenchymal chondrosarcoma is extremely rare [3] and in combination with
psoriasis it is even more rare. To our knowledge the combination of psoriasis
vulgaris and this tumour entity has never been reported before. Furthermore,
there have been no reports in the literature describing wound healing of more
than 30 cm in psoriatic skin. Therefore, we had difficulties in decision making
to operate or not with respect to concerns about wound healing and sepsis.While some publications indicate that there is no increased risk for
infection or wound healing disturbances after elective surgery in psoriatic
skin [4] and psoriasis is not an absolute contraindication to surgery [5],
others state that they have seen more postoperative sepsis in psoriatic
patients [6]. The decision to perform an operative procedure with limb salvage that
usually is conducted to a high postoperative infection rate without any extra
skin disorder was done to persuade the patient to have a good rest
life quality. In case of a postoperative deep wound infection or widespread skin
necrosis, an amputation would have been performed. In this case, preoperative
treatment of the psoriatic skin was limited by the necessity to perform the
operation as soon as possible with respect to rapid tumour growth.After operation the patient received a prolonged antibiotic prophylaxis
over one week and we could not observe any wound infection or healing
complications related to the psoriatic skin. A slight necrosis of the skin in
central parts of the wound is not unusual in such operations with wide
subcutaneous preparation and has no clinical relevance that causes an
intervention.Our case shows that megaprosthesis implantation is possible in patients
with psoriatic lesions in the operation field. There should be applied an
adequate psoriasis treatment preoperatively if possible and a prolonged
antibiotic prophylaxis seems to be helpful. Whether there is an increased
infection risk or not remains unclear.



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