Advances in Oral and Maxillofacial Surgery 8 (2022) 100321

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Advances in Oral and Maxillofacial Surgery

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Case report

Iatrogenic donor site seeding in head and neck carcinoma: A case report
Aaron John Cronin *, Ravi Pancholi, Mahesh Kumar
London North West University Healthcare NHS Trust, Northwick Park Hospital, Watford Road, Harrow, London, HA1 3UJ, UK

A R T I C L E I N F O A B S T R A C T

Keywords: There is an emerging belief that decontamination of the surgical field following excision of a malignant neoplasm
Oncology may help to prevent recurrences or seeding of a head and neck cancer. We present a case of cutaneous head and
Tumour seeding neck squamous cell carcinoma which recurred both locally and at a distant donor site metastasis – to lend further
Reconstruction
weight to this recommendation.
Iatrogenic
Risk management

1. Introduction with poorly differentiated squamous carcinoma, which were in keeping

The risk of malignant seeding during a combined resective and
reconstructive head and neck surgery is conflated with the likelihood of
loco-regional recurrence due to positive resection margins or incomplete
lymph node clearance. The practice of re-prepping the operative field
and changing surgical instruments is, where feasible, customary to
minimise the risk of iatrogenic tumour spread, and has been demon­
strated in the literature. We present a recent case to illustrate this risk,
noting that distant cutaneous metastases to a surgical donor site repre­
sent compelling evidence of the discrete risks of iatrogenic seeding as an
entity distinct from locoregional recurrences.
2. Case report
An 84 year old Caucasian male was referred to the regional maxil­
lofacial unit with respect to new nodules of the left neck and left thigh
(Fig. 1) which occurred approximately 9 months following a diagnosis
and excision of a squamous cell carcinoma of the left ear pinna (6
months following left sided neck dissection and reconstruction with left
tensor fascia lata, 2 months following completion of post-operative
radiotherapy due to lymph node involvement and extension to the
base of skull). The initial treatment occurred in another institution.
Following a first consultation, ultrasound-guided fine needle aspi­
ration cytology was obtained on clinical suspicion of locoregional
recurrence with concern over a possible de novo malignancy or iatro­
genic seeding of malignant cells to the left thigh donor site. Ultrasono­
graphic appearances were suspicious for metastatic foci, and
cytologically both sites demonstrated similar malignant cells consistent
with a known previous squamous cell carcinoma of the left ear pinna.
Discussion at the regional head and neck multi-disciplinary team
(MDT) meeting took place; a PET-CT scan for final staging was recom­
mended. This study confirmed increased avidity within the left neck
(Fig. 2), lower lip, right sphenoid sinus and left thigh (Fig. 3), as well as
bilateral lung metastases and avid lymphadenopathy of the medias­
tinum and retroperitoneum. Discussion of these findings at the MDT
took place in the context of the patients suitability for systemic immu­
notherapy, for which he was duly referred.
Although the clinical picture of metastasis at multiple sites was clear,
the mechanism of tumour occurrence in the left thigh, being cytologi­
cally similar to the neck lesion and initial primary cutaneous tumour,
was deemed highly likely to represent iatrogenic seeding of the donor
site.
3. Discussion
The risk of seeding of malignant cells within the aerodigestive tract
in cases of head and neck cancer has been recognised as a complication
of insertion of percutaneous gastrostomy insertion [1]. A recent litera­
ture review highlighted the controversy and spectrum of surgical opin­
ions with regard to the possibility of intra-operative seeding of
malignant cells [2]. In focusing on malignancies diagnosed within pre­
vious surgical donor harvest sites, there was an attempt to disambiguate
cases of local recurrences or incomplete excision from those which can
uniquely be regarded as iatrogenic. Fifteen case reports were considered
in the review; the consensus in ten of fifteen was that iatrogenic seeding
was the most likely explanation versus a de novo malignancy or

* Corresponding author. London North West University Healthcare NHS Trust, Northwick Park Hospital, Watford Road, Harrow, HA1 3UJ, United Kingdom.
E-mail addresses: aaron.cronin1@nhs.net (A.J. Cronin), ravi.pancholi2@nhs.net (R. Pancholi), maheshkumar@nhs.net (M. Kumar).

https://doi.org/10.1016/j.adoms.2022.100321
Received 4 July 2022; Accepted 13 July 2022
Available online 31 July 2022
2667-1476/© 2022 The Author(s). Published by Elsevier Ltd on behalf of British Association of Oral and Maxillofacial Surgeons. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A.J. Cronin et al.
Fig. 1. Left thigh scar with malignant nodules post fascia lata harvest. Pub­
lished with the patient’s consent.
Fig. 2. Left neck PET-CT/PET coronal images demonstrating increased avidity
of the left neck representing local recurrence. Published with the pa­
tient’s consent.
haematogenous/systemic spread [2]. The proposed vector (of using
contaminated gloves and instruments for the reconstructive phase
following cancer resection) has been tested in vitro, with glove and in­
strument washes having detectable malignant cell debris in up to 73% of
cases [3].
A recent survey of general surgeons demonstrated a belief that the
risk of malignancy seeding locally and to wounds was low, but that glove
and instrument changes were routinely performed following the extir­
pative phase of surgery in 52% and 40% of cases, respectively [4].
Reasons cited for this action ranged from training experience to “gut
instinct”.
It is our view that, where practical, the changeover of instruments
and gloves between the resection and reconstruction phases of head and
neck cancer surgery serves a purpose of reducing the incidence of
Advances in Oral and Maxillofacial Surgery 8 (2022) 100321
Fig. 3. Left thigh PET image demonstrating increased avidity of the left thigh
representing likely tumour seeding at a previous surgical donor site. Published
with the patient’s consent.
iatrogenic implantation, cases of which have been demonstrated in the
literature. Notwithstanding a lack of consensus guideline, most surgeons
follow the convention of re-prepping or protecting the surgical field as a
risk-reducing measure.
Confirmation of patient consent to publication
The patient provided written consent for the use of images/photo­
graphs for publishing purposes.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgement
The authors sincerely thank Dr Subhadip Ghosh-Ray (Head & Neck
Imaging, Paul Strickland Scanner Centre, London, United Kingdom) for
providing reformatted PET-CT images of the case presented.
References
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