Surgeons at The University of Texas MD Anderson Cancer Center recently performed a unique, extensive soft tissue transplant between identical twins to repair a large wound resulting from a rare, recurrent cancer in one of the twins.
One of the 65-year-old twin sisters presented to MD Anderson in early 2017 with a large recurrent tumor on her back and an open wound from previous surgeries and radiation treatments. This tumor was so extensive that it had been deemed unresectable at other institutions because the wound would be too big for reconstruction using standard techniques. MD Anderson pathologists diagnosed the tumor as plexiform fibrohistiocytic sarcoma, a rare, aggressive skin cancer that often recurs and invades surrounding tissue but does not spread to distant parts of the body.
The tumor resection and reconstruction were planned by a multidisciplinary team led by Keila Torres, M.D., Ph.D., an associate professor in the Department of Surgical Oncology, and Jesse Selber, M.D., an associate professor in the Department of Plastic Surgery. Dr. Selber said that the reconstruction was challenging because the patient herself did not have adequate donor tissue to provide coverage for the surgical wound (22 ×x 55 cm, extending down to the spine and ribs). The patient’s sister, however, was substantially larger because she had once had a pituitary tumor that led to gigantism; the sister therefore had enough abdominal tissue to donate for the procedure.
Dr. Selber said that reconstructive allogeneic transplants are seldom performed following cancer surgery because the immunosuppressive regimens necessary to prevent tissue rejection also impair the immune system’s ability to fight cancer cells. But having a donor who is both genetically identical and histocompatible could theoretically allow the transplant to be done without postoperative immunosuppression therapy. However, without a perfect match, immunosuppression would be necessary to prevent graft rejection, and the risk of cancer recurrence would become too great. For this reason, Dr. Selber asked the transplant team from Houston’s Methodist Hospital to perform a living related donor workup, which confirmed that the twins were 100% histocompatible as well as genetically identical.
Four days after Dr. Torres performed the tumor resection, once pathological analysis of the resected specimen had confirmed negative margins, Dr. Selber and a team of five reconstructive plastic surgeons performed the tissue harvest from one sister and transplant to the other in two adjacent operating rooms. The surgeons removed a 54.6 × 21.6 × 5.1 cm flap of abdominal skin, muscle, and blood vessels from the donor sister and repaired the donor site using a procedure similar to a combination of a tummy tuck and a hernia repair. The flap was so large that eight separate microvascular anastomoses were required to restore and maintain circulation to the entire volume of transplanted tissue.
The patient and donor recovered without complications. “They’re now at home and doing well,” Dr. Selber said.