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Magnus L, Di Marco A, Thaveau F, Georg Y. Oncovascular Surgery for Soft-Tissue Sarcomas of the Lower Limbs with Vascular Contact: Comparison of Arterial Reconstruction and Arterial Subadventitial Dissection. Ann Vasc Surg 2024; 101:204-208. [PMID: 38307229 DOI: 10.1016/j.avsg.2023.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/17/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Soft-tissue sarcomas represent approximately 1% of adult malignancies. When they involve the lower limbs (LLs) and come into contact with blood vessels, the therapeutic choice was historically a primary amputation. Today, radical surgical resection with wide margins of safety is the primary therapeutic option for multidisciplinary limb-salvage surgery. The aim was to compare the morbidity and mortality results of an oncologic resection of LL soft-tissue sarcomas with arterial replacement (AR) to that obtained with arterial subadventitial dissection (ASD). METHODS All consecutive patients with arterial close contact soft-tissue sarcomas of LL were included. Two groups were formed: an AR group where AR was performed following surgical resection and an ASD group in which the artery in contact with the tumor was preserved by ASD. Fisher's exact test was used. RESULTS Eighteen patients with a median age of 61.50 (interquartile range [IQR] 54.25-69.75) years underwent oncovascular surgery with orthopedic and vascular surgeons between August 2013 and May 2022. Sarcomas were all located in the thigh. Nine patients were enrolled in each of the 2 groups. The 6-month survival rate was 77.78% in the AR group and 100% in the ASD group (P = 0.4). In the AR group, 2 patients presented local recurrence, with a median recurrence-free time of 24.48 (IQR 14.08-34.87) months, and 2 patients presented distant metastases, with metastasis-free time of 13.45 (IQR 8.12-35.11) months. In the ASD group, no local recurrence was observed, and 2 patients presented metastases with a median metastasis-free time of 3.90 (IQR 3.18-4.61) months. Six patients in the AR group and 7 in the ASD group required surgical revision (P = 0.017). No major amputation was necessary. CONCLUSIONS Oncovascular surgery for LL sarcomas with ASD is certainly more locally morbid perioperatively than that with AR but provides patients with better medium-term survival.
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Affiliation(s)
- Louis Magnus
- Department of Vascular and Endovascular Surgery, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.
| | - Antonio Di Marco
- Department of Orthopedic Surgery and Traumatology, Pôle Santé La Ligne Bleue, Épinal, France
| | - Fabien Thaveau
- Department of Vascular and Endovascular Surgery, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Yannick Georg
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
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Sheahan M, Tullos A, Kim J, Sethi D, Owens K, Kenney K, Torrance B, Hollier LH, Sheahan C. The role of vascular surgeons in the management of pediatric bone tumors. J Vasc Surg 2023; 78:223-229. [PMID: 36924975 DOI: 10.1016/j.jvs.2023.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/03/2023] [Accepted: 03/07/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVES The objective of this study was to review the outcomes of a multidisciplinary approach to the surgical management of pediatric bone tumors with blood vessel involvement over a 14- year period. METHODS A retrospective review was conducted of all pediatric bone tumor resections performed with the assistance of vascular surgery at our institution between January 2006 and January 2021. Inclusion criteria for the study included the presence of a vascular surgeon at the operative resection and radiographic evidence of major blood vessel involvement. RESULTS From 2006 to 2021, 117 patients underwent a bone tumor resection by a single orthopedic surgeon/vascular surgeon team. Sixty were malignant tumors, and 57 were benign. Of the 117 procedures, 5.1% (6/117) required reconstruction of an artery; five in malignant cases and one in benign. No venous reconstructions were undertaken in this study. Ligation of a major artery without reconstruction was performed in 8.8% (5/57) of malignant and 1.7% (1/60) of benign resections. Despite this vessel-sparing approach, microscopic margins were clear in all cases. Local recurrence occurred in a single patient in the malignant group at 61 months. CONCLUSIONS The ideal management of pediatric bone tumors with major blood vessel involvement remains poorly defined. Our results demonstrate that even in the setting of radiographic evidence of vessel involvement, a multidisciplinary team of vascular and orthopedic surgeons can employ a vessel-sparing approach with minimal blood loss, excellent limb salvage, and minimal local recurrence.
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Affiliation(s)
- Malachi Sheahan
- Division of Vascular and Endovascular Surgery, Louisiana State University School of Medicine, New Orleans, LA.
| | - Amanda Tullos
- Division of Vascular and Endovascular Surgery, Louisiana State University School of Medicine, New Orleans, LA
| | - Joyce Kim
- Division of Vascular and Endovascular Surgery, Louisiana State University School of Medicine, New Orleans, LA
| | - Danielle Sethi
- Division of Vascular and Endovascular Surgery, Louisiana State University School of Medicine, New Orleans, LA
| | - Kapland Owens
- Division of Vascular and Endovascular Surgery, Louisiana State University School of Medicine, New Orleans, LA
| | - Kevin Kenney
- Division of Vascular and Endovascular Surgery, Louisiana State University School of Medicine, New Orleans, LA
| | - Bruce Torrance
- Division of Vascular and Endovascular Surgery, Louisiana State University School of Medicine, New Orleans, LA
| | - Larry H Hollier
- Division of Vascular and Endovascular Surgery, Louisiana State University School of Medicine, New Orleans, LA
| | - Claudie Sheahan
- Division of Vascular and Endovascular Surgery, Louisiana State University School of Medicine, New Orleans, LA
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Lutz BM, Schaser KD, Weitz J, Kirchberg J, Fritzsche H, Disch AC, Busch A, Wolk S, Reeps C. Thoracoabdominal Aortic Replacement Together with Curative Oncological Surgery in Retroperitoneal and Spinal Tumours. Curr Oncol 2023; 30:2555-2568. [PMID: 36975408 PMCID: PMC10047559 DOI: 10.3390/curroncol30030195] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/11/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023] Open
Abstract
Malignancies with an extended encasement or infiltration of the aorta were previously considered inoperable. This series demonstrates replacement and subsequent resection of the thoracoabdominal aorta and its large branches as an adjunct to curative radical retroperitoneal and spinal tumor resection. Five consecutive patients were enrolled between 2016 and 2020, suffering from cancer of unknown primary, pleomorphic carcinoma, chordoma, rhabdoid sarcoma, and endometrial cancer metastasis. Wide surgical resection was the only curative option for these patients. For vascular replacement, extracorporeal membrane oxygenation (ECMO) was used as a partial left-heart bypass. The early technical success rate was 100% for vascular procedures and all patients underwent complete radical tumour resection with negative margins. All patients required surgical revision (liquor leak, n = 2; hematoma, n = 3; bypass revision, n = 1; bleeding, n = 1; biliary leak, n = 1). During follow-up (average 47 months, range 22–70) primary patency rates of aortic reconstructions and arterial bypasses were 100%; no patient suffered from recurrent malignant disease. Thoracoabdominal aortic replacement with rerouting of visceral and renal vessels is feasible in oncologic patients. In highly selected young patients, major vascular surgery can push the limits of oncologic surgery further, allowing a curative approach even in extensive retroperitoneal and spinal malignancies.
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Affiliation(s)
- Brigitta M. Lutz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universitaet Dresden, Fetscherstr. 74, 01307 Dresden, Germany
- Correspondence:
| | - Klaus-Dieter Schaser
- University Center for Orthopedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Technische Universitaet Dresden, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universitaet Dresden, German Cancer Research Center (DKFZ), Helmholtz-Zentrum Dresden-Rossendorf (HZDR), 01037 Dresden, Germany
| | - Jurgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universitaet Dresden, Fetscherstr. 74, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universitaet Dresden, German Cancer Research Center (DKFZ), Helmholtz-Zentrum Dresden-Rossendorf (HZDR), 01037 Dresden, Germany
| | - Johanna Kirchberg
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universitaet Dresden, Fetscherstr. 74, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universitaet Dresden, German Cancer Research Center (DKFZ), Helmholtz-Zentrum Dresden-Rossendorf (HZDR), 01037 Dresden, Germany
| | - Hagen Fritzsche
- University Center for Orthopedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Technische Universitaet Dresden, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universitaet Dresden, German Cancer Research Center (DKFZ), Helmholtz-Zentrum Dresden-Rossendorf (HZDR), 01037 Dresden, Germany
| | - Alexander C. Disch
- University Center for Orthopedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Technische Universitaet Dresden, 01307 Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universitaet Dresden, German Cancer Research Center (DKFZ), Helmholtz-Zentrum Dresden-Rossendorf (HZDR), 01037 Dresden, Germany
| | - Albert Busch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universitaet Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Steffen Wolk
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universitaet Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Christian Reeps
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universitaet Dresden, Fetscherstr. 74, 01307 Dresden, Germany
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Yonezawa H, Yamamoto N, Hayashi K, Takeuchi A, Miwa S, Igarashi K, Morinaga S, Asano Y, Saito S, Tada K, Nojima T, Tsuchiya H. Do Liquid Nitrogen-treated Tumor-bearing Nerve Grafts Have the Capacity to Regenerate, and Do They Pose a Risk of Local Recurrence? A Study in Rats. Clin Orthop Relat Res 2022; 480:2442-2455. [PMID: 35976198 PMCID: PMC10540061 DOI: 10.1097/corr.0000000000002336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/01/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Under most circumstances, the resection of soft tissue sarcomas of the extremities can be limb-sparing, function-preserving oncologic resections with adequate margins. However, en bloc resection may require resection of the major peripheral nerves, causing poor function in the extremities. Although liquid nitrogen treatment has been used to sterilize malignant bone tumors, its use in the preparation of nerve grafts has, to our knowledge, not been reported. Hence, this study aimed to investigate the tumor recurrence and function after peripheral nerve reconstruction using liquid nitrogen-treated tumor-bearing nerves in a rat model. QUESTIONS/PURPOSES (1) Do liquid nitrogen-treated frozen autografts have regeneration capabilities? (2) Do liquid nitrogen-treated tumor-bearing nerves cause any local recurrences in vivo in a rat model? METHODS Experiment 1: Twelve-week-old female Wistar rats, each weighing 250 g to 300 g, were used. A 10-mm-long section of the right sciatic nerve was excised; the prepared nerve grafts were bridge-grafted through end-to-end suturing. The rats were grouped as follows: an autograft group, which underwent placement of a resected sciatic nerve after it was sutured in the reverse orientation, and a frozen autograft group, which underwent bridging of the nerve gap using a frozen autograft. The autograft was frozen in liquid nitrogen, thawed at room temperature, and then thawed in distilled water before application. The third group was a resection group in which the nerve gap was not reconstructed. Twenty-four rats were included in each group, and six rats per group were evaluated at 4, 12, 24, and 48 weeks postoperatively. To assess nerve regeneration after reconstruction using the frozen nerve graft in the nontumor rat model, we evaluated the sciatic functional index, tibialis anterior muscle wet weight ratio, electrophysiologic parameters (amplitude and latency), muscle fiber size (determined with Masson trichrome staining), lower limb muscle volume, and immunohistochemical findings (though neurofilament staining and S100 protein produced solely and uniformly by Schwann cells associated with axons). Lower limb muscle volume was calculated via CT before surgery (0 weeks) and at 4, 8, 12, 16, 20, 24, 32, 40, and 48 weeks after surgery. Experiment 2: Ten-week-old female nude rats (F344/NJcl-rnu/rnu rats), each weighing 100 g to 150 g, were injected with HT1080 (human fibrosarcoma) cells near the bilateral sciatic nerves. Two weeks after injection, the tumor grew to a 10-mm-diameter mass involving the sciatic nerves. Subsequently, the tumor was resected with the sciatic nerves, and tumor-bearing sciatic nerves were obtained. After liquid nitrogen treatment, the frozen tumor-bearing nerve graft was trimmed to a 5-mm-long tissue and implanted into another F344/NJcl-rnu/rnu rat, in which a 5-mm-long section of the sciatic nerve was resected to create a nerve gap. Experiment 2 was performed with 12 rats; six rats were evaluated at 24 and 48 weeks postoperatively. To assess nerve regeneration and tumor recurrence after nerve reconstruction using frozen tumor-bearing nerve grafts obtained from the nude rat with human fibrosarcoma involving the sciatic nerve, the sciatic nerve's function and histologic findings were evaluated in the same way as in Experiment 1. RESULTS Experiment 1: The lower limb muscle volume decreased once at 4 weeks in the autograft and frozen autograft groups and gradually increased thereafter. The tibialis anterior muscle wet weight ratio, sciatic functional index, muscle fiber size, and electrophysiologic evaluation showed higher nerve regeneration potential in the autograft and frozen autograft groups than in the resection group. The median S100-positive areas (interquartile range [IQR]) in the autograft group were larger than those in the frozen autograft group at 12 weeks (0.83 [IQR 0.78 to 0.88] versus 0.57 [IQR 0.53 to 0.61], difference of medians 0.26; p = 0.04) and at 48 weeks (0.86 [IQR 0.83 to 0.99] versus 0.74 [IQR 0.69 to 0.81], difference of median 0.12; p = 0.03). Experiment 2: Lower limb muscle volume decreased at 4 weeks and gradually increased thereafter. The median muscle fiber size increased from 0.89 (IQR 0.75 to 0.90) at 24 weeks to 1.20 (IQR 1.08 to 1.34) at 48 weeks (difference of median 0.31; p< 0.01). The median amplitude increased from 0.60 (IQR 0.56 to 0.67) at 24 weeks to 0.81 (IQR 0.76 to 0.90) at 48 weeks (difference of median 0.21; p < 0.01). Despite tumor involvement and freezing treatment, tumor-bearing frozen grafts demonstrated nerve regeneration activity, with no local recurrence observed at 48 weeks postoperatively in nude rats. CONCLUSION Tumor-bearing frozen nerve grafts demonstrated nerve regeneration activity, and there was no tumor recurrence in rats in vivo. CLINICAL RELEVANCE A frozen nerve autograft has a similar regenerative potential to that of a nerve autograft. Although the findings in a rat model do not guarantee efficacy in humans, if they are substantiated by large-animal models, clinical trials will be needed to evaluate the efficacy of tumor-bearing frozen nerve grafts in humans.
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Affiliation(s)
- Hirotaka Yonezawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Norio Yamamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Katsuhiro Hayashi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Akihiko Takeuchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Shinji Miwa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Kentaro Igarashi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Sei Morinaga
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Yohei Asano
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Shiro Saito
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Kaoru Tada
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Takayuki Nojima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
- Department of Diagnostic Pathology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
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The Orthopedic-Vascular Multidisciplinary Approach Improves Patient Safety in Surgery for Musculoskeletal Tumors: A Large-Volume Center Experience. J Pers Med 2021; 11:jpm11060462. [PMID: 34073954 PMCID: PMC8225121 DOI: 10.3390/jpm11060462] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/03/2021] [Accepted: 05/20/2021] [Indexed: 12/27/2022] Open
Abstract
Objective: Wide-margin resection is mandatory for malignant bone and soft tissue tumors. However, this increases the complexity of resections, especially when vessels are involved. Patients in this high-risk clinical setting could be surgically treated using the multidisciplinary orthopedic-vascular approach. This study was carried out in this healthcare organization to evaluate patient safety in term of oncologic outcomes and reduction of the complication rate. Materials and Methods: We retrospectively reviewed 74 patients (37 males, 37 females; mean age 46 years, range 9–88) who underwent surgical excision for bone/soft tissue malignant tumors closely attached to vascular structures from October 2015 to February 2019. Vascular surgery consisted of isolation of at least one vessel (64 patients), bypass reconstruction (9 patients), and end-to-end anastomosis (1 patient). Mean follow-up was 27 months. Patients’ demographics, tumor characteristics, adjuvant treatments, type of orthopedic and vascular procedures, and oncologic and functional outcomes and complications were recorded. Results: Overall survival was 85% at 3 years follow-up. In total, 22 patients experienced at least one major complication requiring further surgery and 13 patients experienced at least one minor complication, whereas 17 reported deviations from the normal postoperative course without the need for pharmacological or interventional treatment. Major complications were higher in pelvic resections compared to limb-salvage procedures (p = 0.0564) and when surgical time was more than 4 h (p = 0.0364) at univariate analysis, whereas the most important multivariate independent predictors for major complications were pelvic resection (p = 0.0196) and preoperative radiotherapy (p = 0.0426). Conclusions: A multidisciplinary ortho-vascular approach for resection of malignant bone and soft tissue tumors tightly attached to important vascular structures should be considered a good clinical practice for patient safety.
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O'Brien AL, West JM, Zewdu A, Grignol VP, Scharschmidt TJ, Moore AM. Nerve transfers to restore femoral nerve function following oncologic nerve resection. J Surg Oncol 2021; 124:33-40. [PMID: 33831232 DOI: 10.1002/jso.26487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Advances in the care of soft-tissue tumors, including imaging capabilities and adjuvant radiation therapy, have broadened the indications and opportunities to pursue surgical limb salvage. However, peripheral nerve involvement and femoral nerve resection can still result in devastating functional outcomes. Nerve transfers offer a versatile solution to restore nerve function following tumor resection. METHODS Two cases were identified by retrospective review. Patient and disease characteristics were gathered. Preoperative and postoperative motor function were assessed using the Medical Research Council Muscle Scale. Patient-reported pain levels were assessed using the numeric rating scale. RESULTS Nerve transfers from the obturator and sciatic nerve were employed to restore knee extension. Follow up for Case 1 was 24 months, 8 months for Case 2. In both patients, knee extension and stabilization of gait without bracing was restored. Patient also demonstrated 0/10 pain (an average improvement of 5 points) with decreased neuromodulator and pain medication use. CONCLUSION Nerve transfers can restore function and provide pain control benefits and ideally are performed at the time of tumor extirpation. This collaboration between oncologic and nerve surgeons will ultimately result in improved functional recovery and patient outcomes.
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Affiliation(s)
- Andrew L O'Brien
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Julie M West
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Abbie Zewdu
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Valerie P Grignol
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Thomas J Scharschmidt
- Department of Orthopaedic Surgery, The Ohio State University James Wexner Medical Center, Columbus, Ohio, USA
| | - Amy M Moore
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Shah A, Ramanujan V, Muralidharan K, AnRaja A. Outcomes of Vascular Resection and Reconstruction in Extremity Soft Tissue Sarcoma and Bone Tumors. Vasc Specialist Int 2021; 37:22-28. [PMID: 33795550 PMCID: PMC8021495 DOI: 10.5758/vsi.200064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/09/2020] [Accepted: 03/16/2021] [Indexed: 11/20/2022] Open
Abstract
Purpose This study aimed to evaluate and analyze the feasibility and the oncological and functional outcomes of limb salvage surgery in extremity soft tissue sarcomas (ESTS) and bone tumors invading vessels. Materials and Methods This single-center retrospective analysis included patients with ESTS encasing or invading major blood vessels that were treated by limb salvage surgery with vascular resection and reconstruction between January 1995 and December 2019. Patients with contiguous involvement of major blood vessels and nerves and patients requiring amputation were excluded from the study. Results A total of 24 vessels (14 arteries and 10 veins) in 14 patients were reconstructed. Ten (71.4%) patients underwent both arterial and venous reconstruction, and four (28.6%) underwent only arterial reconstruction. Reconstruction was performed with a reversed saphenous vein (RSV) graft in 12 patients and with a synthetic graft (SG) in the other 12 patients. At a median follow-up of 27 months, RSV grafts were patent in 10 of 12 (83.3%) vessels and SGs were patent in 6 of 12 (50.0%) vessels (log-rank test, P=0.083). Out of 14 arteries and 10 veins, 11 arteries and 5 veins were patent, respectively. No patient developed local recurrence, and 2 (14.3%) patients developed distant metastases. Limb salvage rate was 13/14 (92.9%). The mean Musculoskeletal Tumor Society score was 83.3%. The 5- and 10-year overall survival rates were 80% and 50%, respectively. Conclusion Limb salvage surgery in ESTS with vascular resection and reconstruction is feasible and provides favorable oncological and functional outcomes.
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Affiliation(s)
- AnChetan Shah
- Department of Surgical Oncology, Cancer Institute (WIA), Chennai, India
| | - Vishnu Ramanujan
- Department of Surgical Oncology, Cancer Institute (WIA), Chennai, India
| | - Krishna Muralidharan
- Department of Vascular Surgery, Government Multi Super Speciality Hospital, Chennai, India
| | - Anand AnRaja
- Department of Surgical Oncology, Cancer Institute (WIA), Chennai, India
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Kumar S, Manjunath NML, Manoj Gowda S, Kumar N, Bharati S, Deo SVS. Limb Preservation Using Vascular Reconstruction in Patients with Large Extremity Soft Tissue Sarcomas: Results of Multi-Modality Therapy. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02161-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Fujiki M, Kimura T, Takushima A. Limb‐salvage surgery with vascular reconstruction after lower extremity sarcoma resection: A systematic review and meta‐analysis. Microsurgery 2020; 40:404-413. [DOI: 10.1002/micr.30553] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/26/2019] [Accepted: 12/26/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Masahide Fujiki
- Department of Plastic Surgery Kyorin University School of Medicine Tokyo Japan
| | - Takeichiro Kimura
- Department of Plastic Surgery Kyorin University School of Medicine Tokyo Japan
| | - Akihiko Takushima
- Department of Plastic Surgery Kyorin University School of Medicine Tokyo Japan
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Twenty years of experience in vascular reconstructions associated with resection of malignant neoplasms in a single cancer center. J Vasc Surg 2019; 69:1880-1888. [DOI: 10.1016/j.jvs.2018.08.196] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 08/16/2018] [Indexed: 02/07/2023]
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Shimatani A, Aono M, Hoshi M, Oebisu N, Iwai T, Takada N, Nakamura H. Two case reports of fair lower limb function after sciatic nerve sacrifice for the treatment of a malignant peripheral nerve sheath tumor. Int Cancer Conf J 2019; 7:137-141. [PMID: 31149533 DOI: 10.1007/s13691-018-0338-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022] Open
Abstract
Wide resection for malignant soft tissue tumors may require resection of a major nerve. When a limb salvage procedure is selected in these cases, the anticipated functional outcome of the procedure must be clearly discussed with the patient, as recovery of normal function cannot be expected. In this report, we describe our surgical management of two cases of malignant peripheral nerve sheath tumor, a 58-year-old man and a 10-year-old girl, requiring a limb salvage procedure with sacrifice of the sciatic nerve. Although both patients required a short-leg brace for walking, because of a drop foot, both patients reported satisfactory functional results and were able to perform their activities of daily living with only slight difficulties. Based on our experience, limb salvage surgery can be considered for the treatment of malignancies involving the sciatic nerve, with fair functional outcomes expected.
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Affiliation(s)
- Akiyoshi Shimatani
- 1Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-ku, Osaka, 545-8585 Japan
| | - Masanari Aono
- 2Department of Orthopedic Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021 Japan
| | - Manabu Hoshi
- 1Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-ku, Osaka, 545-8585 Japan
| | - Naoto Oebisu
- 1Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-ku, Osaka, 545-8585 Japan
| | - Tadashi Iwai
- 1Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-ku, Osaka, 545-8585 Japan
| | - Naoki Takada
- 1Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-ku, Osaka, 545-8585 Japan
| | - Hiroaki Nakamura
- 1Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-ku, Osaka, 545-8585 Japan
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Akgül T, Sormaz İC, Aksoy M, Uçar A, Özger H, Eralp L. Results and functional outcomes of en-bloc resection and vascular reconstruction in extremity musculoskeletal tumors. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:409-414. [PMID: 30274704 PMCID: PMC6318543 DOI: 10.1016/j.aott.2018.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/14/2018] [Accepted: 08/29/2018] [Indexed: 01/28/2023]
Abstract
Objectives This paper aims to evaluate the extremity function and vascular outcome after limb-sparing surgery for extremity musculoskeletal tumors invading vascular structure required reconstruction. Methods Of the 507 patients with musculoskeletal tumors, who underwent surgery between 2004 and 2007, 17 (3,3%) patients with major vessel involvement were included in the study. The mean age was 37.8 ± 14.5, with a female/male ratio of 8/9. Thirteen (76.4%) patients had Stage IIb disease, and 2 (11,7%) patients had Stage III disease. In 2 (11,7%) patients have locally aggressive tumor that had Stage 3. Fifteen (88.2%) of the cases involved lower extremity, whilst 2 (11.8%) of them involved upper extremity. An arterial reconstruction was carried out in all patients. Wide tumor resection and endoprosthetic reconstruction were performed in 6 (35.2%) patients. Other 11 (65.8%) patients were treated with wide resection and soft tissue reconstruction. Postoperative data included; perioperative morbidities such as bleeding, infection, graft thrombosis, rupture, metastatic local recurrence and mortality. Ankle brachial index (ABI) and color-flow-duplex-scan (CFDS) were done at the final follow-up of the study, in order to prove the efficacy of reconstruction. Functional outcome was evaluated with International Society of Limb Salvage (ISOLS) criteria. Results The mean follow-up was of 39 months (range 3–120). Perioperative complications were arterial graft thrombosis occurred in 3 (17.6%) patients treated acutely with thrombectomy, uncontrolled deep wound infection occurred in 2 patients whom extremities were amputated. The most frequent complication after surgery was limb edema according to possibly venous and lymphatic obstruction, staged as C1, C2 and C3 disease was established in 6 patients (two patients in each group), and 1 patient was classified as C6 disease. Three (17.6%) patients had local recurrence (1/3 patient died and 2/3 (11.7%) patients underwent transfemoral amputation). At the last follow-up, 9 (52.9%) patients were alive without evidence of disease, 8 (47.1%) patients were died due to primary disease. There were 8 (47.1%) patients alive with an intact limb. Although functional outcome scores were satisfactory, emotional acceptance scores were low. The limb salvage probability was 74.0%. Conclusion Limb-sparing oncological surgery in musculoskeletal tumors with vascular invasion provides a satisfactory limb function, which may lead to an improved life quality. Arterial reconstruction has a high rate of patency in the long term. The surgeon should be aware of early perioperative complication related to vascular reconstruction and infection that effect on the rate of extremity survival. Level of evidence Level IV, Therapeutic study
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Affiliation(s)
- Turgut Akgül
- Department of Orthopedics and Traumatology, Istanbul Medical Faculty, Istanbul, Turkey.
| | - İsmail Cem Sormaz
- Department of General Surgery, Istanbul Medical Faculty, Istanbul, Turkey.
| | - Murat Aksoy
- Department of General Surgery, Bahcesehir University, Liv Hospital, Istanbul, Turkey.
| | - Adem Uçar
- Department of Radiology, Istanbul Medical Faculty, Istanbul, Turkey.
| | - Harzem Özger
- Department of Orthopedics and Traumatology, Istanbul Medical Faculty, Istanbul, Turkey.
| | - Levent Eralp
- Department of Orthopedics and Traumatology, Istanbul Medical Faculty, Istanbul, Turkey.
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Okamoto K, Koga A, Tazume H, Noguchi R, Kumamoto S, Satoh H, Sueyoshi T, Fukui T. Early and Mid-Term Outcomes after Vascular Reconstruction for Patients with Lower-Extremity Soft-Tissue Malignant Tumors. Ann Vasc Dis 2018; 11:228-232. [PMID: 30116416 PMCID: PMC6094028 DOI: 10.3400/avd.oa.18-00027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Objective: To evaluate limb-salvage surgery including vascular resection for lower-extremity soft-tissue sarcomas and carcinomas for adult patients. Materials and Methods: Eight consecutive patients (median age, 59 years) who underwent vascular replacement during surgery for malignant tumors in the lower limbs between November 2006 and March 2018 were evaluated. Patient data were retrospectively obtained in a computerized database. Arterial and venous reconstructions were performed for seven patients, with one additional patient receiving venous reconstruction only. Autologous-vein (n=6) and synthetic bypasses were used for arterial repairs, whereas only autologous veins were implanted for venous repairs. Results: Morbidity was 62.5%, and in-hospital mortality was 12.5%. At a median follow-up of 24 months, the primary patency rates of arterial and venous reconstructions were 85.7% and 62.5%, respectively. Limb salvage was achieved in all cases. Conclusion: Early and mid-term bypass patency rates, the high percentage of limb salvage, and the oncologic outcome underline the efficacy of en bloc resection of soft-tissue tumors involving major vessels of the lower limbs. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma and carcinoma resections. However, efforts to achieve better control over systemic spread are required for long-term survival.
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Affiliation(s)
- Ken Okamoto
- Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Ayumi Koga
- Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Hirokazu Tazume
- Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Ryo Noguchi
- Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Sayahito Kumamoto
- Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Hiroo Satoh
- Department of Orthopedic Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Takanao Sueyoshi
- Department of Orthopedic Surgery, Kumamoto University Hospital, Kumamoto, Japan
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Kumamoto University Hospital, Kumamoto, Japan
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Limb-Salvage Surgery of Soft Tissue Sarcoma with Sciatic Nerve Involvement. Sarcoma 2018; 2018:6483579. [PMID: 29692655 PMCID: PMC5859890 DOI: 10.1155/2018/6483579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 02/08/2018] [Indexed: 12/20/2022] Open
Abstract
Background The surgical resection of soft tissue sarcomas (STS) with sciatic nerve involvement presents a significant surgical and oncological challenge. Current treatment strategies pursue a multimodal approach with the aim of limb preservation. We aim to evaluate the outcomes of limb-sparing surgery of STS in a patient cohort and to propose a classification for STS with sciatic nerve involvement. Methods Patients receiving limb-preserving resections for STS with sciatic nerve involvement between 01/2010 and 01/2017 were included. Clinical and oncological data were prospectively collected in a computerized database and retrospectively analyzed. Sciatic nerve involvement in STS was classified preoperatively as follows: type A for nerve encasement; type B for nerve contact; and type C for no nerve involvement. Results A total of 364 patients with STS were treated, of which 27 patients had STS with sciatic nerve involvement. Eight patients with type A tumors (29.6%) underwent sciatic nerve resection, and 19 patients with type B tumors (70.4%) received epineural dissections. Disease progression was observed in 8 patients (29.6%) with a local recurrence of 11.1% and distant metastasis in 29.6%. The type of nerve resection significantly influenced leg function but had no impact on disease recurrence or overall survival. Conclusion In a cohort of carefully selected patients with STS and sciatic nerve involvement, the extent of sciatic nerve resection had no significant impact on disease recurrence or survival. Precise classification of neural involvement may therefore be useful in selecting the appropriate degree of nerve resection, without compromising oncological outcome or unnecessarily sacrificing leg function.
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Teixeira LEM, Leão TM, Regazzi DB, Soares CBG. Risco de amputação após procedimento de revascularização nas ressecções de sarcoma. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Teixeira LEM, Leão TM, Regazzi DB, Soares CBG. Amputation risk after the revascularization procedures in sarcoma resections. Rev Bras Ortop 2017; 52:714-719. [PMID: 29234656 PMCID: PMC5720856 DOI: 10.1016/j.rboe.2017.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 08/30/2016] [Indexed: 01/27/2023] Open
Abstract
Objective The objective of this study is to evaluate the efficacy of vascular reconstructive surgery after resection of bone and soft tissue tumors in extremities and the risk of progression to amputation. Methods This is a retrospective, observational data collection from medical records of patients who underwent resection of bone and soft tissue tumors in the period of 2002–2015. Thirteen patients met the inclusion criteria, which evaluated the correlations between certain factors (gender, tumor type, location, reconstruction, revascularization and patency, infection) with amputation in the postoperative period. Results In this study, of the 13 patients undergoing reconstruction, five (38.46%) evolved to amputation. All patients who progressed to amputation had the following in common: presence of bone sarcoma (p = 0.005), having undergone reconstruction with an orthopedic prosthesis (p = 0.005), lack of vascular patency in the revascularization site in the postoperative period (p = 0.032), and surgical site infection (p = 0.001). None of the patients with soft tissue sarcoma underwent amputation, and the only patient with bone sarcoma who did not undergo amputation had no infection and maintained vascular patency of the graft. Conclusion The occurrence of infection appears to be one of the main risk factors for failure of revascularization, especially in cases of bone sarcoma in which vascular reconstruction is performed with placement of a non-conventional joint prosthesis.
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Affiliation(s)
- Luiz Eduardo Moreira Teixeira
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Belo Horizonte, MG, Brazil.,Hospital Madre Teresa, Serviço de Ortopedia e Traumatologia, Belo Horizonte, MG, Brazil
| | - Thiago Marques Leão
- Universidade Federal de Minas Gerais (UFMG), Hospital das Clínicas, Belo Horizonte, MG, Brazil
| | - Daniel Barbosa Regazzi
- Universidade Federal de Minas Gerais (UFMG), Hospital das Clínicas, Belo Horizonte, MG, Brazil
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Peripheral Non-atherosclerotic Arterial Disorders: What Radiologists Need to Know. Acad Radiol 2017; 24:497-505. [PMID: 27940229 DOI: 10.1016/j.acra.2016.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 11/01/2016] [Accepted: 11/01/2016] [Indexed: 12/24/2022]
Abstract
Peripheral non-atherosclerotic arterial disorders (NAADs) are a heterogeneous group of rather uncommon conditions that tend to manifest in subjects without atherosclerosis. Each of these conditions has distinctive pathophysiology; however, there are some common clinical and radiological characteristics and in some cases a common treatment approach that unifies these conditions to a specific group, hence the NAADs. Clinicians and radiologists often fail to recognize NAADs, and there might be a delay in the management of such patients; this may result in seriously adverse outcomes that could otherwise have been avoided or minimized. Knowledge of these conditions and of their radiological appearances is therefore important to help establish a correct diagnosis to allow the prompt initiation of treatment. The purpose of this pictorial review is to present a selection of NAADs cases and to discuss the radiological characteristics and the most common lines of therapeutic approaches.
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Wortmann M, Alldinger I, Böckler D, Ulrich A, Hyhlik-Dürr A. Vascular reconstruction after retroperitoneal and lower extremity sarcoma resection. Eur J Surg Oncol 2017; 43:407-415. [DOI: 10.1016/j.ejso.2016.10.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 10/16/2016] [Accepted: 10/31/2016] [Indexed: 12/17/2022] Open
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Davis LA, Dandachli F, Turcotte R, Steinmetz OK. Limb-sparing surgery with vascular reconstruction for malignant lower extremity soft tissue sarcoma. J Vasc Surg 2017; 65:151-156. [DOI: 10.1016/j.jvs.2016.05.094] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/26/2016] [Indexed: 10/20/2022]
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Miyamoto S, Fujiki M, Setsu N, Kawai A. Simultaneous reconstruction of the bone and vessels for complex femoral defect. World J Surg Oncol 2016; 14:291. [PMID: 27863500 PMCID: PMC5116157 DOI: 10.1186/s12957-016-1037-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 11/04/2016] [Indexed: 11/10/2022] Open
Abstract
Background Several methods have been reported for intercalary reconstruction of femoral defects. Of these, free vascularized fibula grafts (FVFG) are preferred because of their durability, bone-healing potential, and tolerance to infection. If the bone tumor invades the femoral vessels, simultaneous vascular reconstruction also becomes necessary and significant technical hurdles make limb salvage difficult. Case presentation We present a 10-year-old girl who underwent limb-sparing surgery for a distal femur osteosarcoma. The femoral defect was 15 cm long, and the femoral vessel defect was 10 cm long. The femur was reconstructed with bilateral FVFG, and the femoral vessels were reconstructed with saphenous vein grafts. The grafts survived without vascular compromise, and the affected limb was preserved successfully. Conclusions Combined use of bilateral FVFG and autologous vein grafts makes limb-sparing surgery for a large osteosarcoma of the femur possible.
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Affiliation(s)
- Shimpei Miyamoto
- Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 1040045, Japan.
| | - Masahide Fujiki
- Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 1040045, Japan
| | - Nokitaka Setsu
- Division of Orthopedic Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 1040045, Japan
| | - Akira Kawai
- Division of Orthopedic Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 1040045, Japan
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Radaelli S, Fiore M, Colombo C, Ford S, Palassini E, Sanfilippo R, Stacchiotti S, Sangalli C, Morosi C, Casali PG, Gronchi A. Vascular resection en-bloc with tumor removal and graft reconstruction is safe and effective in soft tissue sarcoma (STS) of the extremities and retroperitoneum. Surg Oncol 2016; 25:125-31. [PMID: 27566012 DOI: 10.1016/j.suronc.2016.05.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/04/2016] [Accepted: 05/06/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND To analyze the outcome of a series of patients who underwent vascular resection as part of an excision of a soft tissue sarcoma (STS). STUDY DESIGN All consecutive patients affected by localized STS of an extremity or retroperitoneum treated between January 2000 and December 2013 with surgery including vascular resection were considered. Overall survival (OS), crude cumulative incidence (CCI) of local recurrence (LR) and distant metastases (DM) were estimated by Kaplan-Meier. Long-term vascular graft patency rate was assessed. RESULTS 2692 patients received an operation for localized disease with 105 (3.9%) cases undergoing vascular resection. Median FU was 32 months. 5-year OS, CCI of LR and DM were 62%, 12% and 58% respectively. Vascular reconstructions consisted of 52 arterial and 16 venous grafts in extremities; 12 arterial and 33 venous grafts in the retroperitoneum. Graft thrombosis occurred in 16 patients (7/64 arterial and 9/49 venous reconstructions). Arterial occlusions occurred at a median of 36 months after surgery and were treated by prosthesis replacement (3), Fogarty catheter embolectomy (2), percutaneous angioplasty (1) and observation (1). One patient eventually required amputation. Venous occlusions occurred at a median of 4 months post surgery and were all treated conservatively. Overall arterial and venous reconstruction patency rates were 89% and 82% respectively. CONCLUSIONS Vascular resection to facilitate resection of STS has an acceptable long term patency rate. However it was associated to a high risk of distant spread. Although the encasement of the vascular bundle does not represent a contraindication to surgery there is an association with a high metastatic risk by virtue of the locally advanced nature of the disease and this should be considered when planning treatment.
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Affiliation(s)
- Stefano Radaelli
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Marco Fiore
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Chiara Colombo
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Samuel Ford
- Department of Surgery, University Hospital, Birmingham, United Kingdom.
| | - Elena Palassini
- Department of Cancer Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Roberta Sanfilippo
- Department of Cancer Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Silvia Stacchiotti
- Department of Cancer Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Claudia Sangalli
- Department of Radiology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Carlo Morosi
- Department of Radiology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Paolo G Casali
- Department of Cancer Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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Poultsides GA, Tran TB, Zambrano E, Janson L, Mohler DG, Mell MW, Avedian RS, Visser BC, Lee JT, Ganjoo K, Harris EJ, Norton JA. Sarcoma Resection With and Without Vascular Reconstruction: A Matched Case-control Study. Ann Surg 2015; 262:632-40. [PMID: 26366542 PMCID: PMC4657732 DOI: 10.1097/sla.0000000000001455] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the impact of major vascular resection on sarcoma resection outcomes. SUMMARY BACKGROUND DATA En bloc resection and reconstruction of involved vessels is being increasingly performed during sarcoma surgery; however, the perioperative and oncologic outcomes of this strategy are not well described. METHODS Patients undergoing sarcoma resection with (VASC) and without (NO-VASC) vascular reconstruction were 1:2 matched on anatomic site, histology, grade, size, synchronous metastasis, and primary (vs. repeat) resection. R2 resections were excluded. Endpoints included perioperative morbidity, mortality, local recurrence, and survival. RESULTS From 2000 to 2014, 50 sarcoma patients underwent VASC resection. These were matched with 100 NO-VASC patients having similar clinicopathologic characteristics. The rates of any complication (74% vs. 44%, P = 0.002), grade 3 or higher complication (38% vs. 18%, P = 0.024), and transfusion (66% vs. 33%, P < 0.001) were all more common in the VASC group. Thirty-day (2% vs. 0%, P = 0.30) or 90-day mortality (6% vs. 2%, P = 0.24) were not significantly higher. Local recurrence (5-year, 51% vs. 54%, P = 0.11) and overall survival after resection (5-year, 59% vs. 53%, P = 0.67) were similar between the 2 groups. Within the VASC group, overall survival was not affected by the type of vessel involved (artery vs. vein) or the presence of histology-proven vessel wall invasion. CONCLUSIONS Vascular resection and reconstruction during sarcoma resection significantly increases perioperative morbidity and requires meticulous preoperative multidisciplinary planning. However, the oncologic outcome appears equivalent to cases without major vascular involvement. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma resection.
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Affiliation(s)
| | - Thuy B. Tran
- Division of Surgical Oncology, Department of Surgery, Stanford University
| | | | | | | | - Matthew W. Mell
- Division of Vascular Surgery, Department of Surgery, Stanford University
| | | | - Brendan C. Visser
- Division of Surgical Oncology, Department of Surgery, Stanford University
| | - Jason T. Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University
| | - Kristen Ganjoo
- Division of Oncology, Department of Medicine, Stanford University
| | - E. John Harris
- Division of Vascular Surgery, Department of Surgery, Stanford University
| | - Jeffrey A. Norton
- Division of Surgical Oncology, Department of Surgery, Stanford University
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Abstract
Soft tissue sarcomas are a rare and heterogeneous group of tumors. Surgery clearly remains the standard therapy of non-metastatic soft tissue sarcoma. A pretreatment biopsy is necessary to determine the histology and grade of soft tissue sarcomas and to diagnose entities that can be treated by targeted therapies, such as dermatofibrosarcoma protuberans or alveolar soft tissue sarcoma once they are in a metastatic stage. Nevertheless, locally advanced disease requires multimodal treatment and interdisciplinary treatment decisions. Limb sarcoma of borderline resectability (encasement of vessels, invasion of joints or close proximity to motor nerves) may profit from isolated limb perfusion with recombinant tumor necrosis factor and melphalan. Preoperative chemotherapy may be applied in locally advanced high grade tumors when clear resection margins are difficult to achieve. Deep wave hyperthermia has proven to be a useful addition to systemic chemotherapy in such a neoadjuvant setting. Also preoperative radiation therapy has proven to be effective in controlling locally advanced sarcoma despite higher perioperative morbidity which pays off in the long run by better limb function. Postoperative adjuvant external beam irradiation therapy with the best available technique is recommended for any tumor larger than 5 cm with (FNLCC) grades 2 and 3 (American Joint Committee on Cancer stage IIb/III). Given all these therapeutic options, it is absolutely crucial that interdisciplinary decision-making starts early in the therapeutic process. Patients are often seen first by the surgeon. For an optimal treatment surgeons need to know the efficacy and toxicity of the multimodal treatment options described.
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Lun DX, Hu YC, Huang HC. Management of great vessels and nerves in limb-salvage surgery for bone and soft tissue tumors. Orthop Surg 2013; 5:233-8. [PMID: 24254445 DOI: 10.1111/os.12066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 08/25/2013] [Indexed: 01/13/2023] Open
Abstract
In recent years, limb-salvage surgery has gradually replaced amputations and become one of the main treatment strategies for patients with bone and soft tissue tumors of the extremities. The goals of tumor resection in limb-salvage surgery are to reduce the recurrence rate and preserve as much limb function as possible. However, depending on the size and specific location of the tumor, large neurovascular bundles may be involved. In addition, management of large nerves and vessels can make wide marginal resection more difficult. Sites where these problems commonly arise include the sciatic and tibial common peroneal nerve, artery and vein in the lower limbs.
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Affiliation(s)
- Deng-xing Lun
- Department of Spine Surgery, Weifang People's Hospital, Weifang City, Shandong Province, China
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27
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Vascular reconstruction for limb preservation during sarcoma surgery: A case series and a management algorithm. Rev Esp Cir Ortop Traumatol (Engl Ed) 2013. [DOI: 10.1016/j.recote.2013.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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28
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Viñals Viñals JM, Gomes Rodrigues TA, Perez Sidelnikova D, Serra Payro JM, Palacin Porté JA, Higueras Suñe C. [Vascular reconstruction for limb preservation during sarcoma surgery: a case series and a management algorithm]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2012; 57:21-6. [PMID: 23594979 DOI: 10.1016/j.recot.2012.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 08/29/2012] [Accepted: 08/30/2012] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To evaluate the results of vascular reconstruction in soft tissue sarcoma surgery and establish an algorithm based on current evidence. MATERIAL AND METHODS We studied patients undergoing soft-tissue sarcoma in a tertiary hospital. A retrospective review of 8 cases was carried out, analysing the demographics, surgical planning, complications, disease-free survival and bypass patency. RESULTS Successful limb preservation was observed in all patients, and the bypass remained patent in all cases. The mean follow-up was 38.4 months average, with 87.5% survival and no recurrences. CONCLUSIONS The involvement of major vascular structures in soft tissue sarcomas of the limbs does not necessarily exclude resectability. In selected cases, resection is possible with vascular reconstruction and limb preservation. However, multidisciplinary planning is needed.
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Affiliation(s)
- J M Viñals Viñals
- Servicio de Cirugía Plástica, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
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Surgery with vascular reconstruction for soft-tissue sarcomas in the inguinal region: oncologic and functional outcomes. Ann Vasc Surg 2012; 26:693-9. [PMID: 22664282 DOI: 10.1016/j.avsg.2011.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 11/29/2011] [Accepted: 12/06/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND Treatment of soft-tissue sarcomas involving the inguinal region remains challenging because of difficulties in achieving wide surgical margins due to anatomical features. The study aimed to analyze the oncologic and functional outcomes of wide resection with vascular reconstruction for inguinal soft-tissue sarcomas. METHODS Three men and seven women were treated for inguinal soft-tissue sarcomas by wide surgical resection with vascular reconstruction. RESULTS Arteries and veins were replaced in nine patients, and artery replacement alone was carried out in one patient. Femoral nerve resections were performed in six patients. One patient and five patients developed local recurrence and distant metastases, respectively. Limb salvage was achieved in 9 of 10 patients (90%). Six patients and one patient developed vascular (arterial graft occlusion [n = 1], lymphedema [n = 5]) and nonvascular (hematoma [n = 1]) complications, respectively. Five-year arterial primary patency was 77%. Five-year disease-free and overall survival rates were 45% and 77%, respectively. Functional outcome scores at latest follow-up averaged 87.5% for Musculoskeletal Tumor Society 1993. CONCLUSIONS En-bloc resection of major critical structures along with tumor and vascular reconstructions using synthetic grafts is a feasible option in limb salvage surgery for inguinal soft-tissue sarcomas.
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Deo SVS, Manjunath NML, Shukla NK. A review of controversies in the management of soft tissue sarcomas. Indian J Surg 2012; 74:228-33. [PMID: 23730049 PMCID: PMC3397189 DOI: 10.1007/s12262-012-0587-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Accepted: 05/13/2012] [Indexed: 01/17/2023] Open
Abstract
Soft tissue sarcomas (STS) constitute a rare and challenging group of solid tumor in the field of oncology. Unlike other malignancies STS can affect a wide variety of anatomical regions in the body with varied histo-pathological variants and clinical outcomes. There are controversies in the diagnosis and management of STS due to rarity and heterogeneity of the disease entity. Due to dedicated research and advances made in the field of imaging, pathology, surgery, radiotherapy and chemotherapy certain controversies were laid to rest and treatment approach to STS could be standardized to a large extent in the recent past. A review of controversies related to STS was performed in this article and an attempt was made to present a balanced view pertaining to these issues.
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Affiliation(s)
- S. V. S. Deo
- Department of Surgical Oncology, Institute Rotary cancer Hospital, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | - N. M. L. Manjunath
- Department of Surgical Oncology, Institute Rotary cancer Hospital, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | - N. K. Shukla
- Department of Surgical Oncology, Institute Rotary cancer Hospital, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
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Joshi RM, Gangurde GK, Talathi NP, Telavane PP, Singh R, Hanamshetti SR, Adhikari DR. Large retroperitoneal liposarcoma - a series of five cases. Indian J Surg 2011; 75:64-8. [PMID: 24426516 DOI: 10.1007/s12262-011-0348-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2010] [Accepted: 10/06/2011] [Indexed: 11/30/2022] Open
Abstract
Large retroperitoneal liposarcomas represent a unique situation and require a more aggressive surgical approach, including multiple resections for recurrences. We report a series of 5 cases of large retroperitoneal liposarcoma managed aggressively with surgical resection. All cases presented with lump and abdominal pain and diagnosis was established by Ultrasonography and CT scan. Post-operative course was uneventful and a median follow up of 3 years, all patients were free from recurrence.
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Affiliation(s)
- Rajeev M Joshi
- Department of General Surgery, T. N. Medical College and B.Y. L. Nair Ch. Hospital, 504 B, Gold Coin, Tardeo Road, Mumbai, 4000034 India
| | - Gautum K Gangurde
- Department of General Surgery, T. N. Medical College and B.Y. L. Nair Ch. Hospital, 504 B, Gold Coin, Tardeo Road, Mumbai, 4000034 India
| | - Nikhil P Talathi
- Department of General Surgery, T. N. Medical College and B.Y. L. Nair Ch. Hospital, 504 B, Gold Coin, Tardeo Road, Mumbai, 4000034 India
| | - Parag P Telavane
- Department of General Surgery, T. N. Medical College and B.Y. L. Nair Ch. Hospital, 504 B, Gold Coin, Tardeo Road, Mumbai, 4000034 India
| | - Rajinder Singh
- Department of General Surgery, T. N. Medical College and B.Y. L. Nair Ch. Hospital, 504 B, Gold Coin, Tardeo Road, Mumbai, 4000034 India
| | - Satish R Hanamshetti
- Department of General Surgery, T. N. Medical College and B.Y. L. Nair Ch. Hospital, 504 B, Gold Coin, Tardeo Road, Mumbai, 4000034 India
| | - Devbrata R Adhikari
- Department of General Surgery, T. N. Medical College and B.Y. L. Nair Ch. Hospital, 504 B, Gold Coin, Tardeo Road, Mumbai, 4000034 India
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Mehrabi A, Houben P, Attigah N, Böckler D, Büchler M, Weitz J. Gefäßersatz in der abdominellen Tumorchirurgie. Chirurg 2011; 82:887-97. [DOI: 10.1007/s00104-011-2096-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Muramatsu K, Ihara K, Miyoshi T, Yoshida K, Taguchi T. Clinical outcome of limb-salvage surgery after wide resection of sarcoma and femoral vessel reconstruction. Ann Vasc Surg 2011; 25:1070-7. [PMID: 21831587 DOI: 10.1016/j.avsg.2011.05.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Revised: 01/29/2011] [Accepted: 05/24/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Malignant sarcomas of the femur present major challenges in their management. Radical resection of sarcoma frequently requires concomitant major femoral vessel resection and reconstruction. We describe the clinical outcomes of vascular reconstruction, the long-term patency of vascular repair, and complications involved, and also discuss possible solutions to the problems associated with this procedure. METHODS In the past 15 years, 15 patients underwent wide resection of sarcoma of the femur with curative intent, including vascular reconstruction of the femoral arteries and/or veins. Arterial reconstruction was performed in 14 patients. In 12 patients, femoropopliteal reconstruction was performed with a contralateral great saphenous vein graft. In two cases involving femoroinguinal reconstruction, expanded polytetrafluoroethylene grafts were used because of unacceptable discrepancy. Myocutaneous flaps were used for covering of soft-tissue in 12 patients. RESULTS One patient developed a local recurrence and eight died because of their tumor. Seven patients remained completely free of recurrence after a mean follow-up time of 69 months. One case showed gradual deterioration with ischemic pain in the affected lower extremity requiring amputation. The remaining 14 cases showed sufficient vascularity primarily. Complications after surgery were noted in nine cases, with the most common being leg edema in five cases, wound infection in three, and lymphatic fistula in two. The average Musculoskeletal Tumor Society score at the final assessment was 24 points (80%). CONCLUSIONS For patients with sarcoma involving major vessels in the lower limb, wide resection followed by vascular reconstruction provides long-term local control and limb salvage with acceptable function. The complication rate from extensive resection and associated vascular reconstruction is high. The great saphenous vein graft produced results that were superior to prosthetic graft. Aggressive use of musculocutaneous flap transfers may help to minimize complications and reduce postoperative severe edema.
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Affiliation(s)
- Keiichi Muramatsu
- Department of Orthopedic Surgery, Yamaguchi University School of Medicine, Yamaguchi, Japan.
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Huh WW, Guadagnolo BA, Munsell MF, Patel S, Lewis VO. Soft tissue sarcomas of the popliteal fossa: a single-institution retrospective review. Cancer 2011; 117:2728-34. [PMID: 21656751 DOI: 10.1002/cncr.25736] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 09/21/2010] [Accepted: 09/27/2010] [Indexed: 11/10/2022]
Abstract
BACKGROUND Soft tissue sarcomas (STSs) arising from the popliteal fossa present a challenge with regard to local control of primary tumors. Due to concerns of functional morbidity and neurovascular compromise, there is debate about what represents the best therapy for these patients. METHODS We conducted a retrospective medical record review of patients treated at The University of Texas M. D. Anderson Cancer Center for STS of the popliteal fossa from 1990 to 2008. RESULTS There were 47 eligible patients, 28 of whom were male and 19 of whom were female. Synovial sarcoma was the most common diagnosis, with 12 cases. Most patients had T2b tumors (31 patients; 66%). The median duration of follow-up was 3.8 years (range, 0.6-17.9 years). The 5- and 10-year overall survival rates were 63% and 51%, respectively. Metastasis at diagnosis was associated with poorer overall survival (5-year overall survival, 74% versus 13%; P<.001) and poorer recurrence-free survival (5-year recurrence-free survival, 51% versus 0%; P<.001) on univariate analysis. Radiation therapy improved local recurrence-free survival (5-year local recurrence-free survival, 56% versus 17%; P = .004), whereas a trend was observed for surgical margin status (P = .07). Tumor size and neurovascular involvement did not influence outcome. Twenty-two patients had recurrent disease, with 15 patients having local recurrence, and 16 patients died from progressive disease. CONCLUSIONS Radiation therapy may play an important role in the treatment of popliteal fossa STS, but further study is needed to better define the best clinical application. Additional study is needed to re-evaluate association of surgical margin status and outcome.
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Affiliation(s)
- Winston W Huh
- Division of Pediatrics, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
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Abstract
Musculoskeletal sarcomas are a heterogeneous group of malignant neoplasms derived from connective tissue. Sarcomas represent about 1% of cancer in adults. The annual incidence in adults in Europe is around 14,000 new cases of soft tissue sarcomas (STS) and 4,800 new cases of bone sarcomas. Musculoskeletal tumours arise anywhere in the body, although lower extremities are the most common site of appearance, followed by upper extremities, trunk, retroperitoneum and head and neck area. Adequate management of STS is a stimulating challenge for oncologists. The aim of treatment should be focused on four main aspects: improving survival, avoiding local recurrence, maximising organ function and, finally, minimising morbidity. Surgery, radiotherapy and, sometimes though increasingly, chemotherapy are the pillars on which rests the modern treatment of sarcomas. The optimal management of musculoskeletal tumour requires a multidisciplinary integration of these different approaches in treatment planning right from the initial diagnoses. Referring patients to qualified centres should be desirable to achieve the maximum probability of control and even cure for STS.
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Affiliation(s)
- Ángel Montero Luis
- FEA de Oncología Radioterápica, Hospital Universitario Ramón y Cajal, Madrid, Spain.
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Spark JI, Charalabidis P, Laws P, Seben R, Clayer M. Vascular reconstruction in lower limb musculoskeletal tumours. ANZ J Surg 2009; 79:619-23. [PMID: 19895517 DOI: 10.1111/j.1445-2197.2009.05016.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Individual experience in the investigative, planning and operative aspects of lower limb musculoskeletal tumours is often small, making comparison between results difficult. The aim of the study was to describe the recent experience of a single tertiary referral unit performing limb salvage surgery, to identify areas of concern that are amenable to intervention and to provide clinicians an understanding of the surgical options. METHODS Nine patients with peripheral limb musculoskeletal tumours are described. Four patients had a leiomyosarcoma, and one each of osteosarcoma, synovial chondrosarcoma, synovial sarcoma, liposarcoma and recurrent malignant peripheral nerve sheath tumour. RESULTS Thirty-day mortality was nil. Two patients (one with a leiomyosarcoma and one with an osteosarcoma) died at 6 months follow-up because of pulmonary metastases. One patient with synovial chondrosarcoma developed a local recurrence and underwent an above-knee amputation. Six patients at 18 months follow-up are alive with no evidence of local recurrence and a functional lower limb. CONCLUSION These cases are a challenge to the clinicians, radiologists and pathologists. Review by a multidisciplinary team can produce successful results with low post-operative morbidity and mortality. Longer follow-up is required to determine the long-term implications.
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Affiliation(s)
- J Ian Spark
- Department of Vascular Surgery, Flinders Medical Centre and Repatriation General Hospital, Bedford Park, Adelaide, South Australia 5042, Australia.
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López-Anglada Fernández E, Rubio Sanz J, Braña Vigil A. Reconstrucción vascular durante cirugía conservadora de la extremidad en el tratamiento de sarcomas del miembro inferior. Rev Esp Cir Ortop Traumatol (Engl Ed) 2009. [DOI: 10.1016/j.recot.2009.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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López-Anglada Fernández E, Rubio Sanz J, Braña Vigil A. Vascular reconstruction during limb preserving surgery in the treatment of lower limb sarcoma: A report on four cases. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/s1988-8856(09)70199-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Primary tumors of the sartorial canal: limb sparing resection of soft-tissue sarcomas arising in a unique location. CURRENT ORTHOPAEDIC PRACTICE 2009. [DOI: 10.1097/bco.0b013e318199ccfa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sternheim A, Bickels J, Ben-Tov T, Malawer MM. Space sarcomas: extra compartmental soft tissue tumors of the lower extremities a systematic approach to sarcomas of the femoral triangle, sartorial canal, and popliteal space. J Surg Oncol 2009; 99:281-91. [PMID: 19143031 DOI: 10.1002/jso.21223] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Extra-compartmental soft tissue sarcomas may grow in virtual spaces in close proximity to major neurovascular structures and thus, require a complex resection. We analyzed the general principles by which these resections are planned. METHODS We retrospectively analyzed 53 patients with sarcomas located in the femoral triangle (15), sartorial canal (16), and the popliteal fossa (22). These lesions were grouped into three categories based on involvement of spatial structure; neurovascular involvement = 13, musculofascial involvement = 19 and no involvement = 11. RESULTS Limb sparing surgery was feasible in lesions that had either no structural or musculofascial involvement. Amputation, however, was required in 3 of 13 patients with neurovascular involvement because of gross involvement of the surrounding tissues. Overall, limb sparing was feasible in 94% (50 of 53 patients). The 2- and 5-year local recurrence rates were 10% and 14%, respectively. Five-year survival was 88%. CONCLUSIONS Limb sparing resection of space sarcomas is feasible in the majority of extra-compartmental sarcomas by utilizing a systematic approach which emphasizes specific planes of resection.
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Affiliation(s)
- Amir Sternheim
- Department of Orthopedic Oncology, Washington Cancer Institute, Washington Hospital Center, Washington, DC 20010, USA.
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Mahendra A, Gortzak Y, Ferguson PC, Deheshi BM, Lindsay TF, Wunder JS. Management of vascular involvement in extremity soft tissue sarcoma. Recent Results Cancer Res 2009; 179:285-299. [PMID: 19230547 DOI: 10.1007/978-3-540-77960-5_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Advances in adjuvant treatment protocols and improvements in imaging techniques have helped improve the limb-salvage rate for extremity soft tissue sarcomas to approximately 95%. Moreover, improvements in operative techniques have enabled successful limb-salvage surgery to be performed even in the face of vascular invasion or encasement by tumor. En bloc resection of major vascular structures with the tumor and reconstruction with reversed saphenous vein grafts, femoral venous grafts, or synthetic grafts has proved to be a feasible option in limb-salvage surgery. However, the surgical oncologist and patient should be aware that although overall function is only slightly worse after these procedures, individual functional results are less predictable. In addition, procedures requiring vascular resection and reconstruction are associated with an increased risk of complications, including amputation.
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Affiliation(s)
- Ashish Mahendra
- Department of Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
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Vogel P, Bolder U, Scherer MN, Schlitt HJ, Jauch KW. Long-term outcome after multivisceral and tumor/vascular resection in patients with soft tissue sarcoma. Langenbecks Arch Surg 2008; 394:331-7. [DOI: 10.1007/s00423-008-0403-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Accepted: 07/21/2008] [Indexed: 10/21/2022]
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Christopher Windham T, Sondak VK. Soft Tissue Sarcoma. Oncology 2007. [DOI: 10.1007/0-387-31056-8_58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Baxter BT, Mahoney C, Johnson PJ, Selmer KM, Pipinos II, Rose J, Neff JR. Concomitant arterial and venous reconstruction with resection of lower extremity sarcomas. Ann Vasc Surg 2007; 21:272-9. [PMID: 17484959 DOI: 10.1016/j.avsg.2007.03.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Limb salvage can now be achieved in many cases of lower extremity sarcoma. Obtaining disease-free margins may require resection of adjacent vascular structures. We present our experience with a consecutive series of patients undergoing resection of lower extremity sarcomas en block with the artery and vein, focusing on the mid- and long-term outcomes of their vascular reconstruction. METHODS Records were reviewed retrospectively for patient age, tumor location and type, procedure, and early and late outcomes. Between 1991 and 2004, 10 children (mean age 12 years, range 6-18 years) and 9 adults (mean age 48 years, range 24-73 years) underwent wide resection of lower extremity sarcomas to include the involved arterial and venous segments. All children had bone sarcomas, and because of their skeletal immaturity, they were treated with rotationplasty--a type of intercalary amputation that removes the distal thigh, knee, and proximal tibia while preserving the distal leg and foot. In rotationplasty, the distal residual limb is preserved, rotated 180 degrees, and attached to the thigh, positioning the ankle at the level of the former knee joint. In these cases, the residual vessels were reconstructed by primary anastomosis. All of the adults except one had soft tissue sarcomas; the resected vessels were reconstructed with contralateral saphenous vein. In all cases, the operative approach included shunting of artery and vein during tumor removal and orthopedic reconstruction. RESULTS The mean follow-up was 5.7 years. Three patients died of metastatic disease, and one died from a postoperative pulmonary embolism. No patient had local recurrence. Two patients ultimately required above-knee amputation: one child for tissue loss secondary to reperfusion injury, and one adult because of graft thrombosis secondary to progression of peripheral arterial disease. Two patients required early re-exploration for perioperative graft thrombosis. Both required replacement of saphenous vein conduits with polytetrafluoroethylene (PTFE) prosthetic graft; one of the PTFE grafts became infected. CONCLUSIONS Limb salvage can be achieved in the majority of patients who have lower extremity sarcomas even when en bloc resection includes the artery and vein. Intraoperative shunting can limit ischemia and is especially useful when immediate vascular repair is delayed by orthopedic reconstruction. The long-term patency rate of the reconstructed vessels is high. Saphenous vein is the preferred conduit when it is of adequate caliber.
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Affiliation(s)
- B Timothy Baxter
- Department of General and Orthopedic Surgery, the University of Nebraska Medical Center, Omaha, NE, USA.
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Adelani MA, Holt GE, Dittus RS, Passman MA, Schwartz HS. Revascularization after segmental resection of lower extremity soft tissue sarcomas. J Surg Oncol 2007; 95:455-60. [PMID: 17458861 DOI: 10.1002/jso.20679] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Limb salvage surgery combined with vascular reconstruction has replaced amputation as the preferred treatment of soft tissue sarcomas involving major vascular structures of the extremities. We describe our experience with soft tissue sarcomas involving major vascular structures and examine outcomes according to the type of graft selected for arterial reconstruction. We also examine the effect of venous reconstruction on post-operative edema. METHODS This retrospective review includes 14 patients with lower extremity soft-tissue sarcomas that encased major vessels, requiring combined limb-preserving tumor resection and revascularization with a synthetic or autogenous saphenous vein graft. Edema in patients with and without venous reconstruction was compared. The incidence of infection, wound dehiscence, and graft thrombosis were compared according to arterial graft type. RESULTS There was no significant difference in edema in patients with venous reconstruction and those without. There was also no significant difference in infection and graft thrombosis in patients with synthetic grafts and those with autogenous saphenous vein grafts. Wound dehiscence occurred more often in patients with synthetic grafts (P = 0.029). CONCLUSIONS Although this study was small, these results suggest that further studies are needed to determine the roles that vascular graft selection and venous reconstruction play in clinical outcome.
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Affiliation(s)
- Muyibat A Adelani
- Department of Orthopaedics and Rehabilitation, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Abstract
Soft tissue sarcomas of the popliteal fossa are rare diseases. Resection is challenging because of their extracompartmental location and proximity to neurovascular structures. Their prognosis is inferior to intracompartmental extremity soft tissue sarcomas. We ascertained the mode of initial presentation, the rates of local recurrence and distant metastasis, and the morbidity and complications of limb salvage procedures. We retrospectively analyzed the data of 29 consecutive patients operated on between 1989 and 2003. The median followup was 79 months. Sixteen, five, and eight patients were diagnosed with high-, intermediate-, and low-grade tumors, respectively. High-grade tumors were smaller than low- and intermediate-grade tumors. Thirty-one percent of patients presented with localized pain. Of the 26 patients who had primary limb salvage resections, 14 had negative surgical margins, six had close margins, and six had positive margins. Seventeen patients were treated with radiotherapy and 10 patients received chemotherapy. The local recurrence rate was 10.3%, four patients with high-grade tumors had distant metastasis, and the limb-salvage rate was 86.2%. Postoperatively, six patients experienced wound dehiscence and four had mild flexion contractures. Soft tissue sarcomas of the popliteal fossa have an atypical presentation. Limb salvage can be accomplished in most patients with low morbidity and good systemic and local control.
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Affiliation(s)
- Tamir Pritsch
- Department of Orthopedic Oncology, Washington Cancer Institute, Washington Hospital Center, Washington, DC 20010, USA.
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McKay A, Motamedi M, Temple W, Mack L, Moore R. Vascular reconstruction with the superficial femoral vein following major oncologic resection. J Surg Oncol 2007; 96:151-9. [PMID: 17443742 DOI: 10.1002/jso.20788] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Involvement of critical vascular structures has historically been considered a contraindication to tumor resection. This study describes outcomes following radical oncologic resection with concomitant resection of critical vascular structures and reconstruction with the superficial femoral vein (SFV). METHODS All patients undergoing radical oncologic resection requiring resection of major vascular structures and concomitant reconstruction using the SFV as conduit were retrospectively reviewed. Primary outcomes were surgical morbidity and mortality; secondary measures included long-term patency and oncologic outcomes. RESULTS Seven patients were included. There were three retroperitoneal and two groin sarcomas, and two squamous cell carcinomas metastatic to groin lymph nodes. No perioperative mortality occurred. Five patients experienced minor morbidity. One vein graft in a patient with pre-existing chronic deep venous thrombosis (DVT) occluded post-operatively. No subsequent long-term venous or arterial graft occlusions occurred (median 20.2 months, range 9.0-49.7). Two patients died of tumor recurrence during follow-up. CONCLUSIONS Resection of tumors involving critical vascular structures is feasible. The SFV conduit is a versatile option for major vascular reconstruction, providing good long-term patency rates with acceptable morbidity and mortality. Vascular resection and reconstruction with the SFV offers another technique to provide limb-sparing surgery in patients traditionally offered only amputation, while providing favorable oncologic outcomes.
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Affiliation(s)
- Andrew McKay
- Department of Surgery, Division of Surgical Oncology, University of Calgary, Calgary, Alberta, Canada.
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Hünerbein M, Hohenberger P, Stroszczynski C, Bartelt N, Schlag PM, Tunn PU. Resection of soft tissue sarcoma of the lower limb after evaluation of vascular invasion with intraoperative intravascular ultrasonography. Br J Surg 2006; 94:168-73. [PMID: 17143849 DOI: 10.1002/bjs.5541] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abstract
Background
This study investigated the value of intravascular ultrasonography (IVUS) in the intraoperative assessment of vascular invasion of soft tissue sarcoma.
Methods
In a 4-year interval, of 337 patients with soft tissue sarcoma, 20 patients with tumours of the lower limb in close relation to the neurovascular bundle underwent intraoperative IVUS (20 MHz). Intraoperative findings were correlated with preoperative imaging, histopathological appearance of the resection specimen and patient outcome.
Results
Intraoperative IVUS was technically successful in all 20 patients. It correctly predicted vascular involvement (true positive) in ten of 11 patients who required resection of major vessels. There was one false-negative and one false-positive result. With magnetic resonance imaging, there were ten true-positive and three false-positive scans, and one false-negative diagnosis. IVUS improved the assessment of vascular involvement in four of the 20 patients. Histopathological examination confirmed complete resection (R0) in 18 patients. Mean survival was 37 months, and no local recurrence was observed in these patients.
Conclusion
Vascular infiltration by soft tissue sarcoma can be visualized accurately by IVUS. This may improve intraoperative decisions about vessel resection.
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Affiliation(s)
- M Hünerbein
- Department of Surgery and Surgical Oncology, Charité University of Medicine Berlin, Campus Berlin Buch and Helios Hospital, Berlin, Germany.
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Nishinari K, Wolosker N, Yazbek G, Zerati AE, Nishimoto IN. Venous reconstructions in lower limbs associated with resection of malignancies. J Vasc Surg 2006; 44:1046-50. [PMID: 17098540 DOI: 10.1016/j.jvs.2006.07.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Accepted: 07/13/2006] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with tumors in the limbs who undergo surgical treatment may have involvement of major vessels. Major arteries are always reconstructed for limb salvage. Major veins may be reconstructed to avoid the onset of venous hypertension signs and symptoms. The objective of this study was to analyze the results from surgical treatment of a sample of patients who underwent lower limb venous reconstructions associated with the resection of malignant tumors. METHODS Follow-up was performed of 17 patients with malignant tumors involving major vessels in the lower limbs. The median length of follow-up was 22 months. Venous reconstruction concomitant to arterial reconstruction was performed in 15 patients, and an isolated venous reconstruction was performed in 2 patients. The venous substitutes used were the contralateral long saphenous vein (n = 12), expanded polytetrafluoroethylene prosthesis (n = 3), and Dacron prosthesis (n = 2). RESULTS Vascular complications occurred in seven patients: three occlusions of the venous graft, edema in seven patients, and one rupture of the arterial graft. The primary 2- and 5-year patency rates of venous reconstructions were 79.3% and 79.3%, respectively. Nonvascular complications occurred in six patients: neurological deficit (n = 3), partial necrosis of the flap (n = 2), wound infection (n = 1), hematoma (n = 1), and enteric fistula (n = 1). Eight patients were still alive and disease free, although one of them underwent above-knee amputation as a result of local disease recurrence. One patient experienced regional disease recurrence and is undergoing chemotherapy. Eight patients died due to pulmonary metastases. The 2- and 5-year overall survival rates were 58.6% and 42.4%, respectively. The 2- and 5-year thrombosis-free survival rates were 51.9% and 35.2%, respectively. CONCLUSIONS Lower limb venous reconstructions associated with tumor resection in this study gave good functional results, although the prognosis for these patients had been unfavorable. The saphenous vein is a suitable substitute.
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Affiliation(s)
- Kenji Nishinari
- Department of Vascular Surgery, Hospital do Câncer A.C. Camargo, São Paulo, Brazil.
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Pennacchioli E, Deraco M, Mariani L, Fiore M, Mussi C, Collini P, Olmi P, Casali PG, Santinami M, Gronchi A. Advanced Extremity Soft Tissue Sarcoma: Prognostic Effect of Isolated Limb Perfusion in a Series of 88 Patients Treated at a Single Institution. Ann Surg Oncol 2006; 14:553-9. [PMID: 17122991 DOI: 10.1245/s10434-006-9251-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2006] [Revised: 09/01/2006] [Accepted: 09/25/2006] [Indexed: 11/18/2022]
Abstract
PURPOSE To explore the prognostic impact of isolated limb perfusion (ILP) in locally advanced extremity soft tissue sarcomas (ESTS). METHODS From August 1982 to April 2005, 1,119 patients affected by ESTS (girdle excluded) were observed and treated at our institution. Eighty-eight (7.9%) were judged non-resectable or locally advanced and underwent ILP. Thirty-seven patients received antiblastic alone (non-TNF-ILP) while 51 had anti-blastic + recombinant-tumor necrosis factor alpha (TNF-ILP). Local disease-free survival (LDFS) was calculated by the Kaplan-Maier method and was reported separately in the two subgroups. RESULTS Limb salvage was achieved in 83% (73/88) of the patients. The observed overall (complete + partial) response rate was 59%. In the TNF-ILP group a complete response (CR) was achieved in 21 (41%) patients, while in the non-TNF ILP group a CR was obtained in seven (19%) cases (P < 0.05). Patients with in-transit metastases (epithelioid sarcomas and clear cell sarcomas) had a significantly worse long-term outcome (LDFS at 5 years was 40.9 vs 67.3%, P < 0.05). A trend towards a better LDFS at 5 years could be observed in the patients receiving TNF (63.6 vs 57.1%) and post-operative radiation therapy (RT) (79.3 vs 55.4%). CONCLUSIONS Isolated limb perfusion is an active treatment. By adding TNF a better local control seems to be obtained, possibly due to a higher rate of CR. It should therefore be considered as a valid option for patients affected by limb-threatening STS, save for in-transit metastases from epithelioid and clear cell sarcoma. Post-operative RT should always be considered.
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Affiliation(s)
- Elisabetta Pennacchioli
- Department of Surgery, Istituto Nazionale per lo studio e la cura dei Tumori, via Venezian, 1, 20133, Milan, Italy
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