Influence of compartmental involvement on the patterns of morbidity in soft tissue sarcoma of the thigh

What is the incidence and non-union rate of radiation-associated fractures? - A systematic review of the literature

BACKGROUND

Radiation-associated fractures (RAFs) are a challenging complication in oncologic patients, yet their incidence remains unknown and optimal management lacks consensus.

AIM

This review aimed to evaluate the incidence of RAFs in the trunk, pelvis, and extremities as well as non-union rates of surgical and non-surgical treatment.

MATERIALS AND METHODS

A systematic review of PubMed and Embase databases was conducted. The study was registered on PROSPERO (ID: CRD42024513017). Studies were included if they reported RAFs in oncologic populations, had a sample size of at least five patients, and provided extractable data on RAF incidence or number. The STROBE checklist was utilized for evaluation of study quality. For eligible studies, quantitative analyses were conducted to determine weighted incidence of RAF and fracture non-union.

RESULTS

Thirty-five studies comprising 9,980 patients treated with radiation therapy were included. The weighted incidence of RAFs was calculated to be 6.5% across 8,061 patients. The weighted incidence of femoral RAF was 5.2%, while pelvic RAF incidence was 17.1%. Non-union rates after initial treatment varied from 4% to 100%, with an overall weighted incidence of 48%. Treatments included intramedullary nailing, fixation with screws/plate, prosthetic replacement, conservative treatment, and amputation, with varying success rates.

CONCLUSION

This review highlights RAFs as a significant complication of radiation therapy, with a weighted incidence of 6.5% and a non-union rate of 48%. Advanced radiation techniques have reduced RAF occurrences, but non-union remains a challenge, necessitating tailored treatment strategies. Further research is needed to optimize RAF management and improve patient outcomes.

Buried de-epithelialized flap: An original solution to fill dead space after sarcoma resection in the thigh. Surgical technique and results of 12 cases

INTRODUCTION

Soft tissue sarcomas (STS) are often treated with wide excision in combination with adjuvant or neoadjuvant radiotherapy. This is currently the gold standard procedure for the treatment of STS that arise in the extremities. Wound healing complications frequently occur and negatively affect the prognosis. One of the options is to use a buried de-epithelialized flap as it can increase the lymphatic flow, fill the dead space, and cover neurovascular structures and implants. This aim of this retrospective study were two-fold. 1) Describe the surgical technique for this buried de-epithelialized flap after STS removal in the thigh. 2)Evaluate the efficacy of the buried de-epithelialized flap for decreasing wound complications based on a small case series and compare it with previous publications.

HYPOTHESIS

We hypothesized that the complication rate of this flap is not higher than the published complication rate for traditional flaps.

MATERIALS AND METHODS

Twelve patients (7 women and 5 men) with a mean age of 62±12years (38-76), who underwent surgical removal of an STS in the thigh with coverage by a buried de-epithelialized flap were reviewed at a mean follow-up of 15.8months (range 8-24).

RESULTS

Two patients presented with a postoperative wound infection (17%): one superficial and one deep at the surgical site. Neither required an additional plastic surgery procedure. Another patient had a dislocation of their total hip arthroplasty that was managed by closed reduction. One patient died from metastatic progression. There was no skin necrosis of the superficial skin edges, no hematoma or seroma in the other 10 patients. The flap was still visible on cross-sectional imaging at 1 month postoperative with no fluid between the tissue planes or signs of necrosis. The rate of wound healing complications that required surgical treatment was 17% in our case series, versus 16 to 56% in previous publications reporting the results of suture closure only.

CONCLUSION

A buried de-epithelialized flap reduces the risk of skin complications by filling dead space, improving lymphatic flow and covering critical structures. It is a reliable and reproducible option after wide local excision of STS in the thigh, with no additional morbidity.

LEVEL OF EVIDENCE

IV, retrospective study.

Muscle strength and functional recovery for soft-tissue sarcoma of the thigh: a prospective study

BACKGROUND

This study aimed to investigate changes in muscle strength and functional outcome before and after surgery for soft-tissue sarcoma of the thigh and to examine the timing of recovery.

METHODS

From 2014 to 2019, 15 patients who underwent multiple resections of the thigh muscle for soft-tissue sarcoma of the thigh were included in this study. The muscle strength was measured with an isokinetic dynamometer for the knee joint and with a hand-held dynamometer for the hip joint. The functional outcome assessment was based on the Musculoskeletal Tumor Society (MSTS) score, Toronto Extremity Salvage Score (TESS), European Quality of Life-5 Dimensions (EQ-5D), and maximum walking speed (MWS). All measurements were conducted preoperatively and at 3, 6, 12, 18, and 24 months postoperatively, and the ratio of postoperative to preoperative value was used. A repeated-measures analysis of variance was performed to compare changes over time and to investigate the recovery plateau. Correlations between changes in muscle strength and functional outcomes were also examined.

RESULTS

The muscle strength of the affected limb, MSTS score, TESS, EQ-5D, and MWS were significantly decreased at 3 months postoperatively. The recovery plateau was subsequently reached at 12 months postoperatively. The changes in muscle strength of the affected limb and functional outcome showed a significant correlation.

CONCLUSIONS

The estimated postoperative recovery for soft-tissue sarcoma of the thigh is 12 months after surgery.

Brachytherapy in the Treatment of Soft-Tissue Sarcomas of the Extremities-A Current Concept and Systematic Review of the Literature

INTRODUCTION

Evidence on the use of brachytherapy in soft-tissue sarcoma (STS) is sparse. Therapy regimens are determined more by local interdisciplinary tumor conferences than by standardized protocols. Patient-specific factors complicate the standardized application of therapy protocols. The individuality of the treatment makes it difficult to compare results.

MATERIALS AND METHODS

A comprehensive literature search was conducted, whereby the literature from a period of almost 44 years (1977-2021) was graded and included in this systematic review. For this purpose, PubMed was used as the primary database. Search string included "soft-tissue sarcoma", "brachytherapy", and "extremity." Four independent researchers reviewed the literature. Only full-text articles written in English or German were included.

RESULTS

Of the 175 identified studies, 70 were eligible for analysis based on the inclusion and exclusion criteria. The key points to compare were local complications, recurrence rate and correlation with margins of resection, and the use of brachytherapy regarding tumor grading.

CONCLUSION

Brachytherapy represents an important subset of radiotherapy techniques used in STSs, whose indications and applications are constantly evolving, and for which a local control rate of 50% to 96% has been reported as monotherapy, depending on risk factors. However, the best benefit is seen in the combination of further resection and brachytherapy, and most authors at many other centers agree with this treatment strategy.

Factors associated with complications after resection of soft tissue sarcomas of the groin

INTRODUCTION

Soft tissue sarcomas (STS) are rare malignant tumors that require regimented treatment at designated cancer centers. The surgical care of groin tumors is difficult because of frequent local complications. Few studies have been done on prognostic factors and complications. This led us to conduct a retrospective study to: (1) identify factors associated with local postoperative complications during the surgical care of primary groin STS; (2) identify the factors associated with delayed adjuvant radiation therapy; (3) define the optimal surgical treatment strategy to allow adjuvant treatments to start as early as possible, if applicable.

HYPOTHESIS

We hypothesized that certain patients presenting with an STS of the groin or inguinal area are at higher risk of complications.

MATERIALS AND METHODS

This retrospective single-center study included all the patients admitted to our referral sarcoma center between 1995 and 2016 for the resection of a primary STS of the groin. Major complications were defined as surgical revision, an invasive procedure, or prolonged dressing use.

RESULTS

Of the 55 included patients, 13 suffered major complications (24%) of which 10 were surgical revisions, two were repeated aspirations and one was prolonged dressing use. Among the 10 surgical revisions, there were two pedicled salvage flaps. The patients who suffered major complications were significantly more likely to be smokers than the patients who did not have major complications (31% vs 2% (p=0.002)). Obesity and surgical bone exposure were most often associated with complications but not significantly (23% vs 5%, p=0.053 and 38% vs 14% (p=0.057), respectively). Of the 39 patients (71%) who needed postoperative radiation therapy, 5 patients (13%) had it delayed, and 3 patients (8%) did not receive any at all due to major complications.

CONCLUSION

In our study, smoking was associated with the occurrence of major complications after groin STS resection and there was a strong trend for obesity and surgical bone exposure. Major complications were associated with a delay in starting postoperative radiation therapy. Thus, we recommend flap coverage after tumor resection in patients who have factors known to contribute to complications.

LEVEL OF EVIDENCE

IV, Retrospective study.

Influence of the adductor compartment resection on muscle strength and postoperative function in soft-tissue sarcoma of the thigh

OBJECTIVE

To predict the muscle strength and postoperative function for soft-tissue sarcoma arising from the adductor compartment of the thigh.

METHODS

Between 2003 and 2019, 17 cases that underwent resection of the adductor muscle group (adductor longus, adductor magnus, adductor brevis, gracilis and pectineus) for soft-tissue sarcoma in the adductor compartment of the thigh were included. The muscle strength was measured with an isokinetic dynamometer for the knee joint and with a hand-held dynamometer for the hip joint (ratio of affected to unaffected side). The Musculoskeletal Tumor Society score, Toronto Extremity Salvage Score, European Quality of Life-5 Dimensions and maximum walking speed were used to assess postoperative function and examine correlations with muscle strength.

RESULTS

In 13 cases that underwent an isolated resection of the adductor compartment, reduced adduction strength correlated with increased number of resected muscles in the adductor muscle group (P < 0.001). Postoperative function was maintained, showing no correlations with adduction strength. In four cases that underwent combined resections of other compartments, a decrease was observed in adduction strength as well as the muscle strength of other resected muscles, in addition to a decline in postoperative function. In the 4 or 5 adductor muscle resection group, the comparison between isolated and combined resection revealed comparable results for adduction strength but a significant decrease in postoperative function for the combined resection group.

CONCLUSIONS

Postoperative function can be preserved for isolated adductor compartment resection. Combined resections of multiple muscles in other compartments and most adductor muscles may result in decreased postoperative function.

Inflammatory prognostic scoring systems are risk factors for surgical site infection following wide local excision of soft tissue sarcoma

Introduction

Limb-sparing surgery with negative margins is possible in most soft tissue sarcoma (STS) resections and focuses on maximising function and minimising morbidity. Various risk factors for surgical site infections (SSIs) have been reported in the literature specific to sarcoma surgery. The aim of this study is to determine whether systemic inflammatory response prognostic scoring systems can predict post-operative SSI in patients undergoing potentially curative resection of STS.

Methods

Patients who had a planned curative resection of a primary STS at a single centre between January 2010 and December 2019 with a minimum follow-up of 6 months were included. Data were extracted on patient and tumour characteristics, and pre-operative blood results were used to calculate inflammatory prognostic scores based on published thresholds and correlated with risk of developing SSI or debridement procedures.

Results

A total of 187 cases were included. There were 60 SSIs. On univariate analysis, there was a statistically significant increased risk of SSI in patients who are diabetic, increasing specimen diameter, American Society of Anaesthesiology (ASA) grade 3, use of endoprosthetic replacement, blood loss greater than 1 L, and junctional tumour location. Modified Glasgow prognostic score, C-reactive protein/albumin ratio and neutrophil–platelet score (NPS) were statistically associated with the risk of SSI. On multivariate analysis, ASA grade 3, junctional tumour location and NPS were independently associated with the risk of developing a SSI.

Conclusion

This study supports the routine use of simple inflammation-based prognostic scores in identifying patients at increased risk of developing infectious complications in patients undergoing potentially curative resection of STS.

Treatment of Radiation-Associated Fractures: A Critical Analysis Review

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Fractures that result from radiation-induced bone damage are a recognized adverse effect of radiation therapy (RT).

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The mechanisms of damage from RT are thought to be related to impaired vascularity, aberrations in osteoclast and osteoblast-mediated bone turnover, and compromise of cortical and trabecular microarchitecture.

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Treatment of radiation-associated fractures is challenging, with rates of delayed union and nonunion of >50%.

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Fracture management strategies, each with its own profile of risks and benefits, include prophylactic intramedullary nailing of long bones, open reduction and internal fixation with adjunctive iliac crest or vascularized fibular grafting, and endoprosthetic reconstruction.

Postradiation Fractures after Combined Modality Treatment in Extremity Soft Tissue Sarcomas

Soft tissue sarcoma (STS) of the extremities is typically treated with limb-sparing surgery and radiation therapy; with this treatment approach, high local control rates can be achieved. However, postradiation bone fractures, fractures occurring in the prior radiation field with minimal or no trauma, are a serious late complication that occurs in 2–22% of patients who receive surgery and radiation for STS. Multiple risk factors for sustaining a postradiation fracture exist, including high radiation dose, female sex, periosteal stripping, older age, femur location, and chemotherapy administration. The treatment of these pathological fractures can be difficult, with complications including delayed union, nonunion, and infection posing particular challenges. Here, we review the mechanisms, risk factors, and treatment challenges associated with postradiation fractures in STS patients.

Risk Factors for Lymphedema after Thigh Sarcoma Resection and Reconstruction

Secondary lymphedema can be a lifelong and debilitating consequence of lower extremity oncologic resection and reconstruction. The goal of this study was to identify risk factors for the development of lymphedema in patients treated for thigh sarcoma.

Complications after thigh sarcoma resection

BACKGROUND AND OBJECTIVES

Standard treatment for extremity sarcoma is limb-sparing surgery often with radiation, but complications occur frequently. We sought to determine factors predictive of wound complications after thigh sarcoma resection and reconstruction while analyzing trends over time.

METHODS

We reviewed all thigh defects requiring plastic surgeon reconstruction following sarcoma resection at our institution from 1997 to 2014. Patient demographics, comorbidities, operative characteristics, multi-modality therapies, and complications were analyzed. Wound complications were: infection, dehiscence, seroma, hematoma, or partial/total flap loss.

RESULTS

There were 159 thigh reconstructions followed for 30 months on average. Eighty-seven percent of patients underwent radiation and 42% had chemotherapy. Almost half (49.1%) had a complication. The most common wound complication was surgical site infection (23.3%) followed by dehiscence (19.5%), and seroma (10.7%). Less common were partial (2.5%) or total flap loss (0.6%). Reoperation was required in 21 patients (13.2%). Tobacco use, older patient age, cardiac disease, and higher body mass index were independently associated with wound complications. Complications trended towards decreasing over time, but this was not statistically significant.

CONCLUSIONS

Tobacco use, cardiac disease, and higher body mass index, but not the timing of reconstruction, appear to increase the risk of wound complications after thigh soft tissue sarcomas resection and plastic surgery reconstruction.

Risk factor for wound complications following wide resection of soft tissue sarcoma in the adductor compartment of the thigh

Background

The purpose of this study was to investigate deep-seated soft tissue sarcoma (STS) occurring in the adductor compartment of the thigh that underwent wide resection and to clarify the high-risk group for wound complications.

Patients and methods

From 2000 to 2017, we reviewed 104 cases of deep-seated STS occurring in the adductor compartment of the thigh that were treated at four specialized facilities with expertise in sarcoma treatment.

Results

Wound complications occurred in 40 cases (38.5%), of which 23 cases (22.1%) were cases with major wound complications (MWC). In univariate analysis, BMI (P &lt; 0.01), maximum tumor diameter (P &lt; 0.01), operation time (P &lt; 0.01), amount of intraoperative bleeding (P &lt; 0.01), and intraoperative intervention to the femoral artery and vein (P &lt; 0.01) were significantly associated with wound complications. In multivariate analysis, the associated parameters were BMI (P &lt; 0.01), maximum tumor diameter (P = 0.02), and intraoperative intervention to the femoral artery and vein (P = 0.01). When limited to cases with MWC, univariate analysis showed that maximum tumor diameter (P &lt; 0.01), diabetes mellitus (P = 0.03), operation time (P &lt; 0.01), amount of intraoperative bleeding (P &lt; 0.01), and intraoperative intervention to the femoral artery and vein (P = 0.02) were significantly associated parameters. In multivariate analysis, maximum tumor diameter (P = 0.02) and amount of intraoperative bleeding (P = 0.04) were associated parameters.

Conclusions

For patients with risk factors for wound complications, control of bleeding are crucial when resecting deep-seated STS in the adductor compartment of the thigh. In cases with large tumors, surgeons should be especially cautious of cases requiring interventions that surround the femoral artery and vein in order to attain an appropriate surgical margin.

Adjuvant Biophysical Therapies in Osteosarcoma

Osteosarcoma (OS) is a primary bone sarcoma, manifesting as osteogenesis by malignant cells. Nowadays, patients’ quality of life has been improved, however continuing high rates of limb amputation, pulmonary metastasis and drug toxicity, remain unresolved issues. Thus, effective osteosarcoma therapies are still required. Recently, the potentialities of biophysical treatments in osteosarcoma have been evaluated and seem to offer a promising future, thanks in this field as they are less invasive. Several approaches have been investigated such as hyperthermia (HT), high intensity focused ultrasound (HIFU), low intensity pulsed ultrasound (LIPUS) and sono- and photodynamic therapies (SDT, PDT). This review aims to summarize in vitro and in vivo studies and clinical trials employing biophysical stimuli in osteosarcoma treatment. The findings underscore how the technological development of biophysical therapies might represent an adjuvant role and, in some cases, alternative role to the surgery, radio and chemotherapy treatment of OS. Among them, the most promising are HIFU and HT, which are already employed in OS patient treatment, while LIPUS/SDT and PDT seem to be particularly interesting for their low toxicity.

Femoral Fracture in Primary Soft-Tissue Sarcoma of the Thigh and Groin Treated with Intensity-Modulated Radiation Therapy: Observed versus Expected Risk

PURPOSE

This study was designed to compare the observed risk of femoral fracture in primary soft-tissue sarcoma (STS) of the thigh/groin treated with intensity-modulated radiation therapy (IMRT) to expected risk calculated using the Princess Margaret Hospital (PMH) nomogram.

METHODS

Expected femoral fracture risk was calculated by using the PMH nomogram. Cumulative risk of fracture was estimated by using Kaplan-Meier statistics. Prognostic factors were assessed with univariate and multivariate analysis using Cox's stepwise regression.

RESULTS

Between February 2002 and December 2010, 92 consecutive eligible patients were assessed. Median follow-up was 73 months (106 months in surviving patients). IMRT was delivered preoperatively (50 Gy) in 13 (14%) patients and postoperatively in 79 (86%) patients (median dose, 63 Gy; range, 59.4-66.6 Gy). The observed crude risk of fractures was 6.5% compared with 25.6% expected risk from the nomogram; the cumulative risk of fracture using IMRT at 5 years was 6.7% (95% CI 2.8-16.0%). The median time to fracture was 23 months (range, 6.9-88.6). Significant predictors of fracture on univariate analysis were age ≥ 60 years (p = 0.03), tumor location in the anterior thigh (p = 0.008), and periosteal stripping to > 20 cm (p < 0.0001). On multivariate analysis, age ≥ 60 years and periosteal stripping > 20 cm retained significance (p = 0.04 and p = 0.009, respectively).

CONCLUSIONS

In this study, the cumulative risk of femur fracture in patients treated with IMRT (6.7%) is less than the expected risk using the PMH nomogram (25.6%). Established predictors of femur fracture, such as gender, tumor size, and dose of RT, seem to have less impact on fracture risk when using IMRT.

Therapeutic options and postoperative wound complications after extremity soft tissue sarcoma resection and postoperative external beam radiotherapy

Soft tissue sarcomas occur most commonly in the lower and upper extremities. The standard treatment is limb salvage surgery combined with radiotherapy. Postoperative radiotherapy is associated with wound complications. This systematic review aims to summarise the available evidence and review the literature of the last 10 years regarding postoperative wound complications in patients who had limb salvage surgical excision followed by direct closure vs flap coverage together with postoperative radiotherapy and to define the optimal timeframe for adjuvant radiotherapy after soft tissue sarcomas resection and flap reconstruction. A literature search was performed using PubMed. The following keywords were searched: limb salvage, limb-sparing, flaps, radiation therapy, radiation, irradiation, adjuvant radiotherapy, postoperative radiotherapy, radiation effects, wound healing, surgical wound infection, surgical wound dehiscence, wound healing, soft tissue sarcoma and neoplasms. In total, 1045 papers were retrieved. Thirty-seven articles were finally selected after screening of abstracts and applying dates and language filters and inclusion and exclusion criteria. Plastic surgery provides a vast number of reconstructive flap procedures that are directly linked to decreasing wound complications, especially with the expectant postoperative radiotherapy. This adjuvant radiotherapy is better administered in the first 3-6 weeks after reconstruction to allow timely wound healing and avoid local recurrence.

Prediction of muscle strength and postoperative function after knee flexor muscle resection for soft tissue sarcoma of the lower limbs

INTRODUCTION

Oncological margins and prognosis are the most important factors for operative planning of soft tissue sarcomas, but prediction of postoperative function is also necessary. The purpose of this study was to predict the knee flexion strength and postoperative function after knee flexor muscle resection for soft tissue sarcoma of the lower limbs.

MATERIALS AND METHODS

Seventeen patients underwent knee flexor muscle resection for soft tissue sarcoma of the lower limbs between 1991 and 2015. The type of resected muscles was surveyed, knee flexion strength (ratio of affected to unaffected side) was evaluated using the Biodex System isokinetic dynamometer, and differences between the type of resected muscles were examined. The Musculoskeletal Tumor Society (MSTS) score, Toronto Extremity Salvage Score (TESS), European Quality of Life-5 Dimensions (EQ-5D), and Short Form 8 (SF-8) were used to assess postoperative function and examine correlations with flexion strength. The cutoff value for flexion strength to predict good postoperative results was calculated by a receiver operating characteristic (ROC) curve and Fisher's exact test.

RESULTS

Median flexion strength decreased in the resection of sartorius (97.8%), gracilis (95.4%), gastrocnemius (85.2%; interquartile range (IQR): 85.0-86.2), medial hamstrings (semimembranosus and semitendinosus, 76.2%; IQR: 73.3-78.0), lateral hamstrings (long and short head of biceps femoris, 66.1%; IQR: 65.9-70.4), and bilateral hamstrings (27.3%; IQR: 26.6-31.5). A significant difference was observed between lateral and bilateral hamstrings resection (P=0.049). Flexion strength was associated with lower functional scales (MSTS score, P=0.021; TESS, P=0.008; EQ-5D, P=0.034). Satisfactory function was obtained at a flexion strength cutoff value of 65.7%, and strength remained above the cutoff value up to unilateral hamstrings resection.

DISCUSSION

Greater knee flexor muscles resection can result in functional deficits that are associated with decreased flexion strength. If continuity of unilateral hamstrings is maintained, good postoperative results can be expected.

LEVEL OF EVIDENCE

IV, retrospective study.

The Impact of Perioperative Chemotherapy Timing in Conjunction With Postoperative External-Beam Radiation Therapy on Extremity Soft-Tissue Sarcomas Outcome

PURPOSE

The perioperative management of primary extremity soft-tissue sarcomas (ESTS) is multidisciplinary including radiation therapy and chemotherapy (CT). The interplay between these modalities and the relative importance of each remain unclear. Our study aims to determine the relative impact of CT and radiotherapy on the outcome of ESTS patients treated with limb-sparing surgery.

MATERIALS AND METHODS

A retrospective review of ESTS registry yielded 97 patients who received neoadjuvant chemotherapy (NCT) and/or adjuvant CT with or without external-beam radiation therapy (EBRT) from January 1, 1999 through December 31, 2009. The cohort comprised 56 males and 41 females whose age at surgery ranged from 17 to 83 years (median, 56 y). Tumor characteristics included the following: 73 lower ESTS; 70 grade 3 lesions; 63 American Joint Committee on Cancer stage III tumors; and 27 lesions with positive microscopic margins. The following outcome parameters were evaluated for the patients' subgroups: overall survival (OS), locoregional control (LRC), and disease-free survival (DFS).

RESULTS

EBRT was delivered postoperatively to 81 patients and 49 received CT. Median EBRT dose was 63 Gy (range, 50 to 72 Gy). At median follow-up of 54.6 months, the 5-year OS, LRC, DFS was 68.9%, 87.1%, 66.5%, respectively. On multivariate analysis, positive surgical margins negatively impacted LRC, DFS, and OS (hazard ratio [HR]=10.43, P=0.004), (HR=2.37, P=0.03), (HR=2.26, P=0.038), respectively. EBRT use improved LRC (HR=0.24, P=0.018) and DFS (HR=0.36, P=0.021). The impact of EBRT on DFS was retained (HR=0.28, P=0.006) in the high-grade ESTS subgroup who received CT. The 5-year local failure rate was 6.5%, 28.6%, and 22.2% (P=0.019) for patient receiving NCT, adjuvant chemotherapy, and no CT, respectively.

CONCLUSION

Our data support the use of NCT followed by limb-sparing surgery and adjuvant EBRT in ESTS for local failure reduction with a trend toward improved DFS.

Knee extension strength and post-operative functional prediction in quadriceps resection for soft-tissue sarcoma of the thigh

Objectives

Our objective was to predict the knee extension strength and post-operative function in quadriceps resection for soft-tissue sarcoma of the thigh.

Methods

A total of 18 patients (14 men, four women) underwent total or partial quadriceps resection for soft-tissue sarcoma of the thigh between 2002 and 2014. The number of resected quadriceps was surveyed, knee extension strength was measured with the Biodex isokinetic dynamometer system (affected side/unaffected side) and relationships between these were examined. The Musculoskeletal Tumor Society (MSTS) score, Toronto Extremity Salvage Score (TESS), European Quality of Life-5 Dimensions (EQ-5D) score and the Short Form 8 were used to evaluate post-operative function and examine correlations with extension strength. The cutoff value for extension strength to expect good post-operative function was also calculated using a receiver operating characteristic (ROC) curve and Fisher’s exact test.

Results

Extension strength decreased when the number of resected quadriceps increased (p < 0.001), and was associated with lower MSTS score, TESS and EQ-5D (p = 0.004, p = 0.005, p = 0.006, respectively). Based on the functional evaluation scales, the cutoff value of extension strength was 56.2%, the equivalent to muscle strength with resection of up to two muscles.

Conclusion

Good post-operative results can be expected if at least two quadriceps muscles are preserved.

Cite this article: A. Tanaka, Y. Yoshimura, K. Aoki, M. Kito, M. Okamoto, S. Suzuki, T. Momose, H. Kato. Knee extension strength and post-operative functional prediction in quadriceps resection for soft-tissue sarcoma of the thigh. Bone Joint Res 2016;5:232–238. DOI: 10.1302/2046-3758.56.2000631.

Excellent local control with IOERT and postoperative EBRT in high grade extremity sarcoma: results from a subgroup analysis of a prospective trial

Background

To report the results of a subgroup analysis of a prospective phase II trial focussing on radiation therapy and outcome in patients with extremity soft tissue sarcomas (STS).

Methods

Between 2005 and 2010, 50 patients (pts) with high risk STS (size ≥ 5 cm, deep/extracompartimental location, grade II-III (FNCLCC)) were enrolled. The protocol comprised 4 cycles of neoadjuvant chemotherapy with EIA (etoposide, ifosfamide and doxorubicin), definitive surgery with IOERT, postoperative EBRT and 4 adjuvant cycles of EIA. 34 pts, who suffered from extremity tumors and received radiation therapy after limb-sparing surgery, formed the basis of this subgroup analysis.

Results

Median follow-up from inclusion was 48 months in survivors. Margin status was R0 in 30 pts (88%) and R1 in 4 pts (12%). IOERT was performed as planned in 31 pts (91%) with a median dose of 15 Gy, a median electron energy of 6 MeV and a median cone size of 9 cm. All patients received postoperative EBRT with a median dose of 46 Gy after IOERT or 60 Gy without IOERT. Median time from surgery to EBRT and median EBRT duration was 36 days, respectively. One patient developed a local recurrence while 11 patients showed nodal or distant failures. The estimated 5-year rates of local control, distant control and overall survival were 97%, 66% and 79%, respectively. Postoperative wound complications were found in 7 pts (20%), resulting in delayed EBRT (>60 day interval) in 3 pts. Acute radiation toxicity mainly consisted of radiation dermatitis (grade II: 24%, no grade III reactions). 4 pts developed grade I/II radiation recall dermatitis during adjuvant chemotherapy, which resolved during the following cycles. Severe late toxicity was observed in 6 pts (18%). Long-term limb preservation was achieved in 32 pts (94%) with good functional outcome in 81%.

Conclusion

Multimodal therapy including IOERT and postoperative EBRT resulted in excellent local control and good overall survival in patients with high risk STS of the extremities with acceptable acute and late radiation side effects. Limb preservation with good functional outcome was achieved in the majority of patients.

Trial registration

ClinicalTrials.gov NCT01382030, EudraCT 2004-002501-72, 17.06.2011

Prognostic value of external beam radiation therapy in patients treated with surgical resection and intraoperative electron beam radiation therapy for locally recurrent soft tissue sarcoma: a multicentric long-term outcome analysis

BACKGROUND

A joint analysis of data from centers involved in the Spanish Cooperative Initiative for Intraoperative Electron Radiotherapy was performed to investigate long-term outcomes of locally recurrent soft tissue sarcoma (LR-STS) patients treated with a multidisciplinary approach.

METHODS AND MATERIALS

Patients with a histologic diagnosis of LR-STS (extremity, 43%; trunk wall, 24%; retroperitoneum, 33%) and no distant metastases who underwent radical surgery and intraoperative electron radiation therapy (IOERT; median dose, 12.5 Gy) were considered eligible for participation in this study. In addition, 62% received external beam radiation therapy (EBRT; median dose, 50 Gy).

RESULTS

From 1986 to 2012, a total of 103 patients from 3 Spanish expert IOERT institutions were analyzed. With a median follow-up of 57 months (range, 2-311 months), 5-year local control (LC) was 60%. The 5-year IORT in-field control, disease-free survival (DFS), and overall survival were 73%, 43%, and 52%, respectively. In the multivariate analysis, no EBRT to treat the LR-STS (P=.02) and microscopically involved margin resection status (P=.04) retained significance in relation to LC. With regard to IORT in-field control, only not delivering EBRT to the LR-STS retained significance in the multivariate analysis (P=.03).

CONCLUSION

This joint analysis revealed that surgical margin and EBRT affect LC but that, given the high risk of distant metastases, DFS remains modest. Intensified local treatment needs to be further tested in the context of more efficient concurrent, neoadjuvant, and adjuvant systemic therapy.

Intraoperative radiotherapy-containing multidisciplinary management of trunk-wall soft-tissue sarcomas

PURPOSE

A joint analysis of data from centers within the intraoperative radiotherapy (IORT)-Spanish cooperative initiative was performed to investigate the main contributions of IORT to the multidisciplinary treatment of trunk-wall soft-tissue sarcoma (TW-STS).

MATERIALS AND METHODS

Patients with a histologic diagnosis of TW-STS (primary tumor 53 %; locally recurrent 47 %) with absence of distant metastases, undergoing surgery with radical intent and IORT (median dose 12.5 Gy) were considered eligible for participation in this study. In addition, all primary tumors received external-beam radiotherapy (median dose 50 Gy).

RESULTS

From 1986 to 2012, a total of 68 patients were analyzed in the study from three Spanish institutions. With a median follow-up time of 53 months (range 4-316), 5-year local control (LC) was 58 %. Five-year IORT in-field control, disease-free survival (DFS) and overall survival were 70, 45 and 51 %, respectively. On multivariate analysis, only microscopically involved margin (R1) resection status retained significance in relation to LC (HR 3.97, p < 0.001). In regard to IORT in field control, incomplete resection (HR 3.23, p = 0.008) and recurrent disease status (HR 2.52, p = 0.04) retained a significant association in multivariate analysis.

CONCLUSION

From this joint analysis emerges the fact that margin and disease status influences local and central control, but DFS remains modest, given the high risk of distant metastases. Intensified local treatment needs to be tested in the context of more efficient concurrent, neo-, and adjuvant systemic therapy.

Raman spectroscopy demonstrates prolonged alteration of bone chemical composition following extremity localized irradiation

INTRODUCTION

Radiotherapy to the appendicular skeleton can cause an increased risk of developing catastrophic fractures with delayed bone healing or non-union, and may subsequently require multiple procedures and amputation. Biomechanical studies suggest that irradiated bone is more brittle, but the cause is unclear and cannot be explained by changes to bone structure or quantity, suggesting that there are crucial changes in irradiated bone material properties. Raman spectroscopy provides a means to assess the chemical properties of the mineral and matrix constituents of bone, which could help explain post-radiation embrittlement. In this study we use a murine tibial model with focal irradiation and perform Raman spectroscopy to test the hypothesis that changes in bone chemistry following irradiation is consistent with reduced bone quality and persists in the long term after irradiation.

METHODS

Female BALB/F mice aged 12weeks were subjected to unilateral, localized hindlimb irradiation in 4 daily 5Gy fractions (4×5Gy) totaling 20Gy, and were euthanized at 1, 4, 8, 12, and 26weeks post-irradiation (n=6/group). The irradiated (right) and non-irradiated contralateral control (left) tibiae were explanted and assessed by non-polarized and polarized Raman spectroscopy over the proximal cortical bone surface. Raman parameters used included the mineral/matrix ratio, mineral crystallinity, carbonate/phosphate ratio, collagen cross-link ratio, and depolarization ratio.

RESULTS

Significantly increased collagen cross-link ratio and decreased depolarization ratio of matrix were evident at 1week after irradiation and this persisted through 26weeks. A similar significant decrease was observed for depolarization ratio of mineral at all time points except 8 and 26weeks. At 4weeks after irradiation there was a significantly increased mineral/matrix ratio, increased mineral crystallinity, and decreased carbonate/phosphate ratio compared to controls. However, at 12weeks after irradiation these parameters had moved in the opposite direction, resulting in a significantly decreased mineral/matrix ratio, decreased crystallinity and increased carbonate/phosphate ratio compared to controls. At 26weeks, mineral/matrix, crystallinity and carbonate/phosphate ratios had returned to normal.

DISCUSSION

In this mouse model, Raman spectroscopy reports both bone mineral and collagen cross-link radiation-induced abnormalities that are evident as early as one week after irradiation and persists for 26weeks. The picture is one of extensive damage, after which there is an attempt at remodeling. We hypothesize that pathological cross-links formed by radiation damage to collagen are poorly resorbed during the altered remodeling process, so that new tissue is formed on a defective scaffold, resulting in increased bone brittleness.

From wide excision to a compartmental approach in tongue tumors: what is going on?

PURPOSE OF REVIEW

Surgical approaches to tongue cancer have not changed substantially over the years. The literature proposes some indications for tumor excision even though type of intervention, resection margins, neck dissection, and 'en bloc' resection versus separate excision of tumor and lymph nodes do not seem to be standardized. The purpose of this review is to describe the evolution of surgical management of tongue carcinoma with particular attention to recent reports focusing on compartmental tongue surgery.

RECENT FINDINGS

The current literature usually describes resection of tongue carcinoma within wide disease-free margins, ranging from 1.5 to 2 cm. In case of advanced-stage tumors, performing concomitant neck dissection is recommended; otherwise, a deferred neck dissection is indicated if depth of neoplastic infiltration exceeds 4 mm. In recent years, a new technical approach has been formulated based on anatomy of the tongue, thus, introducing the concept of an anatomy-based, function sparing, compartmental surgery.

SUMMARY

Applying such a proposal to clinical practice aims at standardizing a surgical procedure that otherwise might be arbitrary. Compartmental surgery improves overall survival, does not seem to worsen functional outcomes of the residual tongue, and allows comparison of case studies.

Zoledronic acid prevents loss of trabecular bone after focal irradiation in mice

Radiation therapy for soft tissue sarcomas and metastatic disease can adversely affect bone, leading to late-onset fragility fractures. Adjunct administration of bisphosphonates has been postulated as means of minimizing these adverse effects. Using a murine model of focal hindlimb irradiation, we examined the potential for zoledronic acid treatment to minimize the deleterious effects of localized radiotherapy (RTx) on bone. Mice received a single, unilateral hindlimb exposure of 20 Gy. Beginning 4 days prior to irradiation, and at 1, 2 and 3 weeks post-irradiation, animals were treated with zoledronic acid or saline/vehicle injections. Areal bone mineral density was assessed at 4 days, and 2, 4 and 12 weeks post-irradiation by dual-energy X-ray absorptiometry (DXA). Micro-computed tomography and axial compression testing were used to quantify changes in morphological and mechanical properties of femurs at 4 and 12 weeks post-irradiation. Radiation had differential effects on cortical and trabecular bone, increasing cortical bone mineral content (BMC), cortical bone volume (BV) and trabecular separation (Tb.Sp) while decreasing trabecular number (Tb.N) by 12 weeks after localized radiotherapy. Administration of zoledronic acid increased hindlimb areal bone mineral density in both the presence and absence of radiotherapy, increased cortical bone mineral content and bone volume, increased trabecular bone volume (BV/TV), increased trabecular number, increased trabecular thickness (Tb.Th), and decreased trabecular separation compared to irradiated and vehicle control femurs. Despite these improvements in morphology with zoledronic acid, no biomechanical advantage was observed. Further work is needed to define the role of bisphosphonates in prevention of post-irradiation fragility fractures.

[Surgical margins in soft tissue sarcoma of the extremities]

Negative surgical margins (R0 resection) play a key role in the prevention of local recurrences of soft tissue sarcoma of the extremities in the multimodal therapy concept. The prognostic relevance for long-term survival is still under dispute. Despite the fact that numerous recommendations and guidelines have existed for over 100 years, strong evidence-based data from prospective randomized studies are still not available today. These studies should include parameters like tumor localization, subtype and biological aggressiveness. Recommendations as to surgical therapy diverge considerably. They range from amputation and compartment resection to centimetre and millimetre surgical margins. The present article analyses currently available data and definitions and discusses the impact on functional restriction, lymph drainage, local recurrence and the perioperative irradiation field. In the absence of surgical standards, it is doubtful whether existing studies and multicenter trials currently underway are valid. Close co-operation between surgeon and pathologist is imperative to further substantiate the significance of histological examinations and resection margins.

Site-dependent replacement or internal fixation for postradiation femur fractures after soft tissue sarcoma resection

BACKGROUND

High-dose radiation retards bone healing, compromising the surgical results of radiation-induced fractures. Prosthetic replacement has traditionally been reserved as a salvage option but may best achieve the clinical goals of eliminating pain, restoring function and avoiding complications.

QUESTIONS/PURPOSES

We asked whether patients undergoing prosthetic replacement at index surgery for radiation-related subtrochanteric or diaphyseal fractures of the femur had fewer complications than those undergoing open reduction internal fixation at index operation.

METHODS

We retrospectively reviewed records from 1045 patients with soft tissue sarcomas treated with surgical resection and high-dose radiation therapy between 1982 and 2009 and identified 37 patients with 39 fractures. We recorded patient demographics, diagnosis, type of surgical resection, total radiation dose, fracture location and pattern, years after radiation the fracture occurred, type of surgical fixation, and associated complications.

RESULTS

Patients undergoing prosthetic replacement at index surgery had a lower number of major complications and revision surgeries than those undergoing index open reduction internal fixation. Patients undergoing open reduction internal fixation at index surgery had a nonunion rate of 63% (19 of 30). Fractures located in the metaphysis were more likely to heal than those located in the subtrochanteric or diaphyseal regions.

CONCLUSIONS

Radiation-induced fractures have poor healing potential. Our data suggest an aggressive approach to fracture treatment with a prosthetic replacement can minimize complications and the need for revision surgery.

Radiotherapy for soft tissue sarcoma of the proximal lower extremity

Soft-tissue sarcoma (STS) is a histopathologically diverse group of tumors accounting for approximately 10,000 new malignancies in the US each year. The proximal lower extremity is the most common site for STS, accounting for approximately one-third of all cases. Coordinated multimodality management in the form of surgery and radiation is often critical to local control, limb preservation, and functional outcome. Based on a review of currently available Medline literature and professional experience, this paper provides an overview of the treatment of STS of the lower extremity with a particular focus on the modern role of radiotherapy.

Bone density changes after radiation for extremity sarcomas: exploring the etiology of pathologic fractures

PURPOSE

The incidental irradiation (RT) of adjacent bone that takes place during treatment of soft tissue extremity sarcomas is generally presumed to "weaken" the bone by decreasing its density, which subsequently increases the risk for pathologic fracture. This investigation intended to assess the relative effects on bone density of both RT and diminished mechanical loading secondary to tumor-induced and therapy-induced functional extremity impairment.

METHODS AND MATERIALS

19 patients treated with surgical excision and RT for soft tissue extremity sarcomas had bone density measured using dual energy X-ray absorptiometry at four sites: the irradiated (A) and contralateral (B) bone, and an uninvolved bone (C) in the treated extremity and its contralateral counterpart (D). Analysis included (1) [A-B], (2) [C-D], (3) [(A-B), - (C-D)], and (4) [(A-B)/B - (C-D)/D].

RESULTS

The mean bone density for all irradiated sites was increased 0.08 ± 0.22 g/cm(2) (variance) compared to the contralateral unirradiated side when corrected for weight-bearing effects (3). An average increase in bone density of 9 ± 22% (p = 0.08) was also seen when the differences were divided by individual control densities to normalize variation in density of different anatomic sites (4).

CONCLUSIONS

RT does not routinely decrease bone density when corrected for weight bearing or mechanical effects. The pathogenesis for the known increased risk of pathologic fracture in irradiated bones is likely multifactorial, including possible alterations in bone remodeling that can result in stable, or even increased, bone density. Further clinical and basic studies are needed to confirm our unexpected findings.