Oncovascular Surgery for Soft-Tissue Sarcomas of the Lower Limbs with Vascular Contact: Comparison of Arterial Reconstruction and Arterial Subadventitial Dissection

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.

A Systematic Review of the Orthoplastic Approach in Adult Lower Extremity Soft Tissue Sarcoma Flap Reconstruction

BACKGROUND

The orthoplastic approach to patient care has changed the way patients with a wide variety of lower extremity pathology are treated. Through a systematic review, we aim to analyze outcomes in adult patients with lower extremity soft tissue sarcomas who undergo an orthoplastic flap management approach to their care.

METHODS

A systematic review of adult lower extremity soft tissue sarcoma excision with plastic surgery flap reconstruction was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines searching the Pubmed, Embase, and Web of Science databases from inception to April 2023.

RESULTS

After removal of duplicates, title and abstract screening, and full-text review, 26 articles were accepted for inclusion. The total mean follow-up duration was 32.0 ± 24.3 months. Reconstruction used microvascular free flaps in 65.5% (487/743), while 34.5% (256/743) were local flaps. 85.8% (307/358) of patients ambulated postoperatively. Revision surgery was required in 21% of patients during their respective follow-up periods. The limb salvage rate was 93.4% (958/1,026). Among pooled surgical outcomes, 22.2% (225/1,012) of patients experienced a perioperative complication.

DISCUSSION

Our study demonstrates that although complication rates in lower extremity soft tissue sarcoma reconstruction may be further optimized, a multidisciplinary flap reconstructive approach provides high rates of limb salvage and functional postoperative ambulation.

Clinical outcomes after vascular reconstruction using synthetic grafts for limb salvage in patients with lower extremity sarcoma: a single-center retrospective experience

Introduction

Limb-salvage surgery has become the mainstream approaches for the treatment of sarcoma in the lower extremity. In cases where the sarcoma infiltrates the primary vessel, concurrent resection of the vessels and vascular reconstruction are required to ensure sufficient resection and preservation of limb function. The objective of this study is to assess the clinical outcomes of patients who underwent vascular reconstruction utilizing synthetic grafts for limb salvage, specifically in terms of postoperative complications and limb functional status.

Methods

Between September 2016 and October 2021, 15 consecutive patients who underwent 15 arterial and 3 venous reconstruction procedures were included in this retrospective study. Incidence of postoperative morbidity, graft patency, rate of limb salvage, and overall survival of patients were analyzed.

Results

The median follow-up was 12.5 months (range, 4.5-72.0). Graft thrombosis occurred in 5 patients (33.3%) and graft occlusion occurred in 3 patients (20.0%). The median overall survival was 28.0 months with the estimated 2-year and 5-year overall survival of 57.8% and 43.4% respectively. The 1-year and 2-year estimated patency rates of arterial reconstructions were 82.3% and 62.1%, respectively. None of the included patients with limb amputation were observed as a consequence of severe vascular complications, while two patients underwent amputation due to the repeat recurrence, resulting in a limb salvage rate of 86.7%.

Conclusion

Our results show that the combination of vascular reconstruction and oncologic resection is a feasible option for preserving limbs in cases of musculoskeletal sarcoma with vessel involvement in the lower extremity. When vascular reconstruction surgery is performed, synthetic substitutes can be effectively used with low perioperative morbidity and an acceptable rate of limb salvage.

The role of vascular surgeons in the management of pediatric bone tumors

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.

Postoperative drainage management and wound complications following resection of lower limb soft tissue tumors: a retrospective cohort study

PURPOSE

Postoperative wound complications are common in patients undergoing resection of lower extremity soft tissue tumors. Postoperative drainage therapy ensures adequate wound healing but may delay or complicate it. The aim of this study is to evaluate the incidence of postoperative wound complications and delayed or prolonged drainage treatment and to propose a standardized definition and severity grading of complex postoperative courses.

METHODS

A monocentric retrospective analysis of 80 patients who had undergone primary resection of lower extremity soft tissue tumors was performed. A new classification was developed, which takes into account postoperative drainage characteristics and wound complications. Based on this classification, risk factors and the prognostic value of daily drainage volumes were evaluated.

RESULTS

According to this new definition, regular postoperative course grade 0 (no wound complication and timely drainage removal) occurred in 26 patients (32.5%), grade A (minor wound complications or delayed drainage removal) in 12 (15.0%), grade B (major wound complication or prolonged drainage therapy) in 31 (38.8%), and grade C (reoperation) in 11 (13.7%) patients. Tumor-specific characteristics, such as tumor size (p = 0.0004), proximal tumor location (p = 0.0484), and tumor depth (p = 0.0138) were identified as risk factors for complex postoperative courses (grades B and C). Drainage volume on postoperative day 4 was a suitable predictor for complex courses (cutoff of 70 ml/d).

CONCLUSION

The proposed definition incorporates wound complications and drainage management while also being clinically relevant and easy to apply. It may serve as a standardized endpoint for assessing the postoperative course after resection of lower extremity soft tissue tumors.

Study on the effect of artificial joint replacement for osteosarcoma

Osteosarcoma is one of the most prevalent primary malignant bone tumors that affects teenagers more than adults. In recent years, artificial femoral replacement has become more and more common. The use of artificial total femoral replacement surgery prevents the need for amputating the damaged limb, preserves the patient's ability to move and bear weight on the leg, lessens the severity of the psychological trauma, and significantly raises the patient's quality of life. To explore the treatment methods and therapeutic effects of artificial femoral replacement in the treatment of femoral osteosarcoma. The clinical data of 11 patients with femoral malignant tumors who underwent artificial femoral replacement from January 2019 to March 2022 were retrospectively analyzed. Among them, 7 males and 4 females, 11 to 40 years old, average 19.36 ± 9.44 years old. The disease duration is 2 to 7 months, with an average of 4.7 months. Before and 3 months after operation, the patients who had tumors were given a score on the visual analog scale, and their quality of life was also measured. At the most recent follow-up, both the Musculoskeletal Tumor Society score and the Harris hip score were analyzed. Eleven patients were followed up for 6 to 58 months, and an average of 21 months. Complications such as wound infection, joint dislocation, and nerve damage did not occur. In 1 patient, popliteal vein thrombus formation, and in 2 patients with osteosarcoma died from tumor progression. Visual analog scale score at 3 months after surgery and the quality-of-life scores were 3.68 ± 1.39 and 40.04 ± 4.31, respectively, which were significantly improved compared to before surgery (5.94 ± 1.19 and 22.42 ± 3.63, respectively, P < .05). At the last interview, Musculoskeletal Tumor Society score is scored from 18 to 29 points, average 22.5 ± 5.9 points, and Harris hip score is scored from 42 to 90 points, with an average score of 69.0 ± 14.7. Artificial total femoral replacement is an effective limb salvage operation in the treatment of osteosarcoma.

Postoperative Complication and Reoperation Rates Following Resection of Soft Tissue vs. Bone Malignancies Based on Anatomic Location in the Inpatient Setting

Introduction

Surgical excisions of upper and lower extremity malignancies are increasing annually, due in part to the rising incidence of sarcomas. The purpose of this study is to compare readmissions, reoperation rate, and complications following surgical excision of soft/connective tissue vs bone malignancies of the upper and lower extremities.

Methods

The Nationwide Readmissions Database (NRD) was queried from 2016-2017 to conduct a retrospective analysis of 16,435 patients diagnosed with malignant neoplasms of the long bone (ULLB, n = 1,433) and soft tissue (ULST, n = 2,049) of the upper limb and malignant neoplasms of the long bone (LLLB, n = 5,422) and soft tissue (LLST, n = 7,531) of the lower limb. Patients who underwent surgical excision of their neoplasms were included. Binomial multivariate logistic regression was used to compare complications, nonelective readmission rates, and reoperation rates between the two groups at 30 and 90 days.

Results

Average age of the ULST group was 61.88, with 36% female. Average age of the ULLB group was 44.97, with 41.90% female. Average age of the LLST group was 60.96, with 46.90% female. Average age of the LLLB group was 43.09, with 42.60% female. The ULST group had lower odds of readmission within 30 days (p=0.263), which became significant within 90 days of surgery (p=0.045). The LLST group had significantly higher odds of infection, reoperation within 30 to 90 days of the index surgery compared to the LLLB group (p < 0.0001). The LLST group had significantly lower odds of readmission within 30 (p=0.04) and 90 days (p=0.015) of the index surgery.

Conclusion

Patients in the ULST group had significantly lower odds of 90-day readmission compared to the ULLB group. There were also significantly lower odds of 30- and 90-day readmission in the LLST group compared to the LLLB group. However, the LLST group had significantly higher odds of infection and reoperation within 30 and 90 days compared to the LLLB group.

Contemporary role of amputation for patients with extremity soft tissue sarcoma

INTRODUCTION

limb-sparing surgery is the mainstream treatment for primary extremity soft tissue sarcoma (ESTS) at referral centers, following advances in surgical reconstructions and multimodal management. However, amputation is still needed in selected patients and has not yet been described for a ESTS cohort in a contemporary scenario.

MATERIAL AND METHODS

consecutive patients who underwent surgery for primary ESTS from 2006 to 2018 were extracted from a prospectively collected database at our reference center. Patients receiving amputation for either primary tumor or local recurrence (LR) after limb-sparing surgery were selected for analysis.

RESULTS

Among 1628 primary ESTS, 29 patients underwent primary amputation (1.8%), 22/1159 (1.9%) for upper limb and 7/469 (1.5%) for lower limb ESTS. Patients were mainly affected by grade III FNCLCC (89.6%) of notable dimension (median size 16 cm, IQR 10-24). 65.5% of patients received preoperative treatments (systemic or regional chemotherapy, radiotherapy or chemo-radiation). Secondary amputation for LR was performed after a median of 23 months in 16/1599 patients (1%). Median survival time was 16.2 and 29.6 months after primary or secondary amputation respectively. Factors prompting the need for a primary amputation were most often a combination of multifocal disease, bone invasion and pain or neurovascular bundle involvement and relevant comorbidities, mainly for grade III tumors in elderly patients.

CONCLUSION

Contemporary rate of amputation for ESTS at a reference center is extremely low. Still, amputation is required in selected cases with advanced presentations, especially in elderly, frail patients.

Efficacy of Neoadjuvant Chemotherapy plus Limb-Sparing Surgery for Osteosarcoma and Its Impact on Long-Term Quality of Life

Purpose

To assess the efficacy of neoadjuvant chemotherapy plus limb-sparing surgery for osteosarcoma and its impact on long-term quality of life.

Methods

Between August 2016 and December 2018, 90 patients with osteosarcoma treated in Nanchong Central Hospital were recruited and divided at a ratio of 1 : 1 to receive limb-sparing surgery (control group) or limb-sparing surgery plus neoadjuvant chemotherapy (study group) by random number table methods. The clinical endpoints were clinical efficacy and long-term quality of life.

Results

Limb-sparing surgery plus neoadjuvant chemotherapy was associated with a significantly higher efficacy versus limb-sparing surgery alone. Limb-sparing surgery plus neoadjuvant chemotherapy resulted in a significantly higher Enneking score and a higher good function rating of patients versus limb-sparing surgery. The two groups showed a high but similar 1-year survival rate. Patients given limb-sparing surgery plus neoadjuvant chemotherapy showed significantly higher 2-year and 3-year survival and a longer mean survival versus those receiving limb-sparing surgery alone. Limb-sparing surgery plus neoadjuvant chemotherapy resulted in significantly higher scores of role emotional, mental health, physical function, and social function and a lower bodily pain score than limb-sparing surgery alone. Limb-sparing surgery plus neoadjuvant chemotherapy was associated with significantly lower fatigue, nausea and vomiting, dyspnea, constipation, and diarrhea scores and a significantly higher health status score versus monotherapy of limb-sparing surgery.

Conclusion

Neoadjuvant chemotherapy plus limb-sparing surgery improves the postoperative limb function and long-term quality of life of patients with osteosarcoma, which shows great potential for clinical promotion.

Reconstruction of the superficial femoral vessels with muscle flap coverage for soft tissue sarcomas of the proximal thigh

Background

Surgical resection of soft tissue sarcoma with a margin of healthy tissue may necessitate resection and reconstruction of major blood vessels together with soft tissues of the proximal thigh to preserve the limb. The long‐term functional outcomes of these reconstructions remain unestablished. The aim of this report was to assess the vascular and functional outcomes of soft tissue sarcoma patients with femoral vessel reconstructions.

Patients and Methods

Patients who had undergone oncovascular reconstruction during the treatment of proximal thigh soft tissue sarcoma in 2014–2020 were reviewed for details of the vascular and soft tissue reconstructions, and the oncological and functional outcomes. This included eight patients of a median age 59 (range 19–77) years. All had a reconstruction of at least the superficial femoral artery and vein as well as soft tissue reconstruction with a muscle flap. All vessel reconstructions were done with either autologous vein (six grafts/four patients) or allograft (10 grafts/six patients). A microvascular latissimus dorsi flap, with a skin island, was incorporated to cover the vascular grafts in five patients. A pedicled sartorius or gracilis muscle flap was used to fill the defect in three patients.

Results

Graft patency was assessed in seven patients with a median follow‐up of 48 (1–76) months. The arterial graft was patent in 6/8 and the vein graft in 2/8 patients. The gait had returned to normal in five of the six patients assessed. The median MTSS was 70 (43–87)% and the TESS 90 (75–100)%. No local recurrence of the sarcoma was detected.

Conclusions

Vascular reconstruction combined with soft tissue reconstruction enables limb‐sparing surgery in patients with soft tissue sarcoma involving proximal femoral vessels. Although the surgeries are complex with high early morbidity, the achieved long‐term functional outcomes are worthwhile.

Total femur replacement with 18 years of follow-up: A case report

BACKGROUND

Osteosarcoma is one of the most common primary malignant bone tumors and is more common in adolescents. The femur is the most common site of osteosarcoma, and many patients require total femur replacement. We reviewed the relevant literature and case findings, summarized and analyzed this case in combination with relevant literature, and in doing so improved the understanding of the technology.

CASE SUMMARY

The case we report was a 15-year-old patient who was admitted to the hospital 15 days after the discovery of a right thigh mass. The diagnosis was osteosarcoma of the right femoral shaft. After completion of neoadjuvant chemotherapy and preoperative preparation, total right femoral resection + artificial total femoral replacement was performed. Then, chemotherapy was continued after surgery. The patient recovered well after treatment, and the function of the affected limb was good. No recurrence, metastasis, prosthesis loosening, dislocation, fracture or other complications were found during 18 years of follow-up. At present, the patient can still work and lives normally. The results of the medium- and long-term follow-up were satisfactory.

CONCLUSION

Artificial total femur replacement is a feasible limb salvage operation for patients with femoral malignant tumors, and the results of medium- and long-term follow-up are satisfactory.

Versatility of perforator flaps for lower extremity defect coverage: Technical highlights and single center experience with 87 consecutive cases

BACKGROUND

Lower extremity defects have been and remain one of the greatest challenges in reconstructive surgery. Perforator flaps have been accepted as a valid procedure to cover such a defect. Different techniques have been described and nowadays many options are available. However, there were not studies that comprehensively review the most modern techniques and clinical application of the use of perforator flaps in the lower extremity reconstruction. In the present report, we gathered most of them, presenting an updated and large case series where different pedicled and free perforators flaps were employed in simple and complex scenarios in a large series of cases.

PATIENTS AND METHODS

Eighty-seven patients presenting soft tissue defects of the lower extremities were treated by means of different perforator-based flaps, in either free or pedicled fashion. The flaps were based on different perforator vessels, namely deep lateral circumflex femoral artery, profunda femoris artery, superficial femoral artery, medial sural artery, peroneal artery, posterior tibial artery, anterior tibial artery, and medial plantar artery. Patients' mean age was 61.9 years old (range 21-87 years old), 58 were males and 29 females. The 12 patients received sequential flaps and 9 received double free flaps, for a total sum of 106 flaps. The causes of the defects were trauma in 41 patients and tumors in 46 patients, located throughout the lower limbs. Size of the defect ranged from 3 cm × 4 cm to 25 cm × 9 cm.

RESULTS

The dimensions of the flap skin paddles ranged from 3 cm × 4 cm to 16 cm × 5 cm for the pedicled flaps (42 cases) and from 6 cm × 4 cm to 25 cm × 8 cm for the free ones (45 cases). Mean flap's size was 48 cm² (range 12-80 cm² ) for the pedicle flaps and 104 cm² (range 24-200 cm² ) for free flaps. In two pedicled cases, a distal congestion was encountered, requiring a second surgery. Debulking procedures were performed in 2 patients. All the patients were successfully treated and no flaps were lost. Mean follow-up period was 8.4 months (range 3-12 months). No range of motion impairment was encountered after surgery and all the patients were able to return to habitual life.

CONCLUSIONS

The present case series highlights the reliability and versatility of perforator flaps for lower extremity defect coverage. Following careful consideration of the etiology, dimensions, location, patient comorbidities, and presence of adequate perforators, a pedicled or free perforator flap can be potentially successful in the most disparate circumstances.

Safe-margin surgery by plastic reconstruction in extremities or parietal trunk soft tissue sarcoma: A tertiary single centre experience

INTRODUCTION

Tertiary centers recruit a large proportion of locally advanced or recurrent soft tissue sarcomas (STSs) that may have been preoperatively irradiated. The objective of this study was to evaluate the results of oncoplastic surgery (OPS) for patients affected by extremities or parietal trunk STS.

MATERIALS AND METHODS

This retrospective study includes patients who underwent a flap reconstruction after sarcoma resection between January 2018 and December 2020 at Institut Curie. The primary endpoint was the evaluation of the impact of OPS on the quality of surgical margins. The secondary endpoint was to quantify the morbidity of OPS and identify predictive factors for wound complications.

RESULTS

Of 211 patients, 89 (42.2%) had a flap reconstruction. Surgery was realized on an irradiated field in 56 (62.9%) patients. Without OPS, all patients were candidates either for amputation (n = 9,10.1%) due to vessels/nerve infiltration, or R1/R2 resection (n = 80,89.9%). Seventy-two (80.0%) pedicle flaps and 18 (20.0%) free flaps were used. No R2 resections were performed. R0 and R1 margins were achieved in 82 (92.1%) and 7 (7.9%), respectively. The median closest margin was 3 mm (IQR 1-6 mm). Among R1 patients, 5 had positive margins along a preserved critical structure, 2 patients had well-differentiated liposarcomas. The surgical morbidity rate was 33.3% (30/90 flaps). The reoperation rate was 15.7% (14/89 patients).

CONCLUSIONS

In a referral sarcoma center, the collaboration between the surgical oncologist and the plastic surgery team should be considered upfront in the surgical plan, allowing the most adequate wide oncological resection with acceptable postoperative morbidity.

Surgical and oncologic outcomes following arterial resection and reconstruction for advanced solid tumors

BACKGROUND AND OBJECTIVES

Although arterial involvement for advanced tumors is rare, vascular resection may be indicated to achieve complete tumor resection. Given the potential morbidity of this approach, we sought to evaluate perioperative outcomes, vascular graft patency, and survival among patients undergoing tumor excision with en bloc arterial resection and reconstruction.

METHODS

From 2010 to 2020, we identified nine patients with tumors encasing or extensively abutting major arterial structures for whom en bloc arterial resection and reconstruction was performed.

RESULTS

Mean age was 53 ± 20 years, and 89% were females. Diagnoses were primary sarcomas (5), recurrent gynecologic carcinomas (3), and benign retroperitoneal fibrosis (1). Tumors involved the infrarenal aorta (2), iliac arteries (6), and superficial femoral artery (1). Three patients (33%) had severe perioperative morbidity (Grade III + ) with no mortality. At a median follow-up of 23 months, eight patients (89%) had primary graft patency, and five patients (56%) had no evidence of disease.

CONCLUSIONS

Arterial resection and reconstruction as part of the multimodality treatment of regionally advanced tumors is associated with acceptable short- and long-term outcomes, including excellent graft patency. In appropriately selected patients, involvement of major arterial structures should not be viewed as a contraindication to attempted curative surgery.

Variability in the reported surgical techniques and methods for intercalary reconstruction following tumor resection

INTRODUCTION

There is currently no consensus regarding the best techniques or surgical strategies with which to maximize intercalary allograft reconstruction outcomes. The purpose of the current study was to assess which techniques and methods are being utilized by North American orthopaedic oncologists.

METHODS

Members of the Musculoskeletal Tumor Society (MSTS) were invited to complete an anonymous online questionnaire. The survey presented participants with two clinical scenarios and interrogated them on their preferred type of allograft, method of compression and fixation, and additional techniques used.

RESULTS

One hundred and twenty-six physicians completed the questionnaire. The majority studied in the United States (82%) and worked at an academic medical center (71%). Over half (54%) reported seeing over 10 primary bone tumors every year. Respondents were split between preferring a structural allograft alone or using a combined allograft-vascularized fibular graft. A majority indicated a preference for plate(s) and screw fixation but were divided between the use of two compression plates with a spanning plate, a single compression plate with a spanning plate, and two compression plates with an intramedullary nail. Screw fixation preferences were split between the use of unicortical locking only, bicortical locking only, and a combination of unicortical and bicortical locking. Almost equal percentages of respondents reported they would have used two, three, or four screws in both scenarios. Respondents were split between placing screws equidistantly and placing them peripherally within the allograft, adjacent to the allograft-host junction.

DISCUSSION

There is no clear surgical preference for intercalary reconstruction following tumor extirpation within this sample of orthopaedic oncologists. The current survey demonstrates variability across nearly every aspect of allograft reconstruction, which may, in part, explain the wide spectrum of outcomes reported within the literature. Prospective studies are warranted to better evaluate technique-specific outcomes in an effort to maximize reconstructive longevity and minimize allograft related complications.

Safety of limb-salvaging surgery for sarcomas compromising major vessels: A 15-year single-centre outcomes study

INTRODUCTION

Limb-threatening sarcomas invading major vessels present an oncological and reconstructive challenge. Curative resection involves either performing an amputation or an immediate reconstruction of the invaded vessels. We present our 15-year experience of these cases at the North of England Bone and Soft Tissue Tumour Service.

MATERIALS AND METHODS

A Strengthening the Reporting of Observational studies in Epidemiology (STROBE) compliant retrospective review of our prospective database was performed including patients who required major vessel reconstruction following sarcoma excision from 2003 until 2018. Patient demographic data along with tumour and histological subtypes, treatment modality, complications and outcomes were inquired. Autologous and prosthetic vessel reconstruction approaches were compared.

RESULTS

Nineteen patients were identified with the most common tumour locations being the thigh and groin areas. Five cases involved recurrent tumours. Clear resection margins were obtained in 15 cases. Autologous vein grafts were preferred over polytetrafluoroethylene (PTFE) prosthesis in 17 cases. A pedicled flap or free flap was required to achieve adequate soft tissue cover in six patients, while the rest underwent primary closure. Five patients lost the patency of the reconstructed vessels with one of these requiring an amputation. The estimated disease-specific survival at 5 years was 58%.

DISCUSSION

Limb-preservation surgery in the context of vessel compromise is not only safe, but also a functionally and psychosocially beneficial means of avoiding an amputation. We believe that careful pre-operative planning and discussion in a multidisciplinary setting is key for obtaining positive outcomes.

Sarcomas in the groin and inguinal canal: A 16-year single-centre experience

INTRODUCTION

Soft tissue sarcomas arising in the groin and inguinal canal can be difficult to diagnose and manage. This is in part explained by the complex anatomy of the region. Early referral to specialist centres has been advocated, as inadvertent excision of these tumours can jeopardise definitive treatment. We present our 16-year experience at a regional sarcoma service.

MATERIALS AND METHODS

A retrospective review of patients treated for a sarcoma in the groin and inguinal canal within the North of England Bone and Soft Tissue Tumour Service was performed. Demographic information, along with therapeutic approach and outcomes, was recorded and analysed.

RESULTS

A total of 67 patients were identified, out of which 18 presented with new lesions, 32 presented after having a previous inadvertent sarcoma excision, 10 had a planned resection and 7 presented with recurrent disease. Liposarcomas were the most common histological subtype (55%), and the spermatic cord the most common origin (45%). Fifty-seven patients had surgery for this condition, with seven incomplete excision. Regional flaps were used in 60% of the cases, to allow an adequate oncological resection and soft tissue cover. Patients who had undergone a previous inadvertent sarcoma excision did not have worse rates of local recurrence, metastases and disease-specific mortality. Kaplan-Meier disease-specific survival at 5 years was 82%.

DISCUSSION

Inadvertent and inadequate groin sarcoma excision outside of specialist centres remains a problem despite clear guidance. Despite this, an aggressive oncological approach to inadequately managed tumours shows similar outcomes as tumour managed exclusively by our specialist centre.