Concomitant upper extremity soft tissue sarcoma limb-sparing resection and functional reconstruction: assessment of outcomes and costs of surgery

Immediate and delayed flap reconstruction have equivalent outcomes and associated costs following soft tissue sarcoma surgery

BACKGROUND AND OBJECTIVES

Surgical treatment of soft tissue sarcoma (STS) involves wide resection of the tumor, which can necessitate soft tissue reconstruction with local or free tissue flaps. This retrospective study compares cost, surgical and oncologic outcomes between patients undergoing reconstruction with immediate versus delayed flap coverage following STS resection.

METHODS

Thirty-four patients who underwent planned flap reconstruction following resection of primary STS were identified retrospectively. Twenty-four (71%) received immediate reconstruction during the index surgery and 10 (29%) underwent planned delayed reconstruction. Preoperative patient-specific metrics, tumor characteristics, and surgical and patient outcomes were collected. Total hospital charges associated with every encounter during the perioperative period were obtained.

RESULTS

Patient demographics, comorbidities, tumor metrics, and surgical characteristics were equivalent between groups. Postoperative wound complications, reoperations, readmissions, and disease-specific survival did not differ between cohorts. Costs associated with each reconstruction strategy were equivalent on bivariate and multivariate testing, when accounting for operating room time, hospital length of stay, and reoperation rate.

CONCLUSIONS

Our study identifies no significant difference in patient outcome measures or cost between planned immediate and delayed flap reconstruction following STS resection. These results support the implementation of either treatment strategy in keeping with patient-centered, multidisciplinary care principles.

Impact of Institutional Practices and Surgical Complexity on Sarcoma Surgery Costs: Driving Efficiency in Value-Based Healthcare

BACKGROUND

Sarcomas present a unique challenge within healthcare systems due to their rarity and complex treatment requirements. This study explores the economic impact of sarcoma surgeries across three Swiss tertiary healthcare institutions, utilizing a consistent surgical approach by a single surgeon to eliminate variability in surgical expertise as a confounding factor.

METHODS

By analyzing data from 356 surgeries recorded in a real-world-time data warehouse, this study assesses surgical and hospital costs relative to institutional characteristics and surgical complexity.

RESULTS

Our findings reveal significant cost variations driven more by institutional resource management and pricing strategies than by surgical techniques. Surgical and total hospitalization costs were analyzed in relation to tumor dignity and complexity scores, showing that higher complexity and malignancy significantly increase costs. Interestingly, it was found that surgical costs accounted for only one-third of the total hospitalization costs, highlighting the substantial impact of non-surgical factors on the overall cost of care.

CONCLUSIONS

The study underscores the need for standardized cost assessment practices and highlights the potential of predictive models in enhancing resource allocation and surgical planning. By advocating for value-based healthcare models and standardized treatment guidelines, this research contributes to more equitable and sustainable healthcare delivery for sarcoma patients. These insights affirm the necessity of including a full spectrum of care costs in value-based models to truly optimize healthcare delivery. These insights prompt a reevaluation of current policies and encourage further research across diverse geographical settings to refine cost management strategies in sarcoma treatment.

Single-Stage Reconstruction with Innate Chimeric-Free Fibula Flap in Limb-Preserving Excision of Upper Limb Sarcomas

Introduction

The limb-preserving excision is the standard of care in upper limb sarcoma management, but the resulting complex composite defects are exacting the expertise of the reconstructive surgeons. This study was done to evaluate a novel single-stage reconstruction of these defects using an innate chimeric-free fibula flap (a nonfabricated, anatomically available multiple tissue components harvested on independent perforators arising from the same peroneal source vessel).

Patients and Methods

Twenty patients (16 male/4 female) with an average age of 29.5 years with upper extremity sarcoma (Enneking IIA/IIB) were treated by wide local excision and innate chimeric-free fibula flap reconstruction from March 2012 to March 2020. All the patients were followed for an average period of 18.3 months. At the end of the follow-up, the outcome was assessed by musculoskeletal tumor score (MSTS).

Results

The flow-through flap was done in five patients. Muscle-tendon unit defects were reconstructed with a vascularized peroneus longus muscle-tendon unit in 15 patients. Nerve gap reconstruction using vascularized superficial peroneal nerve was done in eight patients. All patients had a segmental defect in the appendicular skeleton that was reconstructed with the vascularized fibular strut component. Soleus chimeric muscle component was used as a void filler and for covering the hardware in seven patients. The average size of the chimeric cutaneous component paddle was 30.7 cm2. The average length of fibula used for reconstruction was 16.6 cm. All flaps survived well, facilitating good hand function at the end of the follow-up. The average outcome score as per the MSTS was 22 (p = 0.035).

Conclusion

The innate chimeric-free fibula flap provides all tissue components facilitating a good functional outcome. The advantage is the restoration of a functional hand in a single-stage reconstruction.

Results of resection of forearm soft tissue sarcoma

PURPOSE

Soft tissue sarcomas (STS) of the forearm are rare. We aim to assess their oncological and functional outcomes.

METHODS

We retrospectively evaluated 34 patients who underwent surgical excision for forearm STS at our institution between 1993 and 2020. We analyzed postoperative Musculoskeletal Tumor Society rating scale (MSTS) and local recurrence-free survival (LRFS), metastasis-free survival, and overall survival (OS) rates. The significance of the following variables was determined: age, sex, histology, tumor size, Fédération Nationale des Centres de Lutte contre le Cancer grade, American Joint Committee on Cancer stage, surgical margin, unplanned excision, metastases upon initial presentation, receipt of chemotherapy, and radiotherapy (RT).

RESULTS

The postoperative median MSTS score was 28. Bone resection or major nerve palsy was the only factor that influenced MSTS scores. The median MSTS scores in patients with or without bone resection or major nerve palsy were 24 and 29, respectively (P < 0.001). The 5-year LRFS rates was 87%. Univariate analysis revealed that the histological diagnosis of myxofibrosarcoma was the only factor that influenced LRFS (P = 0.047). The 5-year MFS rates was 71%. In univariate analysis, no factors were associated with MFS. The 5-year OS rates was 79%. Age was the only factor that influenced OS (P = 0.01).

CONCLUSION

In the treatment of forearm STS, reconstruction of the skin and tendon can compensate for function, while bone resection and major nerve disturbance cannot. Careful follow-up is important, especially in patients with myxofibrosarcoma, due to its likelihood of local recurrence.

Functional Muscle Transfer after Oncologic Extremity Resection

BACKGROUND

 Functional muscle transfer (FMT) can provide wound closure and restore adequate muscle function for patients with oncologic extremity defects. Herein we describe our institutional experience with FMT after oncological resection and provide a systematic review and meta-analysis of the available literature on this uncommon procedure.

METHODS

 A single-institution retrospective review was performed, including all patients who received FMT after oncological resection from 2005 to 2021. For the systematic review and meta-analysis, PubMed, Cochrane, Medline, and Embase libraries were queried according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines; results were pooled, weighted by study size, and analyzed.

RESULTS

 The meta-analysis consisted of seven studies with 70 patients overall, demonstrating a mean Medical Research Council (MRC) score of 3.78 (95% confidence interval: 2.97-4.56; p < 0.01). The systematic review included 28 studies with 103 patients. Receipt of adjuvant chemotherapy was associated with significantly lower mean MRC score (3.00 ± 1.35 vs. 3.90 ± 1.36; p = 0.019). Seventy-four percent of the patients underwent free FMT, with the most common donor muscle being the latissimus dorsi (55%). The flap loss rate was 0.8%. Neoadjuvant chemotherapy (p = 0.03), radiotherapy (p = 0.05), pedicled FMTs (p = 0.01), and a recipient femoral nerve (p = 0.02) were associated with significantly higher complication rates. The institutional retrospective review identified 13 patients who underwent FMT after oncological resection with a median follow-up time of 21 months (range: 6-74 months). The most common tumor necessitating FMT was undifferentiated pleomorphic sarcoma (77%), and the most common donor muscle was the latissimus dorsi (62%). A high body mass index was associated with prolonged neuromuscular recovery (R = 0.87, p = 0.002).

CONCLUSION

 FMT after oncological resection may contribute to improved extremity function. Careful consideration of risk factors and preoperative planning is imperative for successful FMT outcomes.

Morbidity and Function Loss After Resection of Malignant Peripheral Nerve Sheath Tumors

BACKGROUND

Malignant peripheral nerve sheath tumors (MPNSTs) are aggressive soft tissue sarcomas. Their resection may lead to serious morbidity. Incidence of postoperative motor and sensory deficits is unknown, and reconstruction aimed at restoring such deficits is infrequently carried out.

OBJECTIVE

To identify the incidence and risk factors of postoperative morbidity in MPNST as well as the use and outcomes of functional reconstructions in these patients.

METHODS

Postoperative function and treatment of MPNSTs diagnosed from 1988 to 2019 in 10 cancer centers was obtained. Two models were constructed evaluating factors independently associated with postoperative motor (<M3) or critical sensory loss. Critical sensation was defined as partial or complete loss of hand, foot, or buttocks sensation.

RESULTS

A total of 756 patients (33.4% neurofibromatosis type 1, NF1) were included. MPNSTs originated in 34.4% from a major nerve. Of 658 surgically treated patients, 27.2% had <M3 muscle power and 24.3% critical sensory loss. Amputations were carried out in 61 patients. Independent risk factors for motor and sensory loss included patients with NF1, symptomatic, deep-seated, extremity, or plexus tumors originating from major nerves (all P < .05). A total of 26 patients underwent functional reconstructions. The majority (64%) of these patients regained at least M3 muscle power and 33% M4 despite 86% receiving multimodal therapy.

CONCLUSION

Resection of MPNSTs commonly results in motor and sensory deficits. Patients with NF1, symptomatic, deep-seated tumors, arising from major nerves were associated with a higher risk for developing postoperative morbidity. Functional reconstructions are infrequently performed but can improve functional outcomes.

Reconstruction of upper limb soft-tissue defects after sarcoma resection with free flaps: A systematic review

BACKGROUND AND OBJECTIVES

Upper limb preservation after soft tissue sarcoma (STS) surgical excision is now the accepted gold standard and it often requires reconstruction with free flaps. The purpose of this review is to summarize current literature on upper limb reconstruction with free flaps after STS resection.

METHODS

A systematic review was performed in July 2019 in PubMed and MedLine Ovid databases according to the PRISMA guidelines.

RESULTS

A total of 17 studies were included in the final analysis, with 132 patients. The most common diagnosis was Malignant Fibrous Histiocytoma. The most frequent timing of flap coverage was immediate. The success rate was almost always 100%. The length of follow-up was reported in 11 studies with a range of 2-187 months. The most commonly reported patient-centered outcome was the MSTS Score. Based on the evidence of the literature collected, we divided the upper limb into four parts (shoulder, elbow and arm, forearm and wrist, and hand) and described the most common and functional free flaps used for reconstruction after STS resection.

CONCLUSIONS

Free flaps in the treatment of STS of the upper extremity have a good overall outcome, with a low postoperative complication rate. A wide array of free flaps is available for reconstruction, and the choice of flap is based on defect size, types of tissue required, postoperative functional goal, and surgeon preference. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.

A systematic review of functional outcomes after nerve reconstruction in extremity soft tissue sarcomas: A need for general implementation in the armamentarium

Resection of nerves in extremity soft tissue sarcomas (STS) can lead to large functional deficits. Nerve reconstructions are rarely performed and little is known on their outcomes and indications for their use, even though they are essential in restoring sensation in limb salvage procedures. This study investigated current knowledge on functional outcomes and considerations to be taken before performing such reconstructions after sarcoma resection. A systematic search was performed in July 2018 in PubMed and Embase databases according to PRISMA guidelines. Search terms related to "soft tissue sarcoma" and "nerve reconstruction" were used. Studies evaluating functional outcomes after nerve grafting or nerve transfers in extremity STS were included. Qualitative synthesis was performed on all studies. Nineteen studies were included after full-text screening, describing 26 patients. The majority of patients had a nerve reconstruction in the upper extremity (65%). Perioperative radiotherapy was administered in 67% and perioperative chemotherapy in 29% of patients. Nerve grafting was most commonly performed (n = 23) and nerve transfers were performed in six patients. A wide variety of outcome measures were used. Most patients recovered at least some motor function and sensation, but success rates were higher after upper than lower extremity defects. Multimodal treatment did not preclude successful reconstructions. Nerve reconstructions in extremity STS allow the restoration of sensation in limb salvation, even motor nerve function can be restored with satisfactory function. The use of multimodal therapy does not seem to interfere with success. Nerve reconstructions should therefore be considered in STS patients.

Treatment of malignant peripheral nerve sheath tumors in pediatric NF1 disease

BACKGROUND

Malignant peripheral nerve sheath tumors (MPNSTs) are rare yet highly aggressive soft tissue sarcomas. Children with neurofibromatosis type 1 (NF1) have a 10% lifetime risk for development of MPNST. Prognosis remains poor and survival seems worse for NF1 patients.

METHODS

This narrative review highlights current practices and pitfalls in the management of MPNST in pediatric NF1 patients.

RESULTS

Preoperative diagnostics can be challenging, but PET scans have shown to be useful tools. More recently, functional MRI holds promise as well. Surgery remains the mainstay treatment for these patients, but careful planning is needed to minimize postoperative morbidity. Functional reconstructions can play a role in improving functional status. Radiotherapy can be administered to enhance local control in selected cases, but care should be taken to minimize radiation effects as well as reduce the risk of secondary malignancies. The exact role of chemotherapy has yet to be determined. Reports on the efficacy of chemotherapy vary as some report lower effects in NF1 populations. Promisingly, survival seems to ameliorate in the last few decades and response rates of chemotherapy may increase in NF1 populations when administering it as part of standard of care. However, in metastasized disease, response rates remain poor. New systemic therapies are therefore desperately warranted and multiple trials are currently investigating the role of drugs. Targeted drugs are nevertheless not yet included in first line treatment.

CONCLUSION

Both research and clinical efforts benefit from multidisciplinary approaches with international collaborations in this rare malignancy.

Upper extremity sarcoma: impact of current practice guidelines and controversies on reconstructive approaches

The goals of sarcoma management include both a cure and the functional preservation of involved tissues and adjacent critical structures with common opinions favoring immediate reconstruction. The question arises whether these goals are contradictory. This paper discusses the question based on the experience of 28 patients with different types of extremity sarcoma, with 24 surgically treated by the University of California San Diego (UCSD) orthopedic and plastic surgery team (2011–2016) and the collection of evidence from published practice guidelines, reviews, case studies, and clinical trials. Included are the impact of limb-sparing and functional reconstructive concepts, efforts regarding the adequacy of surgical margins, and the rationale of immediate versus delayed reconstructive approaches, and the disease-free status of sarcoma management.

Optimizing functional upper extremity reconstruction-Simultaneous free anterolateral thigh flap and tendon transfers-A case report

Composite upper extremity defects involving muscle-tendon units are amongst the most formidable reconstructive challenges and mandate functional restoration in addition to stable soft-tissue coverage. Here, the authors present a case of a composite defect involving the extensor muscle-tendon units of the forearm resulting from surgical resection of a recurrent Merkel cell cancer. Functional restoration was achieved via multiple tendon transfers followed by soft tissue coverage with a free anterolateral thigh (ALT) flap. No donor- or recipient-site complications were encountered and complete flap survival was noted. Following a 6-week period of immobilization, physical therapy and range of motion exercises were initiated. Excellent functional outcome and high patient satisfaction were noted at 8 weeks postoperatively. In summary, simultaneous tendon transfers and microsurgical tissue transfer may provide a potentially superior approach for upper extremity reconstruction in complex composite defects. © 2014 Wiley Periodicals, Inc. Microsurgery 37:71-74, 2017.

Elbow Reconstruction With Compression Plate Arthrodesis and Circumferential Muscle-Sparing Latissimus Dorsi Flap After Tumor Resection: A Case Report

BACKGROUND

The goals of limb-sparing surgery in the setting of extremity malignancies are 2-fold: oncological clearance and the rehabilitation of function and aesthetics. Treatment success should be defined by the extent of restoration of the patient's premorbid function for reintegration into society.

METHODS

We would like to report an unusual case of a patient with a chronically ankylosed elbow with joint invasion by basal cell carcinoma which resulted from malignant transformation of an overlying, long-standing wound due to inadequately treated septic arthritis from his childhood years.

RESULTS

Following R0 resection, upper limb shortening and compression plate elbow arthrodesis were performed with the aim of restoring the degree of upper limb function that the patient had been accustomed to preoperatively. The resultant circumferential defect was then closed with a contralateral, free muscle-sparing latissimus dorsi flap.

CONCLUSIONS

Functional preservation may therefore be more important than the mere restoration of anatomical defects in these especially challenging situations.