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Elmorsi R, Camacho L, Krijgh DD, Tilney GS, Lyu H, Traweek RS, Witt RG, Roubaud MS, Roland CL, Mericli AF. Optimizing Morbidity in Unplanned Soft Tissue Sarcoma Excisions: Should We Skip the Reconstructive Ladder? Ann Plast Surg 2024; 93:361-368. [PMID: 38920187 DOI: 10.1097/sap.0000000000004013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
INTRODUCTION Soft tissue sarcomas (STSs) are rare and diverse primary malignant tumors that comprise approximately 1% of all malignancies. Misdiagnoses and unplanned excisions of STSs are common due to the tumor's rarity, leading to secondary tumor bed excisions (TBEs). Reconstructive outcomes for TBEs remain poorly understood, prompting this study to address the knowledge gap and inform preoperative discussions. METHODS This was a retrospective cohort study of patients who underwent STS excisions at a quaternary cancer center. Patients were categorized into mass excision (ME) and TBE groups. Reconstructive approaches were divided into simple (primary closure, complex repair, skin grafts, local flaps) and advanced (pedicled or free flaps). The groups were compared for postoperative outcomes, including complications, recurrence, and death. RESULTS When simple reconstructive techniques were used, TBEs exhibited higher rates of overall and major complications, whereas MEs had higher rates of overall and minor complications. Intergroup analysis revealed that with simple reconstruction, rates of overall and major complications were higher in TBEs than in MEs, and rates of minor complications were higher in MEs than in TBEs. Regression analyses revealed that simple reconstruction of TBEs had 90% and 180% higher odds of major complications and reoperation compared to simple reconstruction of MEs ( P < 0.05). CONCLUSION TBEs, despite their smaller size, exhibited a heightened susceptibility to overall and major complications, challenging the notion that simpler techniques suffice in these cases. Our findings encourage the consideration of advanced reconstructive techniques for TBEs that may seem amenable to simple reconstructive techniques.
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Affiliation(s)
- Rami Elmorsi
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Luis Camacho
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David D Krijgh
- Department of Plastic, Reconstructive, and Hand Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Gordon S Tilney
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Heather Lyu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Raymond S Traweek
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Russell G Witt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Margaret S Roubaud
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alexander F Mericli
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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Elmorsi R, Camacho L, Krijgh DD, Tilney GS, Lyu H, Traweek RS, Witt RG, Roubaud MS, Roland CL, Mericli AF. Sarcoma Size and Limb Dimensions Predict Complications, Recurrence, and Death in Patients with Soft Tissue Sarcoma in the Thigh: A Multidimensional Analysis. Ann Surg Oncol 2024; 31:5421-5430. [PMID: 38520583 DOI: 10.1245/s10434-024-15183-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/03/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Limb-sparing resections of thigh soft tissue sarcomas (STSs) can result in adverse outcomes. Identifying preoperative predictors for wound healing complications, tumor recurrence, and mortality is crucial for informed reconstructive decision-making. We hypothesized that preoperative measurements of thigh and tumor dimensions could serve as reliable indicators for postoperative complications, recurrence, and death. PATIENTS AND METHODS In this retrospective cohort study conducted from March 2016 to December 2021, we analyzed patients undergoing thigh STS excisions followed by reconstruction. Preoperative magnetic resonance imaging or computed tomography scans provided necessary thigh and tumor dimensions. Univariate and multivariate regression assessed relationships between these dimensions and postoperative outcomes, including complications, recurrence, and death. RESULTS Upon the analysis of 123 thighs, we found thigh width to be highly predictive of postoperative complications, even surpassing body mass index (BMI) and retaining significance in multivariate regression [odds ratio (OR) 1.19; 95% CI 1.03-1.39; p = 0.03]. Sarcoma-to-thigh width and thickness ratios predicted STS recurrence, with the thickness ratio retaining significance in multivariate regression (OR 1.03; 95% CI 1.001-1.05; p = 0.041). Notably, greater thigh thickness was independently protective against mortality in multivariate analysis (OR 0.80; 95% CI 0.65-0.98; p = 0.030). CONCLUSIONS Thigh width outperformed BMI in association with postoperative complications. This may create an opportunity for intervention, where weight loss can play a role during the neoadjuvant therapy period to potentially reduce complications. Sarcoma-to-thigh width and thickness ratios, particularly the latter, hold substantial predictive value in terms of STS recurrence. Moreover, thigh thickness is an independent predictor of survival.
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Affiliation(s)
- Rami Elmorsi
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Luis Camacho
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David D Krijgh
- Department of Plastic, Reconstructive, and Hand Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gordon S Tilney
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Heather Lyu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Raymond S Traweek
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Russell G Witt
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Margaret S Roubaud
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexander F Mericli
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Okay E, Connolly JJ, Gonzalez MR, Lozano-Calderon SA. Wound-Healing Effects of Common Antineoplastic Agents and Perioperative Considerations for the Orthopaedic Surgeon. J Am Acad Orthop Surg 2024; 32:e671-e682. [PMID: 38713761 DOI: 10.5435/jaaos-d-24-00097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/19/2024] [Indexed: 05/09/2024] Open
Abstract
In oncologic patients, optimal postoperative wound healing is crucial for the maintenance of systemic therapies and improved survival. Although several risk factors for postoperative wound complications have been identified, the clinical effect of new antineoplastic agents on wound healing remains uncertain. The available literature on the effect of antineoplastic agents in wound healing is complex to analyze because of other confounding risk factors such as radiation therapy and certain patient-specific variables. Available perioperative drug recommendations are based on database opinion and case reports from adverse event alerts. This review highlights the characteristics of old and new antineoplastic agents commonly used in the treatment of sarcoma, carcinoma, and other cancers and their potential effects on the wound-healing process. It also aims to provide perioperative treatment cessation recommendations to guide orthopaedic surgeons and prevent drug-related wound complications to the fullest extent possible.
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Affiliation(s)
- Erhan Okay
- From the Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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N Hoang M, Nyqvist E, Hesla AC, Tsagkozis P, Löfgren J. Wound healing after surgery for soft tissue sarcomas, and the effect of primary plastic reconstruction - A retrospective cohort study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108348. [PMID: 38677000 DOI: 10.1016/j.ejso.2024.108348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Immediate vascularized reconstruction after sarcoma resection may reduce wound complications common in primary closure, but previous research is conflicting. The present study analysed wound complication rates and compared wound-related outcomes among immediate vascularized reconstruction with primary closure. MATERIALS AND METHODS Patient- and tumour characteristics were collected from patients who received primary surgery with curative intent between 2010 and 2020 at the Stockholm Sarcoma Centre. Clinical outcomes were sought in free text in medical records. The primary outcome measures were early (<30 days) wound complications. Secondary outcome measures included late (30-day to 2-year) wound complications, time to wound healing, 30-day postoperative complications according to Clavien Dindo, and health care consumption. RESULTS A total of 482 patients were included, of whom 69 had immediate vascularized reconstruction. Comparison of early complications for reconstructive surgery with primary closure revealed a significantly higher complication rate for the first group (59.4 % vs 29.8 %, p < 0.01). The groups had comparable health care consumption the first and second postoperative years. In-depth analyses identified BMI >25, smoking and high-grade lesions as factors with adverse effects on wound healing. CONCLUSIONS Sarcoma patients experience high rates of wound complications and consume considerable health care resources. Reconstructed individuals were more susceptible to such complications than were subjects with primary closure.
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Affiliation(s)
- Madeleine N Hoang
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.
| | - Emmy Nyqvist
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Orthopaedic Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Asle Charles Hesla
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Orthopaedic Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Panagiotis Tsagkozis
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Orthopaedic Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Jenny Löfgren
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden.
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Mericli AF, Elmorsi R, Camacho L, Hassan A, Krijgh DD, Tilney G, Lyu H, Traweek RS, Witt RG, Roubaud MS, Roland CL. When to ditch the ladder and take the elevator: The Anderson SArcoma Risk of Complications (A-SARC) score to guide reconstructive decision-making in extremity soft tissue sarcoma patients. J Surg Oncol 2024; 129:1456-1465. [PMID: 38623064 DOI: 10.1002/jso.27646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/27/2024] [Accepted: 04/04/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND The reconstructive ladder relies mostly on defect size and depth to determine reconstructive technique, however, in actuality, many more variables ultimately inform reconstructive decision making, especially regarding extremity soft tissue sarcoma (eSTS) defects. The purpose of this study was to describe eSTS patients who will most optimally benefit from an advanced method of reconstruction (defined as a pedicled regional flap or free flap) and to create a simple risk assessment scale that can be employed in clinical practice. STUDY DESIGN A single-institution retrospective cohort study examined patients undergoing resection of soft tissue sarcoma affecting the upper or lower extremities between 2016 and 2021. We categorized patients who required a pedicled or free flap as having had advanced reconstruction, and all other techniques were considered simple reconstruction. A regression was used to create a risk scale to guide reconstructive decision-making. RESULTS The following variables were identified as independent predictors of complications and used to create our risk scale: lower extremity tumor location, preoperative radiotherapy, tumor bed excision, male sex, hypertension, and tumor volume. Intermediate and high-risk patients reconstructed using simple techniques had significantly greater overall complication rates compared to those reconstructed with advanced techniques. Major complications were significantly greater in low-risk patients reconstructed with advanced techniques. CONCLUSIONS To minimize postoperative wound complications, low-risk patients should receive simple methods of reconstruction, whereas high-risk patients should be reconstructed using advanced techniques.
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Affiliation(s)
- Alexander F Mericli
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rami Elmorsi
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Luis Camacho
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Abbas Hassan
- Division of Plastic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - David D Krijgh
- Department of Plastic, Reconstructive, and Hand Surgery, University Medical Center Utrecht, the Netherlands
| | - Gordon Tilney
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Heather Lyu
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Raymond S Traweek
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Russell G Witt
- Department of Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Margaret S Roubaud
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christina L Roland
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Samargandi R, Benhenneda R, Rosset P, Bisson-Patoue A, Le Nail LR. Buried de-epithelialized flap: An original solution to fill dead space after sarcoma resection in the thigh. Surgical technique and results of 12 cases. Orthop Traumatol Surg Res 2024; 110:103748. [PMID: 37923176 DOI: 10.1016/j.otsr.2023.103748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/25/2023] [Accepted: 08/28/2023] [Indexed: 11/07/2023]
Abstract
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.
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Affiliation(s)
- Ramy Samargandi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia; Service de chirurgie orthopédique, hôpital Trousseau, CHRU de Tours, faculté de médecine, université de Tours, centre Val-de-Loire, Tours, France.
| | - Rayane Benhenneda
- Service de chirurgie orthopédique, hôpital Trousseau, CHRU de Tours, faculté de médecine, université de Tours, centre Val-de-Loire, Tours, France
| | - Philippe Rosset
- Service de chirurgie orthopédique, hôpital Trousseau, CHRU de Tours, faculté de médecine, université de Tours, centre Val-de-Loire, Tours, France
| | - Audrey Bisson-Patoue
- Service de chirurgie plastique, hôpital Trousseau, CHRU de Tours, faculté de médecine, université de Tours, centre Val-de-Loire, Tours, France
| | - Louis-Romée Le Nail
- Service de chirurgie orthopédique, hôpital Trousseau, CHRU de Tours, faculté de médecine, université de Tours, centre Val-de-Loire, Tours, France; CNRS ERL 7001 LNOX: Leukemic niche & Redox metabolisme, EA 7501 GICC, université de Tours, Tours, France
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Lebas A, Le Fevre C, Waissi W, Chambrelant I, Brinkert D, Noel G. Complications and Risk Factors in Patients with Soft Tissue Sarcoma of the Extremities Treated with Radiotherapy. Cancers (Basel) 2024; 16:1977. [PMID: 38893097 PMCID: PMC11171296 DOI: 10.3390/cancers16111977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 05/18/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
INTRODUCTION Soft tissue sarcomas of the extremities (ESTSs) pose significant challenges in treatment and management due to their diverse nature and potential complications. This study aimed to assess complications associated with multimodal treatments involving surgery and radiotherapy (RT) and to identify potential risk factors. METHODS We retrospectively analyzed nonmetastatic ESTS patients treated with surgery and pre- or post-operative RT between 2007 and 2020 in Strasbourg, France. Complications, including wound complications (WCs), lymphedema, acute and chronic RT-related complications, and fractures, were meticulously evaluated. RESULTS A total of 169 patients diagnosed with localized ESTSs were included, with a median age of 64 years (range 21-94 years). ESTSs primarily occurred proximally (74.6%) and in the lower limbs (71%). The median follow-up was 5.5 years. WCs occurred in 22.5% of patients, with proximal and lower extremity tumors being significant risk factors. Acute RT-related complications included radiodermatitis, with grade ≥ 2 occurring in 43.1% of patients, which was associated with superficial tumors. Three patients had an edema grade ≥ 2. Chronic complications included telangiectasias (21.7%) and fibrosis (38.7%), with higher rates associated with larger PTVs and higher RT doses, respectively. Fractures occurred in 5 patients, mainly in the tibia (40%). CONCLUSIONS Multimodal treatment of ESTSs demonstrated excellent tolerance, with manageable side effects. Numerous risk factors have been highlighted, providing insights for optimizing treatment strategies and enhancing patient care in this rare disease.
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Affiliation(s)
- Arthur Lebas
- Radiotherapy Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17 Rue Albert Calmette, BP 23025, 67033 Strasbourg, France; (A.L.); (C.L.F.); (I.C.)
| | - Clara Le Fevre
- Radiotherapy Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17 Rue Albert Calmette, BP 23025, 67033 Strasbourg, France; (A.L.); (C.L.F.); (I.C.)
| | - Waisse Waissi
- Radiotherapy Department, Léon Bérard Center, 28 Rue Laennec, 69008 Lyon, France;
| | - Isabelle Chambrelant
- Radiotherapy Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17 Rue Albert Calmette, BP 23025, 67033 Strasbourg, France; (A.L.); (C.L.F.); (I.C.)
| | - David Brinkert
- Orthopedic Surgery Department, University Hospital of Hautepierre, 1 Rue Molière, 67200 Strasbourg, France;
| | - Georges Noel
- Radiotherapy Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17 Rue Albert Calmette, BP 23025, 67033 Strasbourg, France; (A.L.); (C.L.F.); (I.C.)
- Faculty of Medicine, Strasbourg University, 4 Rue Kirschleger, 67000 Strasbourg, France
- Radiobiology Laboratory, Centre Paul Strauss, IIMIS—Imagerie Multimodale Integrative en Santé, ICube, Strasbourg University, 67000 Strasbourg, France
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Miwa S, Yamamoto N, Hayashi K, Takeuchi A, Igarashi K, Tada K, Taniguchi Y, Morinaga S, Asano Y, Tsuchiya H. Development and validation of a nomogram to predict surgical site infection after soft-tissue sarcoma resection. Bone Joint J 2024; 106-B:492-500. [PMID: 38688512 DOI: 10.1302/0301-620x.106b5.bjj-2023-1052.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Aims Surgical site infection (SSI) after soft-tissue sarcoma (STS) resection is a serious complication. The purpose of this retrospective study was to investigate the risk factors for SSI after STS resection, and to develop a nomogram that allows patient-specific risk assessment. Methods A total of 547 patients with STS who underwent tumour resection between 2005 and 2021 were divided into a development cohort and a validation cohort. In the development cohort of 402 patients, the least absolute shrinkage and selection operator (LASSO) regression model was used to screen possible risk factors of SSI. To select risk factors and construct the prediction nomogram, multivariate logistic regression was used. The predictive power of the nomogram was evaluated by receiver operating curve (ROC) analysis in the validation cohort of 145 patients. Results LASSO regression analysis selected possible risk factors for SSI, including age, diabetes, operating time, skin graft or flap, resected tumour size, smoking, and radiation therapy. Multivariate analysis revealed that age, diabetes, smoking during the previous year, operating time, and radiation therapy were independent risk factors for SSI. A nomogram was developed based on the results of multivariate logistic regression analysis. In the development cohort, the incidence of SSI was 4.5% in the low-risk group (risk score < 6.89) and 26.6% in the high-risk group (risk score ≥ 6.89; p < 0.001). In the validation cohort, the incidence of SSI was 2.0% in the low-risk group and 15.9% in the high-risk group (p = 0.004). Conclusion Our nomogram will enable surgeons to assess the risk of SSI in patients with STS. In patients with high risk of SSI, frequent monitoring and aggressive interventions should be considered to prevent this.
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Affiliation(s)
- Shinji Miwa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Norio Yamamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Katsuhiro Hayashi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Akihiko Takeuchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Kentaro Igarashi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Kaoru Tada
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Yuta Taniguchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Sei Morinaga
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Yohei Asano
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
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Wu SS, Katabi L, DeSimone R, Borsting E, Ascha M. A Cross-Sectional Evaluation of Publication Bias in the Plastic Surgery Literature. Plast Reconstr Surg 2024; 153:1032e-1045e. [PMID: 37467390 DOI: 10.1097/prs.0000000000010931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
BACKGROUND Publication bias (PB) is the preferential publishing of studies with statistically significant results. PB can skew findings of systematic reviews (SRs) and meta-analyses (MAs), with potential consequences for patient care and health policy. This study aims to determine the extent to which SRs and MAs in the plastic surgery literature evaluate and report PB. METHODS This cross-sectional study assessed PB reporting and analysis from plastic surgery studies published between January 1, 2015, and June 19, 2020. Full texts of SRs and MAs were assessed by two reviewers for PB assessment methodology and analysis. Post hoc assessment of studies that did not originally analyze PB was performed using Egger regression, Duval, Tweedie trim-and-fill, and Copas selection models. RESULTS There were 549 studies evaluated, of which 531 full texts were included. PB was discussed by 183 studies (34.5%), and formally assessed by 97 studies (18.3%). Among SRs and MAs that formally assessed PB, PB was present in 24 studies (10.7%), not present in 52 (23.1%), and inconclusive in eight (3.6%); 141 studies (62.7%) did not report the results of their PB assessment. Funnel plots were the most common assessment method [ n = 88 (39.1%)], and 60 studies (68.2%) published funnel plots. The post hoc assessment revealed PB in 17 of 20 studies (85.0%). CONCLUSIONS PB is inadequately reported and analyzed among studies in the plastic surgery literature. Most studies that assessed PB found PB, as did post hoc analysis of nonreporting studies. Increased assessment and reporting of PB among SRs and MAs would improve the quality of evidence in plastic surgery.
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Affiliation(s)
- Shannon S Wu
- From the Cleveland Clinic Lerner College of Medicine
| | - Leila Katabi
- Department of Anesthesia, University of Michigan School of Medicine
| | - Robert DeSimone
- Department of Plastic Surgery, University of California, Irvine
| | - Emily Borsting
- Department of Plastic Surgery, University of California, Irvine
| | - Mona Ascha
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital
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10
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Cengel KA, Kim MM, Diffenderfer ES, Busch TM. FLASH Radiotherapy: What Can FLASH's Ultra High Dose Rate Offer to the Treatment of Patients With Sarcoma? Semin Radiat Oncol 2024; 34:218-228. [PMID: 38508786 DOI: 10.1016/j.semradonc.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
FLASH is an emerging treatment paradigm in radiotherapy (RT) that utilizes ultra-high dose rates (UHDR; >40 Gy)/s) of radiation delivery. Developing advances in technology support the delivery of UHDR using electron and proton systems, as well as some ion beam units (eg, carbon ions), while methods to achieve UHDR with photons are under investigation. The major advantage of FLASH RT is its ability to increase the therapeutic index for RT by shifting the dose response curve for normal tissue toxicity to higher doses. Numerous preclinical studies have been conducted to date on FLASH RT for murine sarcomas, alongside the investigation of its effects on relevant normal tissues of skin, muscle, and bone. The tumor control achieved by FLASH RT of sarcoma models is indistinguishable from that attained by treatment with standard RT to the same total dose. FLASH's high dose rates are able to mitigate the severity or incidence of RT side effects on normal tissues as evaluated by endpoints ranging from functional sparing to histological damage. Large animal studies and clinical trials of canine patients show evidence of skin sparing by FLASH vs. standard RT, but also caution against delivery of high single doses with FLASH that exceed those safely applied with standard RT. Also, a human clinical trial has shown that FLASH RT can be delivered safely to bone metastasis. Thus, data to date support continued investigations of clinical translation of FLASH RT for the treatment of patients with sarcoma. Toward this purpose, hypofractionated irradiation schemes are being investigated for FLASH effects on sarcoma and relevant normal tissues.
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Affiliation(s)
- Keith A Cengel
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania..
| | - Michele M Kim
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric S Diffenderfer
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Theresa M Busch
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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LaValley MN, Dugue D, Diaddigo SE, Kuonqui KG, Tyler WK, Bogue JT. A Systematic Review of the Orthoplastic Approach in Adult Lower Extremity Soft Tissue Sarcoma Flap Reconstruction. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202403000-00001. [PMID: 38421606 PMCID: PMC10906598 DOI: 10.5435/jaaosglobal-d-23-00290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 03/02/2024]
Abstract
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.
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Affiliation(s)
- Myles N. LaValley
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - David Dugue
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - Sarah E. Diaddigo
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - Kevin G. Kuonqui
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - Wakenda K. Tyler
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - Jarrod T. Bogue
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
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12
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Ivanov YS, Patrikov K. Complications after limb salvage surgeries for musculoskeletal malignancies: 10-year experience of the main sarcoma center in Bulgaria. Folia Med (Plovdiv) 2024; 66:35-40. [PMID: 38426463 DOI: 10.3897/folmed.66.e113390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/30/2023] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION Limb salvage surgery is currently the most frequently used treatment option in Bulgaria for individuals with musculoskeletal malignancies. Clinical data about complications from these procedures is limited in the country, with only a few studies currently available.
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13
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Generaal JD, Glas HH, Ubbels JF, Stevenson MG, Huijing MA, van Leeuwen BL, Been LB. Calculating Tumor Volume Using Three-Dimensional Models in Preoperative Soft-Tissue Sarcoma Surgical Planning: Does Size Matter? J Clin Med 2023; 12:7242. [PMID: 38068294 PMCID: PMC10871107 DOI: 10.3390/jcm12237242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/12/2023] [Accepted: 11/21/2023] [Indexed: 02/18/2024] Open
Abstract
This feasibility study aims to explore the use of three-dimensional virtual surgical planning to preoperatively determine the need for reconstructive surgery following resection of an extremity soft-tissue sarcoma. As flap reconstruction is performed more often in advanced disease, we hypothesized that tumor volume would be larger in the group of patients that had undergone flap reconstruction. All patients that were treated by surgical resection for an extremity soft-tissue sarcoma between 1 January 2016 and 1 October 2019 in the University Medical Center Groningen were included retrospectively. Three-dimensional models were created using the diagnostic magnetic resonance scan. Tumor volume was calculated for all patients. Three-dimensional tumor volume was 107.8 (349.1) mL in the group of patients that had undergone primary closure and 29.4 (47.4) mL in the group of patients in which a flap reconstruction was performed, p = 0.004. Three-dimensional tumor volume was 76.1 (295.3) mL in the group of patients with a complication following ESTS treatment, versus 57.0 (132.4) mL in patients with an uncomplicated course following ESTS treatment, p = 0.311. Patients who had undergone flap reconstruction had smaller tumor volumes compared to those in the group of patients treated by primary closure. Furthermore, a larger tumor volume did not result in complications for patients undergoing ESTS treatment. Therefore, tumor volume does not seem to influence the need for reconstruction. Despite the capability of three-dimensional virtual surgical planning to measure tumor volume, we do not recommend its utilization in the multidisciplinary extremity soft-tissue sarcoma treatment, considering the findings of the study.
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Affiliation(s)
- Jasmijn D. Generaal
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (B.L.v.L.); (L.B.B.)
| | - Haye H. Glas
- Department of Maxillofacial Surgery, 3D Lab, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
| | - Jan F. Ubbels
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
| | - Marc G. Stevenson
- Department of Surgery, Isala Hospital, Dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands;
| | - Marijn A. Huijing
- Department of Plastic Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
| | - Barbara L. van Leeuwen
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (B.L.v.L.); (L.B.B.)
| | - Lukas B. Been
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (B.L.v.L.); (L.B.B.)
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14
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Ouyang Z, Trent S, McCarthy C, Cosker T, Stuart R, Pratap S, Whitwell D, White HB, Tao H, Guo X, Maxime Gibbons CL. The incidence, risk factors and outcomes of wound complications after preoperative radiotherapy and surgery for high grade extremity soft tissue sarcomas: A 14-year retrospective study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107086. [PMID: 37741042 DOI: 10.1016/j.ejso.2023.107086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/30/2023] [Accepted: 09/15/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVE The aim of this study was to analyze the wound complication (WC) rate and to determine the risk factors for WC in patients with soft tissue sarcoma treated with preoperative radiotherapy followed by surgical resection. METHODS Using the database of Oxford University Hospital (OUH) we retrospectively studied 126 cases of soft tissue sarcomas treated with preoperative radiotherapy and surgery between 2007 and 2021. WC were defined as minor wound complication (MiWC) not requiring surgical intervention or major wound complication (MaWC) if they received a secondary surgical intervention. Univariate and multiple regression analyses were performed using frequency of WC and MaWC as a dependent variable. RESULTS The incidence of WC and MaWC was 43.7% (55/126) and 19% (24/126). Age (OR:1.03, 95%CI: 1.00-1.06, p = 0.016), tumor size (OR:1.11, 95%CI:1.01-1.21, p = 0.027) and tumor site namely proximal lower limb vs upper limb (OR:10.87, 95%CI 1.15-103.03, p = 0.038) were risk factors on multivariate analysis. In nested case control analysis, the incidence of MaWC was 43.6% (24/55), the mean recovery time is 143 days in patients with MaWC. Smoking increases the risk for MaWC (OR:8.32, 95%CI:1.36-49.99, p = 0.022). The time interval between surgery and wound complication reduces the risk for MaWC (OR:0.91, 95%CI:0.84-0.99, p = 0.028) in multivariate analysis. CONCLUSIONS Age, tumor site and size are risk factors for WC requiring preoperative radiotherapy. Smoking and the time interval between surgery and wound complication are risk factors for MaWC as compared with MiWC. MaWC rate (19%) are comparable to those in postoperative radiotherapy and surgery alone.
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Affiliation(s)
- Zhengxiao Ouyang
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China; Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation Trust, Oxford, OX3 7LD, UK
| | - Sally Trent
- Department of Oncology, Churchill Hospital, Oxford University Hospitals Foundation Trust, Oxford, Ox3 7LE, UK
| | - Catherine McCarthy
- Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation Trust, Oxford, OX3 7LD, UK
| | - Thomas Cosker
- Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation Trust, Oxford, OX3 7LD, UK
| | - Robert Stuart
- Department of Oncology, Churchill Hospital, Oxford University Hospitals Foundation Trust, Oxford, Ox3 7LE, UK
| | - Sarah Pratap
- Department of Oncology, Churchill Hospital, Oxford University Hospitals Foundation Trust, Oxford, Ox3 7LE, UK
| | - Duncan Whitwell
- Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation Trust, Oxford, OX3 7LD, UK
| | - Harriet Branford White
- Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation Trust, Oxford, OX3 7LD, UK
| | - Huai Tao
- School of Medicine, Hunan University of Chinese Medicine, Changsha, 410208, Hunan, China
| | - Xiaoning Guo
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.
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15
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Foster D, Sebro R, Garner H, Stanborough R, Spaulding AC, Goulding K, Houdek M, Wilke B. Intravenous tranexamic acid is associated with an increased risk of pulmonary embolism following sarcoma resection. J Surg Oncol 2023; 128:869-876. [PMID: 37428014 DOI: 10.1002/jso.27391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/12/2023] [Accepted: 06/16/2023] [Indexed: 07/11/2023]
Abstract
INTRODUCTION Tranexamic acid (TXA) is an antifibrinolytic drug that has been shown to reduce blood loss following surgery. The use of TXA during orthopedic procedures has gained widespread acceptance, with multiple clinical studies demonstrating no increase in thrombotic complications. While TXA has been shown to be safe and effective for several orthopedic procedures, its use in orthopedic sarcoma surgery is not well established. Cancer-associated thrombosis remains a significant cause of morbidity and mortality in patients with sarcoma. It is unknown if intraoperative TXA use will increase the risk of developing a postoperative thrombotic complication in this population. This study aimed to compare the risk of postoperative thrombotic complications in patients who received TXA during sarcoma resection to patients who did not receive TXA. METHODS A retrospective review was performed of 1099 patients who underwent resection of a soft tissue or bone sarcoma at our institution between 2010 and 2021. Baseline demographics and postoperative outcomes were compared between patients who did and did not receive intraoperative TXA. We evaluated 90-day complication rates, including: deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), cerebrovascular accident (CVA), and mortality. RESULTS TXA was used more commonly for bone tumors (p < 0.001), tumors located in the pelvis (p = 0.004), and larger tumors (p < 0.001). Patients who received intraoperative TXA were associated with a significant increase in developing a postoperative DVT (odds ratio [OR]: 2.22, p = 0.036) and PE (OR: 4.62, p < 0.001), but had no increase in CVA, MI, or mortality (all p > 0.05) within 90 days of surgery, following univariate analysis. Multivariable analysis confirmed that TXA was independently associated with developing a postoperative PE (OR: 10.64, 95% confidence interval: 2.23-50.86, p = 0.003). We found no association with DVT, MI, CVA, or mortality within 90 days postoperatively, following intraoperative TXA use. CONCLUSION Our results demonstrate a higher associated risk of PE following TXA use in sarcoma surgery and caution is warranted with TXA use in this patient population.
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Affiliation(s)
- Devon Foster
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Ronnie Sebro
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida, USA
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Hillary Garner
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Aaron C Spaulding
- Department of Biostatistics, Mayo Clinic, Jacksonville, Florida, USA
| | - Krista Goulding
- Department of Orthopedic Surgery, Mayo Clinic Scottsdale, Scottsdale, Arizona, USA
| | - Matthew Houdek
- Department of Orthopedic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Benjamin Wilke
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida, USA
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16
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Lebas A, Le Fèvre C, Waissi W, Chambrelant I, Brinkert D, Noël G. Prognostic Factors in Extremity Soft Tissue Sarcomas Treated with Radiotherapy: Systematic Review of the Literature. Cancers (Basel) 2023; 15:4486. [PMID: 37760456 PMCID: PMC10526842 DOI: 10.3390/cancers15184486] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/03/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Soft tissue sarcomas of the extremities are rare tumors with various prognostic factors. Their management is debatable due to their inconsistent results within the literature and the lack of large prospective studies. The objective of this systematic review is to analyze the available scientific data on prognostic factors concerning the characteristics of the patients, the disease and the treatments performed, as well as their potential complications, on studies with a median follow-up of 5 years at minimum. A search of articles following the "PRISMA method" and using the PubMed search engine was conducted to select the most relevant studies. Twenty-five articles were selected, according to preestablished criteria. This review provides a better understanding of the prognosis and disease outcome of these tumors. Many factors were described comparing the frequency of occurrence according to the studies, which remain heterogeneous between them. Significant factors that could orient patients to radiotherapy were highlighted. These positive prognostic factors provide valuable insight to optimize radiotherapy treatments for patients treated for soft tissue sarcoma of the extremities.
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Affiliation(s)
- Arthur Lebas
- Radiotherapy Department, ICANS, 17 Rue Albert Calmette, 67100 Strasbourg, France; (A.L.); (C.L.F.); (I.C.)
| | - Clara Le Fèvre
- Radiotherapy Department, ICANS, 17 Rue Albert Calmette, 67100 Strasbourg, France; (A.L.); (C.L.F.); (I.C.)
| | - Waisse Waissi
- Radiotherapy Department, Léon Bérard Center, 28 Rue Laennec, 69008 Lyon, France;
| | - Isabelle Chambrelant
- Radiotherapy Department, ICANS, 17 Rue Albert Calmette, 67100 Strasbourg, France; (A.L.); (C.L.F.); (I.C.)
| | - David Brinkert
- Orthopedic Surgery Department, University Hospital of Hautepierre, 1 Rue Molière, 67200 Strasbourg, France;
| | - Georges Noël
- Radiotherapy Department, ICANS, 17 Rue Albert Calmette, 67100 Strasbourg, France; (A.L.); (C.L.F.); (I.C.)
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17
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Gerken ALH, Jawny P, Weigl H, Yang C, Hardt J, Menge F, Hohenberger P, Weiß C, Reißfelder C, Jakob J. Postoperative drainage management and wound complications following resection of lower limb soft tissue tumors: a retrospective cohort study. Langenbecks Arch Surg 2023; 408:202. [PMID: 37209306 PMCID: PMC10199851 DOI: 10.1007/s00423-023-02939-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/12/2023] [Indexed: 05/22/2023]
Abstract
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.
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Affiliation(s)
- A L H Gerken
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - P Jawny
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Department of Cardiothoracic Surgery, University Hospital Augsburg, Medical Faculty Augsburg, Augsburg University, Augsburg, Germany
| | - H Weigl
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - C Yang
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - J Hardt
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - F Menge
- Sarcoma Unit, Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - P Hohenberger
- Sarcoma Unit, Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - C Weiß
- Department of Biometry and Statistics, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - C Reißfelder
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- DKFZ-Hector Cancer Institute, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - J Jakob
- Sarcoma Unit, Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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18
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Barranquero AG, Corral Moreno S, Martínez Lorca A, Hernández-Cosido L, Rioja Martín ME, Mena Mateos A, Cabañas Montero J, Fernández-Cebrián JM. 125I Radioactive Seed Localization vs. Conventional Surgery for the Treatment of Mesenchymal Tumours: A Propensity Score Matching Analysis. Langenbecks Arch Surg 2023; 408:161. [PMID: 37185944 DOI: 10.1007/s00423-023-02907-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 04/21/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE Radioguided localization can assist the surgery of hard-to-find lesions. The aim was to evaluate the results of the 125I Radioactive Seed Localization (RSL) technique to guide a margin-free tumoral resection of mesenchymal tumours compared to conventional surgery and its influence in oncological outcomes. METHODS Retrospective observational study of all consecutive patients who underwent 125I RSL for the surgery of a mesenchymal tumour from January 2012 to January 2020 in a tertiary referral centre in Spain. The control group was formed by patients with conventional surgery in the same period and centre. A Propensity Score matching at 1:4 ratio selected the cases for analysis. RESULTS A total of 10 lesions excised in 8 radioguided surgeries were compared to 40 lesions excised in 40 conventional surgeries, with equal proportion of histological subtypes in each group. There was a higher proportion of recurrent tumours in the RSL group (80 % [8/10] vs. 27.5 % [11/40]; p: 0.004). An R0 was achieved in 80 % (8/10) of the RSL group and 65 % (26/40) of the conventional surgery group. The R1 rate was 0 % and 15 % (6/40), and the R2 rate was 20 % (2/10 and 8/40) in the RSL group and conventional surgery group, respectively (p: 0.569). No differences were detected in disease-free or overall survival between the different histological subtypes in the subgroup analysis. CONCLUSION The 125I RSL technique of a challenging sample of mesenchymal tumours achieved a similar margin-free tumoral resection and oncological outcomes as conventional surgery.
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Affiliation(s)
- Alberto G Barranquero
- General and Digestive Surgery Department, Hospital Universitari Arnau de Vilanova, Av. Alcalde Rovira Roure, 80, 25198, Lleida, Catalunya, Spain.
| | - Sara Corral Moreno
- General and Digestive Surgery Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Lourdes Hernández-Cosido
- Department of General and Digestive Surgery, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | - Antonio Mena Mateos
- General and Digestive Surgery Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Jacobo Cabañas Montero
- General and Digestive Surgery Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
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19
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Novak R, Nevin JL, Rowell PD, Griffin A, Mazin S, Hofer SOP, O'Neill AC, Tsoi K, Ferguson PC, Wunder JS. A Size-Based Criteria for Flap Reconstruction After Thigh-Adductor, Soft-Tissue Sarcoma Resection. Ann Surg Oncol 2023; 30:3701-3711. [PMID: 36840861 DOI: 10.1245/s10434-023-13261-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/01/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Resection of soft-tissue sarcomas from the adductor compartment is associated with significant complications. Free/pedicled flaps often are used for wound closure, but their effect on healing is unclear. We compared wound complications, oncologic, and functional outcomes for patients undergoing flap reconstruction or primary closure following resection of adductor sarcomas. METHODS A total of 177 patients underwent resection of an adductor sarcoma with primary closure (PrC) or free/pedicled flap reconstruction (FR). Patient, tumor, and treatment characteristics were compared, as well as wound complications, oncologic, and functional outcomes (TESS/MSTS87/MSTS93). To examine the relative benefit of flap reconstruction, number needed to treat (NNT) was calculated. RESULTS In total, 143 patients underwent PrC and 34 had FR, 68% of which were pedicled. There were few differences in demographic, tumor, or treatment characteristics. No significant difference was found in the rate of wound complications. Length of stay was significantly longer in FR (18 days vs. PrC 8 days; p < 0.01). Oncologic and functional outcomes were similar over 5 years follow-up. Uncomplicated wound healing occurred more often in FR compared with PrC for tumors with ≥15 cm (NNT = 8.4) or volumes ≥ 800 ml (NNT = 8.4). Tumors ≤ 336 ml do not benefit from a flap, whereas those > 600 ml are 1.5 times more likely to heal uneventfully after flap closure. CONCLUSIONS Although flap use prolonged hospitalization, it decreased wound healing complications for larger tumors, and in all sized tumors, it demonstrated similar functional and oncologic outcomes to primary closure. Our size-based treatment criteria can help to identify patients with large adductor sarcomas who could benefit from flap reconstruction. LEVEL OF EVIDENCE III (Retrospective cohort study).
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Affiliation(s)
- Rostislav Novak
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada.
| | - Jennifer L Nevin
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Philip D Rowell
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Anthony Griffin
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Sergey Mazin
- Department of Software Engineering, ORT Braude Academic College, Karmiel, Israel
| | - Stefan O P Hofer
- Division of Plastic and Reconstructive Surgery, University Health Network, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada
| | - Anne C O'Neill
- Division of Plastic and Reconstructive Surgery, University Health Network, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada
| | - Kim Tsoi
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Peter C Ferguson
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Jay S Wunder
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
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20
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Ballatori AM, Shahrestani S, Ton A, Chen XT, Yamout T, Gettleman BS, Heckmann ND, Menendez LR, Christ AB. Postoperative Complication and Reoperation Rates Following Resection of Soft Tissue vs. Bone Malignancies Based on Anatomic Location in the Inpatient Setting. Sarcoma 2023; 2023:5455719. [PMID: 36937506 PMCID: PMC10023224 DOI: 10.1155/2023/5455719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/20/2023] [Accepted: 02/25/2023] [Indexed: 03/17/2023] Open
Abstract
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.
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Affiliation(s)
- Alexander M. Ballatori
- 1Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Shane Shahrestani
- 1Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Andy Ton
- 1Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Xiao T. Chen
- 1Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Tarek Yamout
- 2Virginia Spine Institute, Reston, Virginia, USA
| | | | - Nathanael D. Heckmann
- 1Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Lawrence R. Menendez
- 1Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Alexander B. Christ
- 1Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
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21
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Potkrajcic V, Kolbenschlag J, Sachsenmaier S, Daigeler A, Ladurner R, Golf A, Gani C, Zips D, Paulsen F, Eckert F. Postoperative complications and oncologic outcomes after multimodal therapy of localized high risk soft tissue sarcoma. Radiat Oncol 2022; 17:210. [PMID: 36544149 PMCID: PMC9768905 DOI: 10.1186/s13014-022-02166-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Standard therapy for localized high-risk soft tissue sarcoma includes surgical resection and neoadjuvant or adjuvant radiation therapy (± chemotherapy and locoregional hyperthermia). No difference in oncologic outcomes for patients treated with neoadjuvant and adjuvant radiation therapy was reported, whereas side effect profiles differ. The aim of this analysis was to analyse oncologic outcomes and postoperative complications in patients treated with multimodal treatment. METHODS Oncologic outcomes and major wound complications (MWC, subclassified as wound healing disorder, infection, abscess, fistula, seroma and hematoma) were evaluated in 74 patients with localized high-risk soft tissue sarcoma of extremities and trunk undergoing multimodal treatment, and also separately for the subgroup of lower extremity tumors. Clinical factors and treatment modalities (especially neoadjuvant vs. adjuvant radiotherapy) were evaluated regarding their prognostic value and impact on postoperative wound complications. RESULTS Oncologic outcomes were dependent on number of high risk features (tumor size, depth to superficial fascia and grading), but not on therapy sequencing (however with higher risk patients in the neoadjuvant group). Different risk factors influenced different subclasses of wound healing complications. Slightly higher MWC-rates were observed in patients treated with neoadjuvant therapy, compared to adjuvant radiotherapy, although only with a trend to statistical significance (31.8% vs. 13.3%, p = 0.059). However, except for wound infections, no significant difference for other subclasses of postoperative complications was observed between neoadjuvant and adjuvant therapy. Diabetes was confirmed as a major risk factor for immune-related wound complications. CONCLUSION Rates of major wound complications in this cohort are comparable to published data, higher rates of wound infections were observed after neoadjuvant radiotherapy. Tumor localization, patient age and diabetes seem to be major risk factors. The number of risk factors for high risk soft tissue sarcoma seem to influence DMFS. Neoadjuvant treatment increases the risk only for wound infection treated with oral or intravenous antibiotic therapy and appears to be a safe option at an experienced tertiary center in absence of other risk factors.
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Affiliation(s)
- Vlatko Potkrajcic
- grid.10392.390000 0001 2190 1447Department of Radiation Oncology, Eberhard-Karls-University Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - Jonas Kolbenschlag
- grid.10392.390000 0001 2190 1447Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik, Eberhard-Karls-University Tuebingen, Schnarrenbergstraße 95, 72076 Tübingen, Germany
| | - Saskia Sachsenmaier
- grid.10392.390000 0001 2190 1447Department of Orthopaedic Surgery, Eberhard-Karls-University Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - Adrien Daigeler
- grid.10392.390000 0001 2190 1447Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik, Eberhard-Karls-University Tuebingen, Schnarrenbergstraße 95, 72076 Tübingen, Germany
| | - Ruth Ladurner
- grid.10392.390000 0001 2190 1447Department of General, Visceral and Transplant Surgery, Eberhard-Karls-University Tuebingen, Hoppe Seyler-Str. 3, 72076 Tübingen, Germany
| | - Alexander Golf
- grid.10392.390000 0001 2190 1447Department of Internal Medicine, Medical Oncology and Pulmonology, Eberhard-Karls-University Tuebingen, Otfried-Müller-Straße 14, 72076 Tuebingen, Germany
| | - Cihan Gani
- grid.10392.390000 0001 2190 1447Department of Radiation Oncology, Eberhard-Karls-University Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - Daniel Zips
- grid.10392.390000 0001 2190 1447Department of Radiation Oncology, Eberhard-Karls-University Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany ,grid.7497.d0000 0004 0492 0584German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK) Partnersite Tuebingen, Heidelberg, Germany ,grid.6363.00000 0001 2218 4662Department of Radiation Oncology and Radiotherapy, Charité University Hospital, Charitépl. 1, 10117 Berlin, Germany
| | - Frank Paulsen
- grid.10392.390000 0001 2190 1447Department of Radiation Oncology, Eberhard-Karls-University Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - Franziska Eckert
- grid.10392.390000 0001 2190 1447Department of Radiation Oncology, Eberhard-Karls-University Tuebingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany ,grid.22937.3d0000 0000 9259 8492Department of Radiation Oncology, Comprehensive Cancer Center, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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22
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Ramsey DC, Walker JR, Wetzel R, Gundle KR, Hayden JB, Doung YC. Is the Addition of Anaerobic Coverage to Perioperative Antibiotic Prophylaxis During Soft Tissue Sarcoma Resection Associated With a Reduction in the Proportion of Wound Complications? Clin Orthop Relat Res 2022; 480:2409-2417. [PMID: 35901448 PMCID: PMC10538887 DOI: 10.1097/corr.0000000000002308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 06/13/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Wound complications are common after resection of soft tissue sarcomas, with published infection rates ranging from 10% to 35%. Multiple studies have reported on the atypical flora comprising these infections, which are often polymicrobial and contain anaerobic bacteria, and recent studies have noted the high prevalence of anaerobic bacterial infections after soft tissue sarcoma resection [ 26, 35 ]. Based on this, our institution changed clinical practice to include an antibiotic with anaerobic coverage in addition to the standard first-generation cephalosporin for prophylaxis during soft tissue sarcoma resections. The current study was undertaken to evaluate whether this change was associated with a change in major wound complications, and if the change should therefore be adopted for future patients. QUESTIONS/PURPOSES (1) After controlling for potentially confounding variables, was the broadening of the prophylactic antibiotic spectrum to cover anaerobic bacteria associated with a lower odds of major wound complications after soft tissue sarcoma resection? (2) Was the broadening of the prophylactic antibiotic spectrum to cover anaerobic bacteria associated with a lower odds of surgical site infections with polymicrobial or anaerobic infections after soft tissue sarcoma resection? (3) What are the factors associated with major wound complications after soft tissue sarcoma resection? METHODS We retrospectively identified 623 patients who underwent soft tissue sarcoma resection at a single center between January 2008 and January 2021 using procedural terminology codes. Of these, four (0.6%) pediatric patients were excluded, as were five (0.8%) patients with atypical lipomatous tumors and two (0.3%) patients with primary bone tumors; 5% (33 of 623) who were lost to follow-up, leaving 579 for final analysis. The prophylactic antibiotic regimen given at the resection and whether a wound complication occurred were recorded. Patients received the augmented regimen based on whether they underwent resection after the change in practice in July 2018. A total of 497 patients received a standard antibiotic regimen (usually a first-generation cephalosporin), and 82 patients received an augmented regimen with anaerobic coverage (most often metronidazole). Of the 579 patients, 53% (307) were male (53% [264 of 497] in the standard regimen and 52% [43 of 82] in the augmented regimen), and the mean age was 59 ± 17 years (59 ± 17 and 60 ±17 years in the standard and augmented groups, respectively). Wound complications were defined as any of the following within 120 days of the initial resection: formal wound debridement in the operating room, other interventions such as percutaneous drain placement, readmission for intravenous antibiotics, or deep wound packing for more than 120 days from the resection. Patients were considered to have a surgical site infection if positive cultures resulted from deep tissue cultures taken intraoperatively at the time of debridement. The proportion of patients with major wound complications was 26% (150 of 579); it was 27% (136 of 497) and 17% (14 of 82) in the standard and augmented antibiotic cohorts, respectively (p = 0.049). With the numbers we had, we could not document that the addition of antibiotics with anaerobic coverage was associated with lower odds of anaerobic (4% versus 6%; p = 0.51) or polymicrobial infections (9% versus 14%; p = 0.25). Patient, tumor, and treatment (surgical, radiotherapy, and chemotherapy) variables were collected to evaluate factors associated with overall infection and anaerobic or polymicrobial infection. Patient follow-up was 120 days to capture early wound complications. A multivariable analysis was performed for all variables found to be significant in the univariate analysis. A p value < 0.05 was used as the threshold for statistical significance for all analyses. No patients were found to have an adverse reaction to the augmented regimen, including allergic reactions or Clostridioides (formerly Clostridium) difficile infection. RESULTS After controlling for other potentially confounding factors such as neoadjuvant radiation, tumor size and anatomic location, as well as patient BMI, anaerobic coverage was associated with smaller odds of wound complications (OR 0.36 [95% confidence interval (CI) 0.18 to 0.68]; p = 0.003). Other factors associated with major wound complications were preoperative radiation (versus no preoperative radiation) (OR 2.66 [95% CI 1.72 to 4.15]; p < 0.001), increasing tumor size (OR 1.04 [95% CI 1.00 to 1.07]; p = 0.03), patient BMI (OR 1.07 [95% CI 1.04 to 1.11]; p < 0.001), and tumor in the distal upper extremity (versus proximal upper extremity, pelvis/groin/hip, and lower extremity) (OR 0.18 [95% CI 0.04 to 0.62]; p = 0.01). CONCLUSION The addition of anaerobic coverage to the standard prophylactic regimen during soft tissue sarcoma resection demonstrated an association with smaller odds of major wound complications and no documented adverse reactions. Treating physicians should consider these findings but note that they are preliminary, and that further work is needed to replicate them in a more controlled study design such as a prospective trial. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Duncan C. Ramsey
- Department of Orthopaedic Surgery, University of Texas Rio Grande Valley School of Medicine, Harlingen, TX, USA
| | - Jorge R. Walker
- School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Rebecca Wetzel
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Kenneth R. Gundle
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
- Operative Care Division, Portland Veteran’s Administration Medical Center, Portland, OR, USA
| | - James B. Hayden
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Yee-Cheen Doung
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
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23
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Isler M. CORR Insights®: Is the Addition of Anaerobic Coverage to Perioperative Antibiotic Prophylaxis During Soft Tissue Sarcoma Resection Associated With a Reduction in the Proportion of Wound Complications? Clin Orthop Relat Res 2022; 480:2418-2419. [PMID: 36599022 PMCID: PMC10538930 DOI: 10.1097/corr.0000000000002406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 08/23/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Marc Isler
- Clinical Professor, Department of Orthopaedic Surgery, University of Montreal, Montreal, Quebec, Canada
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24
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Discuss the natural history and pathophysiology of sarcoma. 2. Summarize the most up-to-date multidisciplinary management of soft-tissue sarcoma. 3. Provide a synopsis of reconstructive modalities based on anatomical location. 4. Highlight some novel strategies for treatment of lymphedema and phantom limb pain that are common sequelae following treatment and resection of soft-tissue sarcomas. SUMMARY The management of soft-tissue sarcoma presents unique challenges to the reconstructive surgeon. The optimal management mandates a multidisciplinary approach; however, reconstruction must take into account the extent of the resection and exposed vital structures, but often occurs in the setting of adjuvant treatments including chemotherapy and radiation therapy. Reconstruction is based on the extent of the defect and the location of the primary tumor. As such, an evidence-based, algorithmic approach following the reconstructive ladder is warranted to minimize the risks of complications and maximize success, which varies from head and neck to torso to breast to extremity sarcomas. Aside from reconstruction of the defect, advances in the surgical treatment of lymphedema and neuropathic pain resulting from treatment and extirpation of soft-tissue sarcoma are critical to maintain function and patients' quality of life.
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Affiliation(s)
- David M Aten
- From the Departments of Medical Graphics and Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Edward I Chang
- From the Departments of Medical Graphics and Plastic Surgery, University of Texas M. D. Anderson Cancer Center
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25
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Lazarides AL, Saltzman EB, Visgauss JD, Mithani SK, Eward WC, Brigman BE. Intraoperative angiography imaging correlates with wound complications following soft tissue sarcoma resection. J Orthop Res 2022; 40:2382-2390. [PMID: 35005805 DOI: 10.1002/jor.25270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 02/04/2023]
Abstract
For soft tissue sarcoma patients receiving preoperative radiation therapy, wound complications are common and potentially devastating. The purpose of this study was to assess the feasibility of intraoperative indocyanine green fluorescent angiography (ICGA) as a predictor of wound complications in these patients. A consecutive series of patients with soft tissue sarcoma of the extremities or pelvis who received neoadjuvant radiation and a subsequent radical resection received intraoperative ICGA with the SPY PHI device (Stryker Inc.) at the time of closure. Retrospective analysis of fluorescence signal along multiple points of the wound length was performed and quantified. The primary endpoint was wound complication, defined as delayed wound healing or wound dehiscence, within 3 months of surgery. Fourteen patients with preoperative irradiated soft tissue sarcoma were consecutively imaged. There were six patients with wound complications classified as "aseptic" in five cases. Using the ICGA, blinded surgeons correctly predicted wound complications in 75% of cases. During the inflow phase, a mean ratio of normal of 0.62 maximized the area under the curve (AUC = 0.90) for predicting wound complications with a sensitivity of 100% and specificity of 77.4%. During the peak phase, a mean ratio of normal of 0.55 maximized the AUC (0.95) for predicting wound complications with a sensitivity of 88.9% and a specificity of 100%. Intraoperative use of ICGA may help to predict wound complications in patients undergoing resection of preoperatively irradiated soft tissue sarcomas of the extremities and pelvis.
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Affiliation(s)
- Alexander L Lazarides
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Eliana B Saltzman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Julia D Visgauss
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Suhail K Mithani
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - William C Eward
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Brian E Brigman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
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26
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Roohani S, Ehret F, Kobus M, Flörcken A, Märdian S, Striefler JK, Rau D, Öllinger R, Jarosch A, Budach V, Kaul D. Preoperative hypofractionated radiotherapy for soft tissue sarcomas: a systematic review. Radiat Oncol 2022; 17:159. [PMID: 36104789 PMCID: PMC9472188 DOI: 10.1186/s13014-022-02072-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/24/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Soft tissue sarcomas (STS) represent a diverse group of rare malignant tumors. Currently, five to six weeks of preoperative radiotherapy (RT) combined with surgery constitute the mainstay of therapy for localized high-grade sarcomas (G2-G3). Growing evidence suggests that shortening preoperative RT courses by hypofractionation neither increases toxicity rates nor impairs oncological outcomes. Instead, shortening RT courses may improve therapy adherence, raise cost-effectiveness, and provide more treatment opportunities for a wider range of patients. Presumed higher rates of adverse effects and worse outcomes are concerns about hypofractionated RT (HFRT) for STS. This systematic review summarizes the current evidence on preoperative HFRT for the treatment of STS and discusses toxicity and oncological outcomes compared to normofractionated RT. METHODS We conducted a systematic review of clinical trials describing outcomes for preoperative HFRT in the management of STS using PubMed, the Cochrane library, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Embase, and Ovid Medline. We followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Trials on retroperitoneal sarcomas, postoperative RT, and hyperthermia were excluded. Articles published until November 30th, 2021, were included. RESULTS Initial search yielded 94 articles. After removal of duplicate and ineligible articles, 13 articles qualified for analysis. Eight phase II trials and five retrospective analyses were reviewed. Most trials applied 5 × 5 Gy preoperatively in patients with high-grade STS. HFRT courses did not show increased rates of adverse events compared to historical trials of normofractionated RT. Toxicity rates were mostly comparable or lower than in trials of normofractionated RT. Moreover, HFRT achieved comparable local control rates with shorter duration of therapy. Currently, more than 15 prospective studies on HFRT + / - chemotherapy are ongoing. CONCLUSIONS Retrospective data and phase II trials suggest preoperative HFRT to be a reasonable treatment modality for STS. Oncological outcomes and toxicity profiles were favorable. To date, our knowledge is mostly derived from phase II data. No randomized phase III trial comparing normofractionated and HFRT in STS has been published yet. Multiple ongoing phase II trials applying HFRT to investigate acute and late toxicity will hopefully bring forth valuable findings.
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Affiliation(s)
- Siyer Roohani
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Felix Ehret
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Marta Kobus
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Anne Flörcken
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany
| | - Sven Märdian
- Centre for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jana Käthe Striefler
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Daniel Rau
- Centre for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Armin Jarosch
- Institute of Pathology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Volker Budach
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - David Kaul
- Department of Radiation Oncology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Berlin, Germany; German Cancer Consortium (DKTK), partner site Berlin, and German Cancer Research Center (DKFZ), 69120, Heidelberg, Germany
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27
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Thomas B, Bigdeli AK, Nolte S, Gazyakan E, Harhaus L, Bischel O, Lehner B, Egerer G, Mechtersheimer G, Hohenberger P, Horch RE, Andreou D, Schmitt J, Schuler MK, Eichler M, Kneser U. The Therapeutic Role of Plastic and Reconstructive Surgery in the Interdisciplinary Treatment of Soft-Tissue Sarcomas in Germany-Cross-Sectional Results of a Prospective Nationwide Observational Study (PROSa). Cancers (Basel) 2022; 14:cancers14174312. [PMID: 36077847 PMCID: PMC9454490 DOI: 10.3390/cancers14174312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary The mainstay of soft-tissue-sarcoma treatment remains ablative surgery with complete tumor resection. In this context, reconstructive plastic surgery has become an important aspect of multidisciplinary sarcoma therapy aiming at limb preservation as an alternative to amputations. In this present study, cross-sectional data collected prospectively at 39 study centers across Germany were analyzed, focusing on both the inhouse availability of plastic surgery and external accessibility to plastic surgery in 621 cases. In summary, unplanned and incomplete primary tumor resections carried out at centers with lower degrees of specialization were associated with a significantly increased need for subsequent flap-based defect coverage. In line with this, a readily available team of plastic surgeons was independently associated with successful defect reconstruction, which in turn was associated with significantly higher chances of limb preservation. We conclude that easily accessible plastic surgery and a high degree of expertise in the field of sarcoma treatment are indispensable for limb preservation following sarcoma resection. Plastic and reconstructive surgery therefore plays a vital role in achieving the best possible outcomes in the interdisciplinary treatment of soft-tissue sarcomas. Abstract Although the involvement of plastic surgery has been deemed important in the treatment of sarcoma patients to avoid oncological compromises and ameliorate patient outcomes, it is not ubiquitously available. The accessibility of defect reconstruction and its therapeutic impact on sarcoma care is the subject of this analysis. Cross-sectional data from 1309 sarcoma patients were collected electronically at 39 German study centers from 2017 to 2019. A total of 621 patients with surgical treatment for non-visceral soft-tissue sarcomas were included. The associated factors were analyzed exploratively using multifactorial logistic regression to identify independent predictors of successful defect reconstruction, as well Chi-squared and Cochran–Mantel–Haenszel tests to evaluate subgroups, including limb-salvage rates in extremity cases. A total of 76 patients received reconstructive surgery, including 52 local/pedicled versus 24 free flaps. Sarcomas with positive margins upon first resection (OR = 2.3, 95%CI = 1.2–4.4) that were excised at centers with lower degrees of specialization (OR = 2.2, 95%CI = 1.2–4.2) were independently associated with the need for post-oncological defect coverage. In this context, the inhouse availability of plastic surgery (OR = 3.0, 95%CI = 1.6–5.5) was the strongest independent predictor for successful flap-based reconstruction, which in turn was associated with significantly higher limb-salvage rates (OR = 1.4, 95%CI = 1.0–2.1) in cases of extremity sarcomas (n = 366, 59%). In conclusion, consistent referral to specialized interdisciplinary sarcoma centers significantly ameliorates patient outcomes by achieving higher rates of complete resections and offering unrestricted access to plastic surgery. The latter in particular proved indispensable for limb salvage through flap-based defect reconstruction after sarcoma resection. In fact, although there remains a scarcity of readily available reconstructive surgery services within the current sarcoma treatment system in Germany, plastic and reconstructive flap transfer was associated with significantly increased limb-salvage rates in our cohort.
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Affiliation(s)
- Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Correspondence: (B.T.); (U.K.); Tel.: +49-(621)-6810-2944 (B.T.); +49-(621)-6810-2328 (U.K.)
| | - Amir K. Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Steffen Nolte
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Department of Otorhinolaryngology, Head and Neck Surgery, Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Leila Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Oliver Bischel
- Department of Trauma and Orthopedics, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen, Germany
| | - Burkhard Lehner
- Department of Orthopaedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, 69118 Heidelberg, Germany
| | - Gerlinde Egerer
- Department of Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | | | - Peter Hohenberger
- Division of Surgical Oncology, Department of Surgery, Mannheim University Medical Center, University of Heidelberg, 68167 Mannheim, Germany
| | - Raymund E. Horch
- Department of Plastic and Hand Surgery, Comprehensive Cancer Center, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Dimosthenis Andreou
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Münster, 48149 Münster, Germany
- Department of Orthopedics and Trauma, Medical University of Graz, 8036 Graz, Austria
| | - Jochen Schmitt
- National Center for Tumor Diseases (NCT/UCC), 01307 Dresden, Germany
- Center for Evidence-based Healthcare, University Hospital Carl Gustav Carus, Technical University Dresden, 01307 Dresden, Germany
| | - Markus K. Schuler
- Clinic and Polyclinic for Internal Medicine I, University Hospital Carl Gustav Carus, Technical University of Dresden, 01307 Dresden, Germany
| | - Martin Eichler
- National Center for Tumor Diseases (NCT/UCC), 01307 Dresden, Germany
- Clinic and Polyclinic for Internal Medicine I, University Hospital Carl Gustav Carus, Technical University of Dresden, 01307 Dresden, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Correspondence: (B.T.); (U.K.); Tel.: +49-(621)-6810-2944 (B.T.); +49-(621)-6810-2328 (U.K.)
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Nomogram Predicting the Risk of Postoperative Major Wound Complication in Soft Tissue Sarcoma of the Trunk and Extremities after Preoperative Radiotherapy. Cancers (Basel) 2022; 14:cancers14174096. [PMID: 36077636 PMCID: PMC9454623 DOI: 10.3390/cancers14174096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/21/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Preoperative radiotherapy increases the risk of postoperative wound complication in the treatment of soft tissue sarcoma (STS). This study aims to develop a nomogram for predicting major wound complication (MaWC) after surgery. Using the Oxford University Hospital (OUH) database, a total of 126 STS patients treated with preoperative radiotherapy and surgical resection between 2007 and 2021 were retrospectively reviewed. MaWC was defined as a wound complication that required secondary surgical intervention. Univariate and multivariate regression analyses on the association between MaWC and risk factors were performed. A nomogram was formulated and the areas under the Receiver Operating Characteristic Curves (AUC) were adopted to measure the predictive value of MaWC. A decision curve analysis (DCA) determined the model with the best discriminative ability. The incidence of MaWC was 19%. Age, tumour size, diabetes mellitus and metastasis at presentation were associated with MaWC in the univariate analysis. Age, tumour size, and metastasis at presentation were independent risk factors in the multivariate analysis. The sensitivity and specificity of the predictive model is 0.90 and 0.76, respectively. The AUC value was 0.86. The nomogram constructed in the study effectively predicts the risk of MaWC after preoperative radiotherapy and surgery for STS patients.
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Hudson T, Burke C, Mullner D, Herrera FA. Risk factors associated with 30-day complications following lower extremity sarcoma surgery: A national surgical quality improvement project analysis. J Surg Oncol 2022; 126:1253-1262. [PMID: 35856569 DOI: 10.1002/jso.27018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 07/04/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Our study aims to identify risk factors associated with complications in lower extremity (LE) sarcoma surgery, as well as the prevalence and complications associated with concurrent plastic surgery procedures (CPSP). METHODS ACS-NSQIP database was accessed to identify patients treated for LE sarcoma (2010-2019). Patient demographics, preoperative lab, comorbidities, tumor type, location, principle procedure, and presence/characteristics of CPSPs were recorded. Thirty-day soft tissue complications were analyzed. Bivariate and multivariate logistic regression was performed on IBM SPSS.™ RESULTS: Nine hundred eighteen patients were included (483 males and 435 females), average age and body mass index (BMI) of 57 and 27.4 kg/m,2 respectively. Comorbidities included smoking (13.9%, 128), hypertension (37.3%, 342), and insulin-dependent diabetes (3.7%, 34). Preoperative lab values included albumin <3.5 (6.8%, 63), hematocrit <30% (8.2%, 75), and platelet count <150 000 (5.9%, 54). Thirty-day soft tissue complication rate was 5.7% (52 of 918). On multivariate logistic regression, increased age (p = 0.039), higher BMI (p = 0.017), and longer operative times (p = 0.002) were significant risk factors independently associated with soft tissue complications. CONCLUSIONS Soft tissue complications within 30 days occur in 6% of patients. Graft procedures carry a 20% risk of complications. Risk factors independently associated with complications include increased age, increased BMI, and longer operative times.
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Affiliation(s)
- Todd Hudson
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Connor Burke
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Donna Mullner
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Fernando A Herrera
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Final safety and HRQoL results of the phase II/III Act.In.Sarc study with preoperative NBTXR3 plus radiotherapy versus radiotherapy in locally advanced soft-tissue sarcoma. Int J Radiat Oncol Biol Phys 2022; 114:422-432. [PMID: 35850363 DOI: 10.1016/j.ijrobp.2022.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/28/2022] [Accepted: 07/02/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE XXXX(Anonymized) demonstrated that the first-in-class radioenhancer NBTXR3, activated by preoperative radiotherapy, doubled the rate of pathological complete response after resection compared with preoperative radiotherapy alone in adult patients with locally advanced soft tissue sarcoma of the extremity or trunk wall (16.1% versus 7.9%, P=0.045), and more patients achieved R0 resections (77.0% versus 64.0%, P=0.042). These are the toxicity and health-related quality of life (HRQoL) results. METHODS AND MATERIALS XXXX(Anonymized) randomized eligible patients 1:1 to either NBTXR3 (single intratumoral injection, volume equivalent to 10% of baseline tumor volume, at 53.3 g/L) activated by external-beam radiotherapy (EBRT) (Arm A) or EBRT alone (Arm B) (50 Gy in 25 fractions), followed by surgery in both arms. Here, we report the safety analyses in the all-treated population with a long-term follow-up of at least two-years, and HRQoL in the intention-to-treat full analysis set. RESULTS During the on-treatment period serious adverse events (SAEs) of all grades related to NBTXR3 occurred in 10.1% (9/89) of patients (Arm A), SAEs related to radiotherapy occurred in 5.6% (5/89) (Arm A) versus 5.6% (5/90) (Arm B); and post-surgery hospitalization due to SAEs occurred in 15.7% (14/89) (Arm A) versus 24.4% (22/90) (Arm B). During the follow-up period, post-treatment SAEs (regardless of relationship) occurred in 13.5% (12/89) (Arm A) versus 24.4% (22/90) (Arm B). NBTXR3 did not negatively impact on HRQoL, during the follow-up period, there was an improvement in most mean Toronto Extremity Salvage Score, EuroQol-5 Dimension (EQ-5D), EQ5D02-EQ Visual Analog Scale, Reintegration to Normal Living Index, and Musculoskeletal Tumor Rating Scale scores. CONCLUSIONS NBTXR3 did not negatively impact safety or HRQoL. Long-term safety results reinforce the favorable benefit-risk ratio of NBTXR3 plus radiotherapy.
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Closed-Incision Negative-Pressure Wound Therapy after Resection of Soft-Tissue Tumors Reduces Wound Complications: Results of a Randomized Trial. Plast Reconstr Surg 2022; 149:972e-980e. [PMID: 35311753 DOI: 10.1097/prs.0000000000009023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Wound healing after resection of large soft-tissue tumors is often impaired by large dead space and fluid collection. Recently, the authors were able to show an association of wound complications with worse oncologic outcome in soft-tissue sarcomas. The aim of the study was to examine the value of closed-incision negative pressure wound therapy on postoperative wound drainage and wound complications after soft-tissue tumor resection. METHODS Patients for whom resection is planned of a soft-tissue tumor larger than 10 cm in diameter of the extremities or the trunk were allocated randomly to one of two groups. After wound closure, patients in the study group received closed-incision negative-pressure wound therapy for a duration of 5 days, whereas those in the control group received regular dressings. The amount of drainage fluid, course of wound healing, length of hospital stay, and wound edge perfusion at postoperative day 5 measured by white-light infrared spectroscopy were compared. RESULTS Sixty patients could be included in the study with even distribution to both study arms, meeting the goal. The postoperative course of wound drainage volume was significantly lower in the study group, and hospital stay was significantly shorter, with 9.1 ± 3.8 days versus 13.9 ± 11.8 days. The occurrence of wound complications was significantly lower in the study group on time-to-event analysis (one versus six). Tissue spectroscopy revealed a significantly higher oxygen saturation increase in the wound edge for the study group versus the control group. CONCLUSION Closed-incision negative-pressure wound therapy should be considered for patients undergoing resection of large soft-tissue tumors. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Bedi M, Singh R, Charlson JA, Kelly T, Johnstone C, Wooldridge A, Hackbarth DA, Moore N, Neilson JC, King DM. Could Five Be the New Twenty-Five? Long-term Oncologic Outcomes from a Phase II, Prospective, 5-Fraction Pre-operative Radiation Therapy Trial in Patients with Localized Soft Tissue Sarcoma. Adv Radiat Oncol 2022; 7:100850. [PMID: 35647402 PMCID: PMC9133395 DOI: 10.1016/j.adro.2021.100850] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/05/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Management of adult soft tissue sarcomas entails a multidisciplinary approach with surgery and radiation therapy with or without chemotherapy. The use of preoperative irradiation has been well established, and although conventional fractionation involves daily treatments over the course of 5 weeks, higher doses per fraction may be beneficial due to the radiobiologic profile of sarcoma. In this study we report long-term oncologic outcomes from a single-institution, phase II study evaluating a 5-fraction hypofractionated course of preoperative radiation. Methods and materials Preoperative hypofractionated radiation therapy was administered to 35 Gy in 5 fractions every other day followed by resection 4 to 6 weeks later. If given, chemotherapy consisted of a doxorubicin-ifosfamide-based regimen delivered neoadjuvantly. The primary endpoint was local control. Additional survival and pathologic outcomes, including overall and distant metastasis-free survival, tumor, and treatment-related pathology, as well as acute and late toxicity were examined. Results Thirty-two patients were enrolled in this prospective, single-arm phase II trial. At a median follow-up of 36.4 months (range, 3-56), no patient developed a local recurrence, and the 3-year overall and distant metastasis-free survival was 82.2% and 69%, respectively. Major acute postoperative wound complications occurred in 25% of patients. Grade 2 and 3 fibrosis occurred in 21.7% and 13% of patients, respectively. The 2-year median and mean Musculoskeletal Tumor Society score for all patients was 28 and 27.4, respectively. Conclusions A condensed course of preoperative hypofractionated radiation therapy leads to excellent rates of local control and survival with acceptable toxicity profiles. Potential studies ideally with phase II or III randomized trials would help corroborate these findings and other preoperative hypofractionated results in soft tissue sarcomas.
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Bones and Soft-Tissue Tumors. Radiol Clin North Am 2022; 60:327-338. [DOI: 10.1016/j.rcl.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Hypofractionated preoperative radiotherapy for high risk soft tissue sarcomas in a geriatric patient population. Radiol Oncol 2021; 55:459-466. [PMID: 34821137 PMCID: PMC8647799 DOI: 10.2478/raon-2021-0038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/17/2021] [Indexed: 12/02/2022] Open
Abstract
Background Standard therapy for localised, resectable high risk soft tissue sarcomas consists of wide excision and radiotherapy over several weeks. This treatment schedule is hardly feasible in geriatric and frail patients. In order not to withhold radiotherapy from these patients, hypofractionated radiotherapy with 25 Gy in 5 fractions was evaluated in a geriatric patient population. Patients and methods A retrospective analysis was performed of 18 geriatric patients with resectable high risk soft tissue sarcomas of extremities and thoracic wall. Wound healing and short term oncologic outcome were analysed. In addition, dose constraints for radiotherapy of the extremities were transferred from normofractionated to hypofractionated radiotherapy regimens. Results Feasibility was good with 17/18 patients completing treatment as planned. Wound healing complication rate was in the range of published data. Two patients developed local and distant recurrence, two patients isolated distant recurrences. No isolated local recurrences were observed. Keeping the constraints was possible in all cases without compromising the coverage of the target volume. Conclusions Hypofractionated radiotherapy and surgery was well tolerated even in this specific patient population. With feasibility concerning early wound healing problems and adapted constraints, which allow for the treatment of most resectable extremity tumours, the concept warrants further evaluation in patients unfit for standard radiotherapy.
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Fourman MS, Ramsey DC, Newman ET, Schwab JH, Chen YL, Hung YP, Chebib I, Deshpande V, Nielsen GP, DeLaney TF, Mullen JT, Raskin KA, Lozano Calderón SA. Assessing the Safety and Utility of Wound VAC Temporization of the Sarcoma or Benign Aggressive Tumor Bed Until Final Margins Are Achieved. Ann Surg Oncol 2021; 29:2290-2298. [PMID: 34751874 DOI: 10.1245/s10434-021-11023-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 10/13/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Local recurrence of microinvasive sarcoma or benign aggressive pathologies can be limb- and life-threatening. Although frozen pathology is reliable, tumor microinvasion can be subtle or missed, having an impact on surgical margins and postoperative radiation planning. The authors' service has begun to temporize the tumor bed after primary tumor excision with a wound vacuum-assisted closure (VAC) pending formal margin analysis, with coverage performed in the setting of final negative margins. METHODS This retrospective analysis included all patients managed at a tertiary referral cancer center with VAC temporization after soft tissue sarcoma or benign aggressive tumor excision from 1 January 2000 to 1 January 2019 and at least 2 years of oncologic follow-up evaluation. The primary outcome was local recurrence. The secondary outcomes were distant recurrence, unplanned return to the operating room for wound/infectious indications, thromboembolic events, and tumor-related deaths. RESULTS For 62 patients, VAC temporization was performed. The mean age of the patients was 62.2 ± 22.3 years (median 66.5 years; 95% confidence interval [CI] 61.7-72.5 years), and the mean age-adjusted Charlson Comorbidity Index was 5.3 ± 1.9. The most common tumor histology was myxofibrosarcoma (51.6%, 32/62). The mean volume was 124.8 ± 324.1 cm3, and 35.5% (22/62) of the cases were subfascial. Local recurrences occurred for 8.1% (5/62) of the patients. Three of these five patients had planned positive margins, and 17.7% (11/62) of the patients had an unplanned return to the operating room. No demographic or tumor factors were associated with unplanned surgery. CONCLUSIONS The findings showed that VAC-temporized management of microinvasive sarcoma and benign aggressive pathologies yields favorable local recurrence and unplanned operating room rates suggestive of oncologic and technical safety. These findings will need validation in a future randomized controlled trial.
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Affiliation(s)
- Mitchell S Fourman
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Duncan C Ramsey
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Erik T Newman
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph H Schwab
- Spine Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Yen-Lin Chen
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Yin P Hung
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Ivan Chebib
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - G Petur Nielsen
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - John T Mullen
- Surgical Oncology Service, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin A Raskin
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Santiago A Lozano Calderón
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Samà L, Binder JP, Darrigues L, Couturaud B, Boura B, Helfre S, Chiche L, Nicolas N, Tzanis D, Bouhadiba T, Gentile D, Perlbarg-Samson J, Bonvalot S. Safe-margin surgery by plastic reconstruction in extremities or parietal trunk soft tissue sarcoma: A tertiary single centre experience. Eur J Surg Oncol 2021; 48:526-532. [PMID: 34702592 DOI: 10.1016/j.ejso.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
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.
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Affiliation(s)
- Laura Samà
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy; Sarcoma, Melanoma and Rare Tumors Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy.
| | | | - Lauren Darrigues
- Division of Plastic and Reconstructive Surgery, Institute Curie, Paris, France
| | - Benoit Couturaud
- Division of Plastic and Reconstructive Surgery, Institute Curie, Paris, France
| | - Benoit Boura
- Department of Vascular Surgery, Hospital Saint Joseph, Paris, France
| | - Sylvie Helfre
- Department of Radiation Oncology, Institute Curie, Paris, France
| | | | - Nayla Nicolas
- Department of Radiology, Institute Curie, Paris, France
| | - Dimitri Tzanis
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France
| | - Toufik Bouhadiba
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France
| | - Damiano Gentile
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| | | | - Sylvie Bonvalot
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France.
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Nepon H, Safran T, Reece EM, Murphy AM, Vorstenbosch J, Davison PG. Radiation-Induced Tissue Damage: Clinical Consequences and Current Treatment Options. Semin Plast Surg 2021; 35:181-188. [PMID: 34526866 PMCID: PMC8432995 DOI: 10.1055/s-0041-1731464] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Radiation therapy is a valuable tool in the treatment of numerous malignancies but, in certain cases, can also causes significant acute and chronic damage to noncancerous neighboring tissues. This review focuses on the pathophysiology of radiation-induced damage and the clinical implications it has for plastic surgeons across breast reconstruction, osteoradionecrosis, radiation-induced skin cancers, and wound healing. The current understanding of treatment modalities presented here include hyperbaric oxygen therapy, autologous fat grafting and stem cells, and pharmaceutical agents.
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Affiliation(s)
- Hillary Nepon
- Division of Experimental Surgery, McGill University, Montreal, Quebec, Canada
| | - Tyler Safran
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | - Edward M. Reece
- Michael E. DeBakey Department of Surgery, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Amanda M. Murphy
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | | | - Peter G. Davison
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
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Million L, Hayes-Jordan A, Chi YY, Donaldson SS, Wolden S, Morris C, Terezakis S, Laurie F, Morano K, Fitzgerald TJ, Yock TI, Rodeberg DA, Anderson JR, Speights RA, Black JO, Coffin C, McCarville MB, Kao SC, Hawkins DS, Spunt SL, Randall RL. Local Control For High-Grade Nonrhabdomyosarcoma Soft Tissue Sarcoma Assigned to Radiation Therapy on ARST0332: A Report From the Childrens Oncology Group. Int J Radiat Oncol Biol Phys 2021; 110:821-830. [PMID: 33548339 PMCID: PMC8767764 DOI: 10.1016/j.ijrobp.2021.01.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/24/2020] [Accepted: 01/21/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE The ARST0332 trial for pediatric and young adults with nonrhabdomyosarcoma soft tissue sarcoma (NRSTS) used risk-based treatment including primary resection with lower-than-standard radiation doses to optimize local control (LC) while minimizing long-term toxicity in those requiring radiation therapy (RT). RT for high-grade NRSTS was based on extent of resection (R0: negative margins, R1: microscopic margins, R2/U: gross disease/unresectable); those with >5 cm tumors received chemotherapy (CT; ifosfamide/doxorubicin). This analysis evaluates LC for patients assigned to RT and prognostic factors associated with local recurrence (LR). METHODS AND MATERIALS Patients aged <30 years with high-grade NRSTS received RT (55.8 Gy) for R1 ≤5 cm tumor (arm B); RT (55.8 Gy)/CT for R0/R1 >5 cm tumor (arm C); or neoadjuvant RT (45 Gy)/CT plus delayed surgery, CT, and postoperative boost to 10.8 Gy R0 <5 mm margins/R1 or 19.8 Gy for R2/unresected tumors (arm D). RESULTS One hundred ninety-three eligible patients had 24 LRs (arm B 1/15 [6.7%], arm C 7/65 [10.8%], arm D 16/113 [14.2%]) at median time to LR of 1.1 years (range, 0.11-5.27). Of 95 eligible for delayed surgery after neoadjuvant therapy, 89 (93.7%) achieved R0/R1 margins. Overall LC after RT were as follows: R0, 106 of 109 (97%); R1, 51 of 60 (85%); and R2/unresectable, 2 of 6 (33%). LR predictors include extent of delayed resection (P <.001), imaging response before delayed surgery (P < .001), histologic subtype (P <.001), and no RT (P = .046). The 5-year event-free survival was significantly lower (P = .0003) for patients unable to undergo R0/R1 resection. CONCLUSIONS Risk-based treatment for young patients with high-grade NRSTS treated on ARST0332 produced very high LC, particularly after R0 resection (97%), despite lower-than-standard RT doses. Neoadjuvant CT/RT enabled delayed R0/R1 resection in most patients and is preferred over adjuvant therapy due to the lower RT dose delivered.
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Affiliation(s)
- Lynn Million
- Department of Radiation Oncology (LM, SSD) and Department of Pediatrics (SS), Stanford University, Stanford, California.
| | - Andrea Hayes-Jordan
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Yueh-Yun Chi
- Department of Biostatistics, University of Southern California, Los Angeles, California
| | - Sarah S Donaldson
- Department of Radiation Oncology (LM, SSD) and Department of Pediatrics (SS), Stanford University, Stanford, California
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Cancer Center, New York, New York
| | - Carol Morris
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore Maryland
| | - Stephanie Terezakis
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Fran Laurie
- Imaging and Radiation Oncology Core (IROC), Lincoln, Rhode Island
| | - Karen Morano
- Imaging and Radiation Oncology Core (IROC), Lincoln, Rhode Island
| | - T J Fitzgerald
- Department of Radiation Oncology, University of Massachusetts, Worcester, Massachusetts
| | - Torunn I Yock
- Department of Radiation Oncology, Massachusetts General Hospital, Boston Massachusetts
| | - David A Rodeberg
- Department of Surgery, East Carolina University, Greenville, North Carolina
| | | | | | - Jennifer O Black
- Department of Pathology, Children's Hospital Colorado, Aurora, Colorado
| | - Cheryl Coffin
- Department of Pathology, Vanderbilt University, Nashville, Tennessee
| | | | - Simon C Kao
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | - Douglas S Hawkins
- Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Sheri L Spunt
- Department of Radiation Oncology (LM, SSD) and Department of Pediatrics (SS), Stanford University, Stanford, California
| | - R Lor Randall
- Department of Orthopedics, University of California Davis, Sacramento, California
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Leite ETT, Munhoz RR, Camargo VPD, Lima LGCAD, Rebolledo DCS, Maistro CEB, Busnardo FDF, Ferreira FDO, Salvajoli JV, Carvalho HDA. Neoadjuvant stereotactic ablative radiotherapy (SABR) for soft tissue sarcomas of the extremities. Radiother Oncol 2021; 161:222-229. [PMID: 34171452 DOI: 10.1016/j.radonc.2021.06.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Soft tissue sarcomas (STS) comprise a diverse group of mesenchymal malignancies that require multidisciplinary care. Although surgery remains the primary form of treatment for those with localized disease, radiation therapy (RT) is often incorporated either in the neo- or adjuvant setting. Given the development of modern RT techniques and alternative dosing schedules, stereotactic ablative radiotherapy (SABR) has emerged as a promising technique. However, the current role of SABR in the treatment of STS of the extremities remains uncertain. METHODS AND MATERIALS This was a single-center, prospective, single-arm phase II trial. Patients with localized STS who were candidates for limb-preservation surgery were included. Experimental treatment consisted of SABR with 40 Gy in 5 fractions, administered on alternate days, followed by surgery after a minimum interval of 4 weeks. The primary outcome was the rate of wound complication. Secondary outcomes included 2-year local control (LC), metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS) rates (and other toxicities). RESULTS Twenty-five patients were enrolled between October 2015 and November 2019 and completed the treatment protocol. The median rate of histopathologic regression was 65% (range 0-100) and 20.8% of tumors presented pathologic complete response (pCR). Wound complications were observed in 7/25 patients (28%). Three patients underwent disarticulation by vascular occlusion after plastic reconstruction and one patient was amputated by grade 3 limb dysfunction. After a median follow up of 20.7 months, the 2-year estimated risk of local recurrence, distant metastasis and cause-specific death were 0%, 44.7% and 10.6% respectively. CONCLUSIONS Neoadjuvant SABR appears to improve the pCR for patients with eSTS, with acceptable rate of wound complications. Nevertheless, this benefit should be weighed against the risk of late of vascular toxicity with SABR regimen since, even in a short median follow-up, a higher rate of amputation than expected was observed. A larger sample size with longer follow-up is necessary to conclude the overall safety of this strategy.
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Affiliation(s)
| | - Rodrigo Ramella Munhoz
- Instituto do Câncer do Estado de São Paulo, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | | | | | | | | | | | - João Victor Salvajoli
- Instituto do Câncer do Estado de São Paulo, Universidade de Sao Paulo, Sao Paulo, Brazil
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40
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Rene NJ, Castiglioni A, Cóccaro N, Scheitlin B, Papa L. Soft Tissue Sarcomas: Is Pre-operative Radiotherapy Associated With More Acute Wound Complications? Cureus 2021; 13:e15654. [PMID: 34277247 PMCID: PMC8281105 DOI: 10.7759/cureus.15654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 12/21/2022] Open
Abstract
Introduction: Increased wound complication rates are attributed to the use of pre-operative radiotherapy. The purpose of this study is to evaluate the incidence of complications with or without pre-operative radiotherapy in our institution. Methods: We retrospectively evaluated 48 adult patients with high-grade extremity soft tissue sarcoma. Twenty-two patients received pre-operative radiotherapy (group A) while 26 patients underwent initial surgery (group B). Complications were defined as major wound complications if they were severe enough to delay the delivery of adjuvant treatment (chemotherapy or radiotherapy) more than eight weeks after surgery or if their resolution required a new surgical intervention. Results: Mean follow-up in group A and group B was 44.3 and 53.8 months, respectively. The incidence of complications of any grade in group A was 45.5% and 53.8% in group B (p: 0.566). Major wound complications in group A and group B occurred in 18% and 23% of the patients (p=0.630), respectively. All patients in group A completed local treatment - radiotherapy and surgery - in 66 days on average. In contrast, in group B post-operative radiotherapy was either delayed or suspended in four patients due to wound complications. This determined that 15.4% of the patients in group B did not receive the local treatment - surgery + radiotherapy - as planned. Conclusions: An increased risk of severe acute wound complications with the administration of pre-operative radiotherapy was not observed in patients with soft tissue sarcomas of the extremities. In addition, local treatment completion was not jeopardized with preoperative radiotherapy, as opposed to post-operative radiotherapy.
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Affiliation(s)
| | | | | | | | - Lucía Papa
- Biostatistics, Sanatorio Britanico, Rosario, ARG
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41
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Hoftiezer YAJ, Lans J, van der Heijden BEPA, Chen NC, Eberlin KR, Lozano-Calderón SA. Long-term patient-reported outcome measures following limb salvage with complex reconstruction or amputation in the treatment of upper extremity sarcoma. J Surg Oncol 2021; 123:1328-1335. [PMID: 33650694 DOI: 10.1002/jso.26426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES This study compares long-term patient-reported outcomes between patients that underwent limb-salvage surgery with complex reconstruction by free or pedicled flap (LS) or amputation. Additionally, the need for revision surgery is compared. METHODS A total of 43 patients were studied at a median follow-up of 9.54 years. Sixteen patients completed questionnaires regarding functional outcome and mental wellbeing. Functional outcomes were measured by using the Toronto Extremity Salvage Score (TESS), QuickDASH, and PROMIS Upper Extremity instruments. Mental wellbeing was assessed using the PROMIS Anxiety and Depression instruments. Revision surgery was assessed for the entire follow-up. RESULTS The median TESS scores were 96.0 versus 71.7 (p = 0.034) and the PROMIS Upper Extremity scores were 50.1 versus 40.3 (p = 0.039) for the LS and amputation cohorts, respectively. No significant difference was found regarding symptoms of anxiety (52.7 vs. 53.8; p = 0.587) or depression (52.0 vs. 50.5; p = 0.745). Of the patients in the LS cohort 51.6% required at least one reoperation compared to 8.33% in the amputation cohort. CONCLUSIONS LS surgery maintains functional benefits over amputation after almost a decade of follow-up. Still, mental wellbeing seems to be comparable between these patients, whereas LS procedures are associated with a sixfold increased need for reoperations.
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Affiliation(s)
- Yannick A J Hoftiezer
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Plastic, Reconstructive, and Hand Surgery, Radboud UMC, Nijmegen, The Netherlands
| | - Jonathan Lans
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brigitte E P A van der Heijden
- Department of Plastic, Reconstructive, and Hand Surgery, Radboud UMC, Nijmegen, The Netherlands.,Department of Plastic Surgery, Jeroen Bosch Hospital, Utrecht, The Netherlands
| | - Neal C Chen
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kyle R Eberlin
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Santiago A Lozano-Calderón
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Okajima K, Kobayashi H, Okuma T, Arai S, Zhang L, Hirai T, Ishibashi Y, Ikegami M, Shinoda Y, Akiyama T, Goto T, Tanaka S. Prognosis and surgical outcome of soft tissue sarcoma with malignant fungating wounds. Jpn J Clin Oncol 2021; 51:78-84. [PMID: 33037437 DOI: 10.1093/jjco/hyaa176] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/29/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Malignant fungating wounds are ulcerating tumors that infiltrate the overlying skin. Little evidence exists regarding the prognosis or treatment of malignant fungating wound in soft tissue sarcoma. This study aimed to reveal the prognosis and outcome of surgical treatment of malignant fungating wound in soft tissue sarcoma. METHODS We retrospectively reviewed 26 patients with malignant fungating wound in high-grade soft tissue sarcoma between 2005 and 2018. The patients' characteristics, treatments, surgical wound complications, local recurrences and prognoses were analyzed. Overall survival was analyzed using the Kaplan-Meier method and compared with that of the control cohort, consisting of 236 consecutive patients with non-malignant fungating wound high-grade soft tissue sarcoma treated during the same period. RESULTS Among the 26 patients, undifferentiated pleomorphic sarcoma was the most common subtype. Twenty-three patients, including 20 (87%) and 3 (13%), underwent limb-salvage surgery and amputation, respectively. Among the 20 patients who underwent limb-salvage surgery, 4 (20%) had surgical wound complications, which required additional surgical procedures. Excluding the patients who underwent palliative surgery, local recurrence occurred in 2 patients (11%). The 5-year overall survival rate for all high-grade malignant fungating wound and non-malignant fungating wound patients was 26.0 and 67.3% (P < 0.0001), respectively. CONCLUSIONS Malignant fungating wounds in soft tissue sarcoma were significantly associated with a poor prognosis; however, the incidence of surgical complications and local recurrence after limb-salvage surgery was comparable to that of general soft tissue sarcoma cases. Limb-salvage surgery should be considered, if possible, to preserve the patient's quality of life because of the dismal prognosis of patients with malignant fungating wound in soft tissue sarcoma.
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Affiliation(s)
- Koichi Okajima
- Department of Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.,Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo Hospital, Tokyo
| | - Hiroshi Kobayashi
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo Hospital, Tokyo
| | - Tomotake Okuma
- Department of Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Sho Arai
- Department of Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Liuzhe Zhang
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo Hospital, Tokyo
| | - Toshihide Hirai
- Department of Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.,Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo Hospital, Tokyo
| | - Yuki Ishibashi
- Department of Orthopaedic Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masachika Ikegami
- Department of Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.,Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo Hospital, Tokyo
| | - Yusuke Shinoda
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo Hospital, Tokyo
| | - Toru Akiyama
- Department of Orthopaedic Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takahiro Goto
- Department of Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo Hospital, Tokyo
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Callegaro D, Raut CP, Keung EZ, Kim T, Le Pechoux C, Martin‐Broto J, Gronchi A, Swallow C, Gladdy R. Strategies for care of patients with gastrointestinal stromal tumor or soft tissue sarcoma during COVID-19 pandemic: A guide for surgical oncologists. J Surg Oncol 2021; 123:12-23. [PMID: 33022754 PMCID: PMC7675701 DOI: 10.1002/jso.26246] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/17/2020] [Accepted: 09/17/2020] [Indexed: 12/15/2022]
Abstract
The coronavirus disease-2019 (COVID-19) pandemic is deeply impacting the accessibility of cancer patients to surgery. In resource-limited conditions, the standard of care might not be deliverable, but evidence to support alternative management strategies often exists. By revisiting available treatment options, this review provides surgical oncologists with an evidence-based framework for treating patients with gastrointestinal stromal tumor, extremity/truncal soft tissue sarcoma, and retroperitoneal sarcoma to rapidly adapt their decision-making to the constant evolution of the COVID-19 pandemic.
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Affiliation(s)
- Dario Callegaro
- Department of SurgeryUniversity of TorontoTorontoONCanada
- Department of SurgeryFondazione IRCCS Istituto Nazionale TumoriMilanItaly
| | - Chandrajit P Raut
- Department of Surgery, Brigham and Women's Hospital, Dana‐Farber Cancer InstituteHarvard Medical SchoolBostonMassachusettsUSA
| | - Emily Z Keung
- Department of Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Teresa Kim
- Department of SurgeryUniversity of WashingtonSeattleWashingtonUSA
| | | | - Javier Martin‐Broto
- Medical Oncology Department in University Hospital Virgen del Rocio and Institute of Biomedicine of Sevilla (IBIS) (HUVR, CSIC)University of SevillaSevillaSpain
| | - Alessandro Gronchi
- Department of SurgeryFondazione IRCCS Istituto Nazionale TumoriMilanItaly
| | - Carol Swallow
- Department of SurgeryUniversity of TorontoTorontoONCanada
| | - Rebecca Gladdy
- Department of SurgeryUniversity of TorontoTorontoONCanada
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44
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Hoftiezer YAJ, Lans J, Freniere BB, Eberlin KR, Chen NC, Lozano-Calderón SA. Factors associated with 30-day soft tissue complications following upper extremity sarcoma surgery. J Surg Oncol 2020; 123:521-531. [PMID: 33333594 DOI: 10.1002/jso.26311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 10/18/2020] [Accepted: 11/09/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES The incidence of soft tissue complications following sarcoma surgery in the upper extremity is reportedly high. Therefore, this study assessed the National Surgical Quality Improvement Program (NSQIP) database to identify independent risk factors, while also reporting the incidence of soft tissue complications in the first 30 days after surgery. METHODS A total of 620 patients that underwent surgical treatment for upper extremity sarcoma were included from the NSQIP database. Soft tissue complications were defined as surgical site infection, wound dehiscence, or soft-tissue related reoperations. Clinically relevant patient and treatment characteristics were selected and analyzed. RESULTS The 30-day soft tissue complication rate was 4.7%. In the multivariable analysis, higher body mass index (p = .047) and longer operative times (p = .002) were independently associated with soft tissue complications. CONCLUSIONS Higher body mass index and longer operative times are risk factors for soft tissue complications following upper extremity sarcoma surgery. The soft-tissue complication rate following resection of upper extremity tumors is low in this national cohort, possibly due to the relatively small tumor size and low prevalence of radiotherapy.
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Affiliation(s)
- Yannick A J Hoftiezer
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jonathan Lans
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brian B Freniere
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kyle R Eberlin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Neal C Chen
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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45
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Noebauer-Huhmann IM, Chaudhary SR, Papakonstantinou O, Panotopoulos J, Weber MA, Lalam RK, Albtoush OM, Fueger BJ, Szomolanyi P, Grieser T, Bloem JL. Soft Tissue Sarcoma Follow-up Imaging: Strategies to Distinguish Post-treatment Changes from Recurrence. Semin Musculoskelet Radiol 2020; 24:627-644. [PMID: 33307581 DOI: 10.1055/s-0040-1721464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Soft tissue sarcomas encompass multiple entities with differing recurrence rates and follow-up intervals. The detection of recurrences and their differentiation from post-therapeutic changes is therefore complex, with a central role for the clinical radiologist. This article describes approved recommendations. Prerequisite is a precise knowledge of the current clinical management and surgical techniques. We review recurrence rates and treatment modalities. An adequate imaging technique is paramount, and comparison with previous imaging is highly recommended. We describe time-dependent therapy-related complications on magnetic resonance imaging compared with the spectrum of regular post-therapeutic changes. Early complications such as seromas, hematomas, and infections, late complications such as edema and fibrosis, and inflammatory pseudotumors are elucidated. The appearance of recurrences and radiation-associated sarcomas is contrasted with these changes. This systematic approach in follow-up imaging of soft tissue sarcoma patients will facilitate the differentiation of post-therapeutic changes from recurrences.
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Affiliation(s)
- Iris-M Noebauer-Huhmann
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Snehansh R Chaudhary
- Department of Clinical Radiology, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | | | - Joannis Panotopoulos
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Vienna, Austria
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Radhesh K Lalam
- Department of Radiology, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom
| | - Omar M Albtoush
- Department of Radiology, University of Jordan, and Department of Radiology, King Hussein Cancer Center, Amman, Jordan
| | - Barbara J Fueger
- Department of Biomedical Imaging and Image Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Pavol Szomolanyi
- High Field MR Center, Department of Biomedical Imaging and Image Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Thomas Grieser
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Johan L Bloem
- Department of radiology, Leiden University Medical Center, Leiden, The Netherlands
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46
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Lex JR, Evans S, Cool P, Gregory J, Ashford RU, Rankin KS, Cosker T, Kumar A, Gerrand C, Stevenson J. Venous thromboembolism in orthopaedic oncology. Bone Joint J 2020; 102-B:1743-1751. [PMID: 33249908 DOI: 10.1302/0301-620x.102b12.bjj-2019-1136.r3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients. METHODS MEDLINE (PubMed), EMBASE (Ovid), Cochrane, and CINAHL databases were searched focusing on VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, or wound complication rates. RESULTS In all, 17 studies published from 1998 to 2018 met the inclusion criteria for the systematic review. The mean incidence of all VTE events in orthopaedic oncology patients was 10.7% (1.1% to 27.7%). The rate of PE was 2.4% (0.1% to 10.6%) while the rate of lethal PE was 0.6% (0.0% to 4.3%). The overall rate of DVT was 8.8% (1.1% to 22.3%) and the rate of symptomatic DVT was 2.9% (0.0% to 6.2%). From the studies that screened all patients prior to hospital discharge, the rate of asymptomatic DVT was 10.9% (2.0% to 20.2%). The most common risk factors identified for VTE were endoprosthetic replacements, hip and pelvic resections, presence of metastases, surgical procedures taking longer than three hours, and patients having chemotherapy. Mean incidence of VTE with and without chemical prophylaxis was 7.9% (1.1% to 21.8%) and 8.7% (2.0% to 23.4%; p = 0.11), respectively. No difference in the incidence of bleeding or wound complications between prophylaxis groups was reported. CONCLUSION Current evidence is limited to guide clinicians. It is our consensus opinion, based upon logic and deduction, that all patients be considered for both mechanical and chemical VTE prophylaxis, particularly in high-risk patients (pelvic or hip resections, prosthetic reconstruction, malignant diagnosis, presence of metastases, or surgical procedures longer than three hours). Additionally, the surgeon must determine, in each patient, if the risk of haemorrhage outweighs the risk of VTE. No individual pharmacological agent has been identified as being superior in the prevention of VTE events. Cite this article: Bone Joint J 2020;102-B(12)1743:-1751.
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Affiliation(s)
- Johnathan R Lex
- Division of Orthopaedic Surgery, University of Toronto, Toronto, Canada.,Oncology Department, Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Scott Evans
- Oncology Department, Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Paul Cool
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK.,Medical School, Keele University, Keele, UK
| | - Jonathan Gregory
- Oncology Department, Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Robert U Ashford
- Joint Reconstruction and Oncology, University Hospitals of Leicester NHS Trust, Leicester, UK.,Leicester Cancer Research Centre, University of Leicester, Leicester, UK
| | - Kenneth S Rankin
- Translational and Clinical Sciences Institute, Newcastle University, Newcastle, UK.,North of England Bone and Soft Tissue Tumour Service, Newcastle upon Tyne University Hospitals NHS Foundation Trust, Newcastle, UK
| | - Tom Cosker
- Orthopaedic Oncology, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Amit Kumar
- Orthopaedics Department, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Craig Gerrand
- Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK
| | - Jonathan Stevenson
- Oncology Department, Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK.,Medical School, Aston University, Birmingham, UK
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The Role of Plastic Reconstructive Surgery in Surgical Therapy of Soft Tissue Sarcomas. Cancers (Basel) 2020; 12:cancers12123534. [PMID: 33256182 PMCID: PMC7760015 DOI: 10.3390/cancers12123534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Soft tissue sarcoma (STS) treatment is an interdisciplinary challenge. Along with radio(chemo)therapy, surgery plays the central role in STS treatment. Little is known about the impact of reconstructive surgery on STS, particularly whether reconstructive surgery enhances STS resection success with the usage of flaps. Here, we analyzed the 10-year experience at a university hospital's Comprehensive Cancer Center, focusing on the role of reconstructive surgery. METHODS We performed a retrospective analysis of STS-patients over 10 years. We investigated patient demographics, diagnosis, surgical management, tissue/function reconstruction, complication rates, resection status, local recurrence and survival. RESULTS Analysis of 290 patients showed an association between clear surgical margin (R0) resections and higher-grade sarcoma in patients with free flaps. Major complications were lower with primary wound closure than with flaps. Comparison of reconstruction techniques showed no significant differences in complication rates. Wound healing was impaired in STS recurrence. The local recurrence risk was over two times higher with primary wound closure than with flaps. CONCLUSION Defect reconstructions in STS are reliable and safe. Plastic surgeons should have a permanent place in interdisciplinary surgical STS treatment, with the full armamentarium of reconstruction methods.
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O'Neill AC, Roy M, Boucher A, Fitzpatrick AM, Griffin AM, Tsoi K, Ferguson PC, Wunder JS, Hofer SOP. The Toronto Sarcoma Flap Score: A Validated Wound Complication Classification System for Extremity Soft Tissue Sarcoma Flap Reconstruction. Ann Surg Oncol 2020; 28:3345-3353. [PMID: 33005992 DOI: 10.1245/s10434-020-09166-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/03/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Flap reconstruction plays an important role in limb preservation after wide resection of extremity soft tissue sarcoma (ESTS), but can be associated with high rates of postoperative wound complications. Currently, no standardized system exists for the classification of these complications. This study aimed to develop a standardized classification system for wound complications after ESTS flap reconstruction. METHODS Outcomes of ESTS flap reconstructions were analyzed in a retrospective cohort of 300 patients. All wound- and flap-related complications were identified and categorized. Based on these data, a scoring system was developed and validated with a prospective cohort of 100 patients who underwent ESTS flap reconstruction. RESULTS A 10-point scoring system was developed based on the level of intervention required to treat each complication observed in the retrospective cohort. Raters applied the scoring system to the prospective patient cohort. Validation studies demonstrated excellent inter-rater and intra-rater reliability (weighted Cohen's kappa range, 0.82 [95% CI, 0.5-1.0] to 0.99 [95% CI, 0.98-1.0] and 0.95 [95% CI, 0.84-1.0] to 0.97 [95% CI, 0.92-1.0], respectively). The majority of the raters reported the score to be simple, objective, and reproducible (respective mean scores, 4.76 ± 0.43, 4.53 ± 0.62, and 4.56 ± 0.56 on 5-point Likert scales). CONCLUSION The Toronto Sarcoma Flap Score (TSFS) is a simple and objective classification system with excellent inter- and intra-rater reliability. Universal adoption of the TSFS could standardize outcome reporting in future studies and aid in the establishment of clinical benchmarks to improve the quality of care in sarcoma reconstruction.
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Affiliation(s)
- Anne C O'Neill
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Toronto, ON, Canada. Anne.O'.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada. Anne.O'.,Department of Surgery, University of Toronto, Toronto, Canada. Anne.O'
| | - Mélissa Roy
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Toronto, ON, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Amelia Boucher
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Toronto, ON, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Aisling M Fitzpatrick
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Toronto, ON, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Anthony M Griffin
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Kim Tsoi
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Peter C Ferguson
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Jay S Wunder
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Stefan O P Hofer
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Toronto, ON, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
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49
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O'Neill AC. ASO Author Reflections: Standardizing Outcome Reporting in Extremity Soft Tissue Sarcoma Flap Reconstruction. Ann Surg Oncol 2020; 28:3354-3355. [PMID: 33000369 DOI: 10.1245/s10434-020-09189-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Anne C O'Neill
- Division of Plastic Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada. Anne.O'
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Risk Factors of Periprosthetic Infection in Patients with Tumor Prostheses Following Resection for Musculoskeletal Tumor of the Lower Limb. J Clin Med 2020; 9:jcm9103133. [PMID: 32998268 PMCID: PMC7601076 DOI: 10.3390/jcm9103133] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/23/2020] [Accepted: 09/26/2020] [Indexed: 12/28/2022] Open
Abstract
Tumor prostheses for the lower limb following resection of musculoskeletal tumors is useful limb salvage management; however, as compared with routine total joint replacement, an increased incidence of deep periprosthetic infection of tumor prosthesis has been observed. The risk factors for periprosthetic infection of tumor prosthesis remain unclear. This study examines the risk factors and outcomes of periprosthetic infection. This was a retrospective observational study including 121 patients (67 males and 54 females) who underwent tumor prosthesis of the lower limb after resection of musculoskeletal tumors between 1 January 2000 and 30 November 2018. Among a total of 121 tumor prostheses, 7 were total femurs, 47 were proximal femurs, 47 were distal femurs, and 20 were proximal tibias. The incidence of postoperative infection and its risk factors were analyzed. Forty-five patients (37%) had osteosarcoma, 36 patients (30%) had bone metastasis, and 10 patients (8%) had soft-tissue tumors invading the bone. The mean operating time was 229 min, and the mean follow-up duration was 5.9 years. Deep periprosthetic infection was noted in 14 patients (12%). In the multivariate analysis, the risk factors for postoperative infection were identified as being male (hazard ratio [HR], 11.2316; p = 0.0100), soft-tissue tumor (HR, 52.2443; p = 0.0003), long operation (HR, 1.0056; p = 0.0184), and radiotherapy (HR, 6.5683; p = 0.0476). The incidence of periprosthetic infection in our institution was similar to that of previous reports. Patients undergoing tumor prosthesis of the lower limb who were male, had a soft-tissue tumor, were predicted to have a long operation, and who underwent radiation, had an increased possibility of postoperative infection.
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