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Polites SF, Rhee DS, Seitz G, Dall'Igna P, Binitie O, Scharschmidt T, Lautz TB, Dasgupta R. Contemporary surgical management of pediatric non-rhabdomyosarcoma soft tissue sarcoma. Pediatr Blood Cancer 2024:e31257. [PMID: 39138613 DOI: 10.1002/pbc.31257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 08/15/2024]
Abstract
Non-rhabdomyosarcoma soft tissue sarcoma (STS) comprises most STS in pediatric patients. It is a diverse set of over 30 histologic subtypes. Treatment is based on risk group determined by tumor size, grade, and the presence of metastases. Surgical resection is a cornerstone of therapy, as tumors are often resistant to chemotherapy or radiation. While patients with isolated tumors less than 5 cm may undergo upfront resection, strong consideration should be given to neoadjuvant chemoradiotherapy to ensure negative margins at surgical resection and optimal outcomes. Sentinel lymph node biopsy is strongly recommended for clear cell and epithelioid sarcomas. The most common metastatic site is the lung, and metastases should be resected at the end of therapy, when feasible. Unfortunately, many high-risk patients progress on therapy, and alternative strategies including earlier metastatic control require investigation.
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Affiliation(s)
| | - Daniel S Rhee
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Guido Seitz
- Department of Pediatric Surgery and Urology, University Hospital Giessen-Marburg, Giessen, Germany
| | - Patrizia Dall'Igna
- Department of Precision and Regenerative Medicine and Jonic Area (DiMePRe-J), Azienda Ospedaliero-Universitaria Consorziale Pediatric Hospital Giovanni XXIII, Bari, Italy
| | - Odion Binitie
- Department of Sarcoma, Moffitt Cancer Center, Tampa, Florida, USA
| | - Thomas Scharschmidt
- Department of Orthopedics, James Cancer Hospital and Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Timothy B Lautz
- Division of Pediatric Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois, USA
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
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Abe Y, Nagasaka S, Yamashita Y, Mineda K, Yamasaki H, Bando M, Mima S, Hashimoto I. Functional outcomes of reconstructive flap surgery for soft tissue sarcoma: Long-term outcomes of functional restoration using innervated muscle transplantation. J Plast Reconstr Aesthet Surg 2024; 91:312-321. [PMID: 38442511 DOI: 10.1016/j.bjps.2024.02.018] [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: 09/14/2023] [Revised: 12/11/2023] [Accepted: 02/04/2024] [Indexed: 03/07/2024]
Abstract
Functional outcomes associated with prognostic factors and innervated muscle transplantation after wide soft tissue sarcoma resection remain unclear. We retrospectively examined the functional outcomes of reconstructive flap surgery for soft tissue sarcoma. Twenty patients underwent innervated muscle transplantation with pedicled or free flaps for functional reconstruction of resected muscles. Thirteen latissimus dorsi muscles and one vastus lateralis muscle combined with an anterolateral thigh flap were transferred as free flaps using the epi-perineural suture technique. Six latissimus dorsi muscles were transferred as pedicled flaps with neural continuity. Postoperative functional outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) scores for the upper and lower extremities of 22 and 24 patients, respectively. The mean MSTS score for all patients was 82.3 at 12 months postoperatively. The mean scores for patients who underwent reconstruction with pedicled and free flaps were 89.2 and 77.1, respectively. The MSTS scores for the lower extremity, tumor size ≥5 cm, and free flap reconstruction were significantly lower than those for the upper extremity, tumor size <5 cm, and pedicled flap reconstruction (P = 0.02, 0.37, and 0.008, respectively). The postoperative MSTS score for innervated muscle transplantation was 76.7 at 12 months and was significantly higher (83.7) at 24 months (P = 0.003). Functional outcomes were significantly associated with tumor location, tumor size, and reconstructive flap type based on the MSTS scores. Innervated muscle transplantation improved functional outcomes at 24 months postoperatively via sufficient recovery of the innervated muscle, not the compensatory recovery of the remaining muscle.
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Affiliation(s)
- Yoshiro Abe
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan.
| | - Shinji Nagasaka
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yutaro Yamashita
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Kazuhide Mineda
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Hiroyuki Yamasaki
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Mayu Bando
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Shunsuke Mima
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Ichiro Hashimoto
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
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Blanco MD, de la Torre M, Lorca C, Del Cañizo A, Bada I, Monje S, García-Casillas MA, Villa Á, de Tomás E, Berenguer B. Use of pedicled flaps after oncologic resections in pediatric patients. Pediatr Surg Int 2024; 40:64. [PMID: 38433161 DOI: 10.1007/s00383-024-05654-8] [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] [Accepted: 02/11/2024] [Indexed: 03/05/2024]
Abstract
The aim of this study is to review the indications of pedicled flaps and analyze the results. A observational retrospective study of under 18-year-old oncology patients who required reconstructive surgery with pedicled flaps between 2011 and 2022 was performed. Demographic and clinical variables, indications, complications, and outcomes were collected. 236 patients were reviewed and 13 met inclusion criteria, eight girls and five boys (mean age: 10.6 years). Indications were Ewing's sarcoma (5), osteosarcoma (5), neuroblastoma, desmoid tumor, and neurofibroma. Preoperative PET-CT, MRI and bone scintigraphy were performed. The flaps were used on costal and extremity reconstruction: latissimus dorsi (5), pectoralis (2), medial gastrocnemius (2), combined latissimus dorsi, trapezius and serratus muscle, biceps femoris, fascio-neuro-cutaneous saphenous and cutaneous advancement-rotation. Two were performed on allograft and eight on prosthesis. All allowed immediate and complete closure. Six patients received intraoperative radiotherapy. One flap infection and two vascular complications were reported, a total necrosis, which required a new flap, and a partial necrosis, treated with a local plasty. Chemotherapy was resumed after 21 days (15-31). Mean follow-up time was 5.34 years. Flaps are an effective therapeutic option allowing reconstruction of large defects after pediatric oncologic surgeries. The most frequent complication was vascular.
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Affiliation(s)
- María Dolores Blanco
- General and Thoracic Pediatric Surgery Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
- Department of Pediatric Surgery, Hospital Materno Infantil Gregorio Marañón, C/O'Donnell, 48, 28009, Madrid, Spain.
| | - Manuel de la Torre
- Plastic Pediatric Surgery Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Concepción Lorca
- Plastic Pediatric Surgery Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Agustín Del Cañizo
- General and Thoracic Pediatric Surgery Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Isabel Bada
- General and Thoracic Pediatric Surgery Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Sara Monje
- General and Thoracic Pediatric Surgery Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Ángel Villa
- Pediatric Traumatology Department Hospital General, Universitario Gregorio Marañón, Madrid, Spain
| | - Elena de Tomás
- Plastic Pediatric Surgery Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Beatriz Berenguer
- Plastic Pediatric Surgery Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Jawad AM, Duraku LS, Susini F, Chaudhry T, George S, Jester A, Power DM. Resect, rewire, and restore: Nerve transfer salvage of neurological deficits associated with soft tissue tumors in a retrospective cohort series at a tertiary reconstructive center. J Plast Reconstr Aesthet Surg 2023; 85:523-533. [PMID: 37280143 DOI: 10.1016/j.bjps.2023.04.054] [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: 10/03/2022] [Revised: 02/28/2023] [Accepted: 04/07/2023] [Indexed: 06/08/2023]
Abstract
AIMS We aimed to explore the effectiveness of nerve transfer as an intervention to restore neurological deficits caused by extremity tumors through direct nerve involvement, neural compression, or as a consequence of oncological surgery. METHODS A retrospective cohort study of consecutive cases was conducted, including all patients who underwent nerve transfers to restore functional deficits in limbs following soft tissue tumor resection. The threshold for a successful nerve transfer was a BMRC motor grade of 4/5 and sensory grade of 3-3+/4 with protective sensation. RESULTS In total, 29 nerve transfers (25 motor and 4 sensory) were completed in 11 patients, aged 12-70 years at referral, over a 6-year period to 2020. This included 22 upper limb and 3 lower limb motor nerve transfers. The timing of delayed nerve transfer reconstructions was 1-15 months following primary oncological resection, with immediate simultaneous reconstructions performed in 4 cases. The threshold for success was achieved in 82% of upper limb and 33% of lower limb motor nerve transfers, while all sensory transfers were successful in restoring protective sensation. CONCLUSION Nerve transfer surgery, a well-established technique in restoring deficits following traumatic nerve injury, is further demonstrably relevant in extremity oncological reconstruction, especially as it can be performed remotely to the tumor location or resection site and introduces a healthy nerve or fascicle to rapidly reinnervate distal muscles without sacrificing major function. This study further illustrates the importance of early recognition and referral to specialist services where multi-disciplinary surgical resection and reconstructive planning can be conducted. LEVEL OF EVIDENCE IV Clinical Case Series.
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Affiliation(s)
- Ali M Jawad
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom
| | - Liron S Duraku
- Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Francesca Susini
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Tahseen Chaudhry
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom
| | - Samuel George
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom
| | - Andrea Jester
- Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, United Kingdom
| | - Dominic M Power
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom.
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Xu Y, Li Y, Fu Y, Wang B, Lin T, Zou C, Huang G, Shen J, Yin J. Autologous menisci-cruciate ligament composite as a flap for soft tissue reconstruction following malignant bone tumor resection around the knee. Cancer Med 2023; 12:8027-8037. [PMID: 36622149 PMCID: PMC10134327 DOI: 10.1002/cam4.5591] [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: 07/31/2022] [Revised: 12/01/2022] [Accepted: 12/17/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Despite significant improvements in oncological treatment, the management of soft tissue defects following malignant tumor resection remains challenging. We investigated whether autologous menisci and cruciate ligament, which are traditionally discarded, can be recycled as a supplemental flap in repairing soft tissue defects following malignant bone tumor resection and endoprosthetic reconstruction around the knee. METHODS Four knee specimens were dissected to provide a basis for the design of the menisci-cruciate ligament composite. Then, 40 patients with bone malignancies around the knee were enrolled and underwent reconstruction with free or vascularized composite following malignant tumor resection. The clinical, radiographic, and functional outcomes of this technique were evaluated in >1-year follow-up in each patient and compared with 87 patients who suffered from bone malignancies around the knee and were treated by limb salvage but without composite at our center over the same period. During the follow-up, a composite from one patient who underwent secondary amputation was retrieved and examined for in vivo remodeling. RESULTS Fourteen patients were treated with vascularized composite transfer (10 distal femurs and 4 proximal tibias) and 26 patients with free composite transfer (19 distal femurs and 7 proximal tibias). The composite can be used to cover the area of soft tissue defect from 22 to 48.38 cm2 (34.67 ± 6.48 cm2 ). With contrast-enhanced ultrasound, peripheral rim healing and dotted blood flow signal at the side of anastomosis were detected on a patient 16 months after free composite transfer. Gross macroscopic remodeling and histopathologic analysis of a retrieved composite also indicated good healing with surrounding tissues and living cells in the composite. The complications and oncologic outcomes were comparable between study and control cohorts, but better Musculoskeletal Tumor Society (MSTS) score for patients reconstructed with composite (26.68 vs. 25.66, p = 0.004). Of note, MSTS score was higher for patients reconstructed with composite at distal femur subdivision compared with the same subdivision in the control cohort (26.97 vs. 25.90, p = 0.009). No statically significant difference was noted in complications, oncologic, and functional outcomes for patients reconstructed with free or vascularized composite. CONCLUSION Autogenous menisci-cruciate ligament composite is an alternative option for soft tissue reconstruction. Either vascularized or free composite can be applied, depending on the size and localization of the defect.
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Affiliation(s)
- Yu Xu
- Department of Orthopedic Oncology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yan Li
- Department of Orthopedic Oncology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yiwei Fu
- Department of Orthopedic Oncology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Bo Wang
- Department of Orthopedic Oncology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Tiao Lin
- Department of Orthopedic Oncology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Changye Zou
- Department of Orthopedic Oncology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Gang Huang
- Department of Orthopedic Oncology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jingnan Shen
- Department of Orthopedic Oncology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, Guangzhou, Guangdong, China
| | - Junqiang Yin
- Department of Orthopedic Oncology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Orthopedics and Traumatology, Guangzhou, Guangdong, China
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Gu X, Ricketts S, Mah E. Functional outcomes after single quadriceps muscle resection in patients with soft tissue sarcoma of the anterior compartment of the thigh. ANZ J Surg 2023; 93:288-293. [PMID: 36511137 DOI: 10.1111/ans.18205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 11/22/2022] [Accepted: 12/04/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Soft tissue sarcoma (STS) occurs most commonly in the anterior compartment of the thigh. Limb salvage surgery is the mainstay of treatment, however, resections frequently involve muscle sacrifice. This study determines the impact of a single quadriceps muscle sacrifice on daily living functions. This is to assist clinical decision-making relating to when a functional reconstruction should be offered over simple soft tissue coverage for these defects. METHODS Patients who underwent single quadriceps resection as part of the management of STS between 2010 and 2020 were selected. Three functional tests were performed: Time Up and Go (TUG), Timed Up and Down Stairs (TUDS) and Toronto Extremity Salvage Score (TESS). The results were compared with age/sex matched healthy reference values and literature cohorts of lower limb STS patients. Correlations between the tests and age and follow-up duration were determined by the Spearman's test. RESULTS The mean TESS, TUG and TUDS results of the 13 patients were 89.6%, 9.8 and 1.01 s/step, respectively. These scores were either similar or significantly better than the comparator values. The TESS score showed no statistical significance compared with patients with no muscle resection. TUG and TUDS scores showed significant positive correlation with each other (ρ = 0.885, P = <0.01) and with age (ρ = 0.646, P = 0.017 and ρ = 0.567, P = 0.043, respectively). CONCLUSION This is the largest documented case series of single quadriceps resection for STS. The study suggests that this group of patients does not show a functional deficit and therefore does not require functional reconstruction.
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Affiliation(s)
- Xinchen Gu
- Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, Parade Fitzroy, Victoria, Australia.,Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - Sophie Ricketts
- Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, Parade Fitzroy, Victoria, Australia
| | - Eldon Mah
- Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, Parade Fitzroy, Victoria, Australia
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Conti L, Buriro F, Baia M, Pasquali S, Miceli R, De Rosa L, Gronchi A, Fiore M. Contemporary role of amputation for patients with extremity soft tissue sarcoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 49:934-940. [PMID: 36517316 DOI: 10.1016/j.ejso.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/01/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION limb-sparing surgery is the mainstream treatment for primary extremity soft tissue sarcoma (ESTS) at referral centers, following advances in surgical reconstructions and multimodal management. However, amputation is still needed in selected patients and has not yet been described for a ESTS cohort in a contemporary scenario. MATERIAL AND METHODS consecutive patients who underwent surgery for primary ESTS from 2006 to 2018 were extracted from a prospectively collected database at our reference center. Patients receiving amputation for either primary tumor or local recurrence (LR) after limb-sparing surgery were selected for analysis. RESULTS Among 1628 primary ESTS, 29 patients underwent primary amputation (1.8%), 22/1159 (1.9%) for upper limb and 7/469 (1.5%) for lower limb ESTS. Patients were mainly affected by grade III FNCLCC (89.6%) of notable dimension (median size 16 cm, IQR 10-24). 65.5% of patients received preoperative treatments (systemic or regional chemotherapy, radiotherapy or chemo-radiation). Secondary amputation for LR was performed after a median of 23 months in 16/1599 patients (1%). Median survival time was 16.2 and 29.6 months after primary or secondary amputation respectively. Factors prompting the need for a primary amputation were most often a combination of multifocal disease, bone invasion and pain or neurovascular bundle involvement and relevant comorbidities, mainly for grade III tumors in elderly patients. CONCLUSION Contemporary rate of amputation for ESTS at a reference center is extremely low. Still, amputation is required in selected cases with advanced presentations, especially in elderly, frail patients.
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Martin E, Pendleton C, Verhoef C, Spinner RJ, Coert JH. Morbidity and Function Loss After Resection of Malignant Peripheral Nerve Sheath Tumors. Neurosurgery 2022; 90:354-364. [PMID: 34528095 DOI: 10.1093/neuros/nyab342] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/16/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Malignant peripheral nerve sheath tumors (MPNSTs) are aggressive soft tissue sarcomas. Their resection may lead to serious morbidity. Incidence of postoperative motor and sensory deficits is unknown, and reconstruction aimed at restoring such deficits is infrequently carried out. OBJECTIVE To identify the incidence and risk factors of postoperative morbidity in MPNST as well as the use and outcomes of functional reconstructions in these patients. METHODS Postoperative function and treatment of MPNSTs diagnosed from 1988 to 2019 in 10 cancer centers was obtained. Two models were constructed evaluating factors independently associated with postoperative motor (<M3) or critical sensory loss. Critical sensation was defined as partial or complete loss of hand, foot, or buttocks sensation. RESULTS A total of 756 patients (33.4% neurofibromatosis type 1, NF1) were included. MPNSTs originated in 34.4% from a major nerve. Of 658 surgically treated patients, 27.2% had <M3 muscle power and 24.3% critical sensory loss. Amputations were carried out in 61 patients. Independent risk factors for motor and sensory loss included patients with NF1, symptomatic, deep-seated, extremity, or plexus tumors originating from major nerves (all P < .05). A total of 26 patients underwent functional reconstructions. The majority (64%) of these patients regained at least M3 muscle power and 33% M4 despite 86% receiving multimodal therapy. CONCLUSION Resection of MPNSTs commonly results in motor and sensory deficits. Patients with NF1, symptomatic, deep-seated tumors, arising from major nerves were associated with a higher risk for developing postoperative morbidity. Functional reconstructions are infrequently performed but can improve functional outcomes.
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Affiliation(s)
- Enrico Martin
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht , the Netherlands
- Department of Surgical Oncology, Erasmus Medical Center , Rotterdam , the Netherlands
| | | | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus Medical Center , Rotterdam , the Netherlands
| | - Robert J Spinner
- Department of Neurosurgery, Mayo Clinic , Rochester , Minnesota , USA
| | - J Henk Coert
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht , the Netherlands
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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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Surgical Management of Upper Limb Sarcomas. Sarcoma 2021. [DOI: 10.1007/978-981-15-9414-4_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Reconstruction of upper limb soft-tissue defects after sarcoma resection with free flaps: A systematic review. J Plast Reconstr Aesthet Surg 2020; 74:755-767. [PMID: 33277214 DOI: 10.1016/j.bjps.2020.10.065] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 06/25/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Upper limb preservation after soft tissue sarcoma (STS) surgical excision is now the accepted gold standard and it often requires reconstruction with free flaps. The purpose of this review is to summarize current literature on upper limb reconstruction with free flaps after STS resection. METHODS A systematic review was performed in July 2019 in PubMed and MedLine Ovid databases according to the PRISMA guidelines. RESULTS A total of 17 studies were included in the final analysis, with 132 patients. The most common diagnosis was Malignant Fibrous Histiocytoma. The most frequent timing of flap coverage was immediate. The success rate was almost always 100%. The length of follow-up was reported in 11 studies with a range of 2-187 months. The most commonly reported patient-centered outcome was the MSTS Score. Based on the evidence of the literature collected, we divided the upper limb into four parts (shoulder, elbow and arm, forearm and wrist, and hand) and described the most common and functional free flaps used for reconstruction after STS resection. CONCLUSIONS Free flaps in the treatment of STS of the upper extremity have a good overall outcome, with a low postoperative complication rate. A wide array of free flaps is available for reconstruction, and the choice of flap is based on defect size, types of tissue required, postoperative functional goal, and surgeon preference. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.
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Brown A, Spazzoli B, Mah E, May D, Chu J, Spelman T, Choong P, Di Bella C. Planned combined onco-plastic (COP) surgical approach improves oncologic outcomes in soft tissue sarcomas. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 47:443-449. [PMID: 32660707 DOI: 10.1016/j.ejso.2020.06.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/22/2020] [Accepted: 06/29/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Combined modality of radiotherapy and surgery is the standard of treatment of soft tissue sarcomas (STS). The goal of this study was to assess whether a Combined Onco-Plastic (COP) surgical approach in the setting of neo-adjuvant radiotherapy can improve the oncologic outcomes of STS and reduce the rate of wound complications. METHODS We performed a retrospective review of all patients with STS treated at a single sarcoma centre (St Vincent's Hospital, Melbourne) between 2007 and 2018. Patients were stratified into two groups based on whether they have received the COP approach or were closed primarily by the orthopaedic surgeon. We analysed oncological outcomes and rate of wound complications. RESULTS A total of 546 patients with comparable demographics and tumor characteristics were included. The COP approach was performed in 75.6% of the patients. Wide margins were obtained in 97.4% of the cases, and this was significantly higher in the COP group (p < 0.001). The cumulative rate of local recurrence was 4.9%, with a 52% risk reduction in the COP approach, although this reduction was not significant (HR = 0.48; 95% CI 0.21-1.06; p = 0.070). The COP approach had better disease free survival (DFS) (aHR 1.86, 95% CI 1.45-2.37; p < 0.001) and Overall survival (risk of death aHR 0.49; 95% CI 0.30-0.79; p = 0.004). The overall wound complication rate was 18.6% with no difference between the two groups. CONCLUSION A planned collaboration between the orthopaedic oncologist and the plastic surgeon is beneficial in the treatment of STS after neo-adjuvant radiotherapy, allowing remarkably good oncological outcomes and a low rate of wound complications.
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Affiliation(s)
- A Brown
- Department of Orthopaedics, Sarcoma Unit, St Vincent's Hospital, Melbourne, Australia
| | - B Spazzoli
- Department of Orthopaedics, Sarcoma Unit, St Vincent's Hospital, Melbourne, Australia; Rizzoli Orthopaedic Institute, Bologna, Italy
| | - E Mah
- Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, Melbourne, Australia
| | - D May
- Department of Orthopaedics, Sarcoma Unit, St Vincent's Hospital, Melbourne, Australia
| | - J Chu
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Australia
| | - T Spelman
- Department of Surgery, The University of Melbourne, Australia
| | - P Choong
- Department of Orthopaedics, Sarcoma Unit, St Vincent's Hospital, Melbourne, Australia; Department of Surgery, The University of Melbourne, Australia
| | - C Di Bella
- Department of Orthopaedics, Sarcoma Unit, St Vincent's Hospital, Melbourne, Australia; Department of Surgery, The University of Melbourne, Australia.
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Oncological Treatment Considerations Differ across Surgical Subspecialties Treating Malignant Peripheral Nerve Sheath Tumors: An International Survey. Sarcoma 2020; 2020:6406439. [PMID: 32189989 PMCID: PMC7064831 DOI: 10.1155/2020/6406439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/15/2020] [Accepted: 01/24/2020] [Indexed: 12/18/2022] Open
Abstract
Background Malignant peripheral nerve sheath tumors (MPNSTs) are rare and aggressive soft tissue sarcomas (STS) that, because of their origin, are operated by several surgical subspecialties. This may cause differences in oncologic treatment recommendations based on presentation. This study investigated these differences both within and between subspecialties. Methods A survey was distributed among several (inter)national surgical societies. Differences within and between subspecialties were analyzed by χ2-tests. Results In total, 30 surgical oncologists, 30 neurosurgeons, 85 plastic surgeons, and 29 “others” filled out the survey. Annual caseload, tumor sites operated, and fellowship training differed significantly between subspecialties. While most surgeons agreed upon preoperative use of MRI, the use of radiological staging and FDG-PET use differed between subspecialties. Surgical oncologists agreed upon core needle biopsies as an ideal type of biopsy while other subspecialties differed in opinion. On average, 53% of surgeons always consider preservation of function preoperatively, but 42% would never perform less extensive resections for function preservation. Respondents agreed that radiotherapy should be considered in tumor sizes >10 cm, microscopic, and macroscopic positive margins. A preferred sequence of radiotherapy administration differed between subspecialties. There was no consensus on indications and sequence of administration of chemotherapy in localized disease. Conclusion Surgical oncologists generally agree on preoperative diagnostics; other subspecialties do not. Considering the preservation of function differed among all subspecialties. Surgeons do agree on some indications for radiotherapy, yet the use of chemotherapy in localized MPNSTs lacks consensus. A preferred sequence of multimodal therapy differs between and within surgical subspecialties, but surgical oncologists prefer neoadjuvant radiotherapy.
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Martin E, Flucke UE, Coert JH, van Noesel MM. Treatment of malignant peripheral nerve sheath tumors in pediatric NF1 disease. Childs Nerv Syst 2020; 36:2453-2462. [PMID: 32494969 PMCID: PMC7575473 DOI: 10.1007/s00381-020-04687-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Malignant peripheral nerve sheath tumors (MPNSTs) are rare yet highly aggressive soft tissue sarcomas. Children with neurofibromatosis type 1 (NF1) have a 10% lifetime risk for development of MPNST. Prognosis remains poor and survival seems worse for NF1 patients. METHODS This narrative review highlights current practices and pitfalls in the management of MPNST in pediatric NF1 patients. RESULTS Preoperative diagnostics can be challenging, but PET scans have shown to be useful tools. More recently, functional MRI holds promise as well. Surgery remains the mainstay treatment for these patients, but careful planning is needed to minimize postoperative morbidity. Functional reconstructions can play a role in improving functional status. Radiotherapy can be administered to enhance local control in selected cases, but care should be taken to minimize radiation effects as well as reduce the risk of secondary malignancies. The exact role of chemotherapy has yet to be determined. Reports on the efficacy of chemotherapy vary as some report lower effects in NF1 populations. Promisingly, survival seems to ameliorate in the last few decades and response rates of chemotherapy may increase in NF1 populations when administering it as part of standard of care. However, in metastasized disease, response rates remain poor. New systemic therapies are therefore desperately warranted and multiple trials are currently investigating the role of drugs. Targeted drugs are nevertheless not yet included in first line treatment. CONCLUSION Both research and clinical efforts benefit from multidisciplinary approaches with international collaborations in this rare malignancy.
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Affiliation(s)
- Enrico Martin
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, G04.126, PO Box 85060, 3508, AB, Utrecht, the Netherlands.
| | - Uta E. Flucke
- Department of Solid Tumors, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands ,Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - J. Henk Coert
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, G04.126, PO Box 85060, 3508 AB Utrecht, the Netherlands
| | - Max M. van Noesel
- Department of Solid Tumors, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
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